Esvot Proceedings 2010

Progetto8:Layout 1 2-09-2010 16:50 Pagina 1
Alma Mater Studiorum

In cooperation with Università di Bologna
Facoltà di Medicina Veterinaria
PROCEEDINGS
3rd World Veterinary Orthopaedic Congress, ESVOT-VOS
15th ESVOT Congress
Bologna (Italy) - September 15th - 18th, 2010
00) Parti iniziali ESVOT2010_ok 02/09/10 13:47 Pagina 1
Alma Mater Studiorum

In cooperation with Università di Bologna
Facoltà di Medicina Veterinaria
3rd World Veterinary Orthopaedic Congress, ESVOT-VOS

15th ESVOT Congress
Bologna (Italy) - September 15th - 18th, 2010
Congress Chairman
J. Houlton
Small Animal Program Chairman

J. Innes
Large Animal Program Chairman

M. Schramme
Local Organizing Committee Chairman

A. Vezzoni
PROCEEDINGS
University of Bologna - Faculty of Veterinary Medicine

Ozzano Emilia (Bologna), Italy
Bologna Congress Center

Piazza della Costituzione, 4/A - Bologna, Italy
Editors
A. Vezzoni
E. Taravella
WVOC 2010, Bologna (Italy), 15th - 18th September • 2
Previous E.S.V.O.T. Congresses

1st E.S.V.O.T. - Congress 1987 Frankfurt, Germany
2nd E.S.V.O.T. - Congress 1988 Milano, Italy
3rd E.S.V.O.T. - Congress 1989 Nice, France
4th E.S.V.O.T. - Congress 1990 Uppsala, Sweden
5th E.S.V.O.T. - Congress 1991 Amsterdam, The Netherlands
6th E.S.V.O.T. - Congress 1992 Roma, Italy
7th E.S.V.O.T. - Congress 1994 Birmingham, UK
8th E.S.V.O.T. - Congress 1996 Munich, Germany
1st World Orthopaedic Veterinary Congress ESVOT-VOS 2002 Munich, Germany
2nd World Orthopaedic Veterinary Congress VOS-ESVOT 2006 Keystone, USA
Board 2008-2010 of the European Society of Veterinary Orthopaedics and Traumatology

President Director
Prof. Olivier M. Lepage Prof. Dr. Ulrike Matis
VetAgro Sup - Veterinary Campus of Lyon Chirurgische Universitäts-Tierklinik
Equine Department - 1, avenue Bourgelat Veterinärstr. 13
F-69280 Marcy L’Etoile (France) D-80539 München
Fax: + 33 4 78 87 26 75 Fax +49-89-395341
E-mail: o.lepage@vetagro-sup.fr E-mail: matis@chir.vetmed.uni-muenchen.de
Vice-President Director
Dr. Rico Vannini Dr. Bernadette Van Ryssen
Bessy’s Kleintierklinik University of Ghent
Dorfstrasse 51 - CH-8105 Watt Fac. Vet. Med., Dept. of Surgery
Fax: ++41 1 871 6065 Salisburylaan 133
E-mail: rico.vannini@bessys.ch B-9820 Merelbeke
Fax: ++32 3772 1245
Past-President E-mail: bernadette.vanryssen@ugent.be
Dr. Aldo Vezzoni
Clinica Veterinaria Director
Via Massarotti 60/a - I-26100 Cremona Prof. Dr. Bruno Peirone
Fax +39-0372-20074 Univeristy of Turin
E-mail: aldo@vezzoni.it Animal Pathology Department
Faculty of Veterinary Medicine
Treasurer via Leonardo da Vinci 44
Dr. Chris Riggs I-10095 Grugliasco (TO)
Equine Hospital - Sha Tin Racecourse - Sha Tin Fax: + 39 011 6709061
PRC – Hong-Kong SAR E-mail:bruno.peirone@unito.it
Fax: + 852 2966 6891
E-mail: chrisriggs@netvigator.com Secretariat
CSM - Congress & Seminar EMOVA - European
Secretary Management Management Office
Dr. John Innes Industriestr. 35 for Veterinary Associations
Univeristy of Liverpool - Small Animal Hospital D - 82194 Gröbenzell Via Trecchi, 20
Division of Small Animal Studies Phone: ++49 8142 57 01 83 I-26100 Cremona
Crown Street - Liverpool L69 0EX Fax: ++49 8142 547 35 Phone: ++39 0372 403509
Fax: + 44 151 794 4304 Email: info@csm-congress.de Fax: ++39 0372 457091
E-mail: J.F.Innes@liverpool.ac.uk www.csm-congress.de E-mail: info@emova.it
http://www.esvot http://www.orthovetsupersite.org
5 • WVOC 2010, Bologna (Italy), 15th - 18th September
CONTENTS
Welcome to the WVOC 2010 by the ESVOT President ................................................7
Program Small and Large Animals ....................................................................................8
List of Speakers & addresses .............................................................................................25
List of Exhibitors and Sponsors .......................................................................................39
Abstracts: State of the Art Lecture......................................................................................41
Abstracts: Main Program Small Animals............................................................................47
Abstracts: Main Program Large Animals .........................................................................191
Abstracts: Pre-congress Seminars ......................................................................................257

Osteoarthritis............................................................................................................259
Fixin ..........................................................................................................................285
Sports medicine ........................................................................................................311
New strategies in pain control .................................................................................339
Small animal arthroscopy working group...............................................................357
Abstracts: In-depth Seminars .............................................................................................379

Challenging fractures ...............................................................................................381
Limb deformities ......................................................................................................399
Juvenile HD..............................................................................................................411
Biomedtrix: current concepts in total joint replacement ........................................425
Physiotherapy ...........................................................................................................439
Kyon news ................................................................................................................447
Case based ultrasound-arthroscopy correlation......................................................453
Surgical revisions in THR .......................................................................................457
Arthrex news ............................................................................................................469
Pathogenesis of cruciate disease ..............................................................................483
Limb alignment in patellar luxation........................................................................493
Distal limb trauma....................................................................................................507
Abstracts: Free Communications & Posters (Small & Large Animals) ...........................531
Abstracts: SCIVAC Congress............................................................................................703

Welcome to the WVOC 2010 by the ESVOT President

Dear friends of the WVOC,
In many ways it is hard to believe another 4 years has passed since the last
WORLD VETERINARY ORTHOPAEDIC CONGRESS in Keystone Colorado (USA). This
World Meeting is traditionally supported by two sister Societies ESVOT (European
Society for Veterinary Orthopaedics and Traumatology) and VOS (Veterinary
Orthopaedic Society). And it is with genuine pleasure that in their names, I wel-
come you from September 15th-18th, 2010 to the 3rd WVOC in Bologna (Italy).
There is no doubt that 2009 and the first months of 2010 have been on all our
minds at least for economic and financial reasons. One way to reduce financial
discomfort for veterinarians is to provide them with education in a reduced number of meetings with-
out a diminution in quality. That is one of the reasons why James L. Cook for VOS and myself for
ESVOT have signed two agreements in February 2009. One is to continue to support the organisation
every 4 years of a WVOC, alternating between North America and Europe, the other is to promote
exchange of information at different levels between these Societies.
The WVOC will commence with wet labs for large and small animal veterinarians organised at the Fac-
ulty of Veterinary Medicine of the University of Bologna. As an example three courses are organised
for the equine colleagues (stemcell and PRP lab, MRI reading lab and a lameness locator lab).
After dry labs and specific in depth seminars, such as in bovine orthopaedics, at the Congress Cen-
tre, the meeting will start and cover emerging discoveries in orthopaedics and traumatology as well
as innovative diagnostics and therapies. Many fine papers will be presented by the leading experts
in the respected fields. The small animal program will focus on “old favourites” such as the stifle,
elbow, patellar luxation and hip trauma while “newer” topics include revisions, distal limb trauma,
legislation & clinical research and tools to measure clinical success. For equine colleagues, In-depth
sessions on advanced imaging, critical review of biologic therapeutics, new technologies in lameness
diagnosis, subchondral bone injury and joint rehabilitation are organised.
This year’s program also continues the successful format of providing you with the best State of the
Art lectures with information all participants will benefit from. This year’s topics will be Tissue engi-
neering with mesenchymal stem cells in human orthopaedics - What do we know today? The fate of
the post-traumatic knee and Cartilage resurfacing with ACI and MACI: have they stood the test of
time?
This program is full of education opportunities. A Welcome Reception will be held in the oldest Uni-
versity of Europe located in the centre of Bologna. You can also attend a wine and cheese party dur-
ing the poster session and the Congress banquet on Saturday at the Palazzo de Rossi.
Finally, everyone working with the WVOC would like to make sincere thanks to all of our sponsors
and exhibitors. Without them, and of course without you, this wonderful event would not happen.
It would also not happen if from the beginning John Houlton, Chairman of the 3rd WVOC Commit-
tee, and his Scientific Committee composed of John Innes and Michael Schramme for ESVOT, Allison
Stewart and Liz Pluhar for VOS, and Bernadette van Ryssen for the arthroscopic group were not ded-
icated to offer you the best ever program in veterinary orthopaedics for bovine, equine and com-
panion animals. Special thanks must also go to Aldo Vezzoni, Local Organising Secretary, for making
the link between ESVOT and SCIVAC and for liaising with the Congress Organising Office.
As your host, it is an honour to welcome you in Bologna.
Prof. Olivier M. Lepage

President of ESVOT
Tuesday, September 14 th, 2010 - 5.00 pm
Pre-congress: Wednesday, September 15 th, 2010 - At the

From 7.30 am to 8.00 am BUSES FROM
SMALL ANIMAL EQUINE
Arthodesis wetlab Stemcell and PRP Lab
Lab/Time
Min 12 - Max 20 seats Min 8 - Max 16 seats

Chair: A. Piras Lecture 1 - Principles of treatment of tendinopathies
Faculty: D. Griffon, B. Peirone, A. Piras, R. Vannini (R. Smith)
General indications and basic general principles of
arthrodesis Lecture 2 - Regenerative medicine for tendon injuries
9:00 am Bone grafting techniques - autograft, allograft and DBM
Carpal arthrodesis - panarthrodesis vs partial arthrodesis
(R. Smith)
Partial carpal arthrodesis - surgical techniques
Pancarpal arthrodesis - surgical techniques
11:10 am Coffee break
Practical 1 - Partial (T-plate) and pancarpal arthrodesis Lecture 3 - Technique for bone marrow aspiration
(3.5/2.7 mm hybrid plate) and use of DBM (R. Smith)
Lecture 4 - Sampling handling and delivery (R. Smith)
11:30 am Lecture 5 - Stem cell implantation technique (R. Smith)
Lecture 6 - Post implantation rehabilitation (R. Smith)
Alternative biological therapies (R. Smith)
1:00 pm Lunch break

Partial tarsal arthrodesis - indications and surgical Group A: Live horse demonstration
techniques (S. Dakin)
2:00 pm Pantarsal arthrodesis - dorsal & medial plating: indications Group B: Injection practical
and surgical techniques (R. Smith)
Complications
3:30 pm Coffee break

Practical 2 - Calcaneoquartal arthrodesis and pantarsal Group A: Injection practical
arthrodesis (dorsal and medial plating) (R. Smith)
3:50 pm Group B: Live horse demonstration

(S. Dakin)
Final discussion
6:00 pm End of the Course End of the Course
From 6:00 pm BUSES FROM THE
SMALL ANIMAL EQUINE SCIVAC

OPENING TIME FOR REGISTRATION
e University of Bologna, Faculty of Veterinary Medicine

THE CONGRESS CENTER TO THE UNIVERSITY
EQUINE EQUINE
MRI Reading Lab Lameness LocatorTM Lab
Min 10 - Max 30 seats Min 8 - Max 18 seats

Lecture 1 - Principles of MRI: technique and artefacts Equine Gait Analysis
(N. Bolas) (K. Keegan)
Lecture 2 - MRI of the foot Part 1
(S. Powell) Introduction to Lameness Locator™
(K. Keegan)
Lecture 3 - MRI of the foot Part 2
(M. Martinelli)
Coffee break
Practical exercise: Image Reading MRI of the foot Lameness Locator™
(S. Powell, C. Judy, N. Bolas, T. Schulze, M. Martinelli) (K. Keegan, M. Schramme, A. Spadari)
Lunch break
Lecture 4 - MRI of the pastern, fetlock and metacarpal/metatarsal End of the Course
regions
(C. Judy)
Practical exercise: Image reporting

At 2:00 pm Bus from the University
(S. Powell, C. Judy, N. Bolas, T. Schulze, to the Congress Center
M. Schramme, M. Martinelli)
Coffee break
Practical exercise: Case discussion
(S. Powell, C. Judy, N. Bolas, T. Schulze,
M. Schramme, M. Martinelli)
End of the Course
UNIVERSITY TO THE CONGRESS CENTER
SIVE IN-DEPTH FREE COMMUNICATION

Pre-Congress: Wednesday, September

Europa Celeste Italia
SIVE SATELLITE OSTEOARTHRITIS SEMINAR FIXIN SEMINAR
Room/ SYMPOSIUM
Time Present and future in the diagnosis
and treatment of equine joint diseases:
Meeting with Wayne Mcllwraith
Chair: G. Ricardi Chair: J. Innes Chair: M. Petazzoni

Disease staging 9:00 Mechanics: Recent novelties
9:15 Advances in diagnosis of equine 9:00 Owner questionnaires - where and improvements (A. Urizzi)
9:40 Fractures in Dogs, Thoracic limb
joint disease are we? (J. Innes, USA) (A. Ferretti)
9:00 am 9:40 Force and pressure platforms 10:00 Fractures of the pelvic limb
(M. Conzemius) (S. Lozier)
10:20 Activity Monitors 10:20 Fracture repair in cats with
(D. Lascelles) implants for angular stability
fixin (B. Verdonck)
10:40 Discussion
11:00 am Coffee break and exhibition
11:15 Identification of new targets for Imaging OA 11:30 Concept of minimally invasive
joint therapy and their 11:30 MRI of cartilage: overview in fracture stabilization (D. Hulse)
relationship to treatment human and veterinary imaging 11:50 New Products
(C. Cook) (M. Petazzoni)
11:30 am 12:15 New concepts in the treatment 12:00 Quantitative MRI of canine 12:20 Sliding Humeral Osteotomy, my
of subchondral bone cysts of elbow joints experience with Fixin
the stifle and management of (J. Innes) (B. Verdonck)
other traumatic lesions of the 12:30 dGEMRIC of canine cartilage 12:40 Discussion
stifle (M. Conzemius)
1:00 pm Lunch break and exhibition

2:30 Current treatments Biomarkers and clinical trials 2:00 TPLO using the FIXIN plate
(conventional and biological) for 2:00 Serum biomarkers (K. Hayashi) (B. Beale)
equine joint disease 2:30 Gene microarray biomarkers for 2:20 CrCL repair technique (TTO)
OA (J. Cook) (R. Properzi)
2:00 pm 3:00 Metabolomics and osteoarthritis 2:40 cTTA (circular Tibial Tuberosity
(P. Clegg) Advancement) (M. Petazzoni)
3:30 Clinical trial design, statistical 3:00 TPLO in small dogs (A. Vezzoni)
issues and sample size 3:20 DPO and bilateral DPO
estimates (F. Brock) (A. Vezzoni)
3:40 Discussion
4:00 pm Coffee break and exhibition
®
4:30 Equioxx pain management Disease management 4:30 Non-Union Mal-Union
symposium with the (U. Reif)
participation of Wayne 4:30 Alternative (adjunctive)
4:50 Implant removal
McIlwraith by Merial/Equality analgesics for canine OA:
(U. Reif)
4:30 pm evidence based approach
At the end Merial will be pleased (D. Lascelles) 5:10 Corrective Osteotomies
to offer a cocktail to the 5:00 Stem cells – fact or fiction (M. Petazzoni)
delegates of the Symposium (M. Conzemius)
5:30 Discussion 5:30 Discussion
6:00 pm Adjourn

15 th, 2010 - At the Congress Center

Indaco Magenta Gialla Verde
SPORTS MEDICINE SEMINAR TTA DRYLAB SA HYBRID EXTERNAL TTO DRYLAB
FIXATION DRYLAB
Chair: J. Houlton Chair: S. Tepic Chair: G. Rovesti Chair: G. Robins

9:00 Injuries in working sheep- Biomechanics of TTA Instruments for use in small
dogs (S. Butterworth) animals Faculty: G. Robins, M. Owen,
9:30 Injuries in working dogs in (S. Tepic) Old and new concepts in linear
the southern hemisphere TTA Instruments & Implants (LEF) and circular external fixation J. Lapish
(R. Eaton-Wells) (S. Tepic) (CEF) for fracture stabilization
10:00 Gundog injuries Preoperative planning Use of the hybrid external fixation Concept of TTO
(J. Houlton) (HEF) for radius-ulna and tibia Decision making
10:30 Carpal injuries - can we ex- (R. Boudrieau)
stabilization Pre-operative planning
trapolate greyhound infor- Surgical Technique Use of HEF for humerus and
mation? (K. Johnson) (A. Vezzoni) femoral fracture
Coffee break and exhibition
11:30 Cruciate injuries - are Practical Exercise: planning Drylab: Preassembling of the TTO Instrumentation
performance dogs frame and basic techniques for TTO Step by Step
different? (E. Comerford) Practical Exercise on Plastic fracture reduction
Aftercare and outcomes
12:00 Shoulder injuries - is Bones
treatment a realistic Drylab: Frame application to the
option? (J. Cook) radius-ulna and tibia
12:30 Feeding for performance
(D. Morgan)
Lunch break and exhibition

2:00 Exercise associated Video of TTA Surgery with New hybrid configurations and Video presentation
collapse - metabolic commentary new materials
causes (M. Herrtage) Results and complications Practical exercise on plastic
2:45 Exercise induced (A. Vezzoni) Destabilization and bones
collapse (EIC) in labrador dynamization
retrievers (L. Ferasin)
3:15 Physiotherapy Drylab: Frame application to the
(M. Conzemius) humerus

4:30 Management of various Clinical Experience, Drylab; Frame application to the Complications
tendon/ligament injuries TTA vs. TPLO (R. Boudrieau) humerus Tips and tricks
in working/sporting dogs Patient selection for TTA Interactive evaluation of clinical
Discussion
(J. Dee) (A. Vezzoni) cases
5:10 Discussion Course debriefing
Meniscal release
Clinical Performance - Feedback
and Financial Matters
6:00 pm - End of the course
(S. Tepic)
Adjourn

Pre-Congress: Thursday,
Bianca Indaco Italia
Room/ EQUINE Seminar Seminar
Interactive Advanced Equine
Time Lameness and Imaging, Panel:
NEW STRATEGIES SA ARTHROSCOPY
Meeting with M. Martinelli (USA) IN PAIN CONTROL WORKING GROUP
Chair: M. Schramme Chair: D. Lascelles Chair: B. Van Ryssen and J.F. Bardet
9:00 Interactive lameness cases 1-5 9:00 Long-acting and tissue targeting 9:00 Welcome
Presentation and interactive NSAIDs: a pharmacokinetic and
discussion of interesting pharmacodynamic view Medial compartment disease
lameness and imaging cases (P. Lees)
(Dr. Mark Martinelli and panel) 9:10 Definition and occurrence of
9:30 Dose reduction or dose MCD
maintenance for NSAIDs (B. Van Ryssen)
administered to dogs with DJD- 9:20 Can we prevent MCD: personal
9:00 am associated pain? experiences with ulnar and
(D. Lascelles) humeral osteotomy
(J.F. Bardet - C. Grußendorf)
10:00 Long-term NSAID use for canine 10:00 The role of arthroscopy in the
OA: is it more effective? treatment of cartilage erosions
(J. Innes) (J. Cook)
10:15 How would I treat MCD
10:30 NSAIDs for feline DJD: new (J. Cook , M. Olivieri -
developments N. Fitzpatrick)
(D. Lascelles)
11:30 Interactive lameness cases 6-10 11:30 Neural ablation in control Clinical cases & studies
Presentation and interactive of pain
discussion of interesting (R. Wiley) 11:30 What went wrong? Diagnostic
lameness and imaging cases failures, bad outcome
(Dr. Mark Martinelli and panel) 12:00 Forelimb blocks in orthopaedics: Special cases: diagnostic
what is the evidence and what is challenges, unusual findings
new? Yves Samoy (1 case report),
(L. Novello) Hannes Kriegleder (2 case
reports), Massimo Olivieri
12:30 Pros and cons of epidurals with (clinical study on shoulder OCD
11:30 am local for orthopaedic surgery failure), José Real (2), Gian
(L. Novello) Luca Rovesti (2 case reports)

September 16 th, 2010 - Morning

Rossa Gialla Verde
IEWG WORKSHOP LOCKING PLATES DRYLAB SOP DRYLAB
Chair: H. Hazewinkel Chair: B. Peirone Chair: M. Ness
9:00 Welcome to the International Elbow Mike Kowaleski (US), Alessandro Piras (Ir), SOP - Design concept and rationale
Working Group Bruno Peirone (I)
(H. Hazewinkel) Range of application and clinical
Introduction to LCP experiences
9:10 Clinical and Radiological
investigation of the dog with elbow Pre-operative planning with LCP Biomechanics, modes of failure.
lameness SOP-SOP 1:4
(R. Palmer & M. Flückiger) Clinical applications of LCP
Intro to saw bones session
9:30 Arthroscopic and surgical treatment
of FCP/OCD
(R. Palmer)

11:30 Treatment of elbow incongruity and Laboratory Sawbones practical exercises
UAP
(B. Beale) Tibia proximal long oblique fracture SOP-TPLO - Design rationale
with envelope: fixation with 2 lag screws and application
12:00 Radiological screening according to and a 3.5 LCP as a neutralization plate
IEWG - new insights in MIPO fashion
(B. Tellhelm)
Humerus distal comminuted intra-articular
12:30 Osteoarthrosis treatment in dogs fracture: fixation with trans-condylar lag
(B. Peirone) screw and 2 LCPs as a bridging plate

Congress: Thursday,
Gialla
Room/ Italia Magenta
LA MAIN PROGRAM
Time SA MAIN PROGRAM SA MAIN PROGRAM
SUBCHONDRAL BONE INJURY
Chair: C. Riggs SA COMPLICATIONS THE STIFLE 1
2:00 Subchondral bone necrosis in Chair: T. Turner Chair: R. Vannini

the human knee and hip joints
(B. Eyes) 2:00 Multi-resistant bacteria: current 2:00 Tibial epiphysiodesis: results
status including management (A. Vezzoni)
2:30 Palmar Osteochondral Disease (D. Lloyd)
(POD) in the fetlock: definition, 2:15 Triple Tibial Osteotomy (TTO):
pathophysiology and diagnosis 2:30 Implant-associated infections results
(C. Riggs) (N. Ehrhart) (G. Robins)
3:00 Palmar Osteochondral Disease 3:00 Implant (surgeon???) failure 2:30 Tightrope: results
(POD): epidemiology, prevention (R. Boudrieau) (J. Cook)
and treatment
(P. Clegg) 3:30 Nosocomial (surgical) infections 2:45 Tibial epiphysiodesis:
(D. Lloyd) complications
3:30 MRI features of subchondral (A. Vezzoni)
bone injury in the 4:00 Negligence claims: can you
2:00 pm metacarpophalangeal and reduce them? 3:00 Complication of the TTO
metatarsophalangeal joints in (J. Houlton) operation
horses (G. Robins)
(M. Schramme)
3:15 Tightrope: complications
4:00 Current standards of treatment (J. Cook)
for subchondral cyst-like lesions
(A. Nixon) 3:35 Biomechanics of osteotomies
and meniscal surgery
(A. Pozzi)
3:55 Managing cruciate disease -

Where are we now?
(R. Boudrieau)
4:15 Discussion

5:00 pm Opening Ceremony - Room Europa
STATE OF THE ART LECTURE - ROOM EUROPA

5:30 pm Stem cell therapy for tissue repair: the stem cell-host interaction (Professor Frank Barry)
Chair: O. Lepage
6:30 pm Adjourn

September 16 th, 2010 - Afternoon
Rossa Bianca Indaco

IEWG WORKSHOP IN-DEPTH SEMINARS IN-DEPTH SEMINARS
cont. IN-DEPTH SEMINAR IN-DEPTH SEMINAR ON

ON CHALLENGING FRACTURES LIMB DEFORMITIES
Free communications:
2:00 Evaluation of incongruencies in the Chair: R. Palmer Chair: J. Tomlinson
canine elbow with FCP by a
standardised X ray method in dogs 2:00 Challenging acetabular (and pelvic) 2:00 CORA method of planning corrective
(I. Pfeil) fractures osteotomies as applied to veterinary
(R. Boudrieau) orthopaedics
2:30 Compartmental Bone Induction (D. Fox)
Stimulus (COBIS) for early treatment 2:30 Challenging elbow fractures
of Osteochondral disease (Coronoid (N. Fitzpatrick) 2:40 Normal bone angles and
disease, OCD) malalignment
(P. Kramers) 3:00 Challenging juxta-articular fractures (J. Tomlinson)
(A. Piras)
3:00 Film reading session: training how to 3:20 Oblique plane closing wedge
score according to IEWG 3:30 Challenging polytrauma cases osteotomy of the radius and ulna
[simultaneous translation in Italian] (R. Palmer) (D. Fox)
(M. Flückiger, E. Auriemma)
4:00 Challenging feline fractures including 4:00 Rear limb deformities
3:30 Results of screening programmes in the patella (J. Tomlinson)
relevant breeds (S. Langely-Hobbs)
(B. Tellhelm)
4:00 Closing remarks

Opening Ceremony - Room Europa

Stem cell therapy for tissue repair: the stem cell-host interaction (Professor Frank Barry)
Chair: O. Lepage
Adjourn

Congress: Friday,
Europa
SCIVAC/SIOVET Gialla Italia
Room/
SATELLITE SYMPOSIUM LA MAIN PROGRAM SA MAIN PROGRAM
Time
New trends in canine and feline ADVANCED IMAGING FACIAL TRAUMA
orthopaedics
Chair: C.M. Mortellaro Chair: M. Schramme Chair: N. Ehrhart
9:00 Elbow dysplasia - what are the 9:00 Pre purchase MRI of 9:00 Imaging facial trauma
new surgical options and are professional football players - (A. Brühschwein)
they successful? what have we learnt?
(B. Beale) (B. Eyes) 9:30 Mandibular and maxillofacial
fracture repair
9:30 Partial tears of the cranial 9:30 Prepurchase MRI of horses - (R. Boudrieau)
cruciate ligament - is it really definition and clinical
that controversial? implications 10:00 Skull fractures
9:00 am (B. Beale) (T. Schulze) (T. Turner)
10:00 How to improve meniscal 10:00 Contrast enhanced MRI in the 10:30 Treatment of large mandibular
visualization horse (C. Judy) defects
(A. Pozzi) (R. Boudrieau)
10:30 Low field MRI aspects of
10:30 Pearls and pitfalls of tibial palmar/plantar
osteotomy techniques metacarpal/metatarsal pain
(A. Pozzi) syndrome
(S. Powell)
Chair: C.M. Mortellaro ADVANCED IMAGING CONT. ELBOW
11:30 How to succeed in repairing 11:30 MRI of the equine stifle in a Chair: J. Cook
medial patellar luxations in clinical setting
small dogs and cats (C. Judy) 11:30 Correlation of the
(B. Beale) biceps/brachialis complex and
12:00 MRI case presentations and microfracture/fragmentation of
12:00 Managing MPL and CCL rupture round table the medial coronoid (D. Hulse)
in small and large breed dogs (B. Eyes, S. Powell,
11:50 Sliding Humeral Osteotomy:
(A. Pozzi) M. Schramme, T. Schulze and
11:30 am C. Judy)
current status and
complications (N. Fitzpatrick)
12:30 Pearls and pitfalls of
extracapsular techniques 12:20 Fragment removal: what’s the
(A. Pozzi) evidence? (B. van Ryssen)
12:40 Scoring canine Elbow Dysplasia
(ED) update recommendations
of the International Elbow
Working Group (IEWG)
(M. Flückiger)

Magenta Verde
Bianca Rossa
SA MAIN PROGRAM LA FREE COMM
IN-DEPTH SEMINARS SA FREE COMM
HIP TRAUMA ON FRACTURES
Chair: J. Innes IN-DEPTH SEMINAR Chair: W. Back Chair: J. Houlton

ON JUVENILE HD 9:00 Multiple Rib Fracture Repair in a 9:00 Clinical and biomechanical evalua-
Standardbred Foal (R. Rinnovati) tions after radial shockwave therapy in 8
9:00 Fractures of the femoral Chair: T. Dueland 9:20 Clinical Management of Fractured dogs presenting a severe hip osteoarthritis
head and neck 9:00 Early diagnosis of CHD Tibia in a Bull with the Use of Interlocking (S-G. Sawaya)
(U. Matis) and case selection (A. Nail without Reaming (R. Pandey) 9:15 Effect of extracorporeal shock wave
therapy on elbow osteoarthritis in dogs (D.
Vezzoni) 9:40 Evaluation of Biomarkers of Bone
Millis)
9:30 Acetabular fractures 9:25 CHD treated by JPS: Formation and Serum Minerals Variations
9:30 Kinematic analysis of stair and de-
for Prediction of Fracture Healing Versus
(L. Pluhar) median 7.6 year results cline slope walking of the pelvic limb in he-
Non-Union Process in Sheep as a Model althy dogs (D. Millis)
(T. Dueland) for Orthopedic Research (I. Dias) 9:45 Novel modular limb salvage endo-
10:00 Traumatic hip luxation in 9:50 Double Pelvic 10:00 Development of First Phalanx prosthesis for treatment of primary appen-
cats Osteotomy: mechanisms Osseous Cyst-Like Lesion after Fracture dicular tumors in dogs: short term outco-
(U. Matis) of action (D. Fox) Repair: Two Cases (F. Beccati) me (N. Fitzpatrick)
10:15 DPO: clinical results 10:20 Use of Hydroxyapatite Pin Coating 10:00 Constrained Total Knee Replace-
for the Prevention of Transfixation Pin ment, a novel prosthesis for salvage arthro-
10:30 Traumatic hip luxation in (A. Vezzoni) Loosening in Horses (T. Lescun) plsty in the dog and cat (N. Fitzpatrick)
dogs 10:40 Mechanical comparison 10:40 Evaluation of the Antibacterial 10:15 Treatment of radius-ulna and tibia
(R. Whitelock) of locked and non-locked Effect of Platelet Concentrates and other fractures using by circular external skeletal
plate fixation applied to Equine Blood Components against fixation system in 9 cats (S. Ulusan)
Methicillin Resistant Staphylococcus 10:30 Treatment of distal radius and ulna
rotational osteotomies in fracture in toy breed dogs by means of cir-
Aureus (J.U. Carmona)
cadaveric canine ilia cular external skeletal fixation: a retrospec-
(R. Palmer) tive study (L.A. Piras)

REVISIONS IN-DEPTH SEMINAR LA FREE COMM ON TENDONS SA FREE COMM
ON BIOMEDTRIX: Chair: O. Lepage Chair: J. Houlton
11:30 Single Injection of Autologous 11:30 Deformity reduction device (DRD
Chair: M. Conzemius CURRENT CONCEPTS IN TOTAL Platelet Rich Plasma (PRP) in Suspen- JIG): a new device for deformity correc-
JOINT REPLACEMENT sory Ligament Lesions in Horses: A Cli- tions (E. Panichi)
11:30 Revisions lecture stream nical Trial (A. Spadari) 11:45 Surgical correction of antebrachial
11:45 Histopathological Evaluation of deformity in a dog by means of a defor-
- "Failed tendon repair" 11:30 Total Hip Replacement mity reduction device (F. Cappellari)
Treatment of Superficial Digital Flexor
(J. Dee) (M. Kowaleski) Tendinitis with Autologus Mesenchymal 12:00 Pantarsal arthrodesis in 11 cats
Stem Cells in Horses (M.M. Dehghan) using a novel dorsal plate: technique and
12:00 Failed humeral condylar 11:50 Hip Replacement in 12:00 Use of Bone Marrow Mesenchy- complications (B. Stapley)
mal Stem Cells in Case of Excision of 12:15 The effect of titanium mesh in the
fracture fixation Small Patients management of segmental long bone de-
Superficial Flexor Tendon in the Horse:
(T. Turner) (B. Liska) a Case Report (E. Iacono) fect: an experimental study in a canine
12:15 Treatment of tibia fractures with model (S. Zoi)
12:30 Failed lateral 12:20 Total Knee Replacement half-circular external fixator in sheep 12:30 Treatment of significant bone de-
(Z. Adamiak) fects with distraction and compression
extracapsular suture (B. Liska) 12:30 Radial Shock Wave Therapy for using autogenous cortico-cancellous bo-
stabilization Tendon Healing and Tendon Adhesion ne graft in a dynamized external fixator
(B. Beale) 12:40 TATE elbow development Prevention: Characterisation of Surgi- construct in 4 dogs and 1 cat (T. Spar-
(R. Acker) cally Induced Goat Model of Tendonitis row)
(A. Kavaguchi De Grandis) 12:45 Minimally invasive plate osteosyn-
12:45 A Conservative Treatment Techni- thesis using two perpendicular oriented
que for Gastrocnemius Muscles Rupture plates for the treatment of tibial fractures
in Young Calves (7 Cases) (A. Bertuglia) in 23 cats (K. Ash)

Congress: Friday,
Europa Gialla
Room/ SCIVAC/SIOVET LA MAIN PROGRAM Magenta
Time SATELLITE SYMPOSIUM Biologic Therapeutics in Equine
SA MAIN PROGRAM
New trends in canine and feline orthopaedics - A critical review
orthopaedics of the evidence
Chair: F.M. Martini Chair: A. Stewart TOOLS TO MEASURE CLINICAL

SUCCESS
2:00 Feline hind limb lameness - 2:00 Critical review of the clinical use
what if it’s not a fracture or an of autologus conditioned serum Chair: K. Johnson
abscess? (ACS) also known as IRAP®
(S. Langley-Hobbs) (W. McIlwraith) 2:00 Limitations of force platform
gait analysis
2:30 Feline forelimb lameness - what 2:20 Critical review of the clinical use (M. Conzemius)
if it’s not a fracture or an of PRP and BMAC
abscess? (A. Nixon) 2:30 Validating subjective clinical
(S. Langley-Hobbs) outcome measures
2:40 Critical review of the clinical use (D. Lascelles)
3:00 Cat fracture quiz of Tiludronate in horses
(S. Langley-Hobbs) (O. Lepage) 2:55 Pressure mats
(E. Viguier)
3:45 Discussion 3:00 Critical review of Regenerative
Cell Therapy: fat-derived, tendon 3:20 Instrumented treadmill analysis
derived, synovial-derived cells (S. Steigmeier)
2:00 pm (A. Stewart)
3:20 Results of treatment of bone

marrow derived mesenchymal
stem cell therapy
(R. Smith)
3:40 Indications and results for intra-

articular use of stem cells
(W. McIlwraith)

The injured joint and post-traumatic osteoarthritis - What happens, what can we do for our patients?
4:15 pm (Professor Stefan Lohmander)
Chair: A. Vezzoni
5:00 pm POSTER SESSION (Chair O. Lepage) and WINE AND CHEESE
6:30 pm Adjourn

Italia Celeste Verde Rossa

SA MAIN PROGRAM IN-DEPTH SEMINARS IN-DEPTH SEMINARS SA FREE COMM
HOT TOPICS IN-DEPTH SEMINAR IN-DEPTH SEMINAR Chair: J. Houlton

ON PHYSIOTHERAPY ON KYON NEWS
Chair: R. Vannini 2:15 Risk for a dog to have
Chair: D. Marcellin-Little Chair: I. Pfeil simultaneous phenotypic
2:00 TPLO in the cat expression of both hip and elbow
(U. Matis) dysplasia. A study based on 1411
2:00 Companion animal 2:00 Various osteotomies for radiographic examinations of both
2:10 Concomitant medial rehabilitation - Were are treatement of elbow joints sent for official screening
patellar luxation we? dysplasia (T. Cachon)
and cranial cruciate An evidence-based (S. Tepic) 2:30 Assessment of the
ligament disease review osteoinductive properties of
(M. Kowaleski) (D. Marcellin-Little) 2:35 Elbow incongruency freeze-dried canine demineralized
2:20 The partially torn CrCl - measurements with X- bone matrix (DBM) (J. Innes)
3:00 Rehabilitation Ray and correction by 2:45 Determination of the
to debride or not platelets and TGF-beta1
(K. Bruecker) Engineering - What is it plated proximal concentration in the plasma rich
and how does it apply to ulnaosteotomie: clinical in growth factors of the canine
2:30 Cranial Closing Wedge
companion animal experience in 46 dogs species (I. Serra)
Osteotomy - When to do?
rehabilitation? (I. Pfeil) 3:00 Effect of Glupamid (N-
(B. Beale)
(D. Marcellin-Little) palmitoyl-D-glucosamine) on knee
2:40 CORA based leveling 3:10 Practical exercise on osteoarthritis pain (B. Costa)
osteotomy for treatment elbow 3:15 Evaluation of the effect of
of the CCL deficient stifle bovine demineralized bone matrix
(D. Hulse) and coralline hydroxyapatite on
radial fracture healing in rabbits
2:50 Ulnar osteotomies: when, (A. Aliabadi)
where, why, how? 3:30 Implantation of autologous
(L. Pluhar) bone marrow mononuclear cells
as a minimal invasive therapy of
3:00 Medial coronoid process legg.Calvé-Perthes’ disease in the
fragmentation in small dog (A. Crovace)
dogs 3:45 Genejammer enhances
(J-F. Bardet) adenoviral BMP-2 gene delivery to
canine bone marrow-derived
3:10 Old dog FCP mesenchymal stem cells
(B. Van Ryssen) (T. Smith)
3:20 Acute FCP with normal
elbow (B. Beale)
3:30 Discussion
The injured joint and post-traumatic osteoarthritis - What happens, what can we do for our patients?
(Professor Stefan Lohmander)
Chair: A. Vezzoni
POSTER SESSION (Chair O. Lepage) and WINE AND CHEESE
Adjourn

Congress: Saturday,
Europa
Gialla
Room/ SCIVAC/SIOVET Magenta Italia
LA MAIN PROGRAM
Time SATELLITE SYMPOSIUM Lameness Diagnosis and SA MAIN PROGRAM SA MAIN PROGRAM
New trends in canine treatment - Recent progress
and feline orthopaedics
Chair: M. Petazzoni Chair: R. Smith DISTAL LIMB TRAUMA ELBOW 2

Chair: B. van Ryssen
9:00 The orthopedic
9:00 How subjective is the Chair: B. Peirone 9:00 Iowa State TER: results
examination - tips and complications
detection of lameness
and tricks to a 9:00 Imaging the foot (M. Conzemius)
and nerve block
successful diagnosis (A. Brühschwein) 9:30 TATE™ Total Elbow
results in horses?
(R. Vannini) Replacement: Results
(R. Smith) 9:30 Limb salvage
9:30 Conservative 9:30 Analysis of gait procedures for and Complications
management and patterns in sound and trauma: where are we
(L. Déjardin)
lame horses 10:00 Incomplete
9:00 am external coaptation of now?
ossification of the
fractures (K. Keegan) (N. Ehrhart) humeral condyle:
(S. Langley-Hobbs) 10:00 Lameness diagnosis
10:00 Digital amputation in outcomes and
with the aid of complications
10:00 Arthrodesis principles performance dogs
ground reaction force (R. Whitelock)
(S. Langley-Hobbs) analysis
(R. Eaton-Wells)
10:30 Radio-ulnar
10:30 Complications of (M. Weishaupt) 10:30 Digits injuries incongruity in dogs
tarsal and carpal 10:30 The Lameness (A. Piras) with medial
arthrodesis Locator compartment disease
(R. Vannini) (K. Keegan) (D. Griffon)

Chair: M. Petazzoni 11:30 Mechanics of PATELLAR LUXATION LEGISLATION
orthopaedic shoeing
11:30 Fracture planning in in horses - what is Chair: A. Vezzoni Chair: M. Ness
cats the evidence?
(R. Vannini) (E. Eliashar) 11:30 CT and decision- 11:30 EU legislation: what
making clinicians need to
12:00 Management of 12:00 The “ice shoe” to (D. Griffon) know and how to stay
cruciate Ligament prevent and treat out of trouble
Rupture in small equine laminitis 11:50 Corrective osteotomy (S. Houlton)
11:30 am breed dogs and cats (L. D’Arpe) for patellar luxation:
(R. Vannini) outcomes and 11:50 Clinical studies and
complications practice: ethical and
12:30 Distal radial fractures (M. Kowaleski) legal perspectives
in toy breed dogs (J. Cook)
(R. Vannini) 12:10 Complications of
patellar luxation 12:10 Discussion
surgery
(S. Langley-Hobbs)
12:30 am ESVOT General Meeting - Room Italia


Verde
Celeste Bianca Rossa
LA FREE COMM
IN-DEPTH SEMINARS IN-DEPTH SEMINARS SA FREE COMM
ON JOINTS
IN-DEPTH SEMINAR ON IN-DEPTH-SEMINAR Chair: A. Spadari Chair: J. Houlton

9:00 Cytotoxicity of Contrast Media 9:00 Orthogonal evaluation of changes
CASE BASED ULTRASOUND- ON SURGICAL REVISIONS in tibial plateau angles after TPLO in the
Iohexol for Arthrography on Bovine
ARTHROSCOPY CORRELATION IN THR Chondrocytes (J. Park) cranial cruciate deficient stifle in dogs. A
9:20 The Regulation of Superficial ten-year review (N. Vecchio)
9:15 Palpation and dorsal acetabular
Chair: J. Cook Chair: A. Vezzoni Zone Protein/Lubricin Expression in
rim radiographic view for early detection
Equine Articular Chondrocytes of canine hip dysplasia: a prospective
(M. Stewart) study (M. Gatineau)
9:00 Ultrasound joint 9:00 Revision of the cemented 9:40 Ovine Anterior Cruciate 9:30 The use of canine scrotum as a
evaluation THR Ligament (ACL) Reconstruction With mesh graft to cover skin defects
(C. Cook) (B. Liska) a New Bioactive Device: In-Vivo (V. Grigoropoulou)
Study (V. Viateau) 9:45 Tibial tuberosity fracture as a
10:00 TLR Expression and Activities complication of tibial tuberosity
10:00 Arthroscopy joint 9:30 Revision of BFXTM Total in Articular Chondrocytes (M. advancement. Risk factors and
evaluation Hip Replacement Stewart) management (I. Calvo)
(C. Cook) (M. Kowaleski) 10:20 The Use of Xylazine 10:00 Prospective evaluation of the
Hydrochloride (Rompun®) in the leipzig stifle distractor in 64 cases - A
multicentric study (P. Winkels)
Analgesic Protocol for Claw 10:15 Ostrich tendon (New xenogenic)
10:00 Revisions of Kyon THR Treatment in Lateral Recumbency on transplantation in rabbits model
(A. Vezzoni) a Surgical Tipping Table in Lame (G.A. Kojouri)
Dairy Cows (A. Rizk) 10:30 Study of the effect of
10:30 Round Table Discussion 10:40 Biochemical characteristics of hydroxyapatite on fracture healing of
the equine autologous conditioned diabetic rats (H. Z. Moslemi)
plasma (ACPTM) (J-C. Ionita) 10:45 Discussion

IN DEPTH-SEMINAR IN-DEPTH SEMINAR ON Chair: J. Houlton
ARTHREX NEWS PATHOGENESIS OF CRUCIATE 11:00 Long term follow-up of
lumbosacral distraction-fusion using
Chair: B. Beale DISEASE combined dorsal and ventral fixation
11:30 Use of ACP in dogs including a novel intervertebral
(J. Cook) Chair: M. Conzemius spacer device (23 dogs)
11:40 Canine Unicompartmental (N. Fitzpatrick)
Elbow (CUE) arthroplasty 11:30 Pathogenesis of cranial 11:20 Geometric change of the
in dogs (J. Cook) humeroradial and humeroulnar
cruciate ligament disease articulation following dynamic
11:50 Clinical update on in the dog - genetics and proximal ulna osteotomy in dogs
meniscal repair (A. Pozzi) anatomy affected by radioulnar incongruence
12:00 A biomechanical (H. Werner)
perspective to current (M. Conzemius)
11:50 Update on canine 11:40 Computerized measurements of
extracapsular stabilization radiographic anatomical parameters
techniques (A. Pozzi) cruciate ligament of the elbow joint of Bernese
12:10 Isometric suture disease: hormones, mountain dogs (S. Stein)
placement for stabilization immunology and trauma 12:00 Effect of articular design on
of the CCL deficient stifle (E. Comerford) rotational contraint of two unlinked
(D. Hulse) 12:15 Inflammation and canine total elbow prosthesis
12:20 Arthrex swivel lock suture (L. Déjardin)
anchor for CrCL and MCL Bacteria 12:20 Discussion
repair (B. Beale) (K. Hayashi)
ESVOT General Meeting - Room Italia


Congress: Saturday,
Europa
SCIVAC/SIOVET Gialla Italia
Room/
SATELLITE SYMPOSIUM LA MAIN PROGRAM SA MAIN PROGRAM
Time
New trends in canine and feline JOINT REHABILITATION LOCKING PLATES
orthopaedics
Chair: A. Vezzoni Chair: O. Lepage Chair: B. Peirone
2:00 Arthroscopic-assisted 2:00 An update on Osteoarthritis 2:00 Advanced Locking Plate System
arthrotomy… ride the wave of (S. Laverty) (ALPS): rationale, biomechanics
the future and early clinical use
(B. Beale) 2:30 Is there a role for arthroscopy in (R. Boudrieau)
the management of OA?
2:30 Medial Patellar Luxation in large (W. McIlwraith) 2:30 The Synthes Locking plate
dogs....what is the difference? (R. Vannini)
(B. Beale) 3:00 Cartilage resurfacing in the
horse - Reality or fiction? 3:00 Locking plates: SOP
3:00 Introduction to minimally (A. Nixon) (M. Ness)
invasive plate osteosynthesis
(A. Pozzi) 3:30 Indication for and results of 3:30 The Fixin system
micropicking or mosaic (M. Petazzoni)
3:30 Orthopedic Infections… what is arthroplasty in human joint
new? resurfacing 4:00 Locking plates - why do we
(B. Beale) (T. Briggs) need them?
2:00 pm (K. Johnson)
4:00 Why did this fracture case go 4:00 A critical review of
wrong? neutraceutical use for
(B. Beale) osteoarthritis in the horse
(S. Laverty)

5:00 pm Cartilage resurfacing with ACI and MACI: have they stood the test of time? (Professor Tim Briggs)
Chair: J. Innes
6:00 pm End of the Congress
7:00 pm BUSES FROM THE CONGRESS CENTER TO BANQUET

Magenta
Bianca Verde Rossa
SA MAIN PROGRAM
IN-DEPTH SEMINARS IN-DEPTH SEMINARS SA FREE COMM
STIFLE 2
Chair: B. van Ryssen IN-DEPTH SEMINAR IN-DEPTH SEMINAR Chair: J. Houlton

ON LIMB ALIGNMENT ON DISTAL LIMB TRAUMA
2:00 Clinical assessment of IN PATELLAR LUXATION 2:00 The complication rate of the
Helica-hip-endoprosthesis is 8.1% in
the stifle joint Chair: A. Piras 37 cases (G. Viefhues)
(M. Ness) Chair: M. Kowaleski 2:15 Influence of locking bolt
2:00 Extreme fracture repair: location (metaphyseal vs. diaphyseal)
2:30 Ultrasonography of the 2:00 Introduction the Wise on the mechanical properties of an
canine stifle joint (M. Kowaleski) (J. Dee) interlocking nail in the canine femur
(C. Burns)
(C. Cook) 2:30 Evaluation of bone healing with
2:10 Femoral and tibial 2:30 Fracture fixation - the using a xenogenic bone plate and
3:00 Computed tomography deformities associated weird screws in a canine fracture model
(CT) of the canine stifle with patellar luxation (N. Fitzpatrick) (N.S. Kim)
(M. Tivers) (frontal plane, sagittal 2:45 In-vivo biomechanical
evaluation of a novel angle-stable
plane, torsion) 3:00 Extreme fracture repair:
interlocking nail design in a canine
3:30 MRI of the canine stifle (M. Petazzoni) the Wild tibial gap fracture model (L. Déjardin)
joint (A. Piras) 3:00 A biomechanical evaluation of
(C. Cook) 2:35 Radiographic planning of the effect of three drop wire
femoral and tibial 3:30 Use of the Fixin locking configuration on the stiffness of
4:00 In vivo kinematics of the deformities: CORA system for carpal and single ring external fixator construct
(D. Lewis)
canine stifle method tarsal arthrodesis 3:15 Comparative evaluation of two
(P. Böttcher) (M. Petazzoni) (M. Petazzoni) composite materials for use in
circular and hybrid external fixation
3:40 Computed tomographic 4:00 Stress fractures in the (G.L. Rovesti)
planning of distal femoral high performance 3:30 Effect of screw insertional
torque on push-out strength in 5
ostectomy athletes: when advanced different angular stable systems (A.
(M. Kowaleski) diagnostic imaging can Boero Baroncelli)
tell us a story 3:45 Assessment of maxillofacial
3:35 Femoral corrective (M.S. Bergh) fractures in the dog using cone beam
osteotomy: Technique computed tomography: an
experimental ex-vivo study (B. van
(K. Bruecker)
Thielen)
4:00 Postoperative analgesic
4:40 Tibial corrective efficacy of meloxicam compared to
osteotomy for combined tolfenamic acid in cats undergoing
MPL and CrCL rupture orthopaedic surgery (P. Murison)
(M. Kowaleski) 4:15 Preclinical safety of
robenacoxib in cats (J. King)

Cartilage resurfacing with ACI and MACI: have they stood the test of time? (Professor Tim Briggs)
Chair: J. Innes
End of the Congress
BUSES FROM THE CONGRESS CENTER TO BANQUET

LIST OF SPEAKERS & ADDRESSES

ACKER, RANDY large body of new data in groundbreaking pre- gating fractured central tarsal bones of racing
DVM, SVAC, Box 177 clinical studies, and has lead to a phase of clinical greyhounds at The Ohio State University. Her
Ketchum, Idaho 83340 testing of mesenchymal stem cells in human tri- clinical and research interests include rac-
After graduation from Colorado State als. In addition he has developed new techniques ing/athletic injuries, total joint arthroplasty, angu-
University in 1979 Randy Acker moved to Sun for the isolation, characterization and commit- lar limb deformity correction, and treatments for
Valley to start a career with the Sun Valley Ani- ment of bone marrow stem cells. He currently cranial cruciate ligament disease in the dog.
mal Center. His focus has been in surgery with a leads the FP7-funded PurStem project, focusing
particular emphasis on canine orthopedics. By on the advanced characterization and preparation BÖTTCHER, PETER
attending courses over the years he has obtained of human MSCs, and is a partner in the ADIPOA DVM, DipECVS
the skills to achieve excellence in orthopedic surg- and GAMBA initiatives.
European Veterinary Specialist in
eries. Courses attended include cruciate ligament Surgery, Fachtierarzt für
repair (TPLO, TTA, and others), hip replace- BEALE, BRIAN
Kleintierchirurgie, Klinik für Kleintiere
ment (BioMedtrix and Kyon), bone plating, DVM, DACVS
Universität Leipzig, An den Tierkliniken 23
arthroscopy, external fixation, and many others. Gulf Coast Veterinary Specialists
He has been the instructor for Kyon hip, and D-04103 Leipzig (Germany)
1111 West Loop South #160
TATE Elbow courses. His interest in orthopedics Dr. Böttcher graduated at Munich in 1996 and
Houston, TX 77027, USA started working on his thesis, which was dedicated
has led him to two patents, invitations to lecture Dr. Brian Beale is a board-certified surgeon with
worldwide, and the development of the TATE to 3D-image rendering in veterinary anatomy. In
Gulf Coast Veterinary Specialists in Houston, 1998 he performed a surgical Internship and
Elbow. The elbow was developed and named Texas (www.gcvs.com). He joined them in 1992
after his yellow lab Tate who suffered from severe entered a standard Small Animal Residency pro-
after completing his residency and serving on the gram of the ECVS under the supervision of Prof.
elbow arthritis. Randy has many long term faculty of the University of Florida’s College of
employees, two DVM brothers, and two DVM Roberto Köstlin one year later. Having finished his
Veterinary Medicine. He also attended the Uni- residency in 2002 he moved to the University of
daughters making the practice a family business. versity of Florida’s College of Veterinary Medi-
The clinic moto is bring your pet to work and Leipzig where he became a Diplomate of the ECVS
cine. Dr. Beale has a special interest in arthroscopy, in 2004. In 2010 Dr. Böttcher qualified as a profes-
treat patients like they are your own pet. minimally-invasive surgery, fracture repair, treat- sor of small animal surgery. Actually, the Universi-
ment of arthritis, and pain management. Dr. Beale
BARDET, JEAN-FRANÇOIS ty of Hannover proposed him the call for Full Pro-
has authored many book chapters and scientific
fessor for Small Animal Surgery. Since 2007 Dr.
DVM, Ms, DECVS articles. He is also a coauthor of two veterinary
Böttcher has been the chief surgeon at the Depart-
32 Rue Pierret, 92200 Neuilly sur textbooks - Small Animal Arthroscopy and The
ment of Small Animal Medicine at the University
Seine - France Pet Lover’s Guide to Canine Arthritis and Joint
of Leipzig, with a strong interest in orthopaedics.
1975: Docteur Vétérinaire, Ecole Nationale Vétéri- Problems. Dr. Beale is a frequent invited speaker
His research is focused on joint disease, especially
naire de Toulouse to local, national and international meetings and
of the elbow and stifle joint. Another more gener-
1977-1981: Resident and Chief Resident, Ohio has lectured frequently in Europe, Asia and Latin
al interest of Dr. Böttcher is joint resurfacing, espe-
State University, Columbus Ohio, U.S.A. America. He is a past-president of the Veterinary
cially osteochondral transfer procedures. Recently
Master of Sciences, Ohio State University, U.S.A. Orthopedic Society, past-president of the Gulf
he has received grants of the “Gesellschaft zur
Position held: 1981-1982: Assistant professor of Coast Veterinary Foundation and active in the
Förderung Kynologischer Forschung e.V.” (gkf)
Orthopaedics, Ohio State University. American College of Veterinary Surgeons. He can
and the University of Leipzig, which allowed him
1982-1983: Post-doctoral graduate, Colorado be contacted at drbeale@gcvs.com or 713-693-
to start a research project dedicated to in-vivo mea-
State University, U.S.A. 1122. Dr. Beale’s current practice is devoted to the
surement of 3D joint kinematics.
1983-1986: Associate Professor of Surgery, care of pets with orthopedic, musculoskeletal and
Maisons-Alfort, Paris, France. arthritic disorders. Dr. Beale uses arthroscopy to
1986-Present - Surgical referral practice: 32 rue treat many disorders of the shoulder, elbow, car- BOUDRIEAU, RANDY
Pierret, 92200 Neuilly-Sur-Seine, France. pus, hip, knee and hock. Minimally-invasive tech- DVM, Diplomate ACVS, ECVS
Societies: Founder, President & Past President of the niques are used to stabilize joints and fractures, Professor of Surgery
European Society of Veterinary Orthopaedics and thus reducing pain, speeding recovery and Section Head - Small Animal
Traumatology (E.S.V.O.T.). Past-president of improving the long term outcome of the pet. Gulf Surgery, Department of Clinical Sciences,
the French Society of Veterinary Surgery. Member Coast Veterinary Specialists (GCVS) is a referral- Cummings School of Veterinary Medicine, Tufts
of the American Society of Orthopaedic Research. only hospital located in the Galleria area of Hous-
ton. The doctors of GCVS work closely with a
University, North Grafton, Massachusetts; USA
AO Vet. Member. Member of the Société Française
Dr. Boudrieau is the Section Head of Small Ani-
d'Orthopédie et de Traumatologie. Past-president pet’s primary care veterinarian to provide the best
mal Surgery and Professor of Surgery in the
of the Société Vétérinaire Pratique. Past-president of and most advanced veterinary care possible. Vet-
Department of Clinical Sciences, Cummings
Confraternelle des Vétérinaires de la Région erinary specialists are available in the following
School of Veterinary Medicine at Tufts Universi-
Parisenne. Over 250 publications and 1200 confer- disciplines: Orthopedic surgery, Soft Tissue and
ty, North Grafton, Massachusetts; USA. His pri-
ences all around the world. Oncologic Surgery, Neurologic Surgery, Neurol-
ogy, Physical Rehabilitation, Avian and Exotic mary areas of interest includes: joint replacement,
Medicine, Physical Rehabilitation, Radiology, cruciate ligament disease, fracture healing, and
BARRY, FRANK maxillofacial trauma. Dr. Boudrieau obtained his
Regenerative Medicine Oncology, Dermatology, Internal Medicine and
Critical Care. Dr. Beale is also a diplomate with veterinary degree from Washington State Univer-
InstituteNational Centre for sity in 1978. His post-graduate training included
the American College of Veterinary Surgeons.
Biomedical Engineering Science (www.acvs.org). When not practicing veterinary an internship at the Rowley Memorial Animal
National University of Ireland, Galway medicine, Dr. Beale enjoys tennis, golf and all Hospital in Springfield, Massachusetts, two years
Frank Barry is Professor of Cellular Therapy at outdoor sports. He loves to travel and meet new in private practice in Seattle, Washington, and
the National University of Ireland, Galway, people around the world. subsequently a surgical residency at The Ohio
Director of the University’s National Centre for State University from 1981-1984. Dr. Boudrieau’s
Biomedical Engineering Science (NCBES) and a academic career began at Tufts University in
BERGH, MARY SARAH
principle investigator at the Regenerative Medi- 1984 at the Angell Memorial Animal Hospital in
cine Institute (REMEDI) Here he directs a large
DVM, MS, Diplomate ACVS Boston, Massachusetts and continued at North
group of researchers who focus on the develop- Assistant Professor, Orthopedic Grafton, Massachusetts from 1985 to the present.
ment of new repair strategies in stem cell therapy Surgery, Iowa State University He became a Diplomate of the American College
and gene therapy in orthopaedics and spinal cord College of Veterinary Medicine of Veterinary Surgeons (ACVS) in 1987 and
injury. REMEDI includes a GMP stem cell man- Dr. Mary Sarah Bergh is an Assistant Professor of the European College of Veterinary Surgeons
ufacturing facility for the preparation of stem Orthopedic Surgery at Iowa State University (ECVS) in 2007. He is an active member in a
cells for use in human clinical studies. Frank College of Veterinary Medicine in Ames, Iowa, number of veterinary orthopedic organizations,
Barry has contributed to the fields of tissue engi- USA. Her training includes veterinary school at including ACVS, ECVS, AO, ESVOT and VOS,
neering and regenerative medicine by developing University of Wisconsin, internship University of the latter of which he also served as President. He
an innovative and successful cellular therapy for Pennsylvania, and small animal surgical residen- also is a reviewer for a number of veterinary jour-
the treatment of acute joint injury and arthritic cy at The Ohio State University. She earned her nals including: Am J Vet Res, J Am Vet Med Assoc,
disease. This has included the generation of a Masters of Science degree in 2008 while investi- Vet Comp Orthop Traumatol and Vet Surg.
BRIGGS, TIM rection), minimally invasive surgery (such as over twenty peer reviewed papers, three BSAVA
MD(Res), MCh(Orth), FRCS laparoscopy) and peri-operative pain manage- Manuals and co-authored an orthopaedic text
Consultant Orthopaedic Surgeon ment. Wobbler syndrome of Doberman pinsch- book and Steve is a past Chairman of the British
ers is his special area of expertise and interest. He Veterinary Orthopaedic Association.
Joint Head of Training, RNOH & has authored numerous articles and book chap-
Joint Medical Director ters on Wobbler syndrome, treatment of inter- CLEGG, PETER
Royal National Orthopaedic Hospital vertebral disk degeneration and spinal fracture MA VetMB PhD DipECVS
Brockley Hill, Stanmore, Middx. HA7 4LP management. He has been an invited speaker CertEO MRCVS
Professor Briggs is Consultant Orthopaedic Sur- throughout the United States, Latin America,
geon at the Royal National Orthopaedic Hospital Europe, Asia and the South Pacific on a variety
Deputy Head of School, School of
Trust and also Medical Director. He qualified in of topics in orthopedics, neurosurgery and pain Veterinary Sciences, Faculty of Health and Life
1982 obtaining Honours in Surgery and a num- management. He is an active participate in work- Sciences, The University of Liverpool,
ber of prizes. He was appointed at the RNOH as ing groups on elbow dysplasia, shoulder injuries, Leahurst, Neston, CH64 7TE, UK
a Consultant in 1992. He is on the Editorial advanced techniques in small animal arthroscopy Peter Clegg qualified from the University of
Board of the Journal of Bone and Joint Surgery, and cranial cruciate ligament repair. Dr. Bruecker Cambridge in 1987 and then spent 4 years in
Journal of Arthroplasty and was Editorial Secre- was the first to offer TPLO surgery, TTA equine practice in Leicestershire. In 1991 he
tary of the British Orthopaedic Association. He is surgery, cementless hip replacement, arthroscopy moved to the Royal Veterinary College, Univer-
also a member of Council of the BOA. His special and laparoscopy to owners of pets in Ventura, sity of London where he undertook a three year
interests are reconstruction of the lower limb, as Santa Barbara and San Luis Obispo Counties, as residency in equine surgery. Between 1994 and
well as sports injuries of the knee and orthopaedic well as to the State of Hawaii. He has been an 1997 he undertook a PhD into aspects of cartilage
oncology. He has a special interest in autologous innovator in the development of new surgical degradation at the University of Liverpool. Since
chondrocyte transplantation around the knee and techniques and orthopedic implants. Dr. Brueck- 1997 Peter has remained at the University of Liv-
is one of the clinical leaders in this field in the er is a past program chair of Neurosurgery for erpool, being firstly lecturer then senior lecturer in
U.K. He has an interest in sports injuries and is the American College of Veterinary Surgeons equine orthopaedics. Since 2005 he has been Pro-
one of the surgeons for the Arsenal men’s and and a past program chair for the technician professor of Equine Surgery at Liverpool where he
Arsenal lady’s football clubs. He has a strong aca- gram for the American College of Veterinary Sur- combines clinical interests in equine orthopaedic
demic interest and publishes widely. geons. He served as the orthopedics program and gastrointestinal surgery with managing a
director for 2004 and 2005 for the American Col- large research group. He became a Diplomate of
BROCK, FIONA lege of Veterinary Surgeons. He was also pro- the ECVS in 1999. His research interests are
BSc. (Hons) MSc. CStat. CSci. gram director for orthopedics, pain management focussed in the area of tendon and cartilage biol-
and anesthesia for the 2006 American Veterinary ogy with projects relating to both man and the
Biometrician horse being undertaken within his group. Out-
Medical Association annual symposium. He is a
Global Development & Operations, past Executive Board Member for Veterinary side work he spends his life driving 4 daughters
Vet Medicine R&D, Pfizer Animal Health Orthopedics Society (2004-2007). Due largely to to numerous sporting activities and attempting to
After growing up in the Netherlands, Fiona com- his commitment to education and training, Dr. continue playing any sport himself which his
pleted her BSc in Statistics at the University of Bruecker was selected as the Veterinarian of the knees allow him to participate in. When time
Bath, followed by her MSc in Statistics with Year for the State of California by the California allows he would rather be either climbing up, or
Applications in Medicine at the University of Veterinary Medical Association in 2004. skiing down big mountains somewhere a long
Southampton. Since 2004, she has been the lead way from home!
statistician for Pfizer Animal Health (PAH) in BRÜHSCHWEIN, ANDREAS
Europe, prior to which her expertise had been in COMERFORD, EITHNE
Human Health R&D. She has over 13 years expe-
Dr. med. vet., Dipl. ECVDI
Clinic of Small Animal Surgery & MVB PhD CertVR CertSAS
rience as a qualified biostatistician, having worked
for two top pharmaceutical companies in Switzer- Reproduction - Head: Prof. Dr. PGCertHE DipECVS MRCVS
land and the UK, two CROs and a specialist Ulrike Matis, Dipl. ECVS - Centre of Clinical RCVS specialist in Small Animal
health authority of the NHS in the UK. When Veterinary Medicine, Veterinary Faculty, Surgery (Orthopaedics), ECVS specialist in
she’s not crunching numbers and being consulted Ludwig-Maximilians-University Munich, Small Animal Surgery, Senior Lecturer in SA
in the design & conduct of clinical trials she is a Veterinärstr. 13, D-80539 Munich, Germany Orthopaedics - School of Veterinary Science,
keen volleyball player. She is a qualified referee Andreas Brühschwein graduated from the Lud- Leahurst Training Campus, Chester High Rd,
for both indoor and beach volleyball and is cur- wig-Maximilians-University Munich in 2001. Neston, CH64 7TE - UK
rently training as a national technical official for After his doctoral thesis (“MR- and CT-anatomy Eithne graduated from the Faculty of Veterinary
volleyball in the 2012 Olympic Games. of the canine carpus with special regard to soft tis- Medicine, UCD, Ireland in 1995. From 1995-
sue structures”) at the Clinic of Small Animal 2006, Eithne worked at the University of Bristol
BRUECKER, KENNETH Surgery and Reproduction in Munich he per- and was awarded her PhD on the pathogenesis of
DVM, MS, DipACVS formed an alternative residency programme of cranial cruciate ligament disease in 2003. From
Board Certified American College of the European College of Veterinary Diagnostic December 2002 to October 2006 she was a lec-
Veterinary Surgeons, Veterinary Imaging in 2006 with stays at veterinary teaching turer in Small Animal orthopaedics at the Uni-
hospitals in Washington State University Pull- versity of Bristol, during which time she devel-
Medical and Surgical Group, Inc. (VMSG),
man (USA), Vetsuisse Faculty Bern (CH) and oped her interest in cell sources for the tissue
2199 Sperry Avenue University Leipzig (D). Dr. Brühschwein passed engineering of ligament. Eithne was appointed to
Ventura, CA 93003-7426 USA the radiology board diploma (ECVDI) in 2009 her current post as Senior Lecturer in Small Ani-
A San Fernando Valley native, Dr. Bruecker and is a faculty member of the Clinic of Small mal Orthopaedics at the University of Liverpool
attended Pierce College then received his bache- Animal Surgery and Reproduction of the Lud- in October 2006. She was awarded the European
lors degree in Animal Science from the Universi- wig-Maximilians-University Munich. Diploma in Small Animal Surgery in 2009. Her
ty of California at Davis. He then entered the main clinical interests include management of the
University of California at Davis, School of Vet- trauma patient and cranial cruciate ligament dis-
BUTTERWORTH, STEVE
erinary Medicine, graduating in 1983. After one ease (CCLD). Research interests include investi-
year of general small animal practice in San Fer- MA VetMB CertVR DSAO
gation of novel techniques for management of
nando, Dr. Bruecker completed an additional MRCVS - Weighbridge Referral canine CCLD as well as the metabolism of the
year of clinical internship at the West Los Ange- Centre, Kemys Way, Swansea extracellular matrix constituents present in the
les Veterinary Medical Group. He received his Enterprise Park, Swansea SA6 8QF UK canine cruciate ligament complex.
master of science degree at the completion of a Steve qualified from Cambridge in 1986, spent a
three year surgical residency at Colorado State year as House Surgeon at Bristol Veterinary CONZEMIUS, MICHAEL
University and moved back to Ventura County School, an assistant in general practice for two
DVM, PhD, Diplomate ACVS
in 1988 to establish specialty veterinary care. Dr. years and then a lecturer in Small Animal
Bruecker is the Medical Director and Chief of Orthopaedics at Bristol Veterinary School for 6 Endowed Professor, Veterinary
Surgery at VMSG. Dr. Bruecker has also been years. In 1995 he established Weighbridge Refer- Clinical Sciences, College of
providing regular surgical support for practices in ral Service in Swansea and has been there ever Veterinary Medicine, University of Minnesota
the state of Hawaii since 1996. A Board Certified since. He holds the RCVS Certificate in Veteri- 1352 Boyd Avenue, St. Paul, MN 55108
Surgeon, Dr. Bruecker’s primary clinical interests nary Radiology and Diploma in Small Animal Dr. Conzemius received his DVM and PhD in
are spinal surgery, sports medicine/orthopedics Orthopaedics, and has been an RCVS Recog- Biomedical Engineering from Iowa State Universi-
(including arthroscopy, TPLO, TTA, cementless nised Specialist in Small Animal Surgery ty. He completed his surgical residency at the Uni-
total hip replacement and limb deformity cor- (Orthopaedics) since 1995. He has contributed to versity of Pennsylvania. He has served as a facul-
ty member at the University of Pennsylvania and ing grants from The National Institutes of Health, DEE, JON
Iowa State University and is currently an Endowed The Orthopaedic Trauma Association, The Mus- DVM, MS, DACVS, DACVSMR
Professor of Surgery at the University of Minneso- culoskeletal Transplant Foundation, Johnson & Hollywood Animal Hospital
ta. His research and clinical interests are pain man- Johnson, Pfizer, Zimmer, DePuy Orthopaedics,
agement, joint replacement, stem cell therapy and
2864 Hollywood Blvd.
Inc, and Arthrex. He has received numerous
genetic testing for orthopedic diseases. awards including America’s Best Veterinarian in Hollywood, Florida 33020 USA
2007, the Orthopaedic Research Society’s New Jon Frederic Dee, is a partner and staff surgeon at
the Hollywood Animal Hospital in Hollywood,
COOK, CRISTI Investigator Recognition Award, the Norden Dis-
Florida. He is also a Courtesy Clinical Professor
DVM, MS, DACVR tinguished Teacher Award, MU Alumnus of the
in the Department of Small Animal Clinical Sci-
University of Missouri, Veterinary Year, MU Faculty-Alumni Award, The Bloomberg
ences at the University of Florida and Adjunct
Memorial Research Award, The Hohn-Johnson
Medical Teaching Hospital, 900 Assistant Professor, Department of Veterinary
Research Award, The Bojrab Research Award,
East Campus Drive, Columbia, MO 65211 Clinical Science, at the Ohio State University. Dr.
The MU Graduate and Professional Council
Board-certified veterinary radiologist, Dr. Cristi Dee earned his DVM degree from Auburn
Gold Chalk Award, and The University of Mis-
Cook attended Purdue University, where she University in 1966. He was a teaching intern
souri Superior Graduate Achievement Award. Dr.
received her Bachelor’s Degree in Animal Science. at Washington State University and in 1974 he
Cook was president of the Veterinary Orthopedic
She completed her Doctorate of Veterinary Medi- earned his master’s degree in surgery while at
Society for 2008-2009. He holds six US Patents Colorado State University. Dr. Dee does research
cine at University of Missouri - Columbia in 1993;
and has seen two biomedical devices through to on the pathogenesis and repair of injuries in com-
a small animal medicine and surgery internship at
FDA approval and human clinical trials. His clini- panion animals and sporting dogs. He specializes
University of Tennessee; and a radiology residen-
cal interests are in arthroscopy, minimally invasive in injuries of the extremities. Dr. Dee has received
cy and Masters of Science at the University of Mis-
orthopaedic surgery, orthopaedic tissue engi- numerous awards, including the A.V.M.A. Prac-
souri - Columbia. She stayed on as an assistant
neering, cartilage repair, and management of titioner Research Award in 1986, the A.A.H.A.
teaching professor of radiology, where she enjoys
osteoarthritis. He regularly speaks at major nation- Practitioner of the Year Award, Southeast Region,
the clinical caseload, teaching and research oppor-
al and international meetings. He currently has a in 1991 and the Wilford S. Bailey Distinguished
tunities in the Comparative Orthopaedic Labora-
dual appointment at the University of Missouri in Alumnus of Auburn in 2001. Dr. Dee has written
tory. Cristi’s particular interested is in muscu-
Small Animal Orthopaedics and Orthopaedic many journal articles and is a co-editor of the
loskeletal imaging, primarily ultrasound and MRI.
Surgery (human), and is the Director of The Com- textbook Canine Sports Medicine and Surgery. He has
She has published articles in a number of veteri-
nary medical journals, including: Journal of the parative Orthopaedic Laboratory and the William been on the editorial review board for Veterinary
American Veterinary Medical Association, Journal & Kathryn Allen Distinguished Professor in Surgery, Journal of the American Animal Hospital Asso-
of Veterinary Medicine Research, Veterinary Orthopaedic Surgery. He is also the co-founder ciation and the Journal of Small Animal Practice. He
Surgery, and Equine Veterinary Journal, as well as and co-director along with his wife Dr. Cristi Cook also speaks both nationally and internationally at
many human orthopaedic journals. She is a mem- (also faculty in Vet Med) of Be The Change Vaca- meetings and symposia. Most importantly, he
ber of the American College of Veterinary Radiol- tions a non-profit organization dedicated to build- enjoys friends and fly fishing.
ogy, American Veterinary Medical Association ing schools in third world countries so that chil-
and Veterinary Orthopedic Society. Cristi is mar- dren around the world can receive the opportuni- DÉJARDIN, LOÏC
ried to Jimi Cook, DVM, PhD, Diplomate Ameri- ties that only education can provide. DVM, MS, Dipl. ACVS,
can College of Veterinary Surgery, who is a pro- Associate Professor - Orthopaedic
fessor of small animal orthopaedics, Distinguished D’ARPE, LORENZO
Surgery, College of Veterinary
Professor in Orthopaedic Surgery, and director of Med Vet, PhD
Medicine, Michigan State University
the Comparative Orthopedic Laboratory. She Università degli Studi di Padova
enjoys photography, international traveling, and East Lansing, Michigan 48824-1314
Dipartimento di Scienze Cliniche Dr. Déjardin graduated from Toulouse Veteri-
building schools in under-priviledged parts of the
Veterinarie, AGRIPOLIS - v.le dell’università nary School in 1981. After several years in acad-
world through Be The Change Vacations. They
enjoy their four-legged kids, cats, Albus, Skeeter, n. 16, 35020 Legnaro (Padova), Italy emia and referral practice at Frégis Referral Hos-
and Bogie, their dogs, Truman and Kodi. They International speaker and well known expert in pital in Paris, he completed his Surgical Residen-
also enjoy puppy raising for New Horizons Service the field of Equine Laminitis. Main field of inter- cy and Master of Science at Michigan State Uni-
Dogs: our current puppy is Chula and Vegas (our est are Laminitis and equine foot biomechanics in versity. He then worked with Arnoczky for 6
first puppy) is now placed with a child with autism. quasi-static. Graduated at the University of years prior to his tenure track appointment at
Bologna in 2000 with a thesis dissertation on MSU. Currently, Dr. Déjardin is an Associate
prepurchase exam, with Professor S. Cinotti. Professor in Small Animal Orthopaedic Surgery;
COOK, JAMES he is the founder and Director of the Collabora-
Founder president of the “Omnia Universitatis”
DVM, PhD, Diplomate ACVS association in the University of Bologna. “Leonar- tive Orthopedic Investigations Laboratory.
William & Kathryn Allen Distin- do” european scolarship awarded in 2001, attend- Dr. Déjardin authored ~ 80 research proposals
guished Professor in Orthopaedic ed the “Clinique Equine de Livet” in Normandy for $ 4.5 M, three invention disclosures and one
Surgery Director, Comparative Orthopaedic (Livarot, France) and with another scolarship patent on a new interlocking nail. His publica-
Laboratory, University of Missouri, 900 East through the University of Bologna attended the tions include > 80 peer-reviewed scientific papers
“Institute of Equine Medicine and Surgery” at the and abstracts, ~ 200 proceedings, 4 book chap-
Campus Drive, Columbia, MO 65211 USA
University of Illinois (Urbana, IL, USA) with ters and ~ 300 presentations in the US, Europe,
James (Jimi) Cook received a BS degree from
Prof. D. Freeman. In 2002 attended frequently the Asia and Latin America. Dr. Déjardin’s clinical
Florida State University in 1988. After a short
“Rood and Riddle Equine Hospital” (Lexington, interests include comparative orthopaedic and
career as a professional water skier, he completed
KY, USA). In the same year began working with traumatology, minimally invasive osteosynthesis,
the DVM degree in 1994 at the University of Mis-
Dr. R. Redden at the “International Equine Podi- revision surgery and total elbow replacement.
souri. He then went on to a small animal rotating
atry Center” (Versailles, KY, USA) and then His current research activity focuses on muscu-
internship at the University of Minnesota. He
became the “European Equine Podiatry Assis- loskeletal applied basic science and biomechanics,
returned to the University of Missouri in 1995 for
tant” in the same center. Moreover, has learnt the implant design, total elbow replacement kinemat-
a dual PhD-Small Animal Surgery Residency pro-
European art of ferriery with Dr. H. Casteljins in ics and ceramic bone substitutes.
gram. He completed his PhD in Pathobiology in
1998 and became a Diplomate of the American his international equine podiatry activity (Siena,
College of Veterinary Surgeons in 1999. His Italy). In 2003 worked at the “Clinique Equine de DUELAND, TASS
PhD research involved developing a unique in Livet” in Normandy (Livarot, France) as special- DVM, Prof Emeritus-retired
vitro system of chondrocyte culture for studying ist in Equine Laminitis and Equine Podiatry. In 9517 Hwy KP,
osteoarthritis. In 1999, he co-founded the Com- June 2009 obtained the PhD in Veterinary Clini- Black Earth, WI 53515 USA
parative Orthopaedic Laboratory at the Universi- cal Sciences at Padova University (Italy) with a Dr. Dueland joined the School of Veterinary Med-
ty of Missouri, which is a research laboratory thesis dissertation on “In vivo study on the use of icine faculty in 1980 as a Professor and served as
involving the College of Veterinary Medicine, The digital venography in equine Laminitis” tutor Prof. chairman of the Department of Surgical Sciences
School of Medicine, and The College of Engineer- D.Bernardini. In 2009 has formulated the “5 Hearts from 1980 to 1986. He holds a joint appointment
ing. Today, more than 30 scientists are currently Theory” and invented the “5 Iced Hearts” system. as Professor of Orthopedic Surgery in the Medical
involved in this laboratory’s research in the areas In 2010 join the Equestes society as “Expert panel School. In 1999 Dr. Dueland retired. He holds a
of osteoarthritis, tissue engineering, and articular member”. Speaker in more then 60 courses, meet- position as Emeritus Professor.
cartilage physiology. He has over 100 peer- ings, congresses and symposiums, Author of more His research interests are in comparative orthope-
reviewed publications to his credit in both the vet- then 45 publications on national and international dics, fracture fixation/biomechanics, pubic sym-
erinary and human medical literature. He has journals, congress proceedings and books chapters physiodesis for hip dysplasia and interlocking nail-
received extensive funding for his research, includ- on equine podiatry and Laminitis. ing of fractures.
EATON-WELLS, RICHARD EYES, BRIAN FITZPATRICK, NOEL

BVSc., MACVSc. MbChB DMRD FRCR DUniv MVB CVR CSAO
263 Appleby Rd , Stafford Heights Consultant Radiologist with MRCVS, Fitzpatrick Referrals,
Brisbane, QLD, 4053, Australia an interest in Musculo-skeletal Surrey, UK
Graduated University of Queensland 1971 BVSc. Radiology, Divisional Medical Director for Noel qualified as a Veterinary Surgeon from
Worked in mixed practice, with an interest in Support Services, University Hospital Aintree Dublin in 1990, he was awarded scholarships at
surgery for 7 years, MACVSc 1976. Resident in The University of Pennsylvania and The Uni-
Foundation Trust, Liverpool, United Kingdom
Small Animal Surgery The Ohio State Universi- versity of Ghent. After a short time in mixed
ty 79-80. He returned to Brisbane and established Radiologist to Liverpool Football Club practice he worked in small animal practice and
a Small Animal Surgical Referral practice which Clinical Lecturer, University of Liverpool, UK spent time at several universities in the UK and
ultimately became the first multi-disciplined vet- I was appointed Consultant Radiologist to Uni- U S attaining certificates in Small Animal
erinary specialist centre on the Eastern seaboard. versity Hospital Aintree in 1979 with occasional Orthopaedics and Radiology. In 2008 Noel was
Developed an interest in returning greyhounds to working trips to work in the St Boniface Hospital, appointed the position of Assistant Professor at
competitive racing post musculo-skeletal injury. Winnipeg, Canada. I began my career as a gener- the University Of Florida School Of Veterinary
This initially resulted in acquiring greyhounds al Radiologist and developed my interest in mus- Medicine in recognition of his contributions to
that owners felt could not be returned to the culo-skeletal and sports imaging. This aspect of science and teaching. He was awarded an Hon-
track. He continues to practice as a Specialist in Radiology was revolutionalised with the introduc- orary Doctorate by The University of Surrey for
Small Animal Surgery in Australia and the Unit- tion of MR imaging. I have a particular interest in his contribution to medical science and has since
ed Kingdom. He has published in scientific liter- sports medicine imaging. I provide this service to a become a Visiting Professor there. In the past
ature, book chapters and conference proceedings number of sporting Clubs including Liverpool FC, decade Noel has conducted research and written
in his disciple and has continued to give continu- the England ladies football team and the British papers with major vet schools in the US and UK
ing education presentations over the last 30 years Gymnastic Association. The provision of imaging and with well respected private referral hospitals
in Australia, the USA and Europe. Spends his to elite, often highly expensive athletes provides a worldwide. He is the first and only veterinary
spare time either sailing in the Great Barrier Reef significant, but interesting challenge. The main surgeon to have contributed six primary author
or working a Gundog in the UK. body of my work revolves around the imaging of and one secondary author scientific papers to a
bones, joints and soft tissue problems in a large single edition of the prestigious journal “Veteri-
EHRHART, NICOLE inner city Hospital. The Hospital comprises of 814 nary Surgery” in February 2009. Noel is a serving
beds with a large accident and emergency Depart- member of the Board of the Veterinary Orthope-
DVM, MS, Diplomate ACVS
ment. I work in a team of 20 Radiologists each of dic Society in the US and Director of Fitzpatrick
Associate Professor, Surgical Oncology which have a special interest, but we all have to con- Referrals in the UK.
Animal Cancer Center, Colorado tribute to the general day to day investigations that
State University, 300 West Drake Street come through any large Radiology Department. FLÜCKIGER, MARK
Fort Collins, CO 80523 USA Prof. Dr.med. vet. Dipl. ECVDI
Dr. Nicole Ehrhart is a graduate of the Universi- FERASIN, LUCA
ty of Pennsylvania School of Veterinary Medi-
Head Dysplasia committee Zürich
DVM PhD CertVC Dip ECVIM- Winterthurerstrasse 270
cine. She did her internship at the Animal Med-
ical Center in New York, New York and her sur-
CA (Cardiology) MRCVS CH 8057 Zürich / Switzerland
gical residency at Colorado State University. She European and RCVS Recognised In 1973 he graduated as Veterinarian at the Uni-
became Board Certified by the American College Specialist in Veterinary Cardiology versity of Zurich, Switzerland and in 1975 he
of Veterinary Surgeons in 1995. She was a fac- Specialist Veterinary Cardiology Consultancy Ltd, obtained a promotion to Dr.med.vet., University
ulty member at the University of Illinois from Newbury, Berkshire, UK of Berne, Switzerland. From 1975 to 1980 he was
1996-2002 and has been a faculty member at Luca graduated with honours in 1992 from the Uni- Junior / Senior Clinician at the Department of
Colorado State University since 2002. She is a versity of Bologna (Italy). After a one-year intern- Small Animal Internal Medicine, University of
Full Professor in Surgical Oncology at Colorado ship at the Department of Animal Science of the Zurich, Switzerland. From to 1980 to 1983 he was
State University’s Animal Cancer Center and is University of Padova (Italy), he carried out a 3-year Radiology residency at the Veterinary Medical
the Principle Investigator in the Musculoskeletal research project in endocrinology at the BBSRC in Teaching Hospital, School of Veterinary Medicine,
Oncology Laboratory. Dr Ehrhart is the Immedi- Cambridge and was awarded his PhD in 1996. Fol- University of California, Davis, California, USA.
ate Past-President of the Veterinary Orthopedic lowing 3 years as Assistant Professor at the Uni- From 1983 to 2003 he was head of Diagnostic
Society and the current President of the Veteri- versity of Padova, he moved to the University of Imaging Department of Veterinary Medicine, Uni-
nary Society of Surgical Oncology. Her research Bristol, where he taught cardio-respiratory medi- versity of Zurich. Since 1997 he is a lecturer (Dr.
centers around limb salvage, bone neoplasia, cine of the dog and cat for 7 years. In 2006 Luca Habil.) at the University of Zurich. Since 2004 he
osteoneogensis and tissue engineering. She has was appointed Associate Professor in Veterinary is a Professor (Titularprofessor) and since 2007 he
two daughters, ages 12 and 14, and enjoys skiing, Cardiology at the University of Minnesota (USA). is a private consulting radiologist.
snowshoeing, backpacking, camping, hiking, run- He moved back to the UK in 2008 and he is cur- Publications, presentations: Author or coauthor of
ning and fitness. rently a visiting cardiology consultant in Southern more than 100 publications. Oral presentation of
more than 160 papers.
England and Northern Italy. During his career,
ELIASHAR, EHUD Additional functions (selected): Chairman of the Dys-
Luca has received several awards and academic
plasia committee of the Vetsuisse faculty, Universi-
BSc, DVM, MRCVS, DiplECVS recognitions, both for his teaching and research
ty of Zurich. Scrutineer in case of appeals for hip
Lecturer in Equine Surgery activities. He has contributed to the veterinary lit-
and elbow joints for various clubs in Europe.
The Royal Veterinary College erature with more than seventy articles, research
Founding member (1989) and past president of the
communications and book chapters. Luca has been
Hawkshead Lane, North Mymms International Elbow Working Group (IEWG).
invited to speak at several national and interna-
Hatfield, AL9 7TA, UK Founding member (1994) of the European Associ-
tional meetings, seminars and continuing education
After graduating from the Koret School of Veteri- ation of Veterinary Diagnostic Imaging (EAVDI).
programs for the veterinary and veterinary nursing
nary Medicine, The Hebrew University, Israel, in Founding member (1994) of the European College
profession. His main interests include, but are by
1996, Ehud continued as an Intern in Large Ani- of Veterinary Diagnostic Imaging (ECVDI),
no means limited to, exercise physiology, feline car-
mal Medicine and Surgery in the Equine Hospi- Diplomate. Founding member (1995) Society for
diology, as well as clinical investigation of syncope,
tal. In 1998 he came to the Royal Veterinary radiographic diagnosis of genetically influenced
collapse and exercise intolerance.
College for a three-year training programme in skelettal diseases in small animals, Germany, mem-
Equine Surgery. In 2000, Ehud was appointed as ber of the executive board and of the examination
a lecturer in Equine Surgery at the Royal Veteri-
FERRETTI, ANTONIO committee.
nary College, and in 2001 he passed the board Med Vet, Dipl ECVS,
exams of the European College of Veterinary Via maestri del lavoro, 29 FOX, DEREK
Surgeons (ECVS) to become a Diplomate, the Legnano (Milano) DVM, PhD
first Israeli born specialist in Equine Surgery. Antonio Ferretti graduated in 1979 at the Universi- Diplomate American College of
During his residency Ehud became interested in ty of Milano. He started studying Ilizarov Tech-
Veterinary Surgeons; Assistant
lameness and corrective farriery, and a few joint nique in 1982 and the following year he started his
projects with the Structure and Motion Lab yield- clinical application. In 1988 and in 1991 he spent Professor, Small Animal Orthopedic Surgery;
ed good and important clinical data. some time studying Ilizarov Technique at Ilizarov Associate Director, Comparative Orthopaedic
Ehud’s clinical interests include orthopaedic Clinic in Curgan, Siberia, URSS. He became Laboratory; Veterinary Medical Teaching
surgery, all aspects of lameness, corrective farriery Board Certified by the European College of Veteri- Hospital; University of Missouri, USA
and limb biomechanics with emphasis on clinical nary Surgeons in 1993. He works in private prac- Dr. Fox graduated from Indiana University in
applications. tice in his own Clinic near Milano. 1993 with a B.S. in Biology. In 1998, he graduat-
ed from the Michigan State University College of Small Animal Veterinary Association, President of sity in 1984, Dr. Hulse served as a clinician in gen-
Veterinary Medicine with a DVM. He completed the European Society of Veterinary Internal Med- eral practice and as a Staff Surgeon at Louisiana
a small animal internship and small animal surgical icine and President of the European Board of Vet- State University and Oklahoma State University.
residency at the University of Missouri - Columbia. erinary Specialisation. He is a Diplomate of both He successfully fulfilled the requirements for
In 2003 he became a diplomate of the American the European College of Veterinary Internal Med- admission into the American College of Veteri-
College of Veterinary Surgeons. He completed icine and of the European College of Veterinary nary Surgeons in 1977. He is a recognized leader
his PhD in the area of Pathobiology at the Univer- Diagnostic Imaging. He has spoken at many inter- in veterinary orthopedics and is frequently an
sity of Missouri - Columbia in 2004. His research national meetings and published over 200 articles invited speaker at National and International Vet-
interests include meniscal tissue engineering focus- in refereed journals. erinary conferences. He has developed techniques
ing on cell-scaffold interactions and in vitro avascu- commonly used for treatment of bone and joint
lar meniscal modeling. He is also investigating cor- HOULTON, JOHN disorders in dogs and is a co-author of Small Ani-
rectional techniques for angular limb deformities in MA, VetMB, DVR, DSAO, mal Arthroscopy. His clinical research interests focus
the dog. He is the recipient of the 2004 SCAVMA on minimally invasive surgery for joint disorders
MRCVS, DECVS
clinical teaching award, and the 2006 Golden and for fracture treatment.
Chalk Teaching Award.
Empshill, Robins Lane, Lolworth,
Cambridge, CB23 8HH INNES, JOHN
John Houlton qualified from the University of
GRIFFON, DOMINIQUE BVSc PhD CertVR DSAS(Orth)
Cambridge in 1970 having gained a 1st Class Nat-
DMV, MS, PhD, DACVS, ural Science Degree in 1967. After 6 years in prac- MRCVS
DECVS tice, he returned to Cambridge as University School of Veterinary Science
Associate Professor, Small Animal Assistant Surgeon to the late Col. Hickman. In University of Liverpool, Leahurst Campus
Surgery Director, Laboratory for Orthopedic 1980 he became University Surgeon, remaining Neston CH64 7TE, UK
Research on Biomaterials, Affiliate, Beckman in that post until 1997. At that time he joined the John qualified from University of Liverpool in
Institute for Technology, Affiliate, Department of Veterinary Defence Society as a Claims Consul- 1991. He was at the University of Bristol for 10
tant and became an Associate Lecturer at the years and he was then appointed professor of
Bioengineering, College of Veterinary Medicine
University of Cambridge. small animal surgery at Liverpool in 2001. In
University of Illinois, 1008 W Hazelwood drive He has been President of the BVOA, AO/Vet 2009, he co-founded Veterinary Tissue Bank,
Urbana IL61802, USA International, E SVOT and ECVS and is an Europe’s first veterinary tissue transplant suppli-
Dominique Griffon is an associate professor in RCVS Diplomate in Veterinary Radiology and in er. John is a RCVS-registered specialist in small
small animal orthopaedic surgery at the Univer- Small Animal Orthopaedics, and a Diplomate of animal surgery (orthopaedics).
sity of Illinois. She is the director of the Labora- the European College of Veterinary Surgeons. He has published over 60 peer-reviewed papers
tory for Orthopedic research on Biomaterials, He is currently European Associate Editor for and his current research projects are focussed
studying osteochondral tissue engineering and Veterinary Surgery, a panellist for the BVA/KC around joint diseases. Clinical interests include all
clinical applications of biomaterials. Her clinical hip and elbow dysplasia schemes and Chairman areas of small animal orthopaedics.
interests include arthroscopy, cranial cruciate dis- of the 3rd World Veterinary Orthopaedic Con-
ease and elbow dysplasia. She has published over gress. In 1985 he was awarded the BSAVA Simon
60 refereed publications, given over 50 interna-
JOHNSON, KENNETH
Award for outstanding contributions to Veteri- MVSc, PhD, FACVSc
tional conferences and serves on several national nary Surgery. He has published extensively and
committees, editorial and grant review panels has co-edited five text books. Beyond veterinary
Diplomate ACVS and ECVS
and professional societies. medicine, his interest in gundogs, and working Clinical Professor of Orthopaedics
Labradors in particular, has become something of University of Sydney, Faculty of Veterinary Science
HAYASHI, KEI an obsession. Sydney NSW 2006 AUSTRALIA
DVM, PhD, Diplomate ACVS Kenneth is a graduate of the University of Syd-
VM:Surg/Rad 2112 Tupper Hall HOULTON, SUE ney where he also completed his graduate work
One Shields Ave., Davis CA BVSc, MA, DVR, DVC, MRCVS on arthrodesis and bone marrow stem cell, in
addition to development to locked nailing tech-
95616, USA Home Office, PO Box 91 niques. After completing a residency in surgery at
Dr. Hayashi is a small animal orthopedic surgeon Cambridge, CB4 0XJ, UK Colorado State University, he was later held aca-
with research interests in pathogenesis of canine Sue Houlton qualified in 1974 from the University demic appointments at University of Wisconsin,
cruciate ligament disease, application of novel tech- of Pretoria, South Africa. After working for eight University of Bristol, and Ohio State University.
nologies in arthroscopy, total joint replacement, years in general practice, focussing on small com- Research on osteoarthritis, locked nailing of frac-
and regenerative medicine to veterinary orthope- panion animals, she began a specialist qualification tures, greyhound fractures and locking implants
dics, and comparative osteoarthritis research and in Veterinary Radiology. To complete the RCVS are among his interests. He served as President of
sports medicine. Dr. Hayashi obtained his veteri- Diploma in Veterinary Radiology, she took a self- AOVET, and is author of more than 100 peer
nary degrees (BVMS/DVM) from the University financed year out at the University of Cambridge. reviewed publications as well as the current edi-
of Tokyo in 1993. He was awarded a PhD in phys- Appointment to a clinical development post at the tion of “Piermattei’s Surgical Approaches to
iology from the University of Tokyo, and com- University then enabled her to further her acade- Bones and Joints”. In addition he is Editor in
pleted a PhD in cell biology and biomechanics at mic interests by extending her post graduate qual- Chief of the journal Veterinary and Compara-
the University of Wisconsin in 1997. ifications to an RCVS Diploma in Veterinary Car- tive Orthopaedics and Traumatology. In spare
Dr. Hayashi completed a post-doctoral fellowship diology. To follow her commitment to animal wel- time, he enjoys offshore sailing with friends.
and internship in 2000, a small animal surgery fare and to take up further scientific and intellec-
residency in 2003 at the University of Wisconsin, tual challenges, she joined the Animals Scientific
and achieved board certification (diplomate JUDY, CARTER E.
Procedures Inspectorate in 1987. In 2001 she was
ACVS) in 2004. He served as an Assistant Pro- promoted to her current post of Superintending DVM DACVS
fessor of Small Animal Orthopedic Surgery at the Inspector, Animal Scientific Procedures Inspec- Alamo Pintado Equine Medical
Michigan State University 2003-2005. He is cur- torate, at the Home Office. The Inspectorate Center, Los Olivos, California
rently an Assistant Professor of Surgery at Universi- works under legislation for the protection of ani- Originally from Pasadena, California, Dr. Judy
ty of California Davis. mals used in experimental or other scientific pro- attended the University of California at San Diego
cedures. The legislation is in line with EU Direc- for his undergraduate work in Animal Physiology
HERRTAGE, MICHAEL tive 86/609, which is expected to be replaced by a and Neurosciences. He then attended the School of
M.A., B.V.Sc., D.V.Sc., D.V.R., revised Directive later this year. Veterinary Medicine at the University of Califor-
D.V.D., D.S.A.M., M.R.C.V.S., nia Davis. After achieving his veterinary degree, he
HULSE, DON completed an internship in large animal medicine
Dip. E.C.V.I.M., Dip. E.C.V.D.I. and surgery at Texas A&M University and a resi-
Department of Veterinary Medicine DVM Dip ACVS,ECVS
dency in equine surgery and performance evalua-
University of Cambridge, Madingley Road, Dept Small Animal Sugery tion at U.C. Davis. Currently, Dr. Judy is a staff
Cambridge CB3 0ES, United Kingdom College Veterinary Medicine surgeon at the Alamo Pintado Equine Medical
Mike Herrtage graduated from the Liverpool Texas A&M University Center in Los Olivos, California. Dr. Judy is a
University and is currently Professor of Small College Station Texas 77843-4474 USA Diplomate of the American College of Veterinary
Animal Medicine at the University of Cambridge. Dr. Hulse graduated from Texas A&M in 1970 Surgeons. Dr. Judy’s current areas of interest are in
He was awarded the B.S.A.V.A. Woodrow Award and completed his surgical training at Kansas advanced imaging of the equine athlete including
in 1986 and the B.S.A.V.A. Blaine Award in 2000. State University in 1973. Commencing in1970 MRI, CAT scan and nuclear scintigraphy and
He has been President of the British Veterinary and continuing until his appointment as a Profes- their application to correcting performance related
Radiology Association, President of the British sor of Orthopedic Surgery at Texas A&M Univer- issues both surgically and medically.
KEEGAN, KEVIN Sorrel Langley-Hobbs graduated from The Royal tilage metabolism. She has reported the pharma-
900 East Campus Drive, Clydesdale Veterinary College, London. After an intern year cokinetics and effects of glucosamine on cartilage
Hall, University of Missouri she spent time in practice before returning to com- and bone in vivo. She is also involved in tendon,
plete a residency in Small Animal Orthopaedics. ligament and cartilage bioengineering projects.
Columbia, Missouri 65211, USA She gained her RCVS Diploma in Small Animal She was awarded the institutional Pfizer award
Kevin G. Keegan graduated from the University of
Surgery (Orthopaedics) in 1997 and her ECVS for research excellence in 2002 and 2009. She has
Missouri’s College of Veterinary Medicine in 1983. diploma in Small Animal Surgery in 1999. She published results of her studies in international
After graduation he spent 2 years in private equine spent six months as Lecturer in Surgery at the peer- reviewed journals including, amongst
ambulatory and surgical practice on the east coast of University of Pennsylvania in 1998 and is cur- others, Equine Veterinary Journal, Veterinary
the United States, primarily concentrating on the rently University Surgeon in Small Animal Surgery, Arthritis and Rheumatism, Osteoarthri-
racing Standardbred Horse. He completed an Orthopaedics at Cambridge. She is interested in all tis and Cartilage and the Journal of Orthopaedic
equine surgery residency and Masters Degree in aspects of small animal orthopaedic surgery but Research. She is also a frequent reviewer for
Veterinary Clinical Medicine at the University of particularly feline orthopaedics, external skeletal many scientific journals and participates on inter-
Illinois at Urbana-Champaign from 1986-1989. fixation and total hip replacement. I am particular- national granting agency reviews. She has also
While at the University of Illinois Dr. Keegan stud- ly interested in feline fracture fixation and bone served on the Editoral Board of the journal Vet-
ied biomechanics and bioengineering at the College disease. I am involved in ongoing work looking at erinary Surgery for 6 Years.
of Engineering. After completing the surgical resi- patella fractures in cats and optimal stabilisation
dency he returned to private practice in a surgical techniques. We have recently installed a forceplate
referral and race track practice outside Detroit,
LEES, PETER
and are starting some prospective studies on dogs C.B.E., B.Pharm. Ph.D., D.Sc.,
Michigan for 1 year. In 1990 he returned to his alma with cranial cruciate ligament disease.
mater, the University of Missouri, College of Veteri- Emeritus Professor of Veterinary
nary Medicine as a clinical instructor. Dr. Keegan Pharmacology
LASCELLES, DUNCAN
became board certified in the American College of
BSc, BVSC, PhD, MRCVS, Department of Veterinary Basic Sciences,
Veterinary Surgeons in 1995. He was named Direc- Royal Veterinary College, Hawkshead Campus,
tor of the E. Paige Laurie Endowed Program in CertVA, DSAS(ST), Diplomate
ECVS, Diplomate ACVS Hatfield, Herts AL1 4RD, United Kingdom
Equine Lameness in 2005 and became full professor Peter Lees is a pharmacologist with interests and
in the College of Veterinary Medicine in 2006. In Associate Professor of Surgery, Director, expertise in basic and applied,veterinary aspects of
2008 Dr. Keegan and co-inventors of a body-mount- Comparative Pain Research Laboratory Director, the discipline. He has a good working knowledge of
ed inertial sensor system founded Equinosis LLC, a Integrated Pain Management Service, all fields of pharmacology. His research interests are
University of Missouri faculty-startup company. Dr. North Carolina State University College of in the field of inflammation, anti-inflammato-
Keegan’s research in kinematics and lameness led to ry drugs, and cartilage biology. His work on
Veterinary Medicine, Raleigh,
the development of a body-mounted inertial sensor inflammatory mediators has focussed particularly
system, now called Lameness Locator, presently NC, 27606, USA, UK
Duncan graduated from the University of Bristol on the eicosanoid group of compounds. The anti-
used as an objective aid for veterinarians for detec- inflammatory drugs in which he has had a particu-
tion and evaluation of lameness in horses. Current- in 1991 with honors, having also gained a First
Class intercalated degree in Zoology. After gain- lar interest over 27 years of investigation are the
ly Dr. Keegan has a 50% clinical appointment in the non-steroidal anti-inflammatory group. He
Veterinary Teaching Hospital and 50% research ing a PhD in aspects of pre-emptive analgesia
from the University of Bristol, he then undertook has researched the toxicology, pharmacokinetics
position in the Department of Veterinary Medicine and pharmacodynamics of these compounds in a
a surgical residency at Cambridge University fol-
and Surgery at the University of Missouri. His wide range of domesticated animal species. His
lowed by a Fellowship in Oncological surgery at
research program is partially supported by private recent work on NSAIDs has involved pharmacoki-
Colorado State University.
endowments and the National Science Foundation’s netic-pharmacodynamic modelling of data to gen-
After a short period working on projects related
Small Business Technology Transfer Program. erate key pharmacodynamic parameters in vivo.
to feline pain and analgesia at the University of
Florida, he moved to a surgical faculty position at These methods have been used to enable determi-
KOWALESKI, MICHAEL North Carolina State University. He is currently nation of COX1:COX2 inhibition ratios for a
DVM, Diplomate ACVS and Associate Professor in Small Animal Surgery, range of existing and novel drugs. He has a special
ECVS, Associate Professor of Director of the Comparative Pain Research Lab- interest in the new range of selective COX-2
Orthopedic Surgery, Tufts Cummings oratory, and Director of the Integrated Pain Man- inhibitors. The actions of NSAIDs and disease
agement Service at North Carolina State Univer- modifying agents on equine cartilage biochemistry
School of Veterinary Medicine, 200 Westboro
sity College of Veterinary Medicine, with active (synthesis and degradation of matrix proteogly-
Road, North Grafton, MA 01536 cans) have been studied in vitro using chondrocytes
Dr. Kowaleski earned his DVM degree at the research in acute and chronic pain, and surgical
techniques. and explants in tissue culture. He has also been
Tufts University School of Veterinary Medicine involved in research on the mediators and mecha-
in 1993. After several years in general practice, he He enjoys travel, mountain biking (although there
are not many mountains nearby), sea-kayaking, nisms of equine degenerative joint disease.
completed his residency training in small animal
landscape and abstract photography, dance, con-
surgery at Tufts University in a joint program
temporary art and live music. LEPAGE, OLIVIER
with the Angell Memorial Animal Hospital in
2002. He earned board certification by the Amer- Professor of Equine Surgery
ican College of Veterinary Surgeons in 2003. He LAVERTY, SHEILA DMV, MSc, PD, DES,
was an Assistant Professor of Small Animal MVB, MRCVS, Dipl. ACVS, Dipl. ECVS, Head Equine Centre
Orthopedic Surgery at The Ohio State Universi- Dipl. ECVS, Director, Comparative VetAgro Sup - Veterinary Campus of Lyon
ty from August 2002-August 2007 at which time Orthopaedic Research Laboratory, University of Lyon, 1, avenue Bourgelat
he was promoted to Associate Professor with Canadian Arthritis Network Strategic Research F-69280 Marcy l’Etoile (France)
tenure. Currently, he is an Associate Professor of Resource, CANADA Actual responsibility: President of the European
Small Animal Orthopedic Surgery at the Cum- Sheila Laverty is a Full Professor of Equine Society of Veterinary, Orthopaedics and Trauma-
mings School of Veterinary Medicine at Tufts Surgery at the University of Montreal’s Veteri- tology (ESVOT), Director of the Equine Center
University. His areas of clinical and research nary Teaching hospital since 1989. She graduated (Veterinary Campus of Lyon, France)
interest include arthroscopy, enhancement of from University College Dublin in 1980 and Degree: HABILITATION A DIRIGER DES RECHERCH-
fracture healing, external skeletal fixation, frac- worked in equine practices (TB racing and stud- ES (HDR): Université Claude Bernard Lyon 1
ture repair and orthopedic implants, total joint farms) in Ireland, Australia and New Zealand (France). P RIVAT D OZENT (PD): University of
replacement, clinical and radiological assessment before completing a residency program in Equine Bern (Switzerland). D IPLOMATE OF THE E URO-
of limb alignment, osteoarthritis, peri-operative Surgery and Lameness at the University of Cali- PEAN C OLLEGE OF V ETERINARY S URGEONS
and chronic pain management, and the role of fornia, Davis in 1988. She is a Diplomate of the (DECVS). MASTER OF SCIENCES (MSC): Univer-
osteotomy in the management of joint disease. American and European Colleges of Veterinary sity of Montréal (Canada). I NTERNSHIP & RESI-
Surgeons. She is also Director of the Compara- DENCY (IPSAV): University of Montréal (Cana-
LANGLEY-HOBBS, SORREL tive Orthopaedic Research Laboratory and has da). D O CTE U R E N MÉDECI N E VÉTÉRI NAI RE
MA BVetMed DSAS(O) DECVS focussed on joint disease research for a number (DMV): University of Liège (Belgium)
MRCVS, European Specialist in of years. She is a member of the Canadian Arthri- Interest: (1) Teaching: integration of ICTE (infor-
Small Animal Surgery, University tis Network, a centre of excellence in research in mation and communication technologies for
Canada funded by the government and grouping education) in the equine cursus; (2) Research:
Surgeon, Head of Small Animal Surgery, 127 researchers from multidisciplinary fields skeletal tissue adaptation to internal and external
Department of Veterinary Medicine, University focussing on arthritis research. She has studied stimuli in the equine species; (3) Clinic: general
of Cambridge, Madingley Road, Cambridge models of joint disease for the evaluation of surgery and Traumatology, including guttural
CB3 OES UK osteoarthritis therapeutics and biomarkers of car- pouch diseases.
LISKA, WILLIAM LOZIER, SCOTT M. MATIS, ULRIKE

DVM, DACVS DVM, MS, Diplomate ACVS, Prof. Dr. med. vet. Dr. med. vet.
Gulf Coast Veterinary Surgery, PA Orthopedic Surgery, NWVS - habil. (PhD) Dipl. ECVS
1111 West Loop South, #160 Northwest Veterinary Specialists Vorstand der Chirurgischen und
Houston, Texas 77027 16756 SE 82nd Drive, Clackamas, Oregon Gynäkologischen, Kleintierklinik der
William D Liska, DVM, DACVS, received his Doc- 97015, 6756 SE 82nd Drive Clackamas, Ludwig-Maximilians-Universität München
tor of Veterinary Medicine from Iowa State Univer- Oregon 97015 Lehrstuhl für Allgemeine und Spezielle Chirurgie
sity in 1973 and went on to complete an Internship einschließlich Augenkrankheiten
Education: DVM: Colorado State University,
and Surgery Residency at The Animal Medical
Fort Collins, CO (1986). Internship: University Veterinärstr. 13, 80539 München
Center in New York City in 1976. He became a
of Missouri, Columbia, MS (1987). Residency: Dr. Matis qualified from the University of Munich
Board Certified Veterinary Surgeon by the Ameri-
University of Missouri, Columbia, MS (1990). in 1970, where she received her Dr. med. vet. degree
can College of Veterinary Surgeons in 1980. He is a
Board Certification: American College of in 1972 and her Dr. med. vet. habil. (PhD) in 1981.
founder of Gulf Coast Veterinary Specialists in She was Professor of Surgery and Head of the
Veterinary Surgeons 1992.
Houston. His primary interest is orthopedic Department of Surgery (including Ophthalmology
Special Expertise: Developmental orthopedic
surgery. He spends a majority of his time doing and Radiology) at the Faculty of Veterinary Medi-
abnormalities and injuries of the sporting dog
joint replacement surgery - hips, knees, and elbows. cine of the Ludwig-Maximilians-University of
particularly of the elbow, stifle, and hip;
arthroscopy and limb alignment; clinical Munich from 1989 until she retired in 2010. Dr.
LLOYD, DAVID orthopedic research. Dr. Lozier has lectured Matis was President of AO Vet International (1996 -
Prof., PhD, B.Vet.Med, FRCVS, nationally and internationally on many of these 1998), President of the European Society of Veteri-
Dip ECVD, Department topics and taught courses in basic and advanced nary Orthopaedics and Traumatology (1998 - 2000)
of Veterinary Clinical Sciences, TPLO and arthroscopy. and President of the European College of Veterinary
Royal Veterinary College, H Surgeons 2005 - 2006). In 2001 she received the
WSAVA Saki Paatsama International Award. Dr.
awkshead Campus, North Mymms, MARCELLIN-LITTLE, DENIS Matis has published numerous articles and textbook
Hertfordshire AL10 0EJ, UK Denis Marcellin-Little, Diplomate chapters in the field of companion animal surgery.
David Lloyd is Professor of Veterinary Dermatol- ACVS, Diplomate ECVS, Professor, She is co-editor of two radiology textbooks. Her pri-
ogy at the Royal Veterinary College (University of mary areas of interest include small animal
London), England. His interests are focussed on
Orthopedic Surgery, North Carolina
orthopaedics and traumatology, computerized gait
the biology of the skin surface, cutaneous infection State University
analysis and imaging techniques.
and immunity, and antimicrobial resistance, with Dr. Marcellin-Little is a French-born veterinarian
special interests in staphylococci and yeasts of the who graduated from the veterinary college of
Toulouse in 1988. Dr. Marcellin-Little is a Diplo- MCILWRAITH, WAYNE
genus Malassezia. The work covers small animals,
mate of the American and European Colleges of BVSc, PhD, DSc, FRCVS,
horses and farm animals. He is a founding mem-
ber and past-president of the European Society of Veterinary Surgeons, a Diplomate of the Ameri- Diplomate ACVS, University
Veterinary Dermatology, the European College of can College of Veterinary Sports Medicine and Distinguished Professor, Barbara
Veterinary Dermatology and the Veterinary Rehabilitation, and a Professor of orthopedic Cox Anthony University Chair, Director of
Wound Healing Association. He is also a founding surgery. Dr. Marcellin-Little has specific knowl- Orthopaedic Research, Colorado State University
member of the European Board of Veterinary Spe- edge of animal physical therapy and rehabilita- Fort Collins, CO 80523
cialisation and the World Congress of Veterinary tion. He is an adjunct clinical faculty member of Prof. McIlwraith holds the position of University
Dermatology. He was founding editor and Editor- the Department of Physical Therapy at the Uni- Distinguished Professor, Barbara Cox University
in Chief of the journal, Veterinary Dermatology. He is versity of Tennessee, Chattanooga, and is active- Endowed Chair in Orthopedics and is Director of
a board member of the World Association for Vet- ly involved in teaching and investigating this the Orthopaedic Research Center at Colorado State
erinary Dermatology. David Lloyd graduated emerging field. Dr. Marcellin-Little chaired the University. He consults world-wide in equine ortho-
from Royal Veterinary College (University of Lon- International Symposium on Animal Physical pedic surgery, and has received national and inter-
don) and received his PhD from the University of Therapy and Rehabilitation in August 2004. Dr. national recognition for his contributions to ortho-
Glasgow, Scotland. He has authored and or co- Marcellin-Little has written approximately 100 pedic surgery and joint research. He is the author of
authored more than 150 peer reviewed research articles half of these are peer-reviewed research four textbooks and has authored or co-authored
papers in dermatology and microbiology. projects in the fields of joint arthroplasty, (circu- over 400 referred publications and textbook chap-
lar) external fixation, biomodeling, and bioman- ters, as well as presenting over 500 seminars, both
LOHMANDER, STEFAN ufacturing. nationally and internationally to equine practi-
MD, PhD tioners, veterinary specialty groups and at human
MARTINELLI, MARK orthopedic meetings. Prof. McIlwraith received his
Professor at Lund University
veterinary degree with distinction from Massey
Malmö Area, Sweden DVM, PhD, Diplomate American University in New Zealand in 1971 and did his sur-
Stefan Lohmander, MD, PhD, is professor of College of Veterinary Surgeons gical residency at Purdue University, as well as MS
Orthopaedic Surgery at Lund University, Swe- California Equine Orthopedics, and PhD degrees in the area of joint disease (arthri-
den. He is editor-in-chief of ‘Osteoarthritis and Inc. 3141 Twin Oaks Valley Road tis). He is Board Certified as a Diplomate of the
Cartilage’. He has published more than 250 scien- American College of Veterinary Surgeons. He is
tific papers, having received more than 9000 cita-
San Marcos, CA 92069 USA
Dr. Martinelli graduated from Michigan State Past-President of the American College of Veteri-
tions with an H-factor of 55. Stefan Lohmander is nary Surgeons, the American Association of Equine
University with a Bachelor of Science and a Doc-
a past president of the Osteoarthritis Research Practitioners and the Veterinary Orthopaedic Soci-
Society International, OARS I. In 1994 he tor of Veterinary Medicine and then entered pri-
vate equine practice. After a short stint working in ety. His honors include honorary doctorates from
received the OARS I Award for Clinical Massey University in New Zealand (2003), the
Osteoarthritis Research, in 2004 the Orthopaedic both a general practice and then in a referral sport
University of Vienna (1995), the University of
Research Society USA (ORS) Arthur Steindler and racehorse practice, he sought advanced train-
Turin (2004) and Purdue University (2001), as well
Award for significant international contributions ing in academia, completing a Clinical Fellowship
as the Founder’s Award for Lifetime Achievement
to the understanding of musculoskeletal disease at Oregon State University before moving to the
from the American College of Veterinary Surgeons
and injury. In 2006 he received the Marshall University of Illinois for a surgical residency and
(2006), the Schering-Plough Award for Equine
Schiff Award from the American College of a Master of Science in MRI. He relocated to Scot-
Applied Research for outstanding research work in
Rheumatology (ACR): “A special lectureship land in 1995 to take up a position as a lecturer in equine locomotor disorders (1995), the John Hick-
established to address the interface between equine surgery at the University of Glasgow, man Award for Equine Orthopaedics from the
rheumatology and orthopedics in musculoskeletal where he also completed a PhD in joint disease. British Equine Veterinary Association (1997) and
medicine”, and in 2007 the Bone and Joint Decade In 1998, Dr. Martinelli gained his Diplomate sta- the Tierklinik Hochmoor Prize at Equitana, Essen,
2000-2010 Award for Research in Osteoarthritis. tus with the American College of Veterinary Sur- Germany for international contributions to equine
He is PI of the Lund University Osteoarthritis geons. He returned to the University of Illinois orthopedics (1993). He was inducted into the Uni-
Research Group, focusing on basic and clinical for a year and a half before moving to Southern versity of Kentucky Equine Research Hall of Fame
aspects of osteoarthritis: Risk factors and disease California. He currently owns California Equine in 2005 and was the Frank Milne lecturer (lifetime
mechanisms of OA on gene, molecule and patient Orthopedics, a referral orthopedic practice based contribution award) from AAEP in 2005. Prof.
level Monitoring OA Outcome by Biomarkers, in Southern California. His main clinical interests McIlwraith was designated University Distin-
Imaging and Patient-reported Outcomes Evi- are integrating imaging, arthroscopy and comput- guished Professor in 2009, the highest recognition
dence-based treatment of OA - Examining Old erization with the diagnosis and treatment of Colorado State University awards for outstanding
and New Interventions for OA in Clinical Trials. equine orthopedic conditions. accomplishments in research and scholarship.
MORGAN, DAVID where he is currently a Professor in the Depart- sity from 1988 to 1991. He was in private practice
BSc, MA, VetMB, CertVR, ment of Clinical Sciences, and served as Chief of in the Monterey Bay region of California from
MRCVS, Scientific Communication Surgery from 1998 to 2002. Dr Nixon has 1991 to 2004. He is currently an Associate Profes-
authored over 280 papers and book chapters, sor of Orthopedic Surgery and Affiliate Faculty of
Manager, External Relations, and has written 2 texts on equine orthopedics, the School of Biomedical Engineering at Colorado
Procter & Gamble Pet Care, 47 Route de Saint one in 1996 entitled Equine Fracture Repair, the sec- State University. He is the founder of the Complete
Georges, 1213 Petit-Lacy 1, Geneva, Switzerland ond edition of which will be published in 2010, Course on External Skeletal Fixation that has been
David Morgan’s first degree was in Biochemistry and a second text with Dr McIlwraith in 2005 providing intensive training to veterinarians from
at Cardiff University (Wales) and in 1986 he called Diagnostic and Surgical Arthroscopy in the Horse. around the world each year since 1991. He is the
graduated from Cambridge University Veteri- Dr Nixon’s clinical and teaching at Cornell focus author of multiple journal articles and book chap-
nary School. After a short time spent in mixed on musculoskeletal injury and repair, with a spe- ters on orthopedic topics and actively teaches at
practice he moved to working with companion cific interest in regenerative medicine. Research numerous regional, national and international vet-
animals for 7 years where his interests were main- and translational clinical application over the past erinary conferences. He mentored the recipients of
ly in surgery and radiology. In 1990 he gained 2 decades have included: Joint pathobiology and the Best Clinical Research Award from the Veteri-
the post-graduate Certificate in Veterinary Radi- cartilage repair with cell grafting, growth factor nary Orthopedic Society and from Colorado State
ology. In 1993 David joined Iams as their Tech- recombinant protein and gene-enhanced chon- University in 2007.
nical Services Veterinarian for the United King- drocyte and stem cell transplantation techniques.
dom, Scandinavia and South Africa and provided Stem cell propagation, characterization, and PEIRONE, BRUNO
technical assistance for seven countries and application in musculoskeletal diseases, including DVM, Prof. PhD
twelve veterinary faculties. In 1999 he moved to bone marrow and adipose derived stem cells for
The Netherlands to take up the position of Acad- Via Leonardo da Vinci, 44
repair of tendinitis. Clinical application of growth
emic Affairs Manager Europe. Since 2000 he has factor recombinant proteins and gene therapy for
10095 Grugliasco (TO) - I
been based in Geneva and is the Scientific Com- Chair of Europe Region of the AOVET
improved joint, tendon, and bone repair. Genetic
munication Manager for P&G Pet Care. This SP Board of the AOVET member
characterization of OCD in animals and man
involves providing technical information on ESVOT Board member
using microarray gene chip expression studies.
Eukanuba, Eukanuba Veterinary Diets and Iams SCIVAC Directory Board member
Dr Nixon’s laboratory group has engaged in over
diets and the role of nutrition in helping manage Past-Chair of SIOVET (Italian Society of Vet-
70 funded research projects and 7 contracts with
clinical disease in dogs and cats. erinary Traumatology)
industry engaged in musculoskeletal research,
Past-Chair of AOVET Educational Commitee
with total budget expenditures of over $15 mil-
NESS, MALCOM lion. He currently has a 5-year National Institutes
BVetMed, CertSAO, DipECVS, of Health R01 award with total costs of 1.8 mil- PETAZZONI, MASSIMO
FRCVS, Croft Veterinary Hospital lion dollars. Dr Nixon has been invited to present DVM, Chief of the Orthopaedic
37 Croft Road his research findings at Medical Schools and and traumatology department of the
Research Institutes in the US and abroad on over “Clinica Veterinaria Milano Sud”,
United Kingdom - Blyth NE24 2EL
70 occasions. He serves as a consultant to the Via della Liberazione 26, 20068 Peschiera
Malcolm is a 1982 graduate of the Royal Veterinary
FDA panel on Cell and Gene Therapy.
College, University of London UK. For six years or Borromeo (Mi)
so after graduation, Malcolm’s career followed an Degree in Veterinary Medicine, University of
unconventional path, with much time spent travel- NOVELLO, LORENZO Milan, Italy, July 14th 1997. Chief of the
ling in Europe, Africa, Asia and Australia funded by Med Vet, Dip ESRA, MRCVS Orthopaedic and traumatology department of the
a series of temporary and locum veterinary jobs President of the Italian Society of “Clinica Veterinaria Milano Sud”, Peschiera Bor-
mainly in mixed and farm animal practice. Realis- Veterinary Regional Anaesthesia romeo, Milano. Member of: SCIVAC, ESVOT,
ing that his real interest lay in small animal surgery, and Pain Medicine (ISVRA, at SIOVET, IEWG and VIN. AO Member. Scientif-
he settled back in his native Northumberland, ic lectures: 232 at national congresses, meetings
www.isvra.org), and clinical anaesthetist at
where along with his wife, Judith a veterinary der- and courses and 46 at International congresses.
matologist they started Croft Vets. As Croft Vets
Referenza Carobbi Novello. Address Author of 6 scientific publications. Particular inter-
grew, Malcolm pursued his interest in small animal correspondence to novello@isvra.org ests: limb alignment, stifle surgery, hybrid external
surgery, specifically orthopaedics and neuro Hertfordshire, AL9 7TA, United Kingdom fixators, Ilizarov technique, elastic internal fixa-
surgery, gaining first the RCVS Certificate in SA Graduated in 1994 (Perugia, Italy). Six year expe- tion. He developed Fixin device, the internal fixa-
orthopaedics then a Fellowship Diploma in SA rience as anaesthetist in Italy. 2002-2005 ECVAA tor with angular stabitity and conic coupling sys-
spinal disease and later passing the European Surgi- residency at Animal Health Trust (Newmarket, tem. He is the secretary of the SIOVET, the Ital-
cal Board exams in 1995. Specialist recognition by UK). 2006-2008 Part-time at Cambridge Univer- ian Society of Orthopaedics and Traumatology.
ECVS and RCVS followed. A full time referral sur- sity, locum at Dick White Referrals (Six Mile Bot- Author of the Merial “Atlas of Clinical Goniome-
geon, current research interests include Canine tom) and Oakland Small Animal Clinic (Newry, try and Radiographic Measurements of the
Elbow Disease, Joint Replacement Surgery and Ireland). 2008 Back to Italy, head of anaesthesia Canine Pelvic Limb” and Innovet “Atlante BOA,
Implant Failure. Malcolm is a partner in IVOA at Carobbi Novello Referrals (Venezia). Founding Bread Orthopaedic Oriented Approach”. Council
LLP, a group dedicated to the design and devel- member of Italian Society of Veterinary Regional Member of the AVORE (Advanced Veterinary
opment of novel veterinary orthopaedic implants. Anaesthesia and Pain Medicine (2001), ESRA Orthopaedic and Research) from 1/2010. He is a
Malcolm has contributed to several veterinary diploma in regional anaesthesia (2003), editor of passionate supporter of FC Internazionale of
orthopaedic textbooks and has published more Veterinary Regional Anaesthesia (free at www. Milano. He loves playing chess. He is training for
than 20 papers in peer reviewed journals. He is cur- isvra.org). Three papers on neuraxial (epidural the Saint Petersburg Marathon.
rently an Associate Editor for the Journal of Small and spinal) blockade and analgesia in dogs in
Animal Practice and has lectured to veterinary audi- peer reviewed international journals, and several PFEIL, INGO
ences in the UK, USA, Africa and Europe. conference abstracts on regional anaesthesia and
DVM
Target Controlled Infusions (TCI) of propofol
and opioids in small animals. Tieraerztliche Klinik, Fischhausstr. 5
NIXON, ALAN 01099 Dresden, Germany
BVSc, MS, Diplomate ACVS He studied in Munich and gave his exami-
College of Veterinary Medicine PALMER, ROSS
DVM, MS, DACVS nation in 1986. He is a german specialist
Cornell University Hospital for for surgery since 1991 and since 1993 he is
Animals, Veterinary Medical Center Associate Professor, Orthopedic
Surgery, Affiliate Faculty, School of the owner of a reveral hospital in Dresden.
Box 25, Ithaca, NY 14853-6401
Dr. Alan Nixon is Professor of Orthopedic Surgery Biomed. Engineer. Colorado State University -
and Director of The Comparative Orthopaedics VTH, 300 West Drake Road PIRAS, ALESSANDRO
Laboratory and the JD&ML Wheat Orthopaedic Fort Collins, CO 80523-1620 DVM, MRCVS, ISVS
Sports Medicine Laboratory at Cornell Universi- Dr. Palmer received his Doctor of Veterinary Med- 44 Pound Road, Newry, Co Down,
ty. He has an adjunct appointment as Professor at icine degree from Kansas State University. He com- BT358DT, Northern Ireland, UK
Colorado State University Graduate Field. He pleted an internship at The Animal Medical Cen- Alessandro graduated from the Turin University
obtained his veterinary degree from the Univer- ter in New York City. He received his small animal College of Veterinary Medicine in 1989. He com-
sity of Sydney in 1978 and completed a surgical surgical residency training and a Master of Science pleted his surgical training in the College of Vet-
residency and research degree at Colorado State degree (Physiology) from the University of Geor- erinary Medicine of the University of Parma in
University in 1983. After five years in the Depart- gia. He is a Diplomate of the American College of 1993 gaining the diploma of Specialist in Veteri-
ment of Surgical Sciences at the University of Veterinary Surgeons. He was an Assistant Profes- nary Surgery. In 1994 he spent an externship at
Florida, Dr. Nixon moved to New York in 1988 sor of Orthopedic Surgery at Texas A&M Univer- the Canine Sport Medicine Center of the Univer-
sity of Florida and at the Hollywood Animal Hos- and residency at the Ohio State University and ROBINS, GEOFF
pital in Hollywood, Miami. Owner and head Sur- became a Diplomate ACVS in 2006. In 2007 he BVetMed(hons), FACVSc
geon of Oakland Small Animal Veterinary Clin- co-founded the Comparative Orthopaedic Bio- 24 Tarcoola Street, St Lucia, Qld.,
ics: Newry Referrals, and Banbridge, Northern mechanical Laboratory, which is a research labo-
Ireland (UK). Since March 2000. Mostly dedicat- ratory involving the College of Veterinary Medi-
4067, Australia and Warrick
ed to second opinions and referred cases on trau- cine, The School of Medicine, and The College J. Bruce BVSc(dist), MVM,
matology, orthopedics and spinal. Active member of Engineering. He currently has a dual appoint- DSAS(orthopaedics), MACVSc, Veterinary
of several scientific organizations, particularly: ment as Assistant Professor at the University Specialist Orthopaedic Services, P.O. Box
SCIVAC, ESVOT and AOVET (member of the of Florida in Small Animal Orthopaedics and 14115, Hamilton, NZ
Veterinary Expert Group since 04 and Interna- Orthopaedics (human). Graduated from the Royal Veterinary College,
tional Chair of the Membership and Community He received several awards for his research in London in 1969 with an honours degree. House
development Commission). Alessandro is very stifle biomechanics and he is internationally rec- surgeon at the RVC London for 2 years followed
active as AO Faculty member and International ognized for his work on meniscal surgery in dogs. by surgical resident’s position at the University of
Speaker in several courses and conferences in His clinical interests range from total joint arthro- Guelph, Canada.
Europe, China, Australia, USA and Latin Ameri- plasty to minimally invasive orthopedic surgery. In 1973 he migrated to Australia to take a job in
ca. Main areas of interest are: fractures treatment The focus of his research is centered on biome- small animal practice in Sydney. In 1974 he took
(particularly of distal extremities), musculo tendi- chanics of joints and fracture fixation, both ex vivo the position of lecturer and later, senior lecturer
nous injuries and conditions, limb deformities cor- and in vivo. in small animal surgery at the Veterinary School
rection, Cruciate disease (TPLO), Total Hip at the University of Queensland.
Replacement, Circular and Hybrid External PROPERZI, ROBERTO In 1990 he joined a private specialist surgical
Skeletal Fixation, Feline orthopedics. Another DVM, Clinica Veterinaria practice in Brisbane. Since 1999 he has been a
area of particular interest is canine sport medicine self-employed Consultant Specialist Surgeon and
Dr. Properzi, Via Santa Maria del
and surgery. A relevant part of Alessandro’s clini- the owner of St Lucia Surgical Services, which
cal activity is dedicated to the treatment of injuries Campo, 16 b, 16035 Rapallo (GE)
Graduated in 1995 at the Institute of Surgical Clin- acts as the Australian agent for Veterinary Instru-
in high performance dogs. Hobbies: Fishing, sail- mentation (UK) and Innovative Animal Prod-
ing, free diving, growing vegetables and berries. ic of the Faculty of Veterinary Medicine, Universi-
ty of Perugia, with supervisor Professor. Mario Bat- ucts (USA).
Love cooking, books and good wine.
tistacci. From 1996 to 2002 he collaborated with the He was awarded the BSAVA Memorial Surgery
study of Dr. Giorgio Bagnasco in Bogliasco (GE). Prize in 1995, the BSAVA Simon Award for ser-
PLUHAR, ELIZABETH In 2002 he opened his own veterinary clinic in vices to surgery in 1998. In 2000 he was made
DVM, PhD, Diplomate ACVS Rapallo (GE). He is co-author in several scientific the ASAVA’s Small Animal Practitioner of the
Associate Professor, Department of articles, mainly in surgery matters. Year. He is a member of AO-Vet and has been
Veterinary Clinical Sciences involved in AO courses in Switzerland, USA,
College of Veterinary Medicine REIF, ULLRICH Japan, UK, Chile, Australia and New Zealand.
University of Minnesota, 1352 Boyd Avenue DVM, Dipl ECVS He is also on the editorial board of the VCOT
journal. Other interests include bush walking,
Saint Paul, MN. 55108 Tierklinik Dr. Reif, Schönhardterstr. golf and good food and wine.
G. Elizabeth Pluhar received her D.V.M. from 36, 73560 Böbingen, Germany
Oregon State University and earned a Master of DVM at the College of Veterinary Medicine of
Science degree in molecular biology from North- Turin, Italy 1995. Clinical Fellowship Small Ani-
SCHRAMME, MICHAEL
ern Illinois University. She earned a Ph.D. in vet- mal Surgery, Michigan State University, USA. DVM CertEO PhD Diplomate
erinary sciences/comparative orthopaedics from Surgical Internship, Universiy Zürich, Switzer- ECVS, Associate Professor Equine
the University of Wisconsin-Madison and land. AO/ASIF International Fellowship, Texas Surgery, North Carolina State
became a diplomate of the American College of A&M University, USA. Residency in Small Ani- University, College of Veterinary Medicine
Veterinary Surgeons. Dr. Pluhar received the mal Surgery, Michigan State University, USA. 4700 Hillsborough Street
prestigious William Harris Award from the Assistant Professor Orthopedic Surgery, Michi-
Orthopaedic Research Society and Harris Fel- Raleigh, NC 27606 USA
gan State University, USA. Since 2003 at the
lows Club in 2002 for outstanding work in Dr. Michael Schramme qualified from the Uni-
Tierklinik Dr. Reif, Böbingen/Schwäbisch Gmünd.
orthopaedic research related to the hip. She has versity of Ghent, Belgium, in 1985, and remained
Dr. Reif is Diplomate ACVS/ECVS, Fachtier-
received numerous awards for both oral and writ- there as an assistant in Large Animal Surgery for
arzt für Kleintiere und Chirurgie - mailto: soc-
ten presentations and scholarships in recognition 3 years. He moved to the Royal Veterinary Col-
spec@scivac.it
of her academic endeavors. She is involved with lege, University of London, as a Home of Rest
several professional organizations, including the Resident in Equine Surgery in 1988, and joined
RIGGS, CHRISTOPHER the equine surgery faculty in 1991. As a Lecturer
Society for Neuro-Oncology, the Orthopaedic
Research Society, the American College of Vet-
BVSc, PhD, DEO, DipECVS, in Equine Surgery, he started a Home of Rest
erinary Surgeons, the American Veterinary Med- MRCVS, The Hong Kong Jockey funded PhD in Equine rheumatology in 1995.
ical Association, and the Veterinary Orthopedic Club, Head of Veterinary Clinical He moved to the Centre for Equine Studies at
Society. Her research interests include improving Services, Equine Hospital, Sha Tin Racecourse the Animal Health Trust in Newmarket as senior
total joint longevity, development of bone graft New Territories, Hong Kong equine surgeon in 2000.
substitutes, and the study of osteoclasts and bone Qualified from University of Bristol (UK) 1986. In 2003 he relocated across the Atlantic and
graft incorporation. She has recently become Undertook training in large animal surgery as became visiting Assistant Professor in Large Ani-
involved in the investigation of novel gene and Intern at the Royal Veterinary College, Universi- mal Surgery at Cornell University’s Hospital for
immunotherapies for brain tumors. ty of London, UK 1986 - 1987. Undertook post- Animals in New York. In 2004 he was appointed
graduate studies into fractures in racehorses at Associate Professor of Equine Surgery at North
POWELL, SARAH the Royal Veterinary College (awarded PhD, Carolina State University.
MA VetMB MRCVS 1991). Worked in mixed and specialist equine Dr. Schramme obtained the Certificate in Equine
practice 1991-1993. Orthopaedics in 1991, the Diploma of the Euro-
Rossdales Equine Diagnostic Centre
Lecturer in Equine Surgery (Orthopaedics) Uni- pean College of Veterinary Surgeons in 1994,
Cotton End Road, Exning, Suffolk, UK RCVS specialist status in Equine Surgery
versity of Liverpool, UK 1993, promoted to
Sarah graduated from Cambridge University in (Orthopaedics) in 1997 and a PhD in equine
Senior Lecturer 1996. Worked as senior sur-
2002 and went on to Canada to complete her rheumatology in 2000. He has an interest in all
geon in a specialist equine referral hospital,
internship. After 2 years in first opinion equine aspects of large animal surgery and diagnostic
Queensland, Australia 1998-2002. Worked as
practice in the South of England, Sarah moved to imaging with special emphasis on MRI. His cur-
senior surgeon in a specialist equine referral
Rossdale & Partners in 2005 where she developed
hospital, Gloucestershire, U K 2002-2003. rent research interest is regenerating equine ten-
and now runs the magnetic resonance and com-
Appointed Head of Department of Veterinary don and ligament tissue with mesenchymal stem
puted tomographic imaging departments at Ross-
Clinical Services, Hong Kong Jockey Club, Hong cells. Michael Schramme has served as an exam-
dales Equine Diagnostic Centre.
Kong, 2003. iner for the ECVS board examinations from
Appointed Special Professor in Equine Surgery, 1999 to 2001 and was chairman of the examina-
POZZI, ANTONIO Nottingham University August 2006. Veterinary tion committee in 2001. He has served the Euro-
DMV, MS, Dipl. ACVS Services Manager for the Equestrian Events of the pean College of Veterinary Surgeons as a mem-
University of Florida 2008 Beijing Olympics Royal College of Veteri- ber of the board of Regents 2001 to 2004 and as
2015 SW 16 Ave, Florida 32610 nary Surgeons Diploma in Equine Orthopaedics treasurer since 2004. He is also past President of
Antonio Pozzi received his DMV at the Universi- in 1997. Diplomat of European College of Veteri- the European Society of Veterinary Orthopaedics
ty of Milan in 1997. He completed an internship nary Surgeons in 2000. and Traumatology.
SCHULZE, THORBEN Shortly, after Dr. Stewart worked as an equine I graduated from the University of Minnesota in
FTA für Pferde surgeon in private practice for 2 years, before 1972 with a Doctor of Veterinary Medicine. I per-
Pferdeklinik Burg Müggenhausen going back into a University practice. formed a small animal internship at the Universi-
Dr. Stewart is currently an assistant professor in ty of Georgia from 1972-1973. I performed a
GmbH, 53919 Weilerswist equine surgery at the University of Illinois. Her small animal surgery residency program at the
Thorben Schulze is a member of the veterinary
current research has been focused on the use of University of Saskatchewan from 1978-1981. I
team of the Equine Clinic Burg Mueggenhausen
tendon, bone marrow, and muscle derived prog- became a Diplomate of the American College of
GmbH which is placed between Cologne and
enitor cells for tendon and joint repair. Veterinary Surgeons in 1985. I am currently a
Bonn in Germany.
Toward this end Dr. Stewart has compared prog- Professor of Small Animal Orthopedic Surgery at
He is specialized in equine orthopedics and has
enitor cells from tendon, bone-marrow, and mus- the University of Missouri, College of Veterinary
written his thesis on the comparison of MR and
cle for their use in equine tendon repair. Medicine where I have taught and performed
CT images of the suspensory ligament in the
During the last three years Dr. Stewart served as orthopedic surgery from 1981 until the present. I
hind limb. In Mueggenhausen he is doing lame-
the scientific program chair for the Veterinary have authored 88 scientific publications and 17
ness cases, orthopedic surgeries and diagnostic
Orthopedic Society meetings and has become a book chapters. I am the chairman of 2 AO North
imaging. Since 7 years the Hallmarq distal limb
strong advocate for the World Veterinary Ortho- America courses including the Masters Osteoto-
scanner is under his responsibility. He offers con-
pedic Conference meetings that are ongoing. my course and Principles of Fracture Repair
sultation and support concerning MR to several
course in San Diego, CA.
equine clinics.
TEPIC, SLOBODAN
Kyon, Technoparkstr. 1 TURNER, THOMAS
SMITH, ROGER
Switzerland - 8005 Zürich DVM, Medical Director, Staff
MA VetMB PhD DEO DipECVS
Education: School of Mechanical Engi- Surgeon, VCA Berwyn Animal
MRCVS RCVS and European neering, U. of Zagreb, 1970-1975, Dipl. Ing.; Hospital, 2845 South Harlem
Specialist in Equine Surgery Mechanical Engineering Dpt., M.I.T., Cam- Avenue, Berwyn, Illinois 60402
(Orthopaedics), Professor of Equine Orthopaedics bridge, USA 1978-1980, M.S. in M.E.; Mechan- Dr. Tom Turner has over thirty-five years of vet-
Dept. of Veterinary Clinical Sciences ical Engineering Dpt., M.I.T., Cambridge, USA erinary surgical experience with national and
The Royal Veterinary College 1980-1982, Dr. Sci. in M.E. international recognition in orthopedics, notably
Hawkshead Lane, North Mymms Work: Teaching Assistant at the U. of Zagreb, in fracture fixation and total joint replacement.
Hatfield, Herts. AL9 7TA, U.K. School of Mech. Eng., 1976-1978; Research Assis- He has over 230 publications, book chapters, and
Roger is Professor of Equine Orthopaedics at tant at M.I.T. 1978-1982; Research Associate at the abstracts that have been presented in numerous
the Royal Veterinary College (RVC). He cur- AO Research Institute, Davos, Switzerland, 1983- scientific meetings and in peer reviewed publica-
rently divides his time equally between running 1996; Co-founder of Cutting Edge Technologies tions. He has been a member of a foremost ortho-
a specialist orthopaedic service within the RVC AG, Dietikon, Switzerland, 1991; Lecturer in the pedic research group at Rush University Medical
and continuing to direct research into equine Mechanical Eng. Dpt., M.I.T., Cambridge, 1994- Center in Chicago for the past thirty-five years.
tendon disease. 2008; Co-founder of Cancer Treatments Interna- Some areas of his research include fracture fixa-
He qualified as a veterinary surgeon from Cam- tional, Zurich, Switzerland, 1995; Full-time consul- tion, bone healing, bone response to implants,
bridge University in 1987 and, after 2 years in tant to Schering-Plough Corp., 1996-1998; Part- bone graft and graft substitutes, total joint replace-
practice, returned to academia to undertake fur- time Research Associate at the School of Vet. ment, and the effects of cemented and cementless
ther clinical training as a Resident in Equine Stud- Med., U. of Zurich, 1998-present; CEO and fixation on bone. These studies have lead to con-
ies at the Royal Veterinary College. President of KYON AG, Zurich, Switzerland, tributions in human and veterinary orthopedics,
Following his residency, he undertook a 3 year 1999-present; CTO and President of Scyon as well as innovations in fracture treatment and
research project culminating in the award of a Orthopaedics AG, Au, Switzerland, 2003-present. pioneering developments for canine total hip and
PhD for his studies on the extracellular matrix Teaching and supervisory activities: Member of facul- stifle replacement.
of equine tendon. He remained at the Royal Vet- ty teams for training courses for trauma and/or
orthopaedic surgeons by: AO/ASIF (Association
erinary College, first as a Lecturer in Equine URIZZI, ANDREA
for the Study of Internal Fixation) Foundation; -
Surgery, then as Senior Lecturer in Equine DVM, Clinica Veterinaria
Scandinavian Orthopedic Association; the M.E.
Surgery before his appointment to a Professor- “Dott. Andrea Urizzi”
Mueller Foundation, Bern, Switzerland.
ship in December 2003.
From 1987 to present, supervised research work San Michele al Tagliamento (VE)
Research: Roger’s main area of research is under-
of five doctoral and two master’s level graduate Andrea Urizzi graduated in 1978 as mechanical
standing the mechanisms of tendon ageing. He
students enrolled in graduate programs of engi- engineer in Portogruaro. He graduated in Vet-
also has projects investigating the epidemiolo-
neering schools in the U.S. and Europe, as well as erinary Medicine at the University of Bologna
gy of tendon disease in the horse, the develop-
a number of undergraduates and M.D.’s doing in 1985. From January 1986 he worked as vet-
ment of a serological assay for tendonitis, and
either their graduation thesis work, or spending erinary for small animals in San Michele al
stem cell therapy for tendons in conjunction
some time in research. Tagliamento (VE). He is the director of his own
with a commercial company, VetCell Bio-
Veterinary Clinic since 1994.
science Ltd.
TIVERS, MICKEY His main interests are in surgery, traumatology
BVSc CertSAS DipECVS and orthopedics. In November 2001 and April
STEIGMEIER, STEPHANIE 2002 he attended the University of Veterinary
DVM, Chirurgische und MRCVS, Department of Veterinary Medicine of Zurich. In 2005 he received the
Gynäkologische Kleintierklinik Clinical Sciences, Royal Veterinary approval for the utilization of the TPLO from
der LMU München College, Hawkshead Lane, North Mymms, Slocu Enterprises for the treatment of cranial
Veterinärstr. 13, 80539 München Hatfield UK cruciate ligament rupture in dogs.
Stephanie Steigmeier graduated 2007 at the Mickey qualified from the University of Bristol in Between 2005 and 2008, he developed with
Ludwig-Maximilians-University Munich, Ger- 2002. He completed a small animal internship at Massimo Petazzoni, the Fixin line of veterinary
many. Following an internship in small animal the Royal Veterinary College (RVC), followed by internal fixator angular stability and he never
surgery, she continued her post graduate train- a year working in small animal practice and a sur- stopped his researches. In 2008 he submitted
ing in veterinary anaesthesia. gical internship at the University of Bristol. Mick- three reports on preliminary experiments con-
Since 2009 Stephanie Steigmeier works in the ey completed a residency in small animal surgery cerning the internal fixation with angular stabil-
gait analysis laboratory of the Clinic of Small at the Royal Veterinary College in 2008. He is a ity systems (Fixin): two of the Italian Society of
Animal Surgery and Reproduction of the Lud- diplomate of the European College of Veterinary Veterinary Orthopaedics (SIOVET) in Cre-
wig-Maximlians-University in Munich. Surgeons and he is a European and RCVS Spe- mona, descriptive and one to the Italian Society
cialist in small animal surgery. He is currently of Traumatology and veterinary orthopedics
enjoying studying for a PhD in congenital por- (SITOV) in Modena. In 2009 he presented a
STEWART, ALLISON
tosystemic shunts in dogs. report on fractures in cats with implants Fixin in
DVM, MS, DACVS a SIOVET meeting and a report on fractures in
University of Illinois, LAC 239 TOMLINSON, JAMES the dog in the International Congress SCIVAC
1008 W Hazelwood Dr DVM, MVSci, DACVS in Rimini. He chaired a masterclass on the sys-
Urbana, Illinois 61802 USA UMC-VMTH tem Fixin for SITOV in Perugia and was
Dr. Allison Stewart completed a combined equine speaker at the National Congress SITOV frac-
surgery residency and master’s degree in 1999 at
Department of Veterinary Medicine tures in dogs and cats treated with Fixin instru-
Cornell University. and Surgery, College of Veterinary Medicine ments. Submitted a report on the mechanics
She became a boarded diplomate of the Ameri- University of Missouri, 900 East Campus Drive of locked orthopedic implants to the National
can College of Veterinary Surgeons in 2000. Columbia, MO 65211 Congress Merial in Cervia.
In 2010 he gave a report on the SIOVET bio- of Veterinary Surgeon in 1993 in Cambridge. In of Large Animal Medicine of the University of
mechanical differences between the plates and 1976 founded his veterinary practice in Cremona Berne. Since fall 1993 he is working at the Uni-
standard plates locked screws; he chaired a where he is working as a referral specialist in versity of Zurich and is in charge of the Equine
masterclss on Fixin system for SITOV in Peru- orthopaedics. President of the Italian Small Ani- Performance Centre, a clinical as well as research
gia. He is a co-author of a report on a retro- mal Veterinary Association (SCIVAC) in 1989- unit of the Equine Department. His special inter-
spective study of the series gained from the use 1991, Secretary of the European Society of ests are equine sports medicine and exercise
of internal fixator in Fixin TPLO submitted in Veterinary Orthopaedics and Traumatology physiology, diseases of the upper airways, equine
September 2008 at the European Congress of (ESVOT) from 1993 to 2004 and President from orthopaedics and biomechanics. In April 2004 he
Orthopaedics and Traumatology ESVOT. He si 2006 to 2008. Member of the Technical Com- finished his PhD on the compensatory mecha-
also co-author of a Brief Communication pub- mission of the Italian Kennel Club since 2000. nisms of weight bearing lameness in horses.
lished by VCOT in June 2010 on the concepts President of Fondazione Salute Animale (FSA) Beside several research papers in the field of
and techniques of internal fixator "Fixin". and Chairman of the FSA Panel for Canine Hip sports medicine and biomechanics, he published
Since June of 2007 he is speaker in Fixin cours- and Elbow Displasia Official Control since 1995. as editor two e-learning tools on equine upper air-
es, both national and international. His main Speaker in several national and international meet- way diseases (Equad) and on horseshoeing and
interest is the study of mechanics in orthopedic ings and Publications Author on orthopaedics, diseases of the hoof (eHoof). Dr. Weishaupt is
implants. radiology, surgery and dentistry. Founder in 2007 racetrack veterinarian and member of the veteri-
and Editor of the ESVOT educational website nary advisory board of the Swiss Horseracing
VAN RYSSEN, BERNADETTE www.orthovetsupersite.org Federation and member of the accreditation
Dep. of Medical Imaging & Small board of the European Federation of Farriers
Animal Orthopaedics, Faculty VIGUIER, ERIC Associations (EFFA).
of Veterinary Medicine Pr. Eric VIGUIER, PhD,
Ghent University, Salisburylaan 133 Dipl ECVS, Unité Chirurgie & WHITELOCK, RICHARD
9820 Merelbeke, Belgium Anesthésiologie, VetAgro Sup, BVetMed, MRCVS, DVR,
Graduated 1988 at the Ghent University, faculty Campus vétérinaire de Lyon, 1 av. Bourgelat DSAS(Orth), Dip ECVS
of Veterinary Medicine. PhD in 1996 on: 69280 Marcy l’Etoile, Lyon France Davies Veterinary Specialists
Arthroscopy in the diagnosis and treatment of Graduated from The National Veterinary School Manor Farm Business park
osteochondrosis in the dog. From 2000: Full proof Maisons-Alfort in 1982. Doctor in Veterinary Higham Gobion, Herts SG5 3HR
fessor at the Ghent University, faculty of Veteri- Medicine in 1983 “ Kidney transplantation in the Having gained my veterinary degree from the
nary Medicine, Department of Medical Imaging dog”. University Diploma of microsurgery, Uni- Royal Veterinary College, London, I spent four
and Small Animal Orthopaedics. versity of Paris VI in 1984. Specialization Certifi- years in general practice (small animal, farm ani-
Special intrests: Arthrology (diagnosis and treat- cate of Ophthalmology, Veterinary school of mal and equine). In 1993 I moved to the depart-
ment) and arthroscopy. Toulouse 1985. Assistant professor in the Depart- ment of radiology at the Royal Veterinary Col-
ment of Surgery, National Veterinary School of lege where I studied for and was awarded the
VANNINI, RICO Maisons-Alfort. (1987-2002). Master of Science in Royal College of Veterinary Surgeons’ Diploma
Dr. med. vet. Dipl. ECVS Biomechanics (ENSAM, Paris) in 1989. Diplo- in Veterinary Radiology in 1994. I completed my
Bessy’s Kleitierklinik, Dorfstr. 51, mate of the European College of Veterinary surgical residency under the tutelage of John
Switzerland - 8105 Watt Surgery (ECVS) in 1993. PhD in Biomechanics Houlton at The Queen’s Veterinary School Hos-
Rico Vannini graduated 1981 from the Universi- (University of Paris XII) “Biomechanical evalua- pital, University of Cambridge and was awarded
ty of Zürich. 1987 he completed his surgical resi- tion of the animal’s spine” in 1996. Professor of the ECVS diploma in 1997.
dency at the Ohio State University. For nine veterinary surgery, Vet Agro Sup, veterinary I specialised further in the field of orthopaedics
years he was faculty surgeon and lecturer at the campus of Lyon of Lyon in 2002. My main cen- and was awarded the Royal College of Veterinary
University of Zürich. 1994 he became Diplomate ters of interest are orthopedics and spinal surgery. Surgeons’ Diploma in Small Animal Surgery
of the European College of Veterinary Surgeons. Nevertheless I still performed many soft tissue (Orthopaedics) in 1998. Since leaving Cambridge
Since 1996 he is head of a private small animal surgeries at the vet school. Since 1990, I have also University I have been head of the orthopaedic
clinic. He is currently vice president of ESVOT. introduced and developed video assisted surgery department at Davies Veterinary Specialists. I
Since many years his is chairing the AOVET in the French vet schools. Member of the Euro- have a very active involvement with the ECVS,
courses in Davos and maintains an active interest pean College of Veterinary Surgery (ECVS) since initially as an examiner and now as a member of
in continuing education. Rico loves doing agility, 1992. Member of the G.E.C.O.V, GEC and the Board of Regents.
canine cross and skiing. He is a passionate scuba GEROS French specialized groups in orthope-
diver and birdwatcher. dics, soft tissue and ENT. Organization of many
professional trainings. 49 Indexed clinical or sci-
WILEY, RONALD G.
M.D., Ph.D.
entific publications - 70 Non indexed clinical pub-
VERDONCK, BART Professor of Neurology and Pharmacology
lications- more than 310 National or internation-
DVM al communications - 62 International Posters.
Researcher, Vanderbilt University Medical
Appelkantstraat 49, 2530 Boechout Hobbies: dreamtheater…, diving, do it yourself… Center 4A-105D, Veterans Administration Medical
Belgium, info@huisdierchirurgie.be Center, Nashville, TN 37232
Doctor in Veterinary Medicine graduated 1991, Started at Vanderbilt U in 1982 as Assistant Pro-
WEISHAUPT, MICHAEL fessor of Neurology and Pharmacology.
University of Ghent, Belgium. Main activity: DVM, PhD, Equine Department,
orthopedic surgery in referral hospital. Currently, Professor of Neurology and Pharma-
Vetsuisse Faculty, University of cology, Vanderbilt University, Nashville, TN.
Zurich, Winterthurerstrasse 260, Chief, Neurology Service and Director of Labo-
VEZZONI, ALDO
CH-8057 Zurich - Switzerland ratory of Experimental Neurology, at Tennessee
Med. Vet., S.C.M.P.A., Dipl. Dr. Michael Weishaupt graded in Veterinary Valley Healthcare System.
ECVS, Clinica Veterinaria Vezzoni Medicine in 1989 at the University of Berne. Chief Scientific Advisor and minority share hold-
Via Massarotti, 60/a Between 1990 and 1993 he worked as an assis- er, Advanced Targeting Systems, San Diego, CA.
26100 Cremona - Italy tant at the Swiss National Stud in Avenches and Member of American Neurological Association
Degree in Veterinary Medicine in 1975, Universi- accomplished his doctoral thesis on the relation- since 1994, Fellow of American Academy of Neu-
ty of Milan, specialisation degree in Small Animal ship among local structural, biochemical and rology since 1994, Member of American Pain
Medicine (S.C.M.P.A.) in 1978, University of functional variables describing muscle oxidative Society and International Association for the
Milan. Board Certified by the European College capacity in horses and steers at the Department Study of Pain (IASP) Biosketch to follow.
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01) State of the art_2010_01) State of the art_2010 02/09/10 12.12 Pagina 41
STATE OF THE ART LECTURE

ABSTRACTS
of
STATE OF THE ART
LECTURES
IN ALPHABETICAL ORDER
OF THE PRESENTING SPEAKERS
43 • WVOC 2010, Bologna (Italy), 15th - 18th September F. Barry
Stem cell therapy for tissue repair:

the stem cell-host interaction
F. Barry, M. Murphy, R. Dwyer, T. O’Brien, C. Kavanagh, G. Duffy
Regenerative Medicine Institute, National University of Ireland, Galway, Ireland
INTRODUCTION
Mesenchymal stem cells (MSCs) reside within the stromal compartment of bone marrow and other tissues.
These cells have generated a great deal of interest because of their potential use in regenerative medicine
and tissue engineering. While the therapeutic testing of these cells has progressed well, there are still many
questions to be addressed concerning the role of endogenous populations of stem cells in the adult and the
function of various stem cell niches. The purpose of this study was to evaluate the nature of the transplanted
stem cell-host interaction that underlies the therapeutic mechanism of action. Three animal models of hu-
man disease were used, each of which allows an assessment of aspects of the host response. The disease
models were (1) osteoarthritis (OA) of the knee, (2) myocardial infarction (MI) and (3) human breast can-
cer xenografts. Each of these models allows an assessment of the mode of action of the transplanted cells.
The results of these studies lead to the conclusion that neither extensive engraftment nor differentiation of
the transplanted cells are prerequisites for a useful therapeutic response.
METHODS
MSCs were isolated from bone marrow aspirates from multiple animal species, and characterised by meas-
urement of cell surface antigens. OA was induced by complete medial meniscectomy in goats and MSCs ex-
pressing GFP were delivered by intraarticular injection. MI was induced by irreversible ligation of the LAD
coronary artery in Fischer rats and PKH26-lebelled MSCs were delivered by myocardial injection. Female
athymic nude mice received a subcutaneous injection of 2x107 T47D cells. When tumors had reached a vol-
ume of 100 mm3 the mice received a subcutaneous injection of 1x106 PKH26-labelled MSCs.
Animals were sacrificed at several time points post delivery of cells and the target tissue was harvested,
processed and sectioned for histological evaluation. In the case of the infarcted rats the hearts were har-
vested, digested with a mixture of collagenase and trypsin and the resulting cell suspension was separated
by high speed cell sorting. The retrieved labelled MSCs were analysed for expression of tissue-specific and
cell-specific markers and for differentiation potential.
RESULTS
In each disease model labelled transplanted cells were observed at the site of injury (Fig. 1). Levels of en-
graftment appeared low in the OA joints and in the infarcted hearts and higher in the xenograft tumours,
even when they cells were delivered by IV infusion. Cells retrieved from the infarcted hearts up to 7 days
after delivery showed no evidence of cardiomy-
ocytic differentiation but appeared to retain the
stem cell phenotype.
DISCUSSION & CONCLUSIONS

MSCs delivered to the injured host have the ca-
pacity to migrate to the site of injury and en-
graft, although with low efficiency. Engrafted
MSCs apparently do not differentiate in a tis-
sue-specific manner, but certainly remain vi-
able. It appears unlikely that the engrafted cells
proliferate but this cannot be ruled out. These
observations suggest that the therapeutic effect
associated with MSC delivery is unrelated to
their capacity to differentiate and more likely Figure 1 - In Vivo MSC engraftment in breast tumor tissue in tumor-
associated with their capacity to deliver soluble bearing mice following injection adjacent to a T47D tumor (A-C) and in-
factors to the injured host. travenous injection (D-F).
ACKNOWLEDGEMENTS
This work was supported by Science Foundation Ireland
T.W.R. Briggs WVOC 2010, Bologna (Italy), 15th - 18th September • 44
Cartilage resurfacing with ACI and MACI:

have they stood the test of time?

T.W.R. Briggs, Prof., MD(Res), MCh(Orth), FRCS
Consultant Orthopaedic Surgeon Joint Head of Training, RNOH & Joint Medical Director
Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middx. HA7 4LP
Chondral damage to the knee is common and, if left untreated, can proceed to degenerative osteoarthritis.
In symptomatic patients established methods of management rely on the formation of fibrocartilage which
has poor resistance to shear forces. The formation of hyaline or hyaline-like cartilage may be induced by im-
planting autologous, cultured chondrocytes into the chondral or osteochondral defect.
Autologous chondrocyte implantation may be used for full-thickness chondral or osteochondral injuries
which are painful and debilitating with the aim of replacing damaged cartilage with hyaline or hyaline-like
cartilage, leading to improved function. The intermediate and long-term function and clinical results are
promising.
This talk provides a review of autologous chondrocyte implantation and describes our experience with this
technique at the Royal National Orthopaedic Hospital in the U.K.
The procedure is shown to offer statistically significant improvement with advantages over other methods
of management of chondral defects.
45 • WVOC 2010, Bologna (Italy), 15th - 18th September S. Lohmander
The injured joint and post-traumatic osteoarthritis -

What happens, what can we do for our patients?
Stefan Lohmander, MD, PhD, Professor
Department of Orthopaedics, Clinical Sciences Lund, Lund University, Sweden - stefan.lohmander@med.lu.se
Osteoarthritis (OA) is a multifactorial condition with genetic and environmental determinants. All cases are
influenced by both genetics and environment, with the distribution and weight of causes forming a contin-
uum between the extremes of predominantly genetic or predominantly environmental. For example, the risk
of post-traumatic OA after a meniscal injury of the knee is influenced by a familial history of OA, by the
presence of nodal OA of the hand (a marker of ‘generalized’ OA), by obesity, and by sex. The expression
of OA in any individual (the presence or absence of inflammation, pain, cartilage loss, bone formation, etc.)
may further be determined by the particular mix of genetic and environmental influences in that individual1.
OA in which previous joint injury is identified as an important cause is common, especially in the young
and middle-aged persons. By 10-20 years after the rupture of a cruciate ligament or meniscus of the human
knee, about half of those injured will show radiographic signs of OA, and many will have significant symp-
toms already when aged between 30 and 502-6. This represents an important clinical treatment challenge in
that there is no high-level evidence that surgical resection or reconstruction of the torn meniscus or cruciate
ligament will benefit the short-term outcome or decrease the risk of OA development, as compared to non-
surgical management7-13.
The young active person with a knee injury leading to later OA may appear straightforward to identify as
post-traumatic OA, but the contribution of additional risk factors for OA development such as family his-
tory, hand OA, and obesity must be taken into account and should form part of patient counseling2, 14. The
seemingly straightforward case definition of post-trauma OA is further muddled by the common presence
in middle-aged persons of meniscus lesions (incidental or elicited by minor sprains) associated with an in-
creased risk of knee OA development15-16. Completing the continuum, lesions of the menisci and cruciate lig-
ament are frequent in OA knees, even in the absence of a clear history of injury17-18.
From the basic research perspective, OA following joint injury offers unique opportunities for studying and in-
tervening in the earlier phases of human and animal OA development. In parallel, joint injury in the animal is
an important pre-clinical model for OA commonly used in the pharmaceutical industry in the development of
new treatments for OA19. We stand to gain much from a better understanding of post-traumatic OA.
REFERENCES
1. Dieppe PD, Lohmander LS. Pathogenesis and management of pain in osteoarthritis. Lancet 2005;365:965-73.
2. Lohmander LS, Englund M, Dahl, LL, Roos EM. The Long-term Consequence of Anterior Cruciate Ligament and
Meniscus Injuries: Osteoarthritis. Am J Sports Med 2007;35:1756-69.
3. Lohmander LS, Östenberg A, Englund M, Roos H. High prevalence of knee osteoarthritis, pain, and functional
limitations in female soccer players twelve years after anterior cruciate ligament injury. Arthritis Rheum
2004;50:3145-52.
4. Roos HP, Laurén M, Adalberth T, Jonsson K, Roos E, Lohmander LS. Knee osteoarthritis after meniscectomy.
Prevalence of radiographic changes after twenty-one years, compared with matched controls. Arthritis Rheum
1998;41:687-93.
5. Roos E, Östenberg A, Roos H, Ekdahl C, Lohmander LS. Long-term outcome of meniscectomy – Symptoms, func-
tion, and performance tests in patients with or without radiographic osteoarthritis compared to matched controls.
Osteoarthritis Cartilage 2001;9:316-24.
6. Englund M, Roos EM, Lohmander LS. Impact of type of meniscal tear on radiographic and symptomatic knee os-
teoarthritis. A 16-year follow-up of meniscectomy with matched controls. Arthritis Rheum 2003;48:2178-87.
7. Linko E, Harilainen A, Malmivaara A, Seitsalo S. Surgical versus conservative interventions for anterior cruciate
ligament ruptures in adults. Cochrane Database Syst Rev 2005:CD001356.
8. Spindler KP, Wright RW. Clinical practice. Anterior cruciate ligament tear. N Engl J Med 2008;359:2135-42.
9. Spindler KP, Kuhn JE, Freedman KB, Matthews CE, Dittus RS, Harrell FE, Jr. Anterior cruciate ligament recon-
struction autograft choice: bone-tendon-bone versus hamstring: does it really matter? A systematic review. Am J
Sports Med 2004;32:1986-95.
10. Meuffels DE, Favejee MM, Vissers MM, Heijboer MP, Reijman M, Verhaar JA. Ten year follow-up study com-
paring conservative versus operative treatment of anterior cruciate ligament ruptures. A matched-pair analysis of
high level athletes. Br J Sports Med 2009;43:347-51.
S. Lohmander WVOC 2010, Bologna (Italy), 15th - 18th September • 46
11. Moksnes H, Risberg MA. Performance-based functional evaluation of non-operative and operative treatment after
anterior cruciate ligament injury. Scand J Med Sci Sports 2009;19:345-55.

12. Biau DJ, Tournoux C, Katsahian S, Schranz PJ, Nizard RS. Bone-patellar tendon-bone autografts versus hamstring
autografts for reconstruction of anterior cruciate ligament: meta-analysis. BMJ 2006;332:995-1001.
13. Frobell RB, Roos EM, Roos HP, Ranstam J, Lohmander LS. A randomized trial of treatment for acute anterior
cruciate ligament tear. New Engl J Med 2010;in press.
14. Englund M, Paradowski P, Lohmander LS. Association of radiographic hand osteoarthritis with radiographic knee
osteoarthritis after meniscectomy. Arthritis Rheum 2004;50:469-75.
15. Englund M, Guermazi A, Lohmander LS. The role of the meniscus in knee osteoarthritis, a cause or consequence?
Radiologic Clinics North America 2009;47:703-12.
16. Englund M, Guermazi A, Lohmander LS. The meniscus in knee Osteoarthritis. Rheum Dis Clin North Am
2009;35:579-90.
17. Englund M, Guermazi A, Roemer FW, Aliabadi P, Yang M, Lewis CE, Torner J, Nevitt MC, Sack B, Felson DT.
Meniscal tear in knees without surgery and the development of radiographic osteoarthritis among middle-aged and
elderly persons: The Multicenter Osteoarthritis Study. Arthritis Rheum 2009;60:831-9.
18. Englund M, Guermazi A, Gale D, Hunter DJ, Aliabadi P, Clancy M, Felson DT. Incidental meniscal findings on
knee MRI in middle-aged and elderly persons. N Engl J Med 2008;359:1108-15.
19. Wollheim FA, Lohmander LS. Pathology and animal models of osteoarthritis. In Sharma L, Berenbaum F. Os-
teoarthritis. Philadelphia, Mosby Elsevier 2007, pp. 104-12.
02) MAIN PROGRAM_Small animal_02) Small animal_10 02/09/10 12.15 Pagina 47
MAIN PROGRAM
SMALL ANIMALS
ABSTRACTS
of
MAIN PROGRAM
SMALL ANIMALS
49 • WVOC 2010, Bologna (Italy), 15th - 18th September J.F. Bardet
Medial coronoid process fragmentation in small dogs

Jean François Bardet, DVM, Ms, DECVS
32 Rue Pierret, 92200 Neuilly sur Seine - France
INTRODUCTION
Fraggmented Medial Coronoid Process (FMCP) is a developmental disease seen most commonly in young
large breed dogs (Labradors, golden retrievers, German shepherds, Newfoulands and Chows). The disease
process starts when the animal is immature with clinical signs first becoming appearent at 5 to 7 months of
age. However, FMCP may be seen at any age. The underlying pathophysiological mechanisms resulting in
MAIN PROGRAM
SMALL ANIMALS
the development of FMCP are not well understood. However, proposed theories include osteochondrosis,
elbow joint incongruity due to trochlear notch dysplasia or asynchronous growth of the radius and ulna, fa-
tigue microdamage of the subchondral. Occasionally, FCP are seen in smal dogs. The goal of our presenta-
tion is to review all the cases of FMCP in small dogs.
MARERIALS AND METHODS

In a retrospective study over 21 years (1989-2010) 12 FMCP in12 small dogs (less than 20 kg)were evalu-
ated and treated. Each patient had a complete orthopedic examination, radiographs and 3 had an
arthroscopy of the elbow. A CT-scan was done on 7 elbows. The surgical treatment used either an arthro-
tomy (4 elbows) or an arthroscopy (7 elbows) of the medial compartment of the elbow joint associated with
a proximal dynamic ulnar osteotomy when needed (5 cases). Clinical and radiographic follow-up was done
in each patient with a mean of 2 years and 1 month (11 weeks to 12 years).
RESULTS
Nine breeds were represented in this study. There were 7 right elbow and 5 left. as well as 7 males and 5 fe-
males. The mean age was 18.6 months (yongest: 4 months and oldest 54 months). The mean weight was
10.6 kg (smallest: 4 kg and heaviest: 19kg). The cause of FMCP was associated with a short radius (5), un-
known (4), short ulna (2), and fracture (1). Previous trauma was observed in 3 patients. Osteoarthritis was
observed in 5 of the 12 elbows. The clinical result was good and excellent in 11 of the 12 dogs. The 12th
dog kept a lamness in spite of his severe radius curvus and elbow deformity.
DISCUSSION
Fragmented medial coronoid process (FMCP) has traditionally been described as a developmental disease
that most commonly affects the elbow joints of skeletally immature, rapidly-growing, large breed dogs. How-
ever, it has also been reported in some medium-size and chondrodystrophic breeds. FMCP has been de-
scribed in association with traumatic elbow injuries such as elbow luxation, distal humeral condyle fracture,
and subluxation secondary to premature closure of the distal or proximal radial physis and/or distal ulnar
physis. However, acute traumatic fracture of the medial coronoid process without any other associated le-
sion is uncommon. Recently, ‘jump down syndrome’ (JDS), or traumatic FMCP, has been described as a
common phenomenon in performance dogs. Unlike the classic condition of FMCP affecting the elbow joints
of skeletally immature, large breed dogs, JDS appears to have no age or size limitations. Although the cause
and pathogenesis of JDS have not yet been fully explained,it was proposed that abnormal repetitive loading,
such as landing from a jump, may lead to fatigue microdamage in the subchondral bone and eventual frac-
ture. Dogs with joint incongruity may be predisposed to this condition.
REFERENCES
1. Traumatic fragmented medial coronoid process in a Chihuahua. Hadley HS, Wheeler JL, Manley PA. Vet Comp
Orthop Traumatol. 2009;22(4):328-31. Epub 2009 Jun 23.
2. Use of arthroscopy for debridement of the elbow joint in cats. Staiger BA, Beale BS. J Am Vet Med Assoc. 2005
Feb 1;226(3):401-3, 376.
B.S. Beale WVOC 2010, Bologna (Italy), 15th - 18th September • 50
Failed lateral extracapsular suture stabilization

Brian S. Beale, DVM, Dipl. ACVS
Gulf Coast Veterinary Specialists, Houston, Texas
Extracapsular stabilization using a synthetic prosthetic ligament is a common means of treating a dog hav-
ing a cruciate-deficient stifle. There are over 250 described renditions of this technique to stabilize the sti-
fle. The vast number of techniques available would lead one to believe that none of the available tech-
niques are significantly superior to another. This, in fact, is the case. Nevertheless, advances have been
made in the past decade to improve the outcome using lateral extracapsular suture stabilization. Advances
MAIN PROGRAM
SMALL ANIMALS
include improvements in anatomical position of the implant, improved methods of securing the implant to
attachment points on the bone, greater implant strength and better postoperative management. Unfortu-
nately, despite these advances, complications can still be seen. Postoperative complications following later-
al suture stabilization of the stifle have been reported in a number of retrospective case series, the most re-
cent of which reported a 17.4% rate of complications in 363 procedures (Casale SA and McCarthy RJ, JAV-
MA 2009). The complications encountered included tearing of the fabello-femoral ligament, peroneal
nerve injury, joint infection, incisional infection, self-trauma, swelling and discharge, bandage related com-
plications, meniscal tear, and implant complications. Problems with the lateral suture may lead to increased
patient morbidity, including progressive osteoarthritis, instability of the stifle, infection and meniscal tears.
This lecture will discuss the complications associated with lateral extracapsular suture stabilization of the
stifle in dogs having a tear of the cranial cruciate ligament (CrCL). Decision-making and techniques used
for revision will also be presented.
FAILURE OF THE IMPLANT

The implant may fail by stretching or breaking. This can
occur due to acute overloading or cyclic loading. Acute
overloading leads to an abrupt complete tear of the lateral
suture. This typically occurs after a sudden large load is
placed on the suture. Examples would include explosive
running or jumping. Cyclic loading of the implant can
lead to elongation of the ligament due to creep or can lead
to fraying and partial tearing of the suture. Over time, the
suture may fail completely. This may occur due to several
reasons including poor positioning of the implant, inade-
quate suture strength and stiffness, excessive tension on
the implant when initially placed, excessive activity during Failure of a lateral suture can occur due to concentration of
the early postoperative period or concentration of forces at cyclic loads placed on the implant. This 4-strand TightRope
a discrete location of the suture as might occur at a crimp, failed in a 9 year old 23 kg dog having a 27° TPA.
suture anchor or edge of a bone tunnel. Complications
can be reduced by choosing suture material of adequate
strength, placing the suture at an isometric position as possible and avoiding areas of stress concentration
on the suture.
SUTURE MATERIAL
The prosthetic ligament is used to stabilize the joint and simulate the actions of the native CrCL. The
prosthetic ligament is made of monofilament or braided suture material. When using monofilament, a
heavy monofilament leader line (fishing line) is preferred. Leader line will not stretch over time to the ex-
tent that regular monofilament will.
Most surgeons prefer Mason leader line (Mason Tackle, Otisville, MI), and a variety of sizes are avail-
able. The most commonly used sizes include 80-, 60-, 40-, or 100-pound test depending on the size of pa-
tient. This material can be autoclaved one time without adverse effects. Monofilament suture has a large
amount of creep and commonly elongates. Most patients treated with a monofilament lateral suture tech-
nique will experience stretching of the suture within 2 months following surgery. If using a braided ma-
terial, it is best to use a commercial, sterile medical suture material, usually no. 2 or no. 5. Braided ma-
terials can be used effectively with few complications as long as aseptic technique is used. The newer coat-
ed braided suture materials have much greater tensile strength, less creep (stretch) and are more resistant
to infection.
51 • WVOC 2010, Bologna (Italy), 15th - 18th September B.S. Beale
The most popular suture material used for ligament repair or reconstruction is a braided polyblend poly-
ethylene suture known as Fiberwire (Arthrex Vet Systems). This material is extremely strong, has a rela-
tively small diameter, resists stretching and is resistant to abrasion. This is the material that is available
alone or on preloaded Corkscrew and Fastak anchors. Fiberwire is difficult to cut with regular suture scis-
sors and must be cut with a sharp scalpel blade or Fiberwire scissors. Fibertape is stronger than Fiberwire
and is available in a 2 mm wide strand.
Fibertape is used in the Tightrope (Arthrex Vet Systems) Anchor system. Securos has a similar braided
product called OrthoFiber used for lateral suture repair. OrthoFiber is stronger and less likely to stretch
compared to monofilament nylon and can be secured with the Securos crimp.
Crimps have been used to secure the suture following tensioning instead of a bulky knot. The crimp has
been primarily used in the past to secure heavy monofilament. Recently, crimps have become available to
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secure some of the braided sutures as well. Crimps may increase the chances of the suture breaking due to
SMALL ANIMALS
concentration of loads at the edge of the crimp or damage to the suture material.
ISOMETRIC SITES
There is not a true isometric site for a lateral placed extracapsular suture. However, there are optimal sites
of attachment that are near isometric. A recent study by Hulse et al. assessed isometric positioning of a lat-
eral extracapsular suture anchored to the lateral femoral condyle and the proximal tibia. The study evalu-
ated 2 sites on the femur (F1, F2) and 3 sites on the tibia (T1, T2, T3). The most isometric position for a
single lateral prosthetic extracapsular ligament is from the F2 site to the T3 site. If two prosthetic ligaments
are to be placed, it is recommended that one ligament run from F2 to F3 and the other from F1 to T3. Prox-
imal attachment is done around the femoropatellar ligament (F1 site) or near the origin of the lateral collat-
eral ligament on the lateral femoral condyle (F2 site). The F2 site is located at the caudal extent of the
condyle and at the same level as the distal pole of the lateral fabella of the gastrocnemius muscle. A bone
anchor should be used when anchoring the ligament to the F2 site. A bone anchor can also be used at the
F1 site or the suture may be anchored around the femorofabellar ligament. Distal attachment occurs at the
proximal tibia using a bone tunnel, just caudal to the long digital extensor tendon. The hole for attachment
should be positioned as proximal as possible in the tibia. Care should be taken to avoid drilling the hole too
distal in the tibia because this location is not isometric.
Two femoral sites and three tibial sites Prosthetic ligaments in this position are Prosthetic ligaments in these positions are
were evaluated to assess for the most iso- more isometric. less isometric.
metric position to place a prosthetic liga-
ment.
LIGAMENT ATTACHMENT
The prosthetic ligament can be attached on the femoral side directly to the femur with a bone anchor or
around the femorofabellar ligament. When securing the suture to the femorofabellar ligament it is impor-
tant to direct the suture around the bulk of the ligament rather than around the actual fabella. The ligament
is a broad tight ligament that runs form the cranial aspect of the lateral fabella to the caudal aspect of the
lateral femoral condyle. The most common mistake is for the surgeon to pass the prosthetic ligament around
the fabella and not the femorofabellar ligament. During stifle range of mo-
tion, the prosthetic ligament may shift caudal to the fabella; if this occurs,
the prosthetic ligament only encircles the muscle belly of the gastrocne-
mius muscle, which has little tensile strength. Even if the suture is passed
correctly around the femorofabellar ligament, problems can still arise. Oc-
casionally the suture may cut through the ligament resulting in loosening
of the suture and instability of the fabella.
Bone anchors provide a quick, reliable and cost-effective method of se-
curing the suture prosthesis to bone. Many different styles of veterinary
bone anchors are available. The advantage of using bone anchors is that
they can be placed with minimal invasiveness and can be placed at the rec-
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ommended isometric sites. Bone anchors have excellent pull out strength
SMALL ANIMALS
and are designed to reduce abrasion on the prosthetic ligament. Typically

the prosthetic suture is attached to a bone anchor in the femoral end of Corkscrew bone anchors (Arthrex Vet
the ligament only. The opposite end is usually attached to a bone tunnel Systems) can be used to attach a Fiber-
in the tibia. Bone anchors are simple to place and have little instrumenta- wire prosthetic CrCL to bone.
tion. An appropriate size hole is drilled in the bone and the anchor is in-
serted with a hand driver. The eyelet of the suture anchor has been de-
signed to decrease abrasion and stress concentration on the suture. De-
spite this design feature, the most common mode of failure is suture break-
age at the anchor. Anchor pull-out is possible, but is seen very infrequent-
ly with the newer anchor designs.
A bone tunnel can be used to attach the prosthetic ligament to the tibia.
One or two holes are drilled through the proximal tibia at isometric loca-
tions and the suture prosthesis is passed through the hole or holes. If one
hole is used, the suture is anchored to the medial aspect of the tibia using
a suture button before passing the suture back through the bone tunnel
and tying it to the complimentary end. If two holes are used, the suture is
passed lateral to medial through the first hole, then medial to lateral
through the second hole before tying to the complimentary end. A suture button can be used to anchor
Excessive tension should not be placed on the suture when placing the the prosthetic ligament on the medial
knot. Excessive tensioning of the suture will increase the chance of suture aspect of the tibia when using a single
failure and reduce the range of motion of the stifle due to over-constraint. bone tunnel.
The suture should be tensioned until cranial drawer motion is just elimi-
nated. It may actually be best to leave 1 or 2 mm of cranial drawer rather
than over-constrain the joint. This allows for improved range of motion and may protect the suture from ex-
cessive loads during ambulation as the center of motion of the stifle changes during gait.
Recently a new ECLT technique has been described by Cook et al. has been described for use in medium
and large size dogs. The Tightrope technique uses a Tightrope implant (Arthrex Vet Systems) to place an
extracapsular prosthetic ligament composed of 4 strands of fibertape from the F2 to T3 isometric sites. The
ligament is placed through a femoral and tibial bone tunnel and is secured using 2 suture buttons. Clinical
outcome appears favorable although limitations are expected as patient size and the tibial plateau angle in-
creases.
MENISCAL INJURY
Meniscal injury occurs in 20-80% of dogs having cranial cruciate ligament tear. Tears may be seen at the
time of surgery or following stifle stabilization. It is important to diagnose and treat meniscal tears because
untreated tears lead to pain, lameness and to a suboptimal outcome. The most commonly diagnosed menis-
cal tear is a bucket-handle tear of the medial meniscus. The bucket-handle tear of the medial meniscus may
also be the most under-diagnosed type of the meniscus as well. Many bucket-handle tears are non-displaced
or are incomplete. Accurate diagnosis requires probing and is greatly aided by magnification. Arthroscopy,
arthroscopic-assisted arthrotomy or use of surgical loops can help identify latent meniscal tears. Bucket-han-
dle tears occur rarely in the lateral meniscus. Another common tear is a crushing injury and detachment of
the caudal pole of the medial meniscus. Radial tears of the medial and lateral meniscus are also common,
but many tears of this type are not identified because magnification may be required to see them. Meniscal
tears typically occur due to excessive and repetitive cranial translation of the tibia. The caudal horn of the
medial meniscus becomes impinged by the medial femoral condyle, leading to cyclic stresses on the menis-
cus that can result in an axial tear. Meniscal tears can be avoided if stability of the stifle can be maintained.
The meniscus has a poor capacity to heal, due to a limited blood supply, which is isolated to its outer one-
third. As a result, meniscal treatment in veterinary medicine is primarily centered on preserving the grossly
normal, intact meniscus and removal of the damaged portion of the meniscus. In the rare event that the en-
tire medial meniscus is damaged, a complete meniscectomy can be performed.
PROPHYLACTIC MENISCAL TREATMENT

Latent meniscal injury is meniscal damage that is present at the initial surgery, but undetected by the sur-
geon at the time of joint exploration. A postliminary meniscal tear is one that occurs after the initial surgi-
cal procedure. Postliminary meniscal injury has been reported in 17-30% of dogs with lateral suture stabi-
lization, and 19% of dogs with a modified four-in-one over-the-top stabilization technique, at a median of 6
months following the initial stabilization procedure. Due to the relatively frequent occurrence of postlimi-
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nary meniscal tears, several options to reduce this incidence have been suggested.
SMALL ANIMALS
Some authors suggest that caudal pole hemi-meniscectomy should be routinely performed at the time of
joint exploration if the medial meniscus is grossly normal. This is probably unwise and an extreme measure
to prevent meniscal tears. In this case, removal of the caudal pole of the medial meniscus precludes the pos-
sibility of postliminary damage to the caudal pole. A meniscal release procedure can be performed at the
time of extracapsular suture stabilization to educe the potential of postliminary meniscal tears. The purpose
of the meniscal release is to allow the caudal horn of the medial meniscus to move away from the medial
femoral condyle during cranial tibial translation, preventing meniscal impingement. The incidence of
postliminary meniscal tears may be reduced to a rate as low as 1-2%. Although meniscal release appears to
be effective in reducing the rate of postliminary meniscal tears, it has the adverse affect of diminishing the
load transmission and stability functions of the meniscus (Pozzi A, et al, 2006). Thus, the efficacy of menis-
cal release at diminishing the rate of postliminary meniscal tears must be weighed against its adverse effects
on meniscal function when considering its use on clinical cases.
JOINT INFECTION
Infection of the stifle joint occurs in approximately 3.9% of cases. Clinical signs include deterioration of limb
function and stifle effusion. Commonly, these symptoms develop within the first 3-6 weeks following sur-
gery. Arthrocentesis with fluid analysis is recommended; the presence of intracellular bacteria is diagnostic.
In many cases, bacteria are not observed, however, neutrophilic inflammation with an increased white blood
cell count is evidence enough for a presumptive diagnosis, particularly if weight bearing deteriorates soon
after surgery. A culture and sensitivity should be submitted. Treatment entails systemic antibiotic adminis-
tration (4-6 weeks), and joint exploration/lavage in most cases. Repeat synoviocentesis and fluid analysis is
recommended 2-3 weeks following the end of antibiotic therapy to ensure that the infection has resolved.
INCISIONAL COMPLICATIONS
Self trauma (3.6%), swelling and discharge (3.3%), and bandage related complications (2.8%) are some of
the most frequently encountered complications following stifle stabilization. Client education is paramount
to avoid (place Elizabethan collar as needed) and recognize (proper bandage care and incisional monitoring)
these complications. Treatment can entail antibiotic therapy, and or incisional revision if clinically indicated.
POSTOPERATIVE PERIOD
Cold therapy following surgery is recommended for 24 hours. Ice packs can be applied every 6 hours for
10 minutes to reduce swelling and pain. A bandage is optional following surgery. Bandaging the leg for sev-
eral days can reduce pain, reduce swelling and prevent the patient form traumatizing the wound. Activity
should be restricted to leash walk only for 3 months. Controlled exercise can start suture removal 10-14 days
after surgery. Frequent short walks are begun. After another two weeks the patient can be walked up and
down a small set of stairs or a small hill to increase muscle strength and encourage range of motion. Swim-
ming is permissible 4 weeks after surgery. Use of a professional rehabilitation therapist is recommended if
possible.
REFERENCES
Casale SA and McCarthy RJ: Complications associated with lateral fabellotibial suture surgery for cranial cruciate liga-
ment injury in dogs: 363 cases (1997-2005). J Am Vet Med Assoc 2009; 234:229-235.
Cranial Closing Wedge Osteotomy - When to do?

Brian S. Beale1, DVM, Dipl. ACVS; Michael P. Kowaleski2, DVM, Dipl. ACVS and ECVS
1
2
Associate Professor of Small Animal Orthopedic Surgery, Cummings School of Veterinary Medicine, Tufts University
LEARNING OBJECTIVES
- Identify the indications for performing a tibial plateau leveling osteotomy with a cranial closing wedge
osteotomy (TPLO/CCWO)
- Describe the preoperative planning for a TPLO/CCWO
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SMALL ANIMALS
- Identify the major steps in performing a TPLO/CCWO
Development of proximal tibial osteotomy for the treatment of the cranial cruciate ligament deficient sti-
fle in the dog initiated a new paradigm in stifle joint stabilization. The tibial compression test was first de-
scribed by Henderson in 1978, however it was not until 1983 that the importance of cranial tibial thrust
in the biomechanics of the cranial cruciate ligament deficient stifle joint in the dog, and potentially to the
pathogenesis of rupture of the cranial cruciate ligament was identified by Slocum. This led to the devel-
opment of the cranial tibial wedge osteotomy [also referred to as tibial closing wedge ostectomy (TCWO)
or cranial closing wedge ostectomy (CCWO)] by Slocum in 1984. In this publication, Slocum attributed
the failure of intra-articular grafts or extra-articular prostheses (lateral suture) to the inability of these tech-
niques to effectively neutralize cranial tibial thrust. A later refinement of this technique, the tibial plateau
leveling osteotomy (TPLO) procedure, was described by Slocum in 1993. The aim of both procedures is
to diminish the tibial plateau angle to a magnitude at which cranial tibial thrust is neutralized, however
the position and shape of the osteotomy in each procedure results in dramatically different effects on the
proximal tibia.
The TPLO procedure allows accurate tibial plateau leveling without alteration of the tibial tuberosity or
tibial crest, and consequently, the relative position of the patella at various positions of stifle joint flexion
and extension remains essentially unchanged. In contrast to the TPLO, reduction of the proximal and dis-
tal tibial segments following the TCWO procedure results in cranio-caudal angulation of the tibial crest,
as well as cranio-distal displacement of the tibial tuberosity. As a result, the patella is positioned more dis-
tally in the trochlear groove at any given angle of stifle flexion, than preoperatively. This may be advan-
tageous when treating patella alta. The TCWO may also result in greater extension of the stifle and flex-
ion of the hock in the standing patient post-operatively, as compared to pre-operatively. This may be ad-
vantageous in the patient with a hind limb conformation demonstrating excessive stifle flexion and hock
extension. The TPLO can be combined with the CCWO procedure (TPLO/CCWO) in order to take ad-
vantage of the unique characteristics of each. Indications for TPLO/CCWO include patella alta, exces-
sive tibial plateau slope, concurrent cranial cruciate ligament rupture and medial patellar luxation with
medial displacement of the tibial tuberosity, severe torsional or angular malformation, and selected prox-
imal tibial deformities.
In cases of excessive tibial plateau slope, preoperative planning can be utilized to determine if TPLO alone
or TPLO/CCWO is required to achieve the desired postoperative tibial plateau slope. Since the tibial
plateau segment acts as a buttress for the tibial tuberosity following tibial plateau segment rotation, I elect
to perform a TPLO/CCWO in cases in which tibial plateau segment rotation following a TPLO alone
would result in a tibial plateau segment which is distal to the patellar tendon insertion on the tibial
tuberosity. A useful rule of thumb is that if appropriate rotation of the tibial plateau segment results in po-
sitioning the proximo-cranial margin of the tibial plateau segment below the level of the tibial tubercle,
consider a TPLO/CCWO. The postoperative location of the tibial plateau segment is dependent on the
position of the osteotomy; the size of the radial saw blade utilized, and the angle of rotation. Since indi-
vidual variation exists in the patellar tendon insertion point, the degree of rotation that is “safe” varies as
well; therefore the tibial plateau angle at which a TPLO/CCWO should be considered varies with indi-
vidual patient anatomy. Using the preoperative lateral view, the osteotomy can be planned, and the final
position of the tibial plateau segment can be estimated based on the distance of rotation for the appro-
priate radial saw blade (measurement from the TPLO chart).
Slocum described the use of double radial osteotomies to develop the cranially based wedge if the TPA
is greater than 34 degrees when utilizing the 24 mm TPLO saw blade. It is difficult to accurately calcu-
late the appropriate wedge angle when using the TPLO saw blade, therefore, I recommend using a cra-
nially based triangular wedge (Figure 1).
Figure 1 - A geometric method for preoperative and intraoperative planning of a

cranially based wedge. Limb Y must be parallel to and coincident with the tibial
crest, and limbs X and Y must form a right angle, A is the wedge angle. Geo-
metrically, tan A = Y/X, therefore Y = XtanA. Intraoperatively, if limb length X
is measured, XtanA is the correct length of limb Y to achieve a wedge of angle A.
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SMALL ANIMALS
The TPLO is positioned such that the center of the osteotomy lies at the proximal tibial long axis point, the
point dividing the intercondylar tubercles. The angle of the cranial closing wedge will affect the degree of
rotation required in the TPLO. The “safe” degree of rotation is such that the tibial plateau segment is at the
same level as the tibial tuberosity. This distance is measured, and the preoperative TPA that corresponds to
this distance is read from the TPLO chart, and subtracted from the patient’s TPA to determine the CCWO
angle. Alternatively, a wedge of 10 degrees can be arbitrarily chosen, and the TPLO rotation would be the
patient’s TPA-10 degrees. In cases of patella alta, the distance the patella is to be moved down the trochlear
groove is determined, and substituted as “Y” in the CCWO planning (Figure 1).
The CCWO is positioned such that the apex is placed at the caudal cortical margin of the TPLO. Intraop-
eratively, the TPLO is scored, and the proximal limb of the CCWO is positioned based on the preopera-
tive planning. Distance “X” is measured (the length of the proximal limb of the CCWO) and limb “Y” is
calculated (Figure 1), determining the appropriate position of the distal limb of the CCWO, which is then
scored. The TPLO is completed, the tibial plateau segment is rotated, and holding k-wires are placed. The
CCWO is completed, and a holding k-wire is placed from cranio-distal to caudo-proximal, avoiding the ar-
ticular surface (Figure 2). The TPLO implant(s) are placed, and tension band wire(s) are placed cranially
(Figure 2). The ostectomized CCWO wedge can be morselized and placed as autogenous cortico-cancellous
A B
Figure 2A and B - Preoperative planning (A) and postoperative lateral radiograph (B) of a TPLO/CCWO in a 74 kg Newfoundland
dog with a ruptured cranial cruciate ligament, Grade III MPL, patella alta, and a preoperative TPA of 36.5 degrees. Preoperative-
ly (A), a 10-degree CCWO is based at the caudal cortical margin of the 30 mm radius TPLO, and the TPLO is centered on the intercondylar
tubercles. The safe degree of rotation is indicated by the “X” overlying the planned TPLO. In the postoperative radiograph (B), (2) 3/32”
Steinman pins and (2) 16 gauge figure of eight tension band wires have been applied to the tibial tuberosity segment, a 3.5 mm TPLO plate
and an additional 3.5 mm LCDCP as well as an 0.062” k-wire have been applied to stabilize the tibial plateau segment. The ostectomized
portion of the proximal tibia has been morselized, and applied to the osteotomies as an autogenous bone graft.
bone graft at the osteotomy sites. Torsional correction as well as

lateralization of the tibial tuberosity segment can be accom-
plished utilizing the dual osteotomies, facilitating limb align-
ment corrections in complex cases, such as MPL with cranial
cruciate ligament rupture.
Alternatively, a CCWO can be done with a TPLO such that
the tibial tuberosity component is stabilized with the two holes
of a Synthes broad 3.5mm TPLO plate (Figure 3).
When performing the osteotomy in this manner, the osteotomy
for the TPLO and the CCWO do not intersect at the caudal
border of the tibia. The radial osteotomy intersects the caudal
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tibia approximately 1 cm proximal to the transverse osteotomy

SMALL ANIMALS
used for the CCWO.

The small segment of bone remaining at the caudal aspect of
the tibia in the tibial tuberosity segment facilitates reduction and
initially provides more stability when attempting to initially re-
duce the fragments and provide temporary stability prior to
placing the bone plate.
Postoperative exercise restriction and rehabilitation are similar
to that performed for the TPLO procedure. Complications
particular to this procedure include those of the TPLO alone,
as well as intra-articular placement of the CCWO holding k-
wire, implant failure of the tension band wire(s) or holding k-
wire, delayed union or nonunion of the CCWO, and most Figure 3 - A Synthes 3.5 mm broad TPLO plate can
commonly implant loosening of the holding k-wire or tension be used to stabilize the CCWO segment as well as the
band wire(s). TPLO segment.
REFERENCES
1. Bailey CJ, Smith BA, and Black AP: Geometric Implications of Tibial Wedge Osteotomies. 30th Annual Confer-
ence of the Veterinary Orthopedic Society, Steamboat Springs, Colorado, 2003, p 60 (abstr).
2. Kowaleski MP, Apelt D, Mattoon JS, and Litsky AS: Effect of Tibial Plateau Leveling Osteotomy Position on Cra-
nial Tibial Subluxation. 31st Annual Conference of the Veterinary Orthopedic Society, Big Sky, Montana, 2004, p
46 (abstr).
3. Kowaleski MP and McCarthy RJ: Geometric Analysis Evaluating the Effect of Tibial Plateau Leveling Osteotomy
Position on Postoperative Tibial Plateau Slope. Vet Comp Orthop Tramatol: 17: 30-34, 2004.
4. Slocum B and Devine T: Cranial Tibial Wedge Osteotomy: A Technique for Eliminating Cranial Tibial Thrust in
Cranial Cruciate Ligament Repair. J Am Vet Med Assoc 184: 564-569, 1984.
Acute FCP with normal elbow

INTRODUCTION
Some dogs with fragmented medial coronoid process (FCP) have a sudden onset of lameness and elbow
pain with little evidence of radiographic change of the elbow. “Jump-down syndrome” has been used to de-
scribe dogs affected with this condition. The most common dogs affected with this syndrome are sporting
and retriever breeds, but this condition can happen in any breed of dog. The condition is uncommom. Dogs
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SMALL ANIMALS
typically develop a FCP after activity. The cause is unknown, but two theories exist. The first is that these
dogs have traumatically dislodged an FCP or experienced microfractures of a osteochondromalacic coro-
noid. Congruity in these joints is excellent leading to hypothesize that at some point in development incon-
gruity existed. At the time incongruity was present, a fissure line or multiple fissures were created in the me-
dial coronoid. The incongruity self-corrected as the dog grew but the underlying coronoid abnormality was
established. Later in life, a traumatic incident separated the fissure line(s) leading to clinical signs. The sec-
ond theory is simply a traumatic fracture of a normal medial coronoid process.
PATIENT WORK UP
Dogs affected acute FCP syndrome typically show unilateral forelimb lameness and elbow pain. Elbow pain
can be elicited on flexion or extension depending on the dog. Direct palpation over the MCP process or
pronation of the elbow may also be painful. Affected dogs may have subtle or no obvious radiographic
changes. Standard radiographic views are typically unrewarding. Scintigraphy and CT imaging is more sen-
sitive in confirming a diagnosis. Arthroscopic assessment of the elbow is highly sensitive in identification of
fragmentation of the MCP and should be considered as a diagnostic and therapeutic option.
TREATMENT
Arthroscopic or arthroscopic-assisted treatment is recommended. Surgical intervention is warranted in all
cases and will improve clinical function in most dogs. Removal of fragments and necrotic bone of the me-
dial coronoid process is recommended. Arthroscopic or arthroscopic-assisted removal is recommended be-
cause of its low morbidity and increased precision. Removal of the fragment from the medial coronoid
process can occasionally be accomplished by simply grasping the loose fragment with a grasping forcep
while the medial joint space is opened as valgus pressure is applied by the surgical assistant. This is typical-
ly not possible without causing iatrogenic damage to the cartilage of the medial coronoid process, radial head
and medial coronoid process. Several practical tips can facilitate removal of the fragment. Sometimes the
fragment is visible, but is clearly not dislodged. Occasionally the fissure line associated with the fragment is
not initially visible. Use the probe to gently probe and rub the region of the medial coronoid process. This
maneuver will usually reveal the margins of the fragment. A small curette, probe or banana knife is used to
try to elevate the fragment to facilitate its removal. Fragment removal can be more effectively performed af-
ter removal a small portion of bone and cartilage from the medial coronoid process just cranial to the frag-
ment. A joint distractor can also be used to separate the joint space to allow more room for instrumentation
and removal of the fragment. Chondomalacia and microfractures of the subchondral bone are typically
found in this region. A curette, hand burr or power shaver can be used to remove these damaged tissues,
creating more space and improved access to remove the main fragment. The fragment may have to be re-
moved in multiple pieces, either due to the fragility of the fragment or due to the sheer size of it. Fragments
having necrotic bone and microfractures will often break into smaller fragments when grasped to remove
them. In this case the fragment is removed by passing the grasper multiple times until all the fragments are
removed. Alternatively, a power shaver can be used to remove small multiple fragments. If the fragment is
large and comprised of dense bone, it may be too large to grasp and remove in one piece. The fragment can
be broken into smaller pieces using a small osteotome or power burr. Multiple fragments are often found.
Inspect the region cranial to the radial head carefully using a probe. Many patients have multiple loose frag-
ments and they usually are found cranial to the main fragment adjacent to the radial head. Some fragments
may have a soft tissue attachment which prevents simple withdrawal of the fragment form the joint. Large
soft tissue attachments should be severed from the fragment using a banana knife, aggressive shaver blade
or small forceps. Small soft tissue attachments can often be broken down by simply twisting the fragment
360-720° while it is grasped.
P. Böttcher WVOC 2010, Bologna (Italy), 15th - 18th September • 58
In vivo kinematics of the canine stifle

P. Böttcher, J. Rey
Department of Small Animal Medicine, Faculty of Veterinary Medicine, University of Leipzig, An den Tierkliniken 23,
04103 Leipzig, Germany
INTRODUCTION
Gait analysis in dogs has traditionally been performed using force plate measurements and/or video based
kinematic gait analysis. Both by themselves or together are powerful instruments to objectively characterise
canine gait in-vivo. Whereas force plate analysis represents global limb function, video based kinematic gait
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SMALL ANIMALS
analysis provides measurements of limited precision only. So far precise measurement of in-vivo joint me-
chanics has only been performed in research dogs, using more or less invasive procedures such as external
fixators attached to the limb segments or implanted radiopaque markers (Korvick et al. 1994, Tashman und
Anderst 2003). Today most of our decisions regarding optimal treatment of the cranial cruciate ligament
(CCL) insufficient canine stifle joint are based on appreciation of global limb function in terms of lameness
and radiographically scored osteoarthritis or on in-vitro data objectifying the effect of different methods of
stabilization on cranio-caudal stability, contact area or contact pressure. Most clinicans/researchers would
certainly agree that the ultimate goal of any stabilization method would be the resoration of normal stifle
function, which is characterised by its three-dimensional kinetics and kinematics. To overcome the invasive
character of the aforementioned methods we propose the use of maker-less in-vivo fluoroscopic kinematic
gait analysis, improving our understanding of CCL pathology and its surgical treatment in dogs with natu-
rally occurring CCL rupture.
MATERIAL AND METHODS

Fluoroscopic gait analysis uses either conventional C-arms (Fig. 1a) or high-power x-ray units (Fig. 1b) to al-
low uni- or biplanar fluoroscopic analysis. A biplanar setup is preferred over uniplanar data acquisition as
the latter is of limited precision when movements occur along the x-ray beam (medio-lateral plane). This sig-
nificant methodological limitation can be eliminated by using two overlapping x-ray beams angled to each
other (Fig. 1c), doubling radiation exposure, cost and time for data analysis at the same time.
Similar to video-based kinematic gait analysis, high-frequency image acquisition is mandatory, aiming for at
least 250 images per second, electronically shuttered to 1/2000 s minimizing motion blur during rapid limb
movement. Unfortunately neither standard C-arms nor high-power x-ray units allow for such high-frequen-
cy image acquisition and therefore have to be upgraded using high-speed video cameras which significant-
ly add to the cost of the experimental setup. The estimated cost for a biplanar C-arm based system adds up
to about 100.000 € and about 1.000.000 € for a high-power biplanar system.
Because of physical image distortions introduced when using image intensifiers the obtained fluoroscopic im-
age sequences have to be undistorted prior to data analysis. Using XrayProject#, a set of MATLAB (The
#
www.xromm.org
Figure 1a - Uniplanar fluoroscopic setup using Figure 1b - Biplanar Figure 1c - Biplanar data acquisition using
a standard C-arm equipped with a high-speed setup with two high-power high-power x-ray units and a canine treadmill.
camera and a canine treadmill. x-ray units equipped with
two high-speed cameras.
59 • WVOC 2010, Bologna (Italy), 15th - 18th September P. Böttcher
MathWorks, Inc.) tools distributed freely by Brown University (Brainerd et al. 2010), image distortion as
well as image calibration can easily be performed. Using a piece of perforated stainless steel with known dis-
tribution of the perforations the distortions within the fluoroscopic images can be determined automatical-
ly and corrected accordingly. Calibration is performed using a cube with 64 radio opaque markers. This
way calibration at sub-millimetre accuracy using a direct linear transformation approach is easily feasible.
Once an appropriate image sequence of the stifle has been acquired, undistorted, and calibrated, estimation
of the 3D-pose of the femur and tibia for each of the frames of the image sequence has to be carried out.
This can be done either manually, known as scientific rotoscoping (Gatesy et al. 2010), or automatically us-
ing 2D to 3D image registration technology. In either way the experimental setup used for data acquisition
during gait analysis has to be replicated in virtual space using dedicated software. Based on CT data of the
individual femur and tibia the software generates digitally reconstructed radiographs (DRR) and compares
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them to the real fluoroscopic images. Depending on the pose of the virtual femur and tibia during calcula-
SMALL ANIMALS
tion of the DRRs the digital and the real images will fit - more or less. Based on this analysis the pose of the
bones in virtual space are altered and a new DRR computed and compared at new to the true fluoroscopic
image. This process of DRR generation and comparison is repeated until the DRRs and the real fluoro-
scopic images are identical, meaning that the pose of the bones in virtual space exactly reflects the pose of
the bones in vivo at time of image acquisition when the dog was walking on the treadmill.
RESULTS
Experiments using bone models resulted in a precision for 3D-bone pose estimation using an uniplanar set-
up of 0.31 mm for in-plane movements and 4.5 mm for out-of-plane movements. Biplanar data acquisition
resulted in a mean root square error of 0.77 mm. Under in vivo conditions precision of the method may be
slightly less, as pose estimation greatly depends on the quality of the fluoroscopic images. Due to overlap-
ping of both stifles during walking and superimposition of the stifle with other anatomical structured such
as testes and penis in intact male dogs, contrast of the images may be reduced. Investigation of arthritic sti-
fles is another issue which poses significant problems, as the contours of the bones are less distinct making
automatic 2D-3D-image registration challenging.
CONCLUSION
Fluoroscopic cinematography is a powerful and at the same time minimal-invasive tool to allow for precise
estimation of 3D bone kinematics under in vivo conditions. Our preliminary results in a small number of
dogs has changed our understanding of stifle instability, as it appears that in vivo stifle instability is pre-
dominately an non physiological caudally directed motion of the femur in relation to the tibia, and not the
other way around. Quantitative analysis of kinematic data in chronic cases of CCL rupture with periarticu-
lar fibrosis reveals that even when the stifle appears macroscopically stable significant caudal instability oc-
curs on toe touch. Even though the majority of the CCL deficient stifles experience caudal subluxation of
the femur on toe touch, in some cases subluxation already occurs during swing phase and others show a
cranio-caudal wobbling at the end of stand phase just before lift of. Regarding TPLO it appears that caudal
translation of the femur is limited compared to non operated dogs. However, whether the femoro-tibial con-
tact patterns of TPLO dogs resemble the ones of sound stifles will have to be determined in the future, an-
ticipating significant differences.
ACKNOWLEDGEMENT
Ms. Rommy Pertersohn for her technical assistance during fluoroscopic gait analysis and Prof. Dr. Martin S.
Fischer for giving access to the high-power fluoroscopic x-ray unit at the Institut für Spezielle Zoologie und Evo-
lutionsbiologie mit Phyletischem Museum, Friedrich-Schiller-Universität, Jena, Germany. This study is sup-
ported by a grant of the Gesellschaft zur Förderung Kynologischer Forschung e.V., Bonn, Germany.
REFERENCES
1. Korvick DL, Pijanowski GJ, Schaeffer DJ. (1994). Three-dimensional kinematics of the intact and cranial cruciate
ligament-deficient stifle of dogs. J Biomech 27(1):77-87.
2. Tashman S, Anderst W. (2003). In-vivo measurement of dynamic joint motion using high speed biplane radiogra-
phy and CT: application to canine ACL deficiency. J Biomech Eng 125(2):238-45.
3. Brainerd EL, Baier DB, Gatesy SM, Hedrick TL, Metzger KA, Gilbert SL, et al. (2010). X-ray reconstruction of
moving morphology (XROMM): precision, accuracy and applications in comparative biomechanics research. J Exp
Zool A Ecol Genet Physiol 313(5):262-79.
4. Gatesy SM, Baier DB, Jenkins FA, Dial KP. (2010). Scientific rotoscoping: a morphology-based method of 3-D mo-
tion analysis and visualization. J Exp Zool A Ecol Genet Physiol 313(5):244-61.
R.J. Boudrieau WVOC 2010, Bologna (Italy), 15th - 18th September • 60
Implant (surgeon???) failure

Randy J. Boudrieau, DVM, Dipl. ACVS and ECVS
Professor of Surgery, Cummings School of Veterinary Medicine at Tufts University, North Grafton, MA, USA
Fracture repair is a race that is initiated wherein one of two events occurs (whichever technique is used to
stabilize the fracture): either the bone heals or the fixation fails (the latter manifesting as either loosening or
fracture of the implant, resulting in a partial or total collapse of the fixation). Any form of fixation, if in place too
long, i.e., beyond a “window of opportunity” for the bone to progress to healing, will eventually fail; implants cannot re-
tain their strength indefinitely, as they will succumb to loosening or failure (breakage). The most important
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SMALL ANIMALS
corollary of these statements is that the fixation must provide initial stability to the bone in order to afford
the appropriate environment to not only allow bone healing to occur, but also to promote bone healing with-
in this window of opportunity. It therefore stands to reason that one of the most important factors which
contributes to uneventful bone union is the provision of adequate stability to the reduced bony fragments.
Therein lies the most common cause for fixation failure: inadequate biomechanical stability.
Each of the primary fixation methods: intramedullary pins and wires, external skeletal fixators, screws and
plates, all have a set of principles that guide their application. Following these principles provides the impe-
tus for their correct usage so as to avoid premature loosening and/or breakage, and allows the surgeon to
appropriately neutralize all the distracting forces acting on the fixation.
Unfortunately, many of the rules are ignored - primarily due to a lack of understanding of their biome-
chanical value and importance. Rather than categorizing all of the individual principles for each implant sys-
tem, the focus of this discussion is on the more commonly performed mistakes within each of the primary
fixation methods.
INTRAMEDULLARY (IM) PIN

AND WIRE FIXATION Schematic of a two-piece
Intramedullary pinning is the most commonly transverse mid-shaft
used, and abused, method of skeletal fixation. fracture. The IM pin fills
By far the most common error is the provision the entire medullary cavity
of inadequate rotational stability. A cursory at the level of the fracture
analysis into the benefits of IM pinning site. Compressive
demonstrates that its greatest usefulness is in (large arrows) and shear
the neutralization of bending forces. Shear (small arrows) forces are
forces only can be neutralized if the IM pin neutralized; however,
fills the entire medullary cavity; however, this rotational forces
method of pin insertion has detrimental effects are not neutralized
on the biologic process of fracture healing - (curved arrows).
most notably on the medullary circulation of
the bone. Compressive forces may be similar-
ly neutralized (by filling the entire medullary canal), provided bony defects or comminution are not present.
In no instance is neutralization of rotational forces addressed with the use of an IM pin. Insufficient rotational stability
with fracture repair is the most common precursor to a delayed union, or more likely, nonunion.
A second, and also quite common error, is the inadequate purchase of the implant in one of the major bony
fragments. A sufficient “hold” or “anchor” must be obtained in both major bony fragments spanning the
fracture so as to secure the fixation devices. Besides the obvious problem of simply missing the desired point
of entry in one of the bony fragments, and thus not spanning the fracture, the most common problem cen-
ters on IM pin use with metaphyseal fractures. The latter provides only a short segment of bone in which
to secure the IM pin. This results in the fixation (IM pin) backing out of the smaller bone fragment with a
subsequent loss of not only stability, but of the fracture reduction. The most common example of such in-
appropriate placement involves metaphyseal fractures of the distal femur. In this bone, an IM pin inserted
from proximally to distally will not engage a sufficient amount of the distal bone fragment - primarily as a
result of the cranial bowing of this bone. Another common error is to use an IM pin of insufficient size. Too
small a diameter of a pin allows excessive motion of the bony fragments, resulting in either the pin backing
out, or pin fracture, due to the repetitive cyclic loading forces it is subjected to.
An interlocking nail (ILN) overcomes a number of the problems encountered with an IM pin as screws or
bolts applied through the bone and nail provide the requisite neutralization of both compressive and rota-
tional forces. In addition, because of the generally bigger nail diameter (compared to an IM pin) and the
61 • WVOC 2010, Bologna (Italy), 15th - 18th September R.J. Boudrieau
purchase of the nail at both bone ends, there is improved neu-

tralization of shear forces. The screws or bolts, however, do not
purchase the nail, but simply pass through it. The bolts have a
smaller tolerance than the screws; therefore, there is less rota-
tional motion of each fragment relative to the other with the
bolts – termed “slack”. Therefore, case selection must consider
the strain theory as fractures with high strain (simple fractures
with a small gap) and the slack with the ILN combine to predis-
pose to a the development of a nonunion. Another limitation ex-
ists where the fracture must be sufficiently diaphyseal so that the
holes in the nails are not within the fracture line. In some large
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breed dogs the small size of the screw/bolt and the inherent slack
SMALL ANIMALS
of the system may predispose to screw/bolt failure. The remain-
ing issue with this method of fixation is the occasional difficulty
encountered in placing the bolt through the nail in the distal fe-
mur. Because of the long length of the aiming device, there is less
overall rigidly in the alignment of the aiming device to the nail
within the bone. Nail holes too close to the fracture site, or
screws/bolts not engaging the nail can result in implant failure
prior to healing.
Wiring techniques are all too often used with IM pinning in a misguided attempt to neutralize the distrac-
tive rotational forces in transverse or short oblique fractures. Multiple cerclage wires are satisfactorily and ap-
propriately used in long oblique fractures to neutralize rotational forces - the fracture configuration allowing the
placement of multiple points of fixation, thus distributing the load each wire must sustain. Understanding
rudimentary biomechanical principles dictates that in a transverse or short oblique fracture only a single wire
can be applied across the fracture in addition to the IM pin, thus concentrating all rotational forces to a sin-
gle point. A single wire is never sufficient to neutralize the distractive rotational forces; too much stress is concentrated
in one location with the not unexpected results of wire loosening and subsequent breakage (and loss of the
stability of the fixation). The loose wire further negatively impacts the healing process as it interferes with
one of the first steps of the biologic repair process - continually disrupting the small capillary buds attempt-
ing to re-supply and traverse the fracture site. The latter scenario almost guarantees the development of a
nonunion.
A similar problem of insufficient size often is observed with cerclage wiring techniques. An insufficiently
large wire will not provide adequate stability and also will be subjected to repetitive cyclic loading, resulting
in wire breakage.
EXTERNAL SKELETAL FIXATION

The most commonly observed problems with this technique of fixation involve a lack of understanding of
the device strength in terms of purchase into the bone, i.e., the fixation pins as the “weak link” at the bone-
pin interface. The common mistakes in dealing with the bone-pin interface involve two primary interrelat-
ed factors: insufficient number of fixation pins in each major bony fragment and inadequate purchase of
these fixation pins into the bone.
Logic dictates that the greater number of fixation pins placed in each major bony fragment, the greater dis-
persion of forces amongst these pins - thereby decreasing the reliance on each individual pin. Experimental
evidence has supported this concept within a
very practical limit, i.e., after placement of 4
fixation pins per bone fragment there is not a Fixation pins must penetrate
significant further increase in strength (e.g., 4 through both bone cortices. The
pins vs. 5 pins). A practical clinical guideline is bevel of the fixation pin in (a)
has not fully penetrated the
to place 3 to 4 pins per bone fragment. This
trans cortex; this fixation pin
apparent compromise to 3 pins simply relates placement is incorrect. The bev-
to the length and size of most bones encoun- el of the fixation pin in (b) has
tered in small animal veterinary orthopedics; fully penetrated the trans cortex
however, a minimum of 3 fixation pins always such that the outer shaft diam-
should be placed into each major bony fragment as a eter of the fixation pin is in con-
general rule. tact with the cortex; this fixa-
Logic also dictates that each fixation pin must tion pin placement is correct.
be adequately anchored in the bone. A num-
ber of techniques can be used to more than satisfactorily address this issue. The first, and most obvious, is
to ensure penetration of the fixation pins through both bone cortices.
Only threaded fixation pins should be used with an ESF. Threaded fixation pins (positive pin thread pro-
file), in which the pins are actually screwed into the bone, further enhances their ability to be anchored se-
curely. Parallel fixation pin placement may be used (parallel placement allows a greater number of pins to
be placed per fracture fragment). The technical aspect of placing all threaded pins has become much sim-
pler with the advent of two new external skeletal fixation systems in small animal orthopedics: Securos™
(Securos Inc.; Charlton, MA) and SK™ (IMEX Veterinary, Inc.; Longview, TX) systems.
The method of fixation pin insertion into the bone also is critical, and is an often overlooked, technical as-
pect of this technique. This factor pertains to the “longevity” of pin purchase. Pin “wobble” with hand in-
sertion, and heat generation with high-speed pin application using power insertion both lead to premature
MAIN PROGRAM
pin loosening with time (oval, and large, drill holes with the former, heat necrosis that results in bone re-
SMALL ANIMALS
sorption with the latter). Fixation pins should be pre-drilled with a pilot hole using a drill bit, thus ensuring
appropriate sized holes for the fixation pins, which also simultaneously avoids entry chip fractures at the site
of fixation pin insertion into the bone.
Recognizing the relative strengths of the various fixator designs (re: the differences between Types I, II and
III external skeletal fixators), but also the nuances of fixation pin size and number and connecting bar con-
figurations/designs, are especially important as they relate to the specific fractures and fracture configura-
tions. Improved frame strength also may be obtained by using all full-pins, the general philosophy with the
Securos™ system (Type II ESF). Similarly, improved frame strength also may be obtained by using half-pins,
but with larger connecting bars to the frame, the general philosophy with the SK™ system (Type Ia or Ib
ESFs).
SCREW AND PLATE FIXATION

This method of fixation is fraught with many additional problems relative to the more technical aspects as-
sociated with its use. Many fractures have been repaired with this supposedly “ideal” method of fixation,
only to result in failure due to the lack of adherence to the intricate technical details associated with the tech-
niques of its application.
As with other methods of fixation, a common problem
involves the selection of an implant that is too small,
and therefore, of insufficient strength to maintain the
stability of the reduction. General recommendations on
implant size are available; however, these are general
guidelines, and personal experience must be used as
the ultimate guide. Screws that are too small are most
often subjected to repetitive cyclic loading that result in
their breakage before bone healing has occurred. The
bending strength of a screw (bending moment of iner-
tia: I) is proportional to core diameter of the screw (I α
r4). Therefore, even when considering using cancellous
vs. cortical 3.5-mm ASIF screws, e.g., in a lateral
humeral condylar fracture, the core diameter of the
screw, 2.0-mm vs. 2.5-mm respectively, imparts a sig-
nificantly greater bending strength to the latter. This
despite the apparent limitation of the difference in
thread design for the larger core diameter screw (corti-
cal) and the potential for poorer pullout strength in
comparison with the cancellous screw, the cortical (A) Incorrect measurement of the screw length, resulting in a
screw is preferable in this instance. short screw which does not penetrate the trans cortex, results
Screw placement also is dependent upon adequate pur- in inadequate purchase - and the inability to compress the
chase into the bone. Complete penetration through to fracture (potentially a more common problem with a self-
the opposite cortex (accurate measurement), placement tapping screw). (B) The tap has not followed the axis of the
in the proper location (away from fracture lines) and drill-hole, since contact is made on the trans endosteal surface,
with proper technique (without stripping of the screw continued attempts to advance the tap result in the stripping
of the threads of the cis cortex. (C) Similar to (B), the screw
threads in the bone) are the most commonly observed
has not followed the axis of the drill-hole, and also will strip
errors. the threads of the cis cortex. All of these technical errors will
Similarly, applying plates of insufficient size (width, result in inadequate screw purchase into the bone.
thickness, and length) are common errors. The prob-
A schematic illustration of the relative forces acting with a

long lever arm (L) - compare (A) & (B) with (C) & (D).
The plate selected should span a majority of the length of the
bone in order to decrease the size of the lever arm, thereby
minimizing any potential stress riser at the end of the plate.
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SMALL ANIMALS
lems most often observed are plates that are too short. A minimal length cited in the technique manuals,
such that at least 3 screws can be placed in each major bony fragment on either side of the fracture line, of-
ten is insufficient owing to the long overall length of the bone. Any length of un-plated bone serves as a long
lever arm that adversely affects the screws or plate at the end of the bone - thus acting as a stress concen-
trator. The latter may cause screw loosening or breakage at this site, or cause a new fracture of the bone to
occur adjacent to the end of the plate. A more practical guideline, in addition to the 3-screw minimum, is to size the plate
such that it spans the majority of the length of the bone.
Converse problems to small plate size are plates that overwhelm the size of the bone. In these instances, so
much stress is removed from the bone underneath the plate that stress shielding occurs. The subsequent
bony remodeling that occurs long-term, according to Wolff’s law, results in osteopenia under the plate; once
the bone is weak enough to no longer maintain purchase of the implants (i.e., the screws in the bone), the
bone is subject to re-fracture.
Lastly, a problem most commonly observed with plates, although also observed with other implants or fix-
ation techniques, relates to fracture gaps or lack of a buttress support (i.e., the implant must brace the entire
weight as there is no bony continuity to share the applied loads). This problem most often is seen with plate
fixation due to the misconception that the high strength of the plate will circumvent this difficulty. A plate
placed across such gaps, without a buttress support, places significant stress on the implant. The latter re-
sults in an ideal stress concentrator effect where the gap at the fracture site is spanned, as the plate must sup-
port all of the applied loads. The end result is either fracture of the plate (due to repetitive cyclic loading
causing a fatigue fracture) or nonunion as a result of the continual motion at this site. A cancellous bone
graft placed in any fracture gap is an attempt to stimulate bone healing before fatigue failure of the implant
can occur, or the fracture fails to heal in its window of opportunity.
Large fracture gaps may be spanned with specially designed lengthening plates (which have no screw-holes
over a designated central span); such an implant provides greater strength than a standard plate used in this
fashion, as the latter has further stress concentration present at the open screw-holes. An alternative method
of fixation in such instances is the “plate-rod” combination. In this technique, a small diameter IM pin is first
placed within the medullary canal (pin diameter approximately 50% the diameter of the medullary canal).
A standard plate is applied (full cortical screws are necessary only at the metaphyseal ends of the bone: the
remaining screws may be monocortical, and are limited only by the presence of the IM pin). This technique
is based upon a simple mechanical engineering principle: the bending moment of inertia and will reduce
plate strain (i.e., compared to a plate used alone).
With the advent of locking plate technology there is a tendency to forget the basic rules of plating, as the
“enchantment” of the fixed angle construct seems to attract an idea whereby fewer screws can be utilized.
There may be some merit to this thought; however, a minimum of 3-4 screws per major bone fragment re-
mains recommended. The majority of the literature indicates that locking plate fixation is comparable to
standard plate fixation (and NOT superior!), except in situations where the purchase of the screws is in ques-
tion, e.g., osteopenic bone. Furthermore, in small animals, bicortical screw fixation remains recommended
over monocortical screw fixation due to the thin nature of the cortices. Monocortical screw fixation can be
used in concert with other implants, however; for example the plate/rod technique, or 2nd plating. In the for-
mer, this is no different than the techniques of the standard plate/rod; the difference with locking screws is
that the fixed angle construct makes it more difficult to place screws to pass-by the IM pin. This leads to the
faulty thinking that the pin is unnecessary, i.e., stronger fixation due to the fixed angle construct. It must be
recognized that the strength of the plate bridging the fracture is dependent on the IM pin to increase the con-
struct strength. A comparison of the plates alone demonstrates that the locking plate actually is weaker than
the standard plate due to the configuration of the screw holes (re: LCP® vs. LC-DCP®; Synthes Vet; Davos,
SW). In the past, multiple plate fixation was frowned upon due to the potential compromise to the biology
with such an invasive approach; however, the entire premise of the locking construct development was
preservation of the biology. Therefore, 2nd plate application (opposite or orthogonal) is not contraindicated,
especially in situations where a short bone length precludes the application of a sufficient number of screws
with a single plate (periarticular or periprosthetic fractures). In these instances, the application of multiple
plates attains the needed multiple screw purchase in the short bone fragment, yet spares the biology. Inter-
estingly, the only documented indications for locked plating in humans include osteopenic bone, periarticu-
lar and periprosthetic fractures.
In summary, fracture fixation will result in errors by any surgeon. Some of these errors may be unavoidable
owing to the nature of the specific fracture; however, those errors that are avoidable must be recognized and
subsequently corrected. The importance of the biomechanical limitations cannot be overemphasized (re: ad-
herence to the principles of application of each device employed!). The orthopedic surgeon must continually per-
MAIN PROGRAM
form honest retrospective evaluations of his/her repairs - both in terms of the fixation utilized and the functional out-
SMALL ANIMALS
comes obtained, and learn from the mistakes encountered.
REFERENCES
1. Aguila A Z, Manos J M, Orlansky AS: In vitro biomechanical comparison of limited contact dynamic compression
plate and locking compression plate. Vet Comp Orthop Traumatol 18:220-226, 2005.
2. Arens S, Eijer H, Schlegel U, et al: Influence of the design for fixation implants on local infection: experimental
study of dynamic compression plates versus point contact fixators in rabbits. J Orthop Trauma. 13:470-476, 1999.
3. AO Principles of Fracture Management in the Dog and Cat, Johnson AL, Houlton JEF, Vannini R (eds.). Georg
Thieme Verlag, Stuttgart; 2005.
4. AO Manual of Fracture Management. Internal Fixators: Concepts and Cases Using LCP and LISS. Wagner M,
Frigg R (eds.), Thieme, Stuttgart, 2006.
5. Boudrieau RJ. Locking plates: More questions than answers. Proceedings of the 2007 ACVS Veterinary Sympo-
sium. Chicago, Illinois. October 18-21, 2007; pp 391-394.
6. DeTora M, Kraus K. Mechanical testing of 3.5 mm locking and non-locking bone plates. Vet Comp Orthop Trau-
matol 21:318-322, 2008.
7. Greiwe RM, Archdeacon MT: Locking plate technology. J Knee Surg 20:50-55, 2007.
8. Horstman CL, Beale BS, Conzemius MG, et al: Biological Osteosynthesis Versus Traditional Anatomic Recon-
struction of 20 Long-Bone Fractures Using an Interlocking Nail: 1994–2001. Vet Surg 33:232–237, 2004.
9. Howard PE: Principles of intramedullary pin and wire fixation. Semin Vet Med Surg (Sm Anim) 6(1):52-67,1991.
10. Hulse D, Hyman W, Nori M, et al : Reduction in plate strain by addition of an intramedullary pin. Vet Surg 26:451-
459, 1997.
11. Kraus KK, Wotton HM, Rand W: Mechanical comparison of two external fixator clamp designs. Vet Surg 27:224-
230, 1998.
12. Kraus KK, Wotton HM, Boudrieau RJ, et al: Type II external fixation, using new clamps and positive-profile
threaded pins, of the radius and tibia in dogs. J Am Vet Med Assoc 212(8):1267-1270, 1998.
13. Johnson AL, Smith CW, Schaeffer DJ: Fragment reconstruction and bone plate fixation versus bridging plate fixa-
tion for treatment of highly comminuted femoral fractures in dogs: 35 cases (1987-1997). J Am Vet Med Assoc
213(8):1157-1161, 1998.
14. Perren SM, Cordley J: The concept of interfragmentary strain, in Uhthoff HK (ed): Current Concepts of Internal
Fixation of Fractures. New York, Springer-Verlag, 1980:63-77.
15. Perren SM: Evolution of the internal fixation of long bone fractures. The scientific basis of biologic internal fixa-
tion: choosing a new balance between stability and biology. J Bone Jt Surg 84B:1092-1110, 2002.
16. Reems MR, Beale BS, Hulse DA: Use of a plate-rod construct and principles of biological osteosynthesis for repair
of diaphyseal fractures in dogs and cats: 47 cases (1994-2001). J Am Vet Med Assoc 223:330-5, 2003.
17. Strauss EJ, Schwarzkopf R, Egol KA: The current status of locked plating: the good, the bad, and the ugly. J Or-
thop Trauma 22:479-486, 2008.
18. Toombs JP, Bronson DG, Ross D, et al.: The SK™ external fixation system: description of components, instru-
mentation, and application techniques. Vet Comp Orthop Traumatol 16:76-81, 2003.
19. Zura RD, Browne JA: Current concepts in locked plating. J Surg Orthop Adv 15:173-176, 2006.
Managing cruciate disease - Where are we now?

A controversy exists in the veterinary field as to which surgical technique is the best to repair a dog’s knee
that has a cranial cruciate ligament (CrCL) injury. There are many accepted surgical techniques described
(over 40 different methods) to correct the CrCL-deficient joint. Results of all of these different surgical re-
pairs indicate a reported success rate of approximately 90% (good to excellent function), regardless of the
surgical technique used. A smaller number of these surgical techniques are more commonly in use today
MAIN PROGRAM
SMALL ANIMALS
with published success rates approaching 95%. The biggest change-to-date is the trend to perform the
“functional stabilization techniques” or “geometric stabilization techniques”, such as the TPLO or TTA,
which have become the most frequently performed procedures in referral institutions – including at Tufts
University, where they are the most common surgical techniques we perform.
Adding to this controversy, however, is that currently there is no documented evidence (published scien-
tific reports) of any superiority to any one of these surgical techniques over the long-term, and the spe-
cific technique chosen primarily depends upon individual surgeon preference (ACVS survey 1999). There
has, however, been much anecdotal evidence (supported by a small unpublished clinical pilot study at
Tufts) that there may be a quicker recovery (return to full function) in a shorter period of time with the
functional techniques (TPLO or TTA). The rapid return to function is the primary reason that these lat-
ter techniques are more frequently performed at Tufts. In addition, there is anecdotal evidence from own-
er reports (not scientific data) that dogs with these techniques do better, interpreted as retuning to work
(hunting, field trials), better than dogs with the historical techniques (extracapsular and intra-articular sta-
bilizations).
The primary surgical techniques in use today by most veterinary surgeons involve some form of the lateral
suture stabilization and the osteotomy techniques. The intra-articular replacements have apparently lost pop-
ularity, but an argument can be made that this area has not been adequately evaluated, and perhaps it is the
future of repair in veterinary medicine; currently, it is the technique of choice in humans.
EXTRACAPSULAR STABILIZATION (LATERAL SUTURE/IMBRICATION)

The lateral suture stabilization procedure was first introduced in 1970. There have been numerous modifi-
cations of the original procedure, but the basic premise of the procedure remains unchanged, i.e., an extra-
articular constraint on the lateral side of the joint that prevents cranial tibial subluxation. Continued success
is predicated on the development of periarticular fibrous connective tissue to stabilize the joint long-term.
The original description that remains most popular is passing this extra-articular restraint from the lateral
fabella to a point on the tibial tuberosity (through 1-2 bone tunnels). A newer technique (Cook 2008) re-
cently has been proposed as a further improvement, the TightRope® (Arthrex Vet Systems; Frechen, Ger-
many), whereby the points of suture anchorage are postulated to be placed at isometric positions; secondly,
the material used (FiberWire®, FiberTape®; Arthrex Vet Systems) has been shown to have significantly su-
perior strength compared to previously utilized suture materials.
The major advantages proposed for this method of stabilization include its simplicity and ease of the surgi-
cal technique, short operative time, good results, low complication rate and low cost. Some of the proposed
disadvantages of anchoring this suture have been with regard to the non-isometric positioning of the lateral
fabella and bone tunnel(s) in the tibial tuberosity. This concept originally was investigated in an experi-
mental study (Hulse 2006) that attempted to define the preferred points of attachment for such a lateral su-
ture. This led to a number of procedures in which the points of attached were secured with bone anchors;
however, suture breakage became an issue (at the anchor/suture interface). The TightRope® procedure ad-
dressed the latter issue by devising a technique whereby the points of attachment at these sites were bone
tunnels rather than anchors at these same points. In addition, as previously noted, the material used was sig-
nificantly stronger than previous suture materials. Finally, this technique has been advocated as a minimal-
ly invasive method whereby the suture can be applied essentially through stab incisions. This technique has
been proposed to be a significant improvement in the application of lateral suture stabilization.
There is no question that this technique remains the most simple of the group discussed. Operative times
have generally been reported to be <1 hr, and results reported to be good or excellent in 85-93% of the cas-
es. Complications have been reported <20%, with re-operation in <8%. Cost is minimal – simply the suture
material, or the addition of ~7-17€ if a crimp-clamp system is utilized (nylon suture material). The costs do
increase for the suture material when performing a variety of the Arthrex System CrCL repair techniques:
FiberWire® ~23€ [Canine CrCL Repair Kit], FiberWire® with corkscrew anchor [Canine CrCL Repair An-
chor System] ~300€, TightRope® (FiberTape® ~145€; in addition, there is some additional expense for
technique-specific implants for the TightRope® technique: scissors, guidewire, cannulated drill, suture ten-
sioner – estimated 400€). There is no comparable data for the TightRope® procedure; however, one small
preliminary short-term study indicates a complication rate of 12.5% (Cook 2010). The recommendations for
this technique have included the bigger/heavier dogs, this despite any longer-term data, and recent published
reports that the lateral suture stabilization (standard suture technique) has increased complications in both
younger (more active) and heavier dogs (Casale 2009).
The primary issues with this technique are multiple. Is there truly an isometric point that is extra-articular?
Despite the study’s (unpublished, Hulse 2006) indications that there are preferential suture locations, this
data is not consistent with a more recent published study (Roe 2008); furthermore, these points cannot be
MAIN PROGRAM
accounted for uniformly in all dogs, i.e., differing conformations between the femurs and tibias. This infor-
SMALL ANIMALS
mation also appears to be borne out by a more recent study evaluating attachment sites and suture tension
(Fischer 2010). Also somewhat rhetorically, if in fact there exists such an isometric position outside the joint,
what anatomic structure does it mimic? The only true isometric position at the joint is in its center, either
the CrCL or caudal cruciate ligament (CaCL), and even these structures are not a single fiber, but are com-
posed of millions of strands. Based upon this fact alone, it is not surprising that instability recurs in the joint,
as a result of stretching of the implant that attempts to mimic the CrCL – or creep into the soft tissues, break-
age, or loss of the anchor point. Furthermore, placement of this suture is not functional, as it minimizes in-
ternal rotation (the normal screw-home mechanism that allows internal rotation with stifle joint flexion) and
turns the stifle joint into a simple hinge. Finally, this technique also does not address issues related to angu-
lar deformities (e.g., tibial varus or valgus, increased tibial plateau angle) should they also be present.
OSTEOTOMY TECHNIQUES (TPLO, TTA)

The TPLO was introduced ~1998, and the TTA ~2003. There has been much anecdotal evidence pre-
sented that these techniques are comparable, and offer a better alternative to the lateral suture stabilization
procedures. Both of these techniques [and others: cranial closing wedge osteotomy (CCWO), triple tibial os-
teotomy (TTO), etc.] all provide stifle joint stability by altering the stifle joint anatomy, attempting to take
advantage of the forces present to intrinsically neutralize cranial tibial thrust. Although their premise (pro-
posed mechanisms of action) may appear to be different, there is evidence to suggest that they all are effec-
tive based upon a single mechanism, re: alteration of the patellar tendon angle, which alters the tibiofemoral
shear forces, i.e., elimination of the cranial tibiofemoral shear force in stifle joint extension.
The major advantages proposed are that these techniques can be used in the most active (athletic) dogs of
large size with good to excellent results (that population of dogs with the greatest number of complications
with a lateral suture stabilization). Additionally, there are many anecdotal reports that with these techniques
the recovery is very quick, and that postoperative weight-bearing is not unusual within the first 24 hr after
surgery. Finally, there is additional anecdotal evidence that this group of athletic dogs perform close to their
pre-injury status (hunting, field trial, etc.), which has not been the case historically with other techniques.
The difference between the TPLO and TTA may indicate that the TTA corrects the cranial tibiofemoral
shear force closer to the neutral point as compared to the TPLO. This may have some ramifications on the
status of the CaCL, which becomes the primary stabilizer to the joint postoperatively. There have not been,
however, and clinical reports of untoward effects on the CaCL despite experimental findings that support
this claim. The TTA also appears to decrease retropatellar pressure and also (presumably) other joint con-
tact pressures, and patellar tendon force. The implications here may affect the postoperative findings, e.g.,
of patellar tendonitis postoperatively in TPLOs (reported incidence ~80%) and meniscal injuries, as the
TTA appears to better return intra-articular contact pressure to normal. Once again, however, there have
not been clinical reports demonstrating these possible negative effects despite experimental findings that
support these claims. As an adjunct, there is much controversy regarding the menisci, and whether – de-
spite the experimental results – the menisci should be preserved or a meniscal release be performed. It ap-
pears that meniscal injury can occur after either of these techniques, but the true incidence reported re-
mains quite variable.
Both the TPLO and TTA are complex procedures, requiring appropriate preoperative planning and accu-
rate execution of the details of the procedure. As originally described, TPLO is a relatively invasive proce-
dure where there is abundant circumferential dissection of the entire proximal aspect of the tibia, and a
greater potential for injuring some vital structures around the joint. There also are a number of surgical tech-
nical errors that can occur with TPLO. Anecdotally, TTA is considered by many to be a much simpler pro-
cedure than the TPLO. Similar comments regarding soft tissue dissection and limited coverage in the area
of the proximal tibia may be made for the TTA; however, the surgical dissection is confined to cranial por-
tion of the bone; therefore, it has been suggested that there is a much more limited possibility for iatrogenic
surgical injury with TTA. It may be argued that despite TTA also being a relatively complex procedure,
there are fewer unrecognized pitfalls that may result in postoperative problems. Regardless, much of this is
supposition as there are no reports of objective comparisons of the two surgical techniques comparing these
factors and their possible effects.
There are a few published reports that document the complication rate of TPLO (comprising a total of 1772
cases), reporting an overall complication rate of 26.3%. A re-operation rate was reported in ~ <10% of the
cases. Similarly, published reports that document the complication rate of TTA (249 total cases) report an
overall major complication rate of 12.3-38.0%. A re-operation rate of 11.3-14.0% was reported. The only uni-
fying similarity in all studies is that they represent early experience with both techniques. The majority of
the complications appeared to be the result of technical errors, underscoring the technical difficulty of the
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procedures. At this time, review of the early results and complications of both the TPLO and TTA indicate
SMALL ANIMALS
that their outcomes are very similar. There are no published clinical reports that compare the techniques,
much less the complications and outcomes with experienced surgeons that might allow a direct comparison
of the techniques and their outcome.
The osteotomy techniques require a great deal of surgical expertise, and also necessitate a good working
knowledge of fracture fixation principles in that plate fixation is required. Not only are there increased costs
pertaining to increased surgical time, but also implant costs. In general, for an average large breed dog, the
implant costs for a TTA are ~180€, whereas for a TPLO they are ~100-250€ depending upon which im-
plant manufacturer is selected and whether locking screw fixation is applied.
The major disadvantages of these techniques include their technical difficulty – as an experienced surgeon
is desired (although this does not always equate to a good result). Furthermore, there is an increased over-
all cost compared to, for example, the [standard] lateral suture technique, where an ~40% greater cost is
present. Neither technique address all of the issues previously noted (e.g., angular deformities of tibial varus
or valgus, increased tibial plateau angle), but both of these procedures can be so modified to address these
issues. The TPLO is a more versatile technique compared to the TTA whereby these anatomic abnormali-
ties may be addressed more easily with the osteotomy being performed. Even under these conditions, how-
ever, this may not be a simple procedure. Alternatively, the TTA is well suited to address simultaneous patel-
lar luxation (and patellar Alta or Baja) as the osteotomy may be transposed medial/lateral or proximal/dis-
tal simultaneously with the advancement.
INTRA-ARTICULAR STABILIZATION
This procedure was first popularized by Paatsama, using fascia lata as a replacement for the CrCL in dogs.
Many modifications were performed [with skin, various tendons and ligaments (patellar tendon)]. The tech-
nique gained greater popularity/usage in 1979 after Arnoczky reported using the medial one third of the
patella tendon and fascia lata, which was passed over-the-top of the lateral femoral condyle. This populari-
ty was not long-lived as despite a revascularization and remodeling (~20 wks) of this autograft, mechanical
stability did not always return to normal. In addition, this was a technically demanding procedure to per-
form as originally described using the patellar tendon; the latter resulted in various modifications using on-
ly fascia, but the disadvantage was lower graft strength. Various ligament augmentation devices have been
suggested to address this issue, but were not met with success. Regardless of the method, and despite anec-
dotal reports of good success, there are no published reports of long-term outcome of these techniques. This
is compounded by a relatively recent clinical study compared the intra-articular, extra-articular and tibial os-
teotomy stabilizations, with inferior results for the intra-articular technique (Conzemius 2005). This tech-
nique no longer appears to be routinely applied in dogs.
Prosthetic grafts (e.g., Gore-Tex, Dacron, etc.) also have been tried in the dog, but have been associated with
high complication and failure rates. Not only are there issue with revascularization and restitution of me-
chanical integrity over time, but issues regarding immediate postoperative fixation. The latter must minimize
graft motion and resist slippage. Placement in an isometric position also must be considered. The over-the-
top position (lateral femoral condyle) proximally, and cranial on the tibial tuberosity distally appear to be
most appropriate positions; however, a bone tunnel at the insertion of the CrCL also has been proposed as
the more anatomic position. There currently is debate about a proximal femoral tunnel as preferred to the
over-the-top position in dogs, as the former position is standardized in humans. The bone-ligament-bone
preparation has traditionally been accepted as the gold standard (Hospodar 2009). It must be recognized
that in the dog historical investigations have indicated that the femoral tunnel technique has a high failure
rate when compared to the over-the-top (OTT) position (Montgomery 1998). The femoral condyle in the
dog has greater flare than in humans, which makes finding the appropriate location of the femoral tunnel
more difficult. This assessment was the initial rationale of the OTT procedure as originally described in the
dog, i.e., less variability of the graft placement (Arnoczky 1979). It also was demonstrated that the OTT po-
sition of the graft resulted in no change to the instant-center-of-motion of the joint through varying degrees
of flexion/extension (Arnoczky 1977).
There are many issues that need to be addressed, but intuitively, if the CrCL could be replaced it would
function in the identical manner of the native CrCL, which theoretically would ameliorate the postoperative
issues with the meniscus and presumably the lack of development of osteoarthritis, which ultimately is con-
sidered the “gold standard” of success – and which currently does not exist in any of the techniques cur-
rently in use. Unfortunately, this area of investigation in the dog has received little attention.
The ideal prosthetic has yet to be developed, but there is renewed interest because of technological advances
in materials design. Perhaps one of the newer modalities – biologic scaffolds – holds some promise (e.g., silk
scaffolds) (Richmond 2010). In this scenario, the scaffold retains sufficient mechanical strength immediate-
MAIN PROGRAM
ly after implantation such that mechanical integrity is immediately restored, and over time the scaffold is re-
SMALL ANIMALS
placed by fibrous ingrowth that gradually replaces the graft while maintaining its integrity, i.e., the remod-
eling process allows a simultaneous increase in strength of the native tissue at the same rate of decline of the
strength of the resorbable graft. This approach may be the future of treatment for the CrCL deficient stifle
joint, either as a stand-alone device or a ligament augmentation device.
REFERENCES
1. Arnoczky, SP, Marshall JL. The cruciate ligaments of the canine stifle: an anatomical and functional analysis. Am
J Vet Res 38:1807-1814, 1977.
2. Arnoczky SP, Torzilli PA, Marshall JL. Biomechanical evaluation of anterior cruciate ligament repair in the dog: an
analysis of the instant center of motion. J Am Anim Hosp Assoc 13:553-558, 1977.
3. Arnoczky SP, Tarvin GP, Marshall JL, Saltzman B. The over-the-top procedure: a technique for anterior cruciate
ligament substitution in the dog. J Am Anim Hosp Assoc 15:283-290, 1979.
4. Bach BR: ACL treatment current trends and directions. [editorial] J Knee Surg 22:5, 2009.
5. Boudrieau RJ. Tibial Plateau Leveling Osteotomy or Tibial Tuberosity Advancement? [Invited Review] Vet Surg
38:1-22, 2009.
6. Casale SA, McCarthy RJ: Complications associated with lateral fabellotibial suture surgery for cranial cruciate lig-
ament injury in dogs: 363 cases (1997–2005). J Am Vet Med Assoc 234:229-235, 2009.
7. Chauvet AE, Johnson AL, Pijanowski GJ, et al: Evaluation of fibular head transposition, lateral fabellar suture, and
conservative treatment of cranial cruciate ligament rupture in large dogs: a retrospective study. J Am Anim Hosp
Assoc 32:247-255, 1996.
8. Conzemius MG, Evans RB, Besancon MF, et al: Effect of surgical technique on limb function after surgery for rup-
ture of the cranial cruciate ligament in dogs. J Am Vet Med Assoc 226:232-236, 2005.
9. Cook JL, Luther JK, Beetem J, et al: Clinical comparison of a novel extracapsular stabilization procedure and tib-
ial plateau leveling osteotomy for treatment of cranial cruciate ligament deficiency in dogs. Vet Surg 39:315-323,
2010.
10. Fischer C, Cherres M, Grevel V, et al: Effects of attachment sites and joint angles at the time of lateral suture fixa-
tion on tension in the suture for stabilization of the cranial cruciate ligament deficient stifle in dogs. Vet Surg 39:334-
342, 2010.
11. Hoffmann DE, Miller JM, Ober CP, et al. Tibial tuberosity advancement in 65 canine stifles. Vet Comp Orthop
Traumatol 19:219-227, 2006.
12. Horan RL, Toponarski I, Boepple, HE, et al: Design and characterization of a scaffold for anterior cruciate liga-
ment engineering. J Knee Surg 22:82-92, 2009.
13. Hospodar SJ, Miller MD. Controversies in ACL reconstruction: Bone-patellar tendon-bone Anterior cruciate liga-
ment reconstruction remains the gold standard. Sports Med Arthrosc Rev 17:242-246, 2009.
14. Hulse D: New concepts in extra-articular stabilization for the CCL deficient stifle. Proceedings of the 23rd ESVOT
Congress. Munich, Germany; September 7-10, 2006; pp 59-60.
15. Kim SE, Pozzi A, Kowaleski MP, et al: Tibial osteotomies for cranial cruciate ligament insufficiency in dogs. [In-
vited Review] Vet Surg 37:111–125, 2008.
16. Kousa P, Jarvinen TL, Vihavainen M, et al: The fixation strength of six hamstring tendon graft fixation devices in
anterior cruciate ligament reconstruction. Part I: femoral site. Am J Sports Med 31:174-181, 2003.
17. Lafaver S, Miller NA, Stubbs WP, et al. Tibial tuberosity advancement for stabilization of the canine cranial cruci-
ate ligament-deficient stifle joint: surgical technique, early results and complication in 101 dogs. Vet Surg 36:573-
586, 2007.
18. Maher SA, Hidaka C, Cunningham ME, et al: What’s new in orthopaedic research? [Specialty update] J Bone Joint
Surg 90:1800-1808, 2008.
19. Mascarenhas R, MacDonald PB. Anterior cruciate ligament reconstruction: a look at prosthetics-past, present and
possible future. McGill J Med 11:29-37, 2008.
20. Montgomery RD, Milton, JL, Terry GC, et al. Comparison of over-the-top and tunnel techniques for anterior cru-
ciate ligament replacement. Clin Orthop 231:144-153, 1988.
21. Moore KW, Read RA: Cranial cruciate ligament rupture in the dog--a retrospective study comparing surgical tech-
niques. Aust Vet J 72:281-285, 1995.
22. Noyes FR, Butler DL, Paulos LE, et al. Intra-articular cruciate reconstruction. I. Perspectives on graft strength, vas-
cularization, and immediate motion after replacement. Clin Orthop Rel Res 172:71-77, 1983.
23. Pacchiana PD, Morris E, Gillings SL, et al: Surgical and postoperative complications associated with tibial plateau
leveling osteotomy in dogs with cranial cruciate ligament rupture: 397 cases (1998-2001). J Am Vet Med Assoc
222:184-193, 2003.
24. Palmisano MP, Andrish JT, Olmstead ML, et al: A comparative study of the length patterns of anterior cruciate lig-
ament reconstructions in the dog and man. Vet Comp Orthop Traumatol 13:73-77, 2000.
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25. Patterson RH, Smith GK, Gregor TP, et al: Biomechanical stability of four cranial cruciate ligament repair tech-
SMALL ANIMALS
niques in the dog. Vet Surg 20:85-90, 1991.
26. Priddy NH, Tomlinson JL, Dodam JR, et al: Complications with and owner assessment of the outcome of tibial
plateau leveling osteotomy for treatment of cranial cruciate ligament rupture in dogs: 193 cases (1997-2001). J Am
Vet Med Assoc 222:1726-1732, 2003.
27. Richmond JC, Weitzel PP. Bioresorbable scaffolds for anterior cruciate ligament reconstruction: Do we need an off-
the-shelf ACL substitute? Review Article. Sports Med Arthrosc Rev 18:40-42, 2010.
28. Roe SC, Kue J, Gemma J: Isometry of potential suture attachment sites for the cranial cruciate ligament deficient
stifle. Vet Comp Orthop Tramatol 21:215-220, 2008.
29. Stauffer KD, Tuttle TA, Elkins AD, et al: Complications associated with 696 tibial plateau leveling Osteotomies
(2001-2003). J Am Anim Hosp Assoc 42:44-50, 2006.
30. Stein S, Schmoekel H. Short-term and eight to 12 months results of a tibial tuberosity advancement as treatment of
canine cranial cruciate ligament damage. J Sm Anim Pract 49:398-404, 2008.
Mandibular and maxillofacial fracture repair

The objective of treatment presented for uncomplicated mandibular and maxillary fracture repair is to pro-
vide early rigid skeletal fixation with simultaneous restoration of dental occlusion; thus achieving an imme-
diate return to full function. Techniques and devices most often described for this purpose include: in-
traosseous wire, used alone or in combination with other skeletal fixation devices, and bone plates and
screws.
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SMALL ANIMALS
MANDIBULAR FRACTURES
Application of the fixation must consider the tension and compression surfaces of the bone. All fixation de-
vices are strongest in tension (stresses parallel to the longitudinal axis of the implant); therefore, they should
be placed along these lines of tensile stress, or on the tension surface of the bone. In cases of mandibular
fractures, this location is along the alveolar border; however, the presence of the teeth will interfere with this
most optimal biomechanical location.
A) Line drawing of the mandible demonstrat-

ing bending moments, i.e., the continuum of ten-
sile to compressive stresses from oral to aboral
bone surface with closure of the jaw during nor-
mal (chewing, biting) function (medium ar-
rows). Large arrows indicate pull of the major
muscles of mastication (T, temporalis m; M,
masseter m; D, digastricus m; P, pterygoideus
m). B) With a fracture, distraction occurs at the
oral (alveolar) margin; compression occurs only
at the point of bone fragment contact (C).
Standard plate fixation of mandibular fractures is useful in

managing mid-body and some ramus fractures, especially in
cases in which there is severe comminution, tooth or bone
loss. Screw and plate fixation offers the advantages of inher-
ent three-dimensional stability; furthermore, all bone frag-
ments may be secured by neutralization or interfragmentary
compression. Compression plates (DCP; Synthes®) have
been previously recommended as the ideal method of fixa-
tion of mandibular fractures. Reconstruction plates (Syn-
thes®) also are recommended, and have the additional ad-
vantage of allowing three-dimensional bending/contouring,
in comparison to DCP plates, permitting the implant to be
contoured more closely to the shape of the mandible. Plate
fixation, however, is on the “wrong” side of the mandible due
to the anatomic restrictions related to the tooth roots, and
must be secured away from the alveolar margin, or on the
compression side of the mandible. This biomechanically un-
favorable position is overcome by supplementing this implant
with interdental wires or miniplates to provide additional fix-
ation on the tension-band surface to offset this disadvantage.
Accurate contouring and adequate screw purchase may be
difficult with these larger implants in some areas of the
mandible due to anatomic irregularities of the bone surface,
especially at the junction of the horizontal and vertical ra-
mus of the mandible. Failure to carefully match the shape of
the plate with the bone will result

in a step at the fracture site when
the plate is secured (and the
screws tightened), resulting in
secondary malocclusion. An al-
ternative to the standard plate
fixation is the miniplate design
[Synthes ® Maxillofacial]. The
miniplate design is based upon applica-
tion of the tension-band principle, plac-
ing the fixation devices along the lines
MAIN PROGRAM
of tensile stress identical to the prin-
SMALL ANIMALS
ciples applied with intraosseous
wire fixation. The small size of
these implants allows placement close to the alveolar border and screw angulation that avoids impingement
on the tooth roots. Two points of fixation may be obtained in order to more effectively neutralize all of the
distractive forces: tension-band fixation on the traction side of the bone (alveolar/oral border) and stabiliza-
tion fixation on the compression side of the bone (aboral margin); the torsional and shear forces are neu-
tralized by applying a second fixation device parallel to the first. The stability of the fixation may be further
improved by using a locking plate (e.g., AO/ASIF 2.0-mm or 2.4-mm uniLOCK® mandibular reconstruc-
tion plate), which will improve the overall purchase at the bone-plate interface.
This may be especially useful when the plate is used in buttress fashion. A locking miniplate is applied when-
ever prolonged healing is anticipated. The difference between a standard plate and a locking plate is the
mechanism of load transfer between the plate and bone. In a locking plate, because the screws are fixed with-
in the hole of the plate, frictional forces between the plate and bone are not necessary to maintain construct
stability.
MAXILLARY FRACTURES
Historically, the usual approach
for many fractures in the max-
illofacial region has been conser-
vative management, i.e., limited
or no fixation. This is most like-
ly due to the difficulty of ob-
taining adequate stabilization of
these multiple, thin bone frag-
ments. Although interfragmen-
tary wire fixation has been widely described as a method to stabilize maxillary fractures, simple interrupted
wires cannot be used in many locations.
Because the bone is very thin, overriding of the fracture fragments frequently occurs due to inadequate but-
tressing of these thin opposing bone fragments. Interfragmentary wire fixation often fails to provide the ap-
propriate stability necessary for these fractures. Most standard plating systems are too large to be applied
to the maxilla. The miniaturized plating systems are designed to achieve adequate screw fixation in these
thin bone fragments. They also may be placed adjacent to the alveolar bone margin and can provide ac-
curate three-dimensional stability to each/all bone fragments they are secured to, and further act as buttress
devices in their ability to support multiple comminuted bone fragments, or span gaps.
The midface has numerous sinuses, or air cavities, which are supported by either vertically or horizontal-
ly oriented struts of bone. These struts are referred to as “pillars” or “buttresses”, and have been illustrat-
ed in the human skull by architectural analyses. A similar anatomic construction of these trusses can be as-
sumed in the dog (and which can be demonstrated by transillumination of the skull), which form the pri-
mary pillars of reinforced bone that provide the necessary bony support of the maxillofacial region. The
buttresses are divided into three principal areas: nasomaxillary (anterior, or medial) buttress, zygomatico-
maxillary (lateral) buttress, and pterygomaxillary (posterior) buttress. The framework of these buttresses
is a triangle, which in three dimensions is a tetrahedron (3-sided pyramid). This orientation can resist dis-
tortion in any direction three-dimensionally, and reconstruction of maxillary fractures is based upon re-
building these buttresses.
An intraoral approach is employed, reflecting the gingiva away

from its attachments to the alveolar bone adjacent to the base of
the teeth. The incision should be made approximately 2-mm
from its attachment, thereby preserving an area for suture place-
ment with subsequent soft tissue closure. The entire dental ar-
cade, from the last molar to the incisors on both sides of the face
can be exposed with a single incision in the gingiva. Miniplate
location is immediately adjacent to the alveolar border. Plate lo-
cation is kept below the infraorbital foramen of the maxilla lat-
erally; similarly, the plate is kept below the nasal cartilages and
applied directly to the incisive bone rostrally. Screw placement
MAIN PROGRAM
is performed so as to avoid the tooth roots, angling the screws

SMALL ANIMALS
in between the tooth roots of the same and adjacent teeth. Clo-
sure of the gingival mucosa is not impaired by the plate due to
its low profile design. For more comminuted fractures involving
the nasal, maxillary and frontal bones, a midline surgical ap-
proach also may be performed. Regardless of the approach, oc-
clusion is used to determine accuracy of the reduction.
The maxilla is reconstructed concentrating first on the lateral,
and then medial, maxillary buttresses (in humans the medial but-
tress is addressed first in order to preserve midface height). Di-
rect reconstruction of the posterior buttress is unnecessary as the
medial buttresses will maintain correct position of the maxilla. It
is imperative that there is direct exposure of all fractures in order
to ensure accurate anatomic realignment of the bone. Each/all
bone fragments are reconstructed with the plate(s). If the bone
fragments are too small to reconstruct, they are removed, and
any gaps are spanned with a plate(s). Rigid buttress plate support
is placed while ensuring passive and accurate contouring of the
miniplate(s). The plates must be accurately and meticulously bent
into the appropriate shape in order to passively fit the contours of
the bone. If the plate is not accurately bent, the underlying bone
will be pulled toward the plate, causing a corresponding shift at
the occlusal level. A malocclusion, in addition to adversely af-
fecting function, also may result in fixation failure as abnormal
leverage is exerted against the fixation devices.
REFERENCES
1. Boudrieau RJ, Kudisch M. Miniplate fixation for repair of mandibular and maxillary fractures in 15 dogs and 3
cats. Vet Surg 25(4):277-291, 1996.
2. Boudrieau RJ. Miniplate reconstruction of severely comminuted maxillary fractures in two dogs. Vet Surg
33(2):154-163, 2004.
3. Boudrieau RJ: Fractures of the mandible, in Johnson AL, Houlton JEF (eds): in AO Principles of Fracture Man-
agement in the Dog and Cat. Stuttgart, Georg Thieme Verlag, 2005, pp 98-115.
4. Boudrieau RJ: Fractures of the maxilla, in Johnson AL, Houlton JEF (eds): in AO Principles of Fracture Manage-
ment in the Dog and Cat. Stuttgart, Georg Thieme Verlag, 2005, pp 116-129.
5. Henney LHS, Galburt RB, Boudrieau RJ. Treatment of dental injuries following craniofacial trauma. Semin Vet
Med Surg (Small Anim) 7:21-35, 1992.
6. Rudy RL, Boudrieau RJ. Maxillofacial and mandibular fractures. Semin Vet Med Surg (Small Anim) 7:3-20, 1992.
7. Tepic S, Perren SM. The biomechanics of the PC-fix internal fixator. Injury; (AO/ASIF Scientific Supplement) 26:S-
B5-10, 1995.
Treatment of large mandibular defects

Bridging reconstruction plates were the first implant used with success in the human mandible. Despite
their greater ease of use and application in this location as compared to conventional plates, the low pe-
rioperative morbidity was unfortunately followed by high long-term morbidity. It was believed that the
pressure between the bone/implant interface interfered with circulation, leading to bone resorption in this
area. This resorption led to loss of contact between the plate and bone, and subsequent instability of the
MAIN PROGRAM
SMALL ANIMALS
entire construct. The uncontrolled forces of mastication resulted in the originally well-fixed screws/fixa-
tion to become overloaded, leading to screw loosening, resulting in further bone resorption and loss of
the fixation.
One of the earliest uses of the locking plate technology was with the treatment of large mandibular de-
fects in humans using the THORP® (Titanium-coated Hollow Screw and Reconstruction Plate) system,
which was introduced in 1984 (Synthes®; Davos, SW) or repair of mandibular fractures, especially as
bridging plates for large defects, and was generally replaced by the UniLOCK® system after it was in-
troduced in 1999 (Synthes®; Davos, SW). The primary advantages of the latter are a thinner profile plate
and a simpler (2-piece) locking screw/plate design.
THORP® 2.4-mm UniLOCK®
The basic premise for this fixation type

was to change from the mixed-mode of
load transfer of standard plating systems
to a screw-only mode of load transfer. In
the former, load transfer occurs directly
between the screw and plate and the screw dependent friction
generated between the plate and the bone; in all cases contact,
or compression, between plate and bone is required. With the
locking plate systems, there is direct load transfer between the
screw and the plate so that contact, or compression, between
plate and bone is not required.
Conventional plate/screw systems require precise adaptation of
the plate to the underlying bone. Without this intimate contact,
tightening of the screws will draw the bone segments toward
the plate, resulting in alterations in the position of the osseous
segments (loss of primary reduction) and the occlusal relation-
ship. With locking plate/screw systems it becomes unnecessary
for the plate to intimately contact the underlying bone in all ar-
eas. As the screws are tightened they “lock” to the plate, thus
stabilizing the segments without the need to compress the bone
to the plate, which makes it impossible for the screw insertion
to alter the reduction.
Another potential advantage in locking plate/screw systems is
that they do not disrupt the underlying cortical bone perfusion
as much as conventional plates, which compress the undersur-
face of the plate to the cortical bone.
A third advantage to the use of locking plate/screw systems is that the screws are unlikely to loosen from
the plate (loss of secondary reduction). Conventional screws are loaded in bending, but the locking screw –
since it is locked in the plate – is in a neutral position without creating any unnecessary stresses in the bone.
This difference results in an increase of the construct yield strength with the locking screws. Finally, because
the screws are locked within the plate, implant loosening will not occur as a result of micromotion. Micro-
motion can result in screw loosening with a standard plate and screw, which then causes a loss of the fric-
tional interface between the plate and bone, the consequence of which is total implant failure. Locking
plate/screw systems have been shown to provide more stable fixation than conventional non-locking
plate/screw systems subjected to the unique environment of the high loads of mastication in a cantilevered
fashion.
The 2.4 UniLOCK® system is a locking reconstruction plate of a low profile design. Standard 2.4-mm
MAIN PROGRAM
screws (1.8-mm drill bit) or locking screws, either 2.4-mm or 3.0-mm (1.8-mm or 2.4-mm drill bit, respec-
SMALL ANIMALS
tively) can be used with these plates. The larger screw is designed as a “rescue” screw if either of the 2.4-
mm screws strip their bone threads. The locking screws have a special double-lead thread beneath the screw
head that engages and locks into the threaded holes of the plate. Plates can be cut to the appropriate lengths,
and because of the reconstruction plate configuration, may be contoured 3-dimensionally.
A 2.0-mm Locking Mandible System was introduced in 2000 (Synthes®; Davos, SW). In this system, 4 plate
sizes are available: 1.0 mm thickness X 4.8 mm width (mini), 1.3 mm thickness X 5.0 mm width (interme-
diate), 1.5 mm thickness X 6.5 mm width (large), and 2.0 mm thickness X 6.5 mm width (extra). A num-
ber of different lengths are available depending on the plate size: 20-hole mini, 12-hole intermediate, 12- and
20-hole large and extra. These plates can be cut to the desired length. The plates will accommodate both
standard and locking 2.0-mm screws. The locking screws have conical double-lead locking threads.
It is important to recognize that because of the capability for 3-dimen-

sional bending that in all of these systems the in-plane bending must
be performed first, followed by the out-of-plane bending, then finally
any twisting. Specialized instrumentation is available in order to pro-
tect the screw-holes from deformation – thus protecting the locking
mechanism (screw inserts only are available with the 2.4-mm recon-
struction plate).
These plating systems have been used in veterinary surgery identical
to their usage in humans for mandibular fracture fixation. In addition,
they have also been successfully utilized in veterinary patients for span-
ning large defects. In the latter, the addition of a variety of bone grafts
has been used so as to restore bony continuity.
With large mandibular defects in humans, various grafting tech-
niques have been used in order to re-obtain bony continuity of
the bone. The use of vascular grafts has greatly improved the re-
sults of these procedures and also reduced the number of com-
plications. Most commonly, these have been the result of tumor
ablation or severe trauma. The largest issue for such reconstruc-
tions is the unfavorable environment – due to the oral contami-
nation present – and the requirements of sufficient structural in-
tegrity/stability to counter the forces of mastication. Bone union
may be difficult to attain across large defects, especially with the
requirement of continued jaw mobility.
Both vascular and avascular (free) grafts have been used with success in mandibular reconstruction. The
main difference is the live cells that vascularized bone maintains, which are capable of regeneration and thus
providing more rapid healing and immediate structural support with early callus formation – especially in
instances where there may be a tenuous fixation. In addition, the vascularized grafts have been shown to
survive in a radiated bed with evidence of callus formation and a fully viable bone marrow. The vascular-
ized graft first used was a rib transposition. Others now commonly used include: the iliac crest, fibula, or
scapula. The success of vascularized bone grafting in clinical studies has exceeded 90%, demonstrating the
safety and reliability of mandibular reconstruction with vascularized bone. At present, in the vast majority
of mandibular reconstructions, the iliac crest, fibula, or scapula is used.
Despite the obvious advantages of vascularized bone grafts for mandibular reconstruction in humans, this
is not a practical technique in veterinary surgery. The obvious limitations include equipment (an operating
MAIN PROGRAM
microscope) and a specialized set of surgical skills (that requires specialized training and constant honing).
SMALL ANIMALS
Furthermore, there is an additional size constraint with small animal practice, as our patients are consider-
ably smaller than the human counterpart, adding to the difficulty of the technical demands of microantas-
tomic vascular techniques. Therefore, use of bone to restore immediate structural continuity in small ani-
mals has been confined to the use of avascular grafts, using primarily either rib or ulna. The basic prereq-
uisites of a free avascular bone graft include: a good (vascular) soft-tissue bed in which the graft has close
contact, and absolute mechanical stability for the graft. Autogenous cancellous grafting is recommended at
the host-graft interface to promote union by providing greater osteogenic and osteoinductive potential at
these critical sites. Despite fairly rapid healing and incorporation at the graft-host interface (~8-12 wks), com-
plete graft incorporation does not occur. The major drawback of these grafts is that large areas of bone be-
come nonviable, and the graft must be replaced by host bone, which occurs via Haversian remodeling. This
process takes much time (years) and never is 100% complete. Another potential disadvantage is the presence
of nonviable bone in a possibly infected environment. Furthermore, the degree of stability that must be pro-
vided by the fixation cannot be compromised. There is an expected loss of ~25% of the original graft size
due to the remodeling; therefore, size overcompensation must be considered at the time of the original pro-
cedure, although this may not always be possible due to the confines of the local environment. Avascular
grafts generally are limited to ~5-cm in length, as longer grafts result in necrosis at the central portion of the
graft, with subsequent structural failure.
Autogenous cancellous bone grafting can be used to span large gaps, and remains the “gold standard”; how-
ever, without structural support the fixation remains at risk for early failure due to premature implant failure,
although the use of the locking systems helps to address this issue. Once again, however, there is a limited
source of autogenous bone graft available, and alternate techniques must be applied when very large defects
are present. Banked allograft may be used to expand the size of the graft, but one drawback is the possibility
of disease transmission; this is a considerable concern in humans. In small animals, commercially available
banked bone is available in a number of forms (Veterinary Transplant Services, Inc.; Kent, WA): cancellous
bone, coritcocancellous chips, and demineralized bone matrix powder, or a combination of these substances.
Alternative options have been suggested for the reconstruction of large mandibular defects in humans due
to the high morbidity, inconvenience and cost associated with the reconstruction procedures, this despite the
current popularity of the microvascular transfer techniques. These involve the bone morphogenetic proteins
(BMPs) that have been shown to be the most effective osteoinductive growth factors both in vitro and in vi-
vo; BMP-2 and BMP-7 (OP-1) have been identified as the most potent of these, and have been reproduced
using recombinant DNA technology (recombinant human BMP’s – rhBMPs). The major limitation for their
clinical use has been the delivery system, or carrier. The carriers most often used at this time include: ce-
ramics such as tricalcium phosphate (TCP), and non-ceramics such as calcium phosphate-based cements
(CPCs), natural polymers [different forms of collagen such as: gelatin, demineralized bone matrix (DBM)],
and composites [varying combinations of synthetic and natural polymers (HA impregnated PLA sponges,
collagen-PLG-alginate, and PLGA-gelatin), or mineral components with natural polymers (collagen-TCP)].
Some of the first experimental evaluations of the rhBMPs in the mandible were performed in an experi-
mental canine mandibular defect model (2001). Subsequent studies at that time in nonhuman primates also
were shown to be effective at quickly and effectively inducing osseous regeneration of the mandible. A few
case report series have been published (off-label use) showing the success of this approach in a number of
human patients.
Similar reports also have been published in veterinary surgery, again demonstrating their utility for treat-
ment of large mandibular defects and their reconstruction with minimal complications. The rapid bone heal-
ing observed in these cases, along with the absence of serious complications, mimics those found under more
controlled experimental conditions. These cases demonstrate the tremendous promise for the treatment of
massive bony mandibular defects in the future.
⇔
26 mo PO
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SMALL ANIMALS
⇔
5-cm defect (solid arrow) spanned with 2.4-mm and 2.0-mm UniLOCK® plates with rhBMP-2 in a collagen sponge (compression re-
sistant matrix) [sponge not shown]; 26 mo PO shows defect bridged with new bone (open arrows), 6 mo after plate removal.
REFERENCES
1. Boudrieau RJ, Tidwell AT, Ullman SL, et al: Correction of mandibular nonunion and malocclusion by plate fixa-
tion and autogenous cortical bone grafts in two dogs. J Am Vet Med Assoc 204:744-750, 1994.
2. Boudrieau RJ, Mitchell S, Seeherman H: Mandibular Reconstruction of a Partial hemimandibulectomy in a dog
with severe malocclusion. Vet Surg 33:119-130, 2004.
3. Boudrieau RJ: Miniplate reconstruction of severely comminuted maxillary fractures in two dogs. Vet Surg 33:154-
163, 2004.
4. Boudrieau RJ: Fractures of the mandible, in Johnson AL, Houlton JEF (eds): in AO Principles of Fracture Man-
agement in the Dog and Cat. Stuttgart, Georg Thieme Verlag, 2005, pp 98-115.
5. Boudrieau RJ: Fractures of the maxilla, in Johnson AL, Houlton JEF (eds): in AO Principles of Fracture Manage-
ment in the Dog and Cat. Stuttgart, Georg Thieme Verlag, 2005, pp 116-129.
6. Boyne PJ: Application of bone morphogenetic proteins in the treatment of clinical oral and maxillofacial osseous
defects. J Bone Joint Surg 83A:146, 2001.
7. Boyne PJ, Salina S, Nakamura A, et al: Bone regeneration using rhBMP-2 induction in hemimandibulectomy type
defects of elderly sub-human primates. Cell Tissue Bank 7:1, 2006.
8. Carter TG, Brar PS, Tolas A, et al: Off-label use of recombinant bone morphogenetic protein-2 (rhBMP-2) foe re-
construction of mandibular bone defects in humans. J Oral Maxillofac Surg 66:1417-1425, 2008.
9. Cloakie CML, Sándor GKB: Reconstruction of 10 major mandibular defects using bioimplants containing BMP-
7. www.cda-adc.ca/jcda/vol-74/issue-1/67.html.
10. Herford AS, Boyne PJ: Reconstruction of mandibular continuity defects with bone morphogenetic protewin-2
(rhBMP-2). J Oral Maxillofac Surg 66:616-624, 2008.
11. Kirker-Head CA, Boudrieau RJ, Kraus KH: Use of bone morphogenetic proteins for augmentation of bone regen-
eration. [Reference Point] J Am Vet Med Assoc 231:1039-1055, 2007.
12. Lewis JR, Boudrieau RJ, Seeherman H, et al. Mandibular reconstruction after gunshot trauma in a dog using re-
combinant human bone morphogenetic protein-2 (rhBMP-2). J Am Vet Med Assoc 233:1598-1604, 2008.
13. Spector DI, Keating JH, Boudrieau RJ. Immediate mandibular reconstruction of a 5 cm defect using rhBMP-2 af-
ter partial mandibulectomy in a dog. Vet Surg 36:752–759, 2007.
14. Toriumi DM, Kotler HS, Luxenberg DP, et al: Mandibular reconstruction with a recombinant bone-inducing fac-
tor. Functional, histologic, and biomechanical evaluation. Arch Otolaryngol Head Neck Surg 117:1101-1112, 1991.
Advanced Locking Plate System (ALPS):

rationale, biomechanics and early clinical use
There has been a change of emphasis over the last few years with regard to the fixation of fractures, from
a mechanical to a more biologic emphasis. The phrase often used has been “biological fracture fixation”.
The philosophic change also has been towards a more “flexible” fixation with less precise, indirect meth-
MAIN PROGRAM
SMALL ANIMALS
ods of fracture reduction. The importance of the blood supply to the fracture – and the preservation of the
vasculature under the plate – is emphasized.
Porosity of bone under a plate was originally thought to be as a result of stress protection; however, the
shape of the area of the porosity did not correlate with the pattern of unloading provided by the plate, and
the transient nature of this phenomena did not equate with the continued “protection” (stress protection)
assumed to be provided by the plate. Plates with reduced contact had less porosity, and plates with more
flexibility (and thus greater bone contact) had greater temporary porosity. These findings were re-assessed
to be the result of bone remodeling secondary to bone necrosis – as a result of the loss of the vascular sup-
ply, and not remodeling changes consistent with Wolff’s law. As a result, the emphasis turned to minimal
plate contact with the bone so as to preserve the vascular supply under the plate. In addition, the more
flexible fixation applied through indirect reduction was consistent with the strain theory (described by Per-
ren) whereby small unstable gaps were avoided. Similarly, the indirect reduction methods provided a min-
imum of biologic interference at the time of implant application. This flexibility of fixation was attained by
bridging the fracture gap at greater distances and decreasing the size and material properties of the implant
[e.g., Dynamic Compression Plate (DCP®) to Low-Contact DCP (LC-DCP®) designs, and commercially
pure Titanium (cpTi) implants; Synthes®; Davos SW].
To preserve the stability at the bone-implant interface the locked construct was developed [Point Con-
tact Fixator (PC-Fix®; Synthes®; Davos SW)], which also minimized the risk of loosening and fretting
abrasion possible at the screw-plate interface; the latter also was minimized by using more corrosive-re-
sistant materials such as Ti. The issues of premature push-out of the screw in the plate, or alternatively
jamming of the locked screws (“cold-welding”) were addressed by changing from a Morse taper (PC-
Fix®) to a conical thread screw connection [e.g., Less Invasive Stabilization System (LISS®), Locking
Compression Plate (LCP®); Synthes®; Davos SW]. Finally, the local resistance to infection has been
shown to be affected by the preservation of the vascularity under the plate (DCP® vs. PC-Fix® in a rab-
bit model was shown to be 1:750).
The biomechanical properties of these locking implants were first described using the PC-Fix®. At this time,
the biomechanics of conventional plating was described as a mixed mode transfer between the bone seg-
ments and implants, whereby the bending moments and transverse forces are balanced by the reactive forces
created by compression in areas of contact, and the torsional and axial forces transferred by the screws di-
rectly or by screw-dependant friction between the implant and bone. In this usage, contact between the im-
plant and bone is required. In contrast, with the PC-Fix® the biomechanics was described as a screw-only
transfer as a result of locking the head of the screw into the plate (an “internal fixator”), whereby there is a
transfer of all moments between the screw and the implant. In addition to the decreased trauma to the bone
(vascular supply under
the plate due to the min-
imal, or point contact) DCP® PC-Fix®
as a result of the plate
application, there also
was a reduction of the
trauma to the endosteal
vascularity as a result of
placing monocortical
screws. The latter could
be applied as a result of
fixed angle construct at
this junction – provided
that the bone could with-
stand implant yielding loads (re: adequate

cortical purchase), which limits their ap- PC-Fix®
plication to the diaphysis.
The object of this preliminary device was
to be able to contour the implant and
then apply monocortical screw fixation
such that the PC-Fix® retained the versa-
tility of the conventional plating systems,
while eliminating their major drawback
of direct bone contact.
In vivo experimental data showed im-
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proved bone healing thought to be as a re-

SMALL ANIMALS
sult of the reduction of implant related damage to the bone. Although the majority of the articles published
since this time have emphasized the mechanical properties of these implants as compared to the more conven-
tional systems, it was the preservation of the blood supply that was the initiating factor in their development.
Development of these ideas over time (Synthes) moved away from the strict idea of a point fixator, due to the
assumption that the technological changes (compression plating to point-contact internal fixation) might be too
large a change for the average surgeon, to a combination of the two ideas. In the latter, the ideas behind limit-
ed contact plate application (LC-DCP®), which was a compromise of the area of bone surface subjected to the
pressures (2000-3000 N) that result from screws that compress the plate to the bone. With the addition of fixed
angle locking constructs the spherical gliding principle (DCU® of the plate hole) was abandoned (LISS®
plates). Later the “combi-hole” was introduced (LCP®) that allowed both applications in a single implant. This
combination, however, has diametrically opposed functions: compression vs. pure splinting: the conventional
plate screw closes the gap between the plate and bone while locking screws keep the plate away from the bone
surface. This combined approach does not take full advantage of either technique, which led to general rec-
ommendations to avoid using the two techniques within the same bone fragment (i.e., the combination of the
two techniques within the same bone fragment should be the exception rather than the rule). A number of
plate/screw designs have been produced that have attempted to include all of the above parameters.
The original design, and proof of concept of the PC-Fix®, both experimentally and clinically, was developed
at the AO Research Institute by Slobodan Tepic in the 1990s. The basic concepts of that plate design have
since been incorporated into the ALPS system, which was introduced by Kyon (Zürich, SW; Kyon Pharma,
Inc., Boston MA) in 2007. The design concept returns to the philosophy of point contact as opposed to min-
imal contact, thus not being totally dependent on the splinting principle of the internal fixator while retaining
the ability to use compression (interfragmentary compression when deemed appropriate), and returning to a
Ti implant, both of which were believed to enhance the biological properties to the fixation. The biologic ben-
efits proposed were: reduced damage to the blood supply, and thus increased resistance to infection and im-
proved bone healing. Because the ALPS plates minimize contact with the periosteum, the surgical insult (ia-
trogenic trauma) to the periosteum is reduced preserving bone perfusion. Endosteal vascularity also is pro-
tected by use of monocortical screw fixation. This preservation of the vascularity has been proposed to re-
duce the potential for infection and accelerate healing as compared to conventional bone plates. In addition,
since the plates are manufactured from titanium, there is improved biocompatibility with the tissues and a fur-
ther absence of fretting corrosion.
The technical features of the ALPS system include: biocompatibility due to the materials used (cpTi and Ti al-
loy), the ability to use both standard and locking screws in all plate holes, an optimal plate geometry for increased
strength, improved plate contouring in 3-dimensions due to the ability to perform both in-plane and out-of-plane
bending, and thus greater ability to utilize the plates in varying locations, and finally, specially designed instru-
mentation that allows bending (in either plane) while preserving the screw-holes such that the locking mecha-
nism is not adversely impacted. A variety of sizing is available to enable their use in all sizes of dogs and cats.
Underside of plate Bending both in-plane

and out-of-plane
Top of plate
The principle of application remains accurate contouring to the bone surface and compression of the plate
to bone; however, due to the geometry of the plate, the contact area between the plate and bone is mini-
mized. The advantage of this approach is greater construct strength in that plate contact with bone mini-
mizes the shear loads to the screws and improves the torsional resistance to failure.
Arrows and “X” indicate points of

contact with bone – note the limited
contact points to the bone while con-
tinuing to compress the plate to the
MAIN PROGRAM
SMALL ANIMALS
bone surface
The mechanical strength of these plates was designed to be comparable to similar standard plates used for
fracture fixation. The manufactured construct similarities are between the 3.5-mm TiLC-DCP and the ALPS
10. Relative sizing was adjusted from this point of reference. Original plate availability was the ALPS 5, 8
and 10. The numerical designation refers to the width (in mm) of the plate. The ALPS plates use 1.5-mm,
2.4-mm and 2.7-mm standard cortical screws, and 2.4-mm, 3.2-mm and 4.0-mm locking screws, respective-
ly, in the ALPS 5, 8 and 10. The screw sizing is designed such that the standard cortical screw may be re-
moved and replaced in the same hole with the larger locking screw. It also should be noted that insertion of
a locking screw also compresses the plate to the bone within the final seating of the screw into the locking
taper of the plate. An ALPS 11 also is available (2009) that uses the same screws as the ALPS 10; more re-
cently an ALPS 6.5 has been introduced (2010) that uses the same screws as the ALPS 5.
Plate application is performed after reduction is obtained (either anatomic or non-anatomic, re: direct or in-
direct techniques). The plate is contoured to match the bone surface and secured in the main proximal and
distal bone fragments with a single standard screw (thus pressing the plate to the bone surface). The re-
maining screws placed are locking screws. These screws are placed using a drill guide that ensures their
placement perpendicular to the plate (fixed angle construct). These screws also have the option of being
placed either mono- or bi-cortically in areas where bone yield loads are lower, e.g., metaphysis or epiphysis.
The preference is to place them mono-cortically, minimizing drilling into the endosteal cavity (preserving the
endosteal blood supply); thus, less trauma is encountered with bilateral or orthogonal plate fixation when
compared to any of the limited contact plates that utilize bicortical screw fixation. Generally, only 3-4 screws
are placed into each major bone fragment. The original standard screws can be left in situ or replaced with
locking screws (outside diameter of the standard screws = core diameter of the locking screws).
1.5 yr MC Boxer
preop PO 10 wk PO
1.5 yr FS Bulldog
MAIN PROGRAM
SMALL ANIMALS
preop PO 6 wk PO 1 yr PO
As noted, additional construct strength may be obtained by placing a second opposite or orthogonal plate.
This concept is most useful in periarticular fractures where minimal screw purchase is obtained due to the
limited bone volume of the metaphyseal/epiphyseal bone fragment(s) – and without expense to the biology.
Although locking plates have been used in numerous locales since their introduction, their definitive rec-
ommended use in humans remains periarticular fractures, periprosthetic fractures and osteoporotic bone.
The indications in veterinary surgery currently are evolving, but it appears that these recommendations are
being borne out.
REFERENCES
1. Arens S, Schlegel U, Printzen C, et al: Influence of materials for fixation implants on local infection: An experi-
mental study of steel versus titanium in rabbits. J Bone Joint Surg [Br] 78B:647-651, 1996.
2. Arens S, Eijer H, Schlegel U, et al: Influence of the design for fixation implants on local infection: experimental
study of dynamic compression plates versus point contact fixators in rabbits. J Orthop Trauma. 13:470-476, 1999.
3. Gautier E, Rahn BA, Perren SM: Vascular remodelling. Injury 29 (Suppl 2):S-B11-19, 1995.
4. Eijer H, Hauke C, Arens S, et al: PC-Fix and local infection resistance--influence of implant design on postopera-
tive infection development, clinical and experimental results. Injury 32 (Suppl 2):B38-43, 2001.
5. Greiwe RM, Archdeacon MT: Locking plate technology. J Knee Surg 20:50-55, 2007.
6. Haidukewych GJ, Ricci W: Locked plating in orthopaedic trauma: a clinical update. [Review] J Am Acad Orthop
Surg 16:347-355, 2008.
7. Kubiak EN, Fulkerson E, Strauss E, et al: The evolution of locked plates. J Bone Joint Surg [Am] 88A(Suppl 4):189-
200, 2006.
8. Miclau T, Remiger A, Tepic S, et al: A mechanical comparison of the dynamic compression plate, limited contact-
dynamic compression plate, and point contact fixator. J Orthop Trauma 9:17-22, 1995.
9. Perren SM, Buchanan JS: Basic concepts relevant to the design and development of the Point Contact Fixator (PC-
Fix). Injury 29 (Suppl 2):S-B1-4, 1995.
10. Perren SM. Evolution of the internal fixation of long bone fractures. [Review]. J Bone Joint Surg [Br] 84B:1093-
1110, 2002.
11. Schlegel U, Perren SM. Surgical aspects of infection involving osteosynthesis implants: implant design and resist-
ance to local infection. Injury 37 (Suppl 2):S67-73, 2006.
12. Strauss EJ, Schwarzkopf R, Egol KA: The current status of locked plating: the good, the bad, and the ugly. J Or-
thop Trauma 22:479-486, 2008.
13. Tepic S, Perren SM: The biomechanics of the PC-fix internal fixator. Injury 29 (Suppl 2): S-B5-10, 1995.
14. Tepic S, Remiger AR, Morikawa K, et al: Strength Recovery in Fractured Sheep Tibia Treated with a Plate or an
Internal Fixator: An Experimental Study with a Two-Year Follow-up. J Orthop Trauma 11:14-23, 1997.
15. Ungersböck A, Pohler OEM, Perren SM: Evaluation of soft tissue reactions at the interface of titanium limited con-
tact dynamic compression plate implants with different surface treatments: an experimental sheep study. Biomate-
rials 17:797-806, 1996.
16. AO Manual of Fracture Management. Internal Fixators: Concepts and Cases Using LCP and LISS. Wagner M,
Frigg R (eds.), Thieme, Stuttgart, 2006.
17. Zura RD, Browne JA: Current concepts in locked plating. J Surg Orthop Adv 15:173-176, 2006.
81 • WVOC 2010, Bologna (Italy), 15th - 18th September K.A. Bruecker
The partially torn CrCL- to debride or not

Kenneth A. Bruecker, DVM, MS, Dipl. ACVS
Veterinary Medical and Surgical Group, Ventura, California USA
THE ARGUMENT FOR REMNANT RETENTION IN PARTIAL CRANIAL CRUCIATE

LIGAMENT (CRCL) INJURY
Primary Joint Stabilizer
The cranial cruciate ligament is an important stabilizer of the stifle joint with reference not only to cranial
tibial thrust, but also to internal rotation of the tibia. Current surgical procedures to treat the cranial cruci-
MAIN PROGRAM
SMALL ANIMALS
ate deficient stifle do not address both of these stabilizing functions. Attempts to maintain this stability is the
sole argument in favor of retaining the remnant for the partially torn cranial cruciate ligament.
THE ARGUMENT FOR REMNANT REMOVAL IN PARTIAL CRANIAL CRUCIATE

LIGAMENT INJURY
Ineffective Healing
The etiopathogenesis of ACL injury in humans is primarily traumatic. The etiopathogenesis of CRCL injury
in dogs is degenerative. In the juvenile dog, the cranial cruciate ligament is supplied by multiple central blood
vessels. By one year of age only a single central arteriole persists. This vessel is absent in some patients as ear-
ly as 12-13 months of age. Ligamentocyes are nourished by joint fluid and capillaries in subintimal layer of syn-
ovium and from bone attachments at either end of the ligament. In patients with an absent central vessel, the
central ligamentocytes are hypoxic. These hypoxic ligamantocytes undergo degeneration and necrosis or meta-
plasia to anaerobic chondrocytes. The collagen fibrils breakdown, fragment and dissolve into tropocollagen
molecules. The fascicles lose tensile strength and are susceptible to injury from lower loads and stresses. Thus,
the partially torn cranially cruciate ligament remnant cannot heal in an appropriate manner.
Incompetent Joint Stabilizer

As mentioned, current surgical procedures to treat the cranial cruciate deficient stifle do not address both of
these stabilizing functions. Thus, there is an inability of any of these techniques to adequately protect the
remnant from further damage.
Persistent Pain
Likewise, since there is an inability of any current surgical technique to eliminate strain on the remnant, the
result is persistent sensory nerve activation and thus persistent pain.
Nidus of Inflammation/Nidus of Degradation

The cruciate ligaments are intra-articular, but because they are covered by synovium they are essentially ex-
tra-synovial. Exposure of the ligament to the joint fluid results in a release of inflammatory mediators and
degradative enzymes. Progressive degenerative changes develop.
Remnant Obscures Visibility of Menisci

A significant number of dogs with partial cranial cruciate ligament tears have concurrent meniscal damage.
The remnant of the ligament obscures full visibility of the menisci resulting in missed meniscal tears and
may prevent successful management of meniscal tears.
SUMMARY
The degenerative nature of cranial cruciate ligament disease in dogs supports the surgical removal of rem-
nants of partially torn cranial cruciate ligaments. A classification scheme for better describing partially torn
cranial cruciate ligaments and a better method to evaluate the core of the ligament are needed before pre-
dictable attempts at remnant retention can be made.
SELECTED REFERENCES
Dr. Roy Pool, Department of Veterinary Pathobiology Osteopathology Specialty Service, Texas A&M University.
Correlative biomechanical and histologic study of the cranial cruciate ligament in dogs. Vasser PB, Pool RR, Arnosky SP,
Lau RE. AJVR 46 (9); 1842-1854, 1985.
Sensory nerve endings in the anterior cruciate ligament (lig. cruciatum anterius) of sheep. Halata Z, Wagner C, Baumann
KI. Anat Rec 254 (1); 13-21, 1999.
K.A. Bruecker WVOC 2010, Bologna (Italy), 15th - 18th September • 82
Distribution of substance-P nerve fibers in intact and ruptured human anterior cruciate ligament: a semi-quantitative im-
munohistochemical assessment. Witonski D, et al. Knee Surg Sports Traumatology Arthrosc. 12 (5); 497-502, 2004.
Localization of Cathepsin K and tartrate-resistant acid phosphatase in synovium and cranial cruciate ligaments with cru-
ciate disease. Muir P, Schamberger GM, Manley PA, Hao Z. Vet Surg 34 (3); 239-246, 2005.
Inflammatory changes in ruptured canine cranial cruciate and human anterior cruciate ligament rupture. Barret JG, eta
al AJVR 66 (12); 2073-2080, 2005.
Detection of DNA from a range of bacterial species in the knee joints of dogs with inflammatory knee arthritis and asso-
ciated degenerative anterior cruciate ligament rupture. Muir P, Oldenhoff WE, Hudson AP, Manley PA, Schaefer
SL, Markel MD, Hao Z. Microb Pathog 42 (2-3); 47-55, 2007.
Evaluation of biomechanical and gene expression patterns in normal and pathologic anterior cruciate ligament explants.
Breshears LA, Cook JL, Stoker AM, Kuroki K, Fox DB, Cockrell MK. (Abstract) Orthop Res Soc, Washington
MAIN PROGRAM
DC, Feb 2005.

SMALL ANIMALS
Collagenolytic protease expression in cranial cruciate ligament and stifle synovial fluid in dogs with cranial cruciate liga-
ment rupture. Muir P, Danova NA, Argyle DJ, Manley PA, Hao Z. Vet Surg 34 (5); 482-490, 2005.
Characterization of matrix metaloproteinase 2 and 9 in normal and pathologic anterior cruciate ligaments using RT-PCR,
gelatin zymography, enzyme activity assay. Breshears LA, Cook JL, Fox DB, Stoker AM, Warnock JJ, Cockrell
MK. (Abstract) Orthop Res Soc, Chicago, Il, March 2006.
Histologic changes in the human anterior cruciate ligament after rupture. Murray MM, Martin SD, Martin TL, Spector
M. J Bone Joint Surg A. 82-A (10); 1387-1397, 2000.
Histologic changes in ruptured canine cranial cruciate ligaments. Hayashi K, Frank JD, Dubinsky C, et al. Vet Surg
32:269-277, 2003.
The central ACL defect as a model for failure ofintra-articular healing. Spindler KP, Murray MM, Devin C, Nanney LB,
Davidson JM. J Orthop Res 24 (3); 401-406, 2006.
Cranial Cruciate Ligament Pathophysiology in Dogs With Cruciate Disease: A Review. Hayashi K. Manley PA, Muir P.
JAAHA 40:385-390, 2004.
83 • WVOC 2010, Bologna (Italy), 15th - 18th September A. Brühschwein
Imaging facial trauma

Andreas Brühschwein, DVM, Dipl. ECVDI
Clinic of Small Animal Surgery and Reproduction
Head: Prof. Dr. Dr. Ulrike Matis, Ludwig-Maximilians-University, Munich
Traumatic injuries are common indications for head and skull imaging. In most cases plain radiography is
the first choice for imaging head injuries. Radiography aids in detection of bone lesions, such as fractures,
temporomandibular joint luxation, symphyseal fractures and dental trauma, because it provides good os-
seous contrast. However, radiography provides poor soft tissue contrast, which limits its use for the evalua-
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tion of soft tissue lesions. Foreign bodies may be visible on radiographs, for example gunshot fragments in
the orbit. A careful search for fractures, particularly of the frontal bone, should be undertaken when gas in-
clusions (emphysema) are seen in the soft tissues. A high detail film/screen combination should be used for
good quality images. A grid is normally not necessary because of a high portion of bone and gas and a low
portion of soft tissue and fat. The feline and canine skull consists of many bones and is an anatomically com-
plex three-dimensional structure, but much of this complexity is lost with radiography because it provides a
two-dimensional image. Superimposition of bone makes interpretation of skull radiographs difficult. When
interpreting DV or VD views of the skull, the first goal is to determine whether both sides are symmetrical.
Thus, care should be taken to ensure that the head is positioned symmetrically when taking these views.
The standard views for the skull are laterolateral and VD or DV, but often additional views are necessary
to obtain more information. Lateral oblique projections provide skyline views of different parts of the skull,
and bilateral oblique views with the same projection angle may be necessary for comparison. Lateral oblique
views are particularly helpful for evaluation of the temporomandibular joint because luxation and/or frac-
ture are common in this area, especially in cats with “high rise syndrome” or dogs and cats after car acci-
dents. In the lateral view, slight elevation (20°) of the nose improves visualization of the temporomandibu-
lar joint, which can be evaluated with the mouth open or closed. Bilateral 30° oblique views with rotation
of the head are another option for evaluating the temporomandibluar joints without superimposition of oth-
er structures. The tympanic bulla can also be visualized with bilateral oblique views, which allow visibility
of lesions such as fractures or increased opacity caused by haemorrhage. An additional open-mouth rostro-
caudal view in the dog and cat or a rostro- 10° ventral-caudodorsal view in the cat completes radiographic
evaluation of the tympanic bullae. A rostrocaudal or caudorostral view with the mouth closed provides sky-
line views of the cranium and frontal sinuses and depicts the foramen magnum. The exact angle of at-
lantooccipital flexion depends on the area of interest and the animal’s skull conformation. Intraoral DV and
VD views allow evaluation of the rostral parts of the maxillae or mandibles without superimposition of the
mandibles or maxillae, respectively. An open mouth ventral 20° rostro-dorsocaudal view in dorsal recum-
bency is an alternative to the intraoral DV view in ventral recumbency. This angled projection allows a more
caudal inspection of the upper jaw; however, one must take distortion into account. In many cases, dental
trauma such as tooth avulsion, luxation or fracture, requires radiographic evaluation of the tooth root and
alveolar bone. Tooth root fractures in particular can easily be missed on visual inspection. Possible dental
involvement in jaw fractures should also be evaluated radiographically. For an isolated view of each quad-
rant, an extra- or intraoral oblique view (approximately bisecting angle technique) provides a good overview
of the bone and associated teeth of each mandible and maxilla. For high-detail imaging of individual teeth,
intraoral dental films provide superior spatial resolution. The incisors including the symphysis and the ros-
tral part of the maxilla can be evaluated using intraoral DV and VD views of the rostral part of the mouth.
Sonography of the head can be helpful in cases with facial swelling and can be used to differentiate soft tis-
sue and fluid-filled areas. Also the bone surface can be visualized with ultrasound. Traumatic disruption,
such as a fracture line or periosteal reaction, can be seen. In animals with a persistent fontanelle, an in-
tracranial view is achieved using a high frequency sector scanner with a small footprint. Sonography is a
valuable tool for evaluation of the orbit and eye, for example in cases with posttraumatic eyelid swelling or
third eyelid protrusion. A direct transcorneal approach gives the best image quality, but transpalpebral im-
ages are also possible. Determining the size and shape of the globe, location of the lens as well as the pres-
ence of intraocular haemorrhage or retinal ablation are important information provided by ultrasonography
in the trauma patient, especially if direct inspection of the eye is not possible.
Computed tomography (CT) is now widely used in veterinary medicine and is better for detection of skull
fractures and temporomandibular joint luxations than radiography. Computed tomography is also better
than radiography for soft tissue resolution because of the window technique. This is important in patients
with traumatic brain lesions. Intracranial hematomas or brain oedema can be visualized with CT using a
A. Brühschwein WVOC 2010, Bologna (Italy), 15th - 18th September • 84
soft tissue technique. The proper window setting (soft tissue, brain or bone window) must be used and care
should be taken in selecting the appropriate reconstruction algorithms (kernel). Thin slices without an in-
terslice gap are required for excellent spatial resolution. For a temporomandibular joint of a cat, a slice thick-
ness of 1mm is appropriate, whereas a slice thickness of 2-3mm may be adequate for a giant-breed dog. With
thinner slices, partial volume effects decrease whereas the quality of multiplanar reconstructions (MPR) and
three-dimensional reconstructions (surface shaded display [SSD] or volume rendering [VR]) improves. For
a comprehensive examination, sagittal and dorsal reconstructed images (MPR) should be evaluated in ad-
dition to the primary transverse scan. Three-dimensional surface rendering techniques are helpful to visu-
alize and assess the course and dimension of osseous injury. Beam-hardening artefacts in the caudal cranial
fossa (“Hounsfield bar”) limit evaluation of the brain stem and cerebellum. The neuronal structures in this
area are best imaged with Magnetic Resonance Imaging (MRI). MRI provides better soft tissue contrast
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resolution than CT, which makes this modality the first choice in patients with neurological signs. The lim-
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ited spatial resolution of MRI may be a limitation in trauma patients because small fissures and non-dis-
placed fractures can easily be missed, especially in bone with close contact to air such as the nasal cavity,
paranasal sinuses or tympanic bulla. Cortical bone and air are hypointense (black) on MRI. This makes dif-
ferentiation difficult and often impossible. The excellent soft tissue contrast provided by MRI may be ad-
vantageous for detecting blunt muscle or brain trauma, such as oedema after contusion, which can be missed
on CT scans even in a soft tissue window.
For a comprehensive examination, complementary imaging is often necessary because of the advantages and
disadvantages of the different imaging modalities.
REFERENCES
J.K. Assheuer, M. Sager. MRI and CT Atlas of the Dog. Blackwell 1997.
Y. Bar-Am, R.E. Pollard, P.H. Kass, F.J.M. Verstraete. The Diagnostic Yield of Conventional Radiographs and Comput-
ed Tomography in Dogs and Cats with Maxillofacial Trauma. Veterinary Surgery 37:294–299, 2008.
W. Beck, S. Hecht, U. Matis. Dreidimensionale Rekonstruktion aus CT-Transversalbildern zur Darstellung komplexer
Schädelfrakturen bei der Katze. Tierärztliche Praxis Kleintiere, 1434-1239, 2000: 219-224.
J. B. Cabassu1, J.-P. Cabassu, L. Brochier, S. Catheland, S. Ivanoff. Surgical treatment of a traumatic intracranial epidur-
al haematoma in a dog. Vet Comp Orthop Traumatol 2008; 21: 457–461.
R. Dennis. Skull – general. In: Manual of Canine and Feline Muskuloskeletal Imaging (Barr/Kirberger). BSAVA 2006.
R. Drees. Kopf. In: Röntgendiagnostik in der Kleintierpraxis (Hecht). Schattauer 2008.
L.J. Forrest. Cranial and Nasal Cavities: Canine and Feline. In: Textbook of Veterinary Diagnostic Radiology (Thrall) 5th
edition, Saunders/Elsevier 2007.
L.J. Forrest. The Head: Excluding the Brain and the Orbit. Clinical Techniques in Small Animal Practice, Vo114, No 3
(August), 1999: pp 170-176.
S. Hecht. Für Studium und Praxis: Die Röntgenuntersuchung des Kopfes. Tierärztliche Praxis Kleintiere, 1434-1239,
2003: Issue 3, 194-198, 2003.
S.P. Kus, J.P. Morgan. Radiography of the canine head. Optimal positioning with respect to skull type. Vet Radiol 1985;
26: 196-202.
C.R. Lamb. Skull – nasal chambers and frontal sinuses. In: Manual of Canine and Feline Muskuloskeletal Imaging
(Barr/Kirberger). BSAVA 2006.
M. Mihaljevic, M. Kramer, H. Gomercic. CT- und MRT-Atlas: Transversalanatomie des Hundes. Parey 2009.
J.M. Owens, D.N. Biery. Skull. In: Radiographic Interpretation for the Small Animal Clinician (Owens/Biery). 2nd ed.
Williams & Wilkins 1998.
T. Schwarz, R. Weller, A.M. Dickie, M. Konar, M. Sullivan. Imaging of the Canine and Feline Temporomandibular Joint:
A Review. Veterinary Radiology & Ultrasound, Vol. 43, No. 2, 2002, pp 85-97.
G. Steenkamp. Skull – teeth. In: BSAVA Manual of Canine and Feline Muskuloskeletal Imaging (Barr/Kirberger). BSA-
VA 2006.
H. Waibl, E. Mayrhofer, U. Matis, L. Brunnberg, R.G. Köstlin, H. Schebitz, H. Wilkens. Atlas of Radiographic Anato-
my of the Cat. Parey 2005.
my of the Dog. Parey 2005.
85 • WVOC 2010, Bologna (Italy), 15th - 18th September A. Brühschwein
Imaging the foot

Andreas Brühschwein, DVM, Dipl. ECVDI
Head: Prof. Dr. Ulrike Matis, Ludwig-Maximilians-University, Munich
Radiography is still the most important imaging modality for the canine carpus, metacarpus, tarsus, metatar-
sus, and digits. For good diagnostic results, high quality radiographs are necessary. A tabletop technique
without a grid and a high detail film/screen combination should be used. A high-detail double emulsion
film/screen combination is sufficient, but a single-emulsion film, for example Mamoray®, provides superior
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spatial resolution.
Standard views include a dorsopalmar projection for the carpus and metacarpus, dorsoplantar/plantarodor-
sal views for the tarsus and metatarsus as well as a lateral view. The field-of-view may include the whole car-
pus/tarsus and foot. Depending on the region of interest, a more focused approach can be used. Additional
views include medial and lateral oblique projections. The most common angle is 45°, but various angles of
rotation are possible, depending on the area of interest. Hyperextended and hyperflexed lateral views as well
as medially and laterally stressed dorsopalmar/dorsoplantar or plantarodorsal views are often indicated for
evaluation of the functional stability of the dorsal, palmar/plantar and collateral ligaments. Evaluation of the
joint under physiological stress is achieved in the standing patient by directing the x-ray beam horizontally.
However, in most cases the joint is stressed manually by applying rotational, tractional or shearing forces or
by moving the joint into a valgus or varus position. Single toes can be isolated in the mediolateral view by
splaying the toes, which can be fixed to the table with tape. A paddle can also be used to isolate a single toe
in the lateral view. In the dorsopalmar/-plantar view, a thin piece of acrylic glass can be used to exert mild
dorsopalmar/-plantar pressure on the paw to extend the toes. To evaluate collateral integrity, stress can be
applied to a single digit by pulling the tip of the toe with forceps. To highlight the tarsocural joint, a flexed
dorsoplantar projection exposes a skyline view of the talus and cochlea tali, as well as a clear view of the me-
dial and lateral malleolus without superimposition of the calcaneus. This view is helpful for evaluation of the
position of a screw that may have been inadvertently placed intraarticularly after distal tibial fracture repair.
A flexed dorsoplantar projection is also useful for assessment of equivocal damage or fractures of the malle-
oli, cochlea and talus. Additional projections include a flexed plantaroproximal-plantarodistal view of the tar-
sus to focus on the calcaneus and proximal parts of the trochlea. Flexed lateral and flexed dorsoproximal-
dorsodistal skyline views, which are commonly used in equine orthopedics, are helpful in the canine carpus
as well. Fistulography is a method of contrast radiography, which may sometimes help in the visualization
of a foreign body in chronic draining tracts.
Comprehensive radiographic evaluation may require many views, and today computed tomography (CT)
has overcome the need for many of these special projections. Radiation safety is another advantage of com-
puted tomography because the examiner is not standing next to the x-ray-tube during the exposures. Com-
puted tomography provides excellent anatomical detail without superimposition. Thin slices, ideally 1mm
or less without an interslice gap, are need for good CT images and for sagittal, dorsal and oblique multi-
planar reconstructions (MPR) as well as three-dimensional reconstructions, such as surface shaded display
(SSD) or volume rendering (VR). Multiplanar reconstructions are recommended for comprehensive evalu-
ation because lesions are easily missed in a single transverse plane. Three-dimensional surface rendering
techniques are helpful to visualize and assess the course and dimension of osseous injury. In addition to a
bone technique using a bone algorithm (kernel) and a bone window, a soft tissue technique can be applied
to the CT scan data to evaluate soft tissue structures of the foot in a soft tissue window. A post-contrast soft
tissue scan is often helpful for evaluating certain lesions, such as determining the size or invasiveness of a
mass in the foot or detecting a foreign body. Computed tomography is most valuable for evaluation of the
carpus, tarsus and metacarpophalangeal joints; in the latter, the palmar/plantar sesamoid bones can be vi-
sualized without superimposition.
Scintigraphy is a diagnostic tool used to localize the cause of lameness when a clinical examination fails to
do so. In the foot, scintigraphy can be used to determine the clinical significance of a radiographically visi-
ble and equivocal lesion by assessing the radionuclide accumulation and activity. This is often helpful to dis-
tinguish between multipartite palmar metacarpophalangeal sesamoid bones attributable to a congenital
anomaly and sesamoid disease caused by traumatic or degenerative fragmentation. The bone phase offers
the most information, but the early vascular phase and the soft tissue phase, assessed approximately 20 min-
utes post injection, can be used to determine the viability of bones and soft tissues and the vascular supply
in degloving or crushing injuries.
A. Brühschwein WVOC 2010, Bologna (Italy), 15th - 18th September • 86
Sonography is used for detecting foreign bodies and for evaluation of ligaments, tendons and tendon
sheaths, especially the Achilles tendon, flexor tendons and the tendon of the abductor digiti I [pollicis]
longus. Fibre disruption and loss of integrity are signs of tendon or ligament injury, which are not visible on
radiographs. Transducer quality is important in orthopaedic diagnostic ultrasound. High-frequency linear
probes are most valuable for high-resolution imaging of the small structures of the foot.
Magnetic resonance imaging (MRI) in multiple planes (transverse, dorsal, sagittal and oblique) with dif-
ferent sequences and weightings allows visualization of bones and soft tissues including muscles, ligaments,
tendons and synovial structures, with excellent contrast. The small structures of the foot require high-reso-
lution imaging. Thin slices and high-resolution three-dimensional sequences with isotropic voxel geometry
capable of multiplanar reconstructions should be part of the examination protocol. In addition to normal
T1w (weighted) and T2w images, water-sensitive and fat-suppressed (fs) sequences are valuable for evalua-
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tion of musculoskeletal structures. Short tau inversion recovery (STIR), T2wfs, or proton-density-weighted
SMALL ANIMALS
fat-suppressed (PDwfs) sequences are ideal for diagnosing musculoskeletal injuries, which appear hyperin-
tense. Tendinous, ligamentous and synovial lesions, tendovaginitis and abnormal joint filling, can be visual-
ized. T1w images taken after the application of contrast medium are useful for detecting inflammation or
neoplastic enhancement. Enhancement is most obvious with spectral fat suppression or when the pre-con-
trast scan is subtracted from the post-contrast acquisition.
Complementary imaging is often necessary for a comprehensive examination because of the advantages and
disadvantages of the different imaging modalities.
REFERENCES
G. Allan, R. Nicoll. Distal limbs – carpus and tarsus. In: Manual of Canine and Feline Muskuloskeletal Imaging
(Barr/Kirberger). BSAVA 2006.
A. Brühschwein. Anatomische Darstellung des caninen Karpalgelenks mittels MRT und CT unter besonderer Berück-
sichtigung der Weichteilstrukturen. Dissertation München 2005.
C.H. Carlisle, K.M. Reynolds: Radiographic anatomy of the tarsocural joint of the dog. JSAP 31: 273-290, 1990.
R. Dennis, R.M. Kirberger, R.H. Wrigley, F.J. Barr. Appendicular skeleton. In: Handbook of Small Animal Radiological
Differential Diagnosis. Saunders 2001.
C.S. Farrow. Stress radiography: Application in small animal practice. JAVMA 181:777-784, 1982.
S. Hecht. Spezielle Techniken der Röntgenuntersuchung der Gliedmaßen beim Kleintier. TP Kleintier 31 4 1871, 2003.
T. Miyabayashi, D.S. Biller, P.A. Manley, KJ Matushek. Use of a flexed dorsoplantar radiographic view of the talo-crur-
al joint to evaluate lameness in two dogs. J Am Vet Assoc 199:598, 1991.
D. Murgia, U. Matis, C. Jorda, E. Adriany. Szintigraphie, Computertomographie und computerisierte Ganganalyse bei
der Sesamoidose des Hundes. Tierärztl Prax 2005; 33 (K): 167-76 2005.
C.P. Ober, L.E. Freeman. Computed tomographic, magnetic resonance imaging, and cross-sectional anatomic features of
the manus in cadavers of dogs without forelimb disease. Am J Vet Res 2009;70:1450–1458.
A. Piras. Radiographic approach to distal extremity injuries. ESVOT, Munich 2004.
my of the Cat. Parey 2005.
my of the Dog. Parey 2005.
M. Zöllner. Anatomische Darstellung des caninen Tarsalgelenks mittels MRT und CT unter besonderer Berücksichtigung
der Weichteilstrukturen. Dissertation München 2008.
87 • WVOC 2010, Bologna (Italy), 15th - 18th September M. Conzemius
Limitations of force platform gait analysis

Michael Conzemius, DVM, PhD, Dipl. ACVS
University of Minnesota, St. Paul, MN
Force platform gait analysis provides an objective outcome measure of limb function that is precise, accurate
and has been shown to be a sensitive and specific diagnostic test. Yet, many clinicians are reluctant to accept
results of papers that use the ground reaction forces (GRF) measured by force platform gait analysis. Some
of this reluctance may be because force plate measures have limitations in what they can do, some is because
the methodology from a paper that used it may have errors in methods and some may be from the clinicians
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being either naïve of the science or they are reluctant to accept the finding because it is not what they want
to see or want to see.
Force platforms, in general are not mobile. Thus the patient must be brought to the area where gait analy-
sis is performed. Force platforms are extremely durable and can be placed in an active hallway of a hospital
making this relatively moot. In addition, pressure platforms and pressure walkways are mobile and it has
been demonstrated that the vertical GRFs they generate are nearly identical to that of traditional force plat-
forms. Force platform gait analysis takes the time of the patient, owner, veterinarian and technician. This can
be real problem when one tries to institute routine gait analysis into a busy outpatient schedule. A fee for
the objective data it creates can be assessed and many owners, when explained the usefulness of the test, are
happy to pay for this. I would also suggest that like most equipment and computational software the more
one uses it the easier and quicker it is to use. However, it undoubtedly takes longer than visual objective
measures of gait. Force platforms are another financial investment that is difficult to make profitable unless
you routinely use it to perform funded research. Force platforms can be difficult to use on small or giant
breed dogs. A typical acceptable foot strike includes a single front leg followed by the ipsilateral rear leg. On-
ly one foot can be on the platform at a time because the forces are additive. Small dogs tend to put too many
feet on the platform at once (this can be addressed by “splitting the plate” to some degree) and giant dogs
tend to step over the plate (this can be addressed by slowing patient velocity or using multiple plates). Force
platforms are ideal for lameness in a single leg but data can be difficult to interpret when lameness or dis-
ease is in multiple legs. This is particularly true if the status of the disease is changing in multiple legs. Giv-
en that most of the breeds that are affected with orthopedic problems generally have multiple diseases in
multiple joints this causes a problem. In studies that evaluate bilateral conditions it is preferable to gather
data from all limbs and focus the treatment effect on a single limb. This is a reasonable approach as long as
comparisons between treatments are made or a control group is included.
Like all diagnostic tests, gait analysis must be performed correctly to have output that is useful. Over the
past 20-years many papers have described the key components to correctly performing gait analysis. That
said, I still read papers and review papers that have errors. First, it is critical that velocity and acceleration
are monitored. Both influence GRFs and they have a paradoxical effect on peak vertical force (PVF) and
vertical impulse (VI). For example, as velocity increases PVF will increase and VI will decrease. This leads
into the second point, both PVF and VI should be documented and used as output measures. While they
can both increase in limb function improves they are influenced paradoxically by other things in gait (such
as velocity). Looking at a single output provides little information. Second, dogs of similar stature need to
be compared or, at a minimum, balanced between study groups. This is because most investigators meas-
ure torso velocity, not limb velocity. It is easy to imagine a beagle and a great dane both walking with the
same torso velocity. However, since the great dane has a long stride it has a slower limb velocity than the
beagle even though they are covering the same distance over time. Limb velocity affects stance time and
stance time proportionally affect VI. Another way to control for this is to either measure limb length in the
study population or to control for stance time instead of torso velocity in the study groups.
Similar to making a diagnosis for a disease GRF can be complimented with other parameters to strengthen
the case that an intervention either led to an improvement or did not. Owner surveys have become popu-
lar but many overlook the use of 2D or 3D kinematics, accelerometers, and pedometers as objective meth-
ods of documenting gait.
The greatest limitation to data that is collected at a veterinary hospital is that it measures a moment in time,
not the day to day level of activity of the dog at home. Use of a pedometer or accelerometer can be used to
measure patient activity level at home over an extended period of time. In one study pedometers were suc-
cessfully used to measure physical activity in dogs over a 14 day period. Pedometer accuracy varied de-
pending upon the patient’s size (overestimated walking in large dogs and underestimated walking in small
dogs), but correlated well to overall reports of the dogs activity level at home and the dog’s condition body
M. Conzemius WVOC 2010, Bologna (Italy), 15th - 18th September • 88
score. Accelerometers are a bit more sophisticated in that some can measure changes in acceleration in the
x-, y- and z- axis. Thus, body movement in any direction is measured. In one study that determined vari-
ability in accelerometer data in companion dogs it was reported that large day-to-day and even week-to-week
variations occurred in dogs but within dogs, a full 7-day comparison of total activity counts from one week
to the next provided the least variable estimate of the dogs’ activity. They also reported that accelerometers
may be most useful for documenting changes in the dog’s activity over time. Given the limitations both pe-
dometers and accelerometers have in their estimates of a patient’s activity level these methods are probably
suited for use in studies that wish to compare large groups of dogs that have similar body size and shape.
To the authors knowledge these methods have not been applied to dogs after RCCL surgery and their use
would be beneficial for outcome comparisons.
The stereometric method of documenting kinematics employs visible markers that are attached to the skin
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on rigid segments of the body (e.g. joints centers of rotation or bony prominences) and tracks their motion
SMALL ANIMALS
using imaging equipment. Using triangulation of the views from an array of cameras and the known loca-
tion of each camera, computer software computes the coordinates for each marker. Two-dimensional meth-
ods have a diminished time and financial investment for the laboratory or clinic that will only perform this
method occasionally but joint motions can only be determined in one plane. Three-dimensional methods
generally employ the use of 3-8 cameras. Motion data allows for calculation of time/distance parameters (ve-
locity, cadence, stance and swing times, etc.) and the angular position of the joints (hips, knees, and ankles)
during the different phases of gait. These methods have been well described and demonstrated in both nor-
mal dogs at a trot, in dogs with orthopedic disease and in dogs swimming.
REFERENCES
Evans R, Horstman C, and Conzemius M. Accuracy and optimization of force platform gait analysis in Labradors with
cranial cruciate disease evaluated at the walking gait. Veterinary Surgery, 2005;34:42-46.
Chan CB, Spierenburg M, Ihle SL, Tudor-Locke C. Use of pedometers to measure physical activity in dogs. J Am Vet
Med Assoc 2005;226:2010-2015.
Dow C, Michel KE, Love M, Brown DC. Evaluation of optimal sampling interval for activity monitoring in companion
dogs. Am J Vet Res. 2009;70:444-448.
Besancon MF, Conzemius MG, Derrick TR, et al. Comparison of vertical forces in normal dogs between the AMTI Mod-
el OR6-5 force platform and the Tekscan (industrial sensing pressure measurement system) pressure walkway. Vet-
erinary Comparative Orthopedics and Traumatology 2003;16:153-7.
Besancon MF, Conzemius MG, Evans RB, et al. Distribution of vertical forces in the pads of Greyhounds and Labrador
Retrievers during walking. Am J Vet Res 2004;65:1497-1501.
Romans CW, Gordon WJ, Robinson DA, et al. Effect of postoperative analgesic protocol on limb function following ony-
chectomy in cats. JAVMA 2005;227(1):89-93.
Romans CW, Conzemius MG, Horstman CL, et al. Use of pressure platform gait analysis in cats with and without bi-
lateral onychectomy. Am J Vet Res 2004;65:1276-78.
Horstman CL, Conzemius MG, Evans R, et al. Assessing the efficacy of perioperative oral carprofen after cranial cruci-
ate surgery using noninvasive, objective pressure platform gait analysis. Vet Surg 2004;33:286-92.
Evans RB, Gordon W, Conzemius M. The effect of velocity on ground reaction forces in dogs with lameness attributa-
ble to tearing of the cranial cruciate ligament. Am J Vet Res 2003;64(12):1479-81.
Conzemius MG, Evans RJ, Besancon MF, et al. Effect of surgical technique on limb function after surgery for rupture of
the cranial cruciate ligament in dogs. JAVMA 2005;226(2):232-9.
Renberg WC, Johnston SA, Ye K, et al. Comparison of stance time and velocity as control variables in force plate analy-
sis of dogs. Am J Vet Res 1999;60:814–819.
DeCamp CE, Riggs CM, Olivier NB, et al. Kinematic evaluation of gait in dogs with cranial cruciate ligament rupture.
Am J Vet Res 1996;57:120-6.
Marsolais GS, McLean S, Derrick T, Conzemius MG. Kinematic analysis of the hind limb during swimming and walk-
ing in healthy dogs and dogs with surgically corrected cranial cruciate ligament rupture. J Am Vet Med Assoc
2003;222(6):739-43.
Iowa State TER: results and complications

Total elbow replacement continues to mature as a surgical procedure for dogs with lameness secondary to
osteoarthritis of the elbow. Although several elbow replacement systems have been designed and tested over
the past decade the author is only aware of two that are commercially available. To date, several abstracts,
proceeding notes and chapters are available to describe these techniques, but only two peer-reviewed scien-
tific papers address total elbow replacement in the dog. These papers address what is sometimes referred to
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as the Iowa State Elbow because that is where is was designed and tested. However, the implants, the im-
planting devices (guides) and surgical technique have changed from those reports in an effort to improve the
technique and the patient outcomes.
The originally described ISU elbow implants that were used and reported on had an 80% success rate.
The limitations were because of several design flaws that predisposed the patient to fracture of the ulna,
fracture of the humerus and elbow luxation. Ulnar fracture occurred because the radioulnar implant had
an ulnar stem that was difficult to put in and the cutting guides left for a jagged cut that created areas of
stress concentration when the triceps pulled on the olecranon. After the report a cutting guide system was
developed that utilized a circular cut. This was a vast improvement but the problem of preparing the ulna
for the ulnar stem still remained. Most recently this has been addressed by eliminating the ulnar stem al-
together. This shortens and simplifies the surgical procedure. Fracture of the humerus occurred because
the humeral implant had large metal shoulders that required removal of bone in the intercondylar area.
This weakened the area and fracture, at the time of surgery, could occur. This was simply addressed by
making the shoulders on the implant smaller. Since this change the author has not seen humeral condylar
fracture or implant fracture.
In this authors experience elbow luxation, or subluxation, in a lateral direction is the most common com-
plication. In fact, I would suggest that is represents about 50% of all complications that occur, or about 10%
of all surgical cases. Several years ago a cutting guide system was developed that allowed for the center of
rotation of the humeral implant to guide the cuts made for the radioulnar implant. This allowed for the two
implants to be implanted with very similar centers of rotation, thus increasing stability between the two im-
plants. However, in my experience, lateral luxation continued to be a problem. This cause of this problem
was recently identified in a mechanical testing study that showed that the ISU elbow implants only have a
small fraction of the stability of the normal elbow – even after all the ligaments of the elbow have been re-
moved. In effect it was too nonconstrained. This problem is present in both translation and in rotation. A
complete design modification to increase resistance between the tow implants in shear and rotation has tak-
en place and mechanical testing has clearly demonstrated that the design is effective, in vitro. Fortunately,
this design change radically alters the articular surface but does not alter the primary method by which the
components are implanted. In addition, the design change has capitalized on ingrowth technologies so the
radial implant (no longer has an ulnar stem) can be used cementless.
I continue to use an elbow replacement system with an open approach because it provides the great advan-
tage of allowing me to realign the misaligned elbow joint. Many of the dogs that I see with end stage elbow
osteoarthritis have dramatic medial collapse and a laterally displaced elbow. Two other reasons I work with
this system include surgeon familiarity and the fact that it has been prospectively and objectively studied
and reviewed. Competition is good. It will likely benefit our patients. However, I think it is important to
have science first and widespread use of novel surgical techniques and implants second.
REFERENCES
1. Conzemius MG. Nonconstrained elbow replacement in dogs. Vet Surg, 2009; 38:279-84. PMID: 19236685.
2. Conzemius MG, Vandervoort J. Total joint replacement in the dog. Vet Clin North Am Small Anim Pract. 2005;
35(5):1213-31. PMID: 16129140.
3. Conzemius MG, Aper RL, Corti LB. Short term outcome after total elbow arthroplasty in dogs with severe natu-
rally occurring osteoarthritis. Vet Surg, 2003; 32:545-52. PMID: 14648533.
4. Conzemius MG, Aper RL, Hill CM. Evaluation of a canine total elbow arthroplasty system. A preliminary study
in normal dogs. Vet Surg, 30:11-20, 2001. PMID: 11172456.
C.R. Cook WVOC 2010, Bologna (Italy), 15th - 18th September • 90
Ultrasonography of the canine stifle joint

Cristi R. Cook, DVM, MS, Dipl. ACVR
University of Missouri - Columbia
Stifle joint disease is a common cause of lameness in the canine patient. Diagnosis of the cause of lameness
are generally based on history, physical and lameness examination, and radiography. Alternate imaging
modalities have become a more commonly used tool for further evaluating the stifle joint, including ultra-
sound, computed tomography, and magnetic resonance imaging. Ultrasonography is relatively inexpensive,
and non-invasive diagnostic tool to evaluate the joint. It is commonly used to evaluate the stifle joint in
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equine patients and human beings.

Joint ultrasound may be more difficult depending on the joint of interest. The shoulder and stifle joints are
most common and easiest of the joints to be imaged with ultrasound. In the normal stifle joint the patellar
and collateral ligaments, infrapatellar fat pad, synovium, lateral and medial menisci, long digital extensor
tendon and cranial cruciate ligament are identifiable. The synovium is commonly thickened with any joint
abnormality (trauma, ligament or tendon injury or other intra-articular structure, such as the meniscus).
Presence or absence, location, and the amount of joint fluid may indicate an inflammatory response within
the joint. This may be helpful to determine the need for further surgical intervention or treatment, follow-
ing a prior intra-articular procedure (ie. cranial cruciate repair).
The superficial bone may be involved with the process, as well. Ultrasound is very sensitive to minor bone
changes and early remodeling changes of the bone may be detected with the ultrasound prior to visualiza-
tion with standard radiography. Early osteomyelitis or bone neoplasias may be seen with the ultrasound as
irregular bone margins or loss of the cortical echo, +/- soft tissue mass effect within or adjacent to the cor-
tex, and surrounding cortical edema. A major advantage of ultrasound is the ability to use it for ultrasound
guided aspirations or biopsies of these lesions, within the joint, or surrounding tissues.
91 • WVOC 2010, Bologna (Italy), 15th - 18th September C.R. Cook
MRI of the canine stifle joint

Magnetic Resonance Imaging (MRI) has been used commonly in human medicine to diagnose and assess
knee injuries, diagnose osteoarthritis and assess therapeutic protocols. It is becoming more commonly avail-
able to utilize MRI in musculoskeletal disorders in the veterinary field, in both the research and clinical pa-
tients. MRI of the stifle is more sensitive than radiography alone and more specific to soft tissue lesions with-
in and around the joint. MRI is the preferred modality for cartilage, ligament and meniscal imaging. Nor-
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mal anatomy knowledge is essential to begin to evaluate the stifle joint and to interpret disorders/injuries.
Limitations of stifle MRI are availability, almost exclusively limited to large specialty referral practices and ac-
ademic institutes, the expense, the need for general anesthesia and the time it takes to acquire the sequences,
and the experience of the interpreter. Multiple planes and sequences of the stifle are needed to acquire the ba-
sic study and provides excellent visualization of the intra-articular anatomic structures. Tendons and liga-
ments are more defined with MRI, as compared to computed tomography (CT) or ultrasonography.
Gadolinium-enhanced (Gd-DTPA) magnetic resonance imaging can be used to better delineate the synovi-
um and detecting synovitis in osteoarthritis. This is used frequently in human medicine and becoming more
common in the veterinary patients.
Protocols for the stifle joint vary, but will include multiple sequences and planes (sagittal, dorsal and axial
planes) for optimal interpretation. T1-weighted sequences are excellent anatomic images and T2-weighted
and proton density sequences are better for identifying pathologic lesions. More specific sequences could be
used for cartilage imaging, including dGEMRIC, T2-mapping, and T1rho.
J.L. Cook WVOC 2010, Bologna (Italy), 15th - 18th September • 92
Tightrope results
James L. Cook, DVM, PhD, DACVS, DACVSMR
Comparative Orthopaedic Laboratory, University of Missouri, Columbia, MO USA
Tightrope CCL (TR) (Arthrex Vet Systems, Naples, FL) is an extracapsular stabilization procedure that can
be used as part of a comprehensive treatment plan for cranial cruciate ligament (CCL) disease in dogs. TR
was developed in an attempt to address perceived shortcomings of current techniques - specifically to be min-
imally invasive, technically feasible, address all aspects of instability, minimize secondary pathology, and
consistently result in functional outcomes with a low complication rate in a cost effective manner. After ini-
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tial testing for safety and efficacy via in vitro, ex vivo, and animal model studies, as well as a prospective co-
hort clinical trial, TR was released for clinical use. As part of a commitment to critically assess outcomes as-
sociated with TR, we enrolled veterinarians using TR in a multicenter outcomes study to further assess clin-
ical safety and efficacy in 1,000 cases.
This study falls within the guidelines of the participating institutions’ animal care and use committees and/or
guidelines for ethical treatment of animals with respect to privately-owned canine patients. Centers were en-
rolled based on their voluntary commitment to prospectively collect and submit outcomes data for all dogs
that they treated with TR for which ≥ 3-month follow-up data were available. Definitions and criteria for re-
porting time frame and outcome associated with TR cases were from a system proposed for clinical or-
thopaedic studies in veterinary medicine (Vet Surg, 2010) and were set and given to each participating cen-
ter a priori as follows:
Time frames - Perioperative (pre, intra, and post op) = 0-3 months; Short term = > 3-6 months; Mid
term = > 6-12 months; Long term = > 12 months;
Outcome - Full Function = restoration to, or maintenance of full intended level and duration of activities
and performance from pre-injury or pre-disease status (without medication); Acceptable Function =
restoration to, or maintenance of intended activities and performance from pre-injury or pre-disease sta-
tus that is limited in level or duration and/or requires medication to achieve; Unacceptable Function =
all other outcomes. Data were reported by each participating center directly to the author and were com-
bined for descriptive analyses. ANOVA with significance set at p<0.05 was used to test for differences
among time frames.
Twenty-nine centers participated in the study. Data from 1,004 TR cases were collected. Dogs ranged in
weight from 2-93 kg. Time frame of assessment ranged from 3 months to 3 years with 58.7% being short
term (3-6 mos), 31.1% being mid term (6-12 mos), and 10.2% being long term (>12 mos) follow-up. Sub-
jective clinical outcomes as assessed by the reporting DVM were determined to be successful in 93.9% of
cases. At follow-up, 54.1% of cases were judged to have “full function”, 39.8% were judged to have “accept-
able function”, and 6.1% were judged to have “unacceptable function”. No significant differences in levels of
function were noted among follow-up time frame categories.
These data suggest that Tightrope CCL can be expected to be associated with successful outcomes in ap-
proximately 94% of patients that are typically presented to veterinary clinics for signs of CCL disease. Ap-
proximately 6% of patients will be judged to have unacceptable function as a final outcome. Based on the
prospective, multicenter nature of this study, these subjective data indicating efficacy of Tightrope CCL for
treatment of dogs with CCL disease can be broadly applied.
Acknowledgments: My sincerest thanks to the conscientious veterinarians at the 29 participating centers

who helped bring TightRope CCL to clinics in a safe and effective manner and honestly reported their data.
Disclosure: The Author is a patent-holder for TR and receives royalties associated with TR sales.
93 • WVOC 2010, Bologna (Italy), 15th - 18th September J.L. Cook
Tightrope complications
Tightrope CCL (TR) (Arthrex Vet Systems, Naples, FL) is an extracapsular stabilization procedure that can
be used as part of a comprehensive treatment plan for cranial cruciate ligament (CCL) disease in dogs. TR
was developed in an attempt to address perceived shortcomings of current techniques - specifically to be min-
imally invasive, technically feasible, address all aspects of instability, minimize secondary pathology, and
consistently result in functional outcomes with a low complication rate in a cost effective manner. After ini-
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SMALL ANIMALS
tial testing for safety and efficacy via in vitro, ex vivo, and animal model studies, as well as a prospective co-
hort clinical trial, TR was released for clinical use. As part of a commitment to critically assess outcomes as-
sociated with TR, we enrolled veterinarians using TR in a multicenter outcomes study to further assess clin-
ical safety and efficacy in 1,000 cases.
This study falls within the guidelines of the participating institutions’ animal care and use committees and/or
guidelines for ethical treatment of animals with respect to privately-owned canine patients. Centers were en-
rolled based on their voluntary commitment to prospectively collect and submit outcomes data for all dogs
that they treated with TR for which ≥ 3-month follow-up data were available. Definitions and criteria for re-
porting time frame and complications associated with TR cases were from a system proposed for clinical or-
thopaedic studies in veterinary medicine (Vet Surg, 2010) and were set and given to each participating cen-
ter a priori as follows:
Time frames - Perioperative (pre, intra, and post op) = 0-3 months; Short term = > 3-6 months; Mid
term = > 6-12 months; Long term = > 12 months;
Complications - Catastrophic – complication or associated morbidity that causes permanent unacceptable
function, is directly related to death, or is cause for euthanasia; Major – complication or associated mor-
bidity that requires further treatment based on current standards of care: 1) requires surgical treatment
to resolve based on current standard of care or 2) requires medical treatment to resolve based on cur-
rent standard of care; Minor – not requiring additional surgical or medical treatment to resolve (e.g.,
bruising, seroma, minor incision problems, etc). Data were reported by each participating center direct-
ly to the author and were combined for descriptive analyses. ANOVA with significance set at p<0.05
was used to test for differences among time frames.
Twenty-nine centers participated in the study. Data from 1,004 TR cases were collected. Dogs ranged in
weight from 2-93 kg. Time frame of assessment ranged from 3 months to 3 years with 58.7% being short
term (3-6 mos), 31.1% being mid term (6-12 mos), and 10.2% being long term (>12 mos) follow-up. No cat-
astrophic complications were reported in this study. Major complications were reported in 9.9% of cases and
consisted of subsequent meniscal tears (4%), infection (2.8%), and failure (3.1%). Minor complications were
reported in 10.1% of cases, the majority of which involved seroma formation. No significant differences in
rates and types of complications were noted among follow-up time frame categories.
Clients should be advised that complications requiring further surgical or medical treatment based on cur-
rent standards of care can be expected to occur in approximately 10% of TR cases. While no catastrophic
complications occurred and the major complication rate is the lowest reported in the peer-reviewed litera-
ture for any CCL surgical technique to the author’s knowledge, the rate and types of complications noted
should be fully disclosed to clients during preoperative discussions regarding treatment of CCL disease in
dogs, including the fact that approximately 6% of patients will be judged to have unacceptable function as a
final outcome. Based on the prospective, multicenter nature of this study, these subjective data indicating
safety and efficacy of Tightrope CCL for treatment of dogs with CCL disease can be broadly applied.
Acknowledgments: My sincerest thanks to the conscientious veterinarians at the 29 participating centers

who helped bring TightRope CCL to clinics in a safe and effective manner and honestly reported their data.
Disclosure: The Author is a patent-holder for TR and receives royalties associated with TR sales.
Clinical studies and practice: ethical and legal perspectives

The current success of veterinary orthopaedic surgery cannot distract us from the need to continue to ele-
vate the standards of practice. To the contrary, the increasing cost of surgical care and the financial success
of surgical specialists make us accountable for more critically assessing the safety and efficacy of the treat-
ments we provide. The application of the results from clinical efficacy studies to patient care is referred to
as evidence based medicine. The concept of evidence-based medicine is being adopted in the human med-
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ical field and to some degree in veterinary medicine. Unfortunately, veterinary orthopaedics does not cur-
rently meet the highest standards in terms of producing data of high evidentiary value or developing and
implementing new devices and procedures in a systematic methodology that ensures safety and efficacy pri-
or to any clinical use. We need to pursue studies and processes that provide the ‘‘best’’ evidence or data for
valid decision making, ethical application of diagnostics and treatments, ensuring patient safety, and accu-
rately weighing the cost-benefit ratio for our clients. Studies of high evidentiary value include both clinical
and basic science research and can have a variety of outcome measures; however, they need to be applica-
ble in terms of time frame, species, model, application, and definition of success. The troubling fact is that
the overwhelming majority of clinically applicable studies in veterinary surgery fail to meet this or even low-
er levels of clinical evidence. Subsequently, decision making is based extensively on substandard clinical
studies, dogma, and the ‘‘personal experience’’ of ourselves or our mentors.
As practicing veterinarians we are all clinical investigators in some form or fashion. As a clinical investiga-
tor, it is your responsibility to fully educate clients regarding the diagnostics, medical and surgical thera-
peutics, and follow-up procedures you will perform, obtain their written consent, and keep them informed
throughout the process. Informed consent means that the client understands the purpose of what you will
do, the protocol, the potential risks and benefits, and alternatives. For clinical studies of any type, it must be
clear to the client that withdrawal is allowed at any time. Informed client consent should always be clearly
documented. Of course, informed client consent is only one aspect of legal and ethical clinical research, and
applicable institutional policies and procedures as well as legislation from all relevant governing bodies must
be adhered to.
A major goal in this process of ethical clinical studies and practice through evidence based medicine is to
“get everyone on the same page” when communicating outcomes from clinical studies in veterinary or-
thopaedics by setting strict criteria so that presented and published results are more immediately under-
standable, more comparable across studies, and less likely to be overstated or over-interpreted. Development
and testing of validated and reliable outcomes instruments, registries, increased use of valid objective out-
come measures, and inclusion of prospective, randomized, controlled clinical studies, systematic reviews,
and meta-analyses should be vigorously pursued in our goal of providing “best clinical care” for our veteri-
nary patients. Effective communication can be achieved if standardized and validated definitions and crite-
ria are adopted by all. Implementation of this as a common theme for us all will foster more efficient progress
in determining optimal delivery of care in veterinary orthopaedics.
95 • WVOC 2010, Bologna (Italy), 15th - 18th September J.F. Dee
Revisions lecture stream - “Failed tendon repair”

Jon F. Dee, DVM, MS, Dipl. ACVS
Hollywood Animal Hospital, Hollywood, Florida 33020 USA
INTRODUCTION
Tendons join muscles to bone and transmit the force of the muscles to the bone. Injuries to muscle tendon
units (strains) can result in an increase in length or contracture, with subsequent increase or decrease in
ROM (range of motion). Both result in a decrease in function. Both ligaments and tendons need time and
protection during healing so that biomechanical function may be restored.
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INJURIES OF THE ACHILLES’ TENDON
The Achilles mechanism consists of the gastrocnemius, superficial digital flexor (SDF), and the common ten-
don of the biceps femoris, gracilis, and the semitendinosus. Injuries may be complete or partial, acute or
chronic. A complete severance will result in a plantigrade stance. A severed gastrocnemius with an intact
SDF will have an incomplete drop of the hock with increased flexion of the digits at the proximal interpha-
langeal joint. A severed SDF with an intact gastrocnemius will have an incomplete drop of the hock with a
flat proximal interphalangeal joint. Mild strains may have no change in hock or interphalangeal angles. Di-
agnosis is via palpation, functional tests, radiography, ultrasound, CT and MRI. Injuries may occur any-
where from the origin of the gastrocnemius to the insertion.
In man, the injuries are associated with poor condition, advanced age, fluoroquinalone antibiotics, corticos-
teroids, and over-exertion. Proponents of surgery cite a shorter rehabilitation (6-9 versus 12 months) and <
risk of re-rupture (5 versus 15%). There is however, operative morbidity/mortality and > cost to consider.
A higher rate of post-operative infection and prolonged recovery is associated with chronic injuries. If the
guidelines on how to treat a fresh AT rupture vary, even less evidence-based data are available on how to
treat typical complications/re-ruptures.
In the canine, acute AT injuries, depending upon the severity, may be managed non-surgically by many
modalities, including RICE-(rest, ice, compression and elevation), buffered platelet-rich plasma injections,
acupuncture, physical therapy and pulsed therapeutic ultrasound or by surgery. Chronic (4-6 weeks) injuries
and failed non-surgical cases tend to be managed in a surgical fashion. Surgery tends to be categorized as 1)
non-augmented (primary reconstruction), 2) augmented, 3) arthrodesis and 4) lastly, amputation.
Failed non-augmented cases tend to be re-operated with a better post-operative management plan or become
surgically augmented cases. Augmentation consists of the following: 1) autogeneous-free fasciae lata, per-
oneus brevis or longus transposition, flexor hallucis longus transfer, and semitendinous origin transfer. 2)
allograft-superficial digital flexor tendon, long digital extensor tendon 3) xenograft-porcine small intestinal
submucosa. 4) synthetic-Biometrix Artelon® (polyurethane urea) degradeable mesh or polypropylene mesh.
Currently, no one method of augmentation appears to be more effective than another.
Strain measurements, during trotting, in the common calcaneal tendon in dogs showed no significant dif-
ference in maximum strain after immobilization compared with maximum strain during normal motion. Al-
though immobilization of the tarsal joint did not eliminate calcaneal tendon strain during weight bearing,
most patients are managed with some degree of tarsal hyper-extension in an attempt to protect the early heal-
ing process. Decreased weight bearing, secondary to the immobilization may attribute to the clinical bene-
fits. Post-operative considerations include: ROM type stretching, functional strength-increased weight bear-
ing and early support (orthotic type braces) to prevent load secondary to severe dorsiflexion. No method of
immobilization has currently proven to be superior to others regarding functional outcome
CHRONIC PAIN OF CHRONIC STRAIN

Sometimes the academic/clinical virtue of an attempted anatomical functional reconstruction versus the pre-
dictable palliative pain relief achieved via the following “salvage” procedures leaves the surgeon in a
quandary: 1) transection of the pectineus, iliopsoas or infraspinatus tendon of insertion or the biceps tendon
of origin 2) partial resection of the damaged portion of the SDF tendon of the paw, yielding a pain-free “flat
toe” versus a painful “bowed tendon” 3) translocation of the origin of biceps to the proximal humerus, or
the origin of the long digital extensor to the distal femur or proximal tibia 4) avulsion of the origin of the
long head of triceps in the canine or the clinical avulsion or surgical translocation of the origin of the later-
al extensors of the forearm in man with the chronic pain of a “tennis elbow”. ALL would have to have some
loss in “functional testing” compared to a normal, but ALL relieve the significant low grade chronic PAIN
associated with a chronic strain injury…hence, improved clinical function. Are these all “failed repairs”?
J.F. Dee WVOC 2010, Bologna (Italy), 15th - 18th September • 96
TENDON LENGTHENING
Tendon lengthening can be very problematic because what is appropriate on the operating table may be very
inappropriate when under physiologic load. For example, consider the amount of extension of the carpus
that is obtained during forced extension under anesthesia versus the significantly greater amount of exten-
sion that is obtained (the metacarpus is nearly parallel to earth) when the dog is running. These situations
can go from a “routine lengthening” to a failed tendon repair, especially if not appropriately supported dur-
ing the early healing process.
Injuries to the flexors of the extremities (see Management of Various Tendon/Ligament Injuries in Work-
ing/Sporting Dogs)
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REFERENCES
SMALL ANIMALS
Lister SA, Renberg WC, Roush JK. Efficacy of immobilization of the tarsal joint to alleviate strain on the common cal-
caneal tendon in dogs. AJVR 2009; 70: 134-39.
Baltzer WI, Rist P. Achilles Tendon Repair in Dogs Using the Semitendinous Muscle: Surgical Technique and Short-Term
Outcome in Five Dogs.Vet Surg 2009; 38:770-79.
Moores AP. Comerford EJ, Tarlton JF, Owen MR. Biomechanical and Clinical Evaluation of a Modified 3-Loop Pulley
Suture Pattern for Reattachment of Canine Tendons to Bone. Vet Surg 2004; 33: 391-97.
Pajala A, Kangas J, Siira P, Ohtonen P, Leppilahti J. Augmented Compared with Nonaugmented Surgical Repair of a
Fresh Total Achilles Tendon Rupture. JBJS 2009;91: 1092-1100.
Lubold R, Brown SG. Allograft Tendon Repair- personal communications-May 2010.
Greenwood, KM. Allograft Tendon Repair-personal communications-May 2010.
Reinke JD, Mughannam AJ, Owens JM. Avulsion of the gastrocnemius tendon in 11 dogs. JAAHA 1993;29:410-18.
97 • WVOC 2010, Bologna (Italy), 15th - 18th September L.M. Déjardin
TATE™ total elbow replacement:

results and complications
Loïc M. Déjardin, DVM, MS, DACVS, DECVS, Reunan P. Guillou, Doc. Vét.
College of Veterinary Medicine
Michigan State University, East Lansing - Michigan
Functional limitations of conservative management and nonreplacement surgeries for the treatment of end-
stage canine elbow osteoarthritis has been the impetus behind the development of total elbow replacement
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(TER). Because early TER systems (Chancrin, Lewis) were cemented, fully constrained hinged designs
SMALL ANIMALS
(linked systems), most of the joint forces were transmitted to the bone/implant interfaces. As a result, high
complication rates were encountered. Subsequent systems (Vasseur, Cook) were developed and rapidly
abandoned due to unacceptable post-operative morbidity and severe complications.
The next TER generation, developed by Conzemius is a cemented, semi-constrained stemmed design, with
no mechanical link between humeral and radio-ulnar components (unlinked system). The stability of such
prostheses is provided by the geometry of the implant surfaces and also depends on bone, collateral liga-
ments and cement mantle integrity. While semi-constrained designs are considered superior to hinged in hu-
mans, the Iowa State system, with a greater than 20% rate of severe complications, has yet to meet clinical
expectations. Several factors, including the relatively invasiveness of the surgical technique may have con-
tributed to the partial success of this system as well as to the nature of the reported post-operative compli-
cations (humeral and ulnar fractures as well as lateral luxations). Another limitation of the stemmed systems
results from the sequential insertion of the humeral and RU components, which increases the risk of rela-
tive malalignment of the prosthetic components and subsequently, the risk of aseptic loosening secondary to
excessive wear.
Recently, a novel TER system (TATE Elbow™) was developed by Acker and Van Der Meulen (Fig. 1). Sim-
ilar to Conzemius’ prosthesis, the TATE is an unlinked, semi-constrained design. However, several differ-
ences exist between these two systems and may explain the improved time-matched results seen with the
TATE. Unlike previous conventional stemmed and cemented systems, the cementless TATE implant was
designed to use a novel resurfacing concept, as well as minimally invasive surgery (MIS).
Figure 1 - Schematics of a
TATE prosthesis. The TATE
is a cementless, stemless press-fit
system. The prosthesis is pre-as-
sembled and implanted as a
single unit (cartridge). Compo-
nents are maintained together
via a set plate, which once re-
moved allow for joint range of
motion.
These innovations in implant design and surgical technique were intended to reduce the incidence of the
two major complications associated with stemmed prostheses (lateral luxation and humeral and/or ulnar
fractures). First, the elbow is approached via an osteotomy of the larger medial humeral epicondyle rather
than a desmotomy of the lateral collateral ligament. Second, the articular surfaces of the humerus, radius
and ulna are removed simultaneously without luxating the elbow using a precision milling tool (Fig. 2). To-
gether, these steps allow for preservation of both collateral ligaments and the majority of the osseous frame
supporting the prosthesis, which in turn should enhance stability, reduce morbidity and hasten functional
recovery.
L.M. Déjardin WVOC 2010, Bologna (Italy), 15th - 18th September • 98
A B C D
Figure 2 - Schematics of the critical steps of the surgical procedure. A) The elbow joint is exposed through a medial epicondyle osteotomy then
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locked at ~ 90° of flexion. B) A milling tool is used to simultaneously remove the articular surfaces of the humerus, radius and ulna. Milling
creates a circular groove centered on the humeral trochlear. C) The TATE cartridge is impacted into the articular space left after milling. D)
The medial epicondyle is reattached using lag screws.
Third, the TATE prosthesis is a cementless system initially stabilized through a “press-fit” mechanism (Fig.
3 – left). Long term stability relies on bone ingrowth into the porous structure of the implants (osteointe-
gration [Fig. 3 – right]). Cementless prostheses have potential advantages over the currently used cemented
model, including reduced risk of infection and reduced rate of implant wear, both of which are regarded as
leading causes of post-operative morbidity and implant failure. Lastly, both TATE components are impact-
ed simultaneously as a pre-assembled cartridge (Fig. 2). Because this feature guarantees accurate alignment
and tracking of the prosthetic components throughout range of motion, stresses at the bone-implant and ar-
ticular component interfaces will likely be reduced. This in turn may optimize osteointegration of the pros-
thesis and lessen the risk of aseptic loosening secondary to premature wear.
Figure 3 - Left: Post-operative radiographs showing proper positioning of a TATE prosthesis. The tree proximal screws are used to stabilize
the medial epicondyle. Lagged between the radius and the ulna the distal screw is used to maintain stability during healing of a surgical RU
synostosis. Right: Immediate and 2 years post-operative radiographs showing good osteointegration of the prosthesis. Note: an additional screw
was used at 4 weeks post-operatively to improve the stability of the medial epicondyle.
To date, the TATE prosthesis has been implanted in approximately 150 cases worldwide since July 2007 (~3
years ago). The following data has been compiled from feedback from the 6 centers where more than 5 cas-
es have been performed (total 73 elbows). We emphasize that this information is subjective in nature and
therefore should be assessed cautiously. Three severe complications consisting of two humeral fractures and one
implant loosening were recorded, all within 5 weeks post-operatively (rate ~4%). Of these, two cases were
associated with secondary infection and one with secondary ulnar fracture. Two cases were euthanized by
the RDVM without reevaluation by the primary surgeon and one was amputated due to concomitant deep
infection. Minor complications including pin migration, screw loosening, fracture of the medial epicondylar frag-
ment, skin dehiscence and neuropraxia were successfully revised. Iatrogenic intra-operative complications due to
surgical errors (transection of the ulnar nerve and trochlear fracture) were described by Acker in one dog
who remains ambulatory two years post-operatively.
99 • WVOC 2010, Bologna (Italy), 15th - 18th September L.M. Déjardin
We have limited knowledge of twenty additional cases treated outside of this study group with the assistance
of a trained surgeon. In that subgroup, we are aware of four severe complications (20%). Humeral fractures
were reported in two cases, one of which was successfully repaired while the other resulted in an amputa-
tion due to associated MRSA infection. The remaining two cases developed infections; one patient under-
went successful arthrodesis, the other was lost to follow-up. Elbow luxations and primary ulnar fractures,
which were complications seen with the Iowa State system, were not reported in any cases. Objective data
regarding functional outcome is limited at this point in time. Subjective feedback suggests that while dogs
appear pain free and show improved range of motion mainly in extension, some subtle to mild lameness
may persist.
Regardless of design, a major limitation of TER is the absence of effective revision options in case of fail-
ure. Unfortunately, because end-stage elbow OA is often a bilateral condition, amputation is not a valid op-
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tion in most cases and arthrodesis remains the main alternative. Although some fractures or luxations may
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successfully be revised, others may require explantation and arthrodesis because of the limited bone stock
available for implant fixation. Infection is and will likely continue to be the most challenging complication
as antibiotherapy alone is unlikely to be effective as long as the prosthesis is implanted. Because of these lim-
itations, owner education is critical and must be thorough and objective. A fair disclosure of alternative treat-
ments and realistic expectations particularly with regards to complications and revisions should be present-
ed to anyone contemplating TER.
R. Eaton-Wells WVOC 2010, Bologna (Italy), 15th - 18th September • 100
Digital amputation in performance dogs

Richard Eaton-Wells, BVSc., MACVSc.
Queensland Veterinary Specialists, Brisbane, Queensland Australia
This presentation will cover the varying reasons for digital amputation, the level they are performed at and
the expected outcome for the performance dog.
Digital amputations should be viewed in the light of the expected use of the animal. Amputation of a se-
verely traumatised single digit can result in a rapid return to work, compared with many weeks trying to
save the toe. This may be important to the owner/ handler and may need to be considered as our treatment
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plan is formulated. In the racing dog we also have an established a level of performance and we, the veteri-
narians, have to return the animal to as near as possible the same level of performance as prior to amputa-
tion. Hence some consideration must be given to the expected work load of the patient. It is an interesting
observation that fewer amputations are being performed, for traumatic reasons, in working dogs, than say
20 years ago. In my opinion there are two main reasons for fewer amputations. Veterinarians have become
better at saving digits and owners are more reluctant to have digital amputations performed.
In an extreme case it could be argued that loss of a limb is just a very high digital amputation. Sheep and
Cattle dogs, even in the harsh Australian bush environment, work quite satisfactorily post limb amputation;
however, a racing greyhound is severely compromised.
Single digital amputations in the general working environment, provided it is performed in an appropriate
manner, should not adversely affect a dog. Dogs with single digit amputation on multiple feet seem to be
functional, 2 digits on a single foot are fine, but which ones and at what level may start to become an issue.
I have seen one working cattle dog with only a single central digit that still functioned satisfactorily but I
think that it could be arguable that a limb amputation would result in a “better” working outcome. How-
ever, in the racing Greyhound there is much discussion about the prognosis, the level and digit involved on
the likely prognosis when a single digit is involved, let alone multiple digits.
Historically, digits were removed for a multitude of reasons. As our knowledge and surgical skills have im-
proved so has our ability to solve digital problems, rather than amputate. As evidenced by the recent work by
Mike Guilliard, using small external fixators, to stabilise and save metacarpo-phalangeal joints in racing grey-
hounds. We have also become accustomed to partial amputations rather than remove the whole digit and to
trying to save the foot’s “normal” anatomy. Both of these factors have improved the surgical outcome.
The Racing Greyhound is easily defined, however the list of “working Dogs” is almost endless. I am sure
that there is a Dachshund out there still being used for badger hunting.
AETIOLOGY
Common reasons for digital or phalangeal amputation include but are not restricted to the following:
Trauma, which has multiple sub divisions, Necrosis, Tumours, Sesamoid disease, Infection, Foreign bodies,
Immune mediated disease, Self mutilation
LEVEL
The level of amputation has changed as our ability to treat various disorders has improved. Hence I leave
as much toe in place as possible.
3rd Phalanx Toe nail amputation

Dis-articulation
Distal P2
2nd Phalanx Distal P2 only
Entire digit
1st Phalanx Rarely performed
Entire digit
Metacarpal / Tarsal Distal
- Dis-articulation
- Ostectomy
- Proximal
- Problems with remodelling
101 • WVOC 2010, Bologna (Italy), 15th - 18th September R. Eaton-Wells
SURGICAL TECHNIQUES
We will assume the dog has been anaesthetised and prepared for routine aseptic surgery. Any osteotomy of
the metacarpal, tarsal or proximal digits should be performed with an oscillating saw. The results achieved
with a saw are superior to those when rongeurs or bone cutters are involved. My personal opinion for this
is the reduced trauma, the smoothness of the cut and the possible reduced incidence of micro fractures, when
a saw is used. This does seem to apply to the toe nail amputations, perhaps because we have to rongeur the
germinal crest off anyway.
Toe nail amputation

This allows us to retain the entire pad and associated structures. An inverted Y shaped incision is made
around the nail bed, a suitable curved pair of bone cutters is used to remove as much as the nail as possi-
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ble, while leaving the flexor and extensor processes intact. This will reveal the ungual crest and germinal
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layer of the toe nail. This germinal layer should be carefully removed; failure to remove the entire germinal
layer will result in regrowth of portions of the nail. This will produce multiple problems post surgically. The
inverted Y is closed routinely. Return to full activity can be as soon as adequate skin healing has occurred,
10-14 days.
Dis-articulation
This allows us to retain the pad, but removes the entire 3rd phalanx. Dis-articulation at the distal inter pha-
langeal joint will allow for easy removal of the 3rd phalanx, but does seem to carry a higher incidence of com-
plications. There is some dispute as to whether it is necessary to remove the articular cartilage, however, fail-
ure to remove all the articular cartilage off the distal end of the 2nd phalanx may result in “mushrooming”
of the distal end of P2 and a chronic chondromalacia developing. In my opinion all the articular cartilage
should be carefully removed prior to closure. This can be achieved with rongeurs, a curette or a high speed
burr. These dogs require a new fibrous pad has to develop to protect the end of P2. These dogs should be
getting small amounts of exercise from day 14 on and return to full activity at 4-6 weeks. Failure to allow
the fibrous pad to develop may result in a chronic lameness.
An alternative method of amputation at this level is by osteotomising the distal end of the second phalanx,
just above the articular cartilage. An oscillating saw should be used. Again, these dogs require the os-
teotomised bone to “heal” and a new fibrous connection with the pad to develop.
It is possible to amputate at the proximal inter-phalangeal joint either by dis-articulation or osteotomy; how-
ever there is an increased risk of perforation of the palmar webbing by the bone ends so the technique is not
recommended.
The surgical approach for all of the above is by incision directly over the area involved. As much soft tissue
as is necessary is maintained and re-apposed with suitable small, 3/0 or 4/0, absorbable material. However,
once the level rises to the metacarpal / tarsal then different approaches may be used. It has become evident
that unless a tumour is involved and we are attempting to achieve “clean margins” better outcomes are
achieved in the racing dog if the webbing is left in place but the digit “filleted” out. I tend to apply this tech-
nique to all breeds.
AMPUTATION OF THE METACARPALS OR METATARSALS

Amputation of a metacarpal or tarsal is usually as a result of multiple trauma, tumour, chronic infection or
chronic instability.
Amputation of metacarpal /tarsal bones will be addresses as per the racing greyhound. As the level at
which they are amputated is critical to the outcome, whereas it is not so important in other working or
pet breeds. It is imperative that, where possible, as much length of left metacarpal / tarsal 5 & right
metaC/T 2 is maintained, as we know that remodelling changes will occur. Leaving these bones at maxi-
mum length will reduce the amount of remodelling that is undertaken. Experimental work has shown that
a proximal 3rd amputation of metacarpal 5 left fore will result in considerable remodelling of metacarpal
4 within a 3-4 week period. This will be evidenced by pain on palpation plus endosteal and periosteal
changes radiographically.
The surgical excision is made directly over the bone involved, the bone is identified and soft tissues, exten-
sor/ flexor tendons identified and freed up. An oscillating bone saw is used to remove the distal end of the
bone just proximal to the articular cartilage. A saw produces a cleaner cut and seems to result in less prob-
lems post surgery. I personally cut the bone at an angle both horizontally and vertically, as I feel that there
is a reduced incidence of post amputation trauma. There is no science in this observation. The palmar
sesamoids are dissected free and removed. Any protruding deep flexor tendon is cut off and the sheath
closed with several small sutures.
Lateral and medial toes are amputated with the webbing. Care is necessary that sufficient skin is left so that
the incision can be closed without tension. Central toes are “filleted out” so as to leave the palmar webbing
intact. Soft tisues are re-apposed with a suitable absorbable suture. The dorsal skin may need to be trimmed
to remove excess prior to closure without tension on the suture line.
A light dressing is applied post operatively this is changed in 12-24 hours. The dressing is then changed as
necessary with the foot supported for 10-14 days. Preoperative antibiotics and a non steroidal inflammato-
ry agent should be given. It is possible to perform this procedure with a tourniquet in place; however I do
not like the use of a tourniquet.
Amputation for tumours

When a digit is amputated due to the presence of a tumour, more aggressive margins should be taken. It is
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sometimes difficult to get adequate margins where malignant tumour or mast cell tumours are involved.
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103 • WVOC 2010, Bologna (Italy), 15th - 18th September N. Ehrhart
Limb salvage procedures for trauma: where are we now?

Nicole Ehrhart VMD, MS, Dipl. ACVS
Animal Cancer Center, Colorado State University, Fort Collins CO
Large skeletal defects resulting from trauma or tumor resection create a clinical challenge for surgeons at-
tempting to salvage an extremity and prevent amputation. Defects resulting from trauma commonly occur
in young, active human and veterinary patients rather than the elderly. Limb preservation is the standard
of care in human medicine; whereas amputation is a common way to address the limb with significant bone
defects in veterinary patients. More and more, owners are seeking limb salvage procedures in their pet ani-
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mals as well. Musculoskeletal tumors such as osteosarcoma are far more common in pet animals than in
man, making the study of limb preservation techniques following removal of a tumor a rich area for com-
parative research.
Novel therapeutic interventions addressing the specific issues surrounding bone healing in trauma and can-
cer patients are needed to improve the quality of life for cancer patients undergoing limb reconstruction. The
Musculoskeletal Tumor Laboratory at Colorado State University’s Animal Cancer Center is involved in re-
search to address some of the unique challenges associated with limb reconstruction in the trauma and can-
cer setting. Recent advances, current research and remaining challenges will be discussed.
ALLOGRAFT RECONSTRUCTION
The use of structural allografts for reconstruction of large bone defects remains as a mainstay of technique
in humans due to the fact that allograft tissue is a more biologic alternative to replacement when compared
with endoprostheses. If early complications are avoided, allografts provide future bone stock and the op-
portunity for excellent soft tissue reconstruction. Human patients with bone tumors that require resection
of the femoral or tibial diaphysis are ideal candidates for allograft reconstruction. The main complication as-
sociated with allografts in human recipients is fracture which is seen in 37% of cases. This is due to the for-
mation of microcracks in the allograft tissue that occur within the nonviable portions of the graft. The mi-
crocracks propagate rather than heal and eventually lead to allograft failure or implant loosening. Infection
is seen in 5-11% of human cases. In canine allograft recipients, infection occurs in 47% of recipients. This
high rate of infection is theorized to occur due to the paucity of soft tissue coverage in distal radial sites, the
influence of chemotherapy and other host factors.
In humans, nonunions occur in 9-15% of cases and are more common when the allograft is stabilized with
an intramedullary nail than when it is stabilized with a plate. Currently, gene and cellular therapy strategies
to enhance allograft incorporation are being studied in our laboratory. These results may have important
implications for human and canine allograft recipients.
PROSTHETIC RECONSTRUCTION
Metal endoprosthetic reconstruction is commonly used in humans to reconstruct limbs after juxta-articular
tumor resection. It provides a construct that allows early weight-bearing and there are relatively few early
postoperative complications allowing patients who require chemotherapy to continue their treatment. The
challenges include a high rate of late complications requiring revisions. The mean life expectancy of pros-
thetic long bone reconstruction prior to first revision is 5-7 years. This becomes problematic for young pa-
tients who may require 7 or more revisions in their life time. Other challenges involve determining the best
option for intramedullary stem fixation and the optimal way to attach soft tissues to metal prosthesis at the
shoulder, hip or knee. One of the more innovative advances in endoprosthetics in the last decade was the
development of a noninvasive expandable prosthesis for skeletally immature patients with juxta-articular
malignant bone tumors. This construct uses energy stored in a compressed spring that is locked with a poly-
ethylene sleeve. Lengthening occurs by applying an electromagnetic field which softens the polyethylene and
allows the spring to relax and lengthen. When the electromagnetic field is removed, the polyethylene hard-
ens again locking the spring in its extended position. Complications with this technique have been similar
to other types of endoprostheses and its disadvantage is that it needs to be replaced with a standard endo-
prosthesis once growth is over to prevent collapse of the telescoping moveable parts over time. Even so, it
has provided a means of avoiding serial surgical interventions to add lengthening segments to prostheses in
growing patients. Endoprosthetic radii are available for use in veterinary patients. Infection rates are similar
to allograft reconstructions. Distal radial endoprosthetic reconstructions appear to be biomechanically su-
perior to allograft reconstructions in cadaver limbs. The availability of these devices may make limb savage
in dogs more widely available.
N. Ehrhart WVOC 2010, Bologna (Italy), 15th - 18th September • 104
BONE TRANSPORT OSTEOGENESIS

Bone transport osteogenesis is used for reconstruction of large segmental defects in humans and veterinary
patients following tumor resection. This technique is most popular for human patients in Asian countries
where cultural factors make allograft replacement or amputation less desirable in some cultures. The tech-
nique is compatible with most chemotherapy agents used for the treatment of musculoskeletal sarcomas. In
contrast, osteogenesis is profoundly inhibited by ionizing radiation and therefore should not be used in pa-
tients who will receive or have received radiation therapy where the affected bone is in the field. Recently a
motorized intramedullary nail was developed with a motorized programmable sliding mechanism for limb
lengthening and bone transport that reduces the risk of infection and scarring usually associated with the
external fixators used for the same purpose in humans. Only a small number of human patients have been
treated with this technique. A recent veterinary study reviewed the results of nine cases of osteosarcoma
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treated with bone transport osteogenesis. Mean defect size was 9.5 cm with a mean of 123 days distraction
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until docking. Mean time from surgery to fixator removal was 205 days.
VASCULARIZED BONE GRAFTS

Vascularized bone grafts have unique advantages for reconstruction in specific anatomic locations. Fibular
transfer is used to reconstruct defects of the skull and mandible in humans. Regarding long bone defects in
humans, vascularized transfer of the fibula has been performed for long bone defects of the upper extremi-
ties. The size discrepancy and biomechanical difference between the fibula and the major weight-bearing
bones of the lower limb make this technique less desirable for weight bearing limbs. Vascularized transfer of
the ulna has been performed for distal radial defects following tumor resection in dogs with favorable re-
sults.
FUTURE DIRECTIONS
At this time, large bony defects remain a significant challenge for human and veterinary orthopedic sur-
geons. Advances in molecular technology and tissue engineering have provided novel opportunities to ma-
nipulate bone formation. Stem cell therapy is an exciting frontier that may provide significant advances with
clinical relevance to animals and humans requiring limb salvage procedures. Gene therapy and novel bone
substitutes are other modalities that show promise for the future.
105 • WVOC 2010, Bologna (Italy), 15th - 18th September N. Ehrhart
Implant-associated infection
Nicole Ehrhart VMD, MS Dipl. ACVS
Professor, Surgical Oncology, Colorado State University, Director, Comparative Musculoskeletal Oncology Laboratory
Orthopedic procedures, including fracture fixation and arthroplasty, have a low but significant infection rate.
In humans, the overall rate of implant-associated infection is estimated to be approximately 5% in clean sur-
gical procedures. In veterinary medicine, it is estimated that the infection rate is somewhat higher due to the
propensity for animals to self-traumatize incisions by licking or scratching. A recent retrospective study in-
volving 902 dogs undergoing surgery for cranial cruciate rupture reported the infection rate following TP-
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LO to be 8.4% (Frey et al. JAVMA 2010). Infections associated with orthopedic implants are characterized
by bacterial colonization and biofilm formation on the implanted device and infection of the adjacent tissues.
Bacteria within biofilms are far more resistant to antibiotics and result in persistent infection despite aggres-
sive antibiotic therapy. Risk factors that may add to the possibility of implant-associated infection include ex-
tensive soft tissue trauma, anatomic location of the implant (e.g. oral cavity versus extremity), whether the
wound is open or closed, and patient co-morbidities such as obesity, diabetes or the use of immune-sup-
pressing medications such as chemotherapy or corticosteroids. In addition to patient-related factors, it must
also be recognized that the material and surface of any fracture fixation device plays a role in the potential
development of implant-associated infection. Implant-associated factors found to influence the susceptibility
of a particular device to infection include: material, biocompatibility, topography, surface area available for
colonization of bacterial, presence of dead space, and tissue or bone compression adjacent to the implant
causing necrosis. Of the commonly available orthopedic implant materials, stainless steel and titanium, stain-
less steel is associated with an increased infection rate in comparison with titanium in animal models. This
observation has been attributed to two factors: the improved biocompatibility of titanium over stainless steel
and the increased observation of fibrous capsule formation around stainless steel implants. Steel is usually
electropolished to a smooth surface whereas titanium in its standard form has a micro-rough surface. Im-
proved adhesion of tissue to titanium over stainless steel has been proposed to be the reason for the reduced
prevalence of capsule formation around titanium implants (Moriority et al. J Mater Sci Med 2009). The flu-
id filled fibrous capsule that is often observed to form around stainless steel is not vascularized and is poor-
ly accessible to local immune defenses.
Staphylococcus aureus, a common infectious agent associated with implant-related infections, as well as other
bacteria, can persist in the surgical site despite aggressive and specific antibiotic therapy. The prevalence of
methicillin-resistant Staphylococcus aureus has been growing for more than a decade and is particularly
prominent in orthopedic trauma and joint replacement patients. These infections are associated with a high
morbidity. Treatment often involves multiple debridement procedures, surgical revisions and long term an-
tibiotic therapy. Even with aggressive treatment, many of these infections are never fully eradicated and of-
ten lead to implant loosening, failure, soft tissue loss and even limb loss. This resistance to treatment is pri-
marily due to the development of a bacterial biofilm on the implant material. A biofilm is a microbially-de-
rived, highly organized community of bacteria irreversibly attached to a surface or substrate and embedded
in a matrix, that have developed more aggressive growth rates and resistance to antimicrobial therapy. The
matrix provides a physical barrier to the penetration of antimicrobial agents. In addition, bacteria living with-
in a biofilm acquire biofilm-specific genes that code for efflux pumps to remove antimicrobials from the mi-
croenvironment. It is estimated that biofilms are involved in greater than 65% of all infections. The preva-
lence of methicillin-resistant Staphylococcus aureus has been growing for more than a decade and is partic-
ularly prominent in orthopedic trauma and joint replacement patients.
The most-effective strategy for managing implant-related infections is, obviously, prevention. Appropriate
sterile technique, responsible antimicrobial use and strict attention to minimizing tissue trauma, debridement
and minimizing dead space are paramount. The treatment of established implant-related infections involves
surgery (debridement with or without implant removal) and long-term antibiotic therapy. The choice of ther-
apy depends upon duration of infection, stability of the implant, antimicrobial susceptibility of the pathogen
and condition of the surrounding soft tissue. Local and systemic antibiotic therapy is often utilized in con-
junction with implant removal where possible. This approach seems to have the best clinical outcome; how-
ever, implant removal is not always possible. These cases remain a clinical challenge. Developing strategies to
prevent or treat implant-associated infections involve novel implants with surface characteristics resistant to
biofilm formation, gene therapy to confer antibiotic sensitivity to biofilm-established organisms, targeted
agents designed to dispersing the biofilm matrix molecules, and early biofilm detection techniques. These
strategies will become more and more important as emerging antibiotic-resistance becomes more challenging.
N. Fitzpatrick WVOC 2010, Bologna (Italy), 15th - 18th September • 106
Sliding Humeral Osteotomy:

current status and complications
Noel Fitzpatrick, DUniv MVB CSAO CVR MRCVS
Fitzpatrick Referrals, Surrey, UK
Elbow dysplasia is an important cause of thoracic limb lameness in large and giant breed dogs. Most fre-
quently, pathologic changes are associated with the medial aspect of the coronoid process of the ulna and
medial aspect of the humeral condyle. Commonly recognized lesions of the medial aspect of the coronoid
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process are cartilage malacia, fibrillation, fissuring, and erosion in addition to subchondral bone micro fis-
suring and fragmentation1.
Frictional erosion (‘‘kissing lesion’’) of the medial humeral condyle is frequently associated with coronoid
disease, whereas osteochondrosis of the medial aspect of the humeral condyle may give rise to lesions of os-
teochondritis dissecans. This spectrum of pathology and ensuing full thickness cartilage erosion in the re-
gion defined by the medial aspect of the coronoid process and medial aspect of the humeral condyle has
been referred to as medial compartment disease (MCD)2,3.
Recent work has looked at the difference in distribution of elbow pathology in older (6y or older) versus
younger (5-18mos) dogs4. Complete erosion of the medial compartment, in the absence of observable fis-
suring or fragmentation of the medial coronoid process, was noted in 3% of younger dogs and 31% of old-
er dogs in the study. This may be correlated with a spectrum of age-associated disease exacerbation due to
humero-ulnar conflict on a progressive basis. In all cases of medial compartment erosion, the lateral com-
partment was grossly normal on arthroscopic examination. This has also been the experience of the author
in the sense that we have observed and documented a chronology of disease due to humero-ulnar conflict
which in its early stages is manifested as subchondral micro cracks then overt fissures communicating with
the joint followed by fragmentation and eventual erosion of the medial compartment. 5 A subgroup of cases
has been observed where fragmentation does not occur and erosion of the medial compartment alone is ob-
served on a progressive basis.
The ateiopathogenic mechanisms leading to these phenomena are as yet under-explored. They may include
primary osseous incongruity between the ulnar trochlear notch and the distal humerus, between the radial
incisure of the medial coronoid process and the radial head, or between the joint levels of the radial head
and the medial coronoid process. Undoubtedly periarticular musculotendinous support structures further
contribute to debilitation of the medial compartment and particular emphasis has been placed on the biceps-
brachialis complex and its role on medial compartment joint pressures in this regard.6,7 The contribution of
the coupling of the radial head and the medial and lateral coronoid processes via the annular ligament is
poorly understood at this time. Elbow incongruity such as radioulnar step defects, humero-ulnar incongru-
ence, varus deformity of the humerus, or imbalance between skeletal and muscular mechanics may all con-
tribute to MCD of the elbow joint in dogs.
Historically, surgical treatment of elbow disease has either been tailored toward the primary lesion where
identified8-14, or has involved radial or ulnar osteotomies15-17 to address perceived incongruity or alter load
distribution at the elbow. In the case of proximal ulnar osteotomy for incongruity it has been noted that the
proximal ulnar articular surface is elevated above the radial articular surface and that varus deformity may
result from loading18. However, more recently the author investigated a different position and trajectory of
proximal ulnar osteotomy which on second look arthroscopy and clinical analysis has yielded more satis-
factory outcomes. Regardless of the technique used, degenerative changes are progressive for all forms of el-
bow dysplasia. Where such techniques are unlikely to result in a favorable clinical outcome because of
chronicity of the lesions, persistence of advanced frictional abrasion, or severity of cartilage disease of the
medial compartment at the time of presentation, there is a rationale and a clinical need for alleviation of pain
and if possible, amelioration of disease progression.
Within our experience, alternatives such as total elbow arthroplasty or elbow arthrodesis may represent sub-
optimal therapeutic choices because of potential complications, potentially poor functional outcome, or po-
tential for failure of the implants within the lifetime of the patient. Current iterations of medial compartment
replacement in isolation are at this time in early investigation and have not yet established medium term out-
come measures.
Sliding humeral osteotomy (SHO) has been increasingly accepted as a valid technique for managing cases
of medial compartment erosion with the prerequisite that the cartilage surface of the humero-radial joint (lat-
eral joint compartment) remains intact. The author reserves sliding humeral osteotomy for cases affected by
107 • WVOC 2010, Bologna (Italy), 15th - 18th September N. Fitzpatrick
full thickness Outerbridge grade 4 cartilage lesions of the medial aspect of the humeral condyle with op-
posing lesions of the medial aspect of the coronoid process. Occasionally SHO is performed in a young dog
that is affected by deep focal lesions of osteochondritis dissecans, but generally SHO is performed in patients
who have sustained severe full thickness cartilage abrasion due to progressive humero-ulnar conflict and me-
dial coronoid disease, both young and older.
Sliding humeral osteotomy involves creation of a mid diaphyseal transverse plane osteotomy in the
humerus. The distal segment of the humerus is then translated medially and fixed in position by using a me-
dially applied stepped locking plate. The result is an axial force vector that is redirected over the lateral com-
partment of the elbow. By redistributing force away from the eroded medial compartment, clinical pain and
lameness are reduced.
A medial approach to the humerus is made and direct visibility of the humeral diaphysis is facilitated by
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blunt dissection with retraction of the biceps cranially and the triceps caudally. The stepped locking plate is
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positioned on the humerus such that the 4th screw is centered cranial to caudal and the step is located at the
longitudinal mid point of the diaphysis. Partial fixation of the plate is achieved by placing bicortical 4.0mm
locking screws in the proximal segment of the plate and two 3.5mm bicortical screws are placed in the dis-
tal segment. Osteotomy is performed using the step of the SHO plate as a cutting guide. Bicortical screws
in the distal segment of the plate are then sequentially tightened and in doing so, translate the distal segment
of the plate medially. Remaining screw holes in the distal segment of the plate are filled with 4.0mm bicor-
tical locking screws, and the 3.5mm bicortical translational screws are then replaced with 4.0mm bicortical
locking screws. Routine three-layer closure completes the procedure.
Technical evolution of the surgery has continued with regard to the number and size of locking screws in
the construct. The use of bicortical 4.0mm locking screws in all 8 positions is the current recommendation.
Reported complications of the technique have included infection, haematoma formation, wound breakdown,
humeral fracture, implant failure, and delayed osteotomy union.
As the technique has evolved and has been refined, complication rates have continued to reduce. The total
complication rate for the procedure has seen a steady decline from 34.5% to 19.0% as the technique has ad-
vanced19. In the last 30 cases performed at the author’s practice, corresponding to the latest evolution of tech-
nical application of sliding humeral osteotomy, a major complication rate of 3% has been observed in that a
single case which was affected by infection which required removal of the implants.
Two further minor complications which did not require surgical intervention were recorded as delayed os-
teotomy union and single screw breakage. Both were treated conservatively. This yielded a total complica-
tion rate of 10%.
Weight bearing is possible within 24 hours of surgery albeit that patients are generally more lame for up to
2 weeks postoperatively than preoperatively. Objective gait analysis studies are ongoing, however early re-
sults on a limited number of cases have revealed that peak vertical force in the operated limb increases from
85.6% pre operatively, to 97.5% postoperatively of that recorded for the contralateral limb by 12wks post op-
eratively. Encouraging as these results are, it must be noted that they are preliminary results only, and cal-
culated from small case numbers.
Favorable functional outcome data gathered from clinical, kinetic and second look arthroscopic evaluations
and from owner visual analogue scale assessments up to three years post-operatively intimates proof of prin-
ciple that sliding humeral osteotomy alleviates pain and discomfort in canine patients, young and old, af-
fected by full thickness cartilage disease of the medial compartment of the elbow. Second look arthroscopy
has revealed islands of fibrocartilage re-growth on areas of the medial aspect of the humeral condyle previ-
ously denuded of hyaline cartilage. Given that the epidemiological significance of medial compartment
pathology in the dog is of great concern to the veterinary community and shows no signs of diminishing in
the canine population, it is evident that a surgical solution is warranted for progressive medial compartment
disease. Sliding humeral osteotomy has now evolved into a reproducible, robust, and viable treatment op-
tion for medial compartment disease of the canine elbow.
Because sliding humeral osteotomy has improved quality of life in the author’s view for in excess of 140 pa-
tients at his referral centre, he is comfortable recommending this procedure to animal owners on a routine
basis. Proof of principle is firmly established and clinical outcomes have been documented with complica-
tion rates comparable to other commonly accepted veterinary orthopaedic procedures such as stifle and
coxo-femoral surgeries. In this regard the author feels that sliding humeral osteotomy has now evolved to a
point where it can be recommended for routine application in such cases, with careful case selection and ex-
amination of the joint surface, preferably arthroscopically, as a pre-requisite.
Whilst training of technique is required, the application has now been successfully and reliably reproduced
by many surgeons globally and patients reliably improve in terms of lameness albeit that osteoarthritis pro-
gresses, as would be expected.
REFERENCES
1. Danielson KC, Fitzpatrick N, Muir P, et al: Histomorphometry of fragmented medial coronoid process in dogs: a
comparison of affected and normal coronoid processes. Vet Surg 35:501–509, 2006.
2. Schulz KS: Diagnostic assessment of the elbow (when in doubt, scope the elbow). Proc 14th Annual American Col-
lege of Veterinary Surgeons Symposium, Denver, CO, October 2004.
3. Kramer A, Holsworth IG, Wisner ER, et al: Computed tomographic evaluation of canine radioulnar incongruence
in vivo. Vet Surg 35:24–29, 2006.
4. Vermote KAG, Bergenhuyzen ALR, Gielen I, van Bree H, Duchateau L, Van Ryssen B: Elbow lameness in dogs
of six years and older: arthroscopic and imaging findings of medial coronoid disease in 51 dogs. Vet Comp Orthop
Traumatol 23:43-50, 2010.
5. Fitzpatrick N and Reuter R: Histopathology of cartilage and subchondral bone following subtotal coronoid ostec-
MAIN PROGRAM
tomy (SCO) for treatment of fragmented medial coronoid process (FMCP). Sci Proc of 47th Annual British Small
SMALL ANIMALS
Animal Veterinary Assoc Congress p586, 2004.

6. Hulse D, Young B, Beale B, Kowaleski M, Vannini R: Relationship of the biceps-brachialis complex to the medial
coronoid process of the canine ulna. Vet Comp Orthop Traumatol 23:173-176, 2010.
7. Fitzpatrick N, and Yeadon R: Working algorithm for treatment decision making for developmental disease of the
medial compartment of the elbow in dogs. Vet Surg 38:285-300, 2009.
8. Meyer-lindenberg A, Longhann A, Fehr M, et al: Arthrotomy versus arthroscopy in the treatment of the Frag-
mented Medial Coronoid Process of the Ulna (FMCP) in 421 Dogs. Vet Comp Orthop Traumatol 16:204–210,
2003.
9. Read RA, Armstrong SJ, O’Keef D, et al: Fragmentation of the medial coronoid process of the ulna in dogs: a study
of 109 cases. J Small Anim Pract 31:330–334, 1990.
10. Huibregtse BA, Johnson AL, Muhlbauer MC, et al: The effect of treatment of fragmented coronoid process on the
development of osteoarthritis of the elbow. J Am Anim Hosp Assoc 30:190–195, 1994.
11. Bennett D, Duff SRI, Kene RO, et al: Osteochondritis dissecans and fragmentation of the coronoid process in the
elbow joint of the dog. Vet Rec 109:329–336, 1981.
12. Boudrieau RJ, Hohn RB, Bardet JF.: Osteochondrosis dissecans of the elbow in the dog. J Am Anim Hosp Assoc
19:627–635, 1983.
13. Henry WB: Radiographic diagnosis and surgical management of fragmented medial coronoid process in dogs. J
Am Vet Med Assoc 184:799–805, 1984.
14. Tobias TA, Miyabayashi T, Olmstead ML, et al: Surgical removal of fragmented medial coronoid process in the
dog: comparative effects of surgical approach and age at time of surgery. J Am Anim Hosp Assoc 30:360–368, 1994.
15. Ness MG: Treatment of fragmented coronoid process in young dogs by proximal ulnar osteotomy. J Small Anim
Pract 39:15–18, 1998.
16. Thomson MJ, Robins GM: Osteochondrosis of the elbow: a review of the pathogenesis and a new approach to
treatment. Aust Vet J 72:375–378, 1995.
17. Slocum B, Pfeil I: Radius elongation for pressure relief of the coronoid process of the ulna. Proceedings 12th ES-
VOT Congress, Munich, 2004; p. 259.
18. Preston CA, Schulz KS, Taylor KT, et al: In vitro experimental study of the effect of radial shortening and ulnar os-
tectomy on contact patterns in the elbow joint of dogs. Am J Vet Res 62:1548–1556, 2001.
19. Fitzpatrick N, Yeadon R, Smith T, Schultz K: Techniques of application and initial clinical experience with sliding
humeral osteotomy for treatment of medial compartment disease of the canine elbow. Vet Surg 38:261-278, 2009.
109 • WVOC 2010, Bologna (Italy), 15th - 18th September M. Flückiger
Scoring canine Elbow Dysplasia (ED)

Updated recommendations of the International Elbow
Working Group (IEWG)
H. Hazewinkel, DVM, PhD, DECVS, DECVCN, M. Flückiger, Dr.med.vet., Dr.habil., DECVDI,
B. Tellhelm, Dr.med.vet., DECVDI, U. Geissbühler, Dr.med.vet. DECVDI
Premise: Primary causes of ED are: Ununited Anconeal Process (UAP), Fragmented Medial Coronoid
MAIN PROGRAM
Process (FCP), Osteochondrosis/Osteochondritis of the medial humeral condyle (OC/OCD), and obvious
SMALL ANIMALS
Incongruity of the radioulnar joint (INC).
The IEWG Board proposes the following scoring refinements:
1) Based on the strong correlation between sclerosis of the base of the coronoid processes at the level of the
radioulnar joint and FCP and INC, presence of obvious sclerosis should be scored at least as ED 2, inde-
pendent of the presence and size of osteophytes.
2) The evident identification of a primary lesion results in a ED-score 3. Indirect signs indicating a primary
lesion result in a ED-score 2, independent of the size of osteophytes. Indirect signs of suspect FCP are a scle-
rotic base of the coronoid processes, a blurred cranial edge of the medial coronoid, and/or a deformed MCP.
An indirect sign of suspect disturbed fusion of the anconeal process is a patchy bone opacity of the former
anconeal growth plate.
3. Spur formation at the distal border of the medial humeral epicondyle or mineralized structures in the flex-
or muscles group are occasionally seen with or without other signs of OA, and should therefore be men-
tioned separately. Currently such findings are not assumed to be a sequela of ED but rather a sign of un-
balanced load at the origin of the flexor muscles.
Amended new elbow dysplasia grading based on degree of arthrosis and/or presence
of primary lesion. Scoring mode effective immediately
Elbow Dysplasia Grading Radiographic Findings
0 Normal elbow joint Normal elbow joint,

No evidence of incongruency, sclerosis or arthrosis
1 Mild arthrosis Presence of osteophytes < 2 mm high

Suspect sclerosis of the base of the coronoid processes
Step of up to 2 mm between radius and ulna
2 Moderate arthrosis Presence of osteophytes of 2 - 5 mm high

or suspect primary lesion Obvious sclerosis of the base of the coronoid processes
Step of > 2-5 mm between radius and ulna (suspect INC)
Suspect presence of a primary lesion (UAP, FCP, OCD)
3 Severe arthrosis or evident Presence of osteophytes of > 5 mm high

primary lesion Step of > 5 mm between radius and ulna (obvious INC)
Obvious presence of a primary lesion (UAP, FCP, OCD)
A Borderline (BL) score between ED 0 and ED 1 is allotted in some countries to dogs with minimal
anconeal process modelling of undetermined aetiology.
D.J. Griffon WVOC 2010, Bologna (Italy), 15th - 18th September • 110
Radio-ulnar incongruity in dogs with medial

compartment disease
Dominique J. Griffon, DMV, MS, PhD, DECVS, DACVS
Associate Professor, University of Illinois, USA
Developmental elbow incongruency is believed to play a prevailing role in the pathognesis of elbow dys-
plasia and may account for the progression of DJD after surgical treatment of elbow dysplasia. Early detec-
tion and treatment of elbow incongruency may improve the post-operative prognosis of FCP and associat-
MAIN PROGRAM
ed medial compartment disease of the elbow. Several types of incongruency have been proposed in associ-
SMALL ANIMALS
ation with medial compartment disease of the canine elbow:

• A relative and potentially temporary undergrowth of the radius compared to the ulna, leading to a step
between the radial head and the ulnar incisure during the growth phase of the elbow.
• A localized radio-ulnar incongruency, consisting of a step between the radial head and the apex of the
MCP, potentially resulting from a remodeling of this process during a temporary phase of asynchronous
growth between the radius and ulna.
• A bicentric concave humeroulnar incongruency consists in a mismatch between the radius of curvature of
the humeral condyle with respect to an underdeveloped ulnar trochlear notch
• A dynamic rotational incongruency due to shear forces generated during contraction of the biceps brachii
This presentation will focus on the imaging and arthroscopic diagnosis of the first two forms of radio-ulnar
incongruence.
Computed tomography (CT) has been considered a gold-standard for detecting radio-ulnar incongruence, al-
though its sensitivity varies. Two clinical studies compared radio-ulnar incongruence in normal elbows and in
dogs with FCP using similar CT protocols: Gemmill et al. reported that radio-ulnar incongruity exists at the
apex of the coronoid process but not at its base, whereas Kramer et al. described exactly the opposite. These
studies illustrate the lack of standardized CT protocol and the complexity in establishing a diagnosis radio-ulnar
incongruence. Arthoscopic evaluation of the elbow requires general anesthesia but allows unparalleled visuali-
zation of joint surfaces and surgical treatment of FCP. Arthroscopy was found to reach a greater sensitivity, speci-
ficity and level of agreement between investigators than CT, using an experimental model of radio-ulnar incon-
gruence (Wagner K et al. 2006). This model relied on a proximo-distal displacement of the radius relative to the
ulna, which may not simulate the type of incongruity occurring in dogs with medial compartment disease. We
consequently enrolled in a prospective clinical study, large breed dogs under 3 years of age, referred for lame-
ness and medial compartment disease of the elbow. All dogs in the study underwent complete orthopedic, ra-
Protocol for CT evaluation of radio-ulnar incongruency

Original description: Holsworth et al., 2005
• Dogs in dorsal recumbency with limbs extended at 135°
• Minimum definition: 1 mm slices with 50% overlap
• Measure vertical distance between the proximal edges of the radius and ulna views reconstructed in
the following planes (Left to Right)
- Frontal projection at the apex of the MCP
- Frontal projection at the midbody of the MCP
- Frontal projection at the ulna incisure
- Sagittal projection at the ulna incisure
111 • WVOC 2010, Bologna (Italy), 15th - 18th September D.J. Griffon
diographic and computed tomographic examinations of both elbows, followed by arthroscopy of abnormal el-
bows. Radio-ulnar incongruity was subjectively evaluated by a radiologist (LB) on 90° flexed lateral radiographs
and CT as congruent, mildly incongruent (less than 2mm) or incongruent (2mm or more).
Incongruity was also measured on four planes, according to the protocol above. Arthroscopic examination
was performed by a surgeon unaware of the radiographic diagnosis and according to a protocol published
by Wagner et al. (2007) and summarized below. Elbows diagnosed as incongruent at any of the 3 levels were
considered as arthroscopically incongruent when testing the correlation between diagnostic techniques. In
addition, the type of MCP disease was assessed based on a classification modified from Bardet (1997). Car-
tilage damage on the medial coronoid process and trochlea was scored separately based on a modified Out-
erbridge classification (Beale et al., 2003).
MAIN PROGRAM
SMALL ANIMALS
Protocol for arthroscopic evaluation of radio-ulnar incongruency
Original description: Wagner et al., 2007
• Measure distance between medial humeral epicondyle and humero-radial joint on pre-operative radi-
ographs (AP) or CT
• Dog in lateral recumbency with elbow against the table
• Place an egress between the anconeus and trochlea and infuse the joint with LRS
• Place medial port distal (distance measured pre-op) and just caudal to the medial epicondyle
• Introduce 1.9mm 30° scope and inspect the joint
• Place an instrument port about 1 cm cranial to the scope
• Introduce a 1.4mm right angle probe
• Place the probe near the incisure and maintain the elbow in neutral position (no supination/pronation
or abduction) at 135°
• Repeat at the level of midbody and near the apex of the MCP
Below: Arthroscopic examination of a congruent elbow: the articular surfaces of the radius and ulna are
generally aligned at the incisure (left) although a small step is occasionally observed (1mm or so) and may
result from manipulation/mispositioning of the elbow. The MCP should start diverging distally at the lev-
el of the midbody (center) and should be a few mm distal to the radius at the level of the apex (right)
The results of this study will be presented in details during the conference and videos will illustrate exam-
ples of clinical cases with or without elbow incongruence. In brief, seven out of 27 elbows were diagnosed
as incongruent via radiography, compared to 13/37 via subjective evaluation of CT and 21/36 via
arthroscopy. There was no correlation between these three diagnostic techniques with regard to the overall
status of each elbow. A step of at least 2mm was measured at the level of the commissure in 26/37 elbows
on frontal views, compared to 6/36 elbows via arthroscopy. The presence of a fragment near the tip of the
MCP prevented evaluation of congruency at the level of the apex in 22 CT examinations and 2 arthroscopic
examinations. No step was identified in any of the 15 other cases via CT, whereas 20/35 elbows were diag-
nosed as incongruent at the apex of the MCP. Fragmented coronoid process was associated with the most
severe degree of cartilage disease, whereas erosions of the lateral border of the MCP were combined with
lower Outerbridge scores. The severity of cartilage disease was increased (p<0.001) in elbows diagnosed as
incongruent on arthroscopy.
Radio-ulnar incongruence does not seem present in all dogs with FCP, and was recently reported in 14 to
22% of dogs with elbow dysplasia, based on CT versus arthroscopy, respectively (Moores et al. 2008). Our
results confirm that incongruency is observed more commonly on arthroscopy than CT. A potential expla-
nation for this discrepancy is that the presence of a fragment affecting the tip of the MCP prevented CT
evaluation at the level, whereas arthroscopy allows visualization of the entire apical region, adjacent to the
fragment. The apex was the most common site of radio-ulnar incongruity identified on arthroscopy, which
was associated with cartilage damage severe enough to expose subchondral bone. Cartilage damage seemed
to affect the MCP and trochlea to a similar degree, which supports the concept of a localized radio-humer-
al conflict. From a clnical standpoint, these cases were treated with subtotal coronoidectomy, in rder to elim-
inate all diseased MCP and eliminate the articular conflict generated by apical radio-unar incongruency.
A step greater than 2mm was commonly measured at the level of the incisure based on CT, which was not
confirmed via arthroscopy. This discrepancy may result from the lack of visualization of the cartilage via
CT, leading to an evaluation of subchondral bone rather then alignment of joint surfaces. This would im-
ply that the ulna and radial head differ in cartilage thickness. We have previously shown the lack of speci-
ficity of CT to diagnose experimental radio-ulnar incongruency (Wagner et al., 2007). This publication com-
MAIN PROGRAM
bined with the lack of correlation between CT diagnosis based on sagital and frontal projections at the in-
SMALL ANIMALS
cisure should prompt surgeons to question a diagnosis of incongruity based solely on CT.
SELECTED REFERENCES
Beale BS, Hulse DA, Schulz KS, Whitney WO: Small animal arthroscopy. Saunders,
Philadelphia 2003, pp51-79.
Danielson KC, Fitzpatrick N, Muir P et al.: Histomorphometry of fragmented medial coronoid process in dogs: A com-
parison of affected and normal coronoid processes. Vet Surg 2006;35:501-509
Gemmill TJ, Clements DN: Fragmented cornoid process in the dog: is there a role for incongruency? J Small Anim Pract
2007;48:361-368.
Gemmill TJ, Clements DN, Clarke Sp et al.: Investigation of elbow incongruency in dogs suffering coronoid disease us-
ing reconstructed computed tomography. Vet Surg, 2004;33:E6.
Holsworth I, Wisner E, Scherrer W, et al: Accuracy of computerized tomographic evaluation of canine radio-ulnar in-
congruence in vitro. Vet Surg 34: 108-113, 2005.
Kramer A, Holsworth IG, Wisner ER et al.: Computed tomographic evaluation of canine radioulnar incongruence in vi-
vo. Vet Surg 2006;35:24-29.
Moores AP, Benigni L, Lamb CR: Computed tomography versus arthroscopy for detection of canine elbow dysplasia le-
sions. Vet Surg 2008;37:390-398.
Samoy Y, Van Ryssen B, Gielen I et al.: Review of the literature – elbow incongruity in the dog. Vet Comp Orthop Trau-
matol 2006;19:1-8.
Wagner K, Griffon DJ, Thomas MW et al.: Radiographic, computed tomographic and arthroscopic evaluation of exper-
imental radio-ulnar incongruence in the dog. Vet Surg 2007;36:691-698.
113 • WVOC 2010, Bologna (Italy), 15th - 18th September D.J. Griffon
Patellar Luxation: CT and decision-making

Dominique J. Griffon, DMV, MS, PhD, DECVS, DACVS
Associate Professor, University of Illinois, USA
Medial patellar luxation (MPL) has been described as the most common orthopedic disease affecting the ca-
nine stifle, diagnosed in 7% of puppies in a study of 1,679 immature dogs. Although MPL has typically been
considered as a disease of small breeds, a recent study of breed susceptibility for developmental orthopedic
diseases expanded the list of breed predisposition for MPL to include larger dogs such as Chinese shar-pei,
Flat-coated retriever, Akita, and Great Pyrenees. Complications are reported in up to 50% of cases, consist-
MAIN PROGRAM
SMALL ANIMALS
ing mainly of recurrence and degenerative joint disease, with an risk increasing in larger dogs. Surgical treat-
ment for MPL includes medial releasing desmotomy, lateral imbrication, modification of the femoral groove,
tibial tuberosity transposition, and femoral and/or tibial corrective osteotomy. In the absence of objective
guidelines, the decision making process for selecting these procedures remain subjective and varies between
surgeons. In order to improve surgical outcome, efforts should focus on measuring conformational factors
associated in the pathogenesis of this disease, the effects of surgical procedures on these factors and the post-
operative impact of their correction. Computed tomography (CT) is one the diagnostic modalities that may
assist clinicians achieve those goals.
This presentation will propose a decision making process for treating patellar luxation in small and large
dogs. Clinical cases will be used to illustrate radiographic and computed tomographic measurements used
to evaluate the coxofemoral joint and extensor mechanism, in particular femoral angulation and torsion in
dogs with patellar luxation. The discussion will focus on the role and limitations of diagnostic techniques in
this decision process, with an emphasis on computed tomography.
Although CT has been used to quantify the anatomic alterations resulting from surgical treatment of MPL,
its most relevant indication may be in the pre-operative evaluation of dogs with patellar luxations and sus-
pected limb angulation. Femoral angulation can be measured as the angle between the anatomic axis of the
femur and the transcondylar axis of the distal femur (aLDFA: anatomic lateral distal femoral joint angle).
Although surgical correction has been recommended in dogs with femoral varus greater than 10-12°, the
normal values for aLDFA in Labrador Retrievers, Golden Retrievers and Rottweilers were reported to reach
an approximate varus of 7-8° ± 3 (Tomlinson et al., 2007). Determination of femoral varus on well posi-
tioned radiographs of normal dogs correlates with computed tomographic measurements (Dudley et al.,
2006). However, angles measured on radiographs are subject to vary with positioning and concurrent
femoral torsion. Limited extension of the hips creates a “bowed” appearance of the femora, falsely increas-
ing the degree of varus angulation. In that respect, CT evaluation of femoral angulation palliates these lim-
itations. The main drawbacks of CT include availability, cost, expertise required to manipulate images and
time to generate and analyze the studies. Alternatively, a lack of proximodistal superposition of the femoral
condyles on well positioned mediolateral radiographs can strengthen a suspicion of femoral angulation. This
evaluation also assumes that the shaft the femur lies parallel to the radiographic film and is therefore sub-
ject to artifacts. A cranio-caudal projection of the femur, obtained with a horizontal radiographic beam (sim-
ilar technique as that used for templating femoral stems prior to total hip replacement) eliminates artifactu-
al femoral varus generated on the
ventrodorsal view of the pelvis due
to a lack of hip extension in dogs
with concurrent hip disease.
Femoral torsion remains even more
challenging to measure and correct
surgically. The angle of antever-
sion, which quantifies femoral tor-
sion can be measured on an axial
projection of the femur, as the an-
gle between the axis of the femoral
neck and the transcondylar axis.
Alternatively, it may be calculated
based on the ventrodorsal view of
the pelvis and the mediolateral pro- Figure 1 - Pre-operative radiographs (A) of a dog with bilateral MPL and apparent
jection of the femur (Bardet 1983). femoral varus of 15°. CT (B) evaluation failed to confirm varus deformity. Successful out-
This technique falsely assumes that come (C) after right trochlear block recession, soft tissue repair and tibial crest transposition.
the degree of magnification is iden-

tical on both radiographic projec-
tions and requires good positioning.
The positioning of the femur on
the ventrodorsal projection of the
pelvis is assessed in dogs with lux-
ated patella based on symmetrical
superposition of the fabellae with
the femur. The positioning of the fe-
mur on the mediolateral view is
evaluated based on superposition
MAIN PROGRAM
of both fabellae in the craniocaudal

SMALL ANIMALS
plane. The angle of anteversion is

affected by other conformational
characteristics of the hindlimb, such
as the angle of inclination of the hip
(coxa valga tends to increase the an-
gle of anteversion) and femoral an-
gulation. Anteversion angles may Figure 2 - CT measurements of femoral torsion. The anteversion angle may be measured
be measured on CT based on using cross sections at the level of the femoral neck and condyles or directly, with a volume
cross sections or using a volume rendered technique. These methods do not differentiate femoral neck version from distal
rendered technique (Figure 2). Al- femoral torsion.
though computed tomography al-
lows correction of positioning arti-
facts, measuring the angle of anteversion does not differentiate femoral neck version from distal femoral tor-
sion. This limitation has immediate clinical implications when considering corrective osteotomy of the fe-
mur in dogs with medial patellar luxation. We have developed CT measurements to determine the level of
torsion along the femur, based on the relative position of the femoral head and condyles with the lesser and
greater trochanter (Mostafa 2009). These measurements allowed identification of a distal femoral torsion in
the sound contralateral limbs of Labrador retrievers with cranial cruciate ligament deficiency but has not
been applied to dogs with patellar luxation.
In summary, CT may be especially relevant in the pre-operative evaluation of dogs with moderate to severe
patellar luxation and suspected femoral angulation and/or torsion. The availability of CT and the possibili-
ty to generate studies under sedation have improved the feasibility and cost effectiveness of this imaging
modality in small animal practices. CT quantification and localization of the level of angulation in three di-
mensions could provide objective guidelines as to the selection of patients considered for corrective os-
teotomies. This information would also be relevant to the pre-surgical planning of corrective osteotomies,
potentially improving surgical outcome.
SELECTED REFERENCES
Bardet JF, Rudy RL, Hohn RB. Measurement of femoral torsion in dogs using a biplanar method. Vet Surg 1983;12:1-6.
Dudley RM, Kowaleski MP, Drost WT et al.: Radiographic and computed tomographic determination of femoral varus
and torsion in the dog. Vet Radiol Ultra, 2006;47:546-552.
Kaiser S, Cornely D, Golder W, et al.b The correction of canine patellar luxation and the anteversion angle as measured
using magnetic resonance images. Vet Radiol & Ultrasound 2001;42(2):113-118.
LaFond E, Breur GJ, Austin CC: Breed susceptibility for developmental orthopedic diseases in dogs. J Am Anim Hosp
Assoc 38:467-477, 2002
Montavon PM, Hohn RB, Olmstead ML, et al. Inclination and anteversion angles of the femoral head and neck in the
dog: evaluation of a standard method of measurement. Vet Surg 1985;14(4):277-282.
Mostafa AM, Griffon DJ, Thomas M, et al. Morphometric characteristics of the pelvic limb of Labrador Retrievers with
and without cranial cruciate ligament deficiency. Am J Vet Res 2009;70(4):498-507.
Nunamaker DM, Biery DN, Newton CD. Femoral neck anteversion in the dog: its radiographic measurement. J Am Vet
Radiol Soc 1973;14(1):45-47.
Swiderski JK, Palmer RH: Long-term outcome of distal femoral osteotomy for treatment of combined distal femoral varus
and medial patellar luxation: 12 cases (1999-2004). J Am Vet Med Assoc 2007;231:1070-1075.
Tomlinson J, Fox D, Cook JL et al.: Measurement of femoral angles in four dog breeds. Vet Surg 2007;36:593-598.
Towle HA, Griffon DJ, Thomas MW, et al. Pre- and postoperative radiographic and computed tomographic evaluation
of dogs with medial patellar luxation. Vet Surg 2005;34:265-272.
115 • WVOC 2010, Bologna (Italy), 15th - 18th September J.E.F. Houlton
Negligence claims: can you reduce them?

John E. F. Houlton, MA, VetMB, DVR, DSAO, MRCVS, DECVS
Claims Consultant, The Veterinary Defence Society, Empshill, Robins Lane, Lolworth, Cambridge
There is frequently confusion as to what constitutes professional misconduct and what amounts to profes-
sional negligence. They are not the same but regulatory bodies have tended to blur the distinction and gross
negligence might, in rare cases, be interpreted as misconduct.
PROFESSIONAL NEGLIGENCE
MAIN PROGRAM
SMALL ANIMALS
The test of professional negligence is whether or not a veterinarian acted, or failed to act, in a way that no
reasonable body of their peers would have acted, or failed to act, given the same circumstances. In other
words, did they fail to do what a similarly qualified person would be reasonably expected to do, or do what
a similarly qualified person would be reasonably expected not to do. This does not mean that all other re-
sponsible veterinary surgeons would have done the same; the law accepts that different professional opin-
ions may be equally respectable.
It follows that, in many ways, it is the profession itself that decides what is negligent and what is not. That
is the reason for judges relying so heavily on expert professional opinion in deciding cases. Experts need to
be aware that it is not what they would have done in a certain situation that is important. The critical ques-
tion they need to answer with regard to what the veterinary surgeon is alleged to have done negligently is
“was it outside the range of what could be regarded as reasonable veterinary practice at the time?”
When negligence is established, the law is careful to ensure that claimants only receive what they have ac-
tually lost financially, as a direct result of the negligence. Sometimes this amounts to nothing at all. Very of-
ten it amounts to considerably less than has been claimed. In veterinary negligence claims, the figure hard-
ly ever includes an award for emotional distress, contrary to the expectations of many. Further, it is normally
necessary for the claimant to mitigate their loss and to provide documentary evidence to substantiate their
claim, ie receipts for purchase of goods or services, evidence of alleged loss of earnings etc.
What level of competence will a veterinary surgeon be judged by?

In short it is the level of competence that you hold yourself out as having. Thus every veterinary surgeon
(even a new graduate) is assumed to have at least the competence of an average general practitioner. Species
or discipline specialists will be judged by the standards of other specialists in their field, and anyone who
embarks on a specialised procedure will be assumed to have the skills of a relevant specialist.
PROFESSIONAL MISCONDUCT
In contrast to negligence, misconduct might include issues such as communication problems, significant mis-
takes over appointments, delays that could have been avoided, unfairness, bias or prejudice, rudeness or not
apologising for mistakes. It does not include failure to make a correct diagnosis or failure to institute correct
management procedures. It does not include pricing for treatment except where such pricing is unclear,
fraudulent or designed to deter emergency treatment. A common area of dispute involves the cost of on-go-
ing treatment, particularly where it is not clear, initially, what the treatment may involve.
Although originally misconduct was seen as a contravention of a professional code of ethics relating essen-
tially to character and behaviour, and not to matters of clinical judgement, in response to a substantial in-
crease in the level of public expectation, both in the medical and veterinary fields, it has been more widely
construed in recent years to include gross negligence. However, there is one clear distinction and that is the
outcome. The result of a successful negligence action is an award of compensation for the wronged party
made against the clinic, whereas a finding of misconduct is likely to lead to the individual’s right to practise be-
ing withdrawn in order to protect the public. Compensation for misconduct would not be payable.
Consent
In the context of the provision of veterinary services, ‘consent’ can be described as the agreement to carry-
ing out specific actions, based on information of what the actions involve and the likely consequences. Ef-
fective communication between veterinary surgeon and client is essential to ensure consent is informed.
Clients should have an opportunity to consent to the services offered, and accept the costs of those servic-
es as estimated and agreed.
Consent forms may be used to record agreement to carry out specific procedures. They form part of the clin-
ical records. A copy of the form should be provided to the person signing the form unless the circumstances
J.E.F. Houlton WVOC 2010, Bologna (Italy), 15th - 18th September • 116
render this impractical. If any amendments are made subsequently, these should be made in ink, initialled and
dated and a note of subsequent conversations recorded in the clinical records. Contrary to popular belief, in-
formed consent does not have to be written; verbal consent is satisfactory but more difficult to substantiate. It
follows that a witness to such consent is a good idea and that it is recorded in the clinical records.
A person may be competent to sign a consent form, but for reasons of physical disability unable to provide
a signature. In such circumstances, an independent witness may be asked to confirm the client has given
consent orally. If this is not practicable, then a suitable member of the practice staff could be asked to con-
firm consent. Persons under the age of 18 are generally considered to lack the capacity to make binding con-
tracts. They should not be made liable for any veterinary or associated fees. Children under the age of 16
should not be asked to sign a consent form. Where they have provided a signature, the parents or guardians
should be asked to countersign.
MAIN PROGRAM
For routine procedures, information leaflets can be useful to explain to clients what is involved with a spe-
SMALL ANIMALS
cific procedure, anaesthesia, expected outcome, after care etc. Clients should be given an opportunity to con-
sider this information before being asked to provide consent. Although the use of information sheets is en-
couraged, they should not be used as a substitute for discussions with the client.
Who is the client?

The client may be the owner of the animal, someone acting with the authority of the owner, or someone
with statutory or other appropriate authority. Occasionally, more than one owner will come forward, or the
ownership of the animal may be the subject of a marital dispute. In such circumstances, while it is not for
the veterinary surgeon to determine ownership, it is important to identify who the client is so it is clear to
whom the professional responsibilities are owed. This should be made clear on the clinical records.
Has the client understood what has been said?

Veterinary surgeons should consider their clients’ language and communication needs. Clinical or technical
terminology may need to be explained and clients may be reluctant to admit to a lack of understanding. Mis-
understandings can also arise when using ambiguous terms or idiosyncratic terms used by the practice. A
person’s understanding of the issues may be affected by a number of factors, such as impaired hearing or
sight, mental incapacity, learning difficulties or difficulties with reading or language.
Where the client’s ability to understand is called into question, veterinary surgeons will need to consider
whether any practical steps can be taken to assist the client’s understanding. For example, consider whether
it would be useful for a family member or friend to be present during the consultation. Additional time may
be needed to ensure the client has understood everything and had an opportunity to ask questions.
REDUCING CLAIMS
Problems often arise when there is a mismatch between the realistic ability of the veterinary surgeon to meet
the unrealistic expectations of the client.
Obtaining the client’s informed consent beforehand (preferably in writing) after they have been given an ap-
propriate explanation of the level of foreseeable risk will reduce the likelihood of such situations arising. A client
is more likely to give their “informed consent” if they have been provided with a jargon free and readily un-
derstood evaluation of the implications of a diagnosis and the risk involved in a chosen treatment programme.
Securing such consent and at the same time providing full details of any proposed treatment will also avoid
claims being made for surgical trespass. Many of these claims are of a surgical nature e.g. the removal of a
wrong lump or an arthrotomy on a wrong joint.
Misunderstandings, disappointments and the client’s sheer inability or undeclared intention not to pay may
engender a claim, even at the successful conclusion of a particular course of therapy. Thus veterinary sur-
geons should keep their clients fully appraised of mounting costs as well as their animal’s clinical progress.
This particularly applies to complex investigative procedures and treatments.
Clients are often confused (sometimes opportunistically!) as to the difference between a binding quotation and
a general (flexible) estimate of the likely cost of a particular investigation or treatment. Although liable to al-
teration, the initial estimates must always be judged to have been set at a “reasonable level”.
Claims can be generated when a client perceives that their animal was referred too late, or their request for
a second opinion or referral was refused or provoked a dilatory response. Some claims are made purely on
the basis that the client had never been made aware that referral to another centre was an available option.
MINIMISING THE RISKS

Where good records exist, claims can often be deflected and are certainly more readily defended. This equal-
ly applies to clinical, anaesthetic or surgical records or even to the record of a relevant discussion with a client.
117 • WVOC 2010, Bologna (Italy), 15th - 18th September S.E. Houlton
EU legislation: what clinicians need to know

and how to stay out of trouble
S.E. Houlton, BVSc, MA, DVR, DVC, MRCVS
Superintending Inspector, Home Office, United Kingdom
INTRODUCTION
This paper sets out the legal considerations for veterinary clinicians planning to use live animals for scien-
tific purposes, whether or not these are patients under their care. The definition of animal use for scientific
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purposes will be set out to help explain the considerations which a clinician should make when proposing
to undertake research using animals. Some examples will be used to illustrate how principles can be applied
to help reach a legally safe conclusion.
THE LEGISLATION
For all European Union countries, the use of animals for scientific or other experimental purposes is subject
to the current EU Directive 86/609 which has been in force since 19861.
The current EU Directive is due to be replaced by fresh legislation, expected to be agreed by the European
Parliament in October 2010, with an implementation date for all Member States of January 2013.
European Directives may either be used unchanged as local legislation or translated into National law for
each Member State.
This presentation focuses on the implementation of the European legislation in the United Kingdom. This
is currently effected by the Animals (Scientific Procedures) Act 19862.
WHAT DOES THE LEGISLATION SAY?

Current EU legislation definitions:
- ‘animal’ unless otherwise qualified, means any live non-human vertebrate, including free-living larval
and/or reproducing larval forms, but excluding foetal or embryonic forms;
- ‘experiment’ means any use of an animal for experimental or other scientific purposes which may cause
it pain, suffering, distress or lasting harm, including any course of action intended, or liable, to result in
the birth of an animal in any such condition, but excluding the least painful methods accepted in modern
practice (i.e. ‘humane’ methods) of killing or marking an animal; an experiment starts when an animal is
first prepared for use and ends when no further observations are to be made for that experiment; the elim-
ination of pain, suffering, distress or lasting harm by the successful use of anaesthesia or analgesia or oth-
er methods does not place the use of an animal outside the scope of this definition. Non experimental,
agricultural or clinical veterinary practices are excluded;
WHAT DOES THE LEGISLATION MEAN?

Answers to a standard set of questions can be used to help determine whether further formal advice should
be taken from either the regulator of experimental animal research or the regulator of the veterinary pro-
fession – or both!
Questions to ask yourself:
1 Are the animals, which I propose to use, protected by the legislation i.e. non-human vertebrates?
2 It is possible that what I plan to do to the animals might cause them pain, suffering, distress or lasting
harm?
3 What is the primary purpose of the work I plan to do – scientific or experimental; agricultural; veterinary
– for the direct benefit of the animal or its immediate peer group?
WHAT ARE THE POTENTIAL PITFALLS FOR VETERINARY CLINICIANS?

1 Understanding the threshold for harm which triggers the consideration of legal authorities for the con-
duct of scientific procedures using animals.
2 Recognising that although you are a veterinary surgeon, everything which you do to an individual ani-
mal is not necessarily for its benefit, within the context of the accepted understanding of veterinary sur-
gery or medicine.
3 Recognising when novel therapies or diagnostic tools move from the experimental stage where they can-
not reasonably be relied upon to benefit patients, to the point where they can be described as recognised
veterinary practice or would be accepted as likely to be used by any reasonable member of the profession.
S.E. Houlton WVOC 2010, Bologna (Italy), 15th - 18th September • 118
4 The legislation is not intuitive.

5 There is a grey area!
APPENDIX 1
EU Countries:
Austria; Belgium; Bulgaria; Cyprus; Czech Republic; Denmark; Estonia; Finland; France; Germany;
Greece; Hungary; Irish Republic; Italy; Latvia; Lithuania; Luxembourg; Malta; Netherlands; Poland; Por-
tugal; Romania; Slovakia; Slovenia; Spain; Sweden; United Kingdom.
BIBLIOGRAPHY
1. Council Directive 86/609/EEC of 24 November 1986 on the approximation of laws, regulations and administrative
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provisions of the Member States regarding the protection of animals used for experimental and other scientific pur-
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poses. 86/609/EEC, Official Journal L 358, 18.12.1986, p. 1. http://eur-lex.europa.eu/LexUriServ/LexUriServ.

do?uri=CELEX:31986L0609:EN:NOT.
2. Guidance on the Operation of the Animals (Scientific Procedures) Act 1986. 23 March 2000, The Stationery Of-
fice, London. http://www.archive.official-documents.co.uk/document/hoc/321/321-00.htm.
119 • WVOC 2010, Bologna (Italy), 15th - 18th September D. Hulse
Correlation of the biceps/brachialis complex

and microfracture/fragmentation of the medial coronoid
Don Hulse DVM Dipl. ACVS, ECVS
Dept Small Animal Sugery, College Veterinary Medicine, Texas A&M University, College Station Texas 77843-4474 USA
Canine Elbow OA is a commonly reported thoracic limb disorder. The

etiology of Elbow OA is controversial and has been ascribed to elbow
dysplasia (incongruence) and/or repetitive mechanical overload. In-
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congruence has classically been associated with elbow dysplasia (ED)
which signifies an abnormal development of the elbow joint coupled
with characteristic pathological changes of the medial compartment.
Pathologic changes are associated with the coronoid process and
humeral condyle. Pathology of the medial coronoid is typified by sub-
chondral bone micro-cracks and fragmentation as well as cartilage ero-
sion secondary to incongruence as seen in Figure 1. The prevailing be-
lief is that radio-ulnar incongruence is secondary to improper growth
of the radius/ulna during maturation. The result is mal-alignment of Figure 1
the articular surfaces where the medial coronoid is subject to high me-
chanical loads and microfracture or fragmentation. There is no question that mal-alignment and incongru-
ence occurs. However, fragmentation and incongruence secondary to radius/ulna growth abnormality
would best explain abnormalities found in younger patients or mature patients with chronic recurring clin-
ical problems. On the other hand, abnormal growth and incongruence may not explain medial joint pathol-
ogy seen cases in dogs which exhibit lameness at an older age. Two populations exist. One cohort is those
with lameness but no other abnormal physical or radiographic findings. Arthroscopy confirms fragmenta-
tion of the medial coronoid adjacent to the radial head without the presence of visible cartilage erosion. In
a second cohort, there is medial compartment OA (Grade 5 articular cartilage pathology). In these cases,
fragmentation/microfracture of the medial coronoid and/or grade 5 articular cartilage pathology may be sec-
ondary to mechanical overload. Mechanical overload may be repetitive stress or catastrophic overload re-
sulting in stress fracture of the medial coronoid or damage to chondrocytes. The cause of mechanical over-
load can be associated with contraction of the biceps brachii/ brachialis muscle complex or progressive
humeral varus associated with mechanical weight bearing mechanical axis. The histologic and ultrastruc-
tural appearance of medial compartment is consistent with mechanical failure and subsequent unsuccessful
fibrous repair.
The biceps/brachialis muscles constitute a large muscular complex. The anatomic origin and insertion of the
biceps and brachialis muscles are such that the muscular complex exerts considerable force on the medial
compartment of the elbow. The force exerted by the biceps is continuous since it is a pennate muscle with
central tendon. More importantly, because the insertion of the biceps/brachialis complex is at the ulnar
tuberosity, a large polar (rotational) moment is exerted at the cranial segment of the medial coronoid. The
magnitude of the polar moment is a product of the moment arm (distance from the ulnar tuberosity to the
tip of the coronoid) multiplied by the force created by the biceps/brachialis muscular complex. The polar
moment rotates and compresses the craniolateral segment of the medial coronoid against the radial head.
The compressive force is medial to lateral transverse to the long axis of the coronoid. A compressive force
generates internal shear stress at an oblique angle to the applied compressive force. In this situation, maxi-
mal internal shear stress would be oblique to the long axis of the coro-
noid. Under the right circumstances, the polar moment and resultant
compressive force produced by the biceps/brachialis complex may pro-
duce sufficient internal shear stress to exceed the material strength of
the cancellous bone in the craniolateral segment of the medial coronoid.
The result would be microfracture/fragmentation adjacent to the radial
head at an oblique angle to the long axis of the medial coronoid. Inter-
estingly, microfracture/fragmentation of the coronoid seen clinically is
in the craniolateral segment of the medial coronoid adjacent to the ra-
dial head. This location corresponds to the plane of maximal shear
stress generated by the compressive force exerted by the polar moment
produced by contracture of the biceps/brachialis complex (Fig. 2). Figure 2
D. Hulse WVOC 2010, Bologna (Italy), 15th - 18th September • 120
CORA based leveling osteotomy for treatment

of the CCL deficient stifle
Don Hulse1 DVM ACVS, ECVS, Brian Beale2 DVM ACVS, Mike Kowaleski3 DVM ACVS, ECVS
1
Dept Small Animal Sugery, College Veterinary Medicine, Texas A&M University, College Station Texas, USA
2
Gulf Coast Veterinary Specialists, Houston, Texas, USA; 3 Associate Professor of Small Animal Orthopedic Surgery,
Cummings School of Veterinary Medicine, Tufts University
Tibial plateau leveling osteotomy (TPLO) is a popular method for treating the CCLD (CCL Deficient) stifle
joint in the dog. Recent studies have shown significant joint mechanical alteration which may be contributory to
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articular cartilage lesions. One explanation for reported abnormal joint mechanics is that the standard Slocum
osteotomy is not based on the mechanical or anatomic CORA. As such, the Axis of Correction (ACA) is not
aligned with the CORA resulting in mal-alignment of the anatomic/mechanical axis and secondary translation.
The result is caudal displacement of the weight bearing axis and a focal increase in joint force. Further, TPLO
creates a caudal thrust. The long term effect of caudal thrust is loss of compliance of cranial supporting struc-
tures such as the fat pad and joint capsule. Encroachment of the cranial supporting structures (joint capsule) on
the cranial articular surface of the medial/lateral femoral condyles can result in abrasion of the articular cartilage.
The subject of this presentation is to report the concept and technique of a tibial plateau leveling osteotomy based
on the anatomic CORA. The concept is supported by anatomic dissection, radiographic analysis of treated ca-
daver specimens, and application in clinical cases having ligament injury to the stifle (55 cases). Clinical cases in-
clude those with multiple ligament injury, acute complete CCL injury with marked craniocaudal and rotational
instability, partial stable CCL injury, and partial unstable CCL injury. Clinical outcome, complications unique
to the technique, and strategies to prevent complications will be addressed. Goals of the technique include:
1. Preservation of the proximal tibial epiphysis which

allows for application of ancillary stabilizing proce-
dures. The location of the anatomic CORA is such
that an osteotomy can be performed which preserves
the anatomy of the proximal tibial epiphysis. An intra-
articular reconstruction using bone tunnels or the un-
der and over technique is readily accomplished. Like-
wise, if the attending surgeon wishes to apply an ex-
tra-articular stabilizing procedure it is easily accom-
plished with the ample bone target of the proximal tib-
ial epiphysis following rotation. The authors have
used isometric placement of Fibertape with a Swive-
lock or IA reconstruction with an autogenous graft. Pre op and 12 week PO Images
of a Labrador having multiple
ligament injury stabilized with a
CORA based osteotomy and an
Arthrex SwiveLock loaded with
2mm FiberTape
2. Alignment of the proximal and distal segment anatomic/mechanical

axis and maintaining approximately 30% of the normal cranial thrust.
CORA based osteotomy aligns the anatomic/mechanical axis following
rotation. The femoral condyles appear “centered” on the tibial plateau
following rotation. The hypothesis is that this will maintain normal
stress distribution and kinematics of the stifle.
Image of a dog with 24 degree TPA pre op and 13 degree TPA post op showing alignment
of the anatomic/mechanical axis.
3. Establish 90 degree plateau/patella tendon angle. An additional advantage of CBLO is that the technique
appears to simulate a TTA in that post operatively the patella tendon (PTA) / tibial plateau slope (TPA) an-
gle is approximately 90 degrees.
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Post op images of two cases showing measurement of the tibial plateau slope/patella tendon angle
Recommended rotation of the TPA is to 12-14 degrees rather than 5 degrees as with the standard TPLO.
Rotation to this slope reduces the stress on an intra-aticular autograft/allograft or stabilizing suture (Fiber-
Tape, FiberWire) by approximately 65%. This helps preserve the integrity of the stabilizing procedure main-
taining long term stability. Additionally, rotation to 12-14 degrees does not generate a caudal thrust as seen
with a standard TPLO. The hypothesis is that by eliminating posterior thrust, one will eliminate the cranial
abrasion lesions seen with TPLO.
IA graft 8 weeks PO Medial joint line 12 weeks PO

K.A. Johnson WVOC 2010, Bologna (Italy), 15th - 18th September • 122
Locking plates - why do we need them?

Kenneth A. Johnson, MVSc, PhD, FACVSc, Dipl. ACVS and ECVS
University of Sydney, Sydney, Australia
LOCKING PLATES
The need for implants that could be used with minimally invasive surgical technique following the phi-
losophy of ‘biological osteosynthesis’ was a driving force behind the development of locking plates. In ad-
dition, plates that had improved mechanics and less impact on bone blood supply were considered to be de-
sirable. It should be appreciated that the Zespol external plate fixator developed in Poland in the 1980’s
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was a concept that was ahead of its time. In principle, the Zespol was exactly the same as modern locking
plates, because it had screw heads that could be locked into plate. These screws were applied perpendicular
to the plate, and were “fixed angle”. The Zespol did not rely on friction between the plate and the bone for
stability. Indeed, the plate was situated just outside the skin, similar to an external fixator.
There are currently several different types of locking plates available that they may be useful for fracture fix-
ation in small animals, including the No Contact Plate,
the String of Pearls, the ALPS, the Fixin and the
Locking Compression Plate (LCP). The LCP (Syn-
thes) have combination locking and compression holes,
or so called “Combi hole” (Fig. 1). This allows the plate
to be applied with either fixed angle locking screws in the
threaded part of the Combi hole, or standard cortical
screws that are placed in the dynamic compression unit
(DCU) part of the Combi hole (Fig. 2).
Application of the LCP with entirely locking screws re-
sults in fixed angle construct. Used it this way, there is not
any compression of the plate to the bone, or between the Figure 1 - The LCP Combi hole screws.
fracture fragments. The most important use of this device
comes in non-reducible shaft fractures when the plate is
acting as a bridge plate. Once the locking screws engage
the plate, no further tightening of the screw is possible.
Therefore the implant locks the bone fragment in their rel-
ative position, regardless of the degree of reduction. Accu-
rate contouring of the plate to the bone is not essential
(Fig. 3). Furthermore, by locking the screws to the plate,
the risk of loss of reduction due to screw toggling and frac-
ture collapse is reduced (Fig. 4).
Since the plate can sit off the bone, and locking of screws
prevents compression of the periosteum by the underside
of the plate, then blood supply to the bone may be im-
proved (Fig. 5). In case of reducible fractures, once the
metaphyseal fragment has been fixed with locking
screws, the fracture can be compressed using standard
screws in the DCU portion of the Combi hole (Fig. 6). Figure 2 - Locking head and standard.
Figure 3 - Accurate plate contouring unnecessary. Figure 4 - Locking screw maintain reduction.
123 • WVOC 2010, Bologna (Italy), 15th - 18th September K.A. Johnson
Figure 5 - Blood supply under LCP. Figure 6 - Locking screws (green) and standard screws (blue) in
the DCU producing interfragmentary compression.
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COMPLICATIONS
1. Need to be able to reduce the fracture, or obtain correct alignment of the bone, prior to application of the
LCP.
2. The plate needs to positioned so that screws are centered over the intramedullary space. If there is axi-
al malalignment of the plate and bone, then some of the screws near the end of the plate will not have
adequate bone purchase, and thus fail (Fig. 7).
3. Cross threading of screws can cause permanent locking of screws especially with titanium implants (Fig.
8). While cross threading of locking screws does not necessarily compromise the stability of the fixation,
implant removal may involve cutting of the plate.
Figure 7 - Axial malalignment of the plate may result in inadequate screw purchase.
The threaded portion of the combi hole in the straight LCP

only allows for placement of screws that are perpendicular to
the plate. This can be problematic in the metaphyseal region.
Development of ‘anatomically’ contoured plates has overcome
this problem, for example the distal tibial plate for humans, al-
though currently there are no such implants for animals.
LCP BROAD 3.5 PLATE

Recently, a broad LCP plate has become available. This plate
has a single round locking hole at one end which is to allow
for the insertion of either a locking screw or conventional
screw in a very short metaphyseal fragment, without interfer-
ence with the joint by the end of the plate. Figure 8 - Cross threading of locking screws.
REFERENCES
Brunnberg L, Horst C, Gacel A, Weiler A, Raschke M: Die no contact plate (NCP) osteosyntheseplatte – ein neues bi-
ologisched implantatsystem. Kleintierpraxis; 48:579-591, 1998.
Frigg R: Development of the locking compression plate. Injury; 34: S-B6-B10, 2003.
Gautier E, Sommer C: Guidelines for the clinical application of the LCP. Injury; 34: S-B63-B76, 2003.
Ramotowski W, Granowski R, Bielawski J. Osteosynteza metoda Zespol. Teoria i praktyka kliniczna. Panstwowy Zaklad
Wydawnictw Lekarskich: Warszawa 1988.
M.P. Kowaleski WVOC 2010, Bologna (Italy), 15th - 18th September • 124
Concomitant medial patellar luxation and cranial cruciate

ligament disease
Michael P. Kowaleski, DVM, Dipl. ACVS and ECVS
Concurrent medial patellar luxation and cranial cruciate ligament disease in large breed dogs is a common
condition that is challenging to treat. Current best evidence suggests that identification of all abnormalities
in a given patient with individualized treatment results in the best outcomes. A comprehensive clinical eval-
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uation including thorough orthopedic examination, gait evaluation, and radiological evaluation serves as the
basis for surgical planning.
A thorough physical examination is imperative to guide the clinician in the interpretation of diagnostic im-
aging studies, and to select an appropriate treatment plan. Coexisting conditions such as hip dysplasia with
subluxation or luxation of the femoral head, partial or complete rupture of the cranial cruciate ligament, tor-
sional malformation of femur, and torsional or angular malformation of the tibia must be first identified clin-
ically to ensure appropriate imaging is obtained and a comprehensive treatment plan is devised. In addition,
gait evaluation is critical to assess limb alignment, and determine the effect of correction on limb alignment
and overall appearance of the patient. For instance, in a patient with genu varum, a femoral corrective os-
teotomy would improve limb alignment and provide a straight limb for the patient. In the case of a patient
with distal femoral varus and proximal tibial valgus, gross limb alignment may appear normal, with the foot
placed under the hip during ambulation. In a case such as this, correction of both the femoral and tibial de-
formities may be necessary to align the skeletal structures and ensure proper overall limb alignment post-
operatively.
In cases of concurrent MPL and cranial cruciate ligament rupture, physical examination findings may in-
fluence the choice of the stabilization technique that is employed. Specific factors to consider are rotational
stability or instability of the stifle, tibial tuberosity position (i.e. medial displacement) and patella/patellar ten-
don alignment, pelvic limb alignment, and femoral and/or tibial deformity. To assess patellar tracking, the
hip, stifle and hock are placed in a neutral position, the patella is centered within the trochlear groove, and
the pes is directed vertically. The patellar tendon is traced from the patella to its insertion on the tibial
tuberosity. If the line of action of the patellar tendon is not centered on, and parallel to the trochlear groove,
then a tibial tuberosity transposition is warranted. In cases of medial patellar luxation, the line of action of
the patellar tendon is typically obliquely directed from proximo-lateral to disto-medial with respect to the
trochlear groove. Since the goals of surgery are to align the extensor mechanism and deepen the trochlear
sulcus to create a stable femoro-patellar articulation, the combination of techniques required is dependent
upon the specific abnormalities of each patient. Utilizing the results of a comprehensive clinical evaluation,
the surgical treatment plan is individualized based on the abnormalities present.
Accurate radiographic assessment of limb alignment is difficult, and requires general anesthesia and precise
patient positioning to avoid positioning artifact. A complete radiographic evaluation includes at least a lat-
eral and ventro-dorsal view of the pelvis including the femora and proximal tibia, and an axial view of the
femur for femoral torsion calculation. In some cases, cranio-caudal and medio-lateral views of the femur, and
caudo-cranial and lateral views of the tibia including the stifle and tarsus may be required, particularly if tib-
ial osteotomy is planned. Since these radiographic views are difficult to obtain, and are highly sensitive to
radiographic positioning artifact, several exposures of each view should be obtained. A variation of more
than 2-3 degrees between radiographs or between left and right femurs in a symmetrically affected patient
suggests positioning or measurement artifact. Alternatively, a computed tomographic method with analysis
of individual slices (Dudley 2006) or three-dimensional reconstruction of the skeletal elements into views
analogous to the radiographic views can be utilized to quantify the deformities present; this technique is
much more rapid that the radiographic technique, and is not subject to positioning artifact.
A well-positioned cranio-caudal view of the femur and proximal tibia is the radiographic view that is used
to screen for and quantify femoral varus deformity. It is imperative that the femur is parallel and the radi-
ographic beam is perpendicular to the radiographic cassette or detector. In cases in which diminished hip
range of motion limits hip extension, the x-ray beam and cassette or detector can be angled such that the x-
ray beam is perpendicular to the long axis of the femur, and the cassette or detector is perpendicular to the
beam. Alternatively, the patient can be elevated in a v-trough, or a horizontal beam, cranio-caudal femur can
be obtained. In a well-positioned view, the fabellae appear bisected by the femoral cortices, the vertical walls
of the intercondylar notch are distinct parallel lines, and the lesser trochanter is only partially visible; often
125 • WVOC 2010, Bologna (Italy), 15th - 18th September M.P. Kowaleski
the proximal femoral nutrient foramen can be identified as a small, round lucency centered between the
femoral cortices in the proximal diaphysis. The benefit of three-dimensional reconstruction of computed to-
mographic images, is that the femoral image can be rapidly manipulated into the appropriate position to sim-
ulate a cranio-caudal view. In a normal femur, the magnitude of femoral varus (or valgus) is determined by
measuring the anatomic lateral distal femoral angle (aLDFA) at the intersection of the femoral anatomic ax-
is and the distal joint reference line of the femur, using the radiographic method described by Tomlinson
(Tomlinson 2007) or the computed tomographic method described by Dudley (Dudley 2006) or three di-
mensional reconstruction can be employed (Figure 1). In a femur with pathologic femoral varus or valgus,
the femoral deformity is determined at the center of angulation of rotation (CORA) located at the intersec-
tion of the proximal and distal anatomical axes of the femur.
In the radiographic and CT methods, the overall length of the femur is determined, and the center of the
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femur at 33% and 50% of its length is identified. A line is drawn connecting these two points; this is the
SMALL ANIMALS
anatomic axis of the femur. The distal joint reference line is a line connecting the most distal aspect of the
medial and lateral condyles of the femur. The aLDFA is measured at the intersection of the anatomic axis
and the distal joint reference line. Comparison of the aLDFA to a breed specific reference range will deter-
mine if significant femoral varus is present. If a significant femoral varus deformity is present, the location
and magnitude of the deformity must be determined. Measure the overall length of the femur, and identi-
fying the center of the femur at 33% and 50% of its length, draw a line connecting these two points to de-
termine the proximal femoral anatomic axis; in this case, the line is not drawn to the joint level. Draw the
distal joint reference line, set the aLDFA to the breed specific value, and draw the distal anatomic axis such
that the line extends along the lateral aspect of the intercondylar notch. The CORA is located at the inter-
section of the proximal and distal anatomic axes, and its magnitude can be measured at this location. If a
breed specific normal value is not available, then the opposite normal femur can be measured as a reference.
If the opposite femur is affected, the aLDFA can be arbitrarily set to 94-98 degrees, as this is the value for
a number of large breed dogs (Tomlinson, 2007). It should be noted, that in some cases external femoral
torsion (decreased angle of anteversion) is the only identifiable femoral deformity, and in these cases, cor-
rection of torsion should be undertaken.
Femoral torsion can be quantified from the axial view of the femur. To obtain the axial view of the femur,
position the patient in dorsal recumbency and flex the hip joint such that the x-ray beam is directed down
the center of the femoral diaphysis, with the cassette under the hip joint. The femoral torsion angle (antev-
Figure 1 - Cranio-caudal, medio-lateral and

axial three-dimensional reconstruction views of
the femur. These views were reconstructed from
a transverse plane CT scan, 1 mm slice thickness.
ersion angle) is determined by the intersection of the transcondylar axis and an axis through the center of
the femoral head and neck. The reported range for anteversion angle is quite broad, varies from study to
study, and no breed specific normal values are available at this time. The mean reported in one study was
27 degrees (range 12-40 degrees). This is the value I generally use clinically, since this publication utilized a
similar radiographic method. In the case of medial patellar luxation, if the patient’s femoral torsion angle is
less than 27 degrees, I consider correction during corrective osteotomy. If the patient’s angle is greater than
27 degrees, I do not decrease the angle, as this may exacerbate medial patellar luxation. Again, three-di-
mensional reconstruction of the femur and manipulation of the view into the appropriate position is much
more rapid and less labor intensive than obtaining this view with radiographs.
Since these radiographic views are difficult to obtain, and are highly sensitive to radiographic positioning ar-
tifact, several exposures of each view should be obtained. A variation of more than 2-3 degrees between ra-
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diographs or between left and right femurs in a symmetrically affected patient suggests positioning or meas-
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urement artifact.
In cases in which tibial torsional or angular abnormalities are evident, caudo-cranial and lateral views of the
tibia including the stifle and tarsus should be obtained. Recently, computed tomographic evaluation of tib-
ial torsion has been described, and this technique was found to be more accurate than the radiographic tech-
nique described by Slocum (Aper 2005, Apelt 2005).
RECONSTRUCTIVE TECHNIQUES
Various techniques have been devised to correct the anatomic abnormalities associated with patellar luxa-
tion. Soft tissue techniques such as fascial release, fascial imbrication, and anti-rotational sutures can be used
to augment anatomic reconstructive techniques, but should not be relied upon as the sole method of cor-
rection.
Trochlear chondroplasty
In the immature animal (<9 months of age), a flap of hyaline cartilage is raised from the trochlear sulcus,
the subchondral bone is removed, and the flap is reseated.
Trochlear sulcoplasty
The sulcus is deepened by débridement of the articular cartilage and subchondral bone with a bone rasp or
high-speed bur. The defect is replaced by hyaline cartilage over time.
Trochlear wedge recession (TWR)

Using an X-acto hobby saw, or similar fine-toothed saw, an osteochondral wedge is developed from the
trochlear sulcus. Additional cut(s) are made to remove slice(s) of cartilage and bone so that the original
wedge can be seated deeper in the trochlear sulcus.
Trochlear block recession

A rectangular osteochondral block is developed from the trochlear sulcus using a saw and osteotome. Ad-
ditional subchondral bone is removed allowing the block to be seated deeper in the trochlear sulcus. This
technique is reported to preserve a greater surface area of the hyaline cartilage within the trochlear sulcus
than the trochlear wedge recession.
Tibial tuberosity transposition (TTT)

The tibial tuberosity and associated patellar tendon insertion is osteotomized, leaving the distal periosteal at-
tachment intact. The tuberosity is moved to align the quadriceps mechanism, and reattached with 2 K-wires.
Femoral osteotomy
In cases with significant femoral varus, valgus, or torsional deformities, the femur must be straightened by
angular and torsional correction. Multiple techniques have been described including the laterally based clos-
ing wedge ostectomy, the medial opening wedge osteotomy, and the radial osteotomy; plate fixation is usu-
ally employed.
LATERAL CLOSING WEDGE FEMORAL OSTEOTOMY FOR DISTAL FEMORAL VARUS

CORRECTION
1. Measure the varus angle and determine the point of maximal curvature from well-positioned radiographs.
Compare this to the accepted normal value of 0-10 degrees to determine if femoral varus is contributing
to misalignment of the extensor apparatus.
2. Measure the anteversion angle from the axial view, and compare this to the normal value of 27 degrees
to determine if femoral torsion is contributing to the misalignment of the extensor apparatus.
3. Determine if medial displacement of the tibial tuberosity and/or tibial torsional abnormalities are present.
4. Carefully assess the integrity of the cranial cruciate ligament. If rupture of the cranial cruciate ligament is
present, internal tibial torsion is present, and the tibial tuberosity is medially displaced, a TPLO proce-
dure with internal tibial torsional correction can be utilized to stabilize the stifle and lateralize the tibial
tuberosity. If no tibial torsion is present, consider a TTT and a lateral suture, or a TPLO with internal
torsional correction combined with a de-rotational proximal tibial osteotomy, lateral translation of the tib-
ial tuberosity segment following TPLO/CCWO or TCWO and tibial tuberosity transposition.
5. Perform a lateral approach to the femur and stifle joint, carefully elevating the joint capsule from the lat-
MAIN PROGRAM
SMALL ANIMALS
eral femoral condyle in the area of bone plate application (Figure 2).
6. Plan the femoral osteotomy ensuring that the distal femoral segment is large enough to accommodate at
least 3 plate screws without interference of the implants with the stifle joint. Score the proposed osteoto-
my lines on the bone with the bone saw or electrocautery (Figure 3).
7. The TPLO jig can be applied on the cranial aspect of the femur with the distal pin immediately proximal
to the cartilage of the trochlear groove, and the proximal pin within the span of the bone plate. If no
femoral torsion is present, the jig pins are placed parallel to the cranio-caudal plane of the femur. If a
femoral torsional abnormality is present, the jig pins are applied parallel to the cranio-caudal plane of the
proximal femur. The frame of the jig is placed medially. A stainless steel ruler and electro-cautery can be
utilized to score an axial line on the femoral cortex to ensure no torsional abnormality is created during
the surgical procedure (Figure 4).
8. Complete the ostectomy and reduce the proximal and distal segments. Torsional correction can be ac-
complished by bending the distal jig pin with hand-held plate bending pliers if a jig is used, or manual
alignment can be performed. Place K-wires to maintain reduction; placement from disto-lateral to proxi-
mo-medial, and proximo-cranial to caudo-distal avoids the area of bone plate application (Figure 5).
Figure 2 Figure 3
Figure 4 Figure 5
9. Contour and apply a 7 hole narrow or broad

LCDCP to the lateral aspect of the femur, ensur-
ing that the implants do not interfere with stifle
joint function. Keep the distal screws in the cau-
dal aspect of the femur to ensure they are not en-
countered during the TWR (Figure 6).
10. Perform a TWR if necessary, the cancellous bone,
which is removed, can be used as an ACBG at the
ostectomy site.
11. Closure is routine.
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SMALL ANIMALS
12. Perform a TTT and/or stabilize the stifle if nec-

essary.
Figure 6
In general, cases complicated by femoral varus can
be subdivided into one of several categories, based on the morphology of the tibia. In all cases, significant
femoral varus is treated by distal femoral ostectomy, and the trochlear groove is deepened as needed.
FEMORAL VARUS WITH NO MEDIALIZATION OF THE TIBIAL TUBEROSITY

In this case, the corrections are the most straightforward. Femoral varus is treated with a distal femoral ostec-
tomy, the trochlear groove is deepened if necessary, and the stifle is stabilized with the procedure of the clini-
cian’s choice, such as TPLO, TTA, or extracapsular stabilization.
FEMORAL VARUS WITH MEDIALIZATION OF THE TIBIAL TUBEROSITY

AND INTERNAL TIBIAL TORSION
In cases in which significant torsional or angular deformity exists, the TPLO procedure is best suited for
correction, since TPLO allows for simultaneous correction of limb alignment and stifle stabilization (Figure
7A and B). Correction of internal tibial torsion at the level of the TPLO results in external rotation of the
distal tibial segment including the tibial tuberosity. Therefore, if the internal torsion correction results in ad-
equate lateralization of the tibial tuberosity, correcting the limb alignment can treat both. However, if the in-
ternal tibial torsion correction results in under correction or over correction of the tuberosity, a TPLO with
proximal tibial osteotomy (see Figure 9A and B) is preferred, as this will allow for independent and precise
tuberosity alignment and tibial torsion correction. Other procedures such as TTA or extracapsular stabi-
lization can be performed, however, tibial torsion correction would require an additional tibial osteotomy,
thus they are not recommended.
A B
Figure 7A and B - TPLO with internal tibial torsion

correction resulting in lateralization of the tibial tuberosi-
ty and correction of patellar tendon alignment. Reprinted
from Langenbach A et al, JSAP 2010.
FEMORAL VARUS WITH MEDIALIZATION OF THE TIBIAL TUBEROSITY AND NO

TIBIAL TORSION
The tibial tuberosity advancement (TTA) procedure (Figure 8A) can be modified to stabilize the stifle and
translate the tuberosity laterally; this has been termed tibial tuberosity transposition advancement (TTTA)
(Figure 8B) (Fitzpatrick VOS 2008). To perform a TTTA, the tuberosity is translated to correct patellar ten-
don alignment, and the plate is contoured to match the lateralized position of the tibial tuberosity. Addition-
ally, the TTA cage must be placed to match this lateralized position. Since the medial cortex of the tibial
tuberosity and the tibia no longer lie in the same plane, the caudal cage ear on the tibial side must be con-
toured and recessed into the medial tibial cortex to allow lateralization of the cage. Alternatively, washer(s)
can be placed under the cranial cage ear on the tibial tuberosity. In cases of extreme lateralization, both cage
ear recession and washers may be needed. It is
MAIN PROGRAM
important not to deplete the medial cortex of
SMALL ANIMALS
the tibia during cage ear recession, as the cage
ear must be place on cortical bone for adequate
implant stability.
Figure 8A and B - Standard TTA (A) and TTTA

(B). Note that the caudal cage ear has been contoured and
recessed into the medial tibial cortex, and the plate has been
contoured around the medial tibial cortex to allow lateraliza-
tion of the tibial tuberosity.
The TPLO procedure can be modified to allow lateralization of the tibial tuberosity by the addition of a
transverse proximal tibial osteotomy (Figure 9A and B). The osteotomy is placed perpendicular to the tibial
crest, such that it intersects the TPLO at the caudal cortex. The tibial tuberosity segment can be translated
as needed to correct patellar tendon alignment. Fixation is as for a TPLO/CCWO (Figure 10).
Figure 9A, B and C - TPLO with

proximal tibial osteotomy (A and B) and
ostectomy (C). Utilizing an additional
proximal tibial osteotomy, the tibial
tuberosity segment is isolated and translat-
ed as needed to align the patellar tendon (A
and B). A proximal tibial ostectomy can be
utilized to correct proximal tibial varus and
valgus with or without excessive plateau
angle; in the later case, the ostectomy is a
cuneiform ostectomy.
FEMORAL VARUS WITH TIBIAL ANGULAR

DEFORMITY
Correction of complex tibial deformity including eTPA, proxi-
mal tibial varus and proximal tibial valgus with or without tibial
torsion and/or medialization of the tibial tuberosity is best ad-
dressed with a TPLO and proximal tibial ostectomy (Figure 9C).
The ostectomy can be a medial closing wedge to correct valgus,
a lateral closing wedge to correct varus, a cranial closing wedge
to correct eTPA, or a cuneiform closing wedge to correct both
eTPA and angular deformity. Tibial torsion can be corrected at
the proximal tibial osteotomy. Fixation is the same as for a TP-
MAIN PROGRAM
LO with proximal tibial osteotomy (Figure 10).

SMALL ANIMALS
Figure 10 - Postoperative radiograph demonstrating the typical fixation applied to

a TPLO with additional proximal tibial osteotomy or ostectomy.
REFERENCES
Apelt D, Kowaleski MP, Dyce J: Comparison of computed tomographic and standard radiographic determination of tib-
ial torsion in the dog, Vet Surg 34:457, 2005.
Aper R, Kowaleski MP, Apelt D et al: Computed tomographic determination of tibial torsion in the dog, Vet Radiol Ul-
trasound 46:187, 2005.
Boudrieau RJ. Tibial Plateau Leveling Osteotomy or Tibial Tuberosity Advancement? Vet Surg 38:1-22, 2009.
Dudley RM, Kowaleski MP, Drost WT et al: Radiographic and computed tomographic determination of femoral varus
and torsion in the dog, Vet Radiol Ultrasound 47:546, 2006.
Fitzpatrick N, Yeadon R, and Kowaleski M: Tibial tuberosity transposition-advancement for treatment of medial patellar
luxation and concomitant cranial cruciate ligament disease in the dog. Abstracts of the 34th Annual Conference of
the Veterinary Orthopedic Society, March 3-10, 2007; p 67.
Hoffmann DR, Kowaleski MP, Johnson KA, Evans RB, Boudrieau RJ. In vitro biomechanical evaluation of the canine
CrCL deficient stifle with varying angles of stifle joint flexion and axial loads after TTA. Abstracts of the 18th An-
nual Scientific Meeting of the European College of Veterinary Surgeons. Nantes, France. July 2-4, 2009; pp 557-559.
Langenbach A, Marcellin-Little DJ: Management of concurrent patellar luxation and cranial cruciate ligament rupture us-
ing modified tibial plateau leveling. J Sm Anim Pract 51:97-103, 2010
Peruski AM, Kowaleski MP, Pozzi A, Dyce J, and Johnson KA: Treatment of Medial Patellar Luxation and Distal Femoral
Varus by Femoral Wedge Osteotomy in Dogs: 30 Cases (2000-2005). 33rd Annual Conference of the Veterinary
Orthopedic Society, Keystone, CO, February 25-March 4, 2006.
Talaat MB, Kowaleski MP, Boudrieau RJ. Combination Tibial Plateau Leveling Osteotomy and Cranial Closing Wedge
Osteotomy of the tibia for the treatment of cranial cruciate ligament-deficient stifles with excessive tibial plateau an-
gle. Vet Surg 35:729-739, 2006.
Tomlinson J, Fox D, Cook JL et al: Measurement of femoral angles in four dog breeds, Vet Surg 36:593, 2007.
Weh, JL, Kowaleski MP, Boudrieau RJ. Combination Tibial Plateau Leveling Osteotomy and Transverse Corrective Os-
teotomy of the Proximal Tibia for the Treatment of Complex Tibial Deformities in 12 dogs. Submitted, Vet Surg
May 2010.
Corrective osteotomy for patellar luxation:

outcome and complications
The importance of distal femoral varus in the pathophysiology of medial patellar luxation in large breed
dogs is becoming increasingly evident. Following corrective osteotomy, stability of the femoro-patellar joint,
healing of the osteotomy and limb function must be critically assessed to quantify the outcome.
MAIN PROGRAM
SMALL ANIMALS
PHYSICAL EXAMINATION
A thorough physical examination is the initial step in outcome assessment. Findings of particular interest fol-
lowing corrective osteotomy of the femur include presence and quantity of stifle effusion, stability of the
patella, discomfort noted overlying the implants including the bone plate on the distal femur, pin and ten-
sion band wire (PTBW) if a tibial tuberosity transposition has been performed, and dynamic or static stifle
stability if a cranial cruciate ligament rupture was present and stabilized.
GAIT EVALUATION
A gait evaluation should be part of any thorough orthopedic examination. Grade of lameness, if present,
and limb alignment and function should noted. In addition, symmetry between the operated and non-oper-
ated limb should be observed, and may play a role in future corrections of the opposite limb if necessary.
RADIOGRAPHIC EVALUATION
Medio-lateral and cranio-caudal radiographic views of the femur should be obtained. The medio-lateral view
is most easily obtained as an “open leg” view, with the affected leg lying on the radiographic table, and the
opposite limb pulled laterally out of the radiographic beam. The cranio-caudal femur is most easily obtained
as a horizontal beam projection, or with the dog “sitting” on the radiographic table. An “OFA” style cranio-
caudal view should be avoided, since the femur is rarely projected in a true cranio-caudal projection.
OUTCOME
In a recent retrospective study, twenty-six dogs were identified that underwent femoral corrective osteotomy
for medial patellar luxation. Of these dogs, four underwent bilateral corrective osteotomy, bringing the total
to 30 affected limbs in the 26 dogs. Radiographic follow-up until osteotomy union was available on 18/30 cas-
es, and the mean healing time was 10.0 +/- 4.8 weeks. In addition, none of these dogs exhibited medial patel-
lar luxation following surgery. Limb function was good or excellent in all dogs at the time of radiographic
union of the osteotomy.
COMPLICATIONS
In this cohort of patients, complications of surgical correction of femoral varus deformity included infection
necessitating implant removal (2/30) and delayed healing of the osteotomy site (1/30) dogs.
REFERENCES
1. Peruski AM, Kowaleski MP, Pozzi A, Dyce J, and Johnson KA: Treatment of Medial Patellar Luxation and Distal
Femoral Varus by Femoral Wedge Osteotomy in Dogs: 30 Cases (2000-2005). 33rd Annual Conference of the Vet-
erinary Orthopedic Society, Keystone, CO, February 25-March 4, 2006.
S.J. Langley-Hobbs WVOC 2010, Bologna (Italy), 15th - 18th September • 132
Complications of patellar luxation surgery

Sorrel J. Langley-Hobbs, M.A., B.Vet.Med., DSAS(O), Dipl. ECVS, MRCVS
The Queens Veterinary School Hospital, University of Cambridge, United Kingdom
INTRODUCTION
Patellar luxation is a disabling condition that commonly affects dogs and, less frequently, cats. Five percent
of all orthopaedic cases presented to orthopaedic specialists and general practitioners in the UK had patel-
lar luxation and it was 7th most common of the conditions presented6. It used to be perceived as a small
breed problem. In an early report 33 of 34 affected dogs were small breeds less than 15kg9. It is now in-
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SMALL ANIMALS
creasingly recognised in large breeds1,2,3.

Medial patellar luxation (MPL) is most common in all sized dog breeds. Lateral patellar luxation (LPL) was
primarily thought to be a problem of large breeds but it is recognised that this is not always the case2. Con-
formation studies have found that MPL is associated with a relatively long patellar ligament and patella al-
ta in medium to giant breed dogs4,5.
Large-breed dogs with L:P values > 1.97 are considered to have patella alta4. Proximal displacement of the
patella within the femoral trochlear groove may be the problem in large-breed dogs4. Conversely LPL is as-
sociated with a relatively long proximal tibia and patella baja5.
Surgery is commonly performed for patellar luxation when the condition is found to be the cause of lame-
ness, or it is severe and likely to result in lameness if left untreated. There are numerous surgical techniques
that can be used alone or in combination to correct the condition. These procedures consist of techniques
to deepen the trochlear groove; techniques to improve tracking such as tibial tuberosity transposition; and
soft tissue release and overlap techniques.
More recently attention has been paid to limb alignment issues and correction of these is perceived to be im-
portant in selected cases (Bounds).
Corrective surgery for patellar luxation is associated with a high complication rate. In one report there was
an 18% complication rate, with 13% of these being major and requiring revision surgery1. A higher compli-
cation rate was seen in dogs > 20kg and in dogs with a higher grade of luxation1. In a study specifically on
large breed dogs complications occurred in 29% of stifles, and increasing bodyweight was also found to be
a risk factor3.
Reluxation was the commonest complication in one study where it occurred in 48% of small dog with patel-
lar luxation9, the incidence was less common in a more recent study with a rate of 8% in a survey of dogs
of variable size1.
Complications that occur after patellar luxation surgery include:

• Tibial tuberosity implant loosening
• Tibial tuberosity fracture avulsion
• Reluxation
• Over correction – medial into lateral luxation
• Seroma
• Tibial and fibular fracture
• Sepsis
• LDE tendonitis
• Patella ligament rupture
• Lameness
• Trochlear wedge migration
How to prevent complications:

• Careful planning and attention to detail
• Correct alignment
• Ensure trochlear groove is deep enough
• Use a tension band wire in large and / or active dogs or if the TT is transposed a big distance
• Soft tissue techniques augment but do not replace realignment techniques
133 • WVOC 2010, Bologna (Italy), 15th - 18th September S.J. Langley-Hobbs
Dogs should be assessed by a good physical examination followed up by radiography. It is vital that the dog
is carefully positioned for radiographs to ensure the bone shape is accurately represented. CT can also be
used to evaluate bone shape and torsion. In cases with higher-grade luxations (III and IV) the patella will
be luxated when the dog is radiographed, this will rotate the stifle and exacerbate or accentuate angulation
or bone rotation. If at all possible take the radiograph with the patella reduced.
To reduce the chance of complications following patellar luxation surgery requires careful planning and at-
tention to detail throughout all aspects of the surgery. The following discussion addresses points sequentially
whereby complications are likely to occur and some possible ways to avoid them happening.
How to deepen the groove?

The groove is deepened most commonly by performing a block or wedge recession sulcoplasty. A wedge is
MAIN PROGRAM
easier to perform but does not deepen the groove at the proximal aspect as well as the block does. If the
SMALL ANIMALS
patella luxates when the stifle is extended or there is patella alta then a block recession would be more suit-
able than a wedge. In large dogs a block is recommended as patella alta is often present4. The groove must
be wide enough to accommodate the patella. The block or wedge must be tight to prevent dislodgement –
small pieces of bone can be wedged in either side of the block to aid this. Appropriate instrumentation is re-
quired to cut the block – use of a thick osteotome will cause leverage and therefore possibly break the block.
If the block breaks then pins can be inserted transversely through the femoral trochlear ridges and block to
pin it in place.
How to avoid complications after tibial tuberosity transposition?

Complications can arise after tibial tuberosity transposition due to too small a fragment being cut, bilat-
eral surgery or from asking too much of the ‘tension band’. To avoid complications ensure a large enough
piece of bone removed – the base should end level to the tibial crest. Use a tension band made of or-
thopaedic wire in large and boisterous dogs, if the tuberosity has been rotated a large distance and if sur-
gery is bilateral (ie if in doubt use a TBW). Do not use pins that are too large, two small ones are prefer-
able. Use large gauge orthopaedic wire. Take care when placing the pins in the bone. The lateral aspect
of the tibia is concave so the wire needs to be angled in a medial direction to ensure it engages bone. To
avoid fracture do not place the pins directly through the insertion point of the patella ligament (this is al-
so recommended for TPLO).
How to do soft tissue release?

Only release what is necessary. Do it a layer at a time, as there is a risk of doing too much of a release and
resulting in luxation in the opposite direction. Seroma formation may be more common after soft tissue re-
lease?
Medial release – elevate the retinaculum and cut this parallel to the patella ligament. Then do a tenotomy
of the sartorius caudal belly, finally a partial tenotomy of the vastus medialis – this tendon is often palpably
taut. Only cut the joint capsule if essential and try and limit the proximal extent of the cut.
When to perform long bone osteotomies?

Well positioned radiographs should be taken and the femoral varus angles determined. The distal femoral
varus angles vary with breed8 so when to correct must be determined for each individual dog. Angles >/=
12 degrees were corrected in 12 dogs with medial patellar luxation, combined with traditional corrective
techniques with good success7.
CONCLUSIONS
Careful planning including palpation, well positioned radiographs and meticulous surgical technique and at-
tention to detail for each individual dog should all contribute to a lower complication rate. All surgically
treated cases of patellar luxation in large breed dogs should be managed with a femoral trochleoplasty, a tib-
ial tuberosity transposition (stabilised with K-wires and a tension band wire), and soft tissue releasing and
tightening procedures3. A reduction in complications was seen when trochlea recession was performed in
combination with a tibial tuberosity transposition1,3.
REFERENCES
1. Arthurs GI, Langley-Hobbs SJ Complications Associated with Corrective Surgery for Patellar Luxation in 109
Dogs Vet Surg 2006, 35: 559-566
2. Bound N, Zakai D, Butterworth SJ, Pead M. The prevalence of canine patellar luxation in three centres. Clinical
features and radiographic evidence of limb deviation. Vet Comp Orthop Traumatol. 2009;22(1):32-7.
S.J. Langley-Hobbs WVOC 2010, Bologna (Italy), 15th - 18th September • 134
3. Gibbons SE, Macias C, Tonzing MA, Pinchbeck GL, McKee WM. Patellar luxation in 70 large breed dogs. J Small
Anim Pract. 2006 Jan;47(1):3-9.
4. Johnson AL, Broaddus KD, Hauptman JG, Marsh S, Monsere J, Sepulveda G. Vertical patellar position in large-
breed dogs with clinically normal stifles and large-breed dogs with medial patellar luxation. Vet Surg. 2006
Jan;35(1):78-81.
5. Mostafa AA, Griffon DJ, Thomas MW, Constable PD. Proximodistal alignment of the canine patella: radiograph-
ic evaluation and association with medial and lateral patellar luxation. Vet Surg. 2008 Apr;37(3):201-11.
6. Ness MG Abercromby RH, May C, Turner BM A survey of orthopaedic conditions in small animal veterinary
practice in Britain. VCOT 43-52, 1996.
7. Swiderski JK, Palmer RH. Long-term outcome of distal femoral osteotomy for treatment of combined distal femoral
varus and medial patellar luxation: 12 cases (1999-2004). J Am Vet Med Assoc. 2007 Oct 1;231(7):1070-5.
MAIN PROGRAM
8. Tomlinson J, Fox D, Cook JL, Keller GG. Measurement of femoral angles in four dog breeds. Vet Surg. 2007
SMALL ANIMALS
Aug;36(6):593-8.
9. Willauer CC, Vasseur PB. Clinical results of surgical correction of medial luxation of the patella in dogs. Vet Surg.
1987 Jan-Feb;16(1):31-6.
135 • WVOC 2010, Bologna (Italy), 15th - 18th September B.D.X. Lascelles
Validating subjective clinical outcome measures

B. Duncan X. Lascelles, BSc, BVSC, PhD, MRCVS, CertVA, DSAS(ST), Dipl. ECVS, Dipl. ACVS
Associate Professor of Surgery, Director, Comparative Pain Research Laboratory, Director, Integrated Pain Management
Service, North Carolina State University College of Veterinary Medicine, Raleigh, NC, 27606, USA
http://www.cvm.ncsu.edu/docs/cprl/
Clinical outcome measures take a variety of forms, but commonly used are subjective assessments. These
subjective assessments usually take the form of a series of questions or ‘graded’ choices. These subjective
assessment tools are referred to as instruments, completed by veterinarians, technicians or owners. The
MAIN PROGRAM
SMALL ANIMALS
physical design of these can vary. For example, they can be of a Visual Analogue Scale (VAS) design, a Nu-
merical Rating Scale (NRS) design, a Descriptive Rating Scale (DRS) design or a combination of these
modalities.
Anyone with some knowledge of veterinary orthopedics or the musculoskeletal system could design an in-
strument to assess subjective clinical outcomes in veterinary orthopedics. For example, veterinarian com-
pleted scales to assess resolution of lameness following surgery for elbow dysplasia; or owner completed
questionnaires to assess pain relief following NSAID administration to their pet dog for OA-associated pain.
However, although these scales or instruments can look ‘correct’, unless they have been validated, the scales
or instruments are simply a measure of how best the animals being assessed fit the questionnaire developer’s preconceived
ideas on how they should look. It is important that instrument development be performed logically and scientif-
ically. What appears intuitively correct may well be so, but not necessarily so!
The steps to create an effective and reliable questionnaire for human subjects have been extensively de-
scribed,1-3 and similar work has more recently been adopted in veterinary medicine. 4-6 Although the details
of the approach to this vary, the main steps in producing a valid instrument are item generation followed
by readability, reliability and validity testing.4,7,8
Item generation is a very important stage as it defines the question topics or the aspects to be assessed. For
example, it would probably not be correct to assess tail carriage as a measure of forelimb lameness in dogs.
The two main approaches that have been used in canine medicine are the generation of items through fo-
cus group meetings and expert input4,6 and the generation of items through using affected and unaffected
groups and evaluating the differences between them.5
Once items were generated, the next stage is to present the items in an appropriate type of format or layout.
In human studies there is no consensus on the optimum number of response alternatives in self-report rat-
ing scales.9-11 Indeed, it has been suggested that patients can only communicate their own pain using between
4 and 6 points of discrimination.12 This issue probably becomes even more problematic in proxy reporting
scales (which is what we use in veterinary medicine).
To the author’s knowledge, there are no studies evaluating the optimal number of response levels for own-
er assessments of pain in animals.
Following the scale or instrument design, readability testing should be performed. This can be performed
using standardized evaluation methods, although many of these methods were developed for evaluation of
prose, and are less well suited to questionnaires. There is considerable subjectivity in this assessment. The
aim is to produce an easily understood instrument.
Validity is the ability of a scale or questionnaire to measure what it was designed to measure and validity
can be classified as: face validity, content validity, criterion validity and construct validity.
Face validity is the subject review of the questionnaire by knowledgeable individuals with the purpose to
confirm that the instrument measures what it was suppose to measure.
Content validity is related to face validity and also relies on expertise to identify if all the possible questions
and factors were addressed to achieve the objective of the measurement.
Criterion validity is when the results obtained when using the instrument correlate well with an objective
assessment. This can be difficult to do, because although in veterinary orthopedics force plate, pressure sen-
sitive walkway and accelerometers have been used to evaluate different aspects of gait and mobility, there
often no universally accepted gold standard measure of what is being assessed by the instrument. For ex-
ample, although force plates have been used to measure limb use, this may not directly measure limb pain
that an instrument may be designed to measure.
Construct validity is the ability of an instrument measure variables that are theoretically related to the
construct that the instrument supposed to measure. It can be measured by testing the instrument in ex-
treme groups of patients (healthy and unhealthy) as well as using factor analysis based on principal com-
ponent analysis.
B.D.X. Lascelles WVOC 2010, Bologna (Italy), 15th - 18th September • 136
REFERENCES
1. Mcdowell I, Newell C. Pain measurements. In: Measuring health: a guide to rating scales and questionnaires, 2nd
ed. New York: Oxford University Press; 1996:470-519.
2. Streiner DL, Norman GR. Health measurements scales. A practical guide to their development and use., 2nd ed.
New York: Oxford University Press; 1995.
3. Sudman S, Bradburn NM. Questionnaire from start to finish. In: Asking questions. A practical guide to question-
naire design. San Francisco: Jossey-Bass Inc; 1982:281-286.
4. Brown DC, Boston RC, Coyne JC, et al. Development and psychometric testing of an instrument designed to meas-
ure chronic pain in dogs with osteoarthritis. Am J Vet Res 2007;68:631-637.
5. Hielm-Bjorkman AK, Kuusela E, Liman A, et al. Evaluation of methods for assessment of pain associated with
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chronic osteoarthritis in dogs. J Am Vet Med Assoc 2003;222:1552-1558.

SMALL ANIMALS
6. Wiseman-Orr ML, Nolan AM, Reid J, et al. Development of a questionnaire to measure the effects of chronic pain
on health-related quality of life in dogs. Am J Vet Res 2004;65:1077-1084.
7. Brown DC. Outcomes based medicine in veterinary surgery: getting hard measures of subjective outcomes. Vet
Surg 2007;36:289-292.
8. McDowell I, Newell C. Measuring Health: A Guide to Rating Scales and Questionnaires, 2nd ed. New York: Ox-
ford University Press; 1996.
9. Maydeu-Olivares A, Kramp U, Garcia-Forero C, et al. The effect of varying the number of response alternatives in
rating scales: Experimental evidence from intra-individual effects. Behav Res Methods 2009;41:295-308.
10. Dworkin RH, Turk DC, Farrar JT, et al. Core outcome measures for chronic pain clinical trials: IMMPACT rec-
ommendations. Pain 2005;113:9-19.
11. Jensen MP, Turner JA, Romano JM. What is the maximum number of levels needed in pain intensity measure-
ment? Pain 1994;58:387-392.
12. Rosier EM, Iadarola MJ, Coghill RC. Reproducibility of pain measurement and pain perception. Pain 2002;98:205-
216.
137 • WVOC 2010, Bologna (Italy), 15th - 18th September D.H. Lloyd
Multi-resistant bacteria:
current status including management
D.H. Lloyd, Prof., PhD, B.Vet.Med, FRCVS, Dip ECVD
Department of Veterinary Clinical Sciences, Royal Veterinary College (University of London), North Mymms, UK
THE PROBLEM OF ANTIMICROBIAL RESISTANCE

Although multiresistance was first highlighted in the human field and agricultural use of antimicrobials as
growth promoters was incriminated as a contributor, the role of small animal practice has become more ap-
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SMALL ANIMALS
parent (Guardabassi et al, 2004). Infections with multi-resistant bacteria that are difficult to treat, such as Es-
cherichia coli and Pseudomonas aeruginosa are now common in pets, and methicillin-resistant Staphylococcus aureus
(MRSA) infections are increasingly recognised. Outbreaks with highly resistant strains of Acinetobacter bau-
mannii are also reported (Boerlin, 2001). Worryingly, S. pseudintermedius (formerly S. intermedius), has now de-
veloped increased capacity for multiresistance, including acquisition of the mecA gene, giving resistance to all
beta-lactam antibiotics. This methicillin-resistant S. pseudintermedius (MRSP) is now common in some coun-
tries; it has spread rapidly in Europe since first described (Loeffler et al, 2007).
The consequences of the rise in frequency of these multiresistant bacteria in veterinary practice go beyond
clinical difficulty in treating cases. These bacteria can cause zoonotic infections and act as a source of resist-
ance genes for organisms associated with human infection. Alarm has been raised in the human field with
the suggestion that some agents should be withdrawn from veterinary use. Veterinary surgeons need to re-
spond to such threats by more careful use of these drugs.
RISK FACTORS FOR THE DEVELOPMENT OF INFECTION WITH ANTIMICROBIAL

RESISTANT ORGANISMS
Dealing with antimicrobial resistance requires an understanding of factors associated with infection by re-
sistant organisms. Although there is a lack of systematic studies both in human and veterinary medicine
(Lloyd, 2007; Carmeli, 2008), there is agreement on the principal pathogens causing concern. These include
pathogenic staphylococci, Enterococcus spp., Enterobacteriaceae and especially E. coli, and Ps. aeruginosa, or-
ganisms which share risk factors promoting nosocomial infection. Sadfar and Maki (2002) reviewed evi-
dence of risk factors for such organisms in human medicine and demonstrated that old age; underlying dis-
eases and severity of illness; inter-institutional transfer; prolonged hospitalisation; gastrointestinal surgery or
transplantation; exposure to invasive devices; and exposure both individually and to combinations of an-
timicrobials were involved. Such studies are lacking in the veterinary field but there is evidence from publi-
cations on MRSA infection which indicates that risk factors for pets mirror those in the human field and in-
clude carriage of MRSA, contact with carriers, duration of hospital admission and invasive procedures
(Lloyd et al, 2007; Loeffler and Lloyd, 2010). In the USA, Black et al (2009) showed that amongst dogs in
an intensive care unit, multidrug-resistant patterns occurred in 27% of all isolates and were more likely in
organisms cultured after 48 hours hospitalisation. Veterinary staff and owners are at increased risk of be-
coming carriers of such organisms when they are in contact with infected animals (Loeffler and Lloyd,
2010). Indeed studies in animal hospitals have shown that staff MRSA carrier rates as high as 27% can oc-
cur (Baptisite et al., 2005).
INFECTION CONTROL AND PRUDENT ANTIMICROBIAL USE

There is now an impetus to define measures to control infections and use antimicrobials in animals in re-
sponsible ways so as to reduce levels of resistance (Prescott 2008). Guidelines are being created at different
levels of complexity varying from general concepts to specific recommendations for individual disease con-
ditions and specific organisms. The Federation of European Companion Animal Veterinary Associations
(FECAVA) has established a Working Group on Hygiene and the Use of Antimicrobials in Veterinary Prac-
tice to bring together and co-ordinate recommendations within small animal practice in Europe (Lloyd et al,
2009). This group has produced a poster, “FECAVA Guidelines for Hygiene and Infection Control in Vet-
erinary Practice”, which outlines under 8 headings the essential approaches and is to be made available to
veterinarians throughout Europe.
In the UK, both the British Veterinary Association and the British Small Animal Veterinary Association
have published recommendations on prudent use of antimicrobials (see BVA, 2009; BSAVA 2009). The
BVA has produced a downloadable poster suitable for display which lists an 8 point plan providing actions
and advice suitable for veterinary practice. The key points are a) development of protocols which ensure
D.H. Lloyd WVOC 2010, Bologna (Italy), 15th - 18th September • 138
that antimicrobials are used only when necessary, b) selection of appropriate antimicrobials following sensi-
tivity tests if possible, and compliance with correct dosage and administration, c) limitation of prophylactic
and perioperative use, and d) maintenance of records of treatment outcomes so that therapeutic regimens
can be evaluated and modified if necessary.
Selection of appropriate drugs and their correct use is, of course, of vital importance. When treatment must
be instituted rapidly or there is a high level of confidence that the causative organism and its sensitivity can
be predicted, appropriate “first line” drugs can be selected (see Weese, 2006). Otherwise, sensitivity tests
should be carried out and “second line” drugs may be required. An important component of this process is
client education conveying the dual message that both avoidance of non-essential antimicrobial administra-
tion and full compliance with dosage regimens of prescribed courses of antimicrobial drugs reduce the risk
of increasing bacterial resistance.
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To this list must be added the need for rigorous hygiene so that as resistant organisms are encountered, in
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infected animals or in healthy carriers, transmission to other patients or humans is prevented.
REFERENCES
Baptiste K.E., Williams K., Willams N.J. et al. Methicillin-resistant staphylococci in companion animals. Emerg. Infect.
Dis. 2005; 11: 1942-1944.
Black D.M., Rankin S.C., King L.G. Antimicrobial therapy and aerobic bacteriologic culture patterns in canine intensive
care unit patients: 74 dogs (January-June 2006). J. Vet. Emerg. Crit. Care (San Antonio) 2009; 19: 489-95.
Boerlin P., Eugster S., Gaschen F. et al. Transmission of opportunistic pathogens in a veterinary teaching hospital. Vet.
Microbiol. 2001; 82: 347-59.
BVA. Responsible Use of Antimicrobials in Veterinary Practice. The 8 Point Plan. 2009. http://www.bva.co.uk/public/
documents/BVA_Antimicrobials_Poster.PDF
BSAVA. BSAVA Guide to the Use of Veterinary Medicines. Prudent Use of Antimicrobial Agents. 2009. http://www.bsa-
va. com/Advice/BSAVAGuidetotheUseofVeterinaryMedicines/Prudentuseofantimicrobialagents/tabid/363/De-
fault. aspx).
Carmeli Y. Strategies for managing today’s infections. Clin. Microbiol. Infect. 2008; 14 Suppl 3: 22-31.
Gould IM. Antibiotic resistance: the perfect storm. Int. J. Antimicrob. Agents. 2009; 34 Suppl 3: S2-5.
Guardabassi L., Schwarz S., Lloyd D. H. Pet animals as reservoirs of antimicrobial resistant bacteria. J. Antimicrob.
Chemother. 2004; 54: 321-332.
Lloyd, D.H. Reservoirs of antimicrobial resistance in pet animals. Clin. Infect. Dis. 2007; 45: S148–52.
Lloyd D.H., Boag A., Loeffler A. Dealing with MRSA in small animal practice. European J. Comp. Anim. Pract. 2007;
17: 85-93.
Lloyd D.H., Carlotti D-N., Loukaki K. et al. Development of multiresistant bacteria and the threat to small animal prac-
tice. European J. Comp. Anim. Pract. 2009: 19: 101.
Loeffler A., Linek M., Moodley A. et al. First report of multi-resistant, mecA-positive Staphylococcus intermedius in Eu-
rope: 12 cases from a veterinary dermatology referral clinic in Germany. Vet. Dermatol. 2007: 18; 412-421.
Loeffler A., Lloyd D.H. Companion animals: a reservoir for methicillin-resistant Staphylococcus aureus in the communi-
ty? Epidemiol. Infect. 2010; 138: 595-605.
Prescott J.F. Antimicrobial use in food and companion animals. Anim. Health Res. Rev. 2008; 9: 127-33.
Safdar, N., Maki, D.G. The commonality of risk factors for nosocomial colonization and infection with antimicrobial-re-
sistant Staphylococcus aureus, Enterococcus, gram-negative bacilli, Clostridium difficile, and Candida. Ann. Intern.
Med. 2002; 136: 834-844.
Weese J.S.: Prudent use of antimicrobials. In: Antimicrobial Therapy in Veterinary Medicine, 4th edn. Eds. S. Giguere,
J.F. Prescott, J.D. Baggot, R.D. Walker and Dowling PM. Blackwell Publishing, Ames, 2006, 437–448.
139 • WVOC 2010, Bologna (Italy), 15th - 18th September D.H. Lloyd
Nosocomial (surgical) infections

D.H. Lloyd, Prof., PhD, B.Vet.Med, FRCVS, Dip ECVD
Department of Veterinary Clinical Sciences, Royal Veterinary College (University of London), North Mymms, UK
INTRODUCTION
Although we generally have a good idea of what is meant by “nosocomial infection”, the term should be
used in a precise way when we are thinking of ways of evaluating and controlling this problem. A useful
definition, which was established for the United States Centers for Disease Control National Nosocomial
Infections Surveillance System (see CDC NNIS), states that nosocomial infection is a localised or systemic
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condition occurring in a hospital resulting from adverse reaction to the presence of an infectious agent(s) or
its toxin(s) that was not present or incubating on admission to the hospital. For bacterial nosocomial infec-
tions, infection normally is evident 48h (typical incubation period for signs to appear) after admission but
this delay may be longer for some micro-organisms. Two non-infectious nosocomial conditions are also in-
cluded: colonisation (presence of microbes not causing adverse signs) and inflammation (signs resulting
from response to injury or non-infectious agents). This presentation will not deal with the inflammatory
component.
THE INCREASING THREAT OF NOSOCOMIAL INFECTION

Nosocomial infection is an inevitable occurrence in veterinary practice. Animals with wounds or increased
susceptibility to infection are examined and treated in our clinics and hospitals, and will inevitably come in-
to contact with potential pathogens. These microbes may be introduced by infected animals or may be car-
ried by animals, owners or staff and transferred to susceptible animals by contact with them or with con-
taminated fomites.
Although nosocomial infections have always been a threat in veterinary practice, they are a growing prob-
lem as modern medicine and surgery enables us to manage cases with more severe illnesses or injuries in
the face of micro-organisms that are increasingly resistant to the antimicrobial agents that we have come to
rely on to prevent or control them. Few studies have been carried out to determine the factors responsible
for nosocomial infection, particularly in first opinion practice but there is evidence that the situation in vet-
erinary medicine mirrors that in the human field. Infections with multiresistant bacteria such as Escherichia
coli, Pseudomonas aeruginosa, Enterococcus spp, and methicillin-resistant clones of Staphylococcus aureus (MRSA)
and, increasingly, S. pseudintermedius are a particular problem (Guardabassi et al, 2004; Loeffler et al, 2007).
In horses, nosocomial infections with Salmonella are of special concern (Weese, 2004). Duration of stay in vet-
erinary hospitals, use of invasive devices, repeated treatment with antimicrobials and carriage of pathogens
by other animals and hospital staff (Loeffler et al, 2010; Soares Magalhães et al, 2010; Walther et al, 2009)
have been shown to be risk factors for infection.
HOW CAN NOSOCOMIAL INFECTION BE PREVENTED?

It is essential to recognise and record nosocomial infections when they occur as this will enable action to be
taken to identify possible causes and appropriate preventive measures to be instituted. As control measures
are developed and implemented in the clinic or hospital, the records will demonstrate how progress is being
achieved and will help to identify where further measures may be required. An important component of this
recording process is that it makes staff more aware of infections which may have been accepted or regarded
as normal in the past. Reducing such infections is then seen as an achievement and has a beneficial effect on
staff morale. Furthermore, the cost benefit of reducing these infections will be become apparent and support
the effort and expenditure required for control.
Monitoring nosocomial infections can be achieved in various ways. Analysis on a continuing basis of ex-
isting records in the practice relating to the occurrence, frequency and patterns of infections or clinical signs
that are suggestive of infection (coughing diarrhoea), and of the results of antimicrobial culture and sensi-
tivity tests, is readily achievable. However, this must be done methodically and regularly with specific ob-
jectives e.g. identification of rates, types and trends of infection, occurrence of specific pathogens that may
be of special concern such as MRSA or MRSP, and rapid notification of staff involved so that action can
be taken without delay. In the face of specific problems, more active measures may be taken, with planned
sampling of environments and/or individuals. Such measures might be taken if routing monitoring indi-
cates a trend of infection in a particular practice activity e.g. MRSA infections associated with certain sur-
gical procedures. This will yield more reliable data but is likely to be too costly for use on a regular basis.
Monitoring of the environment can be useful to identify problems with practice hygiene and may enable
D.H. Lloyd WVOC 2010, Bologna (Italy), 15th - 18th September • 140
failure of established cleaning or disinfection procedures to be identified but is not normally used as a rou-
tine procedure.
Methods for prevention of nosocomial infection depend principally on good hygiene, barrier precautions
and isolation protocols designed to prevent transmission of pathogens (Weese, 2004), and on prudent use
of antimicrobials to ensure rapid and effective treatment that minimises the duration of exposure of microbes
to antimicrobials and avoids selection of resistant bacteria. Practice hygiene is the subject of a document pro-
duced by the FECAVA Working Group on Hygiene and the Use of Antimicrobials in Veterinary Practice
(see FECAVA 2010). This document focuses on the key elements: 1) cleaning and disinfection of hands, re-
garded as the most important hygiene procedure, 2) cleaning and disinfection of premises, 3) use of gloves,
in addition to hand hygiene, 4) appropriate protective clothing, 5) staff training and 6) education of animal
owners in good hygiene practices, 7) appropriate waste management, and 8) effective procedures for laun-
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dry of clothing and bedding.

SMALL ANIMALS
Several national and international organisations have produced or are producing recommendations for pru-
dent antimicrobial use. In the UK, the British Veterinary Association, the British Small Animal Veterinary
Association and the Responsible Use of Medicines in Agriculture Alliance have done this (See BVA, BSA-
VA and RUMA recommendations). Key points are a) development of protocols which ensure that antimi-
crobials are used only when necessary, b) selection of appropriate antimicrobials following sensitivity tests if
possible, and compliance with correct dosage and administration, c) limitation of prophylactic and periop-
erative use, and d) maintenance of records of treatment outcomes so that therapeutic regimens can be eval-
uated and modified if necessary.
A vital component of measures for prevention of nosocomial infections is compliance. This requires the es-
tablishment of a committed infection control culture within the practice staff and it is essential for the clinic
or hospital to have a member of staff with responsibility for training, management, monitoring and commu-
nication of the necessary measures who will ensure that good practice is maintained on a long term basis.
REFERENCES
B SAVA. B SAVA Guide to the Use of Veterinary Medicines. Prudent Use of Antimicrobial Agents. 2009.
http://www.bsava.com/Advice/BSAVAGuidetotheUseofVeterinaryMedicines/Prudentuseofantimicrobialagents/tabi
d/363/Default.aspx).
BVA. Responsible Use of Antimicrobials in Veterinary Practice. The 8 Point Plan. 2009. http://www.bva.co.uk/public/
documents/BVA_Antimicrobials_Poster.PDF
CDC NNIS definition http://health.utah.gov/epi/diseases/legionella/plan/cdcdefsnosocomial%20infection.pdf
FECAVA 2010. FECAVA Recommendations for Hygiene and Infection Control in Veterinary Practice, June 2010. Draft
poster to be circulated to all FECAVA associations in 2010.
Guardabassi L., Schwarz S., Lloyd D. H. Pet animals as reservoirs of antimicrobial resistant bacteria. J. Antimicrob.
Chemother. 2004; 54: 321-332.
Loeffler A., Linek M., Moodley A. et al. First report of multi-resistant, mecA-positive Staphylococcus intermedius in Eu-
rope: 12 cases from a veterinary dermatology referral clinic in Germany. Vet. Dermatol. 2007: 18; 412-421.
Loeffler, A., Pfeiffer, D. U., Lloyd, D. H., Smith, H. Soares-Magalhaes, R., Lindsay, J. A. MRSA carriage in UK veteri-
nary staff and owners of infected pets: new risk groups. Journal of Hospital Infection 2010; 74: 282-8.
RUMA recommendations. See http://www.ruma.org.uk/ for specific recommendations for different species.
Soares Magalhães RJ, Loeffler A, Lindsay J, Rich M, Roberts L, Smith H, Lloyd DH, Pfeiffer DU. Risk factors for me-
thicillin-resistant Staphylococcus aureus (MRSA) infection in dogs and cats: a case-control study. Vet Res. 2010;
41(5):55.
Walther B, Wieler LH, Friedrich AW, Kohn B, Brunnberg L, Lübke-Becker A. Staphylococcus aureus and MRSA colo-
nization rates among personnel and dogs in a small animal hospital: association with nosocomial infections. Berl
Munch Tierarztl Wochenschr. 2009;122:178-85.
Weese JS. Barrier precautions, isolation protocols, and personal hygiene in veterinary hospitals. Vet Clin North Am
Equine Pract. 2004 Dec;20(3):543-59.
141 • WVOC 2010, Bologna (Italy), 15th - 18th September U. Matis
Fractures of the femoral head and neck

U. Matis, Prof. Dr. med. vet., Dr. med. vet. habil, Dipl. ECVS, S. Strodl, Dr. med. vet.
Centre for Veterinary Clinical Science, Ludwig-Maximilians-University of Munich, Germany
INTRODUCTION
Fractures of the proximal femur constitute approximately 13% of canine and 16% of feline femoral fractures.
In contrast to dogs, in which physeal separation of the femoral head is more commonly seen, cats incur
mostly femoral neck fractures, which are usually extracapsular. The joint capsule is important not only for
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the stability of the hip joint but also for the blood supply to the femoral head. In intracapsular fractures, the
epiphyseal vessels of the joint capsule are torn or compromised by haemarthrosis. Thus, extracapsular frac-
tures have a better prognosis than intracapsular fractures, in which flattening and/or late segmental collapse
of the femoral head can occur because of an impaired blood supply. The risk of compromised blood supply
to the femoral head is particularly high in the first five months of life when the physeal plate does not allow
anastomoses between the epiphyseal and metaphyseal blood vessels.
OBJECTIVE
To evaluate short- and long-term results of internal fixation in cats and dogs with proximal femoral frac-
tures and to compare the outcome in cats with those of conservative treatment and femoral head and neck
excision.
STUDY DESIGN
Retrospective study.
MATERIALS AND METHODS

The clinical and radiographic findings of 199 osteosyntheses in 100 cats and 99 dogs with proximal femoral
fractures re-evaluated an average of 6 months (75 cats and 66 dogs; short-term evaluation1) or 7 years (25
cats and 33 dogs; long-term evaluation4,5) post-treatment were investigated. The data were analysed for a
possible relationship between the outcome and the course of the fracture line, fracture displacement and the
time between occurrence of the fracture and treatment. As well, the results of internal fixation were com-
pared in cats with those of conservative treatment6 and excision arthroplasty7. For osteosynthesis, a cranio-
lateral approach was usually carried out with the joint capsule incision parallel to the long axis of the femoral
neck. Two wires, which were placed parallel and crossed the fracture line as far apart as possible from one
another, were used for the repair.
RESULTS
In both short- and long-term re-evaluations, 63% of osteosyntheses were not associated with lameness or
arthrosis. In 17% of the short-term and 16% of the long-term evaluations, arthrotic changes were seen on ra-
diographs but there was no functional impairment of the limbs. In 17% of the short-term and 24% of the
long-term re-evaluations, there was coxarthrosis with intermittent lameness. In all cases, consolidation of the
fracture had occurred, whereas in 20 cats with conservatively treated proximal femoral fractures, the rate of
non-union was 80%. Of 15 cats that underwent excision arthroplasty, evaluation at an average of 4 years
post-operatively revealed limb shortening in 13, muscle atrophy in 7, limited range of motion in 11 and pain
during passive movement of the hip in 4 cases. Five of the cats that underwent femoral head and neck ex-
cision had a temporary lameness, which was noted by the owners as well. As expected, of the fractures re-
paired surgically, extracapsular fractures had a better outcome than intracapsular fractures. The time be-
tween occurrence of the fracture and treatment had a lesser effect on long-term outcome than the extent of
fragment displacement.
CONCLUSION
Fracture healing does not take place in a high percentage of femoral head and neck fractures that are man-
aged conservatively or not treated, even though some of our patients, especially cats, have the innate abili-
ty to protect an injured limb.
Osteosynthesis should be the treatment of choice rather than excision arthroplasty, although the latter is
straightforward and therefore frequently selected. In the majority of cases, reconstruction of the joint results
in a more rapid and long-lasting return to function.
U. Matis WVOC 2010, Bologna (Italy), 15th - 18th September • 142
REFERENCES
1. Matis U, Waibl H. Proximal femoral fractures in cats and dogs. Tierärztl. Prax 1985; Suppl 1, 158-178.
2. Matis U. Femoral head and neck fractures. In: Whittick WG(ed): Canine Orthopedics 2nd ed. Lea + Febiger,
Philadelphia 1990; p 417-430.
3. Strodl S. Spätergebnisse nach intraartikulären und gelenknahen Frakturen des Hüft- und Kniegelenks von Hund
und Katze. Diss thesis, Munich 2000.
4. Matis U, Strodl S. Femoral head and neck fractures in cats. Vet Comp Orthop Traumatol 2005; 18:A10.
5. Papmahl-Hollenberg U. Zur konservativen Behandlung der Frakutr des Collum und der Epiphysiolysis des Caput
ossis femoris bei der Katze. Kleintierprax 1980, 25:163-167.
6. Off W, Matis U. Excision arthroplasty of the hip joint in dogs and cats. Clinical, radiographic, and gait analysis
findings from the Department of Surgery, Veterinary Faculty of the Ludwig-Maximilians-University of Munich,
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Germany. Prax 1997; 25: 379-387 and Vet CompOrthop Traumatol 2010; in press.
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Traumatic hip luxation in cats

U. Matis, Prof. Dr. med. vet., Dr. med. vet. habil, Dipl. ECVS, I. Holz, Dr. med. vet.,
H. Boehmer, Dr. med. vet.
Centre for Veterinary Clinical Science, Ludwig-Maximilians-University of Munich, Germany
INTRODUCTION
Hip luxation is the most common type of luxation in cats and is usually caused by trauma. Compared with
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dogs, the acetabulum of cats covers less of the femoral head and has a Norberg angle of 99°, which is thought
to predispose cats to this injury.
OBJECTIVE
To evaluate the results of different surgical techniques and compare them with those of conservative treat-
ment.
STUDY DESIGN
Retrospective study.

The medical records of 543 cats with 552 femoral luxations (9 [1.7%] had bilateral luxation), which were
presented to the Clinic of Small Animal Surgery and Reproduction, Ludwig-Maximilians-University of Mu-
nich, Germany, during a 15-year period, were evaluated. Of the 543 cats, 455 (83.8%) were treated for
femoral luxation: 25% were treated conservatively and the remainder underwent open reduction. Surgical
treatment included simple suturing of the joint capsule (49.2%), a combination of suturing of the joint cap-
sule and a figure-eight suture from the trochanter major to the iliopubic eminence (18.5%), capsular strength-
ening by passing suture material transosseously through the femoral neck and supra-acetabular pelvic region
(15.6%), and femoral head and neck resection (6.6%).
Clinical and radiographic re-evaluation an average of 7.9 months postoperatively was carried out in 177
(32.5%) cats. Long-term follow-up evaluations done more than four years postoperatively were available for
55 cats. The latest re-evaluation was done 10 years postoperatively.
RESULTS
Of 133 closed reductions, 58 (43.6%) required a second operation using open reduction because reluxation
occurred soon after the initial reduction. Of the 177 re-evaluated cats, 19 were successfully treated with con-
servative therapy, 89 with simple suturing of the joint capsule, 35 with an additional figure-eight suture, 23
with a transosseous suture technique to support the joint capsule, and two with resection of the femoral head
and neck.
The best results were achieved in the group treated conservatively, which had a lameness rate of 5.3% and
an arthrosis rate of 21%. The second best outcome was achieved in cats treated with a transosseous suture
technique to support the joint capsule; the lameness rate was 8.7% and the arthrosis rate was 47.8%. Cats
treated with a figure-eight suture technique had a lameness rate of 14.3% and 54.3% had signs of arthrosis.
The poorest functional result was seen in cats treated with simple suturing of the joint capsule; these cats
had a lameness rate of 27.6% and an arthrosis rate of 47.5%. The two cats that underwent resection of the
femoral head and neck were not visibly lame but extension of the hip was severely limited.
CONCLUSION
Compared with our results in dogs with femoral luxation1, cats tend to have a higher incidence of reluxa-
tion, which is why closed reduction and cage rest is seldom successful. However, when the reduced femoral
head remains in place, the prognosis for conservative therapy in cats is most favourable, as it is in dogs.
The functional results of suturing of the joint capsule alone were not as good as either of the other suturing
techniques, which is why one of these other methods should be used additionally, depending on the locali-
sation and extent of the joint capsule rupture. The transosseous suture technique of strengthening the joint
capsule is a more demanding repair treatment. However, it provides good stabilisation even in dorsal and
caudal capsular tears at the border of the acetabulum, in which the cranially-directed figure-eight suture is
less effective.
In summary, our experience indicates that femoral luxation in both dogs and cats has a poorer prognosis,
with respect to the occurrence of posttraumatic arthrosis, than hip fractures that can be successfully recon-
structed.2,3
REFERENCES
1. Köhnlein, H: Zur Luxatio ossis femoris traumatica des Hundes. Behandlung und Ergebnisse in den Jahren 1975 –
1983. Vet Med Diss. München 1986.
2. Matis U, Strodl S: Femoral head and neck fractures in cats, Abstracts ESVOT 2004, VEt Comp Orthop Trauma-
tol A10, 1/2005.
3. Matis U, Böhmer E, Strodl S, Egli C: Ilial and acetabular fractures in cats, Abstracts ESVOT 2004, Vet Com Or-
thop Traumatol 1/2005.
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SMALL ANIMALS
TPLO in the cat

U. Matis, Prof. Dr. med. vet., Dr. med. vet. habil., Dipl. ECVS, I. Holz, Dr. med. vet.,
A. Brühschwein, Dr. med. vet., Dipl. ECVDI
Centre for Clinical Veterinary Medicine, Ludwig-Maximilians-University of Munich, Germany
INTRODUCTION
Over 90% of stifle ligament lesions in dogs involve the anterior cruciate ligament, which primarily under-
goes insidious structural disintegration. In contrast, the stifle of cats usually incurs polytrauma with injury
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SMALL ANIMALS
to both cruciate ligaments, the medial and/or lateral collateral ligaments and one or both menisci1,2,3. How-
ever, in recent years, there has been an increasing number of reports in cats of spontaneous rupture of the
anterior cruciate ligament alone suggesting an underlying degenerative tear. Overweight cats with meta-
plastic calcification in the cranial compartment of the stifle joint appear to be particularly predisposed4. An
increased tibial plateau angle has also been described as a risk factor in cats5.
A thorough clinical and orthopaedic examination is mandatory for diagnosis of multiple stifle injuries. The
stability of the collateral ligaments must be assessed and anterior and posterior drawer signs differentiated1.
This examination serves to identify isolated rupture of the posterior cruciate ligament, which occurs con-
siderably more frequently in cats than dogs and is usually treated conservatively. The posterior drawer sign
test must also be carried out in cases with rupture of the anterior cruciate ligament, especially when plan-
ning a tibial plateau leveling osteotomy (TPLO) according to Slocum because this procedure requires the
presence of an intact posterior cruciate ligament.
Treatment of anterior cruciate ligament rupture in cats includes conservative therapy, which is considered ad-
equate by some authors6,7,8, extracapsular stabilisation by imbrication of the joint capsule and fascia, wires or
sutures that run from the fabella to the tibial tuberosity, fibular head transposition and anterior cruciate liga-
ment replacement using fascia or synthetic material1,2,3,4,7,8,9,10. In stifles with multiple injuries and complete lux-
ation, placement of a transarticular pin for temporary fixation of the reduced joint has also been described10.
We wanted to investigate whether TPLO, which has had good success in dogs, can be used in cats.
OBJECTIVE
To evaluate the results of TPLO in cats
STUDY DESIGN
Retrospective analysis of follow-up examinations.

The pre- and postoperative findings in 29 TPLOs carried out in 28 cats (1 cat had bilateral TPLO) were
analysed. Of 22 TPLOs in 21 cats, postoperative follow-up evaluations were done during a six-week-period
in eight cats, a three- to six-month period in seven cats, and a one- to five-year period in the remaining sev-
en cats (average 2.5 years). Surgery was carried out in lateral recumbency without arthrotomy or meniscal
release and a 12-mm radial saw was used for osteotomy. Mini T-plates were selected for fixation before TP-
LO-plates of 1.5- and 2.0-mm screw dimension were available. In recent years, we have preferably used mod-
ified Slocum plates with a smaller distance between the three proximal screw holes because they allow the
osteotomy to be carried out more caudally. In four cats, extracapsular fixation using suture from the fabel-
la to the tibial tuberosity was done with the patient in dorsal recumbency after completion of TPLO because
the stability provided by the TPLO did not appear adequate.
RESULTS
Complications occurred in three cats: one had implant pull-out, one had avulsion of the tibial tuberosity and
the third had secondary rupture of the medial collateral ligament. All of these complications were attributa-
ble to technical errors.
In two other patients, the clinical outcome was unsatisfactory because of failure to diagnose rupture of the
posterior cruciate ligament, which could not be compensated via the musculature after leveling of the tibial
plateau. This resulted in severe instability with functional impairment of the joint. These negative results
notwithstanding, our experience with TPLO in cats has been predominantly positive. One of the most im-
pressive aspects of TPLO in cats was the very short morbidity period because arthrotomy was not neces-
sary. At the six-week-postoperative re-evaluation, the majority of cats still had discrete lameness and muscle
atrophy. However, the owners reported that a short time after surgery, their cats were able to jump onto fur-
niture and other elevated objects. Five of the cats that had long-term follow-up examinations had marked
stifle arthrosis, but three of these cats had already been affected preoperatively. The remainder had no or
only vague evidence of degenerative joint disease. In a few cats, excessive leveling of the tibial plateau re-
sulted in thickening of the patellar ligament and new bone formation at the patellar apex, although this did
not result in lameness.
CONCLUSION
Although our patient number was small, TPLO appears suitable for cats provided that the posterior cruci-
ate ligament is intact. In cats with a pronounced anterior drawer sign and a marked tendency for inward ro-
tation of the tibia, an additional conventional technique such as extracapsular suture according to Flo may
MAIN PROGRAM
be required for adequate stabilisation. Excessive leveling of the tibial plateau to compensate for a pro-
SMALL ANIMALS
nounced anterior drawer sign does not appear desirable because of possible resultant overload of the
femoropatellar joint. TPLO in cats is technically more demanding than in dogs because of the relatively
small anatomy and brittle bones of cats. The risk of avulsion fracture of the tibial tuberosity must be taken
into account in cats because of their propensity for jumping. Thus, the osteotomy must not be carried out
too far cranially. Further studies and comparison of TPLO with conventional surgical techniques are re-
quired to determine whether the advantages of TPLO that we identified are worth the greater effort and
risk in cats, which have a great ability to compensate functionally.
REFERENCES
1. Matis U, Köstlin R. Zur Kreuzbandruptur bei der Katze. Der Praktische Tierarzt 1978; 8:582-8.
2. Mayer W. Traumatische Sehnen- und Bandverletzungen am Kniegelenk des Hundes und der Katze (Behandlung
und Ergebnisse in den Jahren 1983-1991). Diss med vet, München 1993.
3. Tacke S, Schimke E. Zur Ruptur der Ligamenta Cruciata bei der Katze. Kleintierpraxis 1995; 40:337-16.
4. Voss K. Personal communication.
5. Schnabl E, Reese S, Lorinson K. Measurement of the Tibialplateau Angle in Cats with and without cranial cruci-
ate ligament rupture. Vet Comp Orthop Traumatol 2009; 2:83-86.
6. Connery NA, Rackard, S. The surgical treatment of traumatic stifle disruption in a cat. Vet Comp Orthop Trau-
matology 2000; 13:208-11.
7. Scavelli TD, Schrader SC. Nonsurgical management of rupture of the cranial cruciate ligament in 18 cats. JAAHA
1986; 23:337-4.
8. Umphlet RC. Feline stifle disease. Veterinary Clinics of North America Small Animal Practice 1993; 23,4:897.
9. McLaughlin RM. Surgical diseases of the feline stifle joint. Vet Clin Small Anim 2002; 32:963-82.
10. Ivascu I, Veress C. Resolving stifle luxations in cats. Vet. Med. 1986; 81:815-6.
147 • WVOC 2010, Bologna (Italy), 15th - 18th September M.G. Ness
Clinical assessment of the stifle joint

Malcolm G. Ness BVetMed, Cert SAO, Dip ECVS, FRCVS
Croft Veterinary Hospital, 37 Croft Road, United Kingdom, Blyth NE24 2EL
Others in this seminar will consider diagnosis of stifle disease using advanced imaging modalities so this pa-
per will concentrate on clinical examination and plain radiography.
Stifle disease is a very common cause of lameness and disability in the dog and the most common problem
is failure of the cranial cruciate ligament. In a survey of orthopaedic conditions diagnosed in UK veterinary
practices, cranial cruciate ligament (CCL) failure was the single most common named condition. Further-
MAIN PROGRAM
SMALL ANIMALS
more, stifle osteoarthritis (OA) – much of it probably secondary to CCL failure – was reported commonly
in the same survey (1). Therefore, failure of the CCL and secondary OA is much the most common cause
of canine stifle joint abnormality and very commonly – though not exclusively - the clinical assessment of
the stifle will be, in effect, the clinical assessment of the cruciate deficient stifle.
The basics of good diagnosis are the collection and appraisal of a clinical history followed by careful clinical
examination. Stiffness on rising which is exacerbated by exercise and activity is commonly reported – this
is a non-specific feature strongly suggestive of joint disease but which gives no indication of which joint (or
joints) is affected and no clue about diagnosis.
Observation of the patient at the walk and trot is an essential part of the examination and will allow the cli-
nician to determine which limb, or limbs might be affected.
Bilateral stifle abnormality, due to for example CCL failures, medial patella luxation, stifle osteochondrosis
dissecans (OCD) is remarkably common and the clinician must guard against assuming that a symmetrical
gait is a normal gait. Similarly, hip dysplasia and disease of the lumbo sacral disc are quite common in the
same population of dogs at risk of CCL disease so it is not unusual to encounter patient with several con-
comitant abnormalities.
Clinical examination starts with careful palpation of the stifle joint in the conscious, standing patient. Care-
ful attention is paid to the alignment of the joint relative to hip and hock. The joint is palpated for signs of
thickening, either bony thickenings or fibrous thickening of the joint capsule and other peri-articular soft tis-
sues. The joint is palpated for evidence of swelling – specifically the softer, more fluctuant textures sugges-
tive of joint effusion or recent synovitis. Careful palpation of the straight patellar ligament is often revealing
in this regard – in the normal stifle, the straight patella ligament has relatively distinct, sharp edges when
palpated. However, with even a modest effusion or synovitis, the joint expands from behind the straight
patella ligament giving the structure a relatively smoother-edged and less distinct feeling.
A methodical palpation of the articular and juxta-articular structures including ligaments, tendons, sesamoid
bones etc should be made to identify abnormalities of shape or relationship as well as seats of pain.
The stifle should be moved to establish the range of motion. Discomfort at extremes of flexion and exten-
sion is abnormal and is often quite marked in dogs with otherwise minor lameness. Crepitus and evidence
of “meniscal clunks” should be noted.
Tests to evaluate CCL integrity can be performed – the cranial draw test and the tibial compression test are
well known and widely used. However, great care must be taken to prevent over-interpretation of these tests,
especially in the conscious dog. A recently published study(2) indicated that the sensitivity of these tests is
remarkably low. Assessment of the integrity of ligaments is best performed in the anaesthetised patient.
The patient should be subjected to a similar examination once anaesthetised: in addition, the integrity of the
ligaments of the stifle should be evaluated. The standard tests to assess CCL integrity are well known but
again, some caution should be used when interpreting these tests – even in the anaesthetised patient the cra-
nial drawer test and the tibial compression test can give false negative and false positive results. The assess-
ment of meniscal injury on the basis of clinical examination alone is unreliable and the diagnosis of menis-
cal pathology requires advanced imaging or surgical exploration.
The integrity of the remaining ligaments (caudal cruciate, medial collateral and lateral collateral) is per-
formed by “stressing” the joint against the restraint of each ligament. This procedure should be repeated sev-
eral times for each ligament in turn – first with the stifle extended, then flexed and finally in approximate135
degrees of extension. This part of the examination requires some care and interpretation of findings is often
more challenging than expected – especially where multiple ligament injuries are suspected.
Plain radiography of the stifle requires a minimum of two, well-positioned orthogonal views. The lateral
should be centred on the stifle joint – a true lateral view is seen when the medial and lateral femoral condyles
are superimposed and the medial and lateral fabellae likewise. The orthogonal view can be caudo-cranial or
cranio-caudal. Attention to detail with regard to positioning and exposure is essential. Many of the less com-
M.G. Ness WVOC 2010, Bologna (Italy), 15th - 18th September • 148
mon diagnoses can be made definitively with plain radiography, for example, stifle OCD, articular fractures,
fabella fractures or avulsions, avulsion of the long digital flexor tendon. Good quality radiographs will also
reveal signs of stifle OA – the “loss of the infra-patellar fat pad” is a sign of early OA and results from a sti-
fle effusion plus a synovitis. Though certainly not absolutely indicative of CCL failure, this radiographic
sign (in an otherwise radiographically normal stifle) is usually a sign of a failing CCL.
REFERENCES
1. A survey of orthopaedic conditions in small animal veterinary practice in Britain. NessMG and Colleagues. VCOT
9, 43-52 (1996).
2. Preliminary study evaluating tests used to diagnose canine cranial cruciate ligament failure. Carobbi B and Ness
MG. JSAP 50, 224-226. (2009).
MAIN PROGRAM
SMALL ANIMALS
149 • WVOC 2010, Bologna (Italy), 15th - 18th September M.G. Ness
Locking plates: SOP

Malcolm G. Ness BVetMed, Cert SAO, Dip ECVS, FRCVS
Croft Veterinary Hospital, 37 Croft Road, United Kingdom, Blyth NE24 2EL
The SOP is a novel locking plate system developed specifically for use in veterinary orthopaedics.
SOP is available in three sizes, designated 2.0mm, 2.7mm and 3.5mm according to the screw size. Standard
cortical bone screws are used exclusively. The “plate” comprises a series of almost spherical nodes (the
pearls) which accept the screw and which are connected by a short, cylindrical internode. The system is
available in 316LVM surgical stainless steel or the Titanium alloy, Ti6Al4VELI.
MAIN PROGRAM
The SOP features an increase in cross-sectional diameter of the pearl over the internode which compensates
SMALL ANIMALS
for the loss of metal caused by forming the screw hole. The result is an implant with an almost uniform stiff-
ness profile along its length - the screw holes are not notable weak points. SOP uses standard cortical bone
screws which lock firmly and predictably into the pearl. According to long established engineering princi-
ples, a “double lock” mechanism is employed: the first lock is achieved through a threaded portion in the
base of each pearl which coincides with the thread on the bone screw. A second lock is achieved when the
spherical contour of the screw head is drawn into the pearl and encounters a precisely under-size ridge – the
resulting metal on metal impingement provides a secure fix.
The SOP can be contoured with six degrees of freedom. Dedicated bending instrumentation allows the lock-
ing function to be preserved despite contouring and ensures that contouring is achieved in a manner sym-
pathetic to the implant metal – for example, four point, rather than three point, bending. The stainless steel
SOP was designed to be stiffer and stronger than the corresponding DCP implant and bench studies of the
3.5 SOP have confirmed that this design criterion was achieved1. Furthermore, mechanical testing of the 3.5
SOP following bending or twisting indicates that the contouring of a SOP that might be required in surgery
has a relatively modest effect on stiffness or strength2.
SOP has been used in a wide range of orthopaedic and neurosurgical applications including long bone frac-
tures, pelvic fractures, mandibular and maxillary fractures, arthrodesis (shoulder, elbow, pan-tarsal), limb-
sparing surgery, spinal fractures (cervical, TL, lumbar and lumbo-sacral) spinal stabilisations(cervical,TL,
lumbar and lumbo-sacral). The initial clinical recommendations were based on experience with external fix-
ators, experience with locking compression plates and mathematical modelling. Over the last three years or
more, this has been supplemented by an ever increasing clinical case experience and this information has
been collated to produce a set of clinical guidelines3. As case experience expands and further biomechanical
studies are published, these guidelines may be subject to minor modification5,7,8,9,10.
An increasing number of clinical reports and basic research papers relating to the use of SOP have appeared
in the veterinary literature over the last two years and further studies are known to be underway4-11.
REFERENCES
1. DeTora MD, Kraus KH. Mechanical testing of locking and non-locking 3.5mm bone plates. Vet Comp Orthop
Traumatol 2008; 21: 318-322.
2. Ness MG. The effect of bending and twisting on the stiffness and strength of the 3.5 SOP implant. Vet Comp Or-
thop Traumatol 2009; 22: 132-136.
3. SOP-SOP (vers 1.4) www.orthomed.co.uk.
4. Transilial interlocking plate stabilisation of a sacral fracture and an ilial fracture in a dog. Mills, J. VCOT 2009; 1:
70-73.
5. Vertebral stabilisation and selective decompression for the management of triple thoraco-lumbar disc protrusion –
McKee, WM and Downes, C Journal of Small Animal Practice 2008; 49(10): 536-539.
6. Surgical management of large segmental femoral and radial bone defects in a dog - Segal and Shani VCOT 2010;
1: 66-70.
7. Repair of Y-T humeral fractures in the dog using paired SOP locking plates. Ness, MG. VCOT 2009; 6: 492-497.
8. Minimally invasive percutaneous osteosynthesis for treatment of extra-articular tibial fractures using an SOP-rod
construct. Klein MA, Horstmann CL, Mason DR (2010) Proceedings of 37th Meeting of Veterinary Orthopaedic
Society, Pub by VOS, Feb 2010.
9. Biomechanical testing of the 3.5mm SOP bone plate using a Delrin rod gap model with four different screw con-
figurations. Bufkin BW, Horstman CL, Mason DR, Elder SH, Jones ML. (2010) Proceedings of 37th Meeting of
Veterinary Orthopaedic Society, Pub by VOS, Feb 2010.
10. Biomechanical testing of the 3.5mm SOP bone plate using a Delrin rod gap model with the plate at increasing dis-
tances from the bone model. Bufkin BW, Horstman CL, Mason DR, Elder SH, Jones ML. (2010) Proceedings of
37th Meeting of Veterinary Orthopaedic Society, Pub by VOS, Feb 2010.
11. Management of quadriceps contracture in a dog using a static flexion apparatus and physiotherapy. Moores AP,
Sutton A. J Small Anim Pract. 2009 May; 50(5):251-4.
M. Petazzoni WVOC 2010, Bologna (Italy), 15th - 18th September • 150
The Fixin system

Massimo Petazzoni, DVM
Clinica Veterinaria Milano Sud, 20068 Peschiera Borromeo (Mi)
INTRODUCTION
Fracture fixation by conventional bone-plate and screws provides fracture stabilization allowing primary
bone-healing or healing by means of callus formation. The stability of conventional plating is directly pro-
portional to the pressure of the plate against the bone, caused by the lag force of the screws pulling the bone
to the plate. Main complications associated with conventional plating are implant loosening, impaired pe-
MAIN PROGRAM
SMALL ANIMALS
riosteal and cortical blood supply directly beneath the plate and excessive shielding of stresses from the
bone. The use of locking plates is becoming increasingly popular because these systems offer some advan-
tages in fracture and osteotomy fixation over conventional plating methods. Locking systems achieve their
stability by locking the screw into the plate and the screws into the bone minimizing contact of the plate with
the bone, decreasing the potential of stress-protection at the fracture site and impairment of periosteal blood
supply. Using this type of elastic devices anatomical reduction is not required for bone healing and an ade-
quate tolerable strain can promote secondary bone healing with callus formation. These implants have the
biological advantage similar to external fixators and employ the principles of dynamic osteosynthesis with
internal fixation. Locking systems work in a buttress fashion even in anatomically reconstructed frac-
tures/osteotomies so healing by callus formation is to be expected. Similar to external fixators, the stability
of the locking plates is influenced by several factors including: fracture reduction, bone contact, working
length, number of screws, screw diameter, section and shape of the plate and the plate/bone distance.
MECHANICS
The locking mechanism of the Fixin device is based on a
conical coupling system where the conical head of the screw
is locked in the corresponding conical hole of an insert that
is screwed into the locking plate. This conical coupling con-
sists of a complementary conical male and a female parts.
The stability of the coupling is achieved by friction, micro-
welding and elastic deformation between the screw and the
insert (Fig. 1). The smaller the angle of conicity, α, the high-
er the tangential force, Ft, that is produced with using an ax-
ial force and therefore the smaller is the α angle, the stronger
is the conical coupling.
IMPLANTS AND INSTRUMENTS Figure 1

The internal fixator Fixin is an angle-stable or-
thopedic implant for internal fixation. It consists
of a stainless steel support, with threaded holes
where threaded bushings can be secured (Fig. 2).
The support is made of AISI 316 LVM steel. The
inserts are made of Titanium Ti 6Al 4V, are ex-
ternally threaded, to be screwed into the support.
The inner hole of the insert is conical to lodge the
head of the screw. The grooves on the edge of the
insert couple with the insert device, the instru-
ment used to screw and unscrew the insert into
and from the support. Inserts are screwed into
the support. The support together with the in-
serts give the plate. The screw is a self-tapping,
self-blocking screw. The screw’s head is conical,
corresponding with the conically shaped hole of Figure 2
the bushing. Locking screws are designed with
smaller threads because they are not intended to generate compression between the plate and the bone.
They have a larger core diameter that ensures greater bending and shear strength and dissipate the load
over a larger area of bone. The small animal Fixin system provides 2 series of internal fixators. The mini
151 • WVOC 2010, Bologna (Italy), 15th - 18th September M. Petazzoni
system, designed for cats and small dogs up to 10 Kg, accommodates 1.9mm
and 2.5mm screws that fit the same small bushing and the large system, de-
veloped for medium, large and giant dogs which accommodates 3.0 mm and
3.5 mm screws that both fit the medium blue insert. The plate thickness
ranges from 1.2mm to 2mm in the mini system and from 1.5mm to 3mm in
the large system.
SURGICAL TECHNIQUE
Distraction, realignment and apposition of bone fragments is performed. Pe-
riosteum is left intact to preserve the periosteal blood supply. Although it is
not necessary for stability, as it is with conventional plates, contouring the
MAIN PROGRAM
plate to the shape of the bone cortex, even roughly is advocated to avoid
SMALL ANIMALS
hardware prominence and to reduce the bone/plate distance increasing the
stability and strength of the fixation. A dedicated bending device was devel-
oped to save bushings while bending the plate (Verdonck Bending
Device)(Fig. 3). During the drilling phase the plate needs to be secured to the
bone cortex. This can be done by conventional bone-clamps, with temporary
conventional screws, with pins inserted through appropriate plate’s holes, or
with pins inserted through the drill-guide and temporary secured with pin- Figure 3
stops (Verdonck Technique). To allow proper matching and coupling between
the conical head of the screw and the conical hole of the insert, a special drill-
guide was developed. The conical tip of the drill-guide is inserted into the conical hole of the insert. By ap-
plying a little pressure, the guide is secured within the plate allowing the surgeon to work with both hands.
The drillbit is inserted into the drillguide to make the hole perpendicular to the insert and plate. After meas-
urement with the standard depth-gauge the self-tapping screw is then inserted into the bone. A dedicated
bushing device allows easy removal of the bushing and consequently of the screw when needed.
TECHNICAL REMARKS
Fracture reduction and correct alignment are needed before fixation of the plate to the bone. Since locking
screws are angle-stable screws, the plate needs to be positioned over the centre of the bone longitudinally
otherwise the end-screws of the plate will not have adequate bone purchase. During the drilling-phase the
conical tip of the drill-guide needs to be well seated in the conical hole of the insert to allow the drill-bit to
be perpendicular to the insert. Angle-stable screws only allow placement of screws perpendicular to the plate.
This can be problematic in the epiphyseal area near the joint space or near the epiphyseal plate in young an-
imals. Fixin plates are easy to contour in the frontal plane because of their reduced thickness. Even extreme
bending of the plate will not interfere with their locking system.
Anatomically contoured plates have been developed for the proximal tibia and distal femur. Three bicorti-
cal screws are recommended in each fracture segment for fracture healing. The use of bicortical screws is
strongly suggested because of the absolute superiority they offer in comparison with monocortical screws.
Two Fixin plates can be put side by side or a second plate can be added orthogonally in very complex frac-
tures. Techniques combining the benefits of other implants like cerclage wire, pins, tension bands or lag
screws is possible. The use of an intramedullary pin enhances the stiffness of the construct therefore should
be considered an option when lack of stability could be a concern in long bone fractures like the femur or
the Tibia (plate and rod technique). Minimally invasive approaches combined with biologically friendly in-
ternal fixation can be an option treating fractures. Anatomical reduction of the articular surface in articu-
lar fractures is still of utmost importance. Rarely bone slicing known also as rake phenomenon or plough
phenomenon has been identified in methaphyseal/epiphyseal poor quality bone but never in the diaphy-
seal bone.
ADVANTAGES AND DISADVANTAGES

Advantages of this technique in comparison with standard compression plates are: less surgical trauma and
minimal surgical exposure because of the use of shorter implants and less screws, early bone consolidation
from preservation of the periosteal blood supply and limited contact of the plate, shorter surgery times since
the plate does not have to be perfectly contoured to the bone and greater stability because plate and screws
are locked together. Non-contact locking plates play an important role in Minimally Invasive Plate Os-
teosynthesis (MIPO). Internal fixators offer greater stability than standard reconstruction plates and have
the big advantage to minimally disturb the periosteal blood supply. Advantages of this technique in com-
parison with other locking devices: the number of instruments is minimal and relatively inexpensive. A spe-
cific instrument in the Fixin system allows for easy removal of the screw and insert if needed. This is in con-
trast to other locking mechanisms. Several publications report removal issues when using other locking
plates describing screw jamming (“cold welding phenomenon”) and stripping of the hexagonal screw sock-
et during extraction of the screws. Disadvantages: with angle-stable implants it is impossible to correct the
alignment of the bone once the plate has been applied. With the Fixin screws interfragmentary compression
is not achievable. Implants are more expensive than conventional plates and screws.
AKNOLEDGEMNTS: Gayle Jaeger.
DISCLOSURE: the author is partner of Traumavet, the company which owns the patents on, produces
and sells the Fixin System.
MAIN PROGRAM
SMALL ANIMALS
153 • WVOC 2010, Bologna (Italy), 15th - 18th September A. Piras
Digits injuries
Alessandro Piras, DVM, MRCVS ISVS
Oakland Small Animal Veterinary Clinic, Newry, Northern Ireland
PHALANGEAL FRACTURES
INTRODUCTION
Phalangeal fractures are common injures and often considered insignificant. As a direct consequence of this
underestimation, the treatment of these injuries is not always optimal. The most common complications as-
MAIN PROGRAM
SMALL ANIMALS
sociated with inappropriate treatment of phalangeal fractures are: malunion with imbalance of the flexor and
extensor mechanism, limited range of motion, degenerative joint disease and deformity with interference be-
tween toes. There are a variety of factors to consider when deciding the optimal treatment.
Breed, age, type of activity, owner expectations and compliance as well as injury characteristics, pattern of
the fracture and soft tissue damage are all important factors that must be taken into account when estab-
lishing a treatment plan.
The goal of the treatment of fractured phalanges is to achieve the best possible reduction and the most ef-
fective means of maintaining the reduction in order to promote bony union, early mobilization and func-
tion. This concept is particularly valid for sporting dogs in which performance is directly related to anatom-
ical integrity and function.
ANATOMY
The base of P1 articulates with the head of its corresponding metacarpal/tarsal bone at a dorsal angle slight-
ly more than 90 degrees. In this position the first phalanx is almost parallel to the ground. P2 articulates
with P1 forming a palmar/plantar angle of 135 degrees and on its proximo palmar/plantar aspect inserts the
superficial digital flexor tendon. Distally P2 forms an obtuse dorsal angle with the shallow, sagitally concave
articular surface of P3. On the broad palmar/plantar tubercle of P3 inserts the deep digital flexor tendon;
each side of the tubercle is perforated transversely by a vascular bone tunnel. On the dorsal aspect of P3
there is another bone prominence, the ungueal crest that is the area of attachment of the extensor tendon
and the elastic ligaments.
CLINICAL EXAMINATION
Variable degrees of lameness are usually present.
Clinical examination reveals swelling that is often associated with crepitus and deformity of the affected pha-
lanx. A thorough soft tissue evaluation is necessary to detect the presence of small wounds, some of which
are arising from an open fracture.
Radiologic evaluation of phalangeal injuries should commence with plain radiographs.

A minimum of two views taken at orthogonal angles provide information on two planes. Standard dorso –
palmar/plantar ( DP) and lateral (L) views are the core of the radiologic assessment.
DP views should include the metacarpo/tarso –phalangeal joints and the distal inter-phalangeal joints.
The L view is taken spreading the toes with the aid of a stirrup of tape applied on the nail of the second and
fifth digit (“fan lateral”).
Oblique views are used to increase the sensitivity of imaging of phalangeal fractures, especially in case of se-
verely comminuted fractures.
A lateral view with traction applied to the nail is useful to assess the shape and size of the fragments in case
of comminuted fracture of P2.
TREATMENT PRINCIPLES
To rationalize the treatment of phalangeal fractures it is necessary to take into account the anatomical char-
acteristics of the area as well as the functional angles of the digits.
Fractures of P1 and P2 are the most common, while fractures of P3 are less frequent.
In a survey on 40 phalangeal fractures affecting racing Greyhounds (un-publish data)

P1 was involved in 20 cases, P2 in 14 cases and P3 in 6 cases.
P1 fractures were intra articular in 6 cases P2 in 10 cases and P3 in all the cases. The head of P2 was in-
volved in 9 cases, in P1 the head was involved in 3 cases and the base in 3 cases.
A. Piras WVOC 2010, Bologna (Italy), 15th - 18th September • 154
Fractures of the shaft of P1 and P2 can vary in configuration from transverse, oblique, spiral with or with-
out a butterfly fragment, to highly comminuted. In many cases these fractures are open. Simple, stable non
displaced fractures, especially in young dogs, can be treated with closed reduction with splinting in func-
tional position.
Fractures with unstable configuration are traditionally treated with open reduction and internal fixation with
lag screws (1.5 mm-2.0 mm), mini plates or cerclage wire. In spite of the apparent simplicity of the surgical
approach, internal fixation of complex fractures can be very challenging. Careful handling of the fracture
fragments with appropriate instruments and gentle traction is mandatory in order not to compromise the
delicate vascular structures in this area. Failure to respect the blood supply can lead to severe complications
from non-union to necrosis of the toe.
Fractures of P2 tend to displace due to the pull of the flexor tendons and the reduction of comminuted frac-
MAIN PROGRAM
tures can be extremely challenging.

SMALL ANIMALS
Fractures of the base or of the head are articular and almost invariably involve the insertion of the collater-
al ligament.
Fractures of the condyles can be handled with application of lag screws or with a loop of cerclage wire un-
less the fragments are too small to be safely secured in place. Very small fragments can be excised, but in
cases with large unfixable fragments involving the joint, amputation or arthrodesis is usually done.
Traditionally the lag screw technique has been the standard for fixation of oblique, spiral and condylar frac-
tures. This technique, that is relatively straight foreword for most of the long bones fractures, can be tech-
nically challenging for the fracture fixation of small bones. Despite the availability of very small implants
(1.0 mm – 1.5 mm – 2.0 mm) the size of this screws remain large, relative to the phalanges and the frag-
ments to be fixed leaving little room for error and increasing the chance of iatrogenic comminution.
The application of bicortical (positional) self tapping screws provides the advantage of elimination of a sur-
gical step, there is less chance for the reduction to be lost and for splitting of the fragments. With bicortical
screws the proximal cortex is not over drilled and the screw treads achieve purchase in both cortices while
reduction and compression are maintained with bone clamps.
Open fractures are often comminuted and highly contaminated with severe soft tissue damage and avascu-
lar bone fragments protruding from the skin. In these cases, amputation is the best choice; offering a good
prognosis and for sporting dogs a rapid return to performance.
Fractures of P3 can involve the joint splitting the phalanx obliquely or can occasionally involve the tuberos-
ity of insertion of the deep flexor tendon or the ungual crest. Due to the small size of P3, attempts at inter-
nal fixation are unlikely to be successful and amputation is necessary.
Postoperative care following surgical repair consists of the application of a padded bandage for 3 to 4 weeks
and confinement for a total of 6 to 8 weeks. The bandage can be reinforced with a palmar or plantar splint
for the first 2 weeks. After bandage removal and when radiographs confirm that the bone is healed, 3 weeks
of limited exercise on a lead and a gradual increase in activity should proceed a return to full activity.
In the case of amputation, a light bandage is applied for 2 weeks. As soon as the swelling decreases and the
reflected digital pad is properly sealed, it is possible to gradually reintroduce the dog to exercise. For sport-
ing dogs, the return to full training following amputation is expected by 5 to 6 weeks postoperatively. The
prognosis for non complicated cases is usually good to excellent.
LIGAMENTOUS INJURIES
PHALANGEAL LUXATION
Phalangeal subluxations and luxations are uncommon injuries in the canine pet population but are very
common injuries in sporting dogs especially in racing Greyhounds.
Among the predisposing factors are grass tracks or grass gallops, especially if improperly maintained and
the uneven racing surface has hard and soft spots. Other factors include the dog’s digit conformation such
as “flat toes” or “spread toes” and/or excessively long nails due to poor dog care by the owner or trainer.
In some cases, interference during a race forces the dog to suddenly change direction, provoking an excess
of strain on the interphalangeal ligaments as the dog attempts to grip the ground and stay balanced.
A phalangeal luxation can occur at any level involving the proximal interphalangeal (P1-P2) joint or the dis-
tal interphalangeal (P2-P3) joint. Farrow has classified sprain injuries (Farrow, C.S.: Vet. Clin. Nth. Am. 8
(2): 169-182,1978) according to severity. A first-degree sprain consists of minimal tearing or stretching of the
ligament fibers. A second-degree sprain is a partial rupture with evident structural damage. Third degree
consists of a complete rupture of the ligament fibers and may include avulsive injury of the origin or inser-
tion of the ligament with one or more bone chips.
First- and Second-Degree Sprains

P1-P2 and P2-P3 collateral ligaments: Lameness is usually minimal or absent with bruising, joint effusion
and palpable swelling. To verify the stability of the joint, it is necessary to extend the phalanges and apply
lateral movement. In first-degree injuries there is a light pain response and good joint stability, while in a sec-
ond-degree sprain, there is minimal lateral instability and it is often possible to palpate, with the tip of a fin-
ger, an increased joint space. Treatment consists of initial application of cold for five minutes every 3 to 4
hours for the first 48 hours, NSAID treatment for five days, and local treatment with DMSO applied twice
a day for 2 to 3 weeks. If swelling makes the evaluation of the joint stability difficult, it is possible to drain
the effusion with a syringe and a 25 gauge needle followed by periarticular injection of 0.2 ml of Triamci-
nolone (Triamcinolone Acetonide 10mg in 1 ml). If joint laxity is detected, it is possible to apply a light band-
age or a phalangeal stripping with tape, Elastoplast or elastic tape (Hapla-Band, Smith and Nephew).
MAIN PROGRAM
Shortening the nail is useful to decrease the leverage on the affected joint. Two weeks of confined activity
SMALL ANIMALS
followed by three weeks of controlled exercise are generally sufficient to allow healing of the lesion. A resid-
ual thickening of the joint can be expected and recurrence is not unusual, often involving the opposite liga-
ment. In some second-degree sprains, with excessive instability, surgical reinforcement of the stretched cap-
sule and ligament is advised. One to three synthetic absorbable sutures can be placed over the ligament to
stress protect during the healing process.
Third-Degree Sprain
In the case of complete ligament rupture with the joint in a reduced position, lameness can be from minimal
to slight with weight-bearing. In dogs with a subluxated or totally dislocated joint, lameness can be signifi-
cant. Swelling and bruising are consistent findings.
Palpation of the joint elicits pain and it is possible to dislocate the joint with minimal lateral pressure. In the
case of a bilateral ligament rupture, the joint tends to stay in a subluxated position with the toe slightly ro-
tated. Radiographic evaluation is necessary to evaluate the integrity of the condyles and/or the base of the
phalanges as small avulsed chips are often detected. These type of injuries necessitate surgical repair.
Surgical Technique
The choice of general anesthesia versus local anesthetic depends upon the surgeon’s preferences. In most
cases, the author prefers to sedate the animal with an intravenous administration of Medetomidine (1
mg/ml) and of Butorphanol (10 mg/ml) IV followed by local anesthesia with lignocaine hydrocloride.
The dog is placed in lateral recumbency with the side of the toe to be operated up. The area is clipped,
scrubbed and disinfected. A small direct surgical approach is sufficient to expose the ligament. The joint is
explored to remove any small chip fragments. Three to five horizontal mattress sutures of 4-0 synthetic ab-
sorbable suture material are placed in the ligament and joint capsule followed by a single large Connell su-
ture to encompass the repair. The author’s preferences regarding the suture material are polydioxanone or
polygalactin 910. In bilateral repair, additional strength is achieved by adding some suture of non-absorbable
polypropylene monofilament. The nail is cut back to minimize leverage forces.
The repair is protected with a padded bandage for 2 weeks. Controlled exercise such as swimming and
walks on the lead are allowed until 6 to 8 weeks post operatively.
Severe bilateral ligament ruptures with large articular chips, chronic ligament lesions and gross instability
are usually treated with toe amputation or arthrodesis.
METACARPO (METATARSO) PHALANGEAL INSTABILITY DUE TO LIGAMENT

DAMAGE
These injuries usually affect either the V or the II digit, more often the left V and right II. Metatarsophalangeal
joints are, in the author’s experience, over-represented in racing Greyhound. In acute injuries, the dog is gen-
erally lame, but weight bearing. The affected area is swollen and flexion and extension of the joint elicits a pain
response. Inward or outward rotation of the digit can dislocate the joint. Conservative treatment is not suc-
cessful and surgical repair is preferred. Some dogs with chronic injuries are occasionally able to perform with
the application of a strapping of Elastoplast around the distal metatarsophalangeal joints to provide additional
support. Surgical treatment consist of the repair and support of the damaged ligaments via a palmar/plantar or
lateral approach. The same type of repair described for the interphalangeal ligaments is used.
After surgery, a padded bandage is applied for 3 weeks, followed by strapping with Elastoplast for another
2 weeks. Mild activity is encouraged starting 5 weeks post operatively. Return to training is expected be-
tween 8 and 10 weeks after surgery. These repairs have an high rate of failure and often amputation of the
entire digit is the only choice. After digit amputation, the dog can restart training in 3 to 4 weeks.
References available from the Author upon request.

G.E. Pluhar WVOC 2010, Bologna (Italy), 15th - 18th September • 156
Acetabular fractures
G. Elizabeth Pluhar, DVM, PhD, DACVS
Associate Professor, Veterinary Clinical Sciences, University of Minnesota
Acetabular fractures account for up to 29% of pelvic fractures (Wheaton and others 1973). Major trauma
causes most of these fractures and there are other injuries involved in 40% of dogs and 60% of cats. The ac-
etabular fracture result from indirect trauma transmitted across the femur. They infrequently involve sciat-
ic nerve injury.
Further gross trauma to the articular surfaces can be minimized by early anatomic reconstruction of the joint
MAIN PROGRAM
SMALL ANIMALS
(Hulse and Root 1980, Matta and Merrit 1988). However, post-traumatic osteoarthritis may not be avoid-
ed due to the high energy absorbed to create these fractures. Furthermore, other, life-threatening injuries
should be treated prior to stabilizing any fracture.
Orthogonal radiographs are necessary to interpret the complexity of the fracture, but oblique projections
and 3D reconstruction using CT should provide the most information of the fracture fragments and posi-
tioning of the fragments and implants. Although most of the weight-bearing forces are borne by the cranio-
central zone of the lunate surface, medical management of fractures of any area of the acetabulum may lead
to arthritis. A study of conservatively treated fractures of the caudal acetabulum resulted in moderate to se-
vere degenerative joint disease in 87% of dogs, and 80% had decreased range of motion and 47% were chron-
ically lame (Boudrieau 1988). Conservative management cannot really be recommended for any acetabular
fracture, however it may be appropriate for minimally or non-displaced fractures that do not involve the lu-
nate surface in young dogs.
Open reduction and internal fixation with perfect anatomic reduction and stabilization of unstable or dis-
placed acetabular will provide the best outcome. However, this is difficult to attain and post-traumatic os-
teoarthritis may ultimately lead to a less than optimal outcome. The hip joint is usually exposed by the Gor-
man approach to the craniodorsal and caudodorsal aspects by osteotomy of the greater trochanter of the fe-
mur (Piermattei and Johnson 2004). Similar exposure can be attained by tenotomy of the gluteal muscles,
which may work best in skeletally immature animals to prevent iatrogenic damage to the physis of the
greater trochanter (Piermattei and Johnson 2004). The approach described by Hohn and James 1966 and
Slocum and Hohn 1975 can be used to access caudal acetabular fractures. It can be extended caudally by
osteotomy of the ischial tuberosity (Chalman and Layton 1990). A dorsal muscle separation technique has
been described as an alternative approach for small dogs, < 30 kg in body weight that are not overweight
with simple acetabular fractures (Wadsworth and Henry1974, McCartney and Garvan 2007). The joint cap-
sule should be opened to check the alignment and reduction of the fracture fragments. The ischiatic nerve
showed be identified during the approach and can be protected using the superficial gluteal muscle or the
gemelli and internal obturator muscles.
The fracture fragments are reduced using traction, leverage and rotation using bone forceps on the femur
and/or ischium accessed via a caudal approach. The fracture fragments can be temporarily stabilized using
point-to-point reduction forceps applied to the cranial and caudal aspects of the acetabulum while the
femoral head is reduced. If the reduction forceps prevent the application of the permanent implants, a
Kirschner wire or small Steinmann pin can be inserted across the fracture. The fragments of a comminuted
fracture should be reduced and stabilized with interfragmentary compression until a two-piece fracture re-
sults, which can then be stabilized like a simple fracture. A separate approach to the pubic bone and ventral
aspect of the acetabulum may be necessary to reduce more comminuted fractures.
There are several types of implants that can be used to stabilize the acetabular fragments. A variety of plates
can be used to stabilize acetabular fractures including C-shaped acetabular plates, dynamic compression
plates, reconstruction plates that can be used when ilial and/or ischial fractures are also present, locking
plates, and string-of-pearls (SOP) plates. It can be extremely difficult to perfectly contour the plate to avoid
loosing perfect reduction of the fracture fragments, and this may be where the SOP plate that can be con-
toured in six degrees of freedom may be advantageous. A similarly sized hemipelvis can be used to aid in
contouring the plate. A minimum of 2 screws should be placed on either side of the fracture. Implants oth-
er than plates are also used to stabilize acetabular fractures, such as intramedullary pins or screws or pins
and wire, with and without polymethylmethacrylate (PMMA). This technique was first described in clini-
cal cases by Lewis et al. in 1997. They maintained reduction of the acetabular fragments with Kirschner
wire(s), placed bone screws in the dorsal surface on either side of the fracture leaving the screw head 2-4
mm above the cortex and a wire around the screws in a figure-of-eight pattern, and then molded PMMA
around the implants. The composite fixation maintained anatomic reduction of the fragments, was asso-
157 • WVOC 2010, Bologna (Italy), 15th - 18th September G.E. Pluhar
ciated with few complications, and yielded satisfactory clinical results. The interfragmentary Kirschner wire
may contribute to the bending stability of the repair and should be left in place.
A biomechanical study on cadaveric canine pelves found no difference in the strength, stiffness, or energy
absorbed between a 5-hole, 2.7-mm curved acetabular plate and a 5-hole, 3.5-mm reconstruction plate when
loaded to failure in the acetabulum (Hardie et al. 1999). A recent study examined the use of 5-hole 2.4mm
uniLOCK® reconstruction plates using either 2.4mm locking monocortical or standard bicortical screw fix-
ation and found no apparent advantage of locking plate fixation over standard plate Fixation (Amato et al.
2008). Another study was undertaken to compare the biomechanical properties and the accuracy of reduc-
tion of a 5-hole, 2.0-mm curved acetabular plate and a composite of screws, wires and PMMA. The two
methods had similar failure properties under bending loads, however the composite technique facilitated
more accurate reduction of the osteotomy (Stubbs et al. 1998). Using screws and a tension band wire with-
MAIN PROGRAM
out reinforcement with PMMA significantly decreases the ultimate bending load of a construct as compared
SMALL ANIMALS
to fixation with PMMA, which justifies the use of PMMA with this type of repair.
REFERENCES
Amato NS, Richards A, Knight TA, Spector D, Boudrieau RJ, Belkoff S. Ex vivo biomechanical comparison of the 2.4mm
UniLOCK® reconstruction plate using 2.4mm locking versus standard screws or fixation of acetabular osteotomy
in dogs. Veterinary Surgery 37:741-748, 2008.
Boudrieau RS, Kleine LJ. Nonsurgically managed caudal acetabular fractures in dogs: 15 cases (1979-1984). Journal of
the America Veterinary Medical Association 193:701-705, 1988.
Chalman J, Layton CE. Osteotomy of the ischial tuberosity to provide surgical access to the ischium and caudal acetab-
ulum in the dog. Journal of the American Animal Hospital Association 26:505-514, 1990.
Hardie RJ, Bertram JEA, Todhunter RJ, Trotter EJ. Biomechanical comparison of two plating techniques for fixation of
acetabular osteotomies in dogs. Veterinary Surgery 28:148-153, 1999.
Hohn RB, Janes JM. Lateral approach to the canine ilium. Journal of the American Animal Hospital Association 2:111,
1966.
Hulse DA, Root CR. Management of acetabular fractures: long term evaluation. Compendium of Continuing Education
for the Practicing Veterinarian 3:189-199, 1980.
Lewis DD, Stubbs WP, Neuwirth L, Bertrand SG, Parker RB, Stallings JT, Murphy ST. Results of screw/wire/poly-
methylethacrylate composite fixation of acetabular fracture repair in 14 dogs. Veterinary Surgery 26:223-234, 1997.
Matta JM, Merritt PO. Displaced acetabular fractures. Clinical Orthopaedic Related Research 230:83-97, 1988.
McCartney WT, Garvan CB. Repair of acetabular fractures in 20 dogs using a dorsal muscle separation approach. Vet-
erinary Record 160(24):842-844, 2007.
Piermattei DL, Johnson KA. An Atlas of Surgical Approaches to the Bones of the Dog and Cat. 4th ed, DL Piermattei,
K. A. Johnson, Eds. Philadelphia, W. B. Saunders. pp 300-305, 2004.
Piermattei DL, Johnson KA. An Atlas of Surgical Approaches to the Bones of the Dog and Cat. 4th ed, DL Piermattei,
K. A. Johnson, Eds. Philadelphia, W. B. Saunders. pp 306-309, 2004.
Slocum B, Hohn RB. A surgical approach to the caudal aspect of the acetabulum and the body of the ischium in the dog.
Journal of the American Veterinary Medical Association 167(1):65-70, 1975.
Stubbs WP, Lewis DD, Miller GJ, Quarterman C, Hosgood G. A biomechanical evaluation and assessment of the accu-
racy of reduction of two methods of acetabular osteotomy fixation in dogs. Veterinary Surgery 27:429-437, 1998.
Wadsworth PL, Henry WB. Dorsal surgical approach to acetabular fractures in the dog. Journal of the American Veteri-
nary Medical Association 165:908-910, 1974.
Wheaton LG, Hohn RB, Harrison JW. Surgical treatment of acetabular fractures in the dog. Journal of the American Vet-
erinary Medical Association 162:385-392, 1973.
G.E. Pluhar WVOC 2010, Bologna (Italy), 15th - 18th September • 158
Ulnar osteotomies: when, where, why, how?

G. Elizabeth Pluhar, DVM, PhD, DACVS
Associate Professor, Veterinary Clinical Sciences, University of Minnesota
WHEN?
In keeping with the tenet to do no harm, ulnar osteotomies should only be performed in dogs with elbow
disease that present with clinical signs referable to the elbow joint – lameness, reduced range of motion, pain
on palpation - especially young dogs with significant pain/lameness and whose owners aspire to having a
very active or working animal. Ulnar osteotomy is the most frequently performed procedure for the cor-
MAIN PROGRAM
SMALL ANIMALS
rection of elbow incongruity. It is also a generally accepted procedure for the treatment of UAP (Meyer-Lin-
denberg et al. 2001, Turner et al. 1998) as an alternative to the surgical removal of the loose fragment. In
young dogs, it may be used as a ‘stand alone’ procedure, to induce spontaneous fusion of the anconeal frag-
ment. Osteotomy of the ulna has also been described as an additional procedure to the surgical removal of
a fragmented coronoid process. Osteochondritis dissecans (OCD) lesions of the humeral trochlea can be
treated with osteochondral autograft transfer (OAT) procedures, but ulnar osteotomy may be required to
achieve reproducible positive outcomes (Fitzpatrick and Yeadon 2008).
WHERE AND HOW?

Three studies (Thompson & Robbin 1995, Bardet & Bureau 1996, Ness 1998) have described a proximal ul-
nar osteotomy to treat coronoid disease. Most surgeons use an oscillating saw to create the osteotomy, but
the bone can also be made with an osteotome or Gigli wire. A perpendicular or oblique proximal ulnar os-
teotomy can relieve abnormal pressure within the joint and restore congruity by allowing the proximal part
of the ulna to move proximally and tilt cranially. An oblique osteotomy prevents extreme tilting of the ulna
and reduces the mobility of the proximal part of the ulna, thus avoiding abundant callus and delayed heal-
ing; it also avoids the necessity of an additional intramedullary pin to prevent varus deformation. Pin break-
age is a frequently reported complication when an intramedullary pin is used (Bardet & Bureau 1996, Ness
1998, Vezzoni et al. 2002). In a series of 10 dogs younger than 10 months, Ness performed a transverse,
proximal ulnar osteotomy 25 mm distal to the elbow joint in combination with removal of the fragments via
arthrotomy. The use of an intramedullary pin alone seemed to be redundant since a mild varus deformity
did not cause any functional complications. Bardet and Bureau reported the combination of arthroscopic re-
moval of the coronoid fragment with a proximal ulnar osteotomy, regardless of the animal’s age. An in vit-
ro study showed restoration of joint congruity was best achieved by a proximal oblique osteotomy combined
with an intramedullary pin, while, due to the strong interosseus ligament between radius and ulna, a distal
ulnar osteotomy did not have any effect (Preston et al. 2000). A proximal oblique osteotomy, without in-
tramedullary fixation, has been reported to cause varus deformity (Preston et al. 2000, Schulz 2000). This
is in contradiction to previously described clinical studies where intramedullary fixation was not inserted
and a varus deformity was not seen (Sjöström L et al. 1995, Bardet & Bureau 1996, Ness 1998). A second
contradiction to the study of Preston and Schulz is the recommendation for the use of a distal ulnar os-
teotomy in dogs younger than nine months suffering from a FCP and incongruity (Vezzoni et al. 2002).
They recommended that after surgical removal of the fragmented coronoid process, a partial ostectomy (5
mm) at the distal third of the ulna should be performed. The results of this treatment were reported to have
been good in 77.5%, of a large number of patients (70% of 117 dogs) (Vezzoni et al. 2002). An oblique prox-
imal ulnar osteotomy has been recommended in conjunction with the OAT procedure, and should be di-
rected both caudoproximal to craniodistal and proximolateral to distomedial to counteract potential delete-
rious forces that may affect osteotomy healing or cause deformity at the osteotomy. Transverse osteotomy
of the proximal ulna and dynamic distraction with an external skeletal fixator has been described as a treat-
ment for UAP (Ferrigno et al. 2007).
WHY?
The rationale for a proximal ulnar osteotomy is that the osteotomy allows slight shortening and rotation of
the proximal ulna, which relieves abnormal loading on the medial coronoid process. After transverse, prox-
imal ulnar osteotomy, Ness found that nine out of ten dogs showed clear improvement after two months:
five were completely normal, four had occasional stiffness and one remained significantly lame (Ness 1998).
A 93% success rate was obtained following the treatment of 83 adult dogs (mean age of 12.7 months) in the
Bardet study, despite an increased degree of arthrosis (Bardet & Bureau 1996). However, the use of os-
teotomies for the treatment of FCP has been reported to result in significant postoperative morbidity in some
159 • WVOC 2010, Bologna (Italy), 15th - 18th September G.E. Pluhar
cases (Meyer-Lindenberg and others 2001), and controlled large-scale studies evaluating the outcome of clin-
ical cases after osteotomies are lacking. Furthermore, it has been suggested that in affected elbows, progres-
sive collapse of the medial joint space may occur in the longer term (Schulz 2003). If medial joint collapse
does occur in diseased canine elbows, radial lengthening or ulna shortening osteotomies may actually in-
crease loading of the medial compartment of the joint in the long term, which may worsen the outcome.
Correction of incongruency by osteotomy at one level may induce a subsequent incongruency at another
level, which could lead to further problems. In cases of UAP, the chances are good, particularly in young
dogs, that the anconeal process will fuse after the stress is relieved. Thomson (1995) was the first to describe
the use of an oblique osteotomy in three joints with UAP, of which two healed. Sjöström et al. (1995) ap-
plied a perpendicular osteotomy in 20 dogs (22 joints) with UAP. The anconeal fragment fused in 21 out of
22 joints. Seventy percent of the dogs regained full function, while in 30% residual lameness was attributed
MAIN PROGRAM
to different factors such as arthrosis, too early healing of the ulnar osteotomy, or an abnormal shape of the
SMALL ANIMALS
trochlear notch. Since fusion of the anconeal process is not always achieved, several authors recommend a
combination of an ulnar osteotomy with lag screw fixation of the fragment (Meyer-Lindenberg et al. 2001,
Krotscheck et al. 2000).
REFERENCES
Bardet JF, Bureau S. Fragmentation of the coronoid process in dogs. A case-control study of 83 elbows treated by short-
ening osteotomy of the proximal ulna. Pratique Medicale et Chirurgicale de L’Animal de Compagnie 31:451-463,
1996.
Ferrigno CRA, Schmaedecke A, Sterman FA, Lincoln J. Treatment of ununited anconeal process in 8 dogs by osteotomy
and dynamic distraction of the proximal part of the ulna. Pesquisa Veterinária Brasileira 27(8):352-356, 2007.
Fitzpatrick N, Yeadon R. Algorithm for treatment of developmental diseases of the medial elbow in dogs. Irish Veterinary
Journal 61(6):398-401, 2008.
Krotscheck U, et al. Ununited anconeal process: lag-screw fixation with proximal ulnar osteotomy. Veterinary and Com-
parative Orthopaedics and Traumatology 13: 212–6, 2000.
Meyer-Lindenberg A, Fehr M, Nolte I. Short and long term results after surgical treatment of an ununited anconeal
process in the dog. Veterinary and Comparative Orthopaedics and Traumatology 14:101-110, 2001.
Ness M. Treatment of fragmented coronoid process in young dogs by proximal ulnar osteotomy. Journal of Small Ani-
mal Practice 39:15-18, 1998.
Preston CA, Schulz KS, Taylor KT, Kass PH, Hagan CE, Stover SM. In vitro experimental study of the effect of radial
shortening and ulnar ostectomy on contact patterns in the elbow joint of dogs. American Journal of Veterinary Re-
search 62:1548-1556, 2000.
Schulz K. Analysis of congruency using radiography and CT. Proceedings, ECVS Congress 2000 pp. 12–3.
Schulz KS. Elbow joint contact and critical loading. Proceedings of the British Veterinary Orthopaedic Association. Birm-
ingham, UK. 2003 pp 4-7.
Sjöström L et al. Ununited anconeal process in the dog. Pathogenesis and treatment by osteotomy of the ulna. Veterinary
and Comparative Orthopaedics and Traumatology 8:170–6, 1995.
Thompson MJ, Robbins GM. Osteochondrosis of the elbow: a new approach to treatment. Australian Veterinary Jour-
nal 72:375-378, 1995.
Turner BM, Abercromby RH, Innes J, et al. Dynamic proximal ulnar osteotomy for the treatment of ununited anconeal
process in 17 dogs. Veterinary and Comparative Orthopaedics and Traumatology 11:76-79, 1998.
Vezzoni et al. Surgical treatment of elbow dysplasia: technique and follow-up. Proceedings 13th Annual Meeting 5EWG,
Granada. 2002 pp. 18–24.
A. Pozzi WVOC 2010, Bologna (Italy), 15th - 18th September • 160
Biomechanics of osteotomies and meniscal surgery

Antonio Pozzi DMV, MS, Dipl. ACVS
University of Florida
Normal tibiofemoral motion is constrained by articular surfaces, ligaments, capsule and menisci. Cranial
cruciate ligament (CCL) deficiency alters these constraints, and causes abnormal motion between the artic-
ular surfaces. The modification in cartilage loading caused by the altered surface interaction initiates pro-
gressive osteoarthritis. Thus, the goal for CCL reconstruction should be the restoration of normal stifle me-
chanics, re-establish biomechanical homeostasis, and cease progression of osteoarthritis.
MAIN PROGRAM
SMALL ANIMALS
Much of the current knowledge regarding CCL repair biomechanics in dogs has been derived from cadav-
eric studies evaluating normal, CCL deficient and surgically-treated stifles under controlled, ex-vivo condi-
tions or theoretical analysis. However, cadaveric and theoretical studies cannot replicate functional loading
and represents only the “time-zero” condition (immediately after surgical fixation). These investigations
should be interpreted into the clinical setting with much caution.
Most clinical and experimental studies evaluating surgical techniques for CCL deficiency adopt static sta-
bility as a measure of the success of the surgical technique to reestablish normal joint mechanics (Slocum et
al. 1993, Gambardella et al. 1981, Warzee et al. 2001).
For example, a persistent positive cranial drawer test after an extra-capsular technique has been traditional-
ly considered a sign of stifle instability and an indication of failure of the procedure. A neutralized cranial
tibial thrust following tibial plateau leveling osteotomy (TPLO) has been generally used as an indication for
a “stable” stifle after reduction of the tibial plateau slope. However, in both cases, static stability (palpable
stability on orthopaedic examination) may not necessarily correlate with dynamic stability (controlled align-
ment of the stifle during activity in vivo).
A key concept is that stifle stability is a dynamic phenomenon, describing the response of the neuromuscu-
lo-skeletal system to a complex combination of body position, muscle forces, external loads and sensory in-
puts. The limited value of palpation tests (cranial drawer and tibial compression tests) for predicting clinical
function is likely a reflection of the discrepancy between measures of joint laxity versus measures of dynamic
stability. Laxity tests measure the maximum displacement of the joint in response to an applied external load,
in the absence of muscle forces. Simple laxity elicited by palpation cannot simulate the complexity, directions
and rate of application of muscular forces produced at the stifle during movement. Even the tibial compres-
sion test, which attempts to simulate weight-bearing, fails to replicate significant loads transmitted across the
stifle such as a quadriceps force. For this reason it would be more correct to use the term “laxity” when stat-
ic stability is evaluated, and consider dynamic stability only if stifle kinematics can be evaluated in the whole
range of motion during different gait patterns in vivo.
Based on the predominant cranio-caudal instability generated by CrCL transection in-vivo, it is reasonable
to conclude that neutralization of cranial tibial thrust is likely the most important function of the CrCL. Ac-
cordingly, current tibial osteotomy techniques primarily aim to address the sagittal plane instability that oc-
curs as a result of weight-bearing. Since these procedures do not provide a passive restraint against internal
tibial rotation, excessive internal tibial rotation may still occur (e.g. during certain vigorous activities that in-
volve pivoting on the pelvic limb), and rotational instability may potentially contribute to the subsequent de-
velopment of OA and meniscal injury.
Different tibial osteotomies are routinely performed to stabilize the CrCL-deficient stifle. The common fea-
ture of these osteotomies is the mechanism of neutralization of the cranial femorotibial shear force. Accord-
ing to Slocum, the compressive forces of weight-bearing, assumed to be parallel to the axis of the tibia, can
be resolved into a cranially directed component (the cranial tibial thrust) responsible for cranial tibial trans-
lation, and a joint compressive force. A correlation between tibial plateau slope and anterior or cranial tib-
ial thrust has been confirmed in human and animal in-vitro models. It is, however, important to note that
there is no definitive evidence substantiating that dogs with higher than average TPAs are at greater risk for
developing CrCL insufficiency. Osteotomies aiming at modifying the tibial plateau angle include TPLO,
CTWO and TTO.
More recent biomechanical theories argue that the tibia is not axially loaded as proposed by Slocum. Rather,
Tepic suggests that the total tibiofemoral joint forces in-vivo are directed parallel to the patellar tendon. Cra-
nial tibial thrust, according to this model, is then dependent on the angle between the tibial plateau and the
patellar tendon. This model also predicts that cranial tibial translation should not occur when a CrCL-defi-
cient stifle is flexed beyond 90 degrees. Osteotomies that are based on this concept include TTA and TTO.
Recently it has been suggested that both “tibial plateau leveling procedures” and “patellar tendon angle mod-
161 • WVOC 2010, Bologna (Italy), 15th - 18th September A. Pozzi
ifying-procedures” may provide stability in a similar way, by reducing the PTA to about 90 degrees. Further
in vivo work needs to confirm these concepts.
The lateral circumfabellar-tibial suture technique and in general extracapsular techniques are intended to
provide stability by counteracting cranial tibial thrust by maintaining the tension applied to the suture at the
time of implantation. Clinical guidelines regarding how to tighten the suture and on the amount of tension
necessary to stabilize the stifle are unclear. However, a cadaveric study showed that very high tension of the
prosthesis increases the lateral compartmental pressure, suggesting that excessive tension should be avoided
in clinical cases. Joint stability following extra-articular stabilization techniques has been investigated in ca-
daveric models. In one of the study the authors found no significant differences in displacements between
stifles stabilized with the circumfabellar-tibial suture technique and intact stifles. Other studies have evalu-
ated the isometry of the point of fixation of LS, and emphasized the importance of precise placement to
MAIN PROGRAM
avoid early failure.
SMALL ANIMALS
There are many variations of stifle stabilization that are routinely used to treat the CrCL-deficient stifle and
facilitate clinical improvement. To date, no specific technique has been shown to yield superior results for
treatment of the CrCL-deficient stifle. In vivo kinematic analysis has been performed in human patients with
anterior cruciate ligament rupture and anterior cruciate ligament deficient-knees treated with different tech-
niques to gain a better understanding of the effects on knee stability, function, and the development of OA.
Similar in vivo 3-D kinematic studies might be useful if performed in dogs with CrCL-deficient stifles stabi-
lized with different treatment techniques.
G. Robins WVOC 2010, Bologna (Italy), 15th - 18th September • 162
Triple Tibial Osteotomy (TTO): results

Geoff Robins, BVetMed(hons), FACVSc
24 Tarcoola Street, St Lucia, Qld., 4067, Australia and
Warrick J. Bruce BVSc(dist), MVM, DSAS(orthopaedics), MACVSc
Veterinary Specialist Orthopaedic Services, P.O. Box 14115, Hamilton, NZ
INTRODUCTION
Traditional techniques for treating cruciate ligament insufficiency have focused on replacing the static sta-
bilisers of the stifle, whereas recent advances in surgery have centred on stabilising the stifle joint through
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SMALL ANIMALS
dynamic means. In other words, altering the biomechanics of the joint so that the cranial cruciate ligament
(CrCL) is no longer required and the joint is stabilised by the actions of actively contracting muscles.
The most popular techniques that have emerged are the tibial plateau adjustment techniques e.g. Tibial
Wedge Osteotomy (TWO) and Tibial Plateau Levelling Osteotomy (TPLO)] and the Tibial Tuberosity Ad-
vancement technique (TTA). All of these techniques involve cutting, and re-orientating, the proximal tibia so
that normal shear forces, which would otherwise be apposed by an intact cruciate ligament, are redirected
perpendicular to the articular surfaces. The resultant compressive forces are much better tolerated by the joint
surfaces and the stifle becomes dynamically stable when loaded. Excellent results have been claimed with
these techniques when compared to the traditional techniques, with more rapid recovery times, less progres-
sion in OA, and return to athletic function, even in large breed dogs. However these techniques require spe-
cialised training, instrumentation and implants, and because of their complexity have the potential for high-
er complication rates when compared to the traditional techniques. In addition, the management of more
complex types of CrCL rupture such as dogs with conformation deformities (e.g. pathological tibial plateau
slope angles, patellar luxation, bowed limbs, and torsional deformities) becomes technically very challenging.
THE TRIPLE TIBIAL OSTEOTOMY (TTO)

The objective of the Triple Tibial Osteotomy is to reduce the tibial plateau slope to an angle perpendicular
to the straight patellar ligament and was designed by Dr Warrick Bruce to provide dynamic stability to the
cruciate deficient stifle. It combines some of the features of the above techniques to achieve the same out-
come, but with less radical angular changes. The measurements and calculation of the correction angle are
made from an extended lateral stifle radiograph and applied to a formula [WA (wedge angle) = 0.6 x CA
(correction angle) + 7.0 degrees].
There are two phases to the surgery; initially a medial arthrotomy is performed to inspect the joint, assess
the integrity of the cranial cruciate and to deal with any meniscal issues. The second phase involves the
creation of three partial osteotomies
in the proximal tibia (Figure 1). The
first is a partial tibial crest osteotomy
parallel with the axis of the tibia. The
second and third create a full thick-
ness wedge ostectomy of the tibia, po-
sitioned caudal to tibial crest osteoto-
my. However the apex of the wedge
does not extend as far as the caudal
tibial cortex. The average wedge angle
for a dog with normal conformation
of the tibial plateau is 16°. Wedge re-
duction is achieved using large frag-
ment forceps. Closing the wedge os-
tectomy rotates the proximal tibial
fragment forwards and this simultane-
ously advances the tibial tuberosity,
bringing the tibial plateau perpendicu-
lar to the patellar ligament (Figures
1&2). Approximately 2/3rds of the
correction is achieved via the partial
wedge and 1/3rd from the partial tibial
crest osteotomy. Figure 1 Figure 2
163 • WVOC 2010, Bologna (Italy), 15th - 18th September G. Robins
A T-platea is used to stabilize the osteotomy (Figure 3). There is no need

to stabilize the tibial crest. The net result is a very stable repair with mini-
mal alteration to the relationship between the femur and tibial plateau. Al-
though it is possible to perform this technique without any additional spe-
cialised instrumentation, a few specific TTO instrumentsa have been de-
veloped to make the procedure more precise.
THE SURGICAL RESULTS

A prospective study of the first 64 consecutive cases of CrCL injury in 52
dogs, treated by TTO was completed in 2004 and the results have been
published1.
MAIN PROGRAM
In summary, 43 dogs (55 stifles) returned for long-term evaluation from 11
SMALL ANIMALS
to 26 months post-operatively (mean, 14.5 ± 3.2 months). Lameness
scores ranged from 0 to 1/10, cranial draw signs were present in all cases
and the tibial compression test was positive in 50 stifles (91%). There was
a significant increase in thigh circumference (P < 0.05) and a significant in-
crease in stifle ROM (P < 0.05). There was no statistically significant in-
crease in osteoarthritis scores from pre-operative to long-term post-opera-
tive values (P < 0.001). Figure 3
Seven post-operative complications were encountered (11%). There were
two fractures through the tibial tuberosity, one joint infection, one plate in-
fection, one case of suspect bone neoplasia, and two late meniscal injuries.
Owners completed questionnaires for 48 dogs (92%) at long-term follow-up. Dogs were assessed as being
normal or near normal for all of the physical activities surveyed except sitting and standing, where 2% and
4% of owners respectively judged their dogs as being mildly abnormal. All owners reported the procedure
had resulted in a marked improvement in their dog’s quality of life and all indicated they would have the
procedure performed again if they had another dog with the same condition.
Since the completion of this study, the authors have performed more than 1000 TTO procedures and con-
sistently achieved good results, with the post-operative complication rate reduced to low levels (about 4%).
The technique can be easily adapted to treat dogs with conformation deformities, such as tibial torsion,
patellar luxation and tibial plateaux deformity.
WHY DO I PREFER THIS METHOD?

A review of all known published tibial osteotomy techniques concluded that satisfactory results were
achieved with all the techniques2. The TTO procedure has become my chosen technique as the recovery
rate is quicker when compared with lateral suture stabilization and the progression of the arthritis is slower.
The technique is versatile and causes less alteration to the normal anatomy and function of the limb. The
operation can be easily performed single handed. There is a very low rate of complications with little chance
of creating a limb deformity. Although not scientifically valid I have experienced a very high rate of accept-
ance of the procedure by referring vets.
REFERENCES
1. Bruce WJ, Rose A, Tuke J, Robins GM. Evaluation of the Triple Tibial Osteotomy. A new technique for the man-
agement of canine cruciate-deficient stifles. VCOT 2007. 20: 159-168.
2. Kim SE etal. Tibial osteotomies for cranial cruciate ligament insufficiency in dogs. Vet. Surg. 2008. 37:111-125.
a
Veterinary Instrumentation, Sheffield, UK.
Complications of the TTO operation

Geoff Robins, BVetMed(hons), FACVSc
24 Tarcoola Street, St Lucia, Qld., 4067, Australia and
Warrick J. Bruce BVSc(dist), MVM, DSAS(orthopaedics), MACVSc
Veterinary Specialist Orthopaedic Services, P.O. Box 14115, Hamilton, NZ
INTRAOPERATIVE COMPLICATIONS
The objective of the TTO is to re-mould the shape of the proximal tibia using partial osteotomies and to al-
ter the relationship between the tibial plateau and the patellar ligament1, it is therefore correct to assume that
MAIN PROGRAM
SMALL ANIMALS
care is need to avoid fracturing the hinge points at the distal end of the tibial crest osteotomy and at the apex
of the wedge osteotomy in the caudal aspect of the proximal tibia. However with experience these two com-
plications can be avoided and are relatively rare.
1 Fracture of the TCO. This occurs in about 5% of cases as an intraoperative complication and is a rare post-
operative complication. A split extending from the distal drill hole is more common and is of no conse-
quence. Fracture of the TCO usually occurs when the wedge is being inserted. It can occur if the Kern
bone holders, which are used as the anchor point for the large reduction forceps, are handled too vigor-
ously. Dogs that need larger than normal angular corrections are also prone to TCO fractures.
Two technical things can be done to reduce this complication. Firstly the drill hole should positioned far
enough behind the cranial cortex of the tibia to ensure that the hinge is strong, but at the same time mak-
ing sure that there is sufficient room to insert the bone plate. Secondly the TCO should be wedged apart
slowly and gently. Older dogs and particularly Collies seem more prone to fracture of the TCO. If the
TCO fractures, then a decision has to be made on the need for stabilization. In some cases the segment
is quite stable, supported by the surrounding soft tissues and the sutures in the crural fascia. In this situ-
ation no further stabilization is needed. However if the segment is unstable then it is attached to the tib-
ia with 1or 2 K wires driven at right angles to the shaft. Experience dictates that it is best to avoid plac-
ing the K wires too close to the proximal end of the tibial crest, as this may provide a stress riser which
may lead to an additional fracture. The top pin should be placed just proximal to the closed tibial wedge
osteotomy. If necessary the repair can be further supported with a distally placed tension-band wire.
There is no need to routinely insert K-wires or screws across the TCO to provide additional stabilization.
Moles et al2 concluded that the insertion of intra-operative implants into the tibial crest did not prevent
tibial crest avulsion postoperatively.
2 Fracture of the caudal tibial hinge. Fracture of the caudal hinge is relatively common and is of no significance
if it occurs during the later stages of closing the wedge osteotomy. If the drill hole is placed too far cau-
dally or the saw blade inadvertently breaks through the caudal cortex, then the hinge may fracture prior
to the application of the bone holders. Reduction of the wedge osteotomy is still achieved with the two
bone holders, but an assistant is needed to place pressure against the caudal tibial cortex while simulta-
neously applying tibial thrust. In some cases a compromise is reached and the proximal segment of the
tibia is allowed to displace caudally.
3 Bleeding. It is important to recognize the close proximity of branches of the popliteal blood vessels to the
caudal aspect of the proximal tibia. Before drilling the caudal hinge hole and performing the wedge os-
teotomy it is necessary to elevate the popliteal muscle from the caudal aspect of the tibia shaft. The soft
tissues are then protected by the insertion of a dry swab between the bone and the muscle and the in-
sertion of a small spoon Hohman retractor. If brisk haemorrhage occurs the first step is to pack off the
area with a moist swab and to continue with the surgery. If this is not successful then pressure is applied
to the caudal aspect of the tibia. Once the osteotomy is closed the bleeding usually stops. If on the rare
occasion these strategies do not work or the bleeding continues once the packing has been removed, it
may be necessary to find and ligate the offending blood vessel. In this situation it is helpful to have an
assistant to retract the soft tissues and to use suction while the surgeon concentrates on finding the of-
fending vessel. A pair of small Gelpi retractors can be used to prise open the osteotomy site to help iden-
tify the blood vessel. Fortunately in our hands this has only been rarely necessary (1/700 surgeries).
Moles and Glyde3 performed a study of the vascular anatomy of the area and concluded that the vul-
nerable vessel is the cranial tibial artery. They describe an easy approach between the sartorius muscles
to locate and temporarily occlude the popliteal artery.
165 • WVOC 2010, Bologna (Italy), 15th - 18th September G. Robins
POSTOPERATIVE COMPLICATIONS
1 TCO fracture. This is a rare postoperative complication. It occurs in individuals that have usually been
too active in the immediate postoperative period. For example a Rottweiler that jumped out of a re-
straining play pen 5 days after surgery. Five cases have been seen in 1000 cases and all were managed
conservatively.
2 Tibial tuberosity avulsion has been recognized in 3/1000 cases and in every case was associated with the prox-
imal insertion of a K-wire into a tibial tuberosity that had fractured during surgery.
3 Tibial fracture. Once again this is a rare occurrence, in one case it occurred 3 weeks postoperatively in a
vigorous Labrador. The fracture line extended from the distal end of the TCO and extended transversely
through the penultimate screw hole. The T-plate was replaced with an 8 hole compression plate with an
MAIN PROGRAM
SMALL ANIMALS
uneventful outcome. Another case was only diagnosed when a healing fracture was discovered on the 6
week follow-up radiographs. On reflection the tibia probably fractured during an unusually violent re-
covery from surgery. There appears to be no association between the position of the end of the plate, the
location of distal hinge hole and the incidence of tibial fractures.
The most serious complication seen in the entire series occurred in a Malamute that had bilateral sur-
geries and resisted all attempts at restraint. The dog suffered bilateral implant failure and bilateral tibial
fractures from the distal hinge in the immediate postoperative period and was eventually euthanatized.
4 Infection. In a couple of cases heat and swelling has developed over the operative site about 5 days after
surgery and in each case responded to a course of antibiotics. Joint infection has been identified in 4/1000
cases.
5 Seroma. This is a very rare occurrence and is managed by reassurance and benign neglect.
6 Lateral patellar luxation. Care is needed when moulding the plate not to over bend the proximal portion as
this may lead to significant lateral displacement of the tibial crest. I had this experience in an early case
in a vicious Rottweiler. It required a second surgery to adjust the alignment of the tibial crest to the
trochlear groove. This eventually turned out to be the case from hell as the dog fractured the proximal
end of the tibial crest through the K-wire and then developed a hard to control joint effusion.
7 Bandage problems. In one case the padded dressing became wet over a week-end and the owners didn’t seek
immediate assistance. When the dressing was removed the cranial tibial muscles were very hard and
painful. The dog was reluctant to weight bear and the paw knuckled over. Sciatic nerve function was pres-
ent and the dog responded to prolonged intense physiotherapy, NSAIDs and antibiotics and eventually
made a full recovery. Although the exact cause of this problem was not identified, it does serve as a re-
minder that the tension and positioning of dressings and bandages must be monitored.
8 Death. Two patients died in the first few days after surgery from the complication of bleeding from a per-
forated gastric ulcer, attributed to the administration of NSAIDs.
9 Implant failure: Aside from the manic Malamute, we have only encountered one case that required re-op-
erating for implant related complications. In this large individual that was not restrained well after sur-
gery, loosening of the proximal screws was identified and they required re-tightening. A type 1 external
fixateur was also applied as insurance against further disruption.
LONG TERM COMPLICATIONS

1 Meniscal injuries. This is an occasional problem and occurred in one case 2 years after surgery. Late menis-
cal displacement has been observed in patients that have undergone a meniscal release and in those that
have not. This may beg the question as to whether meniscal release is worthwhile. It is important to en-
sure that the caudal meniscal ligament is completely transected. Late meniscal displacement continues to
be the most significant postoperative complication seen following TTO surgery. In this series of cases the
incidence is approximately 3%.
2 Infections. Two cases develop sinus tracts about 1 year after surgery that necessitated the removal of the
plate. Plate removal has also been necessary in about 5 other cases that developed a painful swelling over
the plate but without the development of sinus tracts. No cultures were taken but it was assumed that a
haematogenous infection localized around the plate and the problem resolved with plate removal.
3 Neoplasia Six cases of proximal tibia neoplasia (assumed to be osteosarcoma) have been seen mostly af-
fecting the operated limb but in one case it affected the opposite tibia.
COMPLICATIONS NOT SEEN TO DATE

Patellar tendonitis (3/97) and patellar fracture (2/97) have been described by Moles et al2, but have not been
identified by us in this series of 1000 joints. Long Digital Extensor tendon trauma or displacement has not
been identified.
CONCLUSIONS
In this large series of cases there has been a very low rate of serious complications requiring further opera-
tive intervention (about 4%). The low number of implant related problems seems to suggest that technique
results in an inherently stable repair and the speed of union of the osteotomies may support this conjecture.
A common reaction amongst surgeons considering this operation is that they feel compelled to insert im-
plants into the tibial tuberosity in the anticipation of intra-operative or postoperative fractures. Experience
MAIN PROGRAM
with a large number of cases indicates that although tibial tuberosity fractures occur occasionally there is
SMALL ANIMALS
rarely a need to stabilize them with implants.
REFERENCES
1. Bruce WJ, Rose A, Tuke J, Robins GM. Evaluation of the Triple Tibial Osteotomy. A new technique for the man-
agement of canine cruciate-deficient stifles. VCOT 2007. 20: 159-168.
2. Moles AG, Hill TP and Glyde M. Triple Tibial Osteotomy for the treatment of the canine cruciate-deficient stifle.
Surgical findings and postoperative complications in 97 stifles VCOT 2009. 22: 473-478.
3. Moles A and Glyde M. Anatomical investigation of the canine tibial artery- a potential source of haemorrhage dur-
ing proximal tibial osteotomies VCOT 2009. 22:351-355.
167 • WVOC 2010, Bologna (Italy), 15th - 18th September S. Steigmeier
Instrumented treadmill analysis

U. Matis, Prof. Dr. med. vet. Dr. med. vet. habil., Dipl. ECVS, S. Steigmeier, DVM,
G-P. Brüggemann, Prof. Dr.*
Clinic of Small Animal Surgery and Reproduction, Centre of Veterinary Clinical Sciences Ludwig-Maximilians
University of Munich, Germany; *German Sport University, Cologne
Computerized gait analysis has proven to be a valuable tool for assessing the outcome of surgical and med-
ical interventions in orthopaedic diseases. Force plate and computer-assisted motion analysis are the most
frequently used tools for the investigation of canine kinetics and kinematics.
MAIN PROGRAM
SMALL ANIMALS
KINETICS
The analysis of ground reaction forces during gait in quadrupeds requires the simultaneous determination
of forces acting at all contact areas with the ground. To date, most studies in dogs have recorded ground re-
action forces with force plates that were built into the ground. However, those measurements are time con-
suming; it may be necessary for the dog to cross the platform up to five times before a valid recording is ob-
tained. Velocity cannot be kept constant and measuring of all four extremities concomitantly - a requirement
for analysis of gait abnormalities - is not possible. To overcome these disadvantages, instrumented treadmills
can be used. Twenty years ago, the Clinic of Small Animal Surgery, University of Munich, in cooperation
with the German Sport University, Cologne, Germany, installed a novel treadmill with built-in force plates
as a pilot project1, 2. This first generation of treadmills allowed measurement of multiple gait cycles in a short
period of time. The system was able to measure vertical forces but not craniocaudal or mediolateral forces.
The original treadmill was therefore modified over the years. The system currently used in Munich contains
four separate force plates, each with four 3-dimensional (3D) Kistler force transducers. Two synchronized
motors pull two belts over the force plates (the coefficient of friction between the belts and force plates is
known). The speed of the belts is accurately and very sensitively controlled by the motor moments. Motor
moments are measured simultaneously and used for the calculation of anterior-posterior shear forces, in
combination with the forces measured by the force plates. When the animal walks on the treadmill at a giv-
en treadmill speed, the 3D ground reaction forces active at each of the limbs, and the shear forces transmit-
ted to the belts, are measured at a sampling frequency of 1000 Hz. Distribution of the shear forces attribut-
able to the motor moments to the platforms occurs in relation to the vertical force component.
KINEMATICS
Kinematic gait analysis yields the position and orientation of limb segments as a function of time. Data are
obtained by recording the position of a number of landmarks on the various limbs and the spine by 3D
video techniques. Four high speed motion capture cameras and nine synchronized and genlocked video cam-
eras, operating at 100 Hz and 50 Hz (50 fields per second), are available at the Munich gait analysis labo-
ratory to document canine gait from all sides. Capture software allows accurate evaluation of every motion
to a millisecond and comparison of all parameters, for example against time, ground reaction force or joint
angle. The 3D character of the system permits evaluation of the body from any direction. As well as as-
sessing classical signs of lameness, such as shortening of the stance time, this system provides information
about more subtle changes in gait and the effect of any disease on various parts of the body, including the
head, back, tail and limbs. This is a substantial advantage over 2-dimensional gait analysis systems, which
are limited to evaluation of gait in the sagittal plane, and are accurate only when the animal moves perpen-
dicular to the camera.
CLINICAL STUDIES
Since the establishment of the gait analysis laboratory, different studies have been completed at the Depart-
ment of Veterinary Surgery in Munich. Four investigations documented
- healthy German shepherd dogs at a walk using 2- and 3-dimensional gait analysis systems3, 4,
- the gait pattern of four joint diseases (HD, CCLR, FCP, UAP) in German shepherd-phenotype dogs5,
- the gait pattern of a dog suffering from paralysis of the suprascapular nerve6
Eight clinical studies evaluated dogs

- after excision of the femoral head and neck7, 8,
- before and after total hip replacement9,
- before and after a rehabilitation programme following anterior cruciate ligament rupture10,
S. Steigmeier WVOC 2010, Bologna (Italy), 15th - 18th September • 168
- before and after tibial plateau leveling osteotomy to evaluate the analgesic efficacy of tepoxalin11,
- after fixation of intraarticular fractures of the hip, stifle, shoulder and elbow12, 13,
- after sesamoidectomy14,
- after surgical treatment of elbow dysplasia15,
- after surgical treatment of patellar luxation16,
- before and after total hip replacement to evaluate the analgesic efficacy of carprofen and dipyrone17.
CONCLUSION
To the authors’ knowledge, the results of treadmill gait analysis do not differ significantly from those of gait
analysis using fixed underground force plates. However, a direct comparison of results of studies using dif-
ferent methods is not possible. It is therefore mandatory that each gait analysis laboratory establish its own
MAIN PROGRAM
reference data. Furthermore, separate kinematic reference values must also be established for different
SMALL ANIMALS
groups of dogs with similar body shapes. However, in our experience, valid results for serial consecutive gait
analyses can be obtained in individual patients, for example for the comparison of preoperative and post-
operative data, even in the absence of habitus-specific reference values. But even in studies that document
one-time gait analysis of an animal, treadmill systems allow objective evaluation of the visual assessment of
limb function because of the comprehensive data they provide. The scientific values of clinical studies can
be strengthened significantly by adding gait analysis data. Although the initial cost is high, instrumented
treadmills take up little space and provide rapid data acquisition for veterinary gait analysis laboratories in-
terested in research (in orthopaedics and traumatology).
REFERENCES
1. Off W, Matis U. Gait analysis in the dog part 1: Dynamometric and kinemetric measurements and their clinical use
in tetrapodes. Tierärztl Prax 1997; 25:8-14.
2. Off W, Matis U. Gait analysis in the dog part 2: Setup of a gait analysis laboratory and kinematic gait analysis.
Tierärztl Prax 1997; 25:303-11.
3. Unkel-Mohrmann F. The gaitanalytic profile of the German shepherd. Diss med vet, Munich 1999.
4. Raith A. The gaitanalytic profile of the German shepherd dog – a reevaluation. Diss med vet, Munich 2010.
5. Hofman D. Gaitanalytic profile of various joint diseases in the dog: Cruciate ligament rupture, hip dysplasia, frag-
mented coronoid process, isolated anconeal process. Diss med vet, Munich 2002.
6. Jorda C, Adriany E, Matis U. Clinical case: Paralysis of the suprascapular nerve in a dog. Computerised gait analy-
sis, neuroradiological diagnosis and therapy. Tierärztl Prax 2004; 32 1:27-39.
7. Off W. Clinical and gaitanalytic evaluation of the excision athroplasty of the hip in dogs and cats between 1978 and
1989, Diss med vet, Munich 1992.
8. Off W, Matis U. Excision arthroplasty of the femoral head and neck in dogs and cats: Clinical, radiographic and
gaitanalytic evaluation at the Surgical Department of the Veterinary Medicine at the Ludwig-Maximilians-Univer-
sity Munich, Germany. Tierärztl. Praxis 1997; 25:379-87.
9. Kosfeld H-U. Total hip replacement in the dog: Clinical, radiographic and gaitanalytic evaluation between 1983 and
1993. Diss med vet, Munich 1996.
10. Baetzner E. Physiotherapy in veterinary medicine: clinical and gait-analysis-based evaluation of the effect of a re-
habilitation programme on the postoperative period following surgical treatment of the ruptured canine cranial cru-
ciate ligament by means of over-the-top fasciaplasty and additional fibular head transposition. Diss med vet, Mu-
nich 1996.
11. Adriany E, Holz I, Jorda C, Matis U, Osterkorn K. Prospective, blinded, gait analysis investigation of the analgesic
efficacy of the NSAID tepoxalin after tibial plateau leveling osteotomy (unpublished data).
12. Strodl S. Long-term follow-up of intraarticular fractures of the canine and feline hip and stifle joint. Diss med vet,
Munich 2000.
13. Kurzbach TM. A long-term retrospective evaluation of internal fixation of intraarticular fractures of the shoulder
and elbow joint in dogs and cats. Diss med vet, Munich 2000.
14. Murgia D, Matis U, Jorda C, Adriany E. Scintigraphy, computed tomography and computerized gait analysis in ca-
nine sesamoid disease. Tierärztl Prax 2005; 33:167-76.
15. Mussmann K. Elbow dysplasia of the dog - a follow-up study after surgical treatment using diagnostic imaging and
force platform analysis. Diss med vet, Munich 2009.
16. Oboladze T. A long-term retrospective evaluation of the treatment of the canine patellar luxation. Diss med vet,
Munich 2010.
17. Stotz-Rudolff A. Evaluation of Dipyrone and Carprofen as postoperative analgesics in canine total hip replacement
(Diss med vet, Munich, in preparation).
169 • WVOC 2010, Bologna (Italy), 15th - 18th September M.S. Tivers
Computed tomography (CT) of the canine stifle

Mickey S. Tivers, BVSc CertSAS DipECVS MRCVS
Department of Veterinary Clinical Sciences, Royal Veterinary College, UK
Diseases affecting the stifle are one of the most

common causes of canine lameness. Although
there are a number of conditions that can affect
the stifle, by far the most common is cranial cru-
ciate ligament (CCL) rupture. This is typically di-
MAIN PROGRAM
SMALL ANIMALS
agnosed on physical examination and radiograph-
ic findings and a variety of surgical treatments are
advocated. However, in some instances (particu-
larly with partial or early CCL tears) diagnosis can
be challenging.
Stifle instability secondary to CCL insufficiency
(CCLI) can result in meniscal injuries in 49-70%
of dogs1-4. Stifle arthrotomy or arthroscopy is rec-
ommended to allow inspection of the menisci, as
a neglected meniscal injury will result in a poor
outcome1,3. “Late meniscal” injury (LMI), where Figure 1 - Dorsal plane CTA of two stifles showing normal medial and
an apparently normal meniscus at the time of sur- lateral menisci. The white arrow highlights the lateral meniscus and the
gery subsequently becomes damaged, is reported black arrow highlights the medial meniscus. The menisci are wedge
in 6.3-21.7% of dogs4-8. shaped and surrounded by white contrast. From Tivers MS and oth-
Diagnosis of LMI can be challenging and tradi- ers, JSAP 50:324-332, 2009, BSAVA, Blackwell Publishing.
tionally relies upon arthrotomy or arthroscopy.
The ability to diagnose a meniscal injury without
surgery would have significant advantages, guid-
ing decision making and potentially avoiding an
unnecessary procedure. Ultrasonography and
magnetic resonance imaging (MRI) have both
been suggested as useful in the diagnosis of menis-
cal injury in the dog9-12. However, both techniques
have limitations with ultrasound being highly op-
erator dependent10 and MRI being expensive and
requiring an anaesthetic.
In people MRI is the modality of choice for imag-
ing the knee and is associated with excellent sensi-
tivity (95%) and specificity (91%) for meniscal
injury13,14. Computed tomography (CT) arthrogra-
phy is also used for diagnosing meniscal injuries in
people and has similar sensitivities (92-97%) and
specificities (88-90%)15-17.
Until recently there was no information in the vet- Figure 2 - Dorsal plane CTA of the stifle and a surgical image from
erinary literature regarding CT of the canine stifle. a dog with CCLI. The CTA shows a marked axial bulge of the medi-
However, publications have started to appear with al meniscus (red ring). The photograph shows a medial arthrotomy with
increasing frequency which highlights the growing the medial femoral condyle highlighted with an asterix (*). The caudal
interest in this modality. Several studies have de- pole of the medial meniscus is folded forward, consistent with the CTA
scribed the normal CT and CT arthrography findings. From Tivers MS and others, JSAP 50:324-332, 2009,
(CTA) appearance of the canine stifle18-21. Plain CT BSAVA, Blackwell Publishing.
scans show the bony structures clearly but the soft
tissue structures are not visible. With CTA the con-
trast agent highlights the soft tissue structures allowing them to be seen. The cranial and caudal cruciate lig-
aments, medial and lateral menisci and long digital extensor tendon can be seen with CTA. In addition ca-
daver studies demonstrated that CTA can be used to diagnose CCL rupture21 and medial meniscal injury18.
Subsequently two studies have explored the use of CTA for the investigation of CCLI and meniscal in-
jury22,23. The first study investigated CTA using transverse images for the detection of tears to the cruciate
M.S. Tivers WVOC 2010, Bologna (Italy), 15th - 18th September • 170
ligaments and menisci in 25 dogs23. This study reported sensitivities of 96-100% and specificities of 75-100%
for the diagnosis of CCL rupture. However, interpretation of CTA images was not as accurate for the di-
agnosis of meniscal injuries with sensitivities of 13.3-73.3% and specificities of 57.1-100%. The second study
used dorsal images to assess the use of CTA for the diagnosis of meniscal tears in 21 dogs22. This study
found a better accuracy with a sensitivity of 57-64% and a specificity of 71-100%22. This was improved on
retrospective analysis to a sensitivity of 71% and a specificity of 100% with an accuracy of 0.857. Diagnosis
of a meniscal injury was made on the basis of an abnormal outline of the meniscus particularly at the axial
border (an “axial bulge”). This study demonstrated that although metal implants associated with previous
surgery caused streak artefact it was still possible to obtain diagnostic images. Stifle CTA is a new technique
and the reviewers in both papers had little experience of interpretation other than in cadavers. We would
expect that with greater experience the accuracy of the technique will improve further.
MAIN PROGRAM
These studies show that CTA has potential for the investigation of stifle disease in dogs. It has excellent sen-
SMALL ANIMALS
sitivity and specificity for the diagnosis of rupture of the CCL and good sensitivity and specificity for diag-
nosis of meniscal injury. It may be particularly useful in the diagnosis of occult CCLI, isolated meniscal in-
jury and late meniscal injury. It has potential advantages over other imaging techniques as it is not operator
dependent and does not require general anaesthesia. However, image interpretation is associated with a steep
learning curve.
REFERENCES
1. Bennett D, May C: Meniscal Damage Associated with Cruciate Disease in the Dog. Journal of Small Animal Prac-
tice 32:111-117, 1991.
2. Elkins AD, Pechman R, Kearney MT, et al: A Retrospective Study Evaluating the Degree of Degenerative Joint Dis-
ease in the Stifle Joint of Dogs Following Surgical Repair of Anterior Cruciate Ligament Rupture. Journal of the
American Animal Hospital Association 27:533-540, 1991.
3. Flo GL: Meniscal injuries. Veterinary Clinics of North America: Small Animal Practice 23:831-843, 1993.
4. Metelman LA, Schwarz PD, Salman M, et al: An Evaluation of 3 Different Cranial Cruciate Ligament Surgical Sta-
bilization Procedures as They Relate to Postoperative Meniscal Injuries - a Retrospective Study of 665 Stifles. Vet-
erinary and Comparative Orthopaedics and Traumatology 8:118-123, 1995.
5. Thieman KM, Tomlinson JL, Fox DB, et al: Effect of meniscal release on rate of subsequent meniscal tears and
owner-assessed outcome in dogs with cruciate disease treated with tibial plateau leveling osteotomy. Veterinary Sur-
gery 35:705-710, 2006.
6. Lafaver S, Miller NA, Stubbs WP, et al: Tibial tuberosity advancement for stabilization of the canine cranial cruci-
ate ligament-deficient stifle joint: surgical technique, early results, and complications in 101 dogs. Veterinary Sur-
gery 36:573-586, 2007.
7. Case JB, Hulse D, Kerwin SC, et al: Meniscal injury following initial cranial cruciate ligament stabilization surgery
in 26 dogs (29 stifles). Veterinary and Comparative Orthopaedics and Traumatology 21:365-367, 2008.
8. Stein S, Schmoekel H: Short-term and eight to 12 months results of a tibial tuberosity advancement as treatment of
canine cranial cruciate ligament damage. Journal of Small Animal Practice 49:398-404, 2008.
9. Banfield CM, Morrison WB: Magnetic resonance arthrography of the canine stifle joint: technique and applications
in eleven military dogs. Veterinary Radiology and Ultrasound 41:200-213, 2000.
10. Mahn MM, Cook JL, Cook CR, et al: Arthroscopic verification of ultrasonographic diagnosis of meniscal pathol-
ogy in dogs. Veterinary Surgery 34:318-323, 2005.
11. Martig S, Konar M, Schmokel HG, et al: Low-field MRI and arthroscopy of meniscal lesions in ten dogs with ex-
perimentally induced cranial cruciate ligament insufficiency. Veterinary Radiology and Ultrasound 47:515-522,
2006.
12. Blond L, Thrall DE, Roe SC, et al: Diagnostic accuracy of magnetic resonance imaging for meniscal tears in dogs
affected with naturally occuring cranial cruciate ligament rupture. Veterinary Radiology & Ultrasound 49:425-431,
2008.
13. Crues JV, 3rd, Mink J, Levy TL, et al: Meniscal tears of the knee: accuracy of MR imaging. Radiology 164:445-
448, 1987.
14. Mink JH, Levy T, Crues JV, 3rd: Tears of the anterior cruciate ligament and menisci of the knee: MR imaging eval-
uation. Radiology 167:769-774, 1988.
15. Vande Berg BC, Lecouvet FE, Poilvache P, et al: Dual-detector spiral CT arthrography of the knee: accuracy for
detection of meniscal abnormalities and unstable meniscal tears. Radiology 216:851-857, 2000.
16. Vande Berg BC, Lecouvet FE, Poilvache P, et al: Anterior cruciate ligament tears and associated meniscal lesions:
assessment at dual-detector spiral CT arthrography. Radiology 223:403-409, 2002.
17. Ghelman B: Meniscal tears of the knee: evaluation by high-resolution CT combined with arthrography. Radiology
157:23-27, 1985.
171 • WVOC 2010, Bologna (Italy), 15th - 18th September M.S. Tivers
18. Tivers MS, Mahoney P, Corr SA: Canine stifle positive contrast computed tomography arthrography for assess-
ment of caudal horn meniscal injury: a cadaver study. Veterinary Surgery 37:269-277, 2008.
19. Samii VF, Dyce J: Computed tomographic arthrography of the normal canine stifle. Veterinary Radiology and Ul-
trasound 45:402-406, 2004.
20. Soler M, Murciano J, Latorre R, et al: Ultrasonographic, computed tomographic and magnetic resonance imaging
anatomy of the normal canine stifle joint. Veterinary Journal 174:351-361, 2007.
21. Han S, Cheon H, Cho H, et al: Evaluation of partial cranial cruciate ligament rupture with positive contrast com-
puted tomographic arthrography in dogs. Journal of Veterinary Science 9:395-400, 2008.
22. Tivers MS, Mahoney PN, Baines EA, et al: Diagnostic accuracy of positive contrast computed tomography arthrog-
raphy for the detection of injuries to the medial meniscus in dogs with naturally occurring cranial cruciate ligament
insufficiency. Journal of Small Animal Practice 50:324-332, 2009.
MAIN PROGRAM
23. Samii VF, Dyce J, Pozzi A, et al: Computed Tomographic Arthrography of the Stifle for Detection of Cranial and
SMALL ANIMALS
Caudal Cruciate Ligament and Meniscal Tears in Dogs. Veterinary Radiology & Ultrasound 50:144-150, 2009.
T.M. Turner WVOC 2010, Bologna (Italy), 15th - 18th September • 172
Skull fractures
Thomas M. Turner, DVM
VCA Berwyn Animal Hospital, Berwyn, Illinois
The skull is intimately involved in three systems of the body: digestive, respiratory, and neurological sys-
tems. This requires the need for additional consideration regarding the consequences that fractures of the
skull have on these systems. The maxilla and incisive bones provide support for the dentition. The incisive,
maxilla, nasal, and frontal bones also form the initial structures of the respiratory system. The cranial cavi-
ty is formed by the frontal, parietal, sphenoid, temporal and occipital bones.
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SMALL ANIMALS
In general, the bones of the skull are unicortical except for those over the calvarium which are diploic, both
of which are relatively thin bony structures. However, the architectural arrangement of the facial bones func-
tions as a critical buttress to support the dentition and palate during mastication and transfers the consider-
able forces that are formed during that process to the mass of the skull. The restoration of this buttress struc-
ture is important in the successful treatment of skull fractures and restoration of the other associated three
body systems.
Since the bones of the skull are relatively thin, massive implants are generally not necessary but the para-
mount tenets of fracture repair anatomical alignment and rigid fixation must be achieved. A variety of fixa-
tion techniques can be employed for fracture stabilization but some of the more common methods are in-
terfragmentary wiring, bone plates and external fixators. In addition, other techniques include a combina-
tion of Kirschner wires or small diameter position screws combined with a figure of eight wire and stainless
steel wire mesh are occasionally utilized.
Interfragmentary wire is one of the most versatile and frequently used methods of fixing skull fracture frag-
ments. Wire size should be a smaller diameter .8mm to .6mm and smaller since larger diameter will not con-
form well to the bone and can cause an iatrogenic fracture during tightening. In general, a minimum of least
two wires should be applied across a fracture line. If the fracture fragment is free from the adjacent bony
structures, more than two wires should be used to fix the fragment to the surrounding bone. When possi-
ble, the wires should be placed at ninety degrees to the fracture line. When placing the wires, the drill hole
should be directed in a slight converging angle toward the internal aspect of the fracture. (This will aid in
passage of the wire and conforming of the wire to the bone during tightening.) The wire should be twisted
evenly under tension, and the cut ends of the wire bent over to avoid irritation to the overlying soft tissue.
The surgeon should be careful in tightening the wire not to over tightening as this will result in wire cutting
or tearing through the bone fragments.
Bone plate fixation allows for rigid fracture stabilization of the fracture fragments, close conformation to the
bone surface and ease of application. The smaller place series 2.0mm and 1.5mm provide the stability need-
ed without a large implant mass. Also, the smaller diameter screws allow for good screw purchase in the thin
bone fragment. Special plates such as cuttable plates, ‘H’,’Y’ or other shapes, multidirectional plates and re-
construction plates can provide versatility for plate application. A wide variety of plate configurations exist
in human cranial and maxillofacial surgery which can be used but may be economically prohibitive. Wire
mesh can serve as a plate over smaller fragment sites and can be secured with either small diameter wires
as sutures or small diameter screws. The mesh can be easily cut to the fracture site or cover a defect due to
loss of fragments or an un-reconstructable defect. This material can also provide a substrate for fracture frag-
ments support or for bone graft application.
External fixation can provide fixation for selected fractures particular those involving the incisive and max-
illa bones were secure pin purchase can be achieved. Usually small diameter or Kirschner wires are used to
develop a construct surrounding both sides of the maxilla with the connecting bar in a horizontal arch shape.
Occasionally, intraoral wire techniques may be needed for alignment or fixation support combined with
other of the above methods. These are not sufficient alone to restore the buttress support needed for the
maxilla and frontal bones.
Rarely, polymethalymethacrylate cement can be used to cover defects which can be reconstructed. This
must be applied in the dough stage to re-establish the bone contour. Also, the application must avoid defects
with large communication to the mouth or nasal passage to avoid bacterial contamination and subsequent
infection. If used in the calvarium the cement must be cooled during set to avoid neural injury.
Fractures of the nasal area of the skull may be approached through a dorsal midline incision if extensive
fragmentation is present. Isolated fractures are approached directly over the fracture site.
Certain fractures, such as fractures of the incisive bone and palatine portion of the maxilla, may be ap-
proached intra-orally.
173 • WVOC 2010, Bologna (Italy), 15th - 18th September T.M. Turner
Fractures of the sphenoid and incisive bones and are best treated with intra-oral wire or a combination of
pin and figure of eight wire. Maxilla and frontal bones are preferably treated with isolated intra-fragmentary
wire techniques, bone plate fixation or less likely external fixation. Calverial fractures must be fixed with ei-
ther interfragmentary wire sutures or plate or wire mesh fixation. Since maxilla and frontal fractures can al-
low leakage of air leading to subcutaneous emphysema, either a soft (penrose) drain or a hard (tube), drain
should be placed adjacent to the fracture repair exiting through the skin at a dorsal-caudal skull site. Care
must be taken to insure the drains are not affixed or entrapped in the fixation devices prior to closure.
The goals of fracture treatment are precise restoration of the bony architecture in order to achieve normal
dental occlusion and support and to restore the dorsal buttress of the facial bones to the upper skull. Also,
treatment must provide concurrent protection or the supplementation if needed for respiratory or digestive
systems impairment.
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T.M. Turner WVOC 2010, Bologna (Italy), 15th - 18th September • 174
Failed humeral condylar fracture fixation

Thomas M. Turner, DVM
VCA Berwyn Animal Hospital, Berwyn, Illinois
Fractures of the elbow may involve one of the three joints that compose the elbow. These fractures may have
intra-articular or periarticular components. The aim of the treatment of elbow fractures is to obtain anatom-
ical reduction of the fractures, particularly the articular surface of the condyle, restoring joint congruity and
then provide rigid stabilization for the fractures to facilitate the healing process. Following surgery, the goal
of obtaining normal function is dependent upon obtaining successful stable fracture repair and also on the
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SMALL ANIMALS
controlled rehabilitation of the limb to restore full joint motion. If these criteria are not initially attained or
maintained then failure of the repair can ensue and some or all elbow function may be loss.
Anatomy of the distal humerus can present unique challenges to obtain screw or pin purchase for fracture
fixation. Specifically, these are the condyle displaced cranial to the anatomical axis of the humerus, the nar-
row lateral ramus, the supratrochlear foramen and the deep olecranon fossa. In addition, the composite
joints of the elbow have tight tolerances. Therefore, placement of all metal must avoid intrusion into any of
these surfaces or spaces while obtaining maximum bone purchase. Thus, the extreme distal humerus and
condyle present a reduced amount of bone accessible for screw or pin purchase. Biomechanically, there is a
large bending moment acting on the distal humerus in the supracondylar area which must be counteracted.
Many failures can be due to lack of consideration of these structures and forces.
Fractures of the humeral condyle may be classified as (1) supracondylar, (2) epicondylar, (3) lateral condy-
lar, (4) medial condylar, (5) ‘T-Y’condylar, combination intra-articular and supracondylar. All of these frac-
ture types have varying degrees of risks of failure that can occur.
The most common fractures involving the elbow are those of the supracondylar or condylar area. These
fractures may be approached craniolateral, lateral, transolecranon, caudo-medial, or medial. Fixation devices
most commonly applied are lag screw and plate fixation or pin fixation combined with a lag screw. Fractures
of the lateral or medial aspect of the condyle are typically fixed with lag screw to obtain intercondylar com-
pression. Although simple on radiographic appearance, these fractures can easily fail if screw placement tech-
niques are not precisely followed. The combination of a supracondylar and intercondylar fracture, ‘T-Y frac-
ture,’ can be some of the more complex fractures involving the elbow. These fractures require additional at-
tention to assure precise anatomic reduction of the articular surface to this unique anatomic structure and
metaphyseal buttress support. Although these fractures can be approached from the above described direc-
tions, this author prefers the craniolateral approach which allows maximal exposure to the articular surface.
Fixation can be achieved using a reconstruction plate that facilitates contouring to the irregular bone sur-
face. Lag screw fixation into the condyle can then be achieved through the plate adding to the overall con-
struct stability. Alternatively, for additional support a medial plate can also be placed in very large breeds or
if needed for severely comminuted fractures. Another fixation method is the use of a separate lateral to me-
dial directed transcondylar lag screw for condyle fixation and a single plate placed on the medial or caudo-
medial distal humeral surface for metaphyseal stabilization. Alternatively double plates placed along the cau-
dal surface of the medial and lateral rami can be used if support is needed for a high degree of metaphyseal
comminution, additional distal screw purchase, or a markedly overweight patient.
A fracture-luxation of the ulna-humeral joint may result from avulsion of the collateral ligaments from either
the lateral or medial epicondyle of the humerus or from the ulna or radial head attachments. These can be
repaired and the elbow stabilized with primary suture techniques or lag screw fixation. Inadequate fixation
of the epicondyle or ligament reconstruction will result recurrent luxation or in chronic instability.
Failure of the elbow fracture repair occurs most commonly due to error in technique, which inevitably leads
to loss of bone purchase by the device with subsequent loss of implant stability, fragment displacement and
failure of repair. We can categorize technical errors as failure to apply the principles of internal fixation, fail-
ure of the implant, failure of the bone, or failure of the patient.
Whether screw, plate, pin, wire, or external fixator is used, the correct principles must be adhered to for ap-
plication of any of the devices. Fundamental to successful fracture fixation is an understanding and profi-
ciency in clinical application with the fixation device to be used. Initial accurate fracture alignment is para-
mount to a successful fracture repair. Failure to achieve anatomical restoration prior to placement of the de-
vice predisposes the repair to impaired healing, implant failure and a poor functional outcome. Failure of
screw fixation may be due to: infection, improper insertion direction and preparation of the screw hole, or
fragments not anatomically aligned at the time of the application. Similar factors are responsible for failure
of pin fixation or external fixator pins. Options that may be utilized if there is a failure to obtain purchase
175 • WVOC 2010, Bologna (Italy), 15th - 18th September T.M. Turner
with the screw are: (1) to redirect the insertion axis of the screw, (2) use of a larger screw size, (3) use of a
different bony site to achieve similar fixation if possible, or (4) application of bone cement into the hole and
reinsertion of the screw. Plate fixation failure can relate to improper fracture reduction, inadequate plate size
and length, incorrect plate function, poor contouring of the plate to bone surface, and application to the non-
tension bone surface.
Most metal failure is due principally to either; poor application, incorrect size selection of the implant, or ia-
trogenic implant damage during the process of application. Manufacturing incurred or material defects re-
sulting in implant breakage are rare. Implant manufacturing processes and standards are high and tightly
controlled. True metal failure usually can be traced to concurrent use of dissimilar metals or alteration of an
implant surface during application of the device, which can lead to metal fatigue, corrosion and in the ex-
treme metal breakage, or inadequate implant strength for the required application.
MAIN PROGRAM
Failure of fixation can also result due to qualitative and quantitative issues of the bone. There may be un-
SMALL ANIMALS
derlying disease states locally or systemically that can result in a decrease of bone mineralization leading to
poor purchase of the implant, such as renal disease. Local issues that can affect bone quality are infection,
trauma, and disuse osteoporosis. Additional fixation methods or technology or bone graft may be required
to supplement this deficient state. Failure of the bone can result from undetected fissures, fragmentation, and
resorption leading to poor purchase of the implant as well as iatrogenic damage to the bone from unsuc-
cessful fixation attempts. Delayed unions are due to poor vascularity, poor stability, or a lack of bone stock.
Failure of fixation may also be related to the patient. In general, these are due to overuse of the limb prior
to healing of the fracture and self-trauma. Instructions to the owner should specifically detail the amount of
confinement space and activity level and frequency that the pet is permitted. Periodic physical and radi-
ographic examinations of the affected limb and specific fracture can aid in detecting early signs of failure and
allow for treatments to be applied preventing complete failure. These steps will help to diminish this poten-
tial cause for failure.
The elbow is prone to fibrosis more than other joints due to the composite structure of the joint and close
congruency. Lack of adequate fixation and soft tissue injury will result in ankylosis and loss of elbow func-
tion. Therefore, fractures of the elbow and especially of the condyle are not supported in a bandage post-
operatively to allow immediate range of motion and maximum return to motion. In some cases physical
therapy may be beneficial in restoring motion.
The inability to reconstruct a failed condylar fracture repair, a nonunion of the condyle, end stage os-
teoarthritis from an inadequate repair or a painful ankylosis of the elbow may require a salvage procedure.
These procedures are either a total elbow arthroplasty (TEA) or arthrodesis. The opportunity to restore mo-
tion is always the first option. TEA is beginning to have limited clinical success but requires an intact bone
stock and relative anatomical alignment to support the components. However, the potential for infection, de-
gree of ankylosis and soft tissue contracture, and diminished bone stock make this option unsuitable in
many cases. Most commonly, failure of an elbow condyle fracture repair will require an arthrodesis. Al-
though this can relieve pain and restore limb function, it can result in an altered gait pattern which is toler-
ated better in small versus large breed dogs.
Fixation and restoration of elbow joint motion and function can be successfully obtained and expected with
most fractures of the humeral condyle. However, this does necessitate strict attention to surgical and fixa-
tion techniques. Rigid fixation and secure purchase on the distal humeral fragments can allow a rapid return
to motion and function which is imperative in the treatment of elbow fractures to avoid the ankylosis for
which the elbow is predisposed.
B. Van Ryssen WVOC 2010, Bologna (Italy), 15th - 18th September • 176
Fragment removal: what’s the evidence?

B. Van Ryssen, E. de Bakker, Y. Samoy
Department of Veterinary Medical Imaging & Small Animal Orthopedics, Faculty of Veterinary Medicine
Ghent University, Salisburylaan 133, 9820 Merelbeke, Belgium, bernadette.vanryssen@ugent.be, www.orsami.com
Fragmented coronoid process (FCP) can be treated either conservatively or surgically, by means of arthro-
tomy or arthroscopy.1,2,3 A recent analysis of the literature demonstrated that the arthroscopic treatment is
the most successful4. However, there is still a percentage of dogs that do not respond sufficiently to the
arthroscopic treatment. In the authors’ experience, results on a short to middle long term are excellent in
MAIN PROGRAM
SMALL ANIMALS
60% of the cases, while in 35% of the dogs a light to moderate lameness remains present and in 5% there is
no improvement at all. A limited study of 33 dogs with a mean follow-up duration of seven years after treat-
ment demonstrated that one third of the dogs was still sound, one third showed a light to moderate lame-
ness and one third had a limited mobility (student thesis, 2000-2001). Assessing the results, we should bear in
mind that there is a great difference between the degree of lameness, the clinical and radiographic findings.
Results are influenced by several factors: age of the dog, severity and chronicity of the lesions, and the pres-
ence of secondary cartilage lesions, incongruity, OCD and osteoarthrosis. However, even when all circum-
stance are favourable (young dog, early diagnosis, minor lesion, no kissing lesion and good technique), the
result can be bad. Questions we have to ask are: can we achieve a 100% success in the treatment of a joint
problem, particularly of the elbow? How can we prevent unfavourable outcomes? Is there a better alterna-
tive than simple fragment removal?
REFERENCES
1. Van Ryssen B, editor. Role of arthroscopy in elbow diseases in the dog. proceedings 12th international Small Ani-
mal Arthroscopy workshop, refresher course; 2001.
2. Read RA, Armstrong SJ, O’Keefe JD, Eger CE. Fragmentation of the medial coronoid process of the ulna in dogs:
a study of 109 cases. Journal of Small Animal Practice. 1990;31:330-4.
3. Houlton JEF. Osteochondrosis of the Shoulder and Elbow Joints in Dogs. Journal of Small Animal Practice.
1984;25(7):399-413.
4. Evans RB, Gordon-Evans WJ, Conzemius MG. Comparison of three methods for the management of fragmented
medial coronoid process in the dog - A systematic review and meta-analysis. Veterinary and Comparative Ortho-
paedics and Traumatology. 2008;21(2):106-9.
- Student thesis Ghent University: Helleman Marieke. Promotor: B. Van Ryssen. Long-term follow-up.
Arthroscopische behandeling van losse processus coronoideus (2000-2001).
- Student thesis Ghent University: de Bakker Evelien. Promotors: Yves Samoy, Bernadette Van Ryssen.
Long-term follow-up study in dogs with FCP and severe elbow incongruity (2007-2008).
177 • WVOC 2010, Bologna (Italy), 15th - 18th September B. Van Ryssen
Old dog FCP

B. Van Ryssen, K. Vermote, D. van Vynckt
Department of Veterinary Medical Imaging & Small Animal Orthopedics, Faculty of Veterinary Medicine
Ghent University, Salisburylaan 133, 9820 Merelbeke, Belgium, bernadette.vanryssen@ugent.be, www.orsami.com
Fragmented coronoid process is well known as a devolpmental problem in young medium and large breed
dogs. In the latest years, several papers and communications illustrated a similar problem in adult and old
dogs1, 2. A recent study performed at the author’s university described the lesions that were found in 51 dogs
older than 6 years and compared them to the lesions in young dogs. Five types of lesions could be identi-
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SMALL ANIMALS
fied on arthroscopy and CT: chondromalacia-like lesion in 2%, fissure in 27.5%, non-displaced fragment in
12%, displaced fragment in 27.5% and medial compartment erosions without coronoid fragmentation in
31%1. That distribution is different than in young dogs, where a fissure was found in 23%, a non-displaced
fragment in 45%, a displaced fragment in 29% and medial compartment erosions in only 3%. In an ongo-
ing study, prognosis after treatment of FCP in adults dogs is being studied. Preliminary results of this study
show that results are significantly worse in old dogs compared to young dogs: only half of the cases realy
improve substantially after surgery, even when the lesions are limited to a fissure or fragment without ex-
tended kissing lesions. In case of medial compartment disease, prognosis is bad3. When an old dog is pre-
sented with signs of FCP, the owners should be informed about the expectations.
REFERENCES
1. Vermote KAG, Bergenhuyzen ALR, Gielen I, van Bree H, Duchateau L, Van Ryssen B. Elbow lameness in dogs
of six years and older Arthroscopic and imaging findings of medial coronoid disease in 51 dogs. Veterinary and
Comparative Orthopaedics and Traumatology.23(1):43-50.
2. Meyer-Lindenberg A, Langhann A, Fehr M, Nolte I. Prevalence of fragmented medial coronoid process of the ul-
na in lame adult dogs. Veterinary Record. 2002 Aug;151(8):230-4.
3. Vermote K., Van Ryssen B., Gielen I., Scheurs E. Lesions of the medial coronoid process in dogs older than 6 years:
arthroscopic findings and results after treatment. Retrospective studie of 43 cases. Abstract, ESVOT Arthroscopy
Working Group, Sept. 2008.
R. Vannini WVOC 2010, Bologna (Italy), 15th - 18th September • 178
The synthes locking plates

Rico Vannini, Dr. Dipl. ECVS
Bessy’s Kleitierklinik, Dorfstr. 51, Switzerland - 8105 Watt
“Synthes-plates” are plates that have been developed and approved by the AO Foundation, which reflects 50
years of leading experience in plate osteosynthesis. Even so the classical concepts of fracture treatment by
bone plating as postulated by the founders of AO still hold true, considerable changes have taken place in
our understanding how fractures heal under different mechanical and biological environments, how they re-
act to strain and how implants and bone interact.
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SMALL ANIMALS
The concept of locking plates is now well established and represents a clear advance in the management of
many fractures by plate fixation. Fractures in osteoporotic bone, fractures with short metaphyseal segments
and fractures treated with biological fixation are some examples of fractures that are preferably managed
with lockable plates nowadays.
Locking plates evolved through the recognition that in order to get a fracture to heal quickly and satisfac-
torily, it is not always necessary to achieve rigid internal fixation and absolute stability.
Anatomic reduction and rigid internal fixation is still required for simple reducible and articular fractures.
In comminuted shaft fractures, anatomic reconstruction is not possible or would only be possible with ex-
cessive manipulation of the fracture and destruction of the biology. The primary goal of fracture treatment
in non-reducible fracture is therefore correct axial alignment of the two adjacent joint bearing surfaces and
restoration of length, while preserving the biology of the fracture. Being aware of the importance of biolo-
gy, the concept of minimal invasive plate osteosynthesis (MIPO) of shaft fractures evolved parallel and be-
came popular and successful.
Minimally invasive surgical techniques have been improved and facilitated by using low contact implants
combined with locking screws. The locking plates combine the biological benefits of external skeletal fixa-
tion with the post operative management benefits of internal fixation.
With the concept of internal fixators the plate screws are the main load-transferring elements. All the forces
are transferred from the bone to the plate across the screw necks. No compression of the plate onto the bone
is required to achieve stability. Therefore the blood supply of the bone under the plate is preserved. As it is
no longer necessary for the plate to be adapted precisely to the shape of the bone, the need for anatomic
plate contouring is eliminated. With locking head screws, there is less risk of screw loosening compared to
conventional screws and fracture fixation does not depend significantly on the quality of the bone or the
anatomical region of anchorage anymore.
Meanwhile there are a variety of locking plates available. Locking plates refer to those plates that have holes
that will only accommodate locking head screws and are therefore used to bridge across the fracture like an
internal splint or fixator.
The Synthes LCP is a lockable plate, as it can accept either standard screws and/or locking screws. This “hy-
brid implant” can, therefore, be used to produce internal splintage with locking screws or - in a more tradi-
tional fashion - compression, buttressing and neutralization when standard techniques and screws are em-
ployed, as it is needed in reducible simple fractures, osteotomies and complex bone reconstructions. The use
of a non-locking screw may also be indicated when angulation of the screw is necessary such as for fixation
of a fragment, to assist with fracture reduction or to avoid penetration of a joint surface. This unique fea-
ture of the Locking Compression Plate is made possible by a special “Combi-hole” – a combination of the DCU
hole for standard screws with a threaded hole for the locking head screw.
THE LOCKING COMPRESSION PLATE: DESIGN AND SIZES

The LC plate has undercuts which result in an identical cross-section area over the entire length of the plate.
The LCP has a center towards the holes are directed.
On one end, the tip of the plate is tapered to facilitate closed plate insertion during MIPO and to minimiz-
ing impact on soft tissue. This end is also called “slippery toe”. The other side of the Vet LCP’s is rounded
to accommodate a simple round hole instead of the “Combi hole”. This allows to insert the last two screw
closer to each other which might allow to insert an additional screw in a short metaphyseal fracture segment.
If a locking screw inserted at a right angle would penetrate the joint surface, this round hole can be used
with a regular screw, which can be angulated away from the joint,
For veterinary use, the plate is produced in stainless steel, but it is also available in titanium. There are all
sizes from 1.5/2.0, 2.4, 2.7, 3.5 narrow and broad up to the 5.5 mm in a wide variety of different lengths and
shapes.
179 • WVOC 2010, Bologna (Italy), 15th - 18th September R. Vannini
The profile (thickness and width) of the LCP is similar to a LC-DCP of the same size. Both plates also have
similar cross -sectional dimensions through their screw holes. It is therefore not surprising, that the LCP and
LC-DCP plates of the same size have similar mechanical performance, i.e bending stiffness and area mo-
ment of inertia. In a mechanical testing model it was confirmed, that that there is not any difference in bend-
ing stiffness and strength and the selection of the LCP does not compromise the integrity of the implant
strength (DeTora and Kraus, 2008).
Any fixation system is as strong as its weakest link. In the case of locking plates, it seems that overall per-
formance is largely influence by the screws. Many screw factors can influence the stability and performance
of a locking system: screw design & dimensions, locking stability of the screw head in the plate (loosening)
as well as the numbers, placement (monocortical vs bicortical) and orientation of the screws.
The design of the Synthes locking head screws differ from conventional screws, as they are actually more
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like threaded bolts. The threads are smaller as they don’t have to generate compression between the plate
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and the bone. The decreased thread diameter allows however for a larger core diameter of the screw, which
increases the bending and shear strength while dissipating the load over a larger area within the bone. Also
the drive mechanism used for the screw head has been changed to the “StardriveTM”. This screw head de-
sign is self-retaining, 65% stronger in insertion torque and therefore more resistant against stripping than the
classical hexagonal screw head design. The single lead shaft pitch allows the screw to fully engage in the cor-
tex before locking to plate. As the locking stability of the screw head in the plate is of prime importance, the
threads of the head have a conical double lead to facilitate alignment of the screw with the threaded plate
hole pitch. As orthogonal screw insertion is a must with locking head screws, a special drill guide is used
that is screwed into the locking plate hole to assure correct drilling in regard to the plate hole.
Overall performance of the LCP has been compared to the non-locking LC-DCP systems.
It has been shown, that the structural bending stiffness in all loading directions is similar or even slightly
stronger in a simple fracture model. Gap bending stiffness for four planes of bending was investigated and
the LCP was significantly stiffer than the LC-DCP in the latero-medial plane, otherwise there were no sig-
nificant differences (Aguila et al, 2005).
In another study with a cadaveric distal humeral metaphyseal gap model, it was shown that the LCP were
significantly stiffer, than the LC-DCP when loaded in static axial compression. When cyclically loaded in
statical axial compression, the LCP constructs were significantly less stiff than the LC-DCP constructs. They
were also less resistant to torsion over 500 cycles compared to the LC-DCP. Other studies showed howev-
er contrary results with no difference between the two plate systems or even greater resistance of the LCP
to cyclic torque (Fulkerson 2006, Gardner 2005, Kim 2007, Weinstein 2006).
As the LCP allows for combining locking and non-locking screws, the effect of such combination of locking
screws with non-locking screws on stability has been investigated.
Initially it has been shown the load carrying capability of a construct with unicortical screws only is at least
as strong as a conventional construct with bicortical regular screws. However the concept of using only
monocortical screws has been challenged as monocortical screws provide limited torsional stability. Under
torsional loads, replacing the end screws of a locked unicortical configuration with bicortical screws signifi-
cantly improved the construct stiffness: 57.6% increase for the locked screws and 51.6% increase for the un-
locked. In anteroposterior (AP) bending, the highest improvement over the locked unicortical configuration
came from the locked hybrid constructs (42.9% increase). When compared with the unlocked bicortical con-
figuration, both hybrid constructs provide equivalent stability in torsion but superior stability in AP bend-
ing (Roberts 2007).
On the other hand, if a single locking screw is added to an otherwise non-locking construct, it will increase
the torque to the offset failure point by 17%. This would suggest that the addition of just one locking screw
is able to provide an angle stable construct (Gordon 2010).
Failure to recognize that a lockable plate does not necessarily need to have locking head screws inserted is
one of the pitfalls in using these implants.
Allowing for using both, locked and non-locked screws, the LCP offers best of both worlds and has revo-
lutionized operative fracture fixation in human orthopedic surgery. If implant cost reach the cost of regular
plates it certainly will become a very attractive implant system for veterinary surgeons as well. With it, one
implant system could replace all the older conventional plates thereby streamlining the implant inventory
dramatically.
REFERENCES
Aguila et al: In vitro biomechanical comparison of limited contact dynamic compresin plate and locking compression
plate. VCOT 2005; 18:220.
DeTora, Kraus: Mechanical Testing of 3.5mm locking and non-locking plates. VCOT 2008; 4: 318.
Fulkerson et al: Fixation of diaphyseal fractures with a segmental defect: a biomechanical comparison of locked and con-
ventional plating techniques. J Trauma 2006; 60: 830.
Gardner et al. The mechanical behavior of locking compression plates compared with dynamic compression plates in a
cadaver radius model. J Orthop Trauma 2005; 19: 597.
Kim et al: Fixation of osteoporotic distal fibula fractures: a biomechanical comparison of locking vs conventional plates.
J. Foot and Ankle Surg. 2007; 46:2.
Weinstein et al: Locking plates improve torsional resistance in the stabilization of three-part proximal humeral fractures.
J. Shoulder Elbow Surg. 2006; 15: 239.
Roberts et al: Biomechanical Evaluation of Locking Plate Radial Shaft Fixation: Unicortical Locking Fixation Versus
Mixed Bicortical and Unicortical Fixation in a Sawbone Model. Journal Hand Surg. 2007; 32, 971.
Gordon. S et al The effect of the combination of locking screws and non-locking screws on the torsional properties of a
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locking-plate construct. VCOT 2010; 1: 7.

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181 • WVOC 2010, Bologna (Italy), 15th - 18th September A. Vezzoni
Tibial epiphysiodesis: results and complications

Aldo Vezzoni, Med. Vet., S.C.M.P.A., Dipl. ECVS
Clinica Veterinaria Vezzoni, Cremona, Italy
Anterio Cruciate Ligament (ACL) injuries can occur at any age; in immature dogs, avulsion of the origin
or more commonly the insertion may be seen. In acute avulsion cases, one may choose to reattach the bone
fragment with internal fixation. In more chronic cases the contracture of ligament fibers makes it impossi-
ble to anatomically reduce and stabilize the bone fragment. The positive effects, produced by the tibial
plateau leveling osteotomy (TPLO) in ACL deficient knee, have been demonstrated. However, TPLO is not
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appropriate in immature dogs because of the open growth plate. Tibial wedge osteotomy (TWO) to reduce
the tibial plateau slope could be performed distal to the growth plate in immature dogs, but this procedure
is invasive. The author has performed a proximal tibial growth plate fusion in an attempt to level the tibial
slope as growth proceeds. Proximal tibial epiphysiodesis was described by Barclay Slocum in a case report
published in his web-site using a screw inserted in the center of the cranial part of the tibial plateau of a grow-
ing dog with ACL failure. The screw crossing the growth plate arrested the physis at the point of insertion,
while the caudal part was continuing to grow leading to a significative decrease of the tibial plateau slope.
The procedure must be performed before the proximal tibial growth plate normally fuses. Fusion of the lat-
ter occurs between 6th and 11th months of age depending on breed.The purpose of this study was to evalu-
ate the effect of proximal tibial fusion on tibial slope. The amount of tibial plateau leveling achieved at the
time of growth plate closure and end degree of tibial thrust were used as outcome measures. Adverse events
were also recorded.
CLINICAL CASES
From November 1999 to December 2009, 19 puppies, from 4 to 8 months of age were diagnosed with par-
tial or complete ACL injury. Each dog was treated with partial epiphysiodesis of the tibial plateau. Six dogs
had bilateral injury while the other 13 dogs had unilateral injury for a total of 25 treated joints. Follow-up
examinations were conducted at a minimum of 2 months and at a maximum of 8 years.
All dogs were presented because of rear lameness and were evaluated with physical examination under deep
sedation. Joint palpation, drawer sign and tibial compression test (TCT) were performed as diagnostic tests.
Medio-lateral and postero-anterior radiographic views were performed. Diagnosis of ACL avulsion was
done by the identification of a bone chip in the joint space and a radiolucency at its origin/insertion. Diag-
nosis of partial tear was achieved on the basis of a slightly positive drawer sign and TCT with the knee in
moderate flexion, while it was negative with the knee in extension. Complete tear was confirmed by posi-
tive drawer sign and TCT with the knee in extension. Diagnosis of partial and complete tear was confirmed
by the radiographic findings of the fat pad sign and the increased periarticular density of the caudal aspect
of the joint and cranial tibial subluxation. In one dog arthroscopic investigation was performed. The slope
of the tibial plateau was measured on the medio-lateral view according to the method described by Slocum.
Surgical procedure: after sedation with acepromazine (0,05 mg/kg i.m.) and induction with propofol (4,4 mg/kg
i.v.) the patient was positioned in dorsal recumbency and anaesthesia maintained with isofluorane. After sur-
Figure 1 - Mastiff, left knee: A & B post operative, 7 month of age; C& D follow-up at 5 years of age.
A. Vezzoni WVOC 2010, Bologna (Italy), 15th - 18th September • 182
gical prep and draping of the affected limb/s, a 2 to 3 cm skin incision was done lateral to the patellar ten-
don, midway its length. The incision of the fascia and joint capsule allowed the insertion of a Gelpi retrac-
tor and the inspection of the anterior cruciate ligament. In the cases of ACL avulsion the surgical approach
was slightly extended to allow the procedure for its fixation with stainless steel wire EP 3 or with screw and
washer. To insert the screw across the tibial plateau, the patellar ligament was pulled medially and a K wire
# 1.6 mm was driven as a guide into the cranial centre of the tibial plateau, in the direction of the tibial shaft.
The position of the K wire was confirmed with fluoroscopy or with intra-operative radiographs. The desired
point of insertion was the most proximal part of the tibial plateau, in its center. A cancellous screw was then
inserted keeping the same position and orientation of the guide pin. A further check with fluoroscopy or ra-
diograph allowed to confirm correct position of the screw and its depth. In 6 joints 4.0 malleolar cannulat-
ed screws were used and inserted through the guide pin. Closure of the incised planes completed the pro-
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cedure. Post-operative radiographs were taken to evaluate the position of the screw both in lateral and in
SMALL ANIMALS
sagittal views.
Follow-up: all dogs were checked with physical and radiographic exam after 1 month, 2 months, 6 months
and yearly when possible. Lameness was scored from 1 to 4, TCT was tested, the tibial slope was measured
and the radiographic signs of joint OA were recorded as well as any observed complication.
RESULTS
In all dogs the tibial slope was decreased; the degree of change was dependent upon the age of the dog at
the time of surgery. The minimum change of slope was 4°, (Dogue de Bordeaux 8 months old) and the max-
imum change was 24° (Labrador 4,5 months old). Of the 25 joints treated with partial tibial fusion, ACL in-
jury was due to disinsertion of the ligament in 8 cases, 5 of which were treated with a wire or screw fixation
of the ligament and partial fusion and 3 with partial fusion only. In the remaining 17 joints, ACL injury was
a bilateral partial tear associated with early stress of the ligament in giant breed dogs.
COMPLICATIONS
In two cases TPLO was performed 1 and 2 years after partial fu-
sion, because of progression of the ACL tear and lameness, with
a tibial slope of 16° and 20°. In two dogs, the screws were re-
moved after 60 and 40 days since the desired amount of tibial
plateau leveling was already achieved and the growth plate was
still active.
In two dogs a moderate valgus deformity of the tibia was ob-
served. It was not addressed with further surgery because it did
not cause any lameness. In a further dog, a 6 months old
Labrador with a 30° tibial plateau angle, a proximal tibial valgus
of 18° one month after screw insertion required the removal of
the screw and the placement of a medial stapler, achieving a 9°
of proximal tibial valgus at the FU at one year of age, close to
the value of the opposite limb (7°). In this dog the tibial plateau
slope moved from 30° to 20°.
Figure 2 - Labrador 6 mo., one month after screw palcement with 18° of proximal
tibial valgus, when the screw was removed and a medial stapler inserted. At right the
FU at 1 year of age, were the proximal tibial valgus was reduced to 9°, close to the
value of the unaffected opposite limb (7°).
DISCUSSION
This study showed that proximal tibial fusion in growing dogs with ACL injuries affected the slope to such
an extent to balance the forces acting on the ACL deficient knee and to avoid further more invasive treat-
ments. The amount of tibial plateau leveling achieved was related to the age of treatment, being higher in
younger puppies. In this study the remaining potential of physeal growth to alter the tibial slope with par-
tial fusion was observed until 7 months of age, since in the dogs treated later (7,5 and 8 months) this proce-
dure did not get enough efficacy to avoid knee instability. Two dogs were treated 1 and 2 years later with
TPLO where the slope was 16° and 20° and the ligament tear progressed to complete rupture. The maxi-
mum age to significatively affect the tibial slope with partial fusion could be related to the breed variation
too, but this limited study did not allow this evaluation. The time of fusion is also an individual finding and
the potential of growth was evaluated looking at the radiological aspect and the physis width. In younger
puppies the removal of the screw before the complete fusion of the growth plate was considered to avoid ex-
cessive leveling of the tibial plateau. For that purpose we monitored the leveling effect in the post-operative
period to evaluate the achieved slope and the remaining growth potential. In two dogs the screw was re-
moved after 60 and 40 days because the achieved tibial slope (8°) was judged to be enough and the physis
was still slightly open. ACL avulsion was treated with partial tibial fusion in adjunct to internal fixation with
the purpose to protect the fixation and to guarantee more consistent results. In 4 cases of ACL the chip fix-
ation was not performed because the injury was not recent and the ligament was shorter in relation to the
point of avulsion. Nevertheless partial tibial fusion, in these cases, was effective to stabilize the joint at fol-
low-up. In two cases a tibial valgus deviation occurred and it was related to the eccentric insertion of the
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screw that resulted slightly lateral. The medial side of the proximal pyhsis resulted less affected by the screw
SMALL ANIMALS
than the lateral side. The amount of valgus deviation in 2 cases did not cause further problems and was not
corrected. In a third case, the valgus deviation This complication suggests the importance to be very precise
in the screw positioning, that should be perfectly centered. While the insertion of the screw in the tibial
plateau could be done from both sides of the patellar ligament, the lateral approach appeared to result in a
better centered position of the screw. Due to the proximal tibial morphology, with the medial approach the
screw could engage the lateral tibial cortex resulting not centered.
CONCLUSION
From this preliminary study the partial proximal tibial fusion in dogs with ACL injuries was effective in re-
ducing the tibial slope during the residual growing time to such an extent to stabilize the joint when per-
formed in the due time. The technique is mini-invasive and complications can be avoided by correct inser-
tion of the screw which position can be checked with intraoperative X-ray or fluoroscopy. In early partial
ACL tear in large breed dogs this mini-invasive procedure avoided further damage of the ligament and the
need of more invasive surgeries.
REFERENCES
Henderson (R.), Milton (J.) - Tibial Compression Mechanism - A Diagnostic Aid in Stifle Surgeries. Journal of American
Animal Hospital Association 14:474-479, 1978.
Slocum (B.), Devine (T.) - Cranial Tibial Wedge Osteotomy: A Technique for Eliminating Cranial Tibial Thrust inCra-
nial Cruciate Ligament Repair. Journal of the American Veterinary Medical Association, 1984, 184:564-569.
Slocum (B.), Devine (T.) - Tibial Plateau Leveling Osteotomy for Repair of Cranial Cruciate Ligament Rupture in the
Canine. Vet Clin North Am Small Anim Pract, 2000, 23(4): 777-795.
Vezzoni A., Bohorquez-Vanelli A., Modenato M, Dziezyc J, Devive Slocum T. - Proximal tibial epiphysiodesis to reduce
tibial plateau slope in young dogs with cranial cruciate ligament deficient stifle. VCOT 2008; 21: 343-348.
E. Viguier WVOC 2010, Bologna (Italy), 15th - 18th September • 184
Pressure mats
E. Viguier, P. Maitre, A. Colin, L. Poujol, C. Wittman., T. Le Quang
RTI2B VetAgro-Sup Campus Vétérinaire, 69280 Marcy l’étoile, e.viguier@vetagro-sup.fr
The locomotion of animal has been a passion for scientists from antique to now (Pline, Xenophon, and lat-
er Borelli, Bourgelat, Marey or Muybridge) particularly for quadrupeds as the horse or the dog. First, gait
was evaluated by observation or hearing, with the development of recording and measuring devices the gait
can now be qualify and quantify and many gait parameters have been proposed to define the normal and
abnormal gait of human and animals. Many gait analysis systems have been developed. Kinematics systems
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are able to describe motion regardless of the influences of mass and force acting while kinetic systems are
able to study the relationship between motion and the force related to it. They are complementary systems.
The main kinematics systems able to characterize temporal and geometric parameters are picture video sys-
tem2D, footswitches, pressure walkways or mats, electro-goniometers and video motion analysis. Kinetics
devices are forces sensors, force shoes and force plates.
Among all this devices, for our clinical biomechanical lab, we have chosen three systems to analyse the gait
of dogs: Electro-goniometer and surface EMG, 2D video motion system and pressure walkway system.
Pressure mats has been used in research and clinical practice. Many pressure mats are available on the mar-
ket: the Gait rite system, the RSscan, Tekscan Walkway TM System and Gait mat. They differ in length, fre-
quency acquisition, resolution and analysis software.
In 2004 we have developed an original software for the Gait rite Gold system to analysed the quadruped
locomotion. The new Platinium GaitRite® system (CIR Systems, Inc.) is a 4.2 to 8 meters long portable
walkway, which has 7 to 10 sensor pads containing each 2456 sensors measuring spatiotemporal aspects of
gait. The spatial resolution of the device is 1.27*0.82 cm and the sampling frequency is 100 to 240Hz.
This system collects spatio-temporal and pressure data: time and location of footprints, pressure and num-
ber of sensors activated during the stance.
The extrapolated spatial parameter was the stride length (cm) measured between the heel points of two con-
secutive footprints of the same foot (left to left, right to right).
The extrapolated temporal parameter included:
- the stance time (s) measured between the first and the last contact of the same footprint
- the stride time (s) was the time elapsed between the first contacts of two consecutive footfalls of the same
foot
- the relative stance time (% of cycle) was presented as a percentage of the gait cycle time (stance time/stride
time)
- the cadence, also called stride frequency (strides/s) was the number of strides during one second.
- the walking velocity
Extrapolated kinetic parameters were peak pressure (maximal of pressure during stance) mean of pressure
and number of activated sensors.
In addition to the data/parameters collected directly by GaitRite, we calculated fore limb versus hind limb
ratios and symmetry for left/right limbs; left/right fore limbs; left/right hind limbs. This function is present-
ly in the new software.
This validated system was proved to provide useful data: spatiotemporal parameters, maximal pressure and
number of activated sensors of the normal dog and pathological dog at walk, trot, jump or descent of stairs;
and allowed quick analysis as well in research as in clinical practice.
The sensitivity and specificity are very good for principle lameness in dogs.
Is the force plate still a gold standard?
As others systems force platforms aim mainly to capture sensitive and reliable data: the 3 resultant axis ground
reaction forces (peak vertical and horizontal forces, vertical impulse, acceleration, symmetry, etc). They were
used to assess locomotion after a treatment or a surgical procedure in the majority of published biomechani-
cal studies. Nevertheless force platform presents several limits. The system would be complex, hardly portable
and required some specific environment and conditions of use. Moreover, data could not be collected from all
four limbs during one cycle using a single force platform. Consecutive strides could not be assessed without
an associated treadmill. Several trials are necessary to obtain correct placement of the foot on the plate. More-
over to perform a comparison between each side, it’s necessary to have at least 2 trials in the same conditions
of speed and acceleration of the dog, which is hardly feasible and requires many trials and time with a very
quite dog. Even with an appropriate room and floor, the dog as well as old person may feel a different stance
between the ground and the force plate and might interfere with the collection of reliable data.
185 • WVOC 2010, Bologna (Italy), 15th - 18th September E. Viguier
Because of those limits, gait mats have been developed for the human gait analysis. Now they could be
used in association with an accelerometer or a 2D Video kinematics system according to the manufactur-
er. Presently they seem to give more information of the gait balance of the dog during locomotion. This
concept may be easiest to understand for a practitioner or a non-engineer rather than kinetics. The walk-
ways systems even if they are recent and not well known, are easier to use and quicker to analyze and no
less reliable than force plate systems with multiple measurements of forces with no identical experimental
conditions.
REFERENCES
1. Budsberg SC, Verstraete MC, Soutas-Little RW. Force plate analysis of the walking gait in healthy dogs. Am J Vet
Res 1987; 48: 915-918.
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2. Budsberg SC, Jevens DJ, Brown J et al. Evaluation of limb symmetry indices, using ground reation forces in healthy
SMALL ANIMALS
dogs. Am J Vet Res 1993; 54: 1569-1574.
3. DeCamp CE, Riggs CM, Olivier NB et al. Kinematic evaluation of gait in dogs with cranial cruciate ligament rup-
ture, Am J Vet Res 1996; 57: 120-126.
4. Lascelles BDX, Roe SC, Smith E et al. Evaluation of a pressure walkway system for measurement of vertical limb
forces in clinically normal dogs. Am J Vet Res 2006; 67: 277-282.
5. Besancon MF, Conzemius MG, Derrick TR et al. Comparison of vertical forces in normal greyhounds between
force platform and pressure walkway measurement system. Vet Comp Orthop Traumatol 2003; 16: 153-157.
6. Lascelles BD, Findley K, Correa M et al. Kinetic evaluation of normal walking and jumping in cats, using a pres-
sure-sensitive walkway. Vet Rec 2007; 160: 512-516.
7. Romans CW, Conzemius MG, Horstman CL et al. Use of pressure platform gait analysis in cats with and without
bilateral onychectomy. Am J Vet Res 2004; 65: 1276-1278.
8. Bockstahler BA, Skalicky M, Peham C et al. Reliability of ground reaction forces measured on a treadmill system
in healthy dogs. The Veterinary Journal 2007; 173: 373-378.
9. Evans R, Horstman C, Conzemius M. Accuracy and optimization of force platform gait analysis in Labradors with
cranial cruciate disease evaluated at a walking gait. Vet Surg. 2005 Sep-Oct;34(5):445-9.
10. Collard F., Maitre P., Le Quang T., Fau D., Carozzo C., Genevois Jp, Cachon T., Viguier E.: Canine Hip Dener-
vation: Comparison Between Clinical Outcome And Gait Analysis, Revue Méd. Vét. 2010, 161, 6:277-282.
11. Le Quang T., Maitre P., Roger T., Viguier E; Is a pressure walkway system able to highlight a lameness in dog, J.A.
Vet Adv 2009, 8(10):1936-1944.
12. Le Quang T., Maitre P., Colin A., Viguier E.: Spatial, temporal and kinetic evaluation of normal cats at walk, us-
ing a pressure walkway, Computer Methods in Biomechanics and Biomedical Engineering, Volume 11, Issue 1, Sup-
plement 1, 2008, Pages 137-138.
13. Maitre P., Le Quang T., Fau D., Genevois J.P, Viguier E.; Hip dysplasia in dogs: correlation between clinical lame-
ness score, radiographic finding and walkway gait analysis, Computer Methods in Biomechanics and Biomedical
Engineering, Volume 11, Issue 1, Supplement 1, 2008, Pages 153-154.
14. Le Quang T., Maitre P.; T. Roger; Viguier E., The GAITRite® system for evaluation of the spatial and temporal
parameters of normal dogs at a walk Computer Methods in Biomechanics and Biomedical Engineering, Volume
10, Issue 1, Supplement 1, 2007, Pages 109-110.
15. Maitre P.; Arnault A.; Verset M.; Roger T.; Viguier E., Chronic cranial cruciate ligament rupture in dog: four legs
assessment with a walkway, Computer Methods in Biomechanics and Biomedical Engineering, Volume 10, Issue 1,
Supplement 1, 2007, pages 111-112.
16. Viguier E.; Le Quang T.; Maitre P.; Gaudin A.; Rawling M.; Hass D.: The validity and reliability of the GAITRite®
system's measurement of the walking dog Computer Methods in Biomechanics and Biomedical Engineering, Vol-
ume 10, Issue 1, Supplement 1, 2007, Pages 113-114.
R. Whitelock WVOC 2010, Bologna (Italy), 15th - 18th September • 186
Traumatic hip luxation in the dog

Richard Whitelock BVetMed MRCVS DVR DSAS(Orth) DECVS
Davies Veterinary Specialists
The canine hip allows a wide range of movement in three planes: flexion/extension, abduction/adduction
and internal/external rotation. In order to do so it does not have collateral ligaments like most other joints,
but rather a single restraining ligament which is positioned at the centre of rotation or “pivot”. The ligament
of the femoral head alone provides insufficient restraint against luxation. The depth and congruity of the
“ball and socket” play a vital role and within the species there are many breed variations as well as con-
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founding factors such as low grade dysplastic changes. For a joint with the same relative degree of dorsal
SMALL ANIMALS
coverage, the greater the diameter of the femoral head, the greater the force required for luxation. The third
and vital restraining factor is the fact that the hip is a sealed unit with a low volume of synovial fluid. Dis-
traction of the femoral head is extremely difficult due to the negative hydrostatic pressure that is created by
any attempt to separate the femoral head and the acetabulum.
Three biomechanical explanations for traumatic craniodorsal luxation have been proposed:
1. The dog is knocked sideways by a blow to the pelvis/rump. As the animal falls towards the hip to be
luxated, the affected pelvic limb moves into adduction and the femoral head is drawn out of the ac-
etabulum until it is restrained by the ligament of the femoral head and the joint capsule. When the
greater trochanter strikes the ground, the femoral head is driven over the dorsal acetabular rim tear-
ing the joint capsule and ligament. There may be concomitant fractures of the dorsal rim itself1.
2. The pelvis is driven ventrally towards the ground by a caudodorsal force with the affected pelvic limb
extended and bearing weight. As the pelvis is forced ventrally the hip and stifle flex. When the stifle
strikes the ground the limb is forced into external rotation and the joint capsule and ligament of the
femoral head rupture1.
3. A longitudinal force along the long axis of the limb leads to adduction and external rotation of the hip
resulting in tearing of both the ligament of the femoral head and the joint capsule2.
Ventral luxations are caused in a similar fashion to point 2. above, except that the affected pelvic limb is in
an abducted position. As the pelvis is driven ventrally, the limb abducts further until the femoral neck and
greater trochanter strike the dorsal acetabular rim. The ligament and capsule tear and the femoral head lux-
ates in a ventral direction. The caput then moves either cranially or caudally (into the obturator foramen)
depending on whether the leg rotates externally or internally respectively1.
By understanding the mechanism of luxation, it becomes intuitive as to how the joint can then be reduced.
DIAGNOSIS
Diagnosis by palpation should be straightforward but in large breeds, overweight dogs, and cases of early
post-operative reluxation it is not always possible to be certain. In addition to the presence of hip pain, use-
ful diagnostic features for hip luxation include:
1. Relative limb length: the affected limb will appear shorter with a craniodorsal luxation and longer with
a ventral luxation.
2. Foot position: when craniodorsal luxation is present, there is external foot (and stifle) placement with
slight adduction with limited internal rotation the hip. The opposite is true for ventral luxation.
3. The position of the greater trochanter in relation to the ischium and the iliac crest. Compared to the
contralateral side, the trochanter can be difficult to palpate with a ventral luxation.
4. Abduction is limited for both craniodorsal and ventral luxation
5. Thumb displacement test: if the thumb is placed in the depression between the greater trochanter and
the ischium it will be displaced by external hip rotation if the hip is reduced.
Radiography provides definitive diagnosis and should identify avulsion fractures of the ligament of the
femoral head (the avulsed fragment coming from the caput), larger slab fractures of the caput and chip frac-
tures of the acetabular rim. The identification of pre-existing hip disease (e.g. dysplasia or arthritis) is im-
portant in decision-making as this carries a poor prognosis for regaining stability/good function.
TREATMENT
Intuitively, early reduction is recommended to minimise the physical abrasion of the cartilage of the femoral
head on the pelvis, to restore the nourishment of the cartilage by joint fluid and to minimise muscle con-
traction and periarticular fibrosis. The ligament of the femoral head will not heal and long term stability re-
lies on fully reducing the caput into the acetabulum and the restoration of the hydrostatic forces that coun-
teract distraction of the joint surfaces.
187 • WVOC 2010, Bologna (Italy), 15th - 18th September R. Whitelock
Closed reduction should be attempted in all cases. Successful treatment in this way carries a good long term
prognosis3 but early re-luxation is reported in 15-71% of cases4, 5, 6. The technique required for reduction de-
pends on the direction of the luxation and is a reverse sequence of movements that caused the luxation in
the first place (see earlier). If the capsule folds in between the caput and acetabulum, or if there is debris such
as haematoma/fibrin within the joint, then stability is poor as the femoral head does not seat deeply in the
acetabulum. Manipulation of the reduced joint with medial pressure can dislodge this interposed tissue. For
craniodorsal luxations, the use of an Ehmer sling for 7-14 days has been advocated7, as has a flexible, two-
pin external fixator8. A lateral pelvic radiograph should be taken once the sling is in place to confirm that
the joint has not reluxated. Ventral luxations can be difficult to reduce in a closed fashion and the percuta-
neous placement of pointed reduction forceps on the greater trochanter helps to direct the caput distally then
laterally. Hobbles are used by this author after closed reduction of a ventral luxation. Careful rest for 4
MAIN PROGRAM
weeks is essential to allow time for the soft tissues to heal sufficiently to restore the capsular “seal”.
SMALL ANIMALS
Open reduction is reserved for cases where closed reduction has failed or if there are avulsion fractures of the
ligament of the femoral head. Many techniques have been described, but essentially they all need to provide
the same thing: stability for long enough for the joint capsule to heal and hydrostatic pressure to be restored5.
The capsule fails in one of three places: 1) avulsion from the dorsal acetabulum, 2) avulsion from the femoral
neck and 3) rupture of the capsule itself. If a midsubstance tear can be accurately reapposed and sutured to
restore the seal of the joint capsule, then most cases require no other restraint. Reattachment of the avulsed
capsule using tissue anchors/screws has the same benefit but in practice it can be difficult to achieve a good
enough hydrostatic “seal” and therefore additional support may be required. In many cases the capsule is
shredded and in addition it may have been abraded so that it is not possible to reseal the joint. These cases
also require additional support and both intra- and extra-capsular techniques have been described. Intra-
capsular techniques include: toggle pinning9, transarticular pinning10, fascia lata loop stabilisation11.
Extracapsular techniques include: ileofemoral sling12, dorsal capsulorrhaphy13, distal relocation of the greater
trochanter14, De Vita pinning15. With such a wide variety of options it can be difficult to know which technique
to employ. Ultimately there is no one proven perfect technique and the choice is very much surgeon-depen-
dant. Consideration should be given to the direction of luxation, the presence of concomitant orthopaedic in-
juries, the anticipated loads on the joint in the early post-operative period, the size of the dog, the depth of the
acetabulum, the presence of avulsion fractures and the periarticular soft tissue damage. In the author’s practice
transarticular pinning is preferred for cases of craniodorsal or ventral luxation with multiple orthopaedic in-
juries where early and high loads are expected on the operated hip. Alternatively an ileofemoral sling is used,
although in the author’s experience, this is not a reliable technique for the repair of ventral luxations.
REFERENCES
1. Wadsworth PL. Biomechanics of luxations. In: Disease mechanisms in small animal surgery. MJ Bojrab.1993 (sec
edition). Lea and Febiger, Philadelphia. pp 1048-1059.
2. Nunamaker DM. Fractures and dislocations of the hip joint. In: Textbook of small animal orthopaedics. Eds CD.
Newton, DM. Nunamaker. 1985. JB Lippincott, Philadelphia. pp403-414.
3. Evers P, Johnston GR, Wallace LJ et al: Long term results of treatment of traumatic coxofemoral joint luxation in
dogs: 64 cases (1973-1992). JAVMA 210:1:59-64.
4. Basher AWP, Walter MC, Newton CD: Coxofemoral luxation in the dog and cat. Vet Surg 15:356-362, 1986.
5. Bone DL Walker M, Cantwell HD: Traumatic coxofemoral luxation in dogs: results of repair. Vet Surg 13:263-270,
1984.
6. Fox SM: Coxofemoral luxation in dogs. Comp Contin Educ Pract Vet 13:381-388, 1991.
7. Ehmer EE: Special casts for the treatment of pelvic and femoral fractures and hip luxations. North Am Vet 15:31-
35 1934.
8. McLaughlin RM, Tillson DM: Flexible external fixation for craniodorsal hip luxations in dogs. Vet Surg 23:21-30,
1994.
9. Beckham HP, Smith MM, Kern DA. Use of a modified toggle pin for repair of coxofemoral luxation in dogs with
multiple orthopaedic injuries: 14 cases (1986-1994). JAVMA 208:1:81-84.
10. Hunt CA, Henry WB: transarticular pinning for repair of hip luxation in the dog: a retrospective study of 40 cas-
es. J Am Vet Med Assoc 187:828-833, 1985.
11. Lubbe AM, Verstraete FJ. Fascia lata loop stabilisation of the coxofemoral joint in the dog and cat. J Small Anim
Pract 31:234-238. 1990.
12. Meij BP, Hazewinkel HA, Nap RC. Results of extra-articular stabilisation following open reduction of coxofemoral
luxation in dogs and cats. J Small Anim Pract 33:320-326, 1992.
13. Braden TD, Johnson ME: Technique and indications of a prosthetic capsule for repair of recurrent and chronic cox-
ofemoral luxations. Vet Comp Orthop trauma 1:26-29, 1988.
14. Fox SM: Coxofemoral luxation in dogs. Comp Contin Educ Pract Vet 13:381-388, 1991.
15. Beale BS, Lewis DD, Parker RB, et al: Ischio-ilial pinning for stabilisation of coxofemoral luxations in twenty-one
dogs: a retrospective evaluation. Vet Comp Orthop Trauma 4:28-34, 1991.
R. Whitelock WVOC 2010, Bologna (Italy), 15th - 18th September • 188
Incomplete ossification of the humeral condyle:

outcomes and complications
Richard Whitelock BVetMed MRCVS DVR DSAS(Orth) DECVS
Davies Veterinary Specialists
During development, the humeral condyle has two different centres of ossification (medial and lateral) sep-
arated by a cartilaginous intermediate zone. Normal ossification of the humeral condyle starts at 2 weeks of
age and is usually completed between 8 and 12 weeks1, 2. After this period of time the presence of a sagittal
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SMALL ANIMALS
radiolucent line (fissure) between the humeral condyles provides evidence of a failure in the fusion of the
two centres of ossification. This pathological condition is named “Incomplete Ossification of Humeral
Condyle” (IOHC). On a caudocranial projection, the fissure extends slightly obliquely from the articular
surface to, or towards, the supratrochlear foramen. The fissure can therefore be missed if standard radi-
ographic projections are used, and a 15° craniomedial-caudolateral radiographic view has been recom-
mended. In view of the risk of missing a fissure by positioning error and also the potential confusion of mach
lines/ulnar articular cartilage lucency, either CT or MRI are the preferred imaging modalities. Incomplete
ossification of the humeral condyle was first reported as an incomplete condylar fracture causing lameness
in spaniels3. A genetic predisposition with a polygenic recessive trait has been proposed for Cocker spaniels4.
IOHC has been reported in many breeds (Labrador retriever, Yorkshire terrier, soft coat Wheaten terrier, Jack
Russell terrier, Boston terrier, German shepherd dog, English pointer, Rottweiler, Pug, Tibetan mastiffs, giant
Schnauzers, German wirehaired pointer, Newfoundland, Entlebucher Sennenhund, English setter, toy Poodles)
but spaniels are particularly predisposed4, 5, 6, 7, 8, 9, 10, 11. When compared with other breeds, spaniels also have a
higher incidence of humeral condylar fractures4, 9, 12, 13. 14, 15, 16, 17, 18, 19 and many of these are associated with nor-
mal activities, such as running and jumping from moderate heights. These findings have lead to a suggestion
that there is a link between IOHC and condylar fractures in this breed. This theory is given credence by the
fact that condylar fractures often occur in conjunction with contralateral humeral IOHC4, 10 and that animals
with lameness due to IOHC often have active new bone formation along the lateral epicondyle5, 6. Many own-
ers describe a lameness that precedes humeral condylar fracture and this supports the theory of a pre-existing
pathological process. There is a high correlation between IOHC and fragmented medial coronoid process, ra-
dial deformities and humero-ulnar incongruence, suggesting that asynchronous radial and ulnar growth may
change the distribution of forces about the elbow and predispose to IOHC5. This may however simply be re-
lated to concurrent elbow dysplasia. Consequently many dogs have elbow osteoarthrosis at the time of diag-
nosis of IOHC or condylar fracture and this may account for the prodromal lameness in some cases.
The treatment of IOHC in lame dogs remains controversial. The environment at the site of the fissure is
similar to that in an atrophic (fibrous) non-union20 and attempts to achieve fusion by drilling vascular access
channels across the fissure did not produce satisfactory results21. There is a general consensus that it is bet-
ter to stabilise the two portions of the condyle to prevent propagation to a complete uni or bicondylar frac-
ture. Most surgeons employ a transcondylar screw and success rates (resolution of lameness) of 70% have
been reported after lag screw fixation6. There is no evidence that lag screws are associated with better out-
comes to position screws. It is the author’s experience that lag screws are associated with a reduced range
of flexion in the elbow and greater post-operative discomfort. The former is thought to be due to the effect
of compressing the condyle, resulting in a subtle change in its shape. The latter is thought to be due to the
creation of tension on the microfractures in the supracondylar ridge as the condyle is “deformed”. It has be-
come clear that simply stabilising the condyle does not lead to fusion7.
Consequently the implants are subjected to long term cyclical loading and screw failure is not uncommon11.
The diameter of the screw used needs to account for this. One recommendation is for a screw diameter equal
to 30-50% of the diameter of the condyle at the fracture site22. In a small number of cases union of the IO-
HC was confirmed by CT (3/17). Combined transcondylar screw and drilling of vascular access channels did
not show any significant benefit7. More recently the combination of a transcondylar core filled with autoge-
nous bone graft and transcondylar lag screw (Acutrak) has been reported. Good elbow function was achieved
without further treatment in the 78% of the cases. Partial or complete bone union was reported in 87% of the
elbows assessed by CT scan, but image quality was suboptimal due to the presence of the screws and this
may not be a reliable figure. Partially threaded titanium shaft screws have been advocated on the grounds
that they are stronger than cortical/cancellous screws and should reduce the incidence of implant failure22.
It is the author’s experience that the incidence of wound related complications associated with transcondy-
lar screw placement is disproportionately high for such a short and atraumatic surgical procedure. Of 28
189 • WVOC 2010, Bologna (Italy), 15th - 18th September R. Whitelock
dogs that had a transcondylar screw placed for lameness due to IOHC, 13 had seroma/wound infection
(46%). Of 21 dogs treated for a lateral condylar fracture that had known IOHC on the contralateral side,
four developed seroma/wound infection (19%). Interestingly of 71 dogs treated for condylar fractures (both
uni or bicondylar fractures) that had no sign of IOHC in the contralateral elbow, only two (2.83%) had sero-
ma/wound infection. It is unclear why the figures are so much higher for IOHC related condylar fractures.
One possibility is the persistence of instability/micromotion. Long term follow-up of the cases where a
transcondylar position screw was placed for the treatment of symptomatic IOHC, revealed that six of 28
(21%) developed screw failure (fracture). These cases presented as a sudden deterioration in lameness asso-
ciated with exercise with pain on elbow extension and transcondylar pressure. In most, radiographs did not
show the fracture in the screw and this was only confirmed at surgery. All cases were revised by placement
of the screw. In view of this high failure rate, the author uses either 4.5mm cancellous or 5.5mm cortical
MAIN PROGRAM
screws. Analysis of fractured screws revealed that they had failed as a result of multidirectional forces con-
SMALL ANIMALS
firming persistent micromotion between the condyles11.
Although many studies support IOHC as a risk factor for humeral condylar fracture, the benefits of surgi-
cal treatment of asymptomatic cases are not proven. With the increased risk of seroma/wound infection and
screw failure, prophylactic screw placement cannot be considered a benign procedure.
REFERENCES
1. Hare WCD: The age at which the centers of ossification appear roentgenographically in the limb bones of the dog.
Am J Vet Res 22:825-835, 1961.
2. Ticer JW: Radiographic technique in small animal practice. Philadelphia, PA, Saunders, pp97-102, 1975.
3. Meutstege FJ: Incomplete humeral condyle fracture in the canine humerus as a cause of obscure elbow lameness.
Proceedings Vet Orthop Soc. 11, 1989.
4. Marcellin-Little DJ, et al: Incomplete ossification of the humeral condyle in spaniels. Vet Surg 23: 475-487, 1994.
5. Carrera I, et al: Computed tomographic features of incomplete ossification of the canine humeral condyle. Vet Surg
37:226-231, 2008
6. Meyer-Lindenberg A, et al: Incomplete ossification of the humeral condyle as the cause of lameness in dog. Vet
Comp Orthop Traumatol 3:187-194, 2002.
7. Butterworth SJ, et al: Incomplete humeral condyle fracture in the dog. J Small Anim Pract 42:394-398, 2001.
8. Fitzpatrick N, et al: Treatment of incomplete ossification of the humeral condyle with autogenous bone grafting
techniques. Vet Surg 38:173-184, 2009.
9. Cook JL, et al: Fluoroscopically guided closed reduction and internal fixation of fractures of the lateral portion of
the humeral condyle: prospective clinical study of the technique and results in ten dogs. Vet Surg. 28:315-21, 1999.
10. Martin RB, et al: Prevalence of incomplete ossification of the humeral condyle in the limb opposite humeral condy-
lar fracture: 14 dogs. Vet Comp Orthop Traumatol. 23:168-72, 2010. Epub 2010 Apr 26.
11. Charles EA, et al: Failure mode of transcondylar screws used for treatment of incomplete ossification of the humer-
al condyle in 5 dogs. Vet Surg 38:185-91, 2009.
12. Dennis HR: Condylar fracture of the humerus in the dog; a review of 133 cases. J Small Anim Pract 24:185-197,
1983.
13. Cockett PA, at al: The repair of humeral condylar fracture in the dog: a review of seventy-nine cases. J Small An-
im Pract 26:493-520, 1985.
14 Vannini R, et al: Humeral condylar fracture caused by minor trauma in 20 adult dogs. J Am Anim Hosp Assos
24:355-358, 1988.
15. Anderson TJ, et al: Intercondylar humeral fracture in the dog: A review of 20 cases. J Small Anim Pract 31:437-
442, 1990.
16. Kaderly RE, et al: Incomplete humeral condyle fracture due to minor trauma in a mature cocker spaniel. J Am An-
im Assoc 28:361-364, 1992.
17 McKee WM, et al: Bilateral fixation of Y-T humeral condyle fractures via medial and lateral approaches in 29 dogs.
J Small Anim Pract 46:217-26, 2005.
18. McCartney WT, et al: Fixation of humeral intercondylar fractures using a lateral plate in 14 dogs supported by fi-
nite element analysis of repair. Vet Comp Orthop Traumatol 20:285-290, 2007.
19. Ness MG: Repair of Y-T humeral fractures in the dog using paired ‘String of Pearls’ locking plates. Vet Comp Or-
thop Traumatol 22:492-7, 2009.
20. Gnudi G, et al: Incomplete humeral condylar fracture in two English Pointer dogs. Vet Comp Orthop Traumatol
18:243-245, 2005.
21. Rovesti GL, et al: Fragmented coronoid process and incomplete ossification of humeral condyle in a Rottweiler. Vet
Surg 27:354-357, 1998.
22. Moores A: Humeral condylar fractures and incomplete ossification of the humeral condyle in dog. In Practice
28:391-397, 2006.
03) MAIN PROGRAM_Large animal_03) Large animal_2010 02/09/10 12.18 Pagina 191
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ABSTRACTS
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of
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193 • WVOC 2010, Bologna (Italy), 15th - 18th September T.W.R. Briggs
Indications for and results of micropicking or mosaic

arthroplasty in human joint resurfacing
T.W.R. Briggs, Prof., MD(Res), MCh(Orth), FRCS
Consultant Orthopaedic Surgeon Joint Head of Training, RNOH & Joint Medical Director
Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middx. HA7 4LP
Injuries to joint surfaces can result from acute high-impact or repetitive shear and torsional loads on the su-
perficial zone of the articular cartilage. Various methods have been used by orthopaedic surgeons to man-
age patients with severe and persistent pain caused by osteochondral injuries including debridement, drilling
and fixation, abrasion chondroplasty, microfracture and the use of carbon fibre pads, all of which aim to in-
duce fibrocartilaginous repair tissue. Other methods, including articular cartilage autografting and the use
of osteochondral allografts, aim for repair with hyaline cartilage.
Microfracture (micropicking) relies on stimulation of the underlying bone marrow resulting in fibrocartilage
growth. Osteochondral autograft/allograft transfer (OAT/OALT) (mosaicplasty) works by removing several
plus of hyaline cartilage and the underlying subchondral bone from an unaffected, non-weight bearing area
of the knee. These are then used as autograft/allograft implants plugged into the chondral defect.
This talk summarises indications, surgical techniques and results for microfracture and mosaicplasty and at-
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LARGE ANIMALS
tempts to provide an evidence-based approach to what is the best treatment currently available for osteo-
chondral human knee defects.
P. Clegg WVOC 2010, Bologna (Italy), 15th - 18th September • 194
Palmar Osteochondral Disease (POD):

epidemiology, prevention and treatment
Peter Clegg1 Prof. MA VetMB PhD DipECVS CertEO MRCVS,
Gina Pinchbeck1 Dr BVSc PhD MRCVS, Alan Boyde2 Prof. PhD,
Chris Riggs3 Dr. BVSc PhD DipECVS MRCVS
1
Musculoskeletal and Locomotion Research Group, University of Liverpool Veterinary Teaching Hospital, Leahurst, Neston,
UK CH64 7TE; 2Queen Mary, University of London; 3Hong Kong Jockey Club, Sha Tin racecourse,
New Territories, SAR China
The condition which we refer to as palmar/plantar osteochondral disease (POD) of the third metacarpal and
metatarsal (MC/MTIII) condyles has previously been referred to as traumatic osteochondrosis (Pool 1996)
in the equine veterinary literature. Although initially considered to be a manifestation of osteochondritis dis-
secans (Hornof et al. 1981), this condition is now believed to be a biomechanical disorder, resulting from
repetitive overload trauma in horses undergoing cyclic high intensity exercise (Pool 1996). The pathology
of the condition has been described (Pool 1996; Barr et al. 2009). Early findings include a focus of bluish
discolouration of the subchondral bone visible through grossly normal articular cartilage. More severe
changes include physical disruption of the subchondral bone associated with varying degrees of pathology
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LARGE ANIMALS
of the overlying articular cartilage. Ultimately there may be collapse of the subchondral bone with ulcera-
tion of the articular cartilage (Riggs 2006). In some cases these lesions have been reported to be associated
with catastrophic condylar fracture (Krook and Maylin 1988). The pathological changes are clinically evi-
dent as a performance limiting lameness which may be bilateral or, in some cases, quadrilateral and as a re-
sult the affected horse may present with a poor action rather than overt lameness (Pilsworth 2003).
The epidemiology of the condition has so far been poorly described other than the strong belief that the
disease appears to occur only in animals used for racing disciplines. We have shown previously in a post-
mortem survey of 64 racehorses that POD had a within horse prevalence of 67%. There was a significant
linear relationship between grade of POD and grades of wear lines, cartilage ulceration and dorsal impact
injuries within the joint. There was a significant relationship, but this was not linear, between grade of POD
and grade of linear fissures. Using ordinal logistic regression, compared to condyles with grade 0 or grade
2 linear fissures, condyles with grade 1 linear fissures were found to be more likely to have a lower POD
grade (Barr et al. 2009).
Analysis of these 64 horses using univariable linear regression indicated that age at retirement, total num-
ber of race starts, total number of seasons in training, and total winnings were significantly associated with
an increased total POD score. In a final multivariable analysis model, total number of race starts and age at
death were significantly associated with outcome. We concluded that POD is extremely common in this pop-
ulation of racing Thoroughbreds and is most commonly seen in horses with a prolonged racing career (Rig-
gs et al., 2009).
In an analysis of a separate cohort of 104 horses examined at post mortem we demonstrated through multi-
level ordinal regression analysis showed that the grade of POD was significantly higher in the forelimb com-
pared to hind limb. In the forelimb there were higher POD grades medially (P=0.005) whereas in the hind
limb the grade of POD was higher in the lateral condyle (P=0.03). There appeared to be no difference between
left and right forelimbs and this was consistent even after analysing fore and hind limbs separately.
We demonstrated a significant positive relationship between POD grade (i.e. as the grade of pathology in-
creased the probability of higher grades of POD increased) and the following pathologies: grade of cartilage
loss on the condyles; grade of dorsal impact; grade of cartilage loss on the sesamoids and the grade of wear
lines. Horses with signs of marginal remodelling were also more likely to have higher grades of POD.
More recently we have performed epidemiological studies to identify risk factors for POD in a cohort of 164
horses euthanased for welfare reasons at the HKJC in which the grade of POD was assessed at post-mortem
examination and the horses history obtained from veterinary, training and racing records at the HKJC. Uni-
variable analysis showed that a number of racing variables had significant associations with grade of POD.
Those with odds ratio less than one and therefore associated with an increased probability of being in a high-
er POD grade categories were racing before import into Hong Kong; greater age at retirement; increasing
number of races in Hong Kong, in lifetime, on turf, at either Happy valley or Sha tin racecourse; increasing
number of racing seasons; increasing number of races per season; increasing total lifetime race distance and
increasing average race distance over life career or in most recent season; increasing race earnings over life-
time and increasing number of intervals up to 16 weeks between racing.
195 • WVOC 2010, Bologna (Italy), 15th - 18th September P. Clegg
Those with odds ratio greater than one and therefore associated with a decreases probability of being in
higher POD grade categories were fewer and included starting racing career at an older age; increasing time
between retirement or last race and the time of death or euthanasia; an increasing number of intervals of
greater than 16 weeks duration during the lifetime racing career. Variables with no significant effect includ-
ed import age or age of first race in HK, earnings and performance in the most recent racing season and the
horses average or peak weight during its career.
Currently evidence-based treatment protocols for POD are uncertain. Treatment normally consists of some
combination of exercise modification through decrease in training or rest, intra-articular steroids and im-
portantly by improvement to the foot-balance. More recently novel therapies including the use of intra-ar-
ticular autologous conditioned serum and the systemic administration of biphosphonates have been sug-
gested, but there is so far no evidence for efficacy or appropriate times for administration.
ACKNOWLEDGEMENTS
BBSRC, Horserace Betting Levy Board and the Hong Kong Jockey Club for funding and colleagues in the
Department of Vet Clinical Services at the Hong Kong Jockey Club, particularly Susanne Troester, Peter
Curl and Paul Cheung.
REFERENCES
Barr, E.D., Pinchbeck G.L., Clegg, P.D. and Riggs, C.M., (2009) Post Mortem Evaluation of Palmar Osteochondral Dis-
ease (Traumatic Osteochondrosis) of the Metacarpo-/Metatarsophalangeal Joint of Thoroughbred Racehorses – 64
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LARGE ANIMALS
Cases. Equine Veterinary Journal, 41, 366-371.
Hornof W.J., O’Brien T.R., Pool R.R. et al. (1981) Osteochondritis dissecans of the distal metacarpus of the adult racing
Thoroughbred horse. Vet Radiol 22, 98-105.
Krook L. and Maylin G.A. (1988) Fractures in Thoroughbred racehorses. Cornell Vet. 78, 7-133.
Norrdin R.W. and Stover S.M. (2006) Subchondral bone failure in overload arthrosis: a scanning electron microscopic
study in horses. J Musculoskelet Neuronal Interact. 6, 251-7.
Pilsworth R.C. (2003) The European Thoroughbred In: Diagnosis and Management of Lameness in the Horse, Eds:
M.W. Ross and S.J. Dyson, W.B. Saunders Co., Philadelphia, pp 879-894.
Pool R.R. (1996) Pathologic Manifestations of Joint Disease in the Athletic Horse. In Joint Disease in the Horse, Eds: CW
McIlwraith and GW Trotter, W.B Saunders Co, Philadelphia, pp87-104.
Riggs C.M. (2006) Osteochondral injury and joint disease in the athletic horse. Equine vet Educ. 18, 100-112.
Riggs, C.M., Pinchbeck, G.L., Boyde, A.M., Clegg, P.D. and Barr, E.D. (2009) Post mortem evaluation of palmar/plan-
tar osteochondral disease (traumatic osteochondrosis) of the metacarpo- and metatarsophalangeal joint of thor-
oughbred racehorses (64 cases) and identification of preliminary horse level risk factors. In: Proceedings of the In-
ternational Conference of Racing analysts and veterinarians 2009.
L. D’Arpe WVOC 2010, Bologna (Italy), 15th - 18th September • 196
The ice shoe to prevent and treat equine laminitis

Lorenzo D’Arpe Med Vet, PhD
v. Stanislao Mattei 6, Bologna, Italy - lorenzodarpe@tiscali.it
INTRODUCTION
Equine laminitis is a potentially devastating and invalidating disease, one of the most frequent cause of death
in horse1. As perissodactyla the horse is obligated to weightload one finger only for each leg; for this rea-
son, the integrity of the foot is fundamental (no foot, no horse) and laminitis differently from artiodactila
(bovine and swine2) is a life risk and treating condition. The complexity of pathogenic mechanism is still not
completely understood: during the ages the disease changed name many times (from “hordeatio”, to the
present “acute and chronic laminitis”) and many were the treatments suggested, often inefficient because of
the unpredictable, rapid evolution of pain3 and the controversies concerning its etiology.4-5 Recently the au-
thor suggested to distinguish between “Solear Corionitis” (SC) and “Laminar Corionitis” (LC) in order to
better respect the anatomy and time related development of the inflammation that first involve the solear
fimbriae and secondary aggresses the laminae.6
The use of venography first described in 1992 by Pollit7 and standardized by Redden in the standing horse8
changed the clinical diagnostic approach, allowing the use of therapeutical protocols designed to mechani-
cally address forces to improve perfusion of the digit9 and showed a predictive potential anticipating tissue
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damage development before it is detectable by plain radiography.5

Lamellar laminitis lesion can be manifest in varying degrees of severity for each phase; the author differen-
tiated what is normal or mild from what is potentially catastrophic by scoring the gravity of lesion veno-
graphic appearance in low, medium, high and very high.5 Precisely timing the onset and the progression of
disease could be very important in the clinical evaluation of laminitis. Unfortunately the time span of de-
velopmental phase is very variable (hours, days, weeks or sub-clinical indefinitely) depending on previous
foot health and biomechanical foot management. Clinically it has been considered that two main events pre-
dict catastrophic laminitis: the 1st around 72 hours (inflammatory laminitis) and the 2nd at 3-6 weeks (load
induced laminitis) from onset of the first pain event. These two events are indicative of the passage from de-
velopmental to acute and the chronic phase of laminitis.5 The author recognize: developmental; acute (72
hours); sub-acute intermediate (until 3–6 weeks); and chronic laminitis (after 60 days). The latter can even-
tually lead to restitutio ad integrum (return to normality); life-long chronic asymptomatic laminitis with a
clinically compensated lamellar pathology; or symptomatic laminitis with clinically uncompensated lamellar
pathology. It is the authors’ observation that clinical compensation is often related to Sole Depth (SD), a pa-
rameter easily measured with a podiatry radiograph.
Recently the use of bio-mechanical massaging effect to increase the sole depth and the associated prolonged
cryotherapy in case of hyperglycemia have significantly changed author’s clinical approach to “inflammato-
ry laminitis”. Even adopting this therapeutic approach we still do not have found a real key to reverse the
primary cause, but at least we have a temporary antidote to avoid the effect of dermo-epidermal separation
due to MMP activation until the primary cause is no more present and SD > 10-15 mm.
The procedure “Self Adjusting Palmar Angle” (SAPA)10 or massaging shoeing in laminitic horses to increase
SD and hoof growth velocity5, lacked of accepted scientific evidence and has been reserved to few horses.
Recent in vivo investigations on venocompression related to foot load and laminitis11 showed the biome-
chanical influence of foot loading on the vascular bed during quasi-static movement12. The equine foot is
considered as an hydraulic pump with the coronary
band acting as an anatomical safety valve progres-
sively regulated by weightbearing. In the standing
horse limbloading at low range weight <180 kg has
no appreciable effect on biomechanical venocom-
pression, limbloading at medium range weight be-
tween 220-330 kg has shown that the foot system is
able to alternately empty and fill even under con-
stant load by flexion-extension of the DIJ and ap-
parently limbloading at higher weight >500, in the
moving horse, the anatomical safety valve complete-
ly close the blood flux to protect the foot from ex-
cessive arterial pressure during full load.5 These in Photos 1, 2 - Self-adjusting palmar angle with Rail shoe and “5
vivo studies11 support the concept that SAPA mas- Iced Hearts” boot.
197 • WVOC 2010, Bologna (Italy), 15th - 18th September L. D’Arpe
saging shoes11 (Four Point Rail Shoe, Nanric USA, Inc., Versailles, KY) or boots (5 Iced Hearts Boots, Stil-
gomma Italy, srl., Castelli Calepio, Italy) can offer a dynamic in static effect that improves the foot pump action
even during full and constant weight bearing11, helping to increase the SD and as a consequence decreasing
the risk to develop laminitis5.
Perturbed glucose metabolism in developmental phase is associated to insulin resistance and an attendant
hyperinsulynemia, which is not always readily detectable, but hyperglycemia is easy to diagnose13 and cor-
relate to the presence of the laminitis primary insult. According to Pollit’s observation that the equine foot
is not sensible to frost byte until -20°C the author have used cryotherapy at -7°C on normally shod horses
as long as hyperglycemia was present, as temporary antidote for the primary insult in order to reduce the
severity of the acute lesions.14-15-16
The purpose of the present study was to assess the clinical importance of the quasi static auto-massaging ef-
fect associated to prolonged cryotherapy in horses at risk to develop or with already acute or sub-acute in-
flammatory laminitis and to evaluate the effectiveness of conservative treatment in acute and sub-acute
laminitis. The present study evaluates the outcome of this treatments in the long term.

Medical records of 85 horses diagnosed with acute
and sub-acute LC and treated with massaging effects
between 2001 and 2010 were analyzed retrospec-
tively. Diagnosis was based on descriptions given by
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owners and clinical observation of the horses at the
time of the clinical exam. Only records of patients
with complete radiographic and venographic exam-
ination were selected. Starting from 2008 the mas-
saging effect was associated to prolonged cryothera-
py performed with ultimates (Nanric USA, Inc., Ver-
sailles, KY) and ice-cubes at 0-4°C, in 2009 to pres- Photos 3-4 - Cryotherapy boots with ice cubes and with cryothera-
ent cryotherapy was performed with “5 iced hearts” py machine.
boots and cryotherapy machine (POWERFUL MS
385 or STABLE MS 599, ZAMAR srl, Suzzara
(MN) Italy) at -5/-7°C.
All cases have been divided in two groups, the 1st group of 53 acute and sub-acute horses not cryotherapy
treated because not available at that time, 33 low severity cases were treated conservatively screwing “ulti-
mates” to the hoofcapsule and 19 medium-high severity cases and 1 very high severity traumatic total hoof
capsule evulsion4 treated surgically because conservative treatment was not successful to immediately reduce
the venocompression and improve the vascular supply to the digit.
The 2nd group of 32 horses, 4 acute and 28 sub-acute was treated with massaging effects associated to pro-
longed continuous cryotheraphy, 15 with ice-cubes at 0-4 °C and 17 with “5 iced hearts” boots and cold ma-
chine, following the same protocol for each phase:
- developmental for at least 4h/D,
- acute LC for at least 72 h continuously with a 20° PA, until hyperglycemia was present
- sub-acute until hyperglycemia was present or additional 48 h in case digital pouls or coronets heat re-
curred.
When indicated, additional treatments as FANS, antibiotic, bloodletting, controlled diet and diathermy were
installed to improve the horse’s condition.
RESULTS
1st group: Of 19 low severity cases treated conservatively, all of them reduced pain not before 15-20 days
and developed a low-medium chronic laminitis with variable bone damage. Of 34 horses surgically treated,
22 received partial or complete wall ablations, 14 DDFT tenotomy and 7 transcortical casting.17-18 24 horses
needed sugar-dyne bandages. Follow-up evaluation was possible in 10 of them for a period ranging from 2
months up to 4 years.
2nd group: Of 17 treated with cryotherapy machine, none showed rotation related ot laminitis, 1 had an at-
tendant WLD. Of 15 treated with ice-cubes, 10 developed White Line Disease (WLD) 2-3 months later,
probably due to continued wet condition of the foot. 3 horses needed hoof toe resections to drain the inter-
stitial oedema. In 6 of 7 horses, stable improvement was attained only after normalizing the horse’s hyper-
glycemia. In none of the horses adverse effects related to massaging effects and prolonged cryotherapy were
observed, even if this measure had been applied for several months. Only one barefooted acute horse re-
L. D’Arpe WVOC 2010, Bologna (Italy), 15th - 18th September • 198
sulted difficult to handle in the cryotherapy apparatus and received 12 h only in front feet because of be-
havioral problems, all other horses showed immediate calm and well tolerated the procedure without dam-
aging the instruments. Follow-up evaluation was possible in 20 horses for a period ranging from 2 months
up to 2 years. In all of them, the association of the foot massage and prolonged cryotherapy was successful
in eliminating significantly or completely the clinical signs after 12-24 h. Complete restitutio ad integrum
was observed in 2 horses. In both groups manipulating the foot massage increased SD and a new foot was
completed in 3-6 months.
CONCLUSIONS
With prolonged continuous cryotherapy and quasistatic auto-massage the damage and risk severity scores
remained lower during all the laminitis phases described previously. Furthermore, there was less need for
surgically aggressive interventions, such as DDFT tenotomy, wall ablation, and transcortical casting as is
usual in the clinical handling of these cases.5
Restitutio ad integrum was observed after applying prolonged cryotherapy to horses with early, severe acute
laminitis.5
Clinically the prolonged use of cryotherapy at -5/-7°C has a better and faster therapeutic value compared to
the 0-4°C prolonged cryotherapy system used for research purposes with cold water14-15-16 and the ice cubes
previously used by the author in his practice activity and furthermore the “dry” cryotherapy helps to avoid
the risk of WLD observed in the long term.
30 colic horses in 2009 with hyperglycemia received preventive prolonged cryotherapy treatment, none of
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them developed laminitis, as the number was not significant these horses have not been considered in this
study, but this observation needs further investigation.
The laminitic horse need the quasistatic movement in box confinement for at least two months to restore
correctly the laminar insult or damage and acquire an healthy foot with a thick sole.5 The key to minimiz-
ing the destructive potential of laminitis is to support the weight-bearing foot, even overloaded, creating vari-
ations in pressure and volume by manipulating the PA and changing the distribution of the weight-bearing
load and the location of the Static Center of Pressure (SCP), that maintains laminar perfusion and reduces
the biomechanical impact of laminar dermal-epidermal separation. 5
Figure 5 - Equine digital venograms made with the D’Arpe-Moreau block at 15°, 0°, -15°. The contralateral limb was kept raised while
the radiographs were acquired. The coronary plexus is circled in each venogram.
199 • WVOC 2010, Bologna (Italy), 15th - 18th September L. D’Arpe
These results tend to confirm Redden’s observation (2004) that raising the heels to produce a positive PA
preserves vascular perfusion of the dorsal laminae even during full weight bearing.9
Finally Author’s observation about SD in horse agree with Bicalho et al (2009) observations on bovine cush-
ion19.
The author is the inventor and principal developer of the “5 iced hearts” system.
REFERENCES
1. Deniau V., Rossignol F., Perrin R., Corde L., Brochet J.-L. (2004): “La laminite del cavallo: patogenesi e approccio
terapeutico”. Il piede del cavallo, edizione italiana a cura di Milo Luxardo e Cesare Rognoni, Le Point Vétérinaire
Italie.; 59-74.
2. Blood D.C, Radostits O.M., Henderson A.J. (1993): “Patologia medica veterinaria”. Edizione italiana a cura di Ven-
turoli M. Editoriale Grasso.
3. Wagner I.P. e Heymering. H. (1999): “Historical perspectives on laminitis”. Vet Clin North Am Equine Pract.,
15(2); 295-309.
4. Pollitt CC. “Equine Foot Studies” educational DVD, VideoVision, Information Technology Services, The Univer-
sity of Queensland, Queensland, Australia 1992.
5. D’arpe and Bernardini (2010) ”Digital Venograohy in horses and its clinical application in europe” article in press
Veterinary clinic of north america, 2nd volume equine laminitis edited by C.C. Pollit.
6. D’Arpe L., Mascia A., Coppola L. M. and Bernardini D. Is laminitis still a valid term to describe this disease or we
should better distinguish between laminar and solar corionitis? In: Proceedings of the international laminitis sym-
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posium. Berlin 2008.
7. Redden R.F. A technique for performing digital venography in the standing horse. Equine vet. Educ 2001;3:172-8.
8. Redden, R.F. The use of the venogram as a diagnostic tool. In: abstracts of the 7th Bluegrass Laminitis Symposium,
Louisville Ky 1993.
9. Redden RF. Preventing Laminitis in the Contralateral Limb of Horses with Non-Weight-Bearing Lameness. Clin
Tech Equine Pract 2004;3:57-63.
10. Redden RF. How to use Self-adjusting Palmar Angle to treat heel pain. In: Proceedings of the 16th Bluegrass,
Laminitis Symposium, Louisville Ky 2003.
11. D’arpe L., X.Moreau, P.Vigini, Bernardini D. La theorie des cinq coers du cheval. In Abstract of the 13th podiatry
congress Michel Vaillant, Cluses 2009.
12. Hood DM. Center of digital load during quasi –static loading. In: Proceedings of the 12th Annual Bluegrass
Laminitis Symposium, Louisville KY 1998.
13. Corley K. (2010) glicemia in horses in critical conditions. Proceedings of the XVI° international congress SIVE, Ma-
rina di Carrara, Italy.
14. Pollit CC. and van Eps AW., prolonged, continuous distal limb cryotherapy in the horse. Equine Vet J 2004; 36
(3):216-20.
15. van Eps AW and Pollitt CC. Equine Laminitis model: Cryotherapy reduces the severity of lesions evaluated seven
days after induction with oligofructose Equine Vet J 2009;41:741-6.
16. van Eps AW, Pollitt CC. Equine laminitis: cryotherapy reduces the severity of the acute lesions. Equine Vet J
2004;36:255-60.
17. Redden RF. How to treat high scale laminitis with wall ablation and transcortical cast. In: Proceedings of the 16th
Bluegrass, Laminitis Symposium, Louisville Ky 2003.
18. D’Arpe L., Hetzmann A., Rossignol F., Deniau V., Corde R., Bernardini D., Marechalerie et fourbure chez le cheval.
le nouveau Prat vet equine 2008;5:17, 29-33.
19. R. C. Bicalho,1 V. S. Machado, and L. S. Caixeta, Lameness in dairy cattle: A debilitating disease or a disease of
debilitated cattle? A cross-sectional study of lameness prevalence and thickness of the digital cushion. Journal of
Dairy Science 2009.92; 7.
ACKNOWLEDGMENTS
The author acknowledge the assistance of Prof. Spadari A. in the preparation of this abstract.
E. Eliashar WVOC 2010, Bologna (Italy), 15th - 18th September • 200
Mechanics of orthopaedic shoeing in horses -

what is the evidence?
Ehud Eliashar BSc, DVM, Dipl. ECVS, MRCVS
Lecturer in Equine Surgery, Dept. of Veterinary Clinical Sciences, The Royal Veterinary College, UK
Originally, the main reason for applying shoes to horses was to protect the feet against excessive wear. Over
the years, numerous types of shoes and corrective farriery techniques have been developed as a therapeutic
aid to treat lameness. Regaining soundness however, was not the only reason for which improved or differ-
ent hoof or shoe conformations were employed. Attempts to affect performance by altering hoof conforma-
tion have long been practiced.
Classic examples are the historical practice of trimming the foot of racehorses such that a lower heel and
longer toe are achieved in order to promote a “longer” stride, or the attempt to hasten breakover by modi-
fying the way the hooves are trimmed or shod.
Nevertheless, no matter what the purpose of the shoe is, the ways in which horses are shod are still very
similar to the techniques used centuries ago. Most of these techniques rely largely on traditional empirical
craftsmanship, rather than on scientific evidence, mainly as a result of the relatively little research that has
been carried out into the fundamental aspects of shoeing, resulting in lack of basic scientific knowledge.
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There is a fine line between maximal performance of the horse and overload injuries. When overload oc-
curs, the horse’s attempt to unload the painful limb creates the lameness we observe. However, because of
the relatively simple anatomical arrangement of the distal limb, the horse has only a limited scope by which
it can alter its gait. Furthermore, because the horse still has to support its weight, the ability to compensate
and redistribute the load is limited. Similarly, corrective shoeing and farriery techniques attempt to unload
a specific site, and/or to shorten the duration that site is bearing weight.
The past three decades have provided equine veterinarians with new information relating to limb biome-
chanics and the effects of various farriery methods, including so-called “corrective” ones. Obtaining much
of this information became possible once computers, combined with forceplates, pressure mats, and motion
analysis systems, became available. This then allowed for finer analysis of the effects of various shoeing in-
terventions in prospective biomechanical studies.
The effect of a particular shoe or farriery technique can be assessed during both the propulsion phase and/or
the stance phase of the stride. The latter phase is generally considered more important, from a lameness
point of view, as it is during this phase that the limb is subjected to external forces. Biomechanical studies
vary in the way they are conducted, and are affected by many variables. The horses studied can be sound
or lame, standing or moving, on various surfaces or on treadmills, and at different speeds or gaits. In vitro
studies using cadaver limbs can also be performed, although these studies may differ in the length of the
limb depending on the level that it was disarticulated from the body. The investigated change can be sub-
tle, such as when the effects of normal hoof growth and wear are evaluated, or exaggerated using wedges
or special shoes, with horses receiving inconsistent amount of time, if any, to adjust to the change. The in-
strumentation used for the study, as well as the way various points of interest on the limb are marked are
also variable.
Regardless of the method of investigation chosen, the data collected can be used to calculate the resultant
effects on many gait parameters such as foot flight, stride length, foot landing, joint angles, stance duration,
hoof roll and the external forces applied to the foot during stance, the forces exerted on various structures
and many more. However, the evaluation of such data must be made with an eye towards the variables in-
volved with each individual study.
Review of the literature demonstrates that some aspects are still controversial or unclear. Among these con-
troversies are the effects of change in heel height on the angles of the proximal interphalangeal and metacar-
pophalangeal joints, and on the strains of the flexor tendons and suspensory ligament. Comparisons of un-
shod and shod horses are rare, but the use of analysis systems such as the pressure mat, may help clarify
debates about the purported benefits of shoeing horses, versus leaving them barefoot. Fine analysis of the
distal limb appears to be limited by the complex anatomy. Indeed, it seems that full understanding of the
function of smaller structures, such as the distal sesamoidean or collateral ligaments, may only be achieved
with the use of computer simulation.
From an evidence-based perspective, most studies that have been performed evaluating the biomechanical
effects of the common shoeing and farriery techniques have been performed using sound horses, and many
others have been in vitro studies.
201 • WVOC 2010, Bologna (Italy), 15th - 18th September E. Eliashar
Thus, while the information obtained from such studies is interesting, its direct clinical relevance is specu-
lative, and the strength of evidence is not as strong as is desirable. There is a significant deficit in veterinary
knowledge regarding the effects of shoeing and farriery techniques on clinically affected lame horses, or
horses with identified clinical conditions. Hopefully, future studies will be performed to bridge this gap, com-
paring clinically lame horses to sound ones as controls, and/or in prospective designs assessing the long-term
effects of any particular technique.
FURTHER READING
Eliashar E. (2007) An evidence-based assessment of the biomechanical effects of the common shoeing and
farriery techniques. Vet Clin North Am Equine Pract.23(2):425-442.
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B.E. Eyes WVOC 2010, Bologna (Italy), 15th - 18th September • 202
Subchondral bone necrosis in the human knee

and hip joint
Brian E. Eyes, Dr, Mb, ChB, DMRD, FRCR
Consultant Radiologist with an interest in Musculo-skeletal Radiology, Divisional Medical Director for Support Services
University Hospital, Aintree Foundation Trust Liverpool. United Kingdom
Radiologist to Liverpool Football Club, Clinical Lecturer University of Liverpool
Osteonecrosis or avascular necrosis has been described for perhaps two hundred years in the human popu-
lation. The nomenclature for this condition has evolved over the years as the aetiology of the disease has
become better understood. Osteonecrosis can affect many bones in the human skeleton. The commonest
sites will be described and imaging examples will be presented.
The aetiology of this condition is wide and varied. As evidence of this over fifty causes of collapse and frag-
mentation of the femoral head have been described. Extensive research has identified the cause for many of
these conditions, but a significant number of these remain idiopathic.
The commonest causes in the femoral head are trauma, steroid medication, various inherited disorders of
haemoglobin structure, alcoholism and occupational disorders such as dysbaric condition’s (Caisson’s dis-
ease of divers).
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LARGE ANIMALS
The background cause for osteonecrosis is the same for bone as it is for all other organs. The cause must
be a cessation or restriction of blood flow. This may initially begin in any part of the vascular system from
arterial inflow to venous outflow. A reduction in flow through any part of the system will eventually lead to
a reduction of arterial inflow and hence anoxia will develop. This will lead to cell death and the typical ra-
diographic features of avascular necrosis will develop. The various components of bone have different sen-
sitivities to anoxia and it is this which contributes to the imaging findings.
In the human hip there are two peaks of incidence. The early peak occurs in childhood between the ages of
four and seven years. Some of these cases relate to trauma, but a significant number area idiopathic in na-
ture. There is a general spread of cases across the intervening years until there is a second peak in later life
as a consequence of trauma and fracture of the neck of the femur. Also in later life this peak is contributed
to by a further increase incidence of the idiopathic form of avascular necrosis and femoral head fragmenta-
tion and collapse. This condition affects men more than women and occurs between the fourth and seventh
decade of life. This may be unilateral or bilateral, but most often presents unilaterally.
A number of classification systems have been developed to clarify osteonecrosis of the femoral head. The
earlier systems relied on plain x-rays. None of these were entirely satisfactory and a more sensitive predic-
tor of disease activity was required. The introduction of magnetic resonance imaging has greatly enhanced
the later classification system with its ability to quantify the volume of involvement of the femoral head.
Perhaps the single most significant aetiological feature in avascular necrosis of bone is the anatomy of the
local blood supply. In the most commonly affected bones it is the distribution of the vascular anatomy that
probably mostly contributes to the development of bony fragmentation and collapse.
In the human knee osteonecrosis is observed in association with the many known causes of necrosis, but
there are also idiopathic cases in adults. The condition of osteonecrosis dissecans is a distinct entity in ado-
lescents affecting the males more than the females. In adults the affected bone tends to be the weight bear-
ing section of the central third of the medial femoral condyle, whilst in children it is the non weight bearing
section that is involved.
The imaging of avascular necrosis has depended on plain radiography. However, only the very late mani-
festation of bone death can be visualised by x-ray. Nuclear medicine imaging has been used but is not par-
ticularly sensitive.
Over recent years with the increasing availability of scanners, magnetic resonance has now become the im-
aging method of choice.
The radiographic and magnetic resonance imaging features are very similar whichever bone is involved.
Examples of the classical plain x-ray and magnetic resonance features will be demonstrated and described
concentrating on the hip and knee.
203 • WVOC 2010, Bologna (Italy), 15th - 18th September B.E. Eyes
Pre purchase magnetic resonance imaging of professional

football players… what have we learnt?
Brian E. Eyes, Dr, Mb, ChB, DMRD, FRCR
Consultant Radiologist with an interest in Musculo-skeletal Radiology, Divisional Medical Director for Support Services
University Hospital, Aintree Foundation Trust Liverpool. United Kingdom
Radiologist to Liverpool Football Club, Clinical Lecturer University of Liverpool
The provision of Radiological services to a professional football club can be an extremely challenging posi-
tion. The presigning medical has now become an obligatory part of the transfer of players. The player will
have a full medical including fitness assessment, cardiac testing and blood tests for drug abuse. The final
piece of the jigsaw is the magnetic resonance scan.
As a routine, only the knees of the player are scanned as it is this area that is most likely to give problems.
This will be extended to other joints if there has been a previous injury, or the physical examination has re-
vealed an abnormality. Goalkeepers tend to have MR of the shoulders and possibly elbows as a routine.
The number of joints scanned will vary from club to club. Liverpool tend to have the least joints examined
whereas other clubs may have hips, knees, ankles and lumbar spine all included in their medical.
The majority of professional footballers will have had a significant number of injuries and possibly surgery
MAIN PROGRAM
LARGE ANIMALS
over their professional career. This will require assessment both clinically and by magnetic resonance imag-
ing. The consequences of these injuries will be apparent on the images and as the player reaches the latter
part of his career, the inevitable degenerative changes and osteoarthritis will also develop.
There is however a very difficult judgement call to make when assessing any abnormality that becomes ap-
parent on the MR scan. A considerable amount of negotiation has been ongoing in advance for the trans-
fer to reach this stage. The last thing the clubs, player, agent and managers will want is for the deal to stall
at the last moment. There is therefore considerable pressure on the radiologist not to find anything. If a sig-
nificant abnormality is found then the potential risk of signing an injured player for a considerable amount
of money will need to be assessed. There is no absolute scientific method to do this and it is here that ex-
perience and judgement are essential. The manager of course will want the player no matter what and he
will expect the club medical staff to maintain and improve the fitness and availability of the player. In these
circumstances deals are usually agreed on whereby the purchasing club may reduce the fee, or they may
agree to pay an initial deposit and then further instalments based on the number of appearances.
Obviously the younger the player, the more the scrutiny of any injury that is uncovered. For example, a
menisectomy with some loss of articular cartilage will have considerably greater consequences for a young
player as against a player approaching the end of his career.
There is further difficulty in the medical assessment because the previous medical notes are not made avail-
able to the proposed new club. It is surprising how often language difficulties arise when there is any dis-
cussion about previous surgery.
This lecture will concentrate on imaging of the knee joint and its associated soft tissue structures. The an-
kle joint will also be briefly mentioned.
The most commonly encountered previous injuries and surgery are meniscal injuries. Examples of these in-
juries and the appearance following meniscal resection will be demonstrated. An attempt will be made to as-
sess these injuries and their possible future influence on the player’s availability for selection.
The cruciate ligament complex will also be described in detail and the magnetic resonance features of acute
injuries and post surgical changes will be described.
The collateral ligaments are also detailed and examples of injuries will be shown.
Reference will also be made to articular cartilage integrity and its influence on both the player’s fitness and
future transfer prospects. The ankle joint will also be discussed and some examples of injury to the ankle
will be demonstrated.
C.E. Judy WVOC 2010, Bologna (Italy), 15th - 18th September • 204
Contrast enhanced magnetic resonance imaging

in the horse
Carter E. Judy, DVM DACVS, Travis C Saveraid, DVM DACVR,
Elizabeth Rodgers, DVM, Mark C. Rick, DVM, Doug Herthel, DVM
Alamo Pintado Equine Medical Center, PO Box 249, 2501 Santa Barbara Ave, Los Olivos, CA 93441
INTRODUCTION
Magnetic Resonance Imaging (MRI) of the musculoskeletal system is becoming commonplace for the eval-
uation and diagnosis of bone and soft tissue injuries in the horse. While MRI is sensitive to changes with-
in these tissues, in certain cases, subtle injuries can be overlooked. The significance of soft tissue injuries can
be over and under interpreted based on the MR signal characteristics of the affected tissues. Chronic ten-
don injuries that have resulted in scarring of the tissue may remain present on static MRI images without
being part of the current clinical problem. The ability to visualize an anatomical abnormality on MRI does
not necessarily equate to being part of the current clinical process.
In humans, contrast-enhanced MR imaging has helped to both define and follow the healing of soft tissue in-
juries. Contrast enhanced imaging of the Achilles tendon1-3, the tendon sheaths of the wrist4 and the bone mar-
row of the ankle5 have helped to refine the dynamic state of an injury as well as its current state of healing.
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In horses, arterial contrast-enhanced computed tomography has been used to help delineate the soft tissues,
their vascularity and current state of inflammation6. The use of intravenous gadolinium contrast has not
been reported in equine musculoskeletal magnetic resonance imaging. Intravenous contrast has been used
in the imaging of the equine brain7 but other uses have been limited. A concurrent studya of 25 horses un-
dergoing MRI examination for clinical lameness, determined that a dosage of 0.1 mls/kg of gadopentetate
dimeglumine (Magnevist®)b intravenously was safe and provided significant contrast enhancement of the tis-
sues of the foot.
The purpose of this study is to describe the MRI lesions identified in clinical cases using a single intravenous
bolus dose of gadopentetate dimeglumine contrast (Magnevist®)b. It is hypothesized that contrast enhanced
equine orthopedic (CEEO) MRI will improve the ability to detect disorders in equine orthopedic cases and
will help to differentiate between active and inactive lesions.

Twenty-four lame horses presented for routine orthopedic magnetic resonance imaging of the front feet were
utilized. Owners were consulted prior to inclusion in to the study and written and verbal consent was ob-
tained. All horses underwent complete lameness examinations including evaluation in a straight line and in
a circle in both directions on firm and soft ground. Lameness severity was graded according to the Ameri-
can Association of Equine Practitioners lameness grading scalec. Peri-neural analgesia was performed to lo-
calize the region of pain. Horses whose pain was localized to the foot were included. Prior to MRI evalua-
tion, a complete physical examination, complete blood count and survey radiographs of both front feet were
obtained.
Horses were sedated with intravenous xylazine (1.1 mg/kg) and induced into general anesthesia using a com-
bination of intravenous ketamine (2.2 mg/kg) and diazepam (0.05 mg/kg). Horses were maintained under
general anesthesia using isoflurane in oxygen using a custom-made MRI safe large animal anesthesia sys-
temd. Heart rate, direct and indirect arterial blood pressure, oxygen saturation, inspired carbon dioxide, ex-
pired carbon dioxide, inspired and expired isoflurane and temperature were monitored and recordede. Hors-
es were positioned in right lateral recumbency on a custom-made MRI safe equine tablef and the limb to be
a
Judy C, Saveraid T, Rodgers E, Rick M, Herthel D “Development of an Effective Dosage of Gadopentetate Dimeglu-
mine for Contrast Enhanced Equine Orthopedic Magnetic Resonance Imaging,” in preparation.
b
Magnevist® brand gadopentetate dimeglumine – medication package insert – June 2007, Bayer Health Care Pharma-
ceuticals Inc, Wayne, NJ 07470.
c
American Association of Equine Practitioners, 4075 Iron Works Parkway, Lexington, KY 40511.
d
2800C-P Combined large/small animal MRI safe anesthesia ventilation system, Mallard Medical, 20268 Skypark Drive,
Redding, CA USA.
e
Veris MR Vital Signs Monitor, Medrad Inc, 10 Global View Drive, Warrnedale, PA USA.
f
Shank’s Veterinary Equipment, 505 E. Old Mill Street, Milledgeville, IL, USA.
205 • WVOC 2010, Bologna (Italy), 15th - 18th September C.E. Judy
imaged was placed within the bore of the magnet. A 1.5T Siemens Magnetom Espree MR system with a
high resolution 8 channel knee coilg was utilized for all cases. The limb that was sound or was less lame was
imaged first. The lamest limb was imaged second. The following pre-contrast imaging sequences were ob-
tained from both limbs:
• Dual Echo - Proton Density + T2 weighted – axial and sagittal sequences
• T1 weighted Volume Interpolated Enhancement (VIBE) fat suppressed (FS) - axial, sagittal and dorsal
sequences.
• T2 weighted Short Tau Inversion Recovery (STIR) – axial, sagittal and dorsal sequences.
• Proton Density FS – dorsal oblique sequence (impar axial).
The limb with the greatest severity of lameness underwent the post contrast evaluation. Each horse was ad-
ministered intravenous gadopentetate dimeglumine (Magnevist®)b at the end of the standard MR exam. Af-
ter administration, a waiting period of one minute was applied prior to scanning to allow distribution of the
contrast agent. All post contrast sequences consisted of T1 Volume Interpolated Enhancement (VIBE) fat
suppressed (FS) imaging sequences in axial and sagittal planes. The contrast protocol was as follows:
• Standard MR exam of the lame leg including pre-contrast T1 VIBE FS axial and sagittal images.
• Administer IV gadopentetate dimeglumine contrast (Magnevist®)b at 0.1 mls/kg
• Perform post contrast T1 VIBE FS axial and sagittal sequences
Subjective evaluation of both pre and post contrast images were made by a board certified veterinary radi-
ologist (DACVR) and a board certified equine surgeon (DACVS). Each sequence was evaluated individu-
ally for the presence or absence of the pathological abnormalities identified on other sequences. The sever-
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ity of identified lesions on each sequence was recorded as mild, moderate and severe (1, 2, and 3).
Regions of interest (ROI) were collected from both pre and post contrast images from the areas of patho-
logical abnormalities as well as the following regions:
• Medial palmar digital artery and vein, 1 cm proximal to the navicular bone.
• Dorsal aspect of the coffin joint capsule and synovium on midline 1 cm proximal to the extensor process
of the coffin bone.
• The deep digital flexor tendon at the level of the mid pastern (normal region).
• The dorsal cortical bone of the mid-sagittal aspect of the first phalanx at its mid-point from proximal to
distal.
• The ROI pixel intensity of each area was collected using a computerized post-processing image evalua-
tion programh. The signal intensity of the post contrast images was compared to the pre-contrast images
and a relative ratio of pre to post contrast enhancement was determined. This value is calculated using
the following formula:
• Relative Ratio = (Post contrast ROI value – Pre-contrast ROI Value)

Pre-contrast ROI Value
This is a unit less value representing the relative degree of contrast enhancement. A paired t-test was used
to determine if the signal intensity of the post contrast ROI was significantly different from the baseline pre
contrast ROI of both the “normal” regions of interest and the pathological regions of interest. Significance
was set at p<0.05.
RESULTS
Twenty four horses were included in the study. The breeds included thirteen quarter horses, nine warm bloods,
one thoroughbred and one Arabian. The mean age was 9.3 years (range 6-16 years) and there were 14 geld-
ings, 9 mares and one stallion. The left front limb underwent contrast evaluation in 10 horses and the right
front limb underwent contrast evaluation in 14 horses. The mean degree of lameness was 2.5 (range 2-4).
No horses experienced anesthetic or recovery problems. All vital parameters remained within normal limits
prior, during and after intravenous administration of the gadopentetate dimeglumine (Magnevist®)b. The
protocol of single dose contrast added approximately 5 minutes to the total anesthesia time, including in-
jection and scanning. Total anesthesia time for all sequences of both feet was approximately 55 minutes.
Table one summarizes the results of the contrast enhancement of normal structures evaluated in each limb.
The medial palmar digital artery contrast enhanced most significantly and consistently with an average en-
hancement ratio of 0.49 (p<0.00). The dorsal aspect of the coffin joint also significantly enhanced with an
g
Siemens Medical, 51 Valley Stream Parkway, Malvern, PA 19355-1406.
h
Osirix, v. 3.0, www.osirix-viewer.com, 2008.
average enhancement value of 0.23 (p<0.00). The deep digital flexor tendon was noted to enhance mini-
mally and only had a relative enhancement of 0.05. This represents only a 5% increase in the ROI from pre
to post contrast images. This low value results in there being no significant difference between pre and post
ROI’s (p=0.60). The results of the cortical bone of the dorsal aspect of the first phalanx are similar to the
deep digital flexor tendon, with an enhancement ratio of 0.00, with no significant difference in the ROI be-
tween pre and post contrast images (p=0.65).
Table 1 - Normal regions examined on routine and contrast enhanced MRI of the equine foot.
The average relative ratio of contrast enhancement is an average of the ratio of the pre-contrast ROI
subtracted from the post-contrast ROI divided by the pre-contrast ROI value.
This gives a relative degree of contrast enhancement of the given region of interest.
The paired t-test is a comparison of the pre and post contrast enhancement ROI and determines if the
contrast enhancement can be considered significant for a given pathological region (significance is p<0.05)
Region Examined Average Relative Ratio of Contrast Paired

Enhancement (St. Dev) t-test
Medial Palmar Digital Artery 0.49(0.19) 0.00
Dorsal Coffin Joint 0.23(0.18) 0.00
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Deep Digital Flexor Tendon in the mid-pastern 0.05(0.15) 0.60

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Dorsal cortical bone of first phalanx 0.00(0.20) 0.65
Table 2 - Lesions identified on routine and contrast enhanced MRI of the equine foot.
The number of instances is the number of times the abnormality was identified.
Multiple abnormalities may be present in one foot, therefore the sum of these values is greater than the total
number of horses. The average severity represents a subjective interpretive value with 1 being mild, 2 being
moderate and 3 being severe. The average relative ratio of contrast enhancement is an average of the ratio of
the pre-contrast ROI subtracted from the post-contrast ROI divided by the pre-contrast ROI value.
This gives a relative degree of contrast enhancement of the given region of interest. The paired t-test is a
comparison of the pre and post contrast enhancement ROI and determines if the contrast enhancement can
be considered significant for a given pathological region (significance is p<0.05)
Lesions Number Average Average Relative Ratio of Paired
of instances Severity (St. Dev) Contrast Enhancement (St. Dev) t-test
Navicular Bone Edema
14 1.57 (0.85) 0.14 (0.31) 0.16
Collateral Sesamoidean
Ligament Desmitis 9 1.44 (0.53) 0.05 (0.09) 0.04
Deep Digital Flexor Tears 9 1.67 (0.87) 0.16 (0.20) 0.04
Navicular Bursitis 5 1.20 (0.45) 0.29 (0.28) 0.09
Impar Ligament Desmitis 4 1.75 (0.50) 0.69 (0.28) 0.02
Navicular Bone Flexor
4 2.25 (0.96) 1.05 (0.20) 0.00
Cortical Erosion
Pastern Joint Arthritis 3 1 (0.00) 0.08 (0.17) 0.73
Coffin Bone Edema 2 2 (0.00) 0.59 (0.52) 0.39
Collateral Ligament
1 2 0.42
of the Coffin Joint Desmitis
Coffin Joint Synovitis 1 2 0.44
Navicular Bone Avulsion Fragment 1 1 0.12
Subcutaneous Edema 1 2 0.13
None 1
Table two summarizes the results of the pathological regions identified by contrast enhanced MRI. Deep
digital flexor tendon tears (p=0.04), impar ligament desmitis (p=0.02), collateral sesamoidean ligament
desmitis (p=0.04) and navicular bone flexor cortical margin erosions (p<0.00) were the only regions to sig-
nificantly enhance. Navicular bursitis (p=0.09) approaches, but does not reach statistical significance. Col-
lateral ligament of the coffin joint desmitis, and coffin joint synovitis were noted to have high relative ratios
of contrast enhancement (0.59 and 0.42, respectively), but due to the low number of instances, the signifi-
cance of the enhancement was not able to be determined. Likewise, navicular bone avulsion fragments and
subcutaneous edema had mid-range enhancement ratios (0.12 and 0.13, respectively), but significant con-
trast enhancement was not able to be determined due to the low level of incidences in this population.
When comparing the pre and post contrast ROI’s of the deep digital flexor tears that have a mild (grade 1)
subjective severity score, there is not a significant increase in contrast (p=0.31). Similar results are noted for
the collateral sesamoidean ligament desmitis lesions with a mild (grade 1) subjective severity score (p=0.34).
DISCUSSION
This is the first report of contrast enhanced orthopedic imaging of the horse. One of the goals of this study
was to identify which lesions would be most notable with contrast enhancement. Deep digital flexor tendon
tears, impar ligament desmitis, collateral sesamoidean ligament desmitis and navicular bone flexor cortical
margin erosions were all noted to have significant contrast enhancement when compared to pre-contrast
ROI’s. Collateral ligament of the coffin joint desmitis and coffin joint synovitis had high relative ratios of
contrast enhancement, but significance was not able to be determined due to the low level of instances of
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these problems.
The diagnostic utility of contrast enhanced MRI depends on the absolute concentration of the agent in the
desired tissue and the selectivity of the distribution relative to other tissues8. Gadopentetate dimeglumine
(Magnevist®)b can be considered an extracellular fluid agent8 and is well suited for imaging of the equine
foot. These agents are well suited for applications with capillary breakdown, or increases in extracellular vol-
ume8. When disruption occurs within the tissues and there is inflammation, capillary breakdown and leak-
age into the extracellular compartment, gadopentetate dimeglumine (Magnevist®)b, will penetrate the region
and become detectable on MRI. If the capillaries remain intact, and have had a chance to heal, the contrast
will remain in the vascular space and will not result in a relative increase in contrast within the lesion.
Deep digital flexor tears were one of the most frequently encountered pathological problems identified dur-
ing this study (Figure 1). These injuries were noted to enhance significantly. However, when the subjective
severity of the tear was mild (grade 1), the degree of contrast enhancement was no longer significant. This
may be due to the fact that less severe lesions represent chronic injuries and do not have the vascularity, cap-
illary breakdown or active inflammatory conditions of more active lesions. This would result in less disper-
sion of the contrast agent into the lesion. In tendon, the abnormal alignment and cross linking of collagen
will result in a high signal in T1 weighted images. This high signal results in the characteristic tendon lesion
(Figure 2). However, this signal change does not necessarily correlate with active pathology on T1 weight-
ed images. The tendon may be
acutely injured and have dis-
ruption of fibers, or it may
be healed and have irregular
cross-linking of collagen. Con-
trast enhanced MRI enables
further evaluation of such le-
sions and applies a more pre-
cise method to determine if a
lesion is active or chronic and
potentially healed.
The relatively small size of the
impar ligament makes imaging
of this structure difficult. The
addition of contrast vastly im-
proved the detection and classi-
fication of these lesions. These Figure 1 - Pre and post contrast T1 Fat-suppressed VIBE axial image of a deep digital flex-
lesions were often under report- or tendon with high signal within the medial lobe of the deep digital flexor tendon (see circle).
ed or their severity was mis- The image on the left is the pre contrast image and the image is the post-contrast image. The fiber
represented based on the rou- disruption is evident on both images, but the contrast enhancement is indicative of inflammation
tine MRI. With the addition of and active remodeling of the lesion.
the contrast agent, these lesions

became much more evident
(Figure 3).
Bone edema of the navicular
bone was a frequent finding.
This diagnosis was made on
the Short Tau Inversion (STIR)
sequences. Contrast enhance-
ment of these lesions was not
significantly increased com-
pared to pre-contrast ROI val-
ues. This is likely due to the
fact that the term “bone mar-
row edema” is often mislead-
ing because the abnormal sig-
nal is not caused by the pres- Figure 2 - Pre and post contrast T1 Fat-suppressed VIBE axial image of a deep digital flex-
ence of fluid alone9. Bone mar- or tendon with high signal within the lateral lobe of the deep digital flexor tendon (see circle).
row edema is a nonspecific le- The pre contrast image is on the left and the post contrast image is on the right. Notice the lack
sion that is associated with a of contrast enhancement of the lesion on the right image. This would be considered an injury with
variety of disorders. In several little vascularization and inflammation.
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studies about the histopatholo-

gy of equine navicular bones,
it was found that there was a large amount of myxoid fibrous tissue within the medullary cavity of the nav-
icular bones10, or the presence of necrotic fat and cavitary spaces within the medulla of the bone11. This type
of fibrous tissue is unlikely to contrast enhance for the same reasons that a chronic tendon injury will not
enhance. As long as the capillary permeability is low, then contrast will not “leak” into the surrounding ex-
tracellular space and there will be no contrast enhancement.
The contrast enhancement of the “normal” tissues was measured as a relative reference for contrast en-
hancement of a variety of tissues. The artery enhanced most significantly (average relative ratio = 0.49,
p<0.00) while the dorsal coffin joint was intermediate (average relative ratio = 0.23, p<0.00). The deep dig-
ital flexor tendon (average relative ratio = 0.05, p=0.65) and the cortical bone of dorsal P1 (average relative
ratio = 0.00, p=0.65) did not show significant increases in the amount of contrast that was evident. This is
what would be expected given the amount of vascularity of each structure. The artery would contain a large
amount of contrast and the coffin joint synovial membrane is well vascularized and would contain a mod-
erate amount of contrast. Tendon and bone are relatively poorly vascularized, so the level of contrast in a
normal structure should be exceptionally low and not be significantly different from pre-contrast levels.
No problems were encountered with any of the horses receiving the contrast agent during or after the pro-
cedure. The incidence of complications in humans is low, less than one in 400,000 patients experience seri-
ous problems with the majority of these reactions being anaphalactoid8. Long term safety data is not avail-
Figure 3 - Pre contrast, post contrast and digital subtraction of the pre and post contrast T1 FS VIBE axial image of a horse with impar
ligament desmitis of the medial aspect of the ligament. The left image is the pre-contrast image, the middle image is the post-contrast image and
the right image is the digital subtraction of the pre and post contrast images. The subtraction image leaves only contrast material visible and
helps aide in the detection of subtle lesions.
able for the horse currently. The cost of the contrast material is relatively high at a veterinarian cost of about
$200.00 per dose of contrast agent.
In conclusion, the use of contrast enhanced MRI for the detection, and staging of equine orthopedic condi-
tions is useful. It provides further information about the physiological disposition, capillary permeability and
the relative state of the tissues that the contrast interacts with.
REFERENCES
1. Shalabi A. Magnetic resonance imaging in chronic Achilles tendinopathy. Acta Radiol. 2004;45:1-45
2. Shalabi A, Kristoffersen-Wiberg M, Aspelin P, Movin T. MR evaluation of chronic achilles tendinosis. A longitu-
dinal study of 15 patients preoperatively and two years postoperatively. Acta Radiol. 2001;42:269-276.
3. Shalabi A, Kristoffersen-Wiberg M, Papadogiannakis N, Aspelin P, Movin T. Dynamic contrast-enhanced mr im-
aging and histopathology in chronic achilles tendinosis. A longitudinal MR study of 15 patients. Acta Radiol.
2002;43:198-206.
4. Tehranzadeh J, Ashikyan O, Anavim A, Tramma S. Enhanced MR imaging of tenosynovitis of hand and wrist in
inflammatory arthritis. Skeletal Radiol. 2006;35:814-822.
5. Schmid M, Hodler J, Vienne P, Binkert C, Zanetti M. Bone marrow abnormalities of foot and ankle: STIR versus
T1-weighted contrast-enhanced fat-suppressed spin-echo MR imaging. Radiology. 2002;224:464-4694.
6. Puchalski SM, Galuppo LD, Hornof WJ, Wisner ER. Intraarterial contrast-enhanced computed tomography of the
equine distal extremity. Vet Radiol Ultrasound. 2007;48:21-29.
7. Ferrell E, Gavin P, Tucker R, Sellon D, Hines M. Magnetic resonance for evaluation of neurologic disease in 12
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horses. Vet Radiol Ultrasound. 2002;43:510-6.
8. Edelman R, Hessenlink J, Zlatkin M, et al. Clinical Magnetic Resonance Imaging 3rd ed. Philadelphia: Elsevier
Health Sciences. 2006;358-409.
9. Mayerhoefer M, Breitenseher M, Kramer J, Aigner N. STIR vs. T1-weighted fat-suppressed gadolinium enhanced
MRI of bone marrow edema of the knee: computer assisted quantitative comparison and influence of injected con-
trast media volume and acquisition parameters. Journ of Magnetic Resonance Imaging. 2005;22:788-93.
10. Wright I, Kidd L, Thorp B. Gross, histological and histomorphometric features of the navicular bone and related
structures in the horse. Equine Vet J. 1998;30:220-34.
11. Blunden A, Dyson S, Murray R, Schramme M. Histopathology in horses with chronic palmar foot pain and age
matched controls. Part 1: Navicular bone and related structures. Equine Vet J. 2006;38:15-22.
Magnetic resonance imagning of the equine stifle

in a clinical setting
Carter E. Judy, DVM, DACVS, Travis C. Saveraid, DVM DACVR,
Mark C. Rick, DVM, Doug J. Herthel, DVM
Alamo Pintado Equine Medical Center, PO Box 249, 2501 Santa Barbara Ave, Los Olivos, CA 93441
INTRODUCTION
Imaging of the equine stifle in clinical cases has traditionally been limited to radiographic evaluation, ultra-
sound examination, diagnostic arthroscopy and nuclear scintigraphy. Each technique has its benefit and lim-
itations. Magnetic Resonance Imaging (MRI) is the gold standard in imaging human orthopedic conditions
and is becoming increasingly used in the evaluation of lameness in the equine athlete.1-4 MRI provides a non-
invasive technique to evaluate both the soft tissue and bone of a given anatomical region. Previous reports
of MRI evaluation of the equine stifle have been limited to cadaver studies5.
PATIENT AND SCANNER PREPARATION

Imaging of the equine stifle is not for the faint of heart. It requires utilizing the available equipment at the
edge of its design specifications. It requires positioning of the patient within the confines of a relatively small
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gantry (70 cm) and placing the stifle within the useful magnetic field. Many horses will not be able to be im-
aged due to limitations of the currently available scanners.
Prior to anesthesia and imaging, horses are screened by weight, “femur length” as measured from the apex
of the patella to the greater trochanter of the femur, “tibial length” as measured from the apex of the patel-
la to the point of the hock, and “pelvic measurement” as measured from tuber coxae to tuber coxae over
the dorsum. A review of successful MRI examinations revealed that all horses with femur lengths greater
than 44 cm, tibial lengths greater than 44 cm and pelvic measurements less than 62 cm have the best results.
Partial examination of the stifle is possible if one of these measurements is non-compliant, but if more than
one is outside these parameters, imaging of the stifle has not been possible.
Currently MRI images are obtained using a Siemens Magnetom Espree with a field strength of 1.5 Teslaa.
Prior to introducing the horse into the magnet, the attached MRI tablea with integrated spine coila is pre-po-
sitioned into the bore of the magnet. The center of the magnetic field is noted. The horse is anesthetized in-
to general anesthesia and placed in lateral recumbency with the stifle to be imaged on the down side (i.e. if
the right stifle is to be imaged then the horse is placed in right lateral recumbency). The horse is placed on
a separate MRI compatible movable tableb and placed adjacent to the bore of the magnet. The horse is then
manually positioned into the magnet as far as possible. Ropes and padding are used to stabilize the limb to
prevent further movement. A body matrix coila is placed medially over the stifle to be imaged to create a
parallel imaging array with the integrated spine coil within the MRI table that was pre-positioned (Pictures
1 & 2). Use of the integrated body coila is possible, but image quality is compromised.
Picture 1 - Horse in undergoing MRI examination of the stifle. Picture 2 - Positioning of the limbs and coils for optimal imaging
of the equine stifle. The stifle to be imaged is against the table (i.e.
horse is in right lateral recumbency to image the right stifle).
IMAGING SEQUENCES
A combination of a body matrix coila and the integrated spine coila are used in parallel to acquire the signal.
Images are obtained in multiple planes using multiple acquisition sequences - Proton Density and T2 weight-
ing dual echo, T2 FISP (coherent gradient echo), T2 STIR (Short Tau Inversion Recovery), T1-weighted
VIBE (Volume Interpolated Gradient Echo) fat saturation, T2 medic water excitation (Multi-Echo Data Im-
age Combination) and T2 CISS (True FISP dual excitation) sequences.
The average time required to produce 14 sequences is 45 minutes for one stifle. Currently imaging of a sin-
gle stifle is performed since imaging the opposite stifle would require a change in recumbency and would
compromise the anesthetic condition of the patient.
EXAMPLE DIAGNOSES
Imaging of the stifle with MRI has provided further insight into the pathology of this anatomic region. Ex-
amples of abnormalities that have been found include:
• Medial meniscal tearing.
• Bone edema – tiba, femur, and patella.
• Osteochondral fragmentation
• Cranial cruciate desmitis
• Caudal cruciate desmitis.
• Synovitis
• Patellar ligament desmitis
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• Collateral ligament desmitis
• Synovial effusion
• Cartilage erosions / tearing
a
Siemens Medical, 51 Valley Stream
Parkway, Malvern, PA 19355-1406. Example 1 - Proton density (PD) MRI image of an equine stifle in a dorsal plane show-
b
Shank’s Veterinary Equipment, 505 E. ing the presence of a large cystic lucency, marked joint effusion and disruption of the medial
Old Mill Street, Milledgeville, IL, USA. meniscus.
Example 2 - Short Tau Inversion Recovery (STIR) image of an equine stifle in adorsal Example 3 - Proton Density (PD) para-
plane showing edema of the proximal aspect of the tibia consistent with a bone contusion and sagittal projection of the lateral ridge of the
moderate effusion of the synovial structures. trochlea of the femur exhibiting subchondral
defects of the ridge. Marked effusion of the
femoropatellar joint is also noted.
DISCUSSION
Imaging of the equine stifle has long been a difficult proposition. In human orthopedics, MRI has become
the “gold standard” to image the human knee. In the horse, radiographs and ultrasound have been useful
in identifying bony and some soft tissue injuries. Nuclear scintigraphy has been helpful in identifying in-
flammatory conditions, but lacks the anatomical detail. Diagnostic arthroscopy gives excellent visualization
of structures that are visible with the procedure, but lacks in its ability to see the entire joint and deeper in-
to the bone. All of these techniques evaluate limited portions of the equine stifle and do not allow for a com-
plete examination. MRI allows a relatively noninvasive technique to evaluate the structures of the equine
stifle. Historically MRI has not been considered feasible due to magnet size restrictions. With the advent of
a wide bore (70 cm), ultra-short length bore (125 cm), and the ability of the magnet table to handle larger
weights, it has become feasible to image select equine patients. This technique is evolving and has shown
great promise in imaging horses whose problems went previously undiagnosed.
CONCLUSION
Imaging of the equine stifle is feasible using a high field MRI scanner. Limitations remain present and are
determined by the relative size of the patient. The images derived in clinical cases provided information not
possible by other imaging techniques.
REFERENCES
1. Edelman RR, Hessenlink JR, Zlatkin MB, Crues JV. Clinical Magnetic Resonance Imaging 3rd ed. Philadelphia:
MAIN PROGRAM
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Elsevier Health Sciences, 2006.

2. Dyson SJ, Murray R, Schramme M. Lameness associated with foot pain: results of magnetic resonance imaging in
199 horses (January 2001-December 2003) and response to treatment. Equine Vet J. 2005;37:113-121.
3. Zubrod CJ, Schneider RK, Tucker RL, et al. Use of magnetic resonance imaging for identifying subchondral bone
damage in horses: 11 cases (1999-2003). J Am Vet Med Assoc. 2004;224:411-418.
4. Tucker RL, Sande R. Computed tomography and magnetic resonance imaging in equine musculoskeletal condi-
tions. Vet Clin North Am: Equine Pract. 2001;17:115-129.
5. Holcombe SJ, Bertone AL, Biller DS, Haider V. Magnetic Resonance Imaging of the Equine Stifle. Veterinary Ra-
diology & Ultrasound 1995, 36:119-125.
213 • WVOC 2010, Bologna (Italy), 15th - 18th September K.G. Keegan
Analysis of gait patterns in sound and lame horses

Kevin G. Keegan, DVM, MS, Dipl. ACVS
Professor: Veterinary Medicine and Surgery - Director: E. Paige Laurie Endowed Program in Equine Lameness College
of Veterinary Medicine, University of Missouri, Columbia, MO 65201, USA
What is the purpose of equine gait analysis? Is it good for anything practical or is it just something to play
with? The goal of this presentation is to show that it is not just a toy and it is not “soft science”. It is hard
and serious work, and over the years, in many different locations around the world, results of kinematic
studies have provided the veterinary profession with useful information and tools for research and clinical
practice.
Gait analysis can detect phenomena that cannot be “seen” by the unaided human eye. Most gait analysis
techniques sample data at high rate, much higher than the best sampling rate possible with the unaided hu-
man eye, even under ideal environmental conditions of visibility. Gait analysis technique provides objective
measures that can be defined and explained between colleagues and between mentor and student, allowing
standardization of communication and teaching. Standardization and objectivity, if precise and accurate, is
always better than lack of standardization and subjectivity.
First let us examine some of the evidence that speaks to the need of an objective method of lameness eval-
uation. It is based on low agreement between experienced clinicians at detecting mild lameness and the
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propensity of bias in subjective evaluation.
Evaluation of mild lameness in horses trotting on a treadmill: Agreement by clinicians and interns or resi-
dents and correlation of their assessments with kinematic gait analysis. Am J Vet Res 1998. Between observ-
er agreements for detection of lameness; 23% above chance for experienced clinicians, 21% above chance
for interns/residents. Between observer agreement for experienced clinicians for a change in lameness only
19% above chance.
Investigations of the reliability of observational gait analysis for the assessment of lameness in horses. Vet
Rec 2006. Experienced veterinary evaluators only moderately reliable at assessing lameness severity (56-
60% total agreement).
The intra- and inter-assessor reliability of measurement of functional outcome by lameness scoring in hors-
es. Vet J 2006. Inter-assessor agreement barely acceptable (41% above chance).
Evidence of bias affecting the interpretation of the results of local anesthetic nerve blocks when assessing
lameness in horses. Vet Rec 2006. Veterinarians graded lameness 1 degree lower if they thought a block had
been performed.
Repeatability of subjective evaluation of lameness in horses. AJVR 2010. Inter-observer agreement on exis-
tence and location of lameness was 50%. Inter-observer agreement on existence of lameness in a given limb
was 67% for mild forelimb lameness and 50% for mild hind limb lameness.
This suggests that studying and developing objective methods of lameness evaluation in horses is a worth-
while endeavor. There are 2 approaches to objective lameness evaluation, kinetic methods, most notably the
stationary force plate, and kinematic, or the measurement of motion. This presentation will not address ki-
netic methods, except to say that they are very precise and accurate, but impractical for clinical use. Kine-
matic technique is typically accomplished with high-speed cameras and markers, but recently body-mount-
ed inertial sensors have been investigated. Kinematic variables generally have higher test-retest variability
(i.e. are less repeatable) than force plate variables. Despite this, kinematic gait analysis is generally more in-
tuitive to the veterinary practitioner. It is basically measuring what the practitioner sees anyway, only with
greater sensitivity. Computer assistance is used to record, quantify, and then analyze the trajectories of the
marked body parts. Because of the desirability to collect multiple contiguous strides most kinematic studies
of lameness in horses using cameras and markers are performed when the horse is moving on a treadmill.
This is not ideal because the horse moves differently on the treadmill than it does over ground. Recent de-
velopments in wireless inertial sensor system design, however, have made it possible to conduct kinematic
studies of lameness in horses over ground.
Below is a list of kinematic measures shown by experiment to be reasonable indicators of lameness in
horses.
Maximum fetlock extension and maximum coffin joint flexion during the stance phase of the lame limb is
decreased compared to the stance phase of the contralateral sound limb.
Carpal extension during stance is reduced in the lame limb but only with moderate to severe lameness.
Stance duration for the lame limb is greater (not less) than for the sound limb in horses with mild to mod-
erate lameness.
K.G. Keegan WVOC 2010, Bologna (Italy), 15th - 18th September • 214
Step duration, or the time between pushoff of one limb and impact on the contralateral limb, is shorter be-
tween pushoff of the lame and impact of the sound limbs than between pushoff of the sound limb and im-
pact of the lame limbs.
Hind limb protraction is usually decreased in most cases of hind limb lameness.
Step length, or the distance between placements of opposite limbs, is less between placements of the lame
and then sound limbs than between placement of the sound and then lame limb.
There is some evidence that vertical movement of the head and torso are the most sensitive kinematic indi-
cators of lameness. Parameters related to vertical movement of the torso most closely follow vertical ground
reaction force changes, which are known to be precise and accurate for detection of weight-bearing lame-
ness. In one kinematic study, vertical movement of the torso alone provided greater than 95% correct clas-
sification for a 3-class decision (sound, lame in left forelimb, lame in right forelimb). All limb movement pa-
rameters and all horizontal and transverse torso movement parameters were less successful at correct clas-
sification.
In most case of forelimb lameness in the horse the head falls to a lower height during the stance phase of
the sound limb. This is the “down on sound” rule that is frequently cited. However, if the forelimb lame-
ness is most prominent during the acceleration or second half of stance the most prominent head movement
asymmetry is in the upward motion of the head. Lameness in the second half of stance causes the head to
rise to a higher height at or after the end of the stance phase of the lame limb. There is evidence to suggest
that the relationship between low and high heights of the head is determined by the timing of forelimb lame-
ness, i.e. is the lameness most prominent at impact, or in the first half of stance, or during pushoff, in the
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second half of stance.

The majority of forelimb lameness conditions are “impact” type, i.e. they are most prominent in the first half
of stance.
There are 2 methods of using pelvic movement to measure hind limb lameness, evaluating whole vertical
pelvic movement and evaluating pelvic rotation.
VERTICAL PELVIC MOVEMENT METHOD

The whole pelvis falls to a lower height during the stance phase of the lame limb and/or rises to a lower
height after pushoff of the lame limb. There is some evidence that the relationship between lowest and high-
est whole pelvic position is determined by the timing of hind limb lameness, i.e. is the lameness most promi-
nent at impact, in the first half of hind limb stance, or during pushoff, in the second half of stance.
More hind limb lameness conditions cause “pushoff” than “impact” lameness, i.e. most hind limb lameness
conditions are most prominent in the second half of stance.
PELVIC ROTATION METHOD

The hemi-pelvis on the lame hind limb side moves up or down (or both) more than on the sound hind limb
side. If the hind limb lameness is most prominent during the first half of stance the hemi-pelvis on the lame
hind limb side moves up more (a “hip hike”) than the hemi-pelvis on the opposite (sound) side right before
the beginning of stance. If the hind limb lameness is most prominent during the second half of stance the
hemi-pelvis on the lame hind limb side moves down more (a “hip dip”) than the hemi-pelvic on the oppo-
site (sound) side right after the end of stance. The pelvic rotation method is easier for most veterinarians to
see, however, it is speculated that this technique may be faulty in horses with asymmetric pelvis and is less
sensitive to change when observing horses before and after block.
The Lameness Locator (wireless inertial sensors

for detection of lameness in horses)
Kevin G. Keegan, DVM, MS, Dipl. ACVS
Professor: Veterinary Medicine and Surgery - Director: E. Paige Laurie Endowed Program in Equine Lameness College
of Veterinary Medicine, University of Missouri, Columbia, MO 65201, USA
Asymmetry of torso motion can also be measured us-

ing inertial sensors attached to the horse’s body. Mo-
tion data from multiple contiguous strides in an over
ground setting can be collected and evaluated. Lame-
ness Locator™ is one such inertial sensor system. It
was specifically designed as an aid to the practicing
equine veterinarian for detection and evaluation of
difficult lameness in horses. Lameness Locator™ con-
sists of 3 inertial sensors, a tablet PC for data analysis,
a sensor battery charger, and accessories for attaching
the sensors to the horse’s body. The inertial sensors
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are attached to the head, right forelimb pastern and
pelvis (Figure 1). Vertical accelerations of the head
and pelvis and angular velocity of the right distal fore- Figure 1 - Inertial Sensor Lameness Evaluation System.
limb are measured and wirelessly transmitted in real
time to a hand-held tablet computer. Custom-designed
algorithms are used to detect and quantify forelimb and hindlimb lameness when the horse is trotting. Trot-
ting strides are automatically detected by the software when the horse is moving.
Lameness Locator™ algorithms were developed from previous kinematic research. Vertical head and pelvic
acceleration are converted to position and separated into components, one due to lameness at stride fre-
quency and another (natural vertical motion) at twice stride frequency. Lameness is detected and quantified
by reporting 1) the ratio of vertical movement due to lameness to natural vertical movement, and 2) the
means and standard deviations of maximum and minimum height differences of the head (forelimb lame-
ness) and pelvis (hind limb lameness) position between left and right strides. Location of lameness to the
right or left limb and timing of peak lameness within the stride are determined by the association of head
and pelvic movement to angular velocity of the right forelimb.
If the pain of lameness peaks in the first half of forelimb stance, neck muscles restrict the fall of the head, such
that a difference in minimum head position between left and right forelimb stances is measured. This asym-
metry is measured as HEADDIFFMIN with positive values indicating right and negative values left forelimb
lameness. With lameness in the first half of stance, the horse also pushes off the opposite, sound limb harder
so the head is at a higher rela-
tive position before lame limb
stance. Asymmetry in maxi-
mum head position is meas-
ured as HEADDIFFMAX
with positive values indicating
right and negative values left
forelimb lameness.
Horses with positive HEAD-
DIFFMIN and HEADDIFF-
MAX have right forelimb be-
ginning of stance lameness
(Figure 2). Horses with nega-
tive HEADDIFFMIN and
HEADDIFFMAX have left
forelimb beginning of stance
lameness. Figure 2 - Right Forelimb Beginning of Stance Figure 3 - Right Forelimb end of Stance
If the pain of lameness peaks Lameness. Positive HEADDIFFMAX and Lameness. Negative HEADDIFFMAX and
in the second half of forelimb positive HEADDIFFMIN. positive HEADDIFFMIN.
K.G. Keegan WVOC 2010, Bologna (Italy), 15th - 18th September • 216
stance, neck muscle activity reduces force on the limb by raising

the head. The head elevates more after pushoff of the lame limb
causing a difference in maximum head position after pushoff be-
tween right and left limbs. This is measured as HEADDIFFMAX
with negative indicating right and positive values indicating left
pushoff lameness. Lameness in the second half of right forelimb
stance will have negative HEADDIFFMAX and positive HEAD-
DIFFMIN (Figure 3). Horses with positive HEADDIFFMAX
and negative HEADDIFFMIN have left forelimb lameness in the
second half of stance.
Lameness Locator™ displays forelimb lameness in a ray diagram
with the x-axis as HEADDIFFMAX and the y-axis as HEAD-
DIFFMIN (Figures 2 and 3). Each blue ray on the diagram is one
stride. The length of the ray is indicative of the amplitude of
HEADDIFFMIN and HEADDIFFMAX and representative of
the severity of lameness for that stride. Mean HEADDIFFMIN
and HEADDIFFMAX are calculated over all strides. The location Figure 4 - Left Hind Limb Impact Lameness.
of the ray in the ray diagram is indicative of the limb involved Negative PELVICDIFFMIN.
(left/right) and timing (beginning/end of stance) of lameness. Rays
in quadrant 1 indicate right forelimb beginning of stance lameness,
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in quadrant 2, right forelimb end of stance lameness, in quadrant

3, left forelimb beginning of stance lameness, and in quadrant 4,
left forelimb end of stance lameness.
The biomechanics of hind limb lameness in the horse are more
straightforward. There is no large body mass counterweight readi-
ly available for the horse to use to reduce force on the hind limbs.
Reduction of force on the lame hind limb is accomplished either by
falling less hard or pushing off less hard, or, if lameness is severe
enough, both. If pain of lameness is only in the first half of hind
limb stance (and the lameness is mild enough), the horse uses ex-
tensor muscles to limit pelvic fall. This results in a difference of
minimum pelvic height between right and left hind limb stance,
which is measured as PELVICDIFFMIN. Positive PELVICD-
IFFMIN indicates right hind limb beginning of stance, or impact,
lameness and negative PELVICDIFFMIN indicates left hind limb
beginning of stance, or impact, lameness (Figure 5).
If pain of lameness is only in the second half of stance (and the Figure 5 - Right Hind Limb Pushoff Lame-
lameness is mild enough), the horse will push off the affected hind ness. Positive PELVICDIFFMAX.
limb less, thrusting the whole pelvis upwards less. This results in a
difference in maximum pelvic height between pushoff of the right
and left hind limbs, which is measured by Lameness Locator™ PELVICDIFFMAX. Positive PELVICD-
IFFMAX indicates right hind limb end of stance, or pushoff, lameness (Figure 4) and negative PELVICD-
IFFMAX indicates left hind limb pushoff lameness. Although one aspect (impact, pushoff) is frequently
greater than the other, most horses with hind limb lameness display components of both.
Lameness Locator™ displays hind limb lameness as “deficiencies” in left and right hind limb impact and
pushoff (Figures 4 and 5). The left plot indicates left, and the right plot right hind limb deficiencies. For
each limb, “deficiency” of impact and pushoff is indicated with the first stride on the extreme left and the
last on the extreme right of each plot. The amplitude of each red, upwardly-directed line above the hori-
zontal (PELVICDIFFMAX) is an indicator of the “deficiency” of that hind limb’s pushoff for that stride.
The amplitude of each green, downwardly-directed line below the horizontal (PELVICDIFFMIN) is an
indicator of the “deficiency” of that hind limb’s impact for that stride. Mean PELVICDIFFMAX and
PELVICDIFFMIN are calculated over all strides. More red rays pointing upward on the left indicates left
hind limb pushoff lameness and more red rays pointing upward on the right indicates right hind limb
pushoff lameness. More green rays pointing downward on the left indicates left hind limb impact lameness
and more green rays pointing downward on the right indicates right hind limb impact lameness.
Thresholds for PELVICDIFFMIN and PELVICDIFFMAX between normal and lameness are estimated
to be +/- 3 mm.
Detecting Compensatory Lameness with Lameness Locator™:
In trotting horses a primary lameness in the front half of the body will cause compensatory movements in
the back half of the body and vice versa, such that an apparent multiple limb lameness is present. Interpreta-
tion of these compensatory movements is referred to as the “Law of Sides”. The first part of the “Law of
Sides” states that an apparent ipsilateral lameness is likely primary hind limb lameness and compensatory
(but false) forelimb lameness. The second part of the “Law of Sides” states that an apparent contralateral
lameness is likely primary forelimb lameness and compensatory (but false) forelimb lameness.
The first part of the “Law of Sides” is true. Even slight primary hind limb lameness may cause compen-
satory movement in the head that mimics significant forelimb lameness. This suggests the possibility of
missing the primary hind limb lameness because of the more apparent but false forelimb lameness. The
increased sensitivity of the inertial sensors compared to the unaided human eye decreases the chance of
this confusion.
The second part of the “Law of Sides” is only half true and not as simple. Primary forelimb lameness fre-
quently causes compensatory movements in the vertical movement of the pelvis attributable to both hind
limbs. Primary forelimb lameness causes the horse to shift its center of gravity slightly towards the back half
of the body during the stance phase of the affected forelimb. This causes the pelvis to fall more in the con-
tralateral hind limb compared to the ipsilateral hind limb (when the horse is trotting), mimicking impact type
lameness in the ipsilateral hind limb. However, as the horse progresses forward, the opposite sound diago-
nal hind limb (ipsilateral to the forelimb with primary lameness) will push off greater than the hind limb in
the lame diagonal, causing the pelvis to rise more and giving the appearance of a contralateral pushoff type
hindlimb lameness. These compensatory pelvic movements are small compared to the asymmetric head
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movements of primary forelimb lameness and not usually visible to the naked eye unless the primary fore-
limb lameness is considerable. However, compensatory pelvic movement patterns with primary forelimb
lameness are regularly measured with the increased sensitivity of the inertial sensors and these patterns are
useful for helping to detect and evaluate forelimb lameness.
Using inertial sensors to evaluate lameness during the lunge
Lameness Locator™ can be used to objectively quantify lameness while the horse is trotting in a circle.
Thresholds and confidence intervals established for trotting in a straight line and collecting at least 25 con-
tiguous strides, however, are not applicable. When the horse is trotting in a circle the torso is tilted slightly
towards the center of the circle. Depending on the horse and the radius of the circle this tilt can be signifi-
cant. Torso tilt is measured by the inertial sensors as asymmetric vertical motion. However, the effect of tilt
is usually equal in amplitude but opposite in direction. For example, in some horses downward motion of
the pelvis during the stance phase of the inside limb is less, resulting in an increase in the Diff Min Pelvis
absolute value and upward motion of the pelvis on the outside limb is less, resulting in an increase in the
Diff Max Pelvis absolute value. Horses trotting to the right can be expected to have negative Max Diff Pelvis
values and positive Diff Min Pelvis values. Horses trotting to the left can be expected to have positive Diff
Max Pelvis values and negative Diff Min Pelvis values. However, if the amplitude of asymmetry is opposite
in direction but equal in amplitude, this should be considered normal.
One advantage of using inertial™ to evaluate lameness during the lunge is the ability to collect many con-
tiguous strides in a small area at small effort to the handler. Collection of data from large numbers of con-
tiguous strides decreases variability. However, some horses do not lunge well and many horses misbehave
more during the lunge by tossing and shaking the head. This increases variability of vertical torso move-
ment and renders measurement of lameness by the inertial sensors less reliable. Evaluation of hind limb
lameness by inertial sensors during the lunge is more consistent than evaluation of forelimb lameness.
S. Laverty WVOC 2010, Bologna (Italy), 15th - 18th September • 218
An update on osteoarthritis
Sheila Laverty, Prof, MVB, Dipl. ACVS & ECVS
Faculté de Médecine Vétérinaire, Université de Montréal, Canada
Osteoarthritis (OA) is a complex disease that causes degeneration of the whole joint organ (articular carti-
lage, subchondral bone, synovial membrane and fibrous capsule) and is initiated by mechanical, biological
and biochemical factors. A cellular driven increase in extracellular matrix metabolism in both cartilage and
bone, favoring degradation, is the final common pathway leading to joint destruction.
Equine OA most commonly arises due to repetitive loads on the articular surfaces in the upper physiologi-
cal range, but may arise also as a result of a single traumatic event (e.g. fall), osteochondrosis, instability and
infection.
Cartilage cellular events: Chondrocytes respond to mechanical, chemical and biological stimuli (growth fac-
tors, cytokines, inflammatory mediators) by surface receptor activation. Degradative proteinases are upreg-
ulated (MMPs 1, 3, 9, 13 and ADAMTS- 4, 5) causing cleavage and loss of cartilage structural molecules,
proteoglycan and then type II collagen. One of the characteristic changes in advanced human OA cartilage
is the development of the hypertrophic chondrocyte phenotype, characterized by increased production of
MMP-13, type X collagen, alkaline phosphatase and chondrocyte apoptosis (similar to events in the growth
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plate). Apoptosis also is a feature of equine OA cartilage and has been shown to be associated with the sever-
ity of cartilage degeneration.
Cartilage molecular events: Cyclic load at the upper physiologic limit during training and racing damages
joint cells (cartilage, synovial, bone) and the extracellular matrix. There is now evidence that cartilage ma-
trix fragments (fibronectin and type II collagen fragments), liberated by trauma and enzymatic degradation,
bind to receptors on the chondrocyte surface and upregulate production of catabolic mediators and proin-
flammatory cytokines in a dose- dependant manner. When human chondrocytes are treated with collagen
fragments there is a sequential induction of enzymes (MMP-1, 3, 13 and 14 and Cathepsin K), cytokine pro-
duction (IL-1β, TNF-alpha, IL-6 and IL-8) followed by collagen cleavage and release of collagen fragments
from mature fibres. This causes a positive feedback loop and a vicious cycle of protease induction and proin-
flammatory cytokine release that further winds up the catabolic process. IL-1 is believed to be the major cy-
tokine mediating cartilage destruction. IL-1 and TNF-alpha are synergistic and inhibit synthesis of aggrecan
and collagen.
Type II collagen molecules are key structural elements (tensile strength) of the cartilage matrix and possess
a triple helical domain that is very resistant to enzymatic attack. When it is cleaved at this site, many en-
zymes can subsequently degrade it, as it unwinds and this is now believed to be a key irreversible event in
OA. Of the three major MMPs that degrade native collagen, MMP-13, which is upregulated in equine OA,
is considered most important because it preferentially degrades type II collagen. Recently cathepsin K, also
capable of degrading the intact helix of type II collagen, and it’s collagen degradation products, have been
identified in equine OA tissues by our lab. Aggrecan is cleaved by members of the aggrecanase family of en-
zymes called ADAMTS. ADAMTS- 4 and 5 are believed to be the principal culprits in cartilage aggrecan
degradation in OA.
Bone: Bone strength is dependant on both bone quality and bone density. Bone quality depends on archi-
tecture, bone turnover and mineralization and is altered in OA. The subchondral bone is composed of a sub-
chondral plate, similar to cortical bone, and an underlying looser trabecular bone.
The cyclic stresses of racing promote an adaptive remodeling response (coupled synthesis by osteoblasts and
degradation by osteoclasts) in equine subchondral bone. Under normal physiologic conditions these process-
es are finely balanced and bone mass is preserved.
The response of bone to altered mechanical loading results in altered synthetic and degradative activity
within the matrix. At first racing promotes an increase in bone mass and mineralization and the bone be-
comes stronger.
Repetitive loading however also causes microcracks in the calcified cartilage and underlying subchondral
bone plate. As this microdamage accumulates, repair and synthesis is overwhelmed and focal resorption pre-
dominates. Histological specimens of equine OA reveal microcracks in the calcified cartilage and subchon-
dral plate of equine fetlock joints and we have also observed them in the third carpal bone, with associated
resorption of the bone.
219 • WVOC 2010, Bologna (Italy), 15th - 18th September S. Laverty
Bone cellular events: The mechanism by which bone resorption is upregulated remains unknown. The mi-
crocracks may induce resorption through induction of osteoclastic activity which may be followed by the
production of more bone by osteoblasts. There may be a lag in the osteoblastic response resulting in an over-
all loss of bone. The erosion increases porosity within the sclerotic subchondral bone and compaction and
collapse of overlying cartilage occurs leading to OA. IL-6 (produced by chondrocytes and osteoblasts) stim-
ulates osteoclastic bone resorption and a research group in Sweden (Ley et al.) have recently measured ele-
vated levels of IL-6 in equine synovial fluid from OA horses, indicating that it could potentially have a role
in osteoclast activation in the equine OA joint.
Atypical osteocyte morphology has also been observed in the subchondral bone of racehorses but the over-
all osteocyte density was not significantly different from control un-raced animals (Muir el al. 2008). A sig-
nificant proportion of osteoblasts in human OA bone are phenotypically different in terms of the extent to
which they can degrade articular cartilage and upregulate MMPs in chondroytes in vitro. This information,
combined with the knowledge that molecules may pass through the calcified cartilage, indicates that os-
teoblasts could potentially communicate (cross-talk) with chondrocytes in the calcified and hyaline cartilage
and mediators from the bone could reach the cartilage and influence it’s metabolism.
Molecular events in bone: At the molecular level racing has been reported to cause an elevation in bone ma-
trix collagen synthesis and remodelling in both the subchondral plate and trabecular regions of the carpal
bones which results in an altered collagenous matrix with a possible reduced resistance to load (Tidswell et
al. 2008). The carpal bones had a more immature collagen matrix (loss of mature cross links) and a higher
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turnover. This could reflect an attempt at repair of microdamage. A significant increase in MMP activity has
also been observed in the trabecular subchondral bone. This was associated with a lack of TIMP (tissue in-
hibitor of metalloprotease) pointing to an imbalance that could cause an increased degradation of collagen
molecules. A 20 fold increase in collagen turnover has been reported in humans with OA in the femur. In
experimental canine OA MMP 13 and Cathepsin K have also been identified in the subchondral bone and
provide evidence that collagen I degradation and bone resorption are features of this disease. Abnormal col-
lagen metabolism in the subchondral bone in OA mirrors events in the articular cartilage indicating how
closely these events may be linked. We have now identified products of enhanced type I collagen degrada-
tion in horses with carpal OA providing further evidence for increased turnover of collagen in bone in OA.
This increased metabolism may lead to weaker trabeculae and collapse of the overlying cartilage into the de-
fect, a common feature in equine athletes with OA in the carpus and fetlock.
THE WNT SIGNALLING PATHWAY

Factors that could contribute both to focal cartilage loss and accompanying reparative bone response have
led OA investigators to study the Wnt signaling pathways and its protein regulators. The Wnt pathway is
implicated in embryogenesis of the joint and in adult skeletal homeostasis. Changes common to OA and
joint development include an enhanced turnover of cartilage and bone matrix components, and an upregu-
lation of similar gene products. Wnt signaling, is now recognised as a powerful and direct modulator of
chondrocyte maturation. Soluble Wnt glycoproteins signal by binding to a receptor (frizzled) on chondro-
cytes. The activated receptor transmits signals through several pathways, including the β-catenin-dependent
canonical Wnt pathway. Cytoplasmic β-catenin translocates to the nucleus and incites hypertrophy, matrix
mineralization, and expression of MMP-13, all recognized classical features of OA. Thus, Wnt might acti-
vate cartilage matrix catabolism and have a role in cartilage destruction under pathological conditions. In
mechanically injured adult human articular cartilage explants, upregulation of WNT16, downregulation of
FRZB (an antagonist) and upregulation of Wnt target genes has been observed. Furthermore, Wnt 16 and
β-catenin proteins are upregulated in areas of joints with moderate-to-severe OA damage. These data sug-
gest that the canonical Wnt pathway is not only active in the formation of joints during embryogenesis, but
might also be a key component in the early response to mechanical trauma and, potentially, in the repara-
tive response. The Wnt pathway has also a direct effect on global bone density. Combined, these data im-
ply that WNT inhibitors might protect against the development or progression of cartilage loss in OA.
CURRENT THERAPEUTIC TARGETS FOR DISEASE MODIFYING OA DRUGS

(DMOADS)
It is disconcerting to note that no DMOADS have been approved by the Food and Drug Administration
(FDA) or European Medicines agency (EMEA) as disease-modifying efficacy has not been convincingly
demonstrated in any of the compounds tested in humans. DMOADS are selected to be either anti- catabol-
ic agents or anabolic. Anti-catabolic pharmacologic agents aim at slowing or halting the progression of dis-
ease while anabolics aim at inducing cartilage growth. Anti-catabolics under investigation include MMP -13
specific inhibitors, Cathepsin K inhibitors, aggrecanase inhibitors, TIMP 3 (inhibits aggrecanes & MMP13),
Anti-IL-1-beta, TNF-alpha blockers calcitonin and iNOS inhibitors. Biological anabolics currently being ex-
plored include FGF 18, OP-1 (BMP 7) and mesenchymal stem cells.
FURTHER READING
Corr M. Wnt-beta-catenin signaling in the pathogenesis of osteoarthritis. Nat Clin Pract Rheumatol. 2008. 4(10):550-6.
Dejica VM, Mort JS, Laverty S, Percival MD, Antoniou J et al.. Cleavage of type II collagen by cathepsin K in human
osteoarthritic cartilage. Am J Pathol. 2008 173(1):161-9.
Henrotin Y, Pesesse L, Sanchez C. Subchondral bone in osteoarthritis physiopathology: state-of-the art and perspectives.
Biomed Mater Eng. 2009;19(4-5):311-6.
Muir P, Peterson AL, Sample SJ, Scollay MC, Markel MD et al. Exercise-induced metacarpophalangeal joint adaptation
in the Thoroughbred racehorse. J Anat. 2008 213(6):706-17.
Norrdin RW, Stover SM. Subchondral bone failure in overload arthrosis: a scanning electron microscopic study in hors-
es. J Musculoskelet Neuronal Interact. 2006. 6(3):251-7.
Tidswell HK, Innes JF, Avery NC, Clegg PD, Barr AR et al. High-intensity exercise induces structural, compositional
and metabolic changes in cuboidal bones—findings from an equine athlete model. Bone. 2008 43(4):724-33.
Vinardell T, Dejica V, Poole AR, Mort JS, Richard H, Laverty S. Evidence to suggest that cathepsin K degrades articular
cartilage in naturally occurring equine osteoarthritis. Osteoarthritis Cartilage. 2009 17(3):375-83.
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221 • WVOC 2010, Bologna (Italy), 15th - 18th September S. Laverty
A critical review of neutraceutical use for osteoarthritis

in the horse
Sheila Laverty, Prof, MVB, Dipl ACVS & ECVS
Faculté de Médecine Vétérinaire, Université de Montréal, Canada
NEUTRACEUTICALS
There are an increasing number of neutraceutical products being released onto the market and horseown-
ers rely on their veterinarians for advice as to their judicious use. Unfortunately, several substances have
limited experimental data to support their use. This review will focus on the most popular compounds for
which there exists considerable clinical data.
GLUCOSAMINE
Glucosamine is an aminosaccharide that is synthesized and incorporated into many molecules in the body
including the proteoglycan matrix components of articular cartilage. Very small amounts of free endogenous
glucosamine have been detected in horses. Exogenous glucosamine is extracted from crustacean shells and
other sources.
While glucosamine is highly bioactive when added to cell cultures at supraphysiologic concentrations, it’s
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putative effects in vivo be addressed here. We have previously demonstrated that the levels of glucosamine
attained in equine serum (7uM - oral bioavailablity of 2-5%) and synovial fluid (10% of serum levels) are
very low following oral administration. This information caste doubt on the majority of effects previously
reported for glucosamine, as they were based on laboratory studies of joint cells exposed to much higher
levels than those possible to attain in vivo (200-2,000 times higher). However we have recently shown that
the levels attained in the joint are higher in the presence of synovial inflammation. At the levels detected in
synovial fluid in the presence of inflammation, glucosamine could potentially improve aggrecan synthesis
and have antinflammatory effects (reduce COX-2, PGE2 and reduce cartilage degrading enzymes). Novel
intriguing data from a study of a mouse model of cartilage destruction has shown that glucosamine admin-
istration can alter the acute phase response in the liver and reduce circulating cytokines and it is hypothe-
sized that some of glucosamine’s effects on joints could may be indirect effects.
There have been no clinical studies on the efficacy of oral glucosamine alone for osteoarthritis therapy in
horses. Information from animal models of osteoarthritis (rabbits) suggests very modest, positive effects of
long term treatment on articular cartilage and subchondral bone degradation. In the human field, despite a
large number of clinical trials on it’s efficacy, a controversy as to it’s effectiveness persists. Multiple met-
analyses of clinical trials involving both preparations concluded that the hydrochloride formulation (non-in-
dustry sponsored) had no effects on pain but that the industry-sponsored trials on glucosamine sulphate had
positive effects (disease and symptom modifying). This raised the spectre of possible bias in some of the lat-
ter studies. It has been posited that the intestinal absorption of these 2 compounds (glucosamine hy-
drochloride versus glucosamine sulphate) may be different and account for the beneficial effects observed
with glucosamine sulphate. However, both compounds dissociate into the same aminosugar and associated
acid in the stomach. We recently demonstrated that the glucosamine sulphate preparation attains higher lev-
els in the joints, when compared to the hydrochloride formulation, following oral administration. However,
the higher levels attained are not of a great enough magnitude to explain a clinical benefit and they are prob-
ably achieved by the addition of palatability compounds which may enhance absorption.
Recent in vitro work on equine cartilage explants has shown that glucosamine, at physiologically relevant
doses prevents proteoglycan degrading effects of corticosteroids (MPA) and its use could be envisaged fol-
lowing intraarticular corticosteroid therapy to protect cartilage, but this remains to be confirmed in vivo.
Equine veterinarians should also be aware that there is a huge variation in the amount of glucosamine avail-
able in the different formulations on the market and proof of contents, purity and quality control should be
requested before choosing a product. Current recommended doses are 20 mg/kg.
CHONDROITIN SULFATE
Chondroitin sulfate is a component of the extracellular matrix of cartilage, bone, ligaments and tendons. It
is a sulphated GAG composed of long unbranched polysaccharide chains with a repeating disaccharide
structure of n-acetylgalactosamine and glucuronic acid. Chondroitin sulfate is manufactured from animal
sources (bovine, porcine, chicken and marine cartilage) and the molecular composition is species dependant.
Because of this, there is a reported variation in absorption (22-32% reported for the horse) which is reason
for concern when a product is selected. There is an emerging controversy concerning the absorption of
chondroitin sulphate. The most surprising information to come to light recently is that circulating levels of
endogenous chondroitin sulphate in serum, measured using valid technology, in humans were not altered
by the ingestion of chondroitin sulphate and any effects reported are not probably due to the chondroitin
sulphate reaching the joint, but rather indirect effects due to elevated levels in the intestine or first pass
through the liver. In vitro effects detected by the addition of chondroitin sulfate to stressed joint cells or car-
tilage explants include induction of production of proteoglycans and reduction of chondrocyte apoptosis,,
matrix metalloprotease production and bone resorption. A study of equine chondrocytes also revealed that
the combination of glucosamine and chondroitin sulfate may be synergistic.
The administration of chondroitin sulfate to animals with experimental osteoarthritis has been reported to
reduce inflammation, synovitis and proinflammatory cytokines (IL-1 and IL-6). There has only been one
clinical experimental study in horses assessing the effects of a chondroitin sulphate preparation IM and no
beneficial effects were noted.
Data has now revealed that different CS compounds from different manufacturers do not act similarly on
cells in vitro. This is worrying as the results of clinical and scientific studies are directly related to the quali-
ty of the product used.
COMBINATION OF CHONDROITIN SULFATE AND GLUCOSAMINE

Three clinical trials evaluating the combination of glucosamine hydrochloride and chondroitin sulphate
have been performed in horses and all reported beneficial effects on symptoms of joint disease. The most
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recent study which was blinded and randomized assessed their effects on lameness and joint motion in old-
er horses and significant improvements in range of motion, increased stride length and swing duration were
observed at 8 weeks suggesting that the combination offered symptomatic relief. On a positive note it ap-
pears that there are no side effects associated with the use of the combination as it has been reported that 5
times the recommended dose can be administered to horses without adverse side effects.
On a more negative note it has been shown in people that when glucosamine is combined with chondroitin
sulphate the levels of glucosamine attained in the blood are lower than those attained when glucosamine is
administered alone indicating that chondroitin sulfate inhibits glucosamine absorption.
AVOCADO-SOYBEAN UNSAPONIFIABLES (ASUS)

ASUs refer to extracts derived from one third avocado oil and two thirds soybean oil after hydrolysis.
Studies of ASU extracts in vitro have identified anti-inflammatory effects and also positive anabolic effects on
cartilage. Recent in vitro studies on equine tissues, reveal that the combination of ASU with glucosamine
and chondroitin sulfate may have an anti-inflammatory effects on stimulated equine chondrocytes and os-
teoblasts. However this information cannot be extrapolated to a clinical setting until it’s pharmacokinetics
are better understood. Furthermore, it is composed of various components and the activities and absorption
of the various fractions needs to be determined.
To date there has been one blinded controlled study assessing the efficacy of ASU for the treatment of ex-
perimental equine osteoarthritis. This work provides some evidence that this compound could have struc-
ture-modifying effects (cartilage and synovium) on OA joints but no improvement in lameness occurred.
Much research remains to be done in the field of neutraceutical research to fill the information vacuum that
exists. A persisting major knowledge gap remains about the quality, composition, absorption and pharma-
cokinetics of many of these compounds.
FURTHER READING
1. Laverty S, Sandy JD, Celeste C, Vachon P, Marier JF, Plaas AH. Synovial fluid levels and serum pharmacokinet-
ics in a large animal model following treatment with oral glucosamine at clinically relevant doses. Arthritis Rheum.
2005 Jan;52(1):181-91.
2. Meulyzer M, Vachon P, Beaudry F, Vinardell T, Richard H, Beauchamp G, Laverty S. Comparison of pharmaco-
kinetics of glucosamine and synovial fluid levels following administration of glucosamine sulphate or glucosamine
hydrochloride. Osteoarthritis Cartilage. 2009 Feb;17(2):228-34.
3. Meulyzer M, Vachon P, Beaudry F, Vinardell T, Richard H, Beauchamp G, Laverty S. Joint inflammation increas-
es glucosamine levels attained in synovial fluid following oral administration of glucosamine hydrochloride. Os-
teoarthritis Cartilage. 2009 Feb;17(2):228-34.
4. Kawcak CE, Frisbie DD, McIlwraith CW, Werpy NM, Park RD. Evaluation of avocado and soybean unsaponifiable
extracts for treatment of horses with experimentally induced osteoarthritis. Am J Vet Res. 2007 Jun;68(6):598-604.
5. Jackson CG, Plaas AH, Sandy JD, Hua C, Kim-Rolands S, Barnhill JG, Harris CL, Clegg DO. The human phar-
macokinetics of oral ingestion of glucosamine and chondroitin sulfate taken separately or in combination. Os-
teoarthritis Cartilage. 2010 Mar;18(3):297-302.
223 • WVOC 2010, Bologna (Italy), 15th - 18th September O.M. Lepage
Critical review of the clinical use of tiludronate in horses

Olivier M. Lepage
Equine Department, VetAgro Sup - Veterinary Campus of Lyon
University of Lyon, Marcy l’Etoile, F-69280 France
Tiludronate is a non-nitrogen-containing bisphosphonate that inhibits osteoclast-mediated bone resorption

and that is used in equine since a decade (Lepage, 2002; Delguste et al., 2007a). The action on resorption is
consecutive to cellular effects on osteoclasts, rather than by purely physico-chemical mechanism (Rogers et
al., 1999). Used in the nineties to prevent bone resorption in humans, tiludronate is nowadays replaced by
more powerful bisphosphonate such as residronate (Leu et al., 2006).
As tiludronate shown some clinical efficacy in horses? This question is probably the most relevant one
for an equine practitioner and the best way to answer is to follow principals of evidence-based medicine
which aims to apply the best available evidence gained from the scientific method to medical decision
making. A search of all papers on PubMed and ScienceDirect for the period between 2000 and 2010
shows a production of 7095 and 1717 publications respectively for the keywords combination bisphos-
phonate-human and bisphosphonate-animals. If we apply the same combination of keywords but with
tiludronate instead of bisphosphonate we find 35 publications for humans and 13 for animals including 5
involving strictly the equine species (Table 1). The origin of these five papers are from France and are
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supported by CEVA Santé Animale sponsor of the only intravenous form of tiludronate licensed for hors-
es in Europe at this time. Because we are searching for treatment information we can consider these pub-
lications having a very high score in the pyramid of evidence.
Table 1 - Equine publications on tiludronate between 2000 and 2010

Study design Content of the study Year Author and Journal
Unicentre parallel design trial Comparartive pharmacokinetics of 2008 Delguste et al.,
0.1 mg/kg, 10 days versus 1 mg/kg, once J vet Pharmacol Therap
Randomized placebo-controlled Efficacy of tiludronate in osteoarthrosis 2007 Coudry et al.,
clinical trial of the thoracolumbar column Am J Vet Res
Unicentre double-blind randomized Effect of tiludronate on a model 2007 Delguste et al.,
placebo-controlled trial of disuse osteopenia Bone
Multicentre double-blind placebo- Efficacy of tiludronate in navicular 2003 Denoix et al.,
controlled clinical trial disease Eq vet J
Tolerance study Tiludronate at 1 mg/kg, once, 2002 Varela et al.,
slow iv perfusion Ann Med Vét
Tiludronate is licensed in Europe at a dosage of 0.1 mg/kg bodyweight (b.w.) for intravenous bolus once
daily for 10 consecutive days. But if we compare in adult healthy horses 2 dosage regimens (1 mg/kg b.w.
once, versus 0.1 mg/kg b.w. 10 days), the bioavailability and the pharmacological effects of tiludronate are
the same (Delguste et al., 2008a). This study suggests that a more practical dosage regimen is to replace the
administration of 10 daily boluses by a single constant rate infusion at a total dose of 1 mg/kg b.w. It was
previously shown that at this dosage regimen for tiludronate induce a rapid and marked decrease in horse
serum CTX-I, indicating an antiresorptive effect (Varela et al., 2002). The drug is also well tolerated with-
out any clinically relevant adverse effects. The adverse problems reported being a slight non-significant in-
crease in heart rate without dysrhythmia, very light intermittent colic symptoms and a transient slight
hypocalcaemia (Varela et al., 2002). Pre-treatment with flunixin meglumine, sedation products or such drugs
is not needed.
Efficacy of tiludronate has been confirmed by three studies in horses suffering either from navicular disease
(Denoix et al., 2003), disuse osteoporosis (Delguste et al., 2007b) or pain associated with lesions of the tho-
racolumbar vertebral column (Coudry et al., 2007).
O.M. Lepage WVOC 2010, Bologna (Italy), 15th - 18th September • 224
In a multicentre study horses affected with navicular disease (n=39) received tiludronate at 0.1 mg/kg b.w.
for 5 or 10 days (Denoix et al., 2003). To see a significant statistical effect cases were broken down into a
group of horses with clinical signs less than 6 months and another group including individuals with signs of
more than 6 months. The efficacy of tiludronate is demonstrated only at the cumulative dosage of 1 mg/kg
b.w. (10 days) in horses with a more recent onset of clinical signs (less than 6 months). An incomplete char-
acterisation of the source of lameness (no differentiation between bone and soft tissue) may have lead to er-
ror of interpretation. An antiresorptive activity was maybe inappropriate in some cases.
Tiludronate administered at 1 mg/kg b.w., two times, 28 days apart, was found to significantly reduce bone
resorption during a long-term immobilization model (Delguste et al., 2007b). Application for 2 months of a
lower-limb fibreglass cast in this experimental study induced a disuse osteopenia in the metacarpus III of
controlled horses. Simultaneously the loss in bone mineral density, measured by DEXA, was significantly
less in the immobilized canon bone of the tiludronate treated individuals. If this study suggests tiludronate
in the prevention of disuse osteopenia in case of long term immobilisation we have no ideas on the effect of
this drug on equine bone repair. Practitioners should therefore select the long term immobilised patient (flex-
or tendon rupture, fetlock luxation…) that will receive tiludronate for his preventive effect.
To evaluate the efficacy on the pain associated with lesions of the thoracolumbar vertebral column, tilu-
dronate was administered at 1 mg/kg b.w., once or two times at 2 months interval. All 29 horses were mon-
itored 120 days with clinical, radiographic, ultrasonographic and scintigraphic examination (Coudry et al.,
2007). Results of this study show a significant improvement (P = .019) in dorsal flexibility at the canter main-
ly at 60 days for the treated group.
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To get more evidence or opinions on the use of tiludronate in horses we looked in refereed and non refer-
eed proceedings and publications collected in University libraries or on the web. We found another 13 pa-
pers including 3 theses (Poircuitte 2004; Riccio 2006; Delguste 2008b). From the work of Riccio we learn
that intra-articular injection of tiludronate in the distal interphalangeal and metacarpophalangeal joint of
horses rapidly diffuse from the joint to the blood circulation and can induce synovitis confirmed by histo-
logical examination of the synovial membrane. We also learn that an unpublished study on the effects of
tiludronate on distal hock pain (n=8 horses) localised with perineural analgesia or intra-articular anaesthet-
ic injection was not very conclusive (Dyson, 2004). Results that are in contrast with the ones reported in an-
other non refereed paper that shows a beneficial effect of tiludronate one month after an iv administration
at a dosage of 0.1 mg/kg b.w. for 10 days in horses (n=9) affected with bone spavin (Sachot, 2002).
At the exception of a case-report of a single horse with coffin joint DJD that did not answer to convention-
al treatment but resolved with tiludronate 4 months after the last injection with absence of lameness and res-
olution of a PII oedema (Schulze, 2005), the other publications are usually of a low scientific interest. They
often resume or comment the 5 main papers with the idea to make a transfer of information to practition-
ers about the arrival of a new class of therapeutic agent (bisphosphonate) in veterinary medicine (Kamm et
al., 2008; Perrin, 2009).
In conclusion, ten years after we have started using tiludronate on a large scale in equine medicine we still
have a major lack of evidence and we are still waiting to get more clinical relevant information. For exam-
ple tiludronate is often used in young exercising Thoroughbreds with the idea to prevent stress fracture. If
the high price of repetitive tiludronate administration is not a barrier for these cases, we have no evidence
of the effectiveness of such a preventive treatment. Furthermore we do not know the effect of such a drug
on a growing equine skeleton. On the other hand if we have not enough reliable information specific for tilu-
dronate in the equine species to answer the question, we can refer to scientific data about other bisphos-
phonate used in horse (Lepage et al., 1999; McGuigan et al., 2000; Gray et al., 2002) or data obtained with
tiludronate in other species.
A consequence from these data, having in mind that we can not make any direct conclusion from one species
to another one, is the fact that tiludronate administration in a growing horse has to be made in a thought-
ful way. Indeed we found scientific evidence that on a long term or in a repetitive manner high doses of tilu-
dronate in growing rats and baboons induce the accumulation of unresorbed calcified cartilage, adjacent to
the skeletal growth plate (Neer, 1995). This predictable side effect of the drug primary action indicates that
tiludronate should be used with caution in growing equids. In a profession often confronted to osteochon-
drosis and to pressure from owners and trainers to use new drugs these studies are especially relevant in
young exercising horses, We also learn from these data that tiludronate-treated rats cannot maintain normal
serum calcium levels when fed a low-calcium diet probably indicating that horses should also have a normal
calcium intake during tiludronate treatment.
All these examples warn us of the importance of a constant search in scientific evidences for a better use of
bisphosphonate in orthopaedic equine patients. Many more studies being needed to gain confidence in the
efficacy of such drugs.
225 • WVOC 2010, Bologna (Italy), 15th - 18th September O.M. Lepage
REFERENCES
Coudry V., Thibaud D, Riccio B, Audigié F, Didierlaurent D, Denoix JM. (2007) Efficacy of Tiludronate in the treatment
of horses with signs of pain associated with osteoarthritic lesions of the thoracolumbar vertebral column. Am J Vet
Res 68, 329-337.
Delguste C, Lepage OM, Amory H, Doucet M. (2007a) Pharmacologie clinique des bisphosphonates: revue de literature
axe sur le tiludronate chez le cheval. Ann Méd Vét, 151: 269-280.
Delguste C, Amory H, Doucet M, Piccot-Crézollet C, Thibaud D, Garnero P, Detilleux J, Lepage OM (2007b). Phar-
macological effects of tiludronate in horses after long-term immobilization. Bone; 41: 414-421.
Delguste C, Amory H, Guyonnet J, Thibaud D, Garnero P, Detilleux J, Lepage OM, Doucet M (2008a). Comparative
pharmacokinetics of two intravenous regimens of tiludronate in healthy adult horses and effects on the bone re-
sorption marker CTX-1. J Vet Pharmacol Ther, 31: 108-116.
Delguste C. (2008b) Contribution à l’étude pharmacologique et clinique du Tiludronate chez le cheval. Thèse de Doc-
teur en Sciences Vétérinaire, Université de Liège.
Denoix JM, Thibaud D, Riccio B. (2003) Tiludronate as a new therapeutic agent in the treatment of navicular disease: a
double-blind placebo-controlled clinical trial. Equine vet J 35, 407-413.
Dyson SJ. (2004) Are there any advances in the treatment of distal hock joint pain? Proceedings Intern Symp on disease
of the Icelandic horse.
Gray AW. (2002) Generation and activity of equine osteoclasts in vitro: effects of the bisphosphonate pamidronate. Res
Vet Sci 72; 105-113.
Kamm L, McIlwraith W, Kawcak C. (2008) A review of the efficacy of tiludronate in the horse. J equine vet Sci 28: 209-
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214.
Lepage OM, François RJ (1989) Aspects microradiographiques et en microscopie de fluorescence d’une exostose expéri-
mentale du métacarpien chez le poney Shetland et de son traitement par un bisphosphonate, l’AHPrBP (APD). Ap-
plications possibles au cheval d’arme. Ann Med Milit Belg 3: 38-44.
Lepage OM, Varela A. (2002) Bisphosphonates and therapeutic manipulation of bone turnover – Clinical opportunities
in large animals ? Proceedings 1st World Orthopaedic Veterinary Congress, 11: 123.
Leu CT, Luegmayr E, Freedman L, Rodan G., Reszka A. (2006) Relative binding affinities of bisphosphonates for hu-
man bone and relationship to antiresorptive efficacy. Bone, 38: 628-636.
McGuigan MP, Cauvin E, Schramme MC, Pardoe CH, May SA, Wilson AM. (2000) A doubl_blind placebo-controlled
trial of bisphosphonate in the control of navicular syndrome. Proceedings BEVA congress, 207.
Neer RM. (1995) Skeletal safety of tiludronate. Bone 17, 501-503.
Perrin R. (2009) Principe actif : le Tiludronate. Nouveau Prat Vét Equin, 5 : 57-59.
Poircuitte G. (2004) Le Tiludronate : Mode d’action et utilisation thérapeutique dans l’espèce équine en pathologie loco-
motrice. Thèse de Doctorat, Faculté de Médecine de Créteil.
Riccio B. (2006) Evaluation de l’effet du Tiludronate par voie intra-articulaire chez le cheval : aspects pharmacologiques
et cliniques. Thèse de Doctorat, Université Paris XII- Val de Marne.
Rogers MJ, Frith C, Luckman SP, Coxon FP, HL Benford, Monkkonen J, Auriola S, Chilton KM, Russell RGG. (1999)
Molecular mechanisms of action of bisphosphonates. Bone 24, 73-79.
Sachot E. (2002) Les bisphosphonates traitent les boiteries d’origine osseuse. Point Vét, 226 : 16-17.
Schulze (2005) Fallbericht : seltene diagnose und erfolgreiche therapie. Pferde Spiegel, 140-145.
Varela A, Lepage OM, Doucet M, Marcoux M, Garnero P. Tiludronate chez le cheval: tolérance et effets à court terme
sur le métabolisme osseux. Ann Méd Vet 2002, 147: 123-130.
W. McIlwraith WVOC 2010, Bologna (Italy), 15th - 18th September • 226
Critical review of the clinical use of autologous conditioned

serum (ACS) also known as IRAP®
Wayne McIlwraith, BVSc, PhD, DSc, Dr med vet (hc), FRCVS, DACVS
Barbara Cox Anthony University Chair in Orthopaedics
University Distinguished Professor, Director of Orthopaedic Research, Colorado State University
Autologous conditioned serum (ACS) known the trade name of IRAP® (Dechra) or IRAP II® (Arthrex) in-
volves the physico-chemical induction of several beneficial cytokines by incubating whole blood with med-
ical-grade glass beads. Because upregulation of interleukin-1 receptor antagonist (IL-1Ra) has been demon-
strated the trade names IRAP® and IRAP II® were developed. However, based on recent work with human
blood other products that can be unregulated including TNF-α, IL-10, IL-1β but the IL-1ra/IL-1β ratio is
still elevated as well so it provides productive effect. In addition the IRAP systems upregulate fibroblast
growth factor-β (FGF-β), platelet derived growth factor (PDGF), transforming growth factor-β (TGF-β) and
vascular endothelial growth factor (VEGF).
The clinical, biochemical and histologic effects of intra-articular administration of ACS in the treatment of
experimentally induced osteoarthritis in horses has been reported in the author’s laboratory (Frisbie et al
2007). Osteoarthritis was induced arthroscopically in one middle carpal joint of all horses. In placebo treat-
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ed horses 6 mls of physiologic buffered saline (PBS) was injected into the OA affected joint and in the ACS
treated group or 6 mls of ACS was injected into the OA-affected joint on days 14, 21, 28 and 35. PBS was
also administered into the other sham-operated joint. No adverse treated related events were detected. Hors-
es that were treated with ACS had significant improvement in lameness, unlike the placebo-treated horses.
Among the OA-affected joints, ACS treatments also significantly decreased synovial membrane hyperplasia
compared with placebo-treated joints; although not consistent, the ACS-treated joints also appeared to have
less gross cartilage fibrillation and synovial membrane hemorrhage (Not significant at p<0.05 level). The
synovial fluid concentration of IL-1Ra (assessed by the use of mouse anti-IL-1Ra antibodies) was increased
following treatment with ACS).
Since that study there has been considerable use of IRAP® and IRAP II® clinically with beneficial results.
The main clinical use has been with cases where the joint was unresponsive to triamcinolone-HA therapy
or early post-arthroscopic surgery treatment when there has been early OA lesions identified at arthroscopy.
More recently, a comparison of the two commercial ACS systems (IRAP® and IRAP II®) using equine blood
has been done (Hraha et al 2010). Blood was drawn from five horses and incubated for 1 or 24 hours in
IRAP® and IRAP II® products or red top vacutainer tubes as a control. Serum was harvested and analyzed
for the pro-inflammatory marker TNF-α, anti-inflammatory cytokines IL-1Ra and IL-10 as well as growth
factors IGF-1 and TGF-β. The mRNA expression was also performed on the isolated nucleated cell fraction
of each sample. Both IRAP® and IRAP II® increase IL-1Ra protein levels significantly compared to base-
line. A similar significant increase is also seen with IGF-1 protein levels. IRAP® however produced a signif-
icant increase in the proinflammatory cytokine TNF-α. This study concluded a modestly better cytokine
profile with IRAP II® compared to IRAP®.
The IRAP® products have also been used with tendonitis. Recent research in our laboratory on tenocyte
cultures with various treatments has shown that IRAP I® and IRAP II® were the strongest stimulators of
cell proliferation and there was increased hydroxyprolene production as well (Hraha et al 2010).
REFERENCES
1. Frisbie DD, Kawcak CE, Werpy NM, et al. Clinical, biochemical and histologic effects of intra-articular adminis-
tration of autologous conditioned serum in horses with experimentally induced osteoarthritis. AJVR 2007;68:292-
296.
2. Hraha T, Cowley K, McIlwraith W, Frisbie D. Autologous conditioned serum: A comparison of two commercial
methods of IRAP® and IRAP II®. Equine Vet J submitted 2010.
3. Hraha TH, Doremus KAC, McIlwraith CW, Frisbie DD. Anabolic effect of clinical relevant autologous conditioned
blood products (ACBP) on equine digital flexor tenocytes. Manuscript submitted 2010.
227 • WVOC 2010, Bologna (Italy), 15th - 18th September W. McIlwraith
Indication and results for intra-articular use of stem cells

A mesenchymal stem cell (MSC) was a term first coined as a synonym for a mitotically quiescent primor-
dial germ cell. MSCs have been described as the natural units of embryonic generation or adult regenera-
tion of a variety of tissues. Recognition of the potential of MSCs in musculoskeletal disease is typified by
the landmark paper of Pittenger, et al (1999) who described MSCs as multipotent cells that are present in
adult bone marrow and can replicate as undifferentiated cells and have the potential to differentiate into lin-
eages of mesenchymal tissue including bone, cartilage, fat, tendon, and muscle (Pittenger et al 1999). Early
work using labeled mesenchymal stem cells (MSCs) has shown that they have an affinity for damaged joint
tissue and in vivo studies have confirmed their ability to localize and participate in repair in damaged joint
structures, including cruciate ligaments, menisci and cartilage lesions. (Frisbie et al 2009). Isolation of MSCs
from the marrow or digested tissue extracts is most commonly achieved by simple adhesion and prolifera-
tion of MSCs to tissue culture surfaces. This achieves a significant, if not homogenous, MSC population but
near-homogenous MSCs populations have been reported from adhesion sorting (Ferris et al 2010). Research
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continues on more rigorous methods of identifying stem cells through use of cell surface antigens such as
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cluster differentiation (CD factors 34 and 44). Consensus on an exact antigen profile of an MSC has not yet
been reached.
Most of the in vivo clinical studies in utilizing MSCs have focused on meniscal repair in either carriers or
scaffolds or direct intra-articular injection. One study involving total medial meniscectomy and anterior cru-
ciate ligament transaction in goats followed by intra-articular injection of bone marrow-derived cultured
standard MSCs showed regeneration of medial meniscal tissue, as well as a decrease in OA that was sub-
stantial in 7 of 9 cases. The scope of this study did not allow evaluation of a direct effect on the articular
cartilage or progression of OA. However the demonstration that meniscal tissue could regenerate and OA
secondary to cruciate sectioning and medial meniscectomy could be reduced prompted us initiating a clini-
cal study for soft tissue injuries in the stifle of horses (see below).
Work by Frisbie et al (2009) at CSU in the osteochondral fragment model showed a significant improvement
in synovial fluid prostaglandin E2 (PGE2) levels in response to treatment with bone-derived MSCs, but not
with adipose-derived MSCs. There was also a significant negative response via an increase of synovial flu-
id TNF concentrations in response to adipose-derived cells. As a result of the equine study it was suggest-
ed that MSCs by themselves do little to counter-act the progression of OA mediated by enzymatic degra-
dation and joint debris and that modification of MSCs is probably needed for them to be useful in OA.
There may also be a timing problem in that MSCs appear to have trophism for damaged cells including fib-
rillated articular cartilage, but in the CSU study the degree of fibrillation was potentially not sufficient for
MSCs injected at day 14 to have an effect. We have concluded however that based on the goat meniscal re-
generation study; the use of MSCs might be indicated when there is soft tissue damage in the joint. We
therefore initiated a prospective, multicenter trial. The goal of the study was long-term follow-up in horse
with severe intra-synovial lesions (mainly meniscal, cartilage or ligamentous) treated with autologous bone
marrow-derived MSCs. Follow-up information in 40 cases revealed that 15 horses returned to or exceeded
their previous level work, 14 horses returned to some level of work and 11 horses were unable to return to
work. Ten horses were still re-conditioning at the time of follow-up. There were not controls in this study
but we have a fair amount of clinical experience knowing the prognosis after arthroscopic surgery in which
there is tearing of the meniscus, meniscal ligaments or cruciate ligaments and intra-articular MSCs definite-
ly improves the results on clinical follow-up. Results of this study support future controlled trials to be un-
dertaken for further definition of the optimal use of intra-articular MSCs in horses.
There has been considerable interest in the possibilities of aiding articular cartilage repair with MSCs. Ini-
tial work in our laboratory comparing the ability of adult equine bone marrow derived and adipose derived
progenitor cells on chondrogenesis have been conducted. Cells were evaluated after expansion in monolay-
er culture and then transplantation into agarose or peptide gels. They were cultured under chondrogenic
conditions (TGF-β) (Kisiday et al 2008). Histologic analysis of peptide hydrogels seeded with cultured ex-
panded cells with TGF-β and cultured in TGF-β for 21 days revealed significantly increased staining with
toluidine blue (as a marker of aggrecan content) and significantly increased staining on immunohistochem-
ical examination for Type II collagen (there was virtually no staining for Type II collagen with adipose-de-
rived cells). Glycosaminoglycan (GAG) accumulation in hydrogel seeded with cultured expanded cells and
W. McIlwraith WVOC 2010, Bologna (Italy), 15th - 18th September • 228
TGF-β after 21 days of culture showed significant enhancement of GAGs and with no significant enhance-
ment in agarose and significant enhancement on peptide gels with minor enhancement with adipose cells.
An in vivo study with MSCs in fibrin implanted into chondral defects in the lateral trochlear ridge of the
horse there was early benefit demonstrated at 30 days but no significant differences were noted when MSCs
plus fibrin was compared to fibrin alone at 8 months (Wilke et al 2007). We have recently explored the val-
ue of intra-articular bone marrow-derived MSCs injected 4 weeks after creation of microfracture defects on
the medial femoral condyle. There was enhancement of the repair tissue firmness at 12 months as well as a
significant increase in aggrecan staining with immunohistochemistry (Frisbie, et al 2010).
REFERENCES
1. Pittenger M, Mackay A, Beck S, et al. Multi-lineage potential of adult human mesenchymal stem cells. Science 1999;
284:143-147.
2. Frisbie DD, Kisiday JD, Kawcak CE, et al. Evaluation of adipose-derived stromal vascular fractional bone marrow-
derived mesenchymal stem cells for treatment of osteoarthritis. J Orthop Res. 2009;27:1675-1680.
3. Ferris DJ, Frisbie DD, Kisiday JD, et al. Clinical follow-up of 40 orthopedic cases treated with bone marrow-derived
stem cells intra-articularly. Equine Vet J submitted 2010.
4. Kisiday JD, Kopesky PW, Evans CH, et al. Evaluation of adult equine bone marrow-derived and adipose-derived
progenitor cell chondrogenesis in hydrogel cultures. J Orthop Res. 2008;26:332-331.
5. Wilke MM, Nydam DV, Nixon AJ. Enhanced early chondrogenesis in articular defects following arthroscopic mes-
enchymal stem cell implantation in an equine model. J Orthop Res. 2007;25:913-925.
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6. Frisbie DD, McIlwraith CW, Rodkey WG, et al. Mesenchymal augmenting articular cartilage repair in microfrac-
tured chondral defects. Manuscript in preparation, 2010.
229 • WVOC 2010, Bologna (Italy), 15th - 18th September W. McIlwraith
Is there a role for arthroscopy in the management of OA?

The role of arthroscopy in the treatment of osteoarthritis has received much attention recently from human
orthopedic surgeons specifically applied to the human knee. It is highlighted by the guidelines recently pro-
duced by the American Academy of Orthopedic Surgeons (AAOS 2009) (Richmond et al 2003). There have
been a number of level 1 studies that have failed to show benefit of arthroscopic debridement or lavage in pa-
tients with significant osteoarthritis of the knee when compared with less invasive modalities but such studies
eliminated those patients who more likely to benefit from arthroscopy, the patients with significant meniscal
tears (Richmond 2010). This later author strongly believes that arthroscopic partial meniscectomy for a trau-
matic meniscal tear, in a well aligned knee, is an extremely beneficial procedure for that patient with mild to
moderate osteoarthritis (Kellgren-Lawrence Stage 1 to 2) with significant symptoms from the torn meniscus.
Many cases of equine OA are associated with some prior traumatic injury that can cause damage to articu-
lar congruency or some degree of instability, including osteochondral chip fragments, osteochondral frac-
tures requiring internal fixation, injuries to meniscus and meniscal ligaments, cruciate injuries or acute ar-
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ticular cartilage avulsion (McIlwraith CW et al 2005). In addition, developmental conditions such as osteo-
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chondritis dissecans (OCD) will lead to progression of OA if not treated effectively. Because of these caus-
es of secondary OA the use of arthroscopic surgery is often appropriate. If these conditions are treated when
clinical signs first become manifested then secondary OA is avoided or at least minimized. On the other
hand, if the primary condition is not treated immediately, secondary OA can be the consequence.
The author has observed that when osteochondral fragments of the distal radiocarpal bone in the middle
carpal joint are not treated immediately with arthroscopic surgery but referred at some time period later, sec-
ondary OA is common. That would apply to fragments elsewhere in the middle carpal joint but osteochondral
fragments in the antebrachial carpal joint are more forgiving. However instances of very old fragmentation,
such as seen in retired racehorses used for other purposes, in the antebrachial carpal joint presented for
arthroscopy will often manifest widespread areas of articular cartilage erosion. Timely removal of these frag-
ments is critical for the best prognosis. Similarly carpal slab fractures of the third carpal bone will commonly
be accompanied by considerable articular cartilage erosion on the distal radiocarpal bone exemplifying the
need for prompt surgery. A study with proximal dorsal P1 chip fragments of the fetlock joint revealed that if
secondary osteoarthritic change was present the success rate of horses coming back and competing at the same
level was reduced (Kawcak and McIlwraith 1994). Similarly cases of OCD in the tarsocrural joint have a poor-
er prognosis for soundness if accompanied by wear lines on the medial trochlear ridge of the talus. More re-
cently considerable experience has been gained in the femorotibial joints of the horse and lack of prompt at-
tention to tears of the meniscus or meniscal ligaments prompts secondary osteoarthritis. Is there usefulness in
such cases for arthroscopic surgery? In the author’s opinion, the answer is yes, but cases need to be selected.
The best example of late stage treatment of OCD lesions in the femoropatellar joint that have some second-
ary articular cartilage fibrillation, reveal that such cases can still revert to athletic soundness. On the other hand,
if left untreated the fibrillation progresses and secondary fibrillation is never seen in the freshly operated case.
The situation with insidious OA secondary to synovitis is less clear. However, arthroscopic treatment is often
indicated for two reasons: 1). assessing the state of degradation and giving the owner or trainer a prognosis,
as well as the usefulness of associated lavage when arthroscopic examination is carried out and 2). debride-
ment (or the use of instruments such as radiofrequency probe) of articular cartilage fibrillation is a contro-
versial technique with the evidence pointing towards promotion of degradative change rather than resolution.
REFERENCES
1. Richmond J, Hunter D, Irrgang J, et al. Treatment of osteoarthritis of the knee (nonarthroplasty). AAOS Clinical
Practice Guidelines Summary. J Am Acad Orthop Surg, 2009;17:591-600.
2. Osteoarthritis Shoulder Guideline Reference. Available at www.aaos.org/Research/guidelines/gloguideline.asp. De-
cember 14, 2009.
3. Richmond JC. Is there a role for arthroscopy in the treatment of osteoarthritis? Editorial. J Arthroscopic and Re-
lated Surg. 2010;Vol 26:143-144.
4. McIlwraith CW, Nixon AJ, Wright IM. Diagnostic and Surgical Arthroscopy in the Horse. 3rd Edition. Mosby-El-
sevier. 2005.
5. Kawcak CE, McIlwraith CW. Proximodorsal first phalanx osteochondral chip fragmentation in 336 horses. Equine
Vet J. 1994;26:392–396.
A.J. Nixon WVOC 2010, Bologna (Italy), 15th - 18th September • 230
Current standards of treatment for subchondral

cyst-like lesions
Alan J. Nixon, BVSc, MS, Dipl. ACVS
College of Veterinary Medicine, Cornell University, Ithaca, NY 14853
SUBCHONDRAL CYSTIC LESIONS - GENERAL

Subchondral cystic lesions occur at many locations in the horse. The etiology is still thought to involve trau-
matic insult to either normal cartilage or cartilage predisposed to cyst formation by the development of os-
teochondrosis. Lesions classically develop in highly loaded regions of articulations, and almost all show an
opening to the synovial cavity through a communicating channel of varying width. The width of the com-
municating channel often dictates the need for surgical debridement. The most common region for sub-
chondral cystic lesions is the medial condyle of the femur, followed by the distal metacarpus/ metatarsus,
proximal radius, glenoid cavity, proximal tibia, distal radius and various locations throughout the phalanges.
Treatment has involved either steroid injection into the cyst lining, with or without surgery, and arthroscopic
extirpation, leaving the cysts cavity empty, and occasionally filling the cavity with bone, bone substitutes, or
MSCs.
MAIN PROGRAM
LARGE ANIMALS
FEMORAL CONDYLE - SUBCHONDRAL CYSTIC LESIONS

Etiopathogenesis
The etiology of subchondral cystic lesions remains debatable. Early evidence supported the concept that this
was a manifestation of osteochondrosis, however, experimental studies and the fact that mature horses can
get subchondral cysts, lends credence to the suggestion that they may be traumatically induced. Material
gathered from subchondral cysts and examined morphologically, suggests that a combination of abnormal-
ly thick regions of articular cartilage and overlying mechanical stress is the most likely inciting cause for sub-
chondral cysts. The enlarging cyst cavity commences initially as an inflammatory response due to the syn-
ovial fluid being driven into the subchondral plate. Later high levels of inflammatory mediators and associ-
ated enzymes such as interleukin-1, nitric oxide, prostaglandins, cathepsins, and MMP-1 & -13, result in an
expansile lesion.1
Treatment
Treatment options include:
1. Joint medication and reduced exercise
2. Ultrasound guided steroid injection to cyst
3. Arthroscopically guided cyst steroid injection
4. Cyst debridement
5. Cyst debridement and grafting
Successful resolution of lameness, and rarely bony filling of the cyst, has been reported with injection of the
cyst lining with triamcinolone or betamethasone.2 This is useful in yearlings and slightly more mature hors-
es with no sign of arthritis. It should be reserved for immature horses with cysts. It generally fails to prevent
arthritic complications long-term in mature horses. Ultrasound guided injection with steroids (triamcinolone
20 mg) combined with bone marrow aspirate is recommended. Surgical staging, debridement of any addi-
tional cartilage damage outside the cyst, and visual injection of the cyst lining is recommended by Colorado
State University, based on available literature.2 Case selection for cyst injection versus more complex de-
bridement and grafting requires consideration of cyst size, cyst canal width, age of horse, upright hindlimb
stifle/hock conformation, evidence of developing osteoarthritis (OA), and failed corticosteroid cases (Figure 1).
For surgical extirpation of the cyst, the goal is to evacuate the contents of the cyst, including necrotic bony
elements and extensive fibrous infiltrates. Debridement of the surrounding sclerotic rim down to normal
healthy bone should provide an adequate stimulus for osteoblast migration into the organizing blood clot
formed following debridement. The elimination of detritus leaching into the joint, and the increased vascu-
larity to the cyst cavity, generally result in diminished symptoms within the first 2 months. Horses are op-
erated in dorsal recumbency with the stifle partially flexed.
The arthroscopic entry point is made lateral to the lateral patellar ligaments, or on occasion between the lat-
eral and middle patellar ligaments. The cyst cavity is penetrated with a curette or rongeur and the content
removed. The hyaline cartilage forming the edge of the cyst opening is preserved as much as possible. The
entire cyst content is removed; motorized equipment is useful. Perforation (forage) of the sclerotic perime-
231 • WVOC 2010, Bologna (Italy), 15th - 18th September A.J. Nixon
ter is now avoided. While not nec-

essary in every case, large cysts
and those in horses over 2 years
old, need to be packed with can-
cellous bone, TCP, or hydroxyap-
atite (HA) bone substitute, to ex-
pedite osseous filling. Synthetic or
cancellous bone graft packed into
cystic defects in the femorotibial
joint can be secured with autoge-
nous or commercial (Sigma) fibrin
glue. Autogenous cancellous bone
goes through lytic revasculariza-
tion and remodeling for several
years, which makes TCP or HA
more satisfactory. Cartilage repair
over the synthetic bone filling can
be accomplished with fibrin or
Platelet Rich Plasma (PRP) con-
taining autograft bone marrow de- Figure 1 - Treatment paradigm for treatment of subchondral cysts of the femoral condyle.
MAIN PROGRAM
LARGE ANIMALS
rived cultured stem cells (Fig. 2).
Bone Marrow Aspirate Concen-
trate (BMAC) is also increasingly
used as a self clotting (contains fib-
rinogen) cell and growth factor
rich autogenous material for carti-
lage repair.
Published results of surgery using
arthroscopy for cyst debridement
indicate from 56 to 74% of horses
return to functional soundness.3,4
Older horses (>3 yrs) do poorly
(35% sound) after debridement5,
and should be grafted. Any horse Figure 2 - (Left) PRP containing cultured stem cells in larger syringe and throm-
with changes suggesting the start bin in smaller syringe, being injected into stifle cyst. PRP gels in 20 to 30 seconds
of OA should be grafted.6 Until to form confluent surface in cartilage (right).
longer-term results of steroid injec-
tion to cyst lining are available, it
should be used in young horses and horses without evidence of OA. Surgical repair gives better assurance
of bone filling and re-establishment of the subchondral bone plate, the latter of which is vital for soundness.
FETLOCK SUBCHONDRAL CYSTIC LESIONS

Cystic lesions with a focal, narrow communication to the synovial cavity can respond well to intraarticular
hyaluronic acid (HA), and this is a useful initial treatment. Improvement in lameness following intraarticu-
lar HA injection is generally rapid, however, the bony filling of the cyst can be more delayed, and general-
ly incomplete even in the long term. Cystic lesions with wide communication to the synovial cavity are sur-
gical cases at the time of diagnosis. Results of debridement of subchondral cystic lesions of the fetlock in fif-
teen horses have been reported.7 Follow-up data from these cases indicate a reasonably good prognosis fol-
lowing surgical extirpation. Our experience following debridement alone for wide-mouthed cysts has been
clinical improvement, but poor resolution of the cyst lucency. Improved radiographic resolution, particular-
ly important for sales purposes, results from incorporation of compacted cancellous bone or TCP, and chon-
drocyte or MSC grafting, similar to the femoral condyle lesions.
CYSTIC LESIONS IN OTHER LOCATIONS

Subchondral cysts in the shoulder are often concurrent with humeral head OCD in weanlings and yearlings,
and need surgery if any hope of an athletic career is expected. Singular cystic lesions with narrow opening
to the joint may respond to intraarticular HA injection. Subchondral cystic lesions of the proximal radius,
generally respond favorably to conservative therapy. These lesions are frequently associated with a narrow
communication to the joint cavity, and respond to intraarticular medication. Humeral condyle lesions in the
elbow need arthroscopic debridement. Subchondral cystic lesions associated with the distal radius also heal
well when treated conservatively. Cysts within the phalanges represent infrequent sites, but can be devas-
tating. Those involving wide openings to the coffin or pastern joints can lead to on-going lameness and lit-
tle hope of surgical access. Arthroscopic debridement of P3 cysts has resulted in good (10 of 11 cases) re-
turn to function.8 Direct curettage of P3 cysts through the hoof wall generally results in sepsis and failure.
REFERENCES
1. von Rechenberg B, Guenther H, McIlwraith CW, et al. Fibrous tissue of subchondral cystic lesions in horses pro-
duce local mediators and neutral metalloproteinases and cause bone resorption in vitro [In Process Citation]. Vet
Surg 2000; 29:420-429.
2. Wallis TW, Goodrich LR, McIlwraith CW, et al. Arthroscopic injection of corticosteroids into the fibrous tissue of
subchondral cystic lesions of the medial femoral condyle in horses: A retrospective study of 52 cases (2001-2006).
Equine vet J 2007.
3. White NA, McIlwraith CW, Allen D. Curettage of subchondral bone cysts in medial femoral condyles of the horse.
Equine Vet J 1988; Suppl 6:120-124.
4. Howard RD, McIlwraith CW, Trotter GW. Arthroscopic surgery for subchondral cystic lesions of the medial
femoral condyle in horses: 41 cases (1988-1991). J Am Vet Med Assoc 1995; 206:842-850.
5. Smith MA, Walmsley JP, Phillips TJ, et al. Effect of age at presentation on outcome following arthroscopic de-
bridement of subchondral cystic lesions of the medial femoral condyle: 85 horses (1993--2003). Equine vet J 2005;
MAIN PROGRAM
LARGE ANIMALS
37:175-180.
6. Nixon AJ. Arthroscopic techniques for cartilage repair. Clinical Techniques in Equine Practice 2002; 1:257-269.
7. Hogan PM, McIlwraith CW, Honnas CM, et al. Surgical treatment of subchondral cystic lesions of the third
metacarpal bone: results in 15 horses (1986-1994). Equine Vet J 1997; 29:477-482.
8. Story MR, Bramlage LR. Arthroscopic debridement of subchondral bone cysts in the distal phalanx of 11 horses
(1994-2000). Equine vet J 2004; 36:356-360.
Critical review of the clinical use of PRP and BMAC

Alan J. Nixon, BVSc, MS, Dipl. ACVS
Cornell University, Ithaca, New York. E-mail: ajn1@cornell.edu
INTRODUCTION
Platelet-rich plasma (PRP) has emerged as an economical method to provide a source and delivery method
for autologous growth factors and cell-rich fractions. PRP has application in management of extensive skin
wounds, and in orthopedic diseases, primarily for tendon and ligament repair, and cartilage resurfacing. In
equine medicine, our experiences are primarily restricted to its orthopedic application. Platelet-enriched plas-
ma products have also an increasingly broad application in human medicine.
The concept uses blood collected from the individual animal or patient in an acid-citrate-dextrose (ACD)
anticoagulant followed by separation in a centrifuge. Various manufacturers produce centrifuge devices
that use specific centrifugal force and either a barrier specific density shelf or a countercurrent elutriation
technique to enrich platelet numbers approximately 4X, and in some devices up to 10X. Platelets are a
rich source of growth factors, particularly platelet-derived growth factor (PDGF) and transforming
growth factor β (TGF-β). Both growth factors play a role in musculoskeletal repair, and supplementing
these recombinant growth factors has enhanced repair in many models. Autologous platelet gel was de-
veloped in the early 1990s as a byproduct of multicomponent pheresis (plasmaphoresis centrifugation).
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LARGE ANIMALS
The fibrinogen content is typically 2-4 mg per ml, which is lower than the 100-200 mg per ml contained
within commercial fibrinogen preparations or those harvested by cryoprecipitation from plasma, and has
the tensile strength and adhesive capabilities to form a depot for growth factor release and also act as a
vehicle for cell implantation.
Fibrin sealant (glue) has previously been used as the principal autologous biologic in equine orthopedic
applications.1 Additionally, it has been used in hemostasis, sealing blood vessels on parenchymatous or-
gans, re-attaching cartilage flaps, and as a vehicle for cell-based cartilage repair. However, fibrin use is lim-
ited by the preparation time required to produce autologous fibrinogen. Preparation by cryoprecipitation
requires 3 days before use. Additionally, fibrinogen prepared by cryoprecipitation has a limited shelf life.
Autologous PRP minimizes the time required to harvest a self-setting bioactive compound from blood
products. The platelet-rich gel can be used by the surgeon to control bleeding in unsuturable regions, min-
imize oozing, improve healing in tendon and ligament tissues, and as a vehicle for cell implant into carti-
lage, bone, and tendon sites. The direct draw method of platelet isolation can provide product within 20
minutes of harvest of blood.
PLATELET-ENRICHED PLASMA PREPARATION

Platelet-enriched plasma can be effectively prepared from the patient within 20 minutes. Sterile preparation
of the jugular vein for blood aspiration is routine. Either 30 or 60 ml of whole blood is then drawn into a
syringe containing 3 or 6 ml of acid-citrate-dextrose. The blood is then injected into the separation device
or centrifuge.
Several manufacturers provide specific disposable devices, packaged with syringes, needles, and anticoagu-
lant. The separation of the buffy coat and plasma uses differential centrifugation and a specific density float-
ing shelf (Figure 1), to separate the bulk of the red blood cell mass from the small white blood cells, platelets,
and plasma.
Figure 1 - (Left) Centrifuge devel-

oped for PRP preparation, using
floating density shelf. (Right) PRP
is collected in the side decant cham-
ber of centrifugation device (Harvest
Technology, MA, USA). Courtesy
Dr. Lisa Fortier.
The platelet-enriched plasma is concentrated by centrifugation immediately above the buffy coat layer of
white blood cells (Figure 1). The upper layers of plasma represent platelet-poor plasma (PPP), and are
generally drawn off and discarded. Sixty ml of whole blood generally results in generation of approxi-
mately 7 ml of PRP. Other devices use countercurrent centrifugal elutriation to separate out the specific
cell fractions in whole blood.
These units are generally more expensive, as are the disposable devices. Our experience is predominant-
ly with the less expensive differential centrifugation technique (Harvest Technology Inc, MA, USA), us-
ing a floating specific density shelf to compress and retain the red cell mass during decant of the platelet-
rich plasma and buffy coat. Other simple devices include the filtration system using retention filtration for
platelets (Acelere™ fPRP; Pal/ VetCell Biosciences), and the ACP system (Autologous Conditioned Plas-
ma) available through Arthrex. By using an autologous source of PRP, blood-borne disease transmission
is avoided.
The two growth factors of particular interest in PRP are PDGF and TGF-β. Both have a major role in re-
cruiting connective tissue progenitors, stimulating matrix formation, and improving the rate of healing. As
a result, PRP is particularly useful in treating flexor tendinitis, suspensory desmitis, bursitis and synovitis,
and focal cartilage erosion.
APPLICATION
For injection into tendinitis and desmitis lesions, the PRP is injected directly and relies on local coagulation
factors to induce clotting to form a platelet gel. When used as a surface spray on wounds or in cartilage re-
MAIN PROGRAM
LARGE ANIMALS
pair, the platelet-rich plasma is activated to form a platelet gel by the addition of thrombin and calcium. The
resulting coagulum or “platelet gel” has a significant adherent stickiness, largely due to its concentrated fib-
rinogen levels.
Tendon and Suspensory Ligament Repair

Recent in vitro research using equine tendon explants indicates PRP actively supports flexor tendon repair.2
PRP is used as the sole injectable treatment for flexor tendinitis within the first 8 weeks of injury. Ultra-
sonographic evidence of a core lesion is required to allow injection of the platelet-rich product. Depending
on lesion size, 4-7 ml of platelet-rich plasma is harvested. Shorter and smaller cross-sectional area tendinitis
lesions require only 1-2 ml of PRP.
More extensive lesions can accomodate 4-6 ml during the injection. The platelet-rich plasma can also be used
as a vehicle for more aggressive treatment of tendinitis cases, to deliver enriched cultured bone-marrow de-
rived stem cells (Figure 2).
Repeat injection of PRP can be done 2-4 weeks after the initial injection. Combination with check desmo-
tomy of the accessory ligament of the superficial digital flexor tendon can be done, depending on surgeon
preference. There are few published followup studies documenting the results of equine flexor tendinitis
treatment with PRP.
Figure 2 - PRP can be used as a stand-alone biologic, or used as a vehicle for cultured MSC, mixing the cell pellet with PRP (left), in-
serting needles into suspensory or SDFT under ultrasound guidance (middle), and injecting mixture of PRP and MSCs (right).
Figure 3 - Collagen type IIB immuno showing no type II collagen in Figure 4 - Toluidine blue reaction is minimal in PRP-no cells (A),
PRP-no cells (A), significant nodules in PRP with chond (B), and prolific around nodules in PRP with chond (B), and lesser amounts
lesser amounts in PPP (C), and fibrin (D) containing chondrocytes. in PPP (C), and fibrin (D) with chondrocytes.
MAIN PROGRAM
Cartilage Repair
LARGE ANIMALS
PRP makes a very effective vehicle for delivery of cultured chondrocytes or MSCs. PRP can be isolated pa-
tient-side and, when used in combination with calcium-activated thrombin, provides a malleable self-adher-
ent platelet gel that combines enriched growth factors with chondrocytes that contribute to cartilage repair.
An in vitro study of the metabolic function of chondrocytes in PRP compared to platelet-poor plasma or fib-
rin showed the positive impact of PRP on chondrocyte function (Figure 3). PRP enhanced chondrocyte clus-
ter formation, collagen type II in deposition and toluidine staining proteoglycan accumulation (Figure 4).
Given its simplicity at harvest, compared to fibrinogen preparation from cryoprecipitation of plasma, PRP
makes an effective substitute. The only drawback to the use of PRP is the considerable shrinkage that de-
velops following platelet degranulation during the formation of the platelet gel. Clinical experience suggests
that refilling cartilage defects with PRP is required at surgery. Additionally gas arthroscopy is required for
application. No published data are available yet concerning cartilage resurfacing using PRP as a vehicle.
Bone Marrow Aspirate Concentrate (BMAC) alone for Cartilage Repair

The development of patient-side centrifugation techniques for intraoperative stem cell isolation and purification
for immediate grafting have significant advantages in time savings and immediate application of an autogenous
cell for cartilage repair.3 When considered together, cartilage studies reveal that three components are required
for cartilage regeneration; cells, scaffold, and growth factor/s. Recent work has generated a stem cell concentrate
from sternal bone marrow aspirate which can be centrifuged to concentrate the cellular population and platelets
in bone marrow aspirate. Using flow cytometry, current data indicate that the final total nucleated cell popula-
tion contains approximately 15% stem cells (Radcliffe & Fortier, unpublished data, 2008). The concentrate also
contains a large number of platelets which are the body’s natural reservoir of several growth factors such as IGF-
I, TGF-B, and FGF, which are known to enhance cartilage matrix synthesis. The concentrate can be mixed with
thrombin to cleave the fibrinogen into a fibrin scaffold to hold the milieu of MSCs and growth factors. This
method has the advantages of being a point-of-care technique (no laboratory culture period is necessary) that is
completely autogenous, arthroscopically applicable, and delivers all three components believed to be important
for cartilage regeneration; cells, growth factors, and a scaffold. In vivo data, using 10 research horses in which
15mm full thickness defects were made on the lateral trochlear ridge of the femur, revealed no post-operative
synovitis or other detectable adverse reaction.3 In the research cases, the grafted limb had a significantly better
score at 3-month recheck arthroscopy and the control limb. At 8 months (euthanasia) 3T MRI indices, gross
score, and histologic scores were all significantly better in the grafted limb compared to the control limb. Sub-
sequently 28 clinical cases have used BMAC as a sole graft product. BMAC is slow to clot in place, and care-
ful drying is required to get solid adherence of the BMAC, with or without added MSC.
REFERENCE LIST
2. Schnabel LV, Mohammed HO, Miller BJ, et al. Platelet rich plasma (PRP) enhances anabolic gene expression pat-
terns in flexor digitorum superficialis tendons. J Orthop Res 2006.
3. Fortier LA, McCarrel T, Potter HG, et al. Bone marrow aspirate concentrate heals cartilage. JBJS (Am) 2010; (In Press).
Cartilage resurfacing in the horse - Reality or fiction?

Alan J. Nixon BVSc, MS, Dipl. ACVS
Cornell University, Ithaca, New York. E-mail: ajn1@cornell.edu
Cartilage resurfacing implies repair to an organized hyaline architecture not evident in simple manipulative
techniques used in mature horses. Methods that may enhance the quantity and hyaline characteristics of car-
tilage repair tissue, while at the same time maintaining the efficiencies of arthroscopic surgery, allow the sur-
geon to improve the long-term outcome when debriding cartilage lesions. No system routinely provides all
of these advantages. Indeed, those with inherent simplicity such as cartilage debridement, forage, and mi-
crofracture meet many of the criterion for simplicity, economy, and minimal delay between diagnosis and
repair, but provide less assured hyaline cartilage and cartilage durability. Techniques for cartilage repair that
strive to improve chondrocyte preponderance and organized matrix architecture include cell and tissue en-
gineered transplantation techniques. Most are better than local debridement or marrow stimulation proce-
dures, but add complexity to the surgery.
LOCAL MANIPULATION
Surgical techniques that rely on simple manipulative procedures intraoperatively include:
• cartilage debridement,
MAIN PROGRAM
LARGE ANIMALS
• cartilage re-attachment,
• forage or drilling of the subchondral bone using a drill to provide a uniform diameter perforation through
the subchondral plate,
• microfracture or micropick, which uses a tapered surgical awl to perforate the subchondral bone to open
marrow spaces,
Many of these techniques are applied during routine arthroscopy.
Cartilage Re-Attachment Using Resorbable Pins

Indications
Under defined conditions where an OCD cartilage flap has not detached on its entire perimeter, the par-
tially attached flap can be replaced and secured with polydioxanone (PDS) pins (OrthoSorb, DePuy).1 Im-
portantly, the OCD flap must be:
- worth re-attaching, which requires a smooth congruous surface with minimal fibrillation
- still in situ within the original defect, with at least some residual continuity with normal surrounding
cartilage
- not entirely mineralized
Technique
The joint is examined arthroscopically to determine the suitability for OCD flap reattachment or alterna-
tively, debridement and subchondral bone scarification. Cartilage lesions that have detached from underly-
ing bone and remain partially attached to normal cartilage surrounding the lesion are ideal for reattachment.
Several 20 mm length PDS pins are placed with the kit provided. This kit also contains three 40 mm PDS
pins which can conveniently be cut in half and the 20 mm pins used to secure the flap every 10 to 15 mm
along its length. For drilling, an arthroscopic instrument portal directly over the lesion is developed to allow
insertion of the cannula perpendicular to the cartilage surface. The K-wire is secured in the chuck of the drill
to allow 19 mm of K-wire to emerge from the end of the cannula. The K-wire is drilled through the loose
cartilage and into the subchondral bone the full 19 mm.
Repeated entry and withdrawal of the K-wire is vital to make a uniform and appropriately sized hole. The
K-wire is exchanged for the pre-cut 20 mm pin, which is pushed down the cannula and into the drill hole.
Any excess pin can be clipped off with a biopsy rongeur and the pin flared on the protruding end to form
a tack head. Additional pins are placed until the flap is secure. 3 to 10 pins have been required depending
on length and width of the OCD flap.
Results
PDS pins have been used to repair OCD lesions in 44 stifles of 27 horses. Resolution of joint effusion oc-
curred in all but 2 horses within 8 weeks of surgery. Radiographic improvement in lesion subchondral bone
lucency commenced within weeks of surgery, and many lesions appeared radiographically resolved within
3 months of surgery. One horse was lost to follow-up due to a tendon laceration resulting in euthanasia 8
weeks after surgery. Of the remaining 26 horses, mean duration of follow-up was 15.6 months (range 2
months–12 years). Nineteen of these were sound and reached their intended athletic potential, 1 horse re-
mained lame, and an additional 6 were sound but remained unbroken or were convalescing. For horses eval-
uated long-term, an overall success rate based upon continued soundness in performing horses was 95%
(19/20). Resolution of the OCD subchondral defect and contour irregularity was achieved in most horses,
and reformation of the subchondral contour was better than that following cartilage flap removal.
TRANSPLANTATION PROCEDURES
The use of supplemental free cells, various vehicles containing cells, or entire tissues such as periosteum or
cartilage grafts have been advocated to improve the modest impact that local manipulative procedures have
on both the quality and quantity of cartilage repair tissues. Transplantation procedures can be divided into
several currently acceptable areas, according to the type of transplant tissue: 1) osteochondral transplanta-
tion (mosaicplasty, 2) chondrocyte transplantation, 3) pluripotent stem cell transplantation, and 4) bone mar-
row aspirate concentrate (BMAC) implantation.
Transplantation of whole tissues and tissue engineered products usually requires arthrotomy approaches
which are unsatisfactory in most equine joints. These include chondrocytes cultured on collagen (MACI),
polyglycolic acid (PGA), or PGA/polylactic acid (PGA/PLA), or newer synthetic materials such as hyaluro-
nan membranes. This serious practical limitation has tempered interest in using these implants.
Clinical Results of Chondrocyte Transplantation
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LARGE ANIMALS
Chondrocyte grafting in fibrin vehicles has been used successfully in the horse since 1995. Clinical resur-
facing trials in horses have used a autogenous fibrin or more recently platelet rich plasma (PRP) as a vehi-
cle, laden with 50 ug of IGF-1 and 30 million chondrocytes/ ml of fibrin.2 Clinical application of this growth
factor enhanced chondrocyte grafting process in horses has included traumatic cartilage lesions of the third
carpal bone, fetlock metacarpal condylar fractures, and OCD or subchondral cystic lesions of the fetlock
(22 horses) and stifle (49 horses). Results for stifle OCD and subchondral cyst grafting of the stifle and fet-
lock have been generally good.3 Complete radiographic filling has occurred in more than half of the stifle
subchondral cysts radiographed at or beyond 24-months postoperatively, and 73 percent of stifle subchon-
dral cysts, including failures of previous simple debridement alone, have been in athletic work for a mini-
mum of four years. Similarly, fetlock subchondral cysts have been treated using arthroscopic extirpation and
grafting. Radiographic filling of the fetlock cysts can be slow, and residual deeper lytic regions can remain
despite athletic performance.
Clinical Applications of MSC Transplantation

The current cell type of choice is an autologous MSC. Previous clinical work used chondrocyte allografts.
However, allograft chondrocytes occasionally resulted in subtle immune reaction. Autologous MSCs avoid
this problem, but result in further issues with inadequate chondrogenesis at the time of application. Bone
marrow-derived MSCs can be harvested and directed down the chondrocyte lineage.4 In vivo studies in the
horse indicate improved early healing in a femoral trochlear ridge healing model.5 Methods to induce chon-
drogenesis in MSCs are becoming better defined6, and exposure to TGF-β1, 2, or 3, and Sox5,6 & 9, all in-
duce chondrocytic transformation. Clinical cases are currently grafted with autogenous fibrin or PRP con-
taining 20 to 30 million MSCs/ml of vehicle.
Platelet-enriched Plasma (PRP) as an Anabolic Vehicle - Time to surgery can be shortened by using PRP as a ve-
hicle for stable implantation of MSCs. Fibrinogen requires 72 hours to prepare using cryoprecipitation,
which delays the time to surgery after admission to the clinic. However, platelet-rich plasma can be prepared
by centrifugation of blood in the surgery suite in 20 minutes, and has sufficient fibrinogen to clot and ad-
here securely to subchondral bone and cartilage edges. More importantly, PRP is rich in growth factors in-
cluding PDGF, bFGF, and TGF-β, which drive chondrogenesis in MSCs. Adding MSCs also helps control
the shrinkage associated with platelet degranulation during clotting. PRP makes a very effective vehicle for
delivery of cultured MSCs (Fig. 1).
MSC Application - At the time of surgery the MSCs are mixed with fibrinogen or PRP and stored at 4oC.
The vehicle is clotted with 1000 units of activated thrombin, to provide a two-component system for im-
mediate injection. At surgery, the polymerization process develops immediately upon injection of the two
components into the articular defect. Arthroscopic application is routinely performed, using gas insufflation
for the few minutes required for fibrin or PRP injection. Alternatively, for short term gas arthroscopy sev-
eral 60 ml syringes of room air can suffice to dry the cartilage bed and allow injection of the MSC laden fib-
rin or PRP. The polymerizing liquid nature of fibrin and PRP allow contouring of the cell transplant to the
irregularities of many joint surfaces.
Figure 1 - (Left) PRP containing cultured

stem cells in larger syringe and thrombin in
smaller syringe, being injected into stifle cyst.
PRP gels in 20 to 30 seconds to form conflu-
ent surface in cartilage (right).
Clinical application of MSC grafting in horses has included traumatic cartilage lesions of the fetlock metacarpal
condyles and proximal P1, OCD or subchondral cystic lesions of the shoulder, fetlock, and stifle, and third
carpal bone lysis, slab fracture, and bone cysts of other carpal bones. Results for stifle OCD and subchondral
cyst grafting of the stifle and fetlock have been generally good. Many have been re-operation of previous failed
therapies, including simple debridement with or without microfracture and steroid injection.
Bone marrow aspirate concentrate (BMAC) for cartilage repair

The development of patient-side centrifugation techniques for intraoperative stem cell isolation and purifi-
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cation for immediate grafting has provided significant advantages in time savings and immediate application
LARGE ANIMALS
of an autogenous cell for cartilage repair (Fig 2).7 (Fortier et al. JBJS (Am) 2010).
Figure 2 - Bone marrow aspi-

rate concentrate techniques for
concentration of pluripotent cells
and growth factors for cartilage
repair. Top panel: harvest of
bone marrow (left), injection into
separation device, and placing
into programmable centrifuge.
Lower panel: drawing off
bone marrow derived MSC en-
riched fraction (left), debriding
medial femoral condyle erosion in
5 year-old Warmblood with con-
current meniscal tear (center),
and injecting bone marrow stem
cell enriched product mixed with
thrombin to clot in full-thickness
cartilage defect (right).
REFERENCE LIST
1. Nixon AJ, Fortier LA, Goodrich LR, et al. Arthroscopic re-attachment of osteochondritis dissecans lesions using re-
sorbable polydioxanone pins. Equine Vet J 2004; 36:376-383.
3. Ortved K, Greenberg MJ, Fortier L, et al. Treatment of subchondral bone cysts of the medial femoral condyle in
mature horses using chondrocyte implantation: A retrospective study of 49 cases. Proceedings, ACVS Annual Sur-
gical Symposium 2009;22-23.
4. Fortier LA, Nixon AJ, Williams J, et al. Isolation and chondrocytic differentiation of equine bone marrow-derived
mesenchymal stem cells. Am J Vet Res 1998; 59:1182-1187.
5. Wilke MM, Nydam D, Nixon AJ. Enhanced early chondrogenesis in articular defects following arthroscopic mes-
enchymal stem cell implantation in an equine model. J Orthop Res 2007; 25:913-925.
6. Worster AA, Nixon AJ, Brower-Toland BD, et al. Effect of transforming growth factor B1 on chondrogenic differ-
entiation of cultured equine mesenchymal stem cells. Am J Vet Res 2000; 61:1003-1010.
7. Fortier LA, McCarrel T, Potter HG, et al. Bone marrow aspirate concentrate heals cartilage. JBJS (Am) 2010; (In
Press).
239 • WVOC 2010, Bologna (Italy), 15th - 18th September S.E. Powell
Low-field magnetic resonance imaging aspects

of palmar/plantar metacarpal/metatarsal pain syndrome
Sarah E. Powell MA VetMB MRCVS
Rossdale & Partners, Rossdales Equine Diagnostic Centre, Newmarket, UK, sarah.powell@rossdales.com
High-field magnetic resonance imaging of the equine subcarpal and subtarsal regions has been with us for
over a decade and several pioneering papers have resulted1-3. The subsequent introduction of a dedicated
equine standing magnetic resonance imaging system, used without the need for general anaesthesia, has led
to a vast increase in the number of cases of foot, fetlock, subcarpal and subtarsal pain investigated using this
modality. With the increasing throughput of cases an increasing amount of light is gradually being shed on
some long-standing conundrums in equine lameness. The foot was the first focus of attention and MRI has
yielded secrets related to palmar foot syndrome over the last half of the last decade4-8 and will continue to
do so. Perhaps inevitably, as the technology improved, our sights migrated proximally to the fetlock, sub-
tarsal and subcarpal regions. Nagy & Dysons’9 2009 paper was a much-needed comparison of the normal
anatomy of the subcarpal region as it appears on high and low-field magnetic resonance images. This en-
abled clinicians involved in the interpretation of low-field images without experience of high-field compar-
isons to familiarise themselves with the detailed anatomy of the region and how it compares on high and
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low-field pulse sequences in normal cadaver specimens.
Of course, imaging the living, breathing animal under sedation may yield a different quality of images altogether
and attempting to draw diagnostic conclusions from images beset by movement artefact is something we all
strive to avoid. Published work has so far been thin on the ground using low-field MRI systems in clinical prac-
tice as we all concentrate on optimising our horse handling and sedation protocols to maximise the quality of
the images, though this is surely set to change soon. Users are now largely happy with its use in the (more
amenable) forelimb but movement remains a huge problem when imaging the hindlimb in all but the most com-
pliant patients. I believe the holy grail of achieving a complete set of immaculate sequences in the majority of
cases is a task for the technical wizards of the manufacturing companies (rather than the users of the system in
its current form) to dedicate themselves to over the coming years. A quantum leap in the application of motion
correction techniques is need here and I look forward to a second wave of potential when it is achieved.
In the meantime in our practice the subtarsal region undergoes standing magnetic resonance imaging only
in relatively rare cases where the benefits of potentially solving a diagnostic riddle significantly outweighs the
money and time spent carrying out a subtarsal region MRI scan. With a few notable and interesting ex-
ceptions, our competition horse caseload and clinicians dealing with these animals dictate that the majority
of horses with pain abolished by a lateral plantar nerve block or subtarsal infiltration can be adequately im-
aged radiographically and ultrasonographically (with a proportion going by way of the scintigraphy suite)
and successfully managed conservatively or (mainly) surgically depending on the final diagnosis and de-
gree/duration of lameness; making us assume, perhaps foolishly, that an MRI examination is an unneces-
sary adjunct. In addition, the majority of Thoroughbred racehorses with pain related to this region rarely
make it through the Diagnostic Centre doors – their attending yard clinicians finding extracorporeal shock-
wave therapy (ESWT) or regional infiltration of low-dose corticosteroids a successful therapy in the vast ma-
jority of cases with little need for further work-up – perhaps testament to a differing aetiology to their old-
er competition horse counterparts.
By contrast, MR imaging of the subcarpal region is currently far more rewarding in terms of image quality
and diagnostic potential. At our centre subcarpal MRI has come into its own in forming specific diagnoses
of pain related to the subcarpal region in the Thoroughbred racehorse10 where suspensory ligament pathol-
ogy can be differentiated from middle carpal joint pain and stress injuries to the proximal third metacarpal
bone, predominantly in cases where the blocking pattern is ambiguous.
This slide presentation will become available to view at www.rossdales.com after this meeting has ended.
REFERENCES
1. Brokken MT, Schneider RK, Sampson SN, Tucker RL, Gavin PR, Ho CP.Magnetic resonance imaging features of
proximal metacarpal and metatarsal injuries in the horse. Vet Radiol Ultrasound. 2007 Nov-Dec;48(6):507-17.
PMID: 18018721 [PubMed - indexed for MEDLINE]Related citations
2. Bischofberger AS, Konar M, Ohlerth S, Geyer H, Lang J, Ueltschi G, Lischer CJ. Magnetic resonance imaging, ul-
trasonography and histology of the suspensory ligament origin: a comparative study of normal anatomy of warm-
blood horses. Equine Vet J. 2006 Nov;38(6):508-16.
S.E. Powell WVOC 2010, Bologna (Italy), 15th - 18th September • 240
3. Zubrod CJ, Schneider RK, Tucker RL.Use of magnetic resonance imaging to identify suspensory desmitis and ad-
hesions between exostoses of the second metacarpal bone and the suspensory ligament in four horses. J Am Vet
Med Assoc. 2004 Jun 1;224(11):1815-20, 1789.
4. Nagy A, Dyson SJ, Murray RM.Radiographic, scintigraphic and magnetic resonance imaging findings in the pal-
mar processes of the distal phalanx. Equine Vet J. 2008 Jan;40(1):57-63.
5. Barber MJ, Sampson SN, Schneider RK, Baszler T, Tucker RL. Use of magnetic resonance imaging to diagnose
distal sesamoid bone injury in a horse. J Am Vet Med Assoc. 2006 Sep 1;229(5):717-20.
6. Murray RC, Blunden TS, Schramme MC, Dyson SJ.How does magnetic resonance imaging represent histologic
findings in the equine digit? Vet Radiol Ultrasound. 2006 Jan-Feb;47(1):17-31.
7. Murray RC, Schramme MC, Dyson SJ, Branch MV, Blunden TS. Magnetic resonance imaging characteristics of
the foot in horses with palmar foot pain and control horses. Vet Radiol Ultrasound. 2006 Jan-Feb;47(1):1-16.PMID:
16429980 [PubMed - indexed for MEDLINE]Related citations.
8. Dyson S, Murray R, Schramme M, Branch M. Lameness in 46 horses associated with deep digital flexor tendonitis
in the digit: diagnosis confirmed with magnetic resonance imaging. Equine Vet J. 2003 Nov;35(7):681-90.
9. Nagy A, Dyson S. Magnetic resonance anatomy of the proximal metacarpal region of the horse described from im-
ages acquired from low- and high-field magnets. Vet Radiol Ultrasound. 2009 Nov-Dec;50(6):595-605.
10. Powell SE, Ramzan PH, Head MJ, Shepherd MC, Baldwin GI, Steven WN. Standing magnetic resonance imaging
detection of bone marrow oedema-type signal pattern associated with subcarpal pain in 8 racehorses: a prospective
study. Equine Vet J. 2010 Jan;42(1):10-7.
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241 • WVOC 2010, Bologna (Italy), 15th - 18th September C.M. Riggs
Palmar Osteochondral Disease (POD) in the fetlock:

definition, pathophysiology and diagnosis
C.M. Riggs1, A. Boyde2, G.L. Pinchbeck3, E.D. Barr3, P.D. Clegg3
1
Department of Veterinary Clinical Services, The Hong Kong Jockey Club, Sha Tin Racecourse, New Territories,
Hong Kong SAR
2
Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
3
Musculoskeletal and Locomotion Research Group, School of Veterinary Sciences, University of Liverpool, UK
INTRODUCTION
The fetlock joint is the most common site of injury and musculoskeletal disease in the Thoroughbred race-
horse. Acute, catastrophic fractures of its component parts (third metacarpal/metatarsal, first phalanx and
proximal sesamoid bones) account for the majority of deaths on the racecourse. In addition, it is frequently
affected by degenerative conditions, which often cause reduced performance and result in premature retire-
ment. The majority of these acute and chronic injuries arise in subchondral bone and are progressive in na-
ture. Palmar/Plantar Osteochondral Disease (POD) describes a condition which involves focal disease of
subchondral bone and overlying articular cartilage in the palmar/plantar aspect of the distal condyles of the
third metacarpal and third metatarsal bones (McIII & MtIII). It is common, causes chronic lameness of vari-
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able severity and has significant economic and welfare implications for the Thoroughbred racing industry.
Better understanding of POD is required to develop strategies to prevent and treat this condition and will
provide useful information pertinent to subchondral bone disease at other anatomical locations.
DEFINITION
Palmar/Plantar Osteochondral Disease refers to a specific condition associated with focal degeneration of os-
teochondral tissues in the palmar/plantar aspect of the distal condyles of McIII and MtIII. Similar lesions
have been recognised in racehorses for many years and have previously been referred to as traumatic os-
teochondrosis in the equine veterinary literature (Pool 1995). Although initially considered to be a manifes-
tation of osteochondritis dissecans (Hornof et al. 1981), this condition is now believed to be a biomechani-
cal disorder, resulting from repetitive overload trauma in horses undergoing high intensity exercise.
POD lesions are characterised grossly as small, circular defects, typically 4 to 8mm in diameter, in the
palmar or plantar articular surface of the distal condyles McIII/MtIII. Lesions are centred about 5 to
8mm proximal to the transverse ridge and may be located 5 to 15mm from the sagittal ridge on either
the medial or lateral condylar surfaces (Pool 1995). Lesions appear to vary in severity (Figure 1), from
bluish bruising of the subchondral
bone, visible through intact overly-
ing cartilage (Grade 1), through in-
dentation of the subchondral bone
with collapse and fissuring of overly-
ing articular cartilage (Grade II), to
the most severe lesions where ulcer-
ation of articular cartilage defect is
associated with partial or complete
dislodgement of underlying sub-
chondral bone and exposure of a
fracture bed (Grade III). In a post
mortem study of a closed Thorough-
bred racehorse population we have
demonstrated a prevalence of POD
of 67% (Barr et al, 2009).
The condition is more common in the
medial condyle of McIII and lateral
condyle of MtIII and there is correla-
tion between POD and other joint
pathology, such as wear lines, carti-
lage ulceration and dorsal impact in- Figure 1 - Gross images of the distal condyles of McIII and MtIII from Thorough-
juries (Riggs et al, 2010). bred racehorses, illustrating different severities of POD lesions.
C.M. Riggs WVOC 2010, Bologna (Italy), 15th - 18th September • 242
PATHOPHYSIOLOGY
In the absence of longitudi-
nal studies it is assumed
that varying severities of
gross lesion (Figure 1) rep-
resent different stages of a
progressive degenerative
process. Studies have char-
acterised a range of gross
and microscopic changes
in subchondral bone in the
locations where POD le-
sions arise (Pool, 1995,
Nordin et al, 1998, Nordin
& Stover, 2006). Focal ac-
cretion of new bone in vas-
cular spaces immediately
beneath the articular sur-
face and in deeper trabecu-
lae of the palmar condyles,
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resulting in localised scle-

rosis in this location, is
considered a normal adap-
tive response to focal loads
imposed by the proximal Figure 2 - Hypothetical pathways in the development and progression of Palmar Osteochondral Dis-
sesamoid bones in horses ease lesions.
undergoing intense exer-
cise. In cases affected by
POD, the immediate subchondral bone becomes intensely sclerotic and undergoes localised necrosis and
vascular spaces may become occluded with necrotic debris. Dead bone becomes hypermineralised and rel-
atively brittle and there is evidence that it sustains extensive microdamage (Muir et al, 2008), although this
remains controversial. Intense resorptive activity is initiated at the margin of healthy and necrotic bone,
forming a discrete saucer-shaped layer of increased porosity and vascular in growth millimetres beneath the
articular surface. Under continued intense loading, the superficial layer of necrotic bone may collapse in-
wards as the porotic, resorptive layer is crushed or, in severe cases, may flake off as a free osteochondral
fragment, leaving a deep ulcer in the joint surface.
DIAGNOSIS
POD lesions frequently occur bilaterally and so lameness may be overlooked until it becomes severe. Hors-
es with advanced lesions, demonstrable radiographically, usually have evidence of advancing joint disease
with reduced joint flexion, pain on flexion, capsular thickening and joint effusion. However, this is end stage
and earlier recognition of the condition is critical to avoid irreversible pathology.
Thoroughbred racehorses in training frequently exhibit signs of acute-onset bilateral lameness (fore and/or
hind) with pain referable to the fetlock joint in the absence of other clinical signs, negative radiographic find-
ings but intense focal uptake of radiopharmaceutical in the distal condyles of McIII or MtIII (Shephard &
Pilsworth, 1997). This syndrome is more common in younger animals and may reflect adaptive model-
ling/remodelling, which is within normal physiological limits – a proportion of horses without fetlock pain
also have positive scintigraphic findings in the same location. Whether these horses go on to develop POD
requires longitudinal studies yet to be performed.
Specialised radiographic views, particularly flexed dorso-palmar or plantar-dorsal, and proximo-distal ori-
entated oblique projections, aid the identification of POD lesions (O’Brien et al. 1981; Pilsworth et al. 1988).
However, a well position lateral view can sometimes highlight lesions most effectively.
Newer, imaging modalities such as computed tomography (Byron and Goetze 2007; Morgan et al. 2006)
and magnetic resonance imaging (Zubrod et al. 2004) have been found to be useful in diagnosis of POD,
but are limited by expense and restricted availability.
The region of the condyles affected by POD is not accessible to arthroscopic visualisation. However, ul-
ceration of the articular cartilage at the base of a proximal sesamoid bone is strongly suggestive of a POD
lesion.
243 • WVOC 2010, Bologna (Italy), 15th - 18th September C.M. Riggs
REFERENCES
Barr E.D., Pinchbeck G.L., Clegg P.D., Boyde A., and Riggs C.M. (2009) Post mortem evaluation of palmar osteochon-
dral disease (Traumatic Osteochondrosis) of the metacarpo-/metatarsophalangeal joint in Thoroughbred racehors-
es. Equine Vet J 41, 366-371.
Byron C.R. and Goetz T.E. (2007) Arthroscopic debridement of a palmar third metacarpal condyle subchondral bone in-
jury in a Standardbred. Equine vet. Educ. 19, 344-347.
Hornof W.J., O’Brien T.R. and Pool R.R. (1981) Osteochondritis dissecans of the distal metacarpus of the adult racing
Thoroughbred horse. Vet Radiol 22, 98-105.
Morgan J.W., Santschi E.M., Zekas L.J., Scollay-Ward M.C., Markel M.D., Radtke C.L., Sample S.J., Keuler N.S. and
Muir P. (2006) Comparison of radiography and computed tomography to evaluate metacarpo/metatarsophalangeal
joint pathology of paired limbs of Thoroughbred racehorses with severe condylar fracture. Vet Surg. 35, 611-617.
Muir P., Peterson A.L., Sample S.J., Scollay M.C., Markel M.D. and Kalscheur V.L. (2008). Exercise-induced metacar-
pophalangeal joint adaptation in the Thoroughbred racehorse. J. Anat 213, 706-717.
Norrdin R.W., Kawcak C.E., Capwell B.A and McIlwraith C.W. (1998) Subchondral bone failure in an equine model of
overload arthrosis. Bone 22, 133-139.
Norrdin R.W. and Stover S.M. (2006) Subchondral bone failure in overload arthrosis: A Scanning Electron Microscopic
Study in Horses. J Musculoskelet Neuronal Interact 6, 251-257.
O’Brien T.R., Hornof W.J. and Meagher D.M. (1981) Radiographic detection and characterisation of palmar lesions in
the equine fetlock joint. J. Am. Vet. Med. Ass. 178 231-231.
Pilsworth R.C., Hopes R. and Greet T.R.C. (1988) A flexed dorso-palmar projection of the equine fetlock in demon-
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strating lesions of the distal third metacarpus. Vet. Rec. 122, 332-333.
Pool R.R. (1995) Joint disease in the athletic horse: A review of pathologic findings and pathogenesis. Proc Am Assoc
Equine Pract. 41, 20-34.
Riggs C.M., Pinchbeck G.L., Boyde A., Barr E.D and Clegg P.D. (2010) Post mortem evaluation of palmar/plantar os-
teochondral disease of the metacarpo- and metatarsophalangeal joint of racehorses and identification of preliminary
risk factors. Proc. 17th Int Conf Racing Analysts and Vets In press.
Shephard MC and Pilsworth RC (1997) Stress reactions to the plantarolateral condyles of MtIII in UK Thoroughbreds:
26 cases. Proc Am Assoc Equine Pract. 43, 128-131.
Zubrod C.J., Schneider R.K., Tucker R.L., Gavin P.R., Ragle C.A. and Farnsworth K.D. (2004) Use of magnetic reso-
nance imaging for identifying subchondral bone damage in horses: 11 cases (1999-2003) J. Am. Vet. Med. Ass. 224,
411-418.
M.C. Schramme WVOC 2010, Bologna (Italy), 15th - 18th September • 244
MRI features of subchondral bone injury

in the metacarpophalangeal and metatarsophalangeal
joints of horses
Michael C. Schramme
North Carolina State University, College of Veterinary Medicine, Hillsborough Street 4700, Raleigh 27606
INTRODUCTION
Subchondral bone injury is common in the fetlock joint of horses. However, without marked structural bone
damage or demineralization subchondral bone injury may not be visible radiographically or scintigraphi-
cally and magnetic resonance (MR) imaging may be necessary to make the diagnosis. We investigated the
incidence of subchondral bone injury with high field MR in 40 horses with lameness attributable to the
metacarpo/metatarsophalangeal (MP) joint region in which it was difficult to reach a definitive diagnosis
with other imaging modalities.

MR imaging was performed with the horses under general anesthesia in a 1.5 T Magnet (Siemens Sym-
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phony). The standard MR imaging protocol included a dual echo (proton density (PD) and T2) turbo spin
echo (TSE) sequence in sagittal and transverse planes with a slice thickness of 3 mm and 4 mm respective-
ly, a short inversion recovery (STIR) sequence in sagittal and transverse planes with slice thickness of 3
mm and 4 mm respectively, a 3-dimensional fast low angle shot sequence (3D FLASH) with fat saturation
in a sagittal plane with slice thickness of 2mm and a 3D FLASH sequence without fat saturation in a dor-
sal plane with slice thickness of 2 mm.
RESULTS
MR evidence of subchondral bone injury was found in 19 of 40 (48%) horses, (14 in forelimbs and 5 in
hindlimbs). Evidence of subchondral bone damage was bilateral in 8 horses and unilateral in 10 horses (to-
tal 24 limbs). Abnormal MR signal in subchondral bone included diffuse or focal signal increase in STIR
images, diffuse T1, PD and T2 signal decrease with trabecular thickening, and focal T1, PD and T2 signal
increase associated with localized loss of trabecular or cortical bone. Combinations of different signal ab-
normalities were frequently present in bone. Areas of signal hyperintensity were commonly surrounded by
an area of signal hypointensity, presumably due to sclerosis. The transverse and sagittal PD-weighted im-
ages were most useful for recognizing sclerosis-related signal changes. The PD-weighted images provided
good anatomic detail of bone including trabecular thickness and density. The STIR images were most use-
ful for identifying increased fluid signal within bone. The 3D FLASH images with fat saturation were most
useful for detection of small, focal areas of bone or cartilage loss because of the smaller slice thickness and
improved cartilage contrast in this sequence. All but one horse with bone edema associated with subchon-
dral bone disease had a corresponding increased in radionuclide uptake on nuclear scintigraphy.
Subchondral bone lesions were the only finding in 7 horses, although 4 of these had multiple sites of ab-
normal bone signal in the affected joint. Subchondral bone abnormalities were accompanied by obvious car-
tilage loss in 6 more horses. In 3 horses, a chip fracture of the dorsoproximal margin of the proximal pha-
lanx was present concurrently with subchondral bone abnormalities in other areas of the joint. Finally, sub-
chondral bone abnormalities existed in 9 horses with soft tissue injuries at the level of the MP joint (3 sus-
pensory branch desmitis, 3 intersesamoidean desmitis, 2 distal sesamoidean desmitis and 1 deep digital flex-
or tendonitis).
The medial condyle of the distal MC/MT III was most commonly affected (15 limbs), followed by the lat-
eral condyle of the metacarpus (6 limbs) and the proximal phalanx (5 limbs).
There were 7 horses with subchondral bone injury at the palmar/plantar aspect of the metacarpal/metatarsal
condyles. Three were racehorses, 2 were Warmbloods used for hunter jumping, 1 was a Warmblood used for
dressage and 1 was a Thoroughbred used for 3-day eventing. In 5 affected condyles there was a roughly cir-
cular area of sclerosis adjacent to the palmar/plantar surface of the condyle, varying in size from 10 to 20 mm
diameter. In 4 affected condyles, 1 or 2 small, focal, areas of hyperintensity in T2 and PD images were pres-
ent in the sclerotic bone, immediately adjacent to the palmar articular surface. In 2 affected condyles, a large
area of bone edema was the only finding. In 2 racehorses, there was loss of articular cartilage and subchondral
bone in the palmar aspect of the affected metacarpal condyle, varying from 2 to 6 mm in depth.
245 • WVOC 2010, Bologna (Italy), 15th - 18th September M.C. Schramme
There were 9 horses with subchondral bone injury at the dorsal aspect of the metacarpal/metatarsal
condyles, 6 Warmbloods (3 dressage and 3 jumpers), 2 Western pleasure horses and one Thoroughbred
used for hunting. Abnormalities were found in 6 forelimbs and 3 hindlimbs. A history of acute lameness was
reported for 5 horses, while lameness was chronic in 4 horses. Lesions were located at the dorsal aspect of
the medial condyle of MC/MT III in 7 horses, 4 of which had a concurrent area of subchondral bone in-
jury at the dorsal aspect of the sagittal ridge. The dorsal aspect of the sagittal ridge only was affected in 1
horse and another horse had generalized subchondral bone edema across the whole dorsal surface of both
condyles and the sagittal ridge. Dorsal osseous lesions consisted of an area of sclerosis extending for 10 to
20 mm from the dorsal surface of MC/MT III into the cancellous bone. Small, focal areas of signal hyper-
intensity in T1, T2 and PD images, suggestive of small osseous cyst-like lesions, varying from 2 to 6 mm
diameter, were seen within the area of sclerosis in 9 of 13 limbs. Eight focal hyperintensities were found in
the dorsal aspect of the medial condyle and 1 focal signal hyperintensity in the dorsal part of the sagittal
ridge. Six of the focally hyperintense lesions were confluent with the dorsal articular surface of MC/MT III
and in 3 of these a defect was present in the articular cartilage overlying the osseous lesion. In 4 horses with
bilateral dorsal subchondral bone injury, the areas of focal signal hyperintensity surrounded by sclerosis
were only seen in the lame limbs, while sclerosis was the only lesion present in the non lame limbs.
Subchondral bone injury was present in the proximal aspect of the proximal phalanx in 4 horses. All hors-
es were Warmbloods, of which 3 were used for dressage, and 1 for jumping. Lameness was of acute onset
in 3 horses and chronic insidious onset in 1 horse. Lesions typically consisted of a focal hyperintensity in
T1 or STIR images, surrounded by an area of sclerosis distal to the sagittal groove of the proximal phalanx
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in 4 limbs.
DISCUSSION
The subchondral bone of MC III or MT III was the most commonly affected tissue in horses with occult
MP joint lameness in our study. Subchondral bone injury in MC III or MT III of non racehorses occurred
predominantly in the dorsal aspect of the medial condyle. This location is different from that of condylar in-
juries in racehorses and has only been described rarely in horses used for other equestrian activities. Sub-
chondral bone injury of MC III or MT III is less common in mature Sportshorses and general purpose
pleasure horses and its location less predictable than in racehorses. Cartilage defects or osseous cyst like le-
sions were found in the majority of dorsomedial subchondral bone lesions, which suggests that focal trau-
matic injury to the articular surface at the dorsomedial aspect of MC III or MT III might be an initiating
cause. Focal trauma to articular cartilage and subchondral bone can result in osseous cyst-like lesion for-
mation and remodeling in adjacent bone. A relationship between dorsal impact injury and palmar osteo-
chondral disease in the MP joint has been proposed as evidence for a cyclical repetitive overextension dis-
ease mechanism in the MP joints of racing Thoroughbreds. However, such a mechanism would not explain
the high incidence of dorsomedial lesions nor the variable distribution between forelimbs and hindlimbs,
both unilaterally or bilaterally, in the variety of horse breeds seen in our study.
Contrary to the dorsomedial location, subchondral bone injury in the palmar/plantar aspect of the lateral
metacarpal/metatarsal condyle of racehorses is well recognized. Although there were only 3 racehorses in
our study, they all had this injury. Furthermore, we observed 4 distinctly different MR signal patterns in the
affected condyle of these horses. Lesions varied between bone edema without sclerosis, sclerosis without
edema, sclerosis with focal osteonecrosis and intact articular cartilage, and palmar erosions with both loss of
articular cartilage and subchondral bone osteonecrosis. These MR signal patterns correspond with the
pathologic changes described in palmar osteochondral disease and it is possible that they reflect 4 different
stages of increasing severity in a disease continuum that ultimately leads to severe osteoarthritis. Although
stress reactions in the condyles of MC III and MT III in racehorses are usually diagnosed scintigraphical-
ly, a nuclear scan does not provide structural information on the degree of tissue damage and therefore the
disease stage. Bone edema, sclerosis and small focal areas of necrosis are most likely associated with the ear-
ly stages of this disease and can only be detected with MR imaging. Once bone lysis is present radiograph-
ically, treatment is rarely successful. It follows that early MR imaging of palmar osteochondral disease may
improve the prognosis by allowing early selection of treatment.
CONCLUSION
In conclusion, lameness originating in the MP joint region may be associated with osseous or soft tissue in-
juries that may not be identified in radiographic, ultrasonographic or scintigraphic examinations. MR im-
aging was able to provide important diagnostic information about these lesions resulting in an accurate di-
agnosis. A combination of osseous and soft tissue injuries is common in lameness originating in the MP joint
region. Further studies are required to investigate the prognosis of the individual lesion types.
M.C. Schramme WVOC 2010, Bologna (Italy), 15th - 18th September • 246
FURTHER READING AND REFERENCES

1. Dyson SJ, Murray R. Osseous trauma in the Fetlock region of mature sports horses. Proc 52nd Am Assoc Equine
Pract. 2006;52:443-456.
2. Zubrod CJ, Schneider RK, Tucker RL, Gavin PR, Ragle CA, Farnsworth KD. Use of magnetic resonance imaging
for identifying subchondral bone damage in horses: 11 cases (1999-2003). J Am Vet Med Assoc 2004;224:411-418.
3. Sherlock CE, Mair TS, Braake F. Osseous Lesions in the Metacarpo(Tarso)Phalangeal Joint Diagnosed Using Low-
Field Magnetic Resonance imaging in Standing Horses. Vet Radiol Ultrasound 2009;50:13-20.
4. Martinelli MJ, Baker GJ, Clarkson RB, Eurell JC, Pijanowski GJ, Kuriashkin IV. Magnetic resonance imaging of
degenerative joint disease in a horse: a comparison to other diagnostic techniques. Equine Vet J. 1996;28:410-415.
5. Werpy NM, Ho CP, Pease A, Kawcak CE. Preliminary Study on Detection of Osteochondral Defects in the Fet-
lock Joint Using Low and High Field Strength Resonance Imaging. Proc 54th Am Assoc Equine Pract. 2008;54:447-
451.
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247 • WVOC 2010, Bologna (Italy), 15th - 18th September T. Schulze
Prepurchase MRI of horses –

definition and clinical implications
Thorben Schulze, Dr, Cert. in Equine Medicine
Equine Clinic Burg Müggenhausen, Germany
Thorben Schulze is a member of the veterinary team of the Equine Clinic Burg Mueggenhausen GmbH
which is placed between Cologne and Bonn in Germany. He is specialized in equine orthopedics and has
written his thesis on the comparison of MR and CT images of the suspensory ligament in the hind limb.
In Mueggenhausen he is doing lameness cases, orthopedic surgeries and diagnostic imaging. Since 7 years
the Hallmarq distal limb scanner is under his responsibility. He offers consultation and support concerning
MR to several equine clinics.
Standing MRI has developed through the last years and has proved to be a very useful diagnostic tool for
equine orthopaedic medicine. Even though low-field MRI’s of standing patients doesn’t offer the same im-
age quality like GA high-field systems the value it has is in comparison to the standard imaging modalities
(radiography and ultrasound) of much higher importance.
Because of all the benefits the standing MRI technique has to offer there has been much discussion on its
use in pre-purchase examinations. It has been argued that it can be a powerful tool that could lead to a much
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clearer picture of the condition of the horses that are for sale. The main field of interest would be the scans
done on the distal limb.
For us in Germany there are two main disadvantages that should be taken under consideration.
The first concerns the medical aspects. MRI scans allow us to evaluate all anatomical structures in detail
and spot all potential changes. It is, also, not rare that multiple problems are seen and that there are findings
on lame-free limbs. The clinical significance of those abnormalities can not be judged only upon the images.
Furthermore it is hardly ever possible to determine the age of the findings. It must be also pointed out that
there is a great number of important anatomical structures in this region and a low sensitivity of diagnostic
anaesthesia. In pre-purchase examinations where there is no sign of lameness or pain it is even more diffi-
cult to decide what the significance of this findings is and therefore to be able to give a clear picture of what
that could mean for the specific horse. We are, therefore, obliged to just list the findings without being able
to provide a conclusion regarding prognosis. That does not live up to the customers expectations.
When we estimate the results of an MRI examination we encounter the second disadvantage which is the
forensic risk. The use of MRI for pre-purchase examinations runs in Germany under the term “contract for
work” instead of “service contract”.
That means the examiners work does not only require due care
but has to produce a finished product with success. The conditions
are the same like with a castration. To perform the operation is not
enough. The surgeon needs to successfully remove both testicles.
If this will not be the case the veterinarian has to assume the lia-
bility exactly like with the interpretation of the MRI findings. The
veterinarian will be responsible for both missed and wrongly as-
sessed changes. As a complete and 100 percent correct interpreta-
tion and appraisement of MRI findings is not possible at the cur-
rent state of research, the exposure to liability would be unman-
ageable high. The only way to minimize this risk is again to point
out the changes only and to avoid any further estimation and com-
ments. That is particularly difficult because clients expect from
MRI more information for the future of the horse than from any
other imaging modality. Furthermore this is not the purpose of a
pre-purchase examination. In summary we do not recommend the
MRI technique for pre-purchase examinations in Germany with
the current state of knowledge.
Images of a pre-purchase examination: Comparison between a lateral-
medial radiograph and a sagittal T1-weighted GRE images of the
distal toe. The MR image shows a cystic-like lesion with contact
to the joint space and severe changes in the hyaline cartilage. The
horse was not lame.
R.K.W. Smith WVOC 2010, Bologna (Italy), 15th - 18th September • 248
Results of treatment of bone marrow derived mesenchymal

stem cell therapy
Roger K.W. Smith Professor MA VetMB PhD DEO DipECVS MRCVS
Dept. of Veterinary Clinical Sciences, The Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield,
Herts. AL9 7TA. U.K., E-mail: rksmith@rvc.ac.uk
INTRODUCTION
Regenerative medicine offers the prospect of restoring normal, or as close to normal, structure and function
to an injured organ and thereby resulting in a successful restoration of activity without the risk of re-injury.
Over-strain and traumatic tendon and ligament injuries are common in the horse and, for the most part,
heal (repair) naturally by the formation of scar tissue. However the scar tissue formed in this repair is func-
tionally deficient compared to normal tendon, which has important consequences for the animal in terms of
reduced performance and a substantial risk of re-injury, in spite of a multitude of treatments that have been
proposed. As pain is not usually a feature of these conditions in the long-term, the primary need is to restore
functionality and so this has encouraged the development of regenerative strategies.
Mesenchymal progenitor cells (MPCs) have been considered an ideal source of cells for regenerative medi-
cine because it can be demonstrated, in horses as in other species, that they are capable of differentiating in-
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to different cell lines and synthesise new matrix (usually chondrogenesis, adipogenesis and osteogenesis).
These cells are thought to be present in small numbers in most tissues but we have chosen to harness the
action of MPCs recovered from bone marrow because of ease of recovery, minimal donor site morbidity,
and, as these stem cells can be recovered from adult tissue, the possibility of autologous re-implantation
which carries fewer regulatory and safety issues. Furthermore in comparative experiments assessing multi-
potency, bone marrow-derived MPCs tend to out-perform MPCs from other sources.
Equine digital flexor tendon strain injuries provide many of the elements required for tendon tissue en-
gineering – the lesion manifests within the central core of the tissue thus providing a natural enclosure for
implantation and, by the time of stem cell implantation, is filled with granulation tissue which acts in the
role of a scaffold. It has the added advantage of being highly vascularised and therefore capable of nutri-
tional support of the implanted progenitor cells. The cytokine and mechanical environment, which are
potentially important drives for differentiation, is provided by the intra-tendinous location of the cells and
the suspension of MPCs in bone marrow supernatant which we have shown to have significant anabolic
effects in vitro1.
Post injury, tendon does not exhibit a problem with cellular infiltration but those cells actually involved in
the synthesis of new tissue are mostly locally derived cells2. Most tissues have a small population of pre-
cursor cells (tissue-specific progenitor cells) that are used to replenish cells due to natural turnover and aid
in repair post-injury. Evidence of multipotency has been shown for cells derived from young tendon, how-
ever, in adult tendon, it has been difficult in our laboratories to demonstrate the presence of a cell sub-pop-
ulation capable of differentiating into multiple cell lines, other than possibly their own, with similar ability
to bone marrow derived cells, which may explain why this component of the repair process is limited and
hence natural repair inferior to normal tendon.
We have therefore hypothesised that the implantation of autologous MPCs, in far greater numbers than are
present normally within tendon tissue, would have the potential of improving the repair of the tendon both
structurally (by optimising mechanical properties, organisation and composition) and functionally (by re-
duced re-injury rates).

Clinical data: Bone marrow was recovered from the sternum under standing sedation, generally within 1
month of injury, and transferred to a laboratory for culture and expansion of MPCs. After approximately
3 weeks, the cultured cells were transferred back to the veterinarian (10-50x106 cells, depending on the ex-
tent of the lesion) and implanted into the damaged tendon of the same horse under ultrasound guidance.
After implantation, the limb was bandaged and the horses underwent a week of box rest followed by a con-
trolled exercise programme for up to 48 weeks.
Experimental study: 10 horses with naturally occurring SDFT injury were randomly allocated to treatment
groups - 1x107 autologous bone marrow derived MPCs, obtained as described above) were implanted into
the damaged SDFT of the treated group. Saline was injected into the control group. Horses received con-
249 • WVOC 2010, Bologna (Italy), 15th - 18th September R.K.W. Smith
trolled exercise and were euthanased after 6 months. Non-destructive mechanical testing assessed structur-
al stiffness of the SDFT and morphological and compositional analysis was performed on the tendon tissue.
RESULTS
Clinical data: To date in excess of 1500 horses have been treated worldwide with this technique. Ultra-
sonographic appraisal of treated cases showed a rapid filling-in of the hypoechoic lesions although a reduced
longitudinal striated pattern usually persists. Occasional hypoechoic needle tracts can be identified in some
horses for up to 3 months after implantation. Analysis of clinical outcome in 113 treated racehorses gave a
re-injury rate of 27% for those horses which had returned to full training and had been followed up for 3
years after treatment. This re-injury rate was significantly better than for racehorses treated conventionally
and analysed in the same way (57%3; p<0.05). A more limited number of injuries to other tendons and lig-
aments cases have also been treated so that firm conclusions on efficacy for these injuries can not be made.
For lesions present within a tendon sheath, the implantation was performed after tenoscopic evaluation to
ensure that there are no surface defects through which the cells could leak.
Histopathological examination has been carried out on 17 tendons from post mortem samples obtained from
12 horses which have undergone MPC implantation. These have shown both good quality healing with
minimal inflammatory cells, and crimped organised collagen fibers. Furthermore, there was no evidence of
any abnormal tissue or neoplastic transformation. In addition, labeled MPCs were detected in enclosed le-
sions for up to 4 months, similar to that described previously4.
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Experimental study: MPC-treated tendons exhibited normalisation of their mechanical, morphological and
compositional parameters towards that of uninjured tendons. This was significantly different (p<0.05) from
saline treated tendons for cross-sectional area, cellularity, crimp pattern, and DNA content.
CONCLUSIONS
Treatment with MPCs appears to reduce re-injury rates in superficial digital flexor tendon injuries in race-
horses. This is supported by improvement in mechanical, morphological and compositional parameters in a
controlled experimental study using natural disease.
ACKNOWLEDGEMENTS AND DECLARATIONS

This work was performed in collaboration with VetCell Bioscience Ltd. of which RKWS is a Director.
REFERENCES
1. Smith JJ, Ross MW, Smith RK. Vet Comp Orthop Traumatol. 2006; 19(1): 43-7.
2. Kajikawa Y, Morihara T, et al. J Cell Physiol. 2007; 210(3): 684-91.
3. Dyson SJ Equine Vet J. 2004; 36: 415-9.
4. Guest DJ, Smith MR, Allen WR. Equine Vet J. 2008; 40(2): 178-81.
R.K.W. Smith WVOC 2010, Bologna (Italy), 15th - 18th September • 250
How subjective is the detection of lameness

and nerve block results in horses?
Roger K.W. Smith* Professor MA VetMB PhD DEO DipECVS MRCVS and Dr. Thilo Pfau†
*Dept. of Veterinary Clinical Sciences and †Structure and Motion Laboratory,
The Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield, Herts. AL9 7TA. U.K.
E-mail: rksmith@rvc.ac.uk
Visual scoring of lameness is an essential part of clinical lameness examinations. During clinical lameness
examinations horses are often assessed in a straight line as well as on a lunge line on different surfaces
(hard/soft) and at different gaits (walk, trot, and canter), as an aid to identify the likely site(s) of lameness.
In horses that are not either sound or very lame which would carry a risk, and have no definitive localiz-
ing signs, diagnostic analgesia (‘nerve’ and ‘joint’ blocks) are then most frequently used to identify the site
of the lameness.
This assessment is most frequently undertaken at the trot in a straight line and on the lunge (particularly
useful when there is bilateral lameness) before and after each diagnostic analgesic technique as this gait is
the most consistent and easily graded. In order to evaluate whether diagnostic analgesia has alleviated the
lameness, a visual lameness grade is given to the lameness on each occasion from which a percentage im-
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provement can be semi-objectively determined. Different grading systems, varying from 0-4, 0-5, 0-8, and
0-10, has been described, where 0 is sound and the maximum grade is non-weight-bearing, but they have
been shown to have limited inter-observer agreement, to improve with experience (Keegan et al, 1998, Kee-
gan et al, 2010) and to be influenced by bias (Arkell et al, 2006). Recently it has been argued that the lim-
its of human perception might play a role in particular with mild lamenesses (less than 25% asymmetry)
(Parkes et al, 2009).
Technological advances, in particular over the last decade or so, has improved our objectivity in lameness
exams, from the simplest, using high definition video cameras, to the development of more practical sensor
based gait scoring systems which can be deployed within the constraints of clinical lameness workups (e.g.
Keegan et al, 2002, 2004, Pfau et al, 2007, 2009). With these systems essential lameness related parameters
(e.g. head nod or hip hike) can be objectively quantified and we are currently evaluating whether this can
assist clinicians, in particular with mild lamenesses and/or to monitor progress over a longer time period. In
particular we have started to use a five sensor inertial sensor based system during routine clinical lameness
exams and have begun to compare the output of these devices with the semi-objective visual scoring of an
experienced lameness clinician.
Sensors were attached to the head, withers sacrum and both tuber coxae of lame horses at the beginning of
the lameness examination. Horses were trotted in a straight line and on the lunge on both reins and were
videoed. Vertical displacement amplitudes during left and right stance were determined before and after
nerve blocks and symmetry ratios compared.
Compression and push off were lower in the lame limb. Prior to diagnostic analgesia, some horses exhibit-
ed a compensatory increase in loading and push off from the non-lame limb. All horses showed an increased
lameness score during straight and with the lame limb on the inside of the circle, in comparison with the
other rein. After diagnostic analgesia, symmetry ratios increased by > 20% associated with a change in vi-
sual locomotion score in all horses.
The system does not interfere substantially with the routine lameness examination and these preliminary re-
sults indicate that sensor based methods can detect partial improvements after diagnostic analgesia. Hence
such systems can be a practical way of assisting clinical decision-making in complex lamenesses by provid-
ing objective evidence. The use for long term monitoring seems particular appealing and the objectivity of
this and similar systems could prove beneficial to deal with clinical bias.
REFERENCES
Arkell M, Archer RM, Guitian FJ, May SA. Evidence of bias affecting the interpretation of the results of local anaesthet-
ic nerve blocks when assessing lameness in horses. Vet Rec. 2006 Sep 9;159(11):346-9.
Church EE, Walker AM, Wilson AM, Pfau T. Evaluation of discriminant analysis based on dorsoventral symmetry in-
dices to quantify hindlimb lameness during over ground locomotion in the horse. Equine Vet J. 2009 Mar;41(3):
304-8.
Keegan KG, Yonezawa Y, Pai PF, Wilson DA, Kramer J. Evaluation of a sensor-based system of motion analysis for de-
tection and quantification of forelimb and hind limb lameness in horses. Am J Vet Res. 2004 May;65(5):665-70.
251 • WVOC 2010, Bologna (Italy), 15th - 18th September R.K.W. Smith
Keegan KG, Yonezawa Y, Pai PF, Wilson DA. Accelerometer-based system for the detection of lameness in horses. Bio-
med Sci Instrum. 2002;38:107-12.
Keegan KG, Wilson DA, Wilson DJ, Smith B, Gaughan EM, Pleasant RS, Lillich JD, Kramer J, Howard RD, Bacon-
Miller C, Davis EG, May KA, Cheramie HS, Valentino WL, van Harreveld PD. Evaluation of mild lameness in
horses trotting on a treadmill by clinicians and interns or residents and correlation of their assessments with kine-
matic gait analysis. Am J Vet Res. 1998 Nov;59(11):1370-7.
Keegan KG, Dent EV, Wilson DA, Janicek J, Kramer J, Lacarrubba A, Walsh DM, Cassells MW, Esther TM, Schiltz P,
Frees KE, Wilhite CL, Clark JM, Pollitt CC, Shaw R, Norris T. Repeatability of subjective evaluation of lameness
in horses. Equine Vet J. 2010 Mar;42(2):92-7.
Parkes RS, Weller R, Groth AM, May S, Pfau T. Evidence of the development of ‘domain-restricted’ expertise in the
recognition of asymmetric motion characteristics of hindlimb lameness in the horse. Equine Vet J. 2009 Feb;41(2):
112-7.
Pfau T, Robilliard JJ, Weller R, Jespers K, Eliashar E, Wilson AM. Assessment of mild hindlimb lameness during over
ground locomotion using linear discriminant analysis of inertial sensor data. Equine Vet J. 2007 Sep;39(5):407-13.
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A.S. Stewart WVOC 2010, Bologna (Italy), 15th - 18th September • 252
Critical review of Regenerative Cell Therapy:

fat-derived, tendon-derived and synovial-derived cells
Allison A. Stewart, DVM, MS, DACVS
University of Illinois, Urbana, IL 61802
For the past decade, research has focused on regenerative cellular medicine for clinical therapy of human
and animal diseases. The purpose of regenerative cell therapy is to reduce scar formation or “regenerate” in-
jured tissue back to normal. Regenerative cell therapy may work through several different mechanisms.
Some cells may function as tissue builders, while other cells may work to modulate the immune system and
reduce inflammation. The majority of the literature on regenerative cell therapy has focused on bone mar-
row-derived cells. Alternate sources of progenitor cells have also been studied for regenerative therapy, in-
cluding fat-, tendon-, and synovial-derived cells.
Most of the current literature demonostrate the source of progenitor cells will significantly impact the pro-
genitor cell function and ability to regenerate tissue. Important considerations for progenitor cell therapy are
morbidity to the donor site, ease of collection, initial isolation cell numbers, days required to expand cells,
expense and efficacy of therapy.
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Fat-derived cells are classified as either stromal vascular fraction (SVF) or adipose-derived stromal/stem cells
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(ASCs). Adipose tissue digested with collagenase provides a heterogenous population of SVF cells. The ad-
herent population of SVF cells expanded in tissue culture are known as ASCs. There are a small number of
publications regarding the use of SVF for the treatment of osteoarthritis and tendinitis in horses and dogs.
Frisbie et al. showed intra-articular administration of bone marrow-derived mesenchymal stem cells was su-
perior for treatment of osteoarthritis when compared to ASCs. However, neither treatment provided enough
improvement in osteoarthritis to warrant their use. In contrast, two clinical trials in dogs showed improve-
ment in osteoarthritis associated lameness for over 3 months. In human medicine there are five case reports
with a phase one clinical trial in progress in human medicine. Most of the publications provide support for
adipose-derived cell use in regenerative medicine.
Tendon-derived progenitor cells have also been isolated from horses, humans, and mice. We have complet-
ed a study on evaluating the effects of intralesional tendon-derived cell administration on a collagenase mod-
el of tendinitis in equine. We found that treatment of injured tendon with tendon-derived progenitor cells
improved tendon healing at a histological level. Specifically we saw increased collagen content, decreased
proteoglycan content, and improved fiber alignment within the injury. One week post-injection, tendon-de-
rived cells were concentrated at the site. Two weeks post-injection, tendon-derived cells began to distribute
in a linear fashion parallel to the longitudinal fibers of the tendon. By four weeks post-injection there were
only a few tendon-derived progenitor cells still detectable. Tendon-derived cells have only been evaluated
for their efficacy in tendon healing.
Synovial-derived progenitor cells have been isolated from synovial fluid and synovium of horses, humans,
and rabbits. Only a few in-vivo studies have been published evaluating the use of synovial-derived cells to
repair articular cartilage. Our laboratory showed that synovial derived progenitor cells could be easily iso-
lated from synovial fluid. In two weeks these cells produce only 20% of the matrix produced by normal car-
tilage. Another study showed synovial-derived stem cells migrated to the site of meniscal injury and differ-
entiated into meniscal cells without migrating to other organs. Most of these studies evaluating regenerative
cell therapy have low case numbers, lack appropriate controls, or have only short term follow-up informa-
tion. There is an immediate need for more prospective, randomized-blind clinical trials with large numbers
of patients to determine the scientific merit of regenerative cell therapy for tissue regenerative.
REFERENCES
1. Caplan AI. “Adult mesenchymal stem cells for tissue engineering versus regenerative medicine.” J Cell Physiol 2007,
231(2):341-347.
2. Ryan JM, Barry FP, Murphy JM, et al. “Mesenchymal stem cells avoid allogeneic rejection.: J Inflamm. 2005,
26;2:8.
3. Murphy JM, Fink DJ, Hunziker EB, et al. “Stem cell therapy in a caprine model of osteoarthritis.” Arthritis Rheum.
2003, 48:3,464-3,474.
4. Gimbie JM, Guilak F, Bunnell BA. “Clinical and preclinical translation of cell-based therapies using adipose tissue-
derived cells.” Stem Cell Research and Therapy. 2010, June;1(19):1-10.
253 • WVOC 2010, Bologna (Italy), 15th - 18th September A.S. Stewart
5. Black LL, Gaynor J, Gahring D, et al. “Effect of adipose-derived mesenchymal stem and regenerative cells on lame-
ness in dogs with chronic osteoarthritis of the coxofemoral joints: a randomized, double-blinded, multicenter, con-
trolled trial.” Vet Ther. 2007, 8:272-284.
6. Black LL, Gaynor J, Adams C, Dhupa S, et al. “Effect of intra-articular injection of autologous adipose-derived mes-
enchymal stem and regenerative cells on clinical signs of chronic osteoarthritis of the elbow joint in dogs.” Vet Ther.
2008, 9:192-200.
7. Frisbie DD, Kididay JD, Kawcak CE, et al. “Evaluation of adipose-derived stromal vascular fraction or bone mar-
row-derived mesenchymal stem cell for treatment of osteoarthritis” J Orthop Res. 2009, 27:1675-1680.
8. Nixon AJ, Dahlgren LA, Haupt JL, et al. “Effect of adipose-derived nucleated cell fractions on tendon repair in hors-
es with collagenase-induced tendinitis.” Am J Vet Res. 2008,69:928-937.
9. Bi Y, Ehirchiou D, Kilts TM, et al. ”Identification of tendon stem/progenitor cells and the role of the extracellular
matrix in their niche.” 2007, 13(10):1219-1227.
10. Rui YF, Lui PP, LI G, et al. Isolation and characterization of multipotent rat tendon-derived stem cells. Tissue Eng
Part A. 2010 May:16(5):1549-1558.
11. Barrett J, Stewart A, Yates A, Byron C, Pondenis H, Stewart M. Isolation of stem cells from tendon. Proceedings of
the Veterinary Orthopedic Society. March 2007. p 31.
12. Durgam S, Stewart A, Caporali E, Karlin W, Stewart M. Effect of tendon-derived progenitor cells on a collagenase-
induced model of tendinitis in horses. Proceedings of the Veterinary Orthopedic Society. March 2009. p 22.
13. Yu-When C, Caporali E, Stewart A, Stewart M. Chondrogenesis of cells isolated from equine synovial fluid. Pro-
ceedings of the Veterinary Orthopedic Society Veterinary Orthopedic Society. (Big Sky, MT) March 11, 2008.
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14. Horie M, Sekiya I, Muneta T, et al. ”Intra-articular injected synovial stem cells differentiate into meniscal cells di-
rectly and promote meniscal regeneration without mobilization to distant organs in rat massive meniscal defect.”
Stem Cells. 2009, Apr;27(4):878-887.
M.A. Weishaupt WVOC 2010, Bologna (Italy), 15th - 18th September • 254
Lameness diagnosis with the aid of ground reaction force

analysis - Compensatory strategies in horses
with weight-bearing lamenesses
Michael A. Weishaupt, Dr.med.vet., PhD
Equine Department, Vetsuisse Faculty University of Zurich, Winterthurerstrasse 260, CH-8057 Zurich, Switzerland
Horses redistribute load using a consistent strategy to compensate for pain in a fore- and in a hindlimb. From
force plate studies it is known that weight-bearing lameness affects mainly the vertical and longitudinal-hor-
izontal forces, whereas changes in the transverse-horizontal forces are negligible. At the walk, in unilateral
forelimb as well as hindlimb lameness, reduced loading of the lame limb is compensated primarily by the
contralateral limb and to a lesser extent by the concurrently loaded ipsi- or diagonal limb1.
At the trot, four distinct compensatory mechanisms serve to reduce structural stress, i.e. peak vertical forces
(Fzpeak) on the affected limb2,3.
(1) With increasing lameness, horses reduce the total vertical impulse per stride (IzS D) by increasing stride
frequency. The increase in stride frequency results in a more continuous support of the body centre of
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mass by a larger number of strides per unit of time, which, consequently, reduces the vertical movement
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of the body centre of mass. The momentum theorem explains the interdependence of impulse and the
time during which the forces act:
IzS D = IzFL + IzFR + IzH L + IzH R = mgSD
During a complete stride cycle, the time-integrated vertical ground reaction forces (= impulse; Iz) of each
limb (IzFL + IzFR + IzHL + IzHR) equal the gravitational force throughout stride duration (m g SD) where
‘m’ is the body mass of the subject, ‘g’ the gravitational acceleration and ‘SD’ the stride duration. This
adaptation is typically seen during treadmill exercise as the subject is forced to accept the preset treadmill
velocity. In the over ground situation, lame horses adjust by lowering walking and trotting velocities4.
(2) The diagonal vertical impulse (sum of vertical impulses of the diagonal limb pair) decreases selectively
in the lame diagonal (diagonal including the affected limb). This weakness causes a shortened suspen-
sion phase and a faster transition time (contralateral step duration) from the lame to the sound diagonal
stance compared to the transition from the sound to the lame diagonal stance. In correspondence, re-
duced vertical trunk movement during the lame diagonal stance and barely unaffected vertical trunk
movements during the sound diagonal stance can be observed5. Watching the lame horse from the side,
the asymmetric vertical oscillation of the trunk is easily detectable at the withers and the sacrum in fore-
limb and hindlimb lameness, respectively.
(3) In forelimb lameness, the distribution of limb impulse shifts within the lame diagonal to the hindlimb
and in the sound diagonal to the contralateral forelimb. In hindlimb lameness, the impulse shifts occurs
predominantly from the affected to the contralateral hindlimb. The weight-shifting mechanism along the
longitudinal axis of the horse corresponds to the conclusions drawn from the modelling of compensa-
tory head movements in lame horses6. The reduction or even suppression of the downward head accel-
eration during the lame diagonal stance phase decreases the momentum in the trunk, thus unloading the
lame forelimb, but increasing the loading of the diagonal hindlimb. During the sound diagonal stance,
the distinct idiosyncratic vertical head nod together with the higher horizontal braking forces in the con-
tralateral forelimb7, produce a momentum in the trunk, which increases the loading of the contralateral
forelimb and decreases that of the ipsilateral hindlimb. In hindlimb lameness, the impulse shifts occurs
predominantly from the affected to the contralateral hindlimb.
(4) The rate of loading and the peak forces are reduced by prolonging the stance duration (StD). Interest-
ingly this adaptation can be observed not only in the affected but also in the contralateral limb and neu-
tralises the impulse shift resulting from unloading the lame limb.
Shortening of StD is often empirically claimed to be an acoustic indicator for weight-bearing lameness.
As the conclusion of stance is silent, StD is not assessable acoustically. Furthermore, the bilateral equal
prolongation of StD also refutes this theory. However, the asymmetric shortening of contralateral step
duration and, therefore, the shorter transition time from lame to sound limb impact, reinforced by the
louder impact noise of the sound limb, are the more plausible leads for acoustic detection of lameness.
255 • WVOC 2010, Bologna (Italy), 15th - 18th September M.A. Weishaupt
With these load shifting mechanisms, the reduction of peak forces in the lame limb is not only effective but
even suppresses an equivalent compensatory overload situation in the other limbs. Except for moderate fore-
limb lameness, where Fzpeak increased slightly in the diagonal hindlimb, no compensatory increase in Fzpeak
could be observed in other limbs. Likewise, in mild and moderate hindlimb lameness no compensatory in-
crease in Fzpeak was observed in other limbs.
The implications of forelimb lameness on longitudinal-horizontal forces were studied by Morris and co-
workers (1987) using a force plate7. Unsurprisingly, the braking forces during the first half of stance were
decreased in the lame forelimb but increased in the contralateral limb. As a consequence, the propulsive
force of the hindlimb during the lame diagonal was bigger compared to the sound diagonal.
Generally, the concurrence between clinical assessment and selected force parameters is very good8,9. Peak
force differences between contralateral forelimbs correlated best with the clinical lameness scores (r2 = 0.87).
Subtle gait irregularities showed a mean decrease of 4% in Fzpeak of the affected limb, in mild lamenesses it
decreased by 9% and in moderate lamenesses by up to 24% when compared to the sound situation. Sur-
prisingly, for the same clinical score, left-right weight-bearing asymmetry was larger in forelimb lameness
than in hindlimb lameness. In forelimb lamenesses the load redistribution among the 4 limbs caused a
weight-bearing deficit in the ipsilateral hindlimb. This left-right asymmetry grew proportionally with in-
creasing lameness grade and amounted to approximately one third of the asymmetry of the primary fore-
limb lameness. This ipsilateral compensatory strategy of force redistribution does not correspond unequiv-
ocally with kinematic observations, where the compensatory movements are transmitted either diagonally
or ipsilaterally depending lameness aetiology10. Also the clear compensatory head movement observed in
MAIN PROGRAM
LARGE ANIMALS
hindlimb lameness was not reflected by any changes in weight-bearing asymmetry in the forelimb.
The magnitude of Fzpeak is reflected in the extent of hyperextension in the fetlock joint11. In a group of hors-
es with moderate to severe lameness, fetlock hyperextension decreased on average by 10°, which corre-
sponded to a reduction in Fzpeak of 27%4. The expert observer may visually catch the moment of maximal
fetlock extension and integrate this observation in her/his overall judgement. However, asymmetric fetlock
hyperextension may also be caused by unbalanced hooves with asymmetric dorsal hoof angles.
The analysis of GRF is a reliable method to quantify lameness. The force parameters vertical impulse and
especially Fzpeak proved to have the highest limb-specificity and sensitivity in grading lameness. Temporal
stride variables, when considered on their own, are of questionable value in detecting lameness: firstly, mild
lamenesses do not show significant temporal deviations from the sound stride pattern and secondly, key pa-
rameters, such as stance duration or the time of diagonal advanced placement maintain their left-to-right
symmetry with increasing lameness. However, temporal parameters characterising the airborne phase of the
trot, such as contralateral step duration and suspension duration change asymmetrically with increasing
lameness. These tiny time shifts of a few milliseconds are visually hardly perceptible but may be detected
acoustically.
Horses redistribute load by applying a consistent strategy to compensate for pain in a fore or in a hindlimb
and without causing an overload situation in other limbs. However, at higher speeds, i.e. at higher stride fre-
quencies and therefore shorter stance and swing durations, the possibility of adapting the inter- and intra-
limb timing is limited; therefore, compensatory overloads on the other limbs cannot be ruled out. Further-
more, in more severe lameness conditions, the horse will be forced to change to an entirely other compen-
satory mechanism by reducing StD of the affected limb, which will obviously disturb the continuous cadence
of the gait and may induce compensatory overload in the diagonal and contralateral limbs. Gait analysis al-
lows identification of the affected limb, quantification of the degree of lameness, and classification into sup-
porting or swinging limb lameness. The ambitious goal of finding characteristic compensatory patterns that
relate to the localisation of the ailment has still not been reached. It is speculated, that horses adapt their
movement to pain in a limb in a rather uniform way, possibly because of the limited degree of freedom in
their locomotion patterns12.
REFERENCES
1. Merkens, H.W. and Schamhardt, H.C. (1988c) Evaluation of equine locomotion during different degrees of exper-
imentally induced lameness. II: Distribution of ground reaction force patterns of the concurrently loaded limbs.
Equine Vet. J. Suppl. 6, 107-112.
2. Weishaupt, M.A., Wiestner, T., Hogg, H.P., Jordan, P. and Auer, J.A. (2004a) Compensatory load redistribution of
horses with induced weightbearing hindlimb lameness trotting on a treadmill. Equine Vet. J. 36, 727-733.
3. Weishaupt, M.A., Wiestner, T., Hogg, H.P., Jordan, P. and Auer, J.A. (2006a) Compensatory load redistribution of
horses with induced weight-bearing forelimb lameness trotting on a treadmill. Vet. J. 171, 135-146.
4. Clayton, H.M., Schamhardt, H.C., Willemen, M.A., Lanovaz, J.L. and Colborne, G.R. (2000) Kinematics and
ground reaction forces in horses with superficial digital flexor tendinitis. Am. J. Vet. Res. 61, 191-196.
M.A. Weishaupt WVOC 2010, Bologna (Italy), 15th - 18th September • 256
5. Buchner, H.H., Savelberg, H.H., Schamhardt, H.C. and Barneveld, A. (1996) Head and trunk movement adapta-
tions in horses with experimentally induced fore- or hindlimb lameness. Equine Vet. J. 28, 71-76.
6. Vorstenbosch, M.A., Buchner, H.H., Savelberg, H.H., Schamhardt, H.C. and Barneveld, A. (1997) Modeling study
of compensatory head movements in lame horses. Am. J. Vet. Res. 58, 713-718.
7. Morris, E.A. and Seeherman, H.J. (1987) Redistribution of ground reaction forces in experimentally induced equine
carpal lameness. In: Equine Exercise Physiology, Eds: J.R. Gillespie and N.E. Robinson, ICEEP Publications,
Davis, CA. pp 553-563.
8. Weishaupt, M.A., Wiestner, T., Hogg, H.P., Jordan, P., Auer, J.A. and Barrey, E. (2001) Assessment of gait irregu-
larities in the horse: eye vs. gait analysis. Equine Vet. J. Suppl. 33, 135-140.
9. Ishihara, A., Bertone, A.L. and Rajala-Schultz, P.J. (2005) Association between subjective lameness grade and ki-
netic gait parameters in horses with experimentally induced forelimb lameness. Am. J. Vet. Res. 66, 1805-1815.
10. Keegan, K.G. (2007) Evidence-based lameness detection and quantification. Vet. Clin. North. Am. Equine Pract.
23, 403-423.
11. Riemersma, D.J., Schamhardt, H.C., Hartman, W. and Lammertink, J.L. (1988) Kinetics and kinematics of the
equine hind limb: in vivo tendon loads and force plate measurements in ponies. Am. J. Vet. Res. 49, 1344-1352.
12. Buchner, H.H.F. (2001) Gait adaptation in lameness. In: Equine locomotion, Eds: W. Back and H.M. Clayton, W.B.
Saunders, London. pp 251-279.
MAIN PROGRAM
LARGE ANIMALS
04) Pre-congress Sem_04) Pre-congress Sem 02/09/10 12.22 Pagina 257
ABSTRACTS
of
PRE-CONGRESS
SEMINARS
PRE-CONGRESS SEMINARS
Osteoarthritis
Fixin
Sports medicine
New strategies in pain control
Small animal arthroscopy working group
OSTEOARTHRITIS
SEMINAR
261 • WVOC 2010, Bologna (Italy), 15th - 18th September F. Brock
Clinical trial design, statistical issues

and sample size estimates
Fiona Brock BSc. (Hons) MSc. CStat. CSci., Michael Stegemann Dr. med. vet.,
Clark Smothers M.S. Ph.D., Hima B. Vanimisetti M.S. Ph.D.
Veterinary Medicine Research & Development, Pfizer Animal Health
INTRODUCTION
Although observational studies (“case reports”) have some value, they provide weaker empirical evidence than
designed experimental studies where assignment of patients is under the control of the investigator (via ran-
domisation). Therefore regulatory authorities throughout the world request experimental studies to demon-
strate efficacy and safety of veterinary pharmaceutical and biological products. Such studies have to be con-
ducted according to VICH GCP and the relevant statistical guidelines (e.g. EMEA/CVMP/816/00), and thus
need a signed protocol describing all proposed statistical analyses prior to the treatment of the first animal.
CLINICAL TRIAL DESIGNS

Type of Control: Experimental studies can be conducted as either negative or positive controlled studies. A
negative control group consists of experimental units (in OA studies most likely animals rather than groups
of animals) that receive a placebo or sometimes sham treatment. The self-cure rate can be easily determined.
Although this study design is often preferred by regulatory authorities, its conduct may not always be feasi-
ble and more importantly can cause ethical issues. So-called escape clauses can facilitate the execution of the
study, i.e. animals which are withdrawn from treatment before study conclusion due to lack of efficacy. Ani-
mals assigned to the positive control group would be treated with any product previously approved for the
treatment of the condition (although exceptions might be permitted). Most OA studies are designed as par-
allel group design trials. Clinical trials with negative controls require fewer animals to demonstrate efficacy
than positive controlled studies, since the hypothesized difference between treatments is smaller.
Masking/Blinding: It is imperative that experimental studies are masked (blinded) so study participants
OSTEOARTHRITIS
who are involved in making key safety and efficacy assessments are unaware of the treatment allocation. If
assessments are being performed by investigators (i.e. veterinarian) the introduction of a dispenser is a rela-
tively easy way to ensure masking; if assessments and treatment administrations are performed by patient
owner a more complex masking is needed. Differences in dosing regimen (e.g. BID vs. SID) require even
more complex ways of masking (e.g. double dummy).
Design and Treatment Structure: Within an experimental study one distinguishes between treatment
structure and design structure of the experiment. The treatment structure consists of the number of treat-
ments or treatment combinations selected for evaluation. The treatments are compared by measuring their
effect on response variables of interest in the trial. The design structure relates to how the treatments are ad-
ministered during the experiment. It involves the grouping of experimental units such that the conditions by
which the treatments are observed are as uniform as possible. In clinical trials animals are sometimes as-
signed treatments in blocks, for instance based on order of presentation, at each clinic. This tends to main-
tain approximately equal numbers in each treatment group and is known as a randomized complete block
design (RCB). Alternatively, animals can be assigned to treatments at random at each clinic until the total
number of slots are filled. This is known as a completely randomized design (CRD). Other designs are pos-
sible and should be considered according to the resources and requirements of a particular clinical trial.
Randomisation: Randomisation is the process of ensuring that each experimental unit in a clinical trial
has an equal probability of being assigned a treatment. Without proper randomisation, statistical compar-
isons between treatments cannot be trusted. Randomisation also gives protection against bias in the as-
signment of treatments. In a clinical trial where treatments are not randomly assigned to the experimental
units, it is impossible to distinguish between true treatment effects and effects of some systematic method
of assigning them. Systematic methods of assigning treatments (e.g. odd/even date of birth; date of presen-
tation) to experimental units in clinical trials should not be confused with proper randomisation procedures.
Allowing an investigator to use personal judgment in the assignment of treatments to experimental units is
another non-random method that can introduce bias into a clinical trial.
Outcome measure considerations: From a clinical viewpoint it is important that response variables meas-
ured (e.g. pain, joint function, biochemical markers) provide results which are able to differentiate placebo
treated animals from animals treated with the active. Therefore validity, reliability, creditability and respon-
siveness have to be defined upfront for the outcome measures.
F. Brock WVOC 2010, Bologna (Italy), 15th - 18th September • 262
STATISTICAL ISSUES SPECIFIC TO OA TRIALS

Standardisation of outcome measurements is critical for any analyses of OA trials. Whereas for other clini-
cal indications outcome measures are well established (e.g. urinary tract infections – determination of bac-
teria in urine), outcome measurements for OA are either more complex or more difficult to standardise.
Even objective measurements like Force Plate Gait Analysis require standardisation, e.g. training the animals
how to walk/run on the force plate. Subjective measurements whether one-dimensional (e.g. pain values
measured as range of motion, functional values measured as the ability to climb stairs) or multi-dimension-
al (e.g. pain and dysfunction measured with a Visual Analogue Scale (VAS); quality of life assessed by own-
er) have to undergo a meaningful standardisation to be of value for any statistical analyses.
VAS are widely used in trials evaluating treatment of OA, always assuming that the VAS is linear and additive.
As a “continuous” measurement it has replaced “ordered categorical” measurements (i.e. mild, moderate, se-
vere) widely, predominantly because data are easier to analyse. Training of investigators to minimise person to
person variation, minimisation of assessors (e.g. one per clinic), and recording of VAS on different data sheets
at every single time point are essential to make VAS a meaningful way of measuring outcome.
Ordered categorical measurements, using verbal descriptions of severity, can be a useful tool, however nu-
merical assignment (normal – 0, mild – 1, moderate – 2, severe – 3) and subsequent analyses are problem-
atic. The calculation of clinical sum scores (e.g. adding numerical values from several different categorical
measurements like pain on palpation, pain when walking, ability to climb stairs) is statistically and clinical-
ly invalid as it assumes that different outcome measurements can be weighted equal.
From a statistical viewpoint the choice of outcome measurements and subsequent statistical analyses have
to provide statements which are more meaningful than “No visible lameness observed after 2 weeks”.
SAMPLE SIZE ESTIMATES

The type of control and thus primary objective (i.e. demonstration of either superiority or non-inferiority)
are the factors that influence the sample size the most, alongside the statistical power and significance level.
When demonstrating superiority, the type of control group (negative or positive) greatly influences sample
size. When demonstrating non-inferiority to a positive control, the margin (or delta) is a key component of
the experimental design and is based on a clinically acceptable difference (EMEA/CVMP/816/00-FINAL).

That difference can be determined in small scale placebo-controlled pilot studies in which the treatment ef-
OSTEOARTHRITIS
fect is determined. The treatment effect should be larger than the non-inferiority margin. The smaller the
difference we are looking to be able to detect, the larger the sample size gets and thus the choice of margin
must be carefully chosen.
Whether the study is designed to be a non-inferiority or superiority study must be primarily driven by the
objectives and whether one is looking to be at least as good as (non-inferiority), as good as, but not better
than (equivalence) or superior to the control, rather than being influenced by selecting a small sample size
and working back to a design that fits the desired (small) sample size.
The following table provides some example sample size estimates for both non-inferiority and superiority
studies and demonstrate how the study design chosen can have a large impact on the number of animals re-
quired:
Number of Animals per Treatment Group

% Success for
% Success for Reference Product
Test Product
80 78 75 70 40
NI – 10 margin 252 407 1091 NA NA
80%
NI – 15 margin 112 155 273 1162 NA
Superiority NA 6510 1094 294 23
60 58 55 50 20
NI – 10 margin 377 594 1531 NA NA
60%
NI – 15 margin 168 225 383 1539 NA
Superiority NA 9493 1534 388 23
Sample sizes presented above are based on 80% power and a two-sided 5% significance level (superiority) or one-sided
2.5% significance level (NI; non-inferiority).
263 • WVOC 2010, Bologna (Italy), 15th - 18th September P. Clegg
Metabolomics and osteoarthritis

Peter Clegg Professor MA Vet MB PhD CertEO DipECVS MRCVS
Dept. of Musculoskeletal Biology, Institute of Ageing and Chronic Diseases,
Faculty of Health and Life Sciences, University of Liverpool, Leahurst, Neston. CH64 7TE, UK
While the roots of metabolomics may be traced back to ancient Greece where the basic idea that changes in
tissues and biological fluids are indicative of disease originated (Nicholson and Lindon 2008), the modern
techniques of analysis of samples used in metabolomics and the related field of metabonomics are relative-
ly new. In the post-genomic era, it has become clear that solely mapping the genes, mRNA and proteins of
a living system does not reveal its phenotype. Consequently, researchers have turned their interest to the
metabolome (or the metabolic complement of functional genomics) and thus metabolomics is a rapidly ex-
panding post-genomic science that utilises analytical techniques to measure low molecular weight metabo-
lites in biological samples (Dunn et al. 2005; Griffin 2003; Wilson et al. 2005). The low molecular weight
metabolites represent the end products of cell regulatory processes and as such indicate both normal phe-
notype and pathology. Furthermore, low molecular weight metabolites offer the possibility of identifying bio-
markers of disease states due to the potential for abnormal cellular processes to lead to disturbances in the
profile of metabolite profiles (Whitfield et al. 2004).
The distinction between metabolomics and metabonomics has been described as being mainly philosophi-
cal rather than technical (Nicholson and Lindon 2008). Metabonomics is defined as the quantitative meas-
urement of time-related multiparametric metabolic responses of multicellular systems to pathophysiological
stimuli or genetic modification (Nicholson et al. 1999). Metabolomics, on the other hand, is defined as the
comprehensive analysis of all of the low molecular weight metabolites within, or that can be secreted by, a
given cell type or tissue under a given set of conditions (Goodacre et al. 2004; Nicholson and Wilson 2003).
In practice, there is a great deal of overlap between the two techniques with the terms often being used in-
terchangeably and the analytical and modelling procedures used being identical.
The principal analytical techniques used in metabolomics are mass spectrometry (MS) and nuclear magnetic
resonance (NMR) spectroscopy. Both techniques generate huge amounts of data and complex spectral pro-
OSTEOARTHRITIS
files which must then be analysed using bioinformatic and statistical methods. The spectra of samples of in-
terest are compared with those of controls, such that the spectral features caused by the disease state can be
determined (Nicholson and Lindon 2008). Both NMR and MS platforms have advantages and disadvan-
tages, and likewise their proponents and opponents. As compared to MS, NMR spectroscopy is non-de-
structive and requires little or no sample preparation, and is therefore capable of generating a comprehen-
sive profile of low-molecular weight metabolites from intact biofluids and tissues (Reo 2002). However, in
certain circumstances the 1H NMR spectrum is insufficient to provide information that will fully characterise
a metabolite e.g. where analytes contain functional groups that are deficient in protons or where protons can
readily chemically exchange with the solvent (Villas-Boas et al. 2005). MS analysis therefore, has its most
important advantage over NMR in its considerably higher sensitivity.
MS may be combined with separation techniques (e.g. chromatography) to reduce the number of competi-
tive analytes entering the mass spectrometer and to separate complex mixtures of metabolites. This there-
fore expands the capability of chemical analysis of highly complex biological samples (Pham-Tuan et al.
2003; Villas-Boas et al. 2005). Both liquid and gas chromatography may be utilised as separation techniques
prior to MS. A limitation of gas chromatography (GC)-MS is that samples must be volatile to be separated
on a GC column. Most naturally occurring metabolites are not sufficiently volatile to be analysed directly
on a GC system and therefore derivatisation is required, thus adding time and increased variance to the
analysis (Villas-Boas et al. 2005). Early technical problems associated with introduction of liquids to a high
vacuum system as required in coupling liquid chromatography (LC) with MS have been overcome by the
introduction of technical solutions such as soft-ionisation techniques and by the modification of LC meth-
ods (Abian 1999; Niessen 1999; Villas-Boas et al. 2005). LC-MS has advantages in that this platform has the
ability to determine selected metabolites quickly and with simpler sample preparation as compared to GC-
MS (Villas-Boas et al. 2005).
Metabolomic fingerprinting has been performed on urine samples from Hartley guinea-pigs, a strain which
spontaneously develop knee OA (Bendele 1988; Huebner 2002). An NMR fingerprint was generated which
was independent of age or strain effects and which could detect differences in the presence of metabolites
generated as a result of differential treatment of the guinea-pigs with Vitamin C (Kraus 2004). The technique
was able to distinguish guinea-pigs with OA from non-diseased guinea-pigs and highlighted several metabo-
lites which may play a key role in OA pathogenesis including lactic acid, malic acid, hypoxanthine and ala-
P. Clegg WVOC 2010, Bologna (Italy), 15th - 18th September • 264
nine (Lamers 2003). Subsequently, in a profile of human urine from patients with hip or knee OA, investi-
gators were able to distinguish between patients who did not have OA, and those with radiologically ap-
parent disease (Lamers 2005). The profile was equally applicable to male and female patients and allowed
for prediction of state and severity of OA in a sensitive manner. Hydroxybutyrate, pyruvate, creatine/ crea-
tinine and glycerol emerged as important metabolites, potentially indicating the presence of altered energy
utilization in OA patients – a hypothesis which has previously been presented in canine models of OA
(Damyanovich 1999).
ACKNOWLEDGEMENTS
I would like to thank Dr Liz Barr and Dr Elaine Garvican for their assistance in preparation of this abstract
and funding for our studies from BBSRC.
REFERENCES
Abian, J. (1999) The coupling of gas and liquid chromatography with mass spectrometry. J Mass Spectrom 34, 157-168.
Bendele, A.M., Hulman, J.F. (1988) Spontaneous cartilage degeneration in guinea pigs. Arthritis & Rheum 31, 561-565.
Damyanovich, A.Z., Staples, J.R., Chan, A.D., Marshall, K.W. (1999) Comparative study of normal and osteoarthritic
canine synovial fluid using 500 MHz 1H magnetic resonance specrtoscopy. J of Orthop Res. 17, 223-231.
Dunn, W.B., Bailey, N.J. and Johnson, H.E. (2005) Measuring the metabolome: current analytical technologies. Analyst
130, 606-625.
Goodacre, R., Vaidyanathan, S., Dunn, W.B., Harrigan, G.G. and Kell, D.B. (2004) Metabolomics by numbers: acquir-
ing and understanding global metabolite data. Trends in biotechnology 22, 245-252.
Griffin, J. (2003) Metabonomics: NMR spectroscopy and pattern recognition analysis of body fluids and tissues for char-
acterisation of xenobiotic toxicity and disease diagnosis. Current opinion in chemical biology 7, 648-654.
Huebner, J.L., Hanes, M.A., Beekman, B., TeKoppele, J.M., Kraus, V.B. (2002) A comparative analysis of bone and car-
tilage metabolism in two strains of guinea-pig with varying degrees of naturally occurring osteoarthritis. Os-
teoarthritis and Cartilage 10, 758-767.
Kraus, V.B., Huebner, J.L., Stabler, T., Flahiff, C.M., Setton, L.A., Fink, C., Vilim, V., Clark, A.G. (2004) Ascorbic acid
increases the severity of spontaneous knee osteoarthritis in a guinea pig model. Arthritis & Rheum 50, 1822-1831.
Lamers, R.A.N., DeGroot, J., Spies-Faber, E.J., Jellema, R.H.,Kraus, V.B., Verzijl, N., TeKoppele, J. M., Spijksma, G.K.,
OSTEOARTHRITIS
Vogels, J.T.W.E., van der Greef, J., van Nesselrooij, J.H.J. (2003) Identification of Disease- and nutrient-related
Metabolic Fingerprints in Osteoarthritic guinea-pigs. Journal of Nutrition 133, 1776-1780.
Lamers, R.A.N., van Nesselrooij, J.H.J., Kraus, V.B., Jordan, J.M., Renner, J.B., Dragomir, A.D., Luta, G., van der Greef,
J., DeGroot, J. (2005) Identification of an urinary metabolite profile associated with osteoarthritis. Osteoarthritis and
Cartilage 13, 762-768.
Nicholson, J.K. and Lindon, J.C. (2008) Systems biology: Metabonomics. Nature 455, 1054-1056.
Nicholson, J.K., Lindon, J.C. and Holmes, E. (1999) ‘Metabonomics’: understanding the metabolic responses of living
systems to pathophysiological stimuli via multivariate statistical analysis of biological NMR spectroscopic data.
Xenobiotica; the fate of foreign compounds in biological systems 29, 1181-1189.
Nicholson, J.K. and Wilson, I.D. (2003) Opinion: understanding ‘global’ systems biology: metabonomics and the con-
tinuum of metabolism. Nature reviews 2, 668-676.
Niessen, W.M. (1999) State-of-the-art in liquid chromatography-mass spectrometry. J Chromatogr A 856, 179-197.
Pham-Tuan, H., Kaskavelis, L., Daykin, C.A. and Janssen, H.G. (2003) Method development in high-performance liquid
chromatography for high-throughput profiling and metabonomic studies of biofluid samples. Journal of chro-
matography 789, 283-301.
Reo, N.V. (2002) NMR-based metabolomics. Drug and chemical toxicology 25, 375-382.
Villas-Boas, S.G., Mas, S., Akesson, M., Smedsgaard, J. and Nielsen, J. (2005) Mass spectrometry in metabolome analy-
sis. Mass spectrometry reviews 24, 613-646.
Whitfield, P., German, A. and Noble, P. (2004) Metabolomics: an emerging post-genomic tool for nutrition. The British
Journal of Nutrition 94, 549-555.
Wilson, I.D., Plumb, R., Granger, J., Major, H., Williams, R. and Lenz, E.M. (2005) HPLC-MS-based methods for the
study of metabonomics. J Chromatogr B Analyt Technol Biomed Life Sci 817, 67-76.
Force and pressure platforms

Quantitative analysis of animal motion can provide unique insight into normal and abnormal limb function.
This information is useful clinically for the diagnosis of disease and as a measure of outcome following treat-
ment intervention. Historically, gait analysis has been cumbersome and time-consuming. However, sub-
stantial hardware and software improvements over the past ten years have made these techniques readily
available for routine assessment of gait in a modern-day referral hospital. Perhaps the most attractive draw
to gait analysis is that many methods produce objective data of limb function.
A force platform measures the ground reaction forces (GRF) exerted when it is stepped on during the
stance phase. It is important to note that measuring GRF via a force platform is exceeding sensitive, pre-
cise and reproducible in clinical patients. This data should be considered the gold standard as it uses state-
of-the-art engineering designs to report data based on Newton’s laws. Force platforms consist of one or
more metal plate(s) that is mounted level with the surrounding floor or walkway that is separated from a
bottom frame by force transducers near each corner. Forces in an X, Y or Z direction that are exerted on
the top surface are transmitted through the force transducers. Commercially available force plates are fre-
quently grouped into either piezoelectric or strain gauge, there are subtle differences but they have little in-
fluence on the data generated. Although the raw data can be worked with in most any data software (e.g.
excel) commercially available software for dogs has simplified the process. The size of the force platform,
portability, and use with a treadmill (only z direction forces can be measured) are all things to consider
when setting up a gait lab.
Pressure platforms are comparatively new, allowing clinicians to measure both temporal and spatial gait pa-
rameters, and some can be linked to create pressure walkways that are several meters in length (these have
huge advantages but are expensive). These platforms function using a sensor pad that is an ultra thin
(~0.1mm) flexible printed circuit. Contained within the circuit are thousands of pressure sensing locations,
or elements, arranged in rows and columns along the length and width of the platform or walkway. The
OSTEOARTHRITIS
sensing elements act as variable resistors within an electrical circuit. When the sensors are loaded their re-
sistance is very low; when the force is reduced, resistance increases. The output resistance created is then
converted to a raw sum for use in analysis. In effect, this allows one to measure ground reaction forces in
the z-force direction. Sensors can be produced with pressure ranges from as low as 0-5 psi to as high as 0-
25,000 psi. Perhaps it is important to note that ground reaction forces generated from normal dogs on pres-
sure walkways has been shown to parallel that of force platforms.
There are several advantages to using a pressure walkway. Because of its extended length, multiple readings
and simultaneous, consecutive and contralateral foot-strikes can be recorded with a single pass over the
walkway. Some of this advantage can be attenuated if a laboratory is equipped with multiple force platforms.
A single force platform, however, can only measure ½ of a gait cycle in a single pass or trial. Thus by in-
creasing the length of the measuring field one not only gathers data that is more reflective of the patient’s
gait but fewer trials are needed to generate an adequate amount of data for statistical comparison. Reducing
trial repetition is important because it saves time, some weak or lame patients may not be able to physical-
ly perform many trials, and the majority of variance in force platform data is attributable to trial repetition.
Since the geometry of the mat is known, spatial parameters of gait can be calculated. Patient stride length
and width for each limb can be measured for consecutive steps allowing the clinician to look for inconsis-
tencies, improvements or disease progression. Limb velocity and acceleration can be calculated using this
data or they can be measured using a speed gun or photoelectric cells. The distribution of pressure from the
entire foot can be investigated. Both types of platforms measure cumulative force(s) over the cell. For pres-
sure platforms the cell is usually 0.25-square centimeters and for a traditional force platform the cell is 3-
square feet. This difference allows for clinicians to estimate changes in load over the patient’s foot, e.g. is
load being shifted to the left side of the foot because of an injury on the right. Because of the small size of
the cell in pressure platforms there are few limitations in the size of the animal in which data can be accu-
rately collected. Using a traditional force platform, a dog’s stride length must be long enough such that it
place only one foot on the platform at a time. In general, dogs under 20-kg will have a difficult time ac-
complishing this. Likewise an extremely tall dog with a long stride may step over a traditional force plat-
form. Increasing the animal’s velocity through the gaited area will increase its stride length but this method-
ology creates other limitations. Since pressure platforms allow for data collection in animals with a very short
stride length they provide the opportunity to measure limb function in small dogs, cats or in large dogs that
have a short stride length because of disease or because they are recovering from surgery. Finally, pressure
platforms are easy to set-up, break-down and move to a different location. This portability provides oppor-
tunities to measure limb function that would otherwise be impossible with a traditional force platform. How-
ever, they can only measure total GRF. Forces are not deciphered between the x-, y-, and z-direction. Sec-
ond, while other platform systems have components that incorporate velocity and acceleration data for each
trial, most pressure platform systems do not. Pressure platforms are also not nearly as durable as a metal
force platform and they are expensive.
Documentation of patient kinetics generates an enormous amount of data. Forces in the x-, y-, and z-direc-
tion are expressed in both peak and impulse forms, and average rising and falling slope are just a few of
points available. One obvious question is what data the clinician should focus on. Forces in the z-direction
are generated by a vertical compression of the platform and these forces are dramatically larger than that of
the other two directions. Peak vertical force (PVF) is the single largest force during the stance phase and rep-
resents only a single data point. Vertical impulse (VI) is the total area under the stance phase curve. Thus,
most focus on z-direction PVF and VI forces. While this method of expressing the data is common it may
not be ideal. A simple method to mathematically explore gait analysis is to use a multivariate, as opposed
to a univariate, statistical approach. In one report, the optimal set of GRFs was selected using logistic re-
gression and GRF were used as a diagnostic test for patients before and after RCCL surgery as compared
to normal patients. There are several advantages to this methodology. Limb function is determined by eval-
uating all GRFs. In comparison, if a clinician uses z-direction PVF they truly are looking at only 1/1200 of
the data. In addition, this technique allows clinicians to estimate the probability of normal function after gait
analysis and communicate that to an owner. For example, we now know that 6-months after some surgical
procedures the probability of normal limb function is only 20%. This does not mean that function after sur-
gery is not improved or that surgery wasn’t successful, only that function is not normal. This is an impor-
tant step towards differentiating outcomes between treatment options.
Subject velocity significantly influences most GFR measurements. Velocity is usually measured by a photo-
electric cell system. Photoelectric cell systems are usually aligned at so that the subjects’ torso is the trigger
of the system. Thus, photoelectric cells measure average torso velocity rather than limb velocity. The sig-
nificance of this can be envisioned is one were to compare velocities of a Great Dane to that of Toy Poodle.
If both dogs have similar torso velocities the limb velocity of the smaller dog would have to proportionally
OSTEOARTHRITIS
increase relative to its shortened stride length. This limitation can be averted by comparing data from dogs
of similar stature. The other, perhaps easier method for controlling for this problem is to standardize stance
time on the platform.
The entire gait cycle lasts for only one second thus; a systematic and disciplined approach must be used to
clinically evaluate a patient’s gait. To document this in the medical record one could semiquantify the find-
ings by using a visual analog scale or numerical rating scale. Regardless of what mechanism two important
facts are that visual observation of gait is subjective and the scientific literature would strongly suggest it is
unreliable. For example, when the sensitivity of visual observation of gait was compared to that of force plat-
form gait analysis, visual observation was found to be vastly inferior. In this comparison they evaluated 148
adult Labrador Retrievers, 17 were normal and 131 were 6-months after surgery for unilateral CCL injury.
The observer was blinded to the dog’s group assignment. Of the 17 normal dogs the observer correctly iden-
tified all as having no gait abnormality, as did the force platform. However, the observer only identified 15
of 131 dogs’ 6-months after knee surgery as not being normal. Using ground reaction forces from force plat-
form gait analysis, 75% of 131 dogs failed to achieve GRFs consistent with sound Labradors. In this paper
if a dog looked lame it was lame, but if it looked normal by the observer it may in fact have been very ab-
normal. In another recent publication that tried to validate clinician observation of gait neither trained or
untrained observers could reliably identify lameness, there were large disagreements between individuals
and that untrained observers had the same visual acuity for dog lameness as boarded surgeons. The only
saving grace was a finding that trained clinicians provided repeatable data. This would allow a clinician to
compare groups over time, but not necessarily comment success or failure of an individual dog.
dGEMRIC of canine cartilage

Many of the surgical procedures we perform improve patients but even with surgery the patient is left with
a progressive osteoarthritis (OA). This is true with hip and elbow dysplasia and with rupture of the cranial
cruciate ligament. For hip dysplasia it has long been hypothesized (and to some degree studied) that triple
pelvic osteotomy may be more beneficial if performed before too much damage has occurred. Similarly,
treatments for elbow dysplasia have a nearly identical problem. Historically, when selecting patients for sur-
gical correction and for the progression of OA we have used plane radiographs. Unfortunately, we have
learned that radiographs are extremely insensitive to the status of the cartilage and have almost no rela-
tionship to patient status or future outcome. Some manuscripts and texts have suggested that visualization
of the joint via arthroscopy provides a better measure of the status of the joint. It is difficult to argue that it
is superior to plane radiographs but we still do not have documentation that it is predictive of outcome, nor
does it objectively measure the status of the biology of the joint.
A contrast agent-based MRI technique, delayed gadolinium-enhanced MR imaging of cartilage (dGEM-
RIC), measures glycosaminoglycan (GAG) content within cartilage. This technique capitalizes on the re-
pulsive electrostatic interaction between the negative charges on glycosaminoglycans and the negative
charges on Gd-DTPA2- (gadolinium diethylenetriamine pentacetic acid) to measure the distribution of gly-
cosaminoglycan within cartilage. This technique has been described successfully in the dog and recently, it
was shown that GAG content as measured by dGEMRIC could accurately predict prognosis in people that
had a rotational osteotomy because of hip OA. It was concluded that this type of noninvasive approach
would help better identify and classify which patients are the best surgical candidates for a specific set of
surgeries.
In recent work we demonstrated that dGEMRIC and T2 mapping in the canine elbow could be routinely
performed in a referral hospital and the data generated correlated to cartilage GAG content. In addition, the
sensitivity and specificity of the two MRI tests were calculated for future use as an outcome measure of what
OSTEOARTHRITIS
is normal as well as how much of a change from normal, or change over time, must be present before it can
be considered outside the sensitivity of the diagnostic test. This work has been extended to clinical investi-
gations using dGEMRIC as an outcome measure for cartilage status before intervention and progression of
OA between groups for studies in the canine elbow. (Figure 1) Technically, an IV injection of gadopentetate
dimeglumine (0.2 mmol/L per kilogram) is given approximately 2-hr before the MRI; this allows for equi-
libration of the contrast agent within the cartilage. T1 measurements using 1-mm slices are performed, and
the images are imported into MATLAB to calculate T1 maps that reflect the local distribution of Gd-DTPA.
Three-dimensional maps of the humerus and ulna can be created from these T1 maps and GAG content
calculated/estimated (areas of low T1 represent regions of low GAG content; i.e. high concentration of Gd-
DTPA2-).
Figure 1 - The left image is a MRI of a dog with a fragmented coronoid, note the blue colors that represent a low dGEMRIC score an in-
dication of low GAG content and arthritis. In contrast, the MRI on the right image is from a dog with a normal elbow. The brighter (red
and yellow) colors represent a higher dGEMRIC score, an indication of greater GAG content. It is important to note that dGEMRIC in-
tensity scores between these dogs differed by 30%.
REFERENCES
1. Bouck GR, Miller CW, Taves CL. A Comparison of Surgical and Medical Treatment of Fragmented Coronoid
Process and Osteochondritis Dissecans of the canine elbow. Vet Comp Orthop Traumatol. 1995 8: 177-183.
2. Huibregtse BA, Johnson AL, Muhlbauer MC and Pijanowski GJ. J Am Anim Hosp Ass. 1994, 30: 177-195.
3. R. A. Read, S. J. Armstrong, J. D. O'Keefe, C. E. Eger Fragmentation of the medial coronoid process of the ulna in
dogs: A study of 109 cases. J Small Anim Pract. July 1990;31(7):330-334.
4. Gordon, W. J., Conzemius, M. G., Riedesel, E., Besancon, M. F., Evans, R., Wilke, V., et al. The relationship be-
tween limb function and radiographic osteoarthrosis in dogs with stifle osteoarthrosis. Veterinary Surgery, 32(5),
451-454. 2003.
5. Gray, M. L., Burstein, D., Kim, Y. J., & Maroudas, A. 2007 Elizabeth Winston Lanier award winner. Magnetic res-
onance imaging of cartilage glycosaminoglycan: Basic principles, imaging technique, and clinical applications. Jour-
nal of Orthopaedic Research, 26(3), 281-291. 2008.
6. Kwack, Kyu-Sung, et. al. Comparison Study of Intraarticular and Intravenous Gadolinium-Enhanced Magnetic Res-
onance Imaging of Cartilage in a Canine Model. Acta Radiol. 2007 Oct 24:1-10.
7. Bashir, A., Gray, M. L., Boutin, R. D., & Burstein, D. Glycosaminoglycan in articular cartilage: In vivo assessment
with delayed gd(DTPA)(2-)-enhanced MR imaging. Radiology, 205(2), 551-558. 1997.
8. Cunningham, T., Jessel, R., Zurakowski, D., Millis, M. B., & Kim, Y. J. Delayed gadolinium-enhanced magnetic res-
onance imaging of cartilage to predict early failure of bernese periacetabular osteotomy for hip dysplasia. J Bone
Joint Surg. Am, 88(7), 1540-1548. 2006.
9. Holsworth IG; Schulz KS; Kass PH; et. al. Comparison of arthroscopic and radiographic abnormalities in the hip
joints of juvenile dogs with hip dysplasia. J Am Vet Med Assoc. 227 (7). 1087- 1094. 2005.
10. Waxman AW, Robinson DA, Evans R, Hulse D, Innes J, Conzemius MG. Relationship between objective and sub-
jective assessment of limb function in normal dogs with an experimentally induced lameness. Vet Surg 37(3): 241-
6, 2008.
OSTEOARTHRITIS
Stem cells – fact or fiction

Adult stem cells in veterinary medicine can be derived from adipose tissue or from bone marrow. In small
animal veterinary medicine stem cells are far more commonly collected from adipose tissue because when
bone marrow-derived cells are harvested usually a smaller number of cells are collected and the cell harvest
is less predictable. However, it is important to note that there are key species differences and this is one dif-
ference between the canine and equine world. In horses, adult stem cells are usually collected from bone
marrow because it can be performed in the standing horse and the BM provides a better source of cells than
fat. In dogs, adipose-derived stem cells (ASC) are usually collected from the falciform ligament but can also
be collected from any fat deposit such as just caudal to the shoulder or from the inguinal region. That said,
although the data is not definitive; recent investigations have suggested that cell harvest from the falciform
ligament generally yields the largest, most predictable amount of cells. Adipose-derived cells appear to have
a similar potential for differentiation into bone, cartilage, adipose, and neural tissues as bone marrow de-
rived cells. This multipotency is a key component to calling a cell a “stem cell” and is something we, and
others, have been able to demonstrate from fat and BM derived cells in the dog and horse.
Adipose-derived stem cells hold great potential for treatment of many conditions in the dog because of the
trophic, anti-inflammatory and chondrogenic properties of ASCs. To date in the veterinary literature is lim-
ited to the treatment of osteoarthritis (OA). In two, prospective, randomized, placebo-controlled studies dogs
with lameness from osteoarthritis improved as compared to dogs treated with placebo. That said the num-
ber of dogs studied in these papers was small and only subjective outcome measures (owner and veterinar-
ian opinion) we used. However, data in other species would suggest that ASCs could be used for bone and
ligament injuries, spinal cord injury, cardiomyopathies, and inflammatory conditions of the gastrointestinal
tract and skin. Certainly, many empirical stories are available for these types of conditions. In addition, the
potential to gain valuable information from naturally-occurring animal diseases in order to translate it to the
human field is immeasurable. Currently, for veterinary use, ASCs are isolated by collagenase digestion of
OSTEOARTHRITIS
adipose tissue that yields an initial stromal vascular fraction (SVF) that can be further processed by cell cul-
ture. Historically, stem cell therapy in dogs was limited to a commercial operation (Vet Stem) that will
process fat obtained from a patient, and return a stromal vascular fraction (SVF) preparation of stem cells
to the veterinarian for injection. Stem cells are not specifically isolated or cultured. This process is time in-
tensive, requiring a veterinarian specifically trained (this is an online training process via Vet Stem) in prop-
er handling of the care and acquirement of tissue. Thus the patient, with systemic illness, must undergo a
general anesthetic episode for surgical collection of fat. Significant cost can be incurred by the owner for the
surgical procedure and the process of preparing the SVF from the fat. Although this process is far from per-
fect it is what is currently available via Vet Stem and also available at the University of Minnesota and at
some other universities (several universities offer this procedure for horses after collection of cells from the
BM). The author’s opinion is that stem cell therapy shows promise as a therapeutic option for many dis-
eases however, the current limitations of autogenous ASC in veterinary medicine dramatically curb their
clinical applications. If an allogeneic stem cell treatment proved to be safe, effective, affordable and available,
tens of thousands of veterinary patients could benefit.
The potential of allogeneic stem cells for treatment is apparent when evaluating differences in cost, time, pa-
tient morbidity and efficacy. The established technical aspects of culturing and storing ASCs will aid in the
genesis of a large store of treatments because the culture process expands the cell number exponentially; al-
lowing multiple doses to be generated from a single donor. Cells can be harvested from tissue that is nor-
mally discarded from normal patients undergoing elective surgery (e.g. ovariohysterectomy) eliminating pa-
tient morbidity. SVF preparations are limited in cell number and individual variations; allogeneic ASCs sam-
ples could be selected to optimize treatment potential. However, all of this is dependent upon an assumption
that there will be no host adverse immune response because the donor allogeneic cell immune recognition
is lost with passage of the cells in culture. Immunophenotypic changes in harvested cells have been docu-
mented after culture in several species, and the ability of stem cells to stimulate T helper cells has been
shown to be dramatically diminished or lost completely in people and in baboons. Our in vitro and in vivo
data in dogs support this as cell surface markers on the stem cells are lost with cell passage and after in ar-
ticular injection in normal dogs we found no clinical or histopathologic evidence of inflammation.
Another key component to accepting the hypothesis that allogeneic cells are beneficial is that the cells anti-
inflammatory potential changes with cell culture/passage. This is not surprising given that the SVF includes
many cell types and after passage on cells with the ability of self renewal exist. Our lab has reported im-
munophenotypic changes between the SVF and subsequent passaged cells but this preliminary work must
be made comprehensive. From this preliminary data one could conclude that the cells provide a more pre-
dictable product (far less variation) and have less pro-inflammatory potential (COX-II and IL1B expression
decreases dramatically). Both of these things bode well for using allogeneic cells – BUT do they work?!
While the initial SVF may possess many of the proposed properties of ASCs and can potentially be used to
successfully treat many conditions in the dog, specifically for treatment of OA, allogeneic ASCs may hold
the greatest potential for wide spread use.
REFERENCES
Arinzeh, T. L., Peter, S. J., Archambault, M. P., van den Bos, C., Gordon, S., Kraus, K., et al. (2003). Allogeneic mes-
enchymal stem cells regenerate bone in a critical-sized canine segmental defect. Journal of Bone and Joint Surgery.
85A(10), 1927-1935.
Beggs, K. J., Lyubimov, A., Borneman, J. N., Bartholomew, A., Moseley, A., Dodds, R., et al. (2006). Immunologic con-
sequences of multiple, high-dose administration of allogeneic mesenchymal stem cells to baboons. Cell Transplan-
tation, 15(8-9), 711-721.
Black, L. L., Gaynor, J., Adams, C., Dhupa, S., Sams, A. E., Taylor, R., et al. (2008). Effect of intraarticular injection of
autologous adipose-derived mesenchymal stem and regenerative cells on clinical signs of chronic osteoarthritis of
the elbow joint in dogs. Veterinary Therapeutics: Research in Applied Veterinary Medicine, 9(3), 192-200.
Black, L. L., Gaynor, J., Gahring, D., Adams, C., Aron, D., Harman, S., et al. (2007). Effect of adipose-derived mes-
enchymal stem and regenerative cells on lameness in dogs with chronic osteoarthritis of the coxofemoral joints: A
randomized, double-blinded, multicenter, controlled trial. Veterinary Therapeutics: Research in Applied Veterinary
Medicine, 8(4), 272-284.
Gimble, J., Guilak, F. (2003). Adipose-derived adult stem cells: Isolation, characterization, and differentiation potential.
Cytotherapy, 5(5), 362-369.
Granero-Molto, F., Weis, J. A., Miga, M. I., Landis, B., Myers, T. J., O’Rear, L., Longobardi, L, Jansen, E. D., Mortlock,
D. P., Spagnoli, A. (2009) Regenerative Effects of Transplanted Mesenchymal Stem Cells in Fracture Healing. Stem
Cells, 27(8), 1887-1898.

Klyushnenkova, E., Mosca, J. D., Zernetkina, V., Majumdar, M. K., Beggs, K. J., Simonetti, D. W., et al. (2005). T cell
OSTEOARTHRITIS
responses to allogeneic human mesenchymal stem cells: Immunogenicity, tolerance, and suppression. Journal of
Biomedical Science, 12(1), 47-57.
McIntosh, K., Zvonic, S., Garrett, S., Mitchell, J. B., Floyd, Z. E., Hammill, L., et al. (2006). The immunogenicity of hu-
man adipose-derived cells: Temporal changes in vitro. Stem Cells, 24(5), 1246-1253.
McIntosh, K. R., Lopez, M. J., Borneman, J. N., Spencer, N. D., Anderson, P. A., Gimble, J. M. (2009). Immunogenicity
of allogeneic adipose-derived stem cells in a rat spinal fusion model. Tissue Engineering. Part A, 15, 1-10.
Neupane, M., Chang, C. C., Kiupel, M., & Yuzbasiyan-Gurkan, V. (2008). Isolation and characterization of canine adi-
pose-derived mesenchymal stem cells. Tissue Engineering. Part A, 14(6), 1007-1015.
Perin, E. C., Silva, G. V., Assad, J. A., Vela, D., Buja, L. M., Sousa, A. L., et al. (2008). Comparison of intracoronary and
transendocardial delivery of allogeneic mesenchymal cells in a canine model of acute myocardial infarction. Journal
of Molecular and Cellular Cardiology, 44(3), 486-495.
271 • WVOC 2010, Bologna (Italy), 15th - 18th September C.R. Cook
MRI of cartilage: overview in human

and veterinary imaging
Comparative Orthopaedic Laboratory and Veterinary Medical Teaching Hospital University of MO - Columbia
There are an array of cartilage protocols within human and veterinary medicine. The protocols and se-
quences considered the “best” for cartilage lesions is and has been controversial for many years. The pro-
tocols to some extent are dependent on magnet strength, experience, and lesion characteristics. The proto-
cols would include a variety of sequences and planes. The best sequences are the ones that can differentiate
the gradient of the cartilage and demonstrate the contrast between the intermediate signal intensity of the
cartilage and the low to intermediated signal intensity of the joint fluid. In one study, T2 sequences with fat
saturation in axial and coronal planes in combination were accurate in detecting cartilage lesions, which were
confirmed with arthroscopy. With degenerative changes of the collagen and proteoglycan matrix, the T2 re-
laxation is increased, due to the lower water content found in the damaged cartilage. Quantitative techniques
have been developed to assess structural and mechanical properties of cartilage. These quantitative tech-
niques are very valuable with higher strength magnets and have not been fully assessed with a clinical
strength magnet (1-3 Tesla). Delayed gadolinium-enhanced (dGEMRIC) MRI of cartilage is one of these
quantitative techniques. This technique reflects proteoglycan content within cartilage. T2 mapping of the ar-
ticular cartilage is sensitive to collagen network integrity, collagen content and fibril orientation. T1-rho (spin
lock) imaging is a color coded cartilage map of the joint, that are not commercially available. There is a
strong correlation between the loss of proteoglycans and the lengthening of T1p.
MRI techniques are used to assess for cartilage defects, repair and regeneration. A modified classification
scheme was developed by the International Cartilage Repair Society to stage the MRI findings of cartilage,
as they correlate with pathologic and arthroscopic findings. Cartilage repair techniques are assessed with the
use of MRI and the relative signal intensity of the repaired/regenerated cartilage in comparison to the native
cartilage, surface geometry and morphology of the repaired tissue, presence or absence of displacement, de-
OSTEOARTHRITIS
gree of integration to adjacent cartilage and subchondral bone, percentage defect filling and presence of any
reactive synovitis.
Veterinary MRI cartilage imaging is very useful in the research field and becoming more common in the
clinical cases. The limiting factors in the veterinary field are the magnet strengths available, where 1 Tesla
and lower magnets are not useful with cartilage imaging; the 1.5 Tesla magnets may be limited by outdated
software and time to acquire the sequences; and the 3 Tesla magnets have limited availability to the veteri-
nary clinical patients.
Gene microarray biomarkers for OA

One viable strategy for development and testing of osteoarthritis biomarkers in blood samples uses high
density microarrays with cluster and receiver operator curve (ROC) analyses. In this approach, genes which
are differentially expressed between normal and affected patients are determined to optimize molecular
marker sets with high sensitivity and specificity for diagnosing osteoarthritis. The molecular marker sets are
then prospectively validated on another set of patients using real-time PCR testing. One group using this
strategy in humans reported that they could differentiate between normal and osteoarthritic patients, as well
as group the osteoarthritic patients by stage of disease as determined by arthroscopic assessment of cartilage
damage. The completion of the canine genome sequence has led to the development of a commercially avail-
able canine specific high density microarray. This microarray appropriately addresses previous concerns re-
garding specificity and sensitivity when using microarrays designed for other species. Therefore, this pow-
erful gene expression screening tool is now available for the study of OA using traditional and novel mod-
els in dogs. By comparing microarray data with other outcome measures, candidate biomarker sets can be
identified that may be able to diagnose, stage, prognosticate, and monitor OA prior to the development of
clinical symptoms in dogs.
For our initial work in this area, we did an ACUC-approved study in which the cranial cruciate ligament
(CCL) in adult mongrel dogs (mean weight 26.2 kg) was surgically transected (CCLt). After recovery from
surgery, the dogs were allowed unrestricted use of the limb. The contralateral stifle of each dog was used as
the nonoperated control. After 2 weeks, the dogs were euthanatized and evaluated. Separate full-thickness
cartilage samples were collected from the cranial medial femoral condyle (CrMF), caudal medial femoral
condyle (CaMF), cranial lateral femoral condyle (CrLF), caudal lateral femoral condyle (CaLF), cranial me-
dial tibial plateau (CrMT), caudal medial tibial plateau (CaMT), cranial lateral tibial plateau (CrLT), and
caudal lateral tibial plateau (CaLT) of both stifles for molecular, biochemical, and histological evaluation.
Total RNA was extracted using the Trispin method, and stored at -80 oC until used for gene expression
OSTEOARTHRITIS
analysis. 500 ng of total RNA was reverse transcribed to cDNA, diluted 1:5 with water and then 4µl of the
RT reaction was used for real time PCR analysis for a housekeeping gene Glyceraldehyde 3-phospate de-
hydrogenase (GAPDH), collagens 1 and 2 (COL 1, 2), aggrecan (Agg), tissue inhibitors of metallopro-
teinases 1 and 2 (TIMP- 1, -2), matrix metalloproteinases 1, 3, and 13 (MMP-1, -3, -13), aggrecanases 1 and
2 (ADAMTS 4, 5), inducible nitric oxide synthase (iNOS), and cyclooxygenase 2 (COX-2) using the Quan-
tiTect SYBR Green PCR master mix. Total sulfated GAG content was determined using the dimethylmeth-
ylene blue (DMB) assay. Total collagen content was determined using a colorimetric assay to measure hy-
droxyprolene (HP) content. Histologic sections (hematoxylin and eosin and toluidine blue) from all sites
from both CCLt and control stifles were evaluated by one investigator blinded to sample group and num-
ber. Relative expression levels for the genes studied were determined using QGene and expressed as a ratio
to GAPDH. Differences in gene expression between groups were determined using the relative expression
statistical tool, REST-XL with significance set at p<0.05. Biochemical data were analyzed by ANOVA with
significance set at p<0.05.
Significant differences were not observed in total GAG or HP content. No evidence of pathology was seen
in any section of articular cartilage in control or CCLt tissues based on histologic assessment. Significant dif-
ferences in gene expression between CCLt and control stifles were observed in every region analyzed.
To the author’s knowledge, these results represent the first report of site-specific analysis of gene expression
in dogs this early in the course of CCLt induced OA (Stoker, et al. 2006). The gene expression data indi-
cate that the medial femoral condyle and caudomedial tibial plateau, as well as the lateral tibial plateau are
most affected by joint instability resulting from CCLt. Articular cartilage in these regions appears to be al-
ready progressing towards a degradative phenotype, indicated by upregulation of MMPs, ADAMTs, iNOS,
and COX-2. Importantly, these changes in gene expression were detected prior to gross, histologic, or even
biochemical evidence for OA. The consistent expression of COL 1, MMP-13 and COX-2 in regions show-
ing the highest number of differentially expressed genes provides impetus for investigation of this combina-
tion as a diagnostic marker in early OA.
273 • WVOC 2010, Bologna (Italy), 15th - 18th September K. Hayashi
Serum biomarkers
Kei Hayashi, DVM, PhD, Dipl. ACVS
University of California Davis
BACKGROUND
The diagnosis of osteoarthritis (OA) is generally based on clinical and radiographic changes; however, these
occur fairly late during disease progression and have poor sensitivity. Therefore, measuring biochemical
markers of OA process would seem a promising approach. Recently, biomarkers have attracted much at-
tention in a variety of medical specialties, including oncology and cardiology. A biomarker is defined as an
“objective indicator of normal biological processes, pathological processes, or pharmacologic responses to
therapeutic interventions”.1 The key roles of OA biomarkers are to identify early OA, to monitor OA pro-
gression, and to evaluate response to therapy. Currently proposed OA biomarkers can be classified into in-
flammatory mediators, enzymes, synthetic bi-products of matrix, and degradative products of matrix.
A disturbance in the balance between synthesis and degeneration of the extracellular cartilage matrix is one
proposed mechanism for the initiation and development of OA.2 Aggrecan and type II collagen are two ma-
jor constituents of articular cartilage.3 Collagen provides tensile strength to maintain tissue integrity, thus
damage to type II collagen is a fundamental feature of damaged articular cartilage in OA. Degradation of
type II collagen requires highly specialized enzymes such as collagenases. Namely, MMP-1, MMP-8 and
MMP-13 which originate in synovial cells and chondrocytes.4 Cleavage of the type II collagen triple helix
by collagenases results in the generation of neoepitopes at the cleavage site.5
The collagenases cleave the triple helix structure of type II collagen at a single site resulting in a three quar-
ter and a one quarter fragment. The final cleavage products are released from the cartilage tissue and can
be detected by immunoassays.
A NOVEL OA MARKER
Collagenase-generated cleavage epitope of type II collagen (Col2-3/4Clong mono, C2C, or CIIC) has been
demonstrated to be a sensitive and specific biomarker of subtle osteoarthritic change in experimentally in-
OSTEOARTHRITIS
duced OA models in dogs.6,7 Two experimental studies using canine CCL deficient stifle models demon-
strated that the collagenase-generated cleavage epitope of type II collagen (C2C) is a specific biomarker of
early OA, that can precede radiographic changes of OA.6,7 C2C was significantly elevated in serum, urine
and joint fluid of dogs when experimental cranial cruciate ligament (CCL) rupture was induced surgically.6,7
In these studies C2C was elevated significantly from pre-operative levels at 4, 8 and 16 weeks post-opera-
tively. In one of these studies, radiographs were taken at 4, 8 and 16 weeks post experimental CCL rupture
and the progression of OA could clearly be seen by evidence of osteophytosis of the tibial articular surface
and the trochlear ridges of the femur at 16 weeks post-operatively.7 This study concluded that C2C was a
useful indicator of early changes in metabolism which predicted the onset of radiographic changes charac-
teristic of canine stifle OA.
In dogs, numerous markers have been evaluated in the stifle joint with CCL rupture, including inflamma-
tory mediators, enzymes, and nitric oxides.8,9 Despite recent effort to identify more specific biomarkers for
the canine cruciate disease, there is no single OA biomarker that is clinically relevant.10,11
Recently, a study was conducted to determine the clinical value of this novel OA biomarker (C2C) in de-
tecting early canine cruciate disease.12 Using twenty-two dogs diagnosed with CCL rupture and 12 control
dogs, levels of collagenase-generated cleavage epitope of type II collagen C2C in serum, urine, and joint flu-
id were compared between a group of dogs with CCL rupture and a control group. The correlation of C2C
levels to the clinical stage of stifle OA was also evaluated. There were no significant differences in C2C lev-
els in serum, urine, and joint fluid between groups (p>0.05). Subjective scores of lameness, joint effusion,
osteophytosis were significantly more severe in the CCL rupture group when compared with the control
group (p<0.05). There was no significant correlation of C2C levels to the clinical stage of stifle OA (p>0.05).
This OA biomarker did not detect early pathology associated with CCL rupture.
LIMITATIONS OF SERUM OA MARKERS

The specificity with which cartilage-specific biomarkers present in serum and urine can be attributed to ar-
ticular cartilage has been questioned.11 The majority of cartilage in the body is located in the respiratory sys-
tem and spine which would suggest that damage to other populations of cartilage may lead to elevations in
the levels of biomarkers of OA in serum and urine. Elevations in systemic levels of these biomarkers may
mask the contribution of joint specific elevations.
K. Hayashi WVOC 2010, Bologna (Italy), 15th - 18th September • 274
In human medicine, a multi-institutional, multidiciplinary network was recently formed to develop and val-
idate OA biomarkers for various stages of OA.13 The future direction of OA research in veterinary medicine
should focus on a group approach to identify clinically relevant OA markers.
REFERENCES
1. Rousseau JC, Delmas PD. Biological markers in osteoarthritis. Nat Clin Pract Rheumatol 3:346-56, 2007.
2. Poole AR. Can serum markers assays measure the progression of cartilage degeneration in osteoarthritis? Arthritis
Rheum 46:2549-2552, 2002.
3. Poole AR: Immunology of cartilage, in Moskowitz RW, Howell DS, Goldberg VM, et al (eds): Osteoarthritis Di-
agnosis and Medical/Surgical Management. Philadelphia, PA, Saunders, 1992, pp 155-89.
4. Smith R: Degradative enzymes in osteoarthritis. Frontiers in Bioscience 4: d704-712, 1999.
5. Billinghurst RC, Dahlberg L, Ionescu, M et al: Enhanced cleavage of type II collagen by collagenases in os-
teoarthritic articular cartilage. Journal of Clinical Investigation 99: 1534-45, 1997.
6. Chu Q, Lopez M, Hayashi K, et al. Elevation of a collagenase generated type II collagen neoepitope and a proteo-
glycan epitope in synovial fluid following induction of joint instability in the dog. Osteoarthritis Cartilage 10:662-
669, 2002.
7. Maryas JR, Atley L, Ionescu M, et al. Analysis of cartilage biomarkers in the early phase of canine experimental
osteoarthritis. Arthritis Rheum 50:543-552, 2004.
8. Innes JF, Sharif M, Barr AR. Changes in concentrations of biochemical markers of osteoarthritis following surgical
repair of ruptured cranial cruciate ligaments in dogs. Am J Vet Res 60:1164-8, 1999.
9. Johnson KA, Hay CW, Chu Q, et al. Cartilage-derived biomarkers of osteoarthritis in synovial fluid of dogs with
naturally acquired rupture of the cranial cruciate ligament. Am J Vet Res 63:775-81, 2002.
10. Innes JF, Little CB, Hughes CE, et al. Products resulting from cleavage of the interglobular domain of aggrecan in
samples of synovial fluid collected from dogs with early- and late-stage osteoarthritis. Am J Vet Res 66:1679-85,
2005.
11. Salinardi BJ, Roush JK, Schermerhorn T, et al. Matrix metalloproteinase and tissue inhibitor of metalloproteinase
in serum and synovial fluid of osteoarthritic dogs.Vet Comp Orthop Traumatol 19:49-55, 2006.
12. Hayashi K, Lansdowne JL, Kim SY, Kapatkin A, Déjardin LM. Evaluation of collagen derived osteoarthritis bio-
marker in naturally occurring canine cruciate disease. Vet Surg 38:117-121, 2009.
OSTEOARTHRITIS
13. Bauer DC, Hunter DJ, Abramson SB, et al. Osteoarthritis Biomarkers Network. Classification of osteoarthritis bio-
markers: a proposed approach. Osteoarthritis Cartilage 14:723-7, 2006.
275 • WVOC 2010, Bologna (Italy), 15th - 18th September J. Innes
Owner questionnaires for evaluation of canine

osteoarthritis - where are we?
John Innes
Musculoskeletal and Locomotion Research Group, Small Animal teaching Hospital, University of Liverpool,
Leahurst Campus, Neston, CH64 7TE, UK; j.f.innes@liv.ac.uk; www.liv.ac.uk/sath
Evaluation of canine osteoarthritis (OA) is challenging because the disease changes slowly and individual in-
terventions may have relatively small effects. Whilst objective measures such as the force platform have
many advantages, they are often not available for field studies and may not capture the multi-dimensional-
ity of OA sufficiently. Owner-administered questionnaires (clinical metrology instruments [CMIs]) have
been used as outcomes measures in human OA for some considerable time. Examples include the WOM-
AC and Lequesne Index. These instruments have undergone extensive validation often in many different
languages.
In the last 10-15 years, CMIs for canine OA have appeared in the veterinary literature and undergone a vari-
able degree of validation (Innes and Barr 1998; Hielm-Bjorkman, Kuusela et al. 2003; Hudson, Slater et al.
2004; Brown, Boston et al. 2007; Brown, Boston et al. 2008; Hercock, Pinchbeck et al. 2009). Such ques-
tionnaires typically include a semi-objective rating of disease parameters such as “lameness” and “pain” on
either a discontinuous ordinal scale or a visual analogue scale. However, such outcomes measures should be
assessed for validity, reliability (test-retest scenario) and responsiveness (Bellamy, Buchanan et al. 1988;
Innes and Barr 1998). Validity is the degree to which an instrument measures that which it was designed to
measure (Frost and others 2007).
Content validity is the extent to which an instrument measures the appropriate content and measures the
variety of attributes that make up the desired construct. Typically focus groups of experts may review the
content and endorse it, or identify significant omissions. Criterion validity refers to the extent to which the
measure agrees with the external standard measure. Construct validity represents how well the construct re-
flects theoretical hypotheses regarding the construct; this is evaluated by how the construct correlates with
OSTEOARTHRITIS
similar measures and how it diverges from measures that are different. Effect size relates the magnitude of
the change in score to the variability of the measure. It transforms the change in scores into a standard unit
of measurement which can then be compared with score changes on other instruments, which may use dif-
ferent units of measurement (Deyo, Diehr et al. 1991). Although there are no absolute standards for effect
size, it has been suggested that in comparative studies examples of small, medium and large effect sizes might
have values of 0.2, 0.5 and 0.8 respectively.
The Canine Brief Pain Inventory (CBPI) have both been evaluated for content validity, reliability (Brown,
Boston et al. 2007; Hielm-Bjorkman, Rita et al. 2009) and responsiveness (Brown, Boston et al. 2008;
Hielm-Bjorkman, Rita et al. 2009) but not criterion validity. The CMI from Texas A&M (Hudson, Slater
et al. 2004) has been investigated for validity (including construct validity) and reliability but not respon-
siveness. The Liverpool Osteoarthritis in Dogs (‘LOAD’) CMI has been investigated for content and cri-
terion validity as well as reliability and responsiveness but this was only in chronic elbow OA (Hercock,
Pinchbeck et al. 2009). Interestingly, criterion validity was poor using the force platform as the “gold stan-
dard” in this study.
Thus at the current time, no single questionnaire could be said to have been fully validated. It would be re-
assuring to have a questionnaire that had construct validity against the force platform as the referenced gold
standard, and good reliability and responsiveness.
Studies are ongoing in the author’s laboratory to simultaneously compare three of the published ques-
tionnaires (CBPI, LOAD and HCPI) to force platform data in a cohort of dogs with elbow, hip and stifle
lameness.
REFERENCES
Bellamy, N., W. W. Buchanan, et al. (1988). “Validation study of WOMAC: a health status instrument for measuring
clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the
hip or knee.” J Rheumatol 15(12): 1833-40.
Brown, D. C., R. C. Boston, et al. (2007). “Development and psychometric testing of an instrument designed to measure
chronic pain in dogs with osteoarthritis.” American Journal Of Veterinary Research 68(6): 631-637.
Brown, D. C., R. C. Boston, et al. (2008). “Ability of the Canine Brief Pain Inventory to detect response to treatment in
dogs with osteoarthritis.” Journal of the American Veterinary Medical Association 233(8): 1278-1283.
J. Innes WVOC 2010, Bologna (Italy), 15th - 18th September • 276
Deyo, R., P. Diehr, et al. (1991). “Reproducibility and responsiveness of health status measures.” Controlled Clinical tri-
als 12(142-158).
Hercock, C. A., G. Pinchbeck, et al. (2009). “Validation of a client-based clinical metrology instrument for the evaluation
of canine elbow osteoarthritis.” Journal of Small Animal Practice 50(6): 266-271.
Hielm-Bjorkman, A. K., E. Kuusela, et al. (2003). “Evaluation of methods for assessment of pain associated with chron-
ic osteoarthritis in dogs.” Journal Of The American Veterinary Medical Association 222(11): 1552-1558.
Hielm-Bjorkman, A. K., H. Rita, et al. (2009). “Psychometric testing of the Helsinki chronic pain index by completion of
a questionnaire in Finnish by owners of dogs with chronic signs of pain caused by osteoarthritis.” American Jour-
nal of Veterinary Research 70(6): 727-734.
Hudson, J. T., M. R. Slater, et al. (2004). “Assessing repeatability and validity of a visual analogue scale questionnaire for
use in assessing pain and lameness in dogs.” American Journal of Veterinary Research 65(12): 1634-1643.
Innes, J. and A. Barr (1998). “Can owners assess outcome following surgical treatment of canine cranial cruciate ligament
deficiency?” Journal of Small Animal Practice 39: 373-378.
OSTEOARTHRITIS
Quantitative MRI of canine elbow joints

John Innes
Osteoarthritis (OA) is one of the most common disease conditions to affect dogs. Estimates suggest that up
to 20% of the adult canine population may have some form of OA(Johnston 1997). The canine elbow joint
is commonly affected with OA, most frequently secondary to elbow dysplasia (Johnson and others 1994);
certain popular dog breeds, such as the Labrador Retriever, are at particular risk of elbow dysplasia and el-
bow OA (Morgan, Wind et al. 1999).
Osteoarthritis involves the gradual loss of articular cartilage through poorly understood mechanisms which
involve the action of proteolytic activities within cartilage. Key components of the organic extracellular ma-
trix of articular cartilage are type II collagen and aggrecan, the large aggregating proteoglycan. Collagen and
aggrecan are degraded by metalloproteinases from both the matrix metalloproteinase (MMP) and disinte-
grin-metalloproteinases with thrombospondin motifs (ADAMTSs) families (Tortorella, Burn et al. 1999;
Innes, Little et al. 2005; Murphy and Nagase 2008). Reducing this cartilage destruction through medical
therapies is a key aim in the treatment of OA. However, a prerequisite for the development of so-called struc-
ture modifying drugs for OA is the development of disease outcomes measures that match to the target of
therapy (Lequesne, Brandt et al. 1994; Hochberg, Altman et al. 1997). Unfortunately in live dogs, no such
validated measure exists at the current time. Although interbone distance as measured on weight-bearing ra-
diographs has been widely used as a surrogate for the thickness of articular cartilage in human OA (Brandt,
Fife et al. 1991; Reginster, Rovati et al. 2002), weight-bearing radiographs are not practical in dogs.
Magnetic resonance imaging (MRI) provides a possible route to development of a disease outcomes meas-
ure for structure modifying agents in dogs. MRI allows imaging of cartilage and specific fat-suppression se-
quences have been developed to highlight articular cartilage (Blackburn, Chivers et al. 1996; Schaefer, Mohr
et al. 2001; Imhof, Nobauer-Huhmann et al. 2002; Hargreaves, Gold et al. 2003).
The hypothesis of this study was that a longitudinal MR imaging study of the humero-ulnar joint of dogs
OSTEOARTHRITIS
with naturally occurring OA would provide valuable information on disease progression, detection of and
changes in disease-related biomarkers, and some insight into the number of dogs required for, and potential
length of, a clinical trial.

Animals
Dogs with suspected elbow dysplasia were recruited to the study. Entry criteria were: age less than two
years, bodyweight over 20kg, a history and clinical examination consistent with thoracic limb lameness lo-
calised to the elbow joint, and arthroscopically confirmed elbow dysplasia. All dogs were examined by a
board-certified orthopaedic specialist (JI).
MRI protocols
Dogs were under general anaesthesia for routine radiographic examination of both elbow joints as part of
the diagnostic protocol for elbow dysplasia. Whilst anaesthetised, MRI examination of both elbow joints
was also undertaken using a Philips 1.0T gyroscan MR scanner with a standard knee coil. T1 and WATSc
sequences were acquired. MR scans were obtained at entry to the study and again at a routine 6 month fol-
low-up examination.
Arthroscopy
All dogs underwent diagnostic/operative arthroscopy (medial portals, 2.4mm arthrscope) performed by a
single observer (JI) to confirm the presence of elbow dysplasia (medial coronoid disease).
Image analysis
Because a 1.0 Tesla magnet does not provide sufficient resolution to perform cartilage analysis, joint space,
bone surface area and bone curvature were analysed. An automated statistical segmentation algorithm was
then run on the image to identify regions within the image that are statistically similar. This was used as a
starting point for identifying the humerus and the ulna. Manual segmentation of the humerus and ulna was
performed by joining the regions defined within the previous step, and adjusting any of the boundaries as
appropriate. A radiologist then verified and corrected any erroneous boundaries within the manual seg-
mentation. After the bones were identified correctly, the area over which to calculate the thickness, curva-
ture and surface areas was automatically identified using a morphological dilation. The algorithm to identi-
fy this region was as follows: the humerus was dilated in three dimensions by approximately 6 mm; the ul-
na was dilated in three dimensions by approximately 6 mm; any voxel that was not labeled as humerus or
ulna in the original image, that contained both dilated humerus and dilated ulna was added to the region.
From the verified bone segmentation and the regions identified, the following biomarkers were calculated:
• Minimum joint space width of the humero-ulnar joint.
• Average joint space width of the humero-ulnar joint.
• Average curvature of the humerus.
• Average curvature of the ulna.
• Surface area of the subchondral bone plate of the humerus.
• Surface area of the subchondral bone plate of the ulna.
RESULTS AND DISCUSSION

Nine OA joints and 9 contgrol joints were analysed. All of the biomarkers measured were tested using a
paired value t-test for means between the control joint and the OA joint. None of the comparisons proved
significant, that is, they all had a p value greater than 0.05. In addition, the average value for each biomarker
was computed for the OA joint versus the control joint. The only notable difference was that the minimum
joint space was approximately 10% greater for the control limb than for the OA limb. Although the results
for this study do not provide a conclusive answer as to a biomarker that would clearly delineate OA dog el-
bows from non-OA dog elbows, the results do provide an insight into the size of a trial that would be re-
quired. For example, to observe a difference of 0.08mm in minimum joint space width between groups with
a probability of 95%, with a standard deviation of 0.288, it would take a study size of 564 patients.
REFERENCES
Blackburn, W. D., S. Chivers, et al. (1996). “Cartilage imaging in osteoarthritis.” Seminars In Arthritis and Rheumatism
25(4): 273-281.
Brandt, K. D., R. S. Fife, et al. (1991). “Radiographic grading of the severity of knee osteoarthritis: relation of the Kell-
gren and Lawrence grade to a grade based on joint space narrowing, and correlation with arthroscopic evidence of
OSTEOARTHRITIS
articular cartilage degeneration.” Arthritis Rheum 34(11): 1381-6.

Hargreaves, B. A., G. E. Gold, et al. (2003). “Comparison of new sequences for high-resolution cartilage imaging.” Mag-
netic Resonance in Medicine 49(4): 700-709.
Hochberg, M. C., R. D. Altman, et al. (1997). “Design and conduct of clinical trials in osteoarthritis: Preliminary recom-
mendations from a task force of the Osteoarthritis Research Society.” Journal of Rheumatology 24(4): 792-794.
Imhof, H., I. M. Nobauer-Huhmann, et al. (2002). “MRI of the cartilage.” European Radiology 12(11): 2781-2793.
Innes, J. F., C. B. Little, et al. (2005). “Products resulting from cleavage of the interglobular domain of aggrecan in sam-
ples of synovial fluid collected from dogs with early- and late-stage osteoarthritis.” American Journal of Veterinary
Research 66(10): 1679-1685.
Johnston, S. A. (1997). “Osteoarthritis - Joint anatomy, physiology, and pathobiology.” Veterinary Clinics of North Amer-
ica-Small Animal Practice 27(4): 699.
Lequesne, M., K. Brandt, et al. (1994). “Guidelines for testing slow acting drugs in osteoarthritis.” J Rheumatol 21(Sup-
pl. 41): 65-71.
Morgan, J., A. Wind, et al. (1999). “Bone dysplasia in the Labrador Retreiver: a radiographic study.” Journal of the Amer-
ican Animal Hospital Association 35: 332-340.
Murphy, G. and H. Nagase (2008). “Reappraising metalloproteinases in rheumatoid arthritis and osteoarthritis: destruc-
tion or repair?” Nature Clinical Practice Rheumatology 4(3): 128-135.
Reginster, J. Y., L. C. Rovati, et al. (2002). “Glucosamine sulfate slows-down osteoarthritis progression in postmenopausal
women: Pooled analysis of two large, independent, randomised, placebo-controlled, double-blind, prospective 3-
year trials.” Osteoporosis International 13: P140.
Schaefer, F. K., A. Mohr, et al. (2001). “Magnetic resonance imaging of knee cartilage: A correlative study using three dif-
ferent MRI-sequences vs arthroscopy.” Radiology 221: 288-288.
Tortorella, M. D., T. C. Burn, et al. (1999). “Purification and cloning of aggrecanase-1: A member of the ADAMTS fam-
ily of proteins.” Science 284(5420): 1664-1666.
Activity monitors
Two commonly held misconceptions about activity recording are that all monitors use the same methodol-
ogy to determine ‘activity counts’, and that an activity count is a standard unit of measurement. Monitors
can use time above threshold (the time acceleration exceeds a pre-set threshold), zero crossing (the number
of times acceleration crosses the no activity, or zero, point) and digital integration. The Actical® is the small-
est currently commercially available accelerometer, and uses digital integration, where ‘activity counts’ rep-
resent both the duration and intensity of acceleration. ‘Activity counts’ are therefore arbitrary units.
Accelerometers have been objectively evaluated. Most studies have evaluated the validity of accelerometers
as measures of energy expenditure in humans1-5. Under experimental conditions, the validity has generally
been found to be strong1,2,5,6. Other studies have evaluated the reliability of activity monitors. This has been
performed most often using mechanical agitators. In general, intra-instrument coefficients of variation are
low (approx 1.8%)1,7,8, but inter-instrument coefficients of variation are slightly higher (approx 5%)1. A few
studies have evaluated reliability of units by comparing outputs from units worn on opposite sides of the
body. Using this approach, intraclass coefficients of variation have varied depending on the unit: 0.73 to 0.87
for Tritrac® monitors during free living activity1; 0.87 for CSA/MTI units5; 0.66 and 0.84 for Actitrac® and
Biotrainer® monitors respectively in a laboratory setting6.
Although one would think that accelerometer output would be related closely to activity, there is very little
work on the association between accelerometer data and mobility or distance moved. Most of the work has
been performed in veterinary species. Motor behavior in human patients after failed back surgery has been
quantified using an accelerometer-based activity monitor9. In that study, 4 body-mounted accelerometers
connected to a portable data recorder were used and patients concurrently video-taped while performing ac-
tivities in their own home. The activity data produced was compared to the video recordings and the in-
OSTEOARTHRITIS
vestigators concluded that the activity monitor appeared to be a valid instrument to quantify aspects of be-
havior in failed back surgery patients, such as duration of activities and number of transitions between types
of activities 9. Despite the premise of the study being to evaluate a means to quantify pain-related behavior,
no further studies have been forthcoming.
Interest in accelerometry (in particular the Actical® activity monitor) in veterinary medicine has been grow-
ing recently. One study in dogs evaluated accelerometer data against 2-hour segments of video recording,
and concluded that gross differentiation of spontaneous activities might be possible using an accelerometer
if the threshold of the accelerometer and the amount of acceleration volume were set adequately10.
One study has evaluated the Actical® accelerometer as a measure of distance moved in dogs.11 After deter-
mination that accelerometers had good agreement, 5 identical accelerometers were used simultaneously to
test their output at 8 locations (rotated among collar, vest, and forelimb stocking locations) on each dog.
Movement and mobility for each dog were recorded continuously with a computerized videography system
for 7-hour sessions on 4 consecutive days. Accelerometer values were combined into 439 fifteen-minute in-
tervals and compared with 3 videographic measurements of movement and mobility (distance traveled, time
spent walking > 20 cm/s, and time spent changing position by > 12% of 2-dimensional surface area during
1.5 seconds). 96% of values compared between the most discordant pair of accelerometers were within 2
SDs of the mean value from all 5 accelerometers. All mounting locations provided acceptable correlation
with videographic measurements of movement and mobility, and the ventral portion of the collar was de-
termined to be the most convenient location.11 This study led the way for accelerometers to be used as sur-
rogate measures of distance moved in dogs in the home environment.
A recent study has evaluated the optimal sampling interval for accelerometry in dogs. The investigators
found that within dogs, a full 7-day comparison of total activity counts from one week to the next provided
the least variable estimate of the dogs’ activity. The investigators reported that for dogs that have no change
in routine according to the owner’s report, the least variable estimates of activity can be collected by com-
paring activity in 7-day intervals.12 The same investigators evaluated the effect of signalment or body con-
formation on activity counts.13 When activity was well controlled, there was no significant effect of signal-
ment or body conformation on activity counts recorded by the activity monitor. However, when activity was
less controlled, older dogs and larger dogs had lower activity counts than younger and smaller dogs. The
wide range in body conformation (eg, limb or body length) among dogs did not appear to significantly im-
pact the activity counts recorded by the monitor, but age and body weight did and must be considered in
analysis of data collected from the monitors.13
Work has also been performed in cats. In one study, output from an acceleration-based digitally integrated
accelerometer correlated well with distance moved and mobility in freely moving cats.14 Further work using
a blinded, placebo controlled, cross-over approach showed that an NSAID increased activity counts in cats
with DJD-associated pain being treated in the home environment.15 Acceleration-based activity monitors
have subsequently been used in a study to assess the mobility enhancing effects of a therapeutic diet for fe-
line DJD-associated pain.16
The use of accelerometry in veterinary orthopedics to measure ‘activity’ is just beginning, but it is an excit-
ing modality and holds much promise of greater insight into the response of our patients to surgery and
therapeutics. However, much basic work needs to be done to understand what the data output actually
means to the patients being evaluated.
REFERENCES
1. Nichols JF, Morgan CG, Sarkin JA, et al. Validity, reliability, and calibration of the Tritrac accelerometer as a meas-
ure of physical activity. Med Sci Sports Exerc 1999;31:908-912.
2. Pfeiffer KA, McIver KL, Dowda M, et al. Validation and calibration of the Actical accelerometer in preschool chil-
dren. Med Sci Sports Exerc 2006;38:152-157.
3. Puyau MR, Adolph AL, Vohra FA, et al. Validation and calibration of physical activity monitors in children. Obes
Res 2002;10:150-157.
4. Puyau MR, Adolph AL, Vohra FA, et al. Prediction of activity energy expenditure using accelerometers in children.
Med Sci Sports Exerc 2004;36:1625-1631.
5. Trost SG, Ward DS, Moorehead SM, et al. Validity of the computer science and applications (CSA) activity moni-
tor in children. Med Sci Sports Exerc 1998;30:629-633.
6. Welk GJ, Almeida J, Morss G. Laboratory calibration and validation of the Biotrainer and Actitrac activity moni-
tors. Med Sci Sports Exerc 2003;35:1057-1064.
7. Kochersberger G, McConnell E, Kuchibhatla MN, et al. The reliability, validity, and stability of a measure of phys-
ical activity in the elderly. Arch Phys Med Rehabil 1996;77:793-795.

8. Metcalf BS, Curnow JS, Evans C, et al. Technical reliability of the CSA activity monitor: The EarlyBird Study. Med
OSTEOARTHRITIS
Sci Sports Exerc 2002;34:1533-1537.

9. Bussmann JB, van de Laar YM, Neeleman MP, et al. Ambulatory accelerometry to quantify motor behaviour in
patients after failed back surgery: a validation study. Pain 1998;74:153-161.
10. Yamada M, Tokuriki M. Spontaneous activities measured continuously by an accelerometer in beagle dogs housed
in a cage. J Vet Med Sci 2000;62:443-447.
11. Hansen BD, Lascelles BD, Keene BW, et al. Evaluation of an accelerometer for at-home monitoring of spontaneous
activity in dogs. Am J Vet Res 2007;68:468-475.
12. Dow C, Michel KE, Love M, et al. Evaluation of optimal sampling interval for activity monitoring in companion
dogs. Am J Vet Res 2009;70:444-448.
13. Brown DC, Michel KE, Love M, et al. Evaluation of the effect of signalment and body conformation on activity
monitoring in companion dogs. Am J Vet Res 71:322-325.
14. Lascelles BD, Hansen BD, Thomson A, et al. Evaluation of a digitally integrated accelerometer-based activity mon-
itor for the measurement of activity in cats. Vet Anaesth Analg 2008;35:173-183.
15. Lascelles BD, Hansen BD, Roe S, et al. Evaluation of client-specific outcome measures and activity monitoring to
measure pain relief in cats with osteoarthritis. J Vet Intern Med 2007;21:410-416.
16. Lascelles BD, DePuy V, Thomson A, et al. Evaluation of a therapeutic diet for feline degenerative joint disease. J
Vet Intern Med 24:487-495.
Alternative (adjunctive) analgesics for canine OA:

evidence based approach
Osteoarthritic disease is the most common cause of chronic pain in dogs. Clinical experience1 and a review
of experimental studies2-4 reveal that NSAIDs may not provide complete pain relief in all cases of canine os-
teoarthritis. In human medicine, a multimodal approach is used frequently for chronic pain associated with
osteoarthritis.5-8 A multimodal approach has also been suggested for the alleviation of chronic pain in vet-
erinary species.1 Additionally, some canine patients are intolerant of NSAIDs, and so the clinician turns to
other analgesics. This lecture will discuss the use of the most commonly used non-NSAID analgesics, in-
cluding a discussion of the rationale and evidence for using them.
The effectiveness and toxicity of multimodal therapy is an area of active research in veterinary medicine, and
recommendations may change as data is generated. A decision making tree in relation to drug therapy for
canine OA is outlined in Figure 1.
Figure 1 - Decision making
OSTEOARTHRITIS
in multimodal drug treatment
of chronic pain associated with
OA. *These drugs may be used
in combination without an
NSAID, acetaminophen, or a
steroid base but are likely to be
less effective. †Steroids should
not be used in combination
with an NSAID.
‡
Acetaminophen has been used
in combination with NSAIDs,
but it probably increases the
risk of gastrointestinal
ulceration. §“Wind-down”
therapy refers to the unproven
technique of using combinations
of intravenous analgesics over a
48- to 72-hour period in OA
cases that are refractory to oral
treatment in an attempt to
“wind down” the central
nervous system changes and
allow oral treatment to be more
effective. ¶Surgical intervention
refers to total hip or other joint
replacement and arthrodesis.
**“Neurolytic” is used to refer
to surgical dennervation and
also neuroablative procedures.
Integrated drug and nondrug multimodal approach

The benefit of non-drug therapies in the management of osteoarthritis pain is relatively undefined in the vet-
erinary literature although some information is appearing in the veterinary literature.9 However, despite the
lack of experimental evidence for their efficacy, clinical experience recommends the use of acupuncture and
electroacupuncture, acupressure, transcutaneous electrical nerve stimulation and physical therapy (cold and
heat therapy, massage therapy, passive physiotherapy, hydrotherapy, and active controlled exercise, includ-
ing swimming) in conjunction with drug therapy as appropriate.10
Rationale for drug use in chronic osteoarthritis pain

The following outlines the rationale for the major adjunctive drugs that are considered in practice, and reviews the
evidence for their efficacy in canine OA.
Mixed analgesics (tramadol): Tramadol is an opioid derivative, which also has actions on the serotonin-
ergic and alpha-adrenergic systems. Tramadol’s analgesic efficacy is a result of complex interactions between
opiate, adrenergic, and serotonin receptor systems. Hepatic demethylation of tramadol produces the active
metabolite, O-desmethyltramadol (M1). The different metabolites interact with different receptors, and so
efficacy in different species is likely to depend on the metabolism characteristics in the particular species. Ini-
tial work in dogs suggested that tramadol was absorbed ‘sufficiently’, producing levels that would theoreti-
cally provide analgesia.11 However, recently there has been some discussion about the actual amounts of the
M1 metabolite that are formed in dogs, and so the theoretical utility for analgesia.12 Tramadol has been used
successfully in the management of osteoarthritis pain in people and is now recommended as part of a mul-
timodal drug therapy for osteoarthritis pain control.13-15 One unpublished report in dogs is encouraging. An-
imals with chronic OA were treated with a low dose of ketoprofen (0.25 mg/kg PO daily) or low dose ke-
toprofen plus tramadol (5 mg/kg of prolonged release form PO daily) for 28 days. Dogs receiving both drugs
had a greater improvement in pain scores, and even after treatment was discontinued they continued to im-
prove while the dogs in the ketoprofen-only group remained static and had more incidences of acute flare
ups after the end of treatment that the ketoprofen-tramadol animals. There is no published evidence of effi-
cacy for canine OA pain.

Little is known about the side effects of tramadol in dogs, and almost nothing is known about the side ef-
OSTEOARTHRITIS
fects seen when tramadol is combined with other drugs in human or canine medicine. In human medicine,
a recent study found that for patients hospitalized for peptic ulcer treatment, tramadol use prior to admis-
sion was associated with just as high a risk of mortality as was NSAID use prior to admission. Additional-
ly, mortality was 2.02 and 1.41 fold higher in these groups of patients respectively than in patients who used
neither tramadol nor NSAIDs.16 A recent study evaluating the analgesic effects of various doses of rofecox-
ib and tramadol alone and in combination found that the most analgesic combination of tramadol and ro-
fecoxib produced gastric injury in rats that was more severe than with rofecoxib or tramadol alone.17 How-
ever, there is other work (and some from the author’s laboratory) that suggests tramadol may have protec-
tive effects on the GI mucosa.
NMDA. The NMDA receptor plays a key role in inducing and maintaining central sensitization,18,19
changes that appear to be present in chronic pain states. NMDA antagonists have been studied for provid-
ing analgesia in most types of pain.20 Memantine, amantadine, ketamine and dextromethorphan are un-
competitive NMDA antagonists that have been used clinically in humans for neuropathic pain. There are
no reports of NMDA antagonists being used to treat pain associated with osteoarthritis in people. Dogs
probably do not make the active metabolite from dextromethorphan necessary for NMDA blockade.21 One
study in dogs has demonstrated the NMDA antagonist amantadine (3-5mg/kg orally once daily) to be an
effective adjunct to NSAID use in canine osteoarthritis.22 The dose of amantadine was decided upon on the
basis of known kinetics,23 clinical observations and pilot data. Toxicity studies have been performed in
dogs.23,24
Tricyclic antidepressants. The tricyclic antidepressants have been used for many years for the treatment of
chronic pain syndromes in people. Amitryptiline has been used successfully for interstitial cystitis in cats,25
a chronic pain syndrome, but as yet, these drugs have been systematically evaluated in animals. There are
no reports of efficacy of the TCAs for canine OA pain. The TCAs should probably not be used concur-
rently with drugs that modify the serotinergic system, such as tramadol or trazodone.
Anticonvulsants. Many anticonvulsants such as carbamazepine, phenytoin, baclofen, and more recently
gabapentin, have been used for chronic pain, including neuropathic pain, in people. Gabapentin, and the
more recently introduced pregablin, appear to be the most effective for neuropathic pain, and there is grow-
ing interest in their use in chronic joint pain. The mechanism of action appears to be binding to the alpha-
2-delta subunit of calcium channels (see below).
Calcium channel blockade. Calcium channels modulate nociceptive transmission at the level of the neu-
ronal synapse in the central nervous system. Gabapentin and pregablin interact with the alpha-2-delta sub-
unit of the voltage gated calcium channel, and have both been shown to be effective in various neuropath-
ic pain states in humans. Recent basic science studies in rats suggest it may have a role to play in the man-
agement of pain from osteoarthritis.26 There is no peer–reviewed published information on its use in dogs.
However, the author finds this useful drug for neuropathic, neurogenic and osteoarthritic pain, at relatively
low doses of 5-10 mg/kg twice daily.
Sodium channel blockade. Alterations in the level of expression, cellular localization, and distribution of
sodium channels are strongly associated with chronic pain.27 The author has used intravenous lidocaine as
part of an intravenous cocktail for the treatment of neurogenic pain, such as nerve root entrapment pain and
lumbosacral pain, and also severe osteoarthritis pain. There is increasing interest in transdermal lidocaine
patches for osteoarthritis in humans.28 There is currently no information in animals on how to use these
safely and effectively, although studies have evaluated the kinetics of lidocaine absorbed from patches ap-
plied to dogs.29,30
Polysulphated glycosaminoglycans. Polysulfated glycosaminoglycan (PSGAG) is approved for use in dogs

as a disease-modifying agent of osteoarthritis (DMOAD). Two studies are published providing information
on the treatment of OA in dogs using PSGAG.31,32 One study 31 suggested a potential positive effect on pain
but statistical significance was not reached. PSGAGs are heparin analogues, and their use in animals with
bleeding disorders should be avoided. It has been suggested that concurrent use with NSAIDs that exhibit
strong antithromboxane (COX-1) activity should be avoided in all patients.
REFERENCES
1. Lascelles BD, Main DC. Surgical trauma and chronically painful conditions—within our comfort level but beyond
OSTEOARTHRITIS
theirs? J Am Vet Med Assoc 2002;221:215-222.
2. Budsberg SC, Johnston SA, Schwarz PD, et al. Efficacy of etodolac for the treatment of osteoarthritis of the hip
joints in dogs. J Am Vet Med Assoc 1999;214:206-210.
3. Holtsinger RH, Parker RB, Beale BS, et al. The therapeutic efficacy of carprofen (Rimadyl-V) in 209 clinical cases
of canine degenerative joint disease. Veterinary and Comparative Orthopedics and Traumatology 1992;5:140-144.
4. Vasseur PB, Johnson AL, Budsberg SC, et al. Randomized, controlled trial of the efficacy of carprofen, a nons-
teroidal anti-inflammatory drug, in the treatment of osteoarthritis in dogs. J Am Vet Med Assoc 1995;206:807-811.
5. Freedman GM. Chronic pain. Clinical management of common causes of geriatric pain. Geriatrics 2002;57:36-41;
quiz 42.
6. Manek NJ, Lane NE. Osteoarthritis: current concepts in diagnosis and management. Am Fam Physician 2000;
61:1795-1804.
7. Mullican WS, Lacy JR. Tramadol/acetaminophen combination tablets and codeine/acetaminophen combination
capsules for the management of chronic pain: a comparative trial. Clin Ther 2001;23:1429-1445.
8. Schnitzer TJ. Non-NSAID pharmacologic treatment options for the management of chronic pain. Am J Med
1998;105:45S-52S.
9. Crook T, McGowan C, Pead M. Effect of passive stretching on the range of motion of osteoarthritic joints in 10
labrador retrievers. Vet Rec 2007;160:545-547.
10. Johnston SA, McLaughlin RM, Budsberg SC. Nonsurgical management of osteoarthritis in dogs. Vet Clin North
Am Small Anim Pract 2008;38:1449-1470, viii.
11. KuKanich B, Papich MG. Pharmacokinetics of tramadol and the metabolite O-desmethyltramadol in dogs. J Vet
Pharmacol Ther 2004;27:239-246.
12. McMillan CJ, Livingston A, Clark CR, et al. Pharmacokinetics of intravenous tramadol in dogs. Can J Vet Res
2008;72:325-331.
13. Reig E. Tramadol in musculoskeletal pain—a survey. Clin Rheumatol 2002;21 Suppl 1:S9-11; discussion S11-12.
14. Schnitzer TJ, Kamin M, Olson WH. Tramadol allows reduction of naproxen dose among patients with naproxen-
responsive osteoarthritis pain: a randomized, double-blind, placebo-controlled study. Arthritis Rheum 1999;
42:1370-1377.
15. Wilder-Smith CH, Hill L, Spargo K, et al. Treatment of severe pain from osteoarthritis with slow-release tramadol
or dihydrocodeine in combination with NSAID’s: a randomised study comparing analgesia, antinociception and
gastrointestinal effects. Pain 2001;91:23-31.
16. Torring ML, Riis A, Christensen S, et al. Perforated peptic ulcer and short-term mortality among tramadol users.
Br J Clin Pharmacol 2008;65:565-572.
17. Garcia-Hernandez L, Deciga-Campos M, Guevara-Lopez U, et al. Co-administration of rofecoxib and tramadol re-
sults in additive or sub-additive interaction during arthritic nociception in rat. Pharmacol Biochem Behav 2007;
87:331-340.
18. Sluka KA, Westlund KN. An experimental arthritis model in rats: the effects of NMDA and non-NMDA antago-
nists on aspartate and glutamate release in the dorsal horn. Neuroscience Letters 1993;149:99-102.
19. Woolf CJ, Thompson SW. The induction and maintenance of central sensitization is dependent on N-methyl-D-as-
partic acid receptor activation; implications for the treatment of post-injury pain hypersensitivity states. Pain 1991;
44:293-299.
20. Fisher K, Coderre TJ, Hagen NA. Targeting the N-methyl-D-aspartate receptor for chronic pain management. Pre-
clinical animal studies, recent clinical experience and future research directions. J Pain Symptom Manage 2000;
20:358-373.
21. Kukanich B, Papich MG. Plasma profile and pharmacokinetics of dextromethorphan after intravenous and oral ad-
ministration in healthy dogs. J Vet Pharmacol Ther 2004;27:337-341.
22. Lascelles BD, Gaynor JS, Smith ES, et al. Amantadine in a multimodal analgesic regimen for alleviation of refrac-
tory osteoarthritis pain in dogs. J Vet Intern Med 2008;22:53-59.
23. Bleidner WE, Harmon JB, Hewes WE, et al. Absorption, distribution and excretion of amantadine hydrochloride.
J Pharmacol Exp Ther 1965;150:484-490.
24. Vernier VG, Harmon JB, Stump JM, et al. The toxicologic and pharmacologic properties of amantadine hy-
drochloride. Toxicol Appl Pharmacol 1969;15:642-665.
25. Chew DJ, Buffington CA, Kendall MS, et al. Amitriptyline treatment for severe recurrent idiopathic cystitis in cats.
J Am Vet Med Assoc 1998;213:1282-1286.
26. Fernihough J, Gentry C, Malcangio M, et al. Pain related behaviour in two models of osteoarthritis in the rat knee.
Pain 2004;112:83-93.
27. Devor M, Govrin-Lippmann R, Angelides K. Na+ channel immunolocalization in peripheral mammalian axons
and changes following nerve injury and neuroma formation. J Neurosci 1993;13:1976-1992.
28. Galer BS, Sheldon E, Patel N, et al. Topical lidocaine patch 5% may target a novel underlying pain mechanism in
osteoarthritis. Curr Med Res Opin 2004;20:1455-1458.
OSTEOARTHRITIS
29. Ko J, Weil A, Maxwell L, et al. Plasma concentrations of lidocaine in dogs following lidocaine patch application. J
Am Anim Hosp Assoc 2007;43:280-283.
30. Weiland L, Croubels S, Baert K, et al. Pharmacokinetics of a lidocaine patch 5% in dogs. J Vet Med A Physiol Pathol
Clin Med 2006;53:34-39.
31. deHaan JJ, Goring RL, Beale BS. Evaluation of polysulfated glycosaminoglycan for the treatment of hip dysplasia
in dogs. Vet Surg 1994;23:177-181.
32. Fujiki M, Shineha J, Yamanokuchi K, et al. Effects of treatment with polysulfated glycosaminoglycan on serum car-
tilage oligomeric matrix protein and C-reactive protein concentrations, serum matrix metalloproteinase-2 and -9 ac-
tivities, and lameness in dogs with osteoarthritis. Am J Vet Res 2007;68:827-833.
FIXIN
SEMINAR
TPLO using the FIXIN plate

Tibial plateau leveling osteotomy (TPLO) is a common procedure used to treat dogs of all sizes suffering
from partial and complete tears of the cranial cruciate ligament (CrCL).1 TPLO can be considered a joint
mechanic altering technique. The technique converts cranial tibial thrust to a caudal tibial thrust by rotat-
ing the tibial plateau to approximately 6 degrees. After doing so, the caudal cruciate ligament stabilizes the
stifle joint against a caudal tibial thrust of low magnitude during the weightbearing phase of the stride.
Bone plates to stabilize the osteotomy are available from different manufacturers. The plates vary in ap-
pearance and function depending on the manufacturer. No plate has been shown to be clinically superior
at this time. This lecture will discuss the technique and outcome of the FIXIN TPLO plate for use in medi-
um and large breed dogs.
FIXIN TPLO PLATE

The FIXIN TPLO plate is a stainless steel plate that has titanium bushings that accommodate stainless steel
screws. FIXIN offers several plate configuration options for the surgeon to choose when performing TPLO
in medium and large breed dogs. The most common plate used is T-shaped and has four holes and a small
step that accommodates the flare of the proximal tibia. All of the screws lock in the plate via a conical lock-
ing mechanism. FIXIN also has several T-plates without a step that can also be used for TPLO. These plates
give the surgeon the option to use 4-6 locking screws, depending on the size of the dog and discretion of the
surgeon. FIXIN TPLO plates can be applied using a minimally-invasive approach. Application of the plate
is simple and minimal instrumentation is required. The Fixin TPLO plate used on medium and large breed
dogs accommodates 3.0 or 3.5 mm screws. The plate is very low profile due to its comparative thin profile.
The thinner profile allows some elasticity and bone healing is typically associated with a small smooth cal-
lus at the osteotomy site by 2 months postoperative.
TPLO PROCEDURE
FIXIN
A minimally-invasive medial approach to
the proximal tibia and stifle joint is per-
formed and the joint is explored and the
meniscus treated at the discretion of the sur-
geon. The medial collateral ligament is iden-
tified, and the TPLO jig is applied medially
at the surgeon’s discretion. The popliteus
muscle is elevated as little as possible from
the caudomedial aspect of the tibia to per-
form a radial osteotomy and apply the plate.
A radial osteotomy is performed on the
proximal tibia such that the proximal ex-
tent of the osteotomy exits cranial to the
cranial intercondyloid area, and the distal
extent exits the caudal tibial cortex. The
position of the osteotomy has been shown
to affect postoperative TPA, as well as the
geometric relationship between the struc-
tures within the tibial plateau segment and
those of the distal tibial segment, namely
the patellar tendon insertion2,3.
This osteotomy can be centered on the in-
tercondylar tubercles, and thus proximal
tibial plateau segment rotation results in ac-
curate tibial plateau leveling without alter-
ing the geometric relationship of the patel-
lar tendon insertion to the articular surface Figure 1 - Tibial plateau leveling osteotomy using a Fixin plate. Note the place-
of the tibia2. The centered cut position has ment of the osteotomy, and the progressively widening tibial tuberosity segment.
been shown to be geometrically more precise, and biomechanically superior to the distal position3.
The osteotomy is performed partially thorough the tibia. Marks corresponding to the magnitude of rotation
are made on the tibial cortex, referenced from the TPLO chart. The osteotomy is continued through the
bone. The tibial plateau segment is rotated with a pin inserted proximo-cranially, to achieve a postoperative
TPA of approximately 6 degrees. The proximal tibial segment is stabilized in the rotated position with a tem-
porary stabilization pin placed into the distal tibial segment. Interfragmentary compression can be achieved
by application of pointed bone reduction forceps or applying the bone plate in compression. The osteotomy
is stabilized with a FIXIN locking bone plate utilizing standard technique. The plate is temporarlly attached
to the tibia using pin stoppers, small k-wires or a one clamp. One screw is inserted on each side of the os-
teotomy. The remaining screw are then inserted. Anatomic contouring of the plate is unnecessary due to the
use of locking screws in all of the holes of the plate.
Dogs are restricted to leash walk activity for 8 weeks. Radiographic assessment of healing is performed
at 8 weeks. Adequate bony healing of the osteotomy is typically seen at this time. Once adequate healing
I confirmed, the dog is progressively returned to normal activity over the next weeks. Complications are
uncommon and functional outcome is very good. Complications and outcome results will be presented
in the lecture.
REFERENCES
1. Slocum B and Devine T: Cranial Tibial Wedge Osteotomy: A Technique for Eliminating Cranial Tibial Thrust in
Cranial Cruciate Ligament Repair. J Am Vet Med Assoc 184: 564-569, 1984.
2. Kowaleski MP and McCarthy RJ: Geometric Analysis Evaluating the Effect of Tibial Plateau Leveling Osteotomy
Position on Postoperative Tibial Plateau Slope. Vet Comp Orthop Tramatol: 17: 30-34, 2004.
3. Kowaleski MP, Apelt D, Mattoon JS, and Litsky AS: Effect of Tibial Plateau Leveling Osteotomy Position on Cra-
nial Tibial Subluxation. Vet Surg 2005; 34:332-336.
FIXIN
289 • WVOC 2010, Bologna (Italy), 15th - 18th September A. Ferretti
Fractures in dogs - Thoracic limb

Antonio Ferretti, Med. Vet. Dipl. ECVS
Libero professionista, Legnano (MI), Italy
We applied angular stability plates in the treatment of fractures of toracic limb, scapula, humerus and ra-
dioulna. We found the graetest advantages with these plates in treating juxta articular fractures, whose sta-
bilization using traditional plates is often difficult because of the small number of screws we can apply.
Figure 1 - Scapular distal fracture.
The treatment of complex fractures of distal humerus was mostly simplified with the possibility of stabiliz-
ing the humeral metaepiphysis usually with two plates and two or three distal screws. These screws are
locked and they give a great stability to the osteosynthesis (Fig. 2).
Figure 2 - Diacondylar FIXIN
humeral fracture.
The angular stability plates, used as buttress plates, allow to stabilize the comminuted fractures (Fig. 3).
Figure 3 - Proximal radius and ulna frac-

ture.
A. Ferretti WVOC 2010, Bologna (Italy), 15th - 18th September • 290
Distal radius is easily treated using T plates in metaphyseal fractures or straight plates in distal diaphyseal
fractures. One of the advantages is the possibility of keeping the plate nearby or in some cases far from the
bone to stay over the extensor tendons .
Figure 4 - Exposed and contaminated fracture.
Plates with angular stability screws facilitate the osteosynthesis:

- it isn’t necessary to model the plate;
- it is possible to use easily MIPO techniques;
- these plates can be applied far from the bone, respecting soft tissues and periosteum;
- the number of screws is smaller than in synthesis with DCP or LC-DCP plates.
FIXIN
Concept of minimally invasive fracture stabilization

Don Hulse DVM, Dip ACVS, ECVS
Dept Small Animal Sugery, College Veterinary Medicine, Texas A&M University, College Station Texas 77843-4474 USA
Reduction technique is an important decision the surgeon must make prior to surgery. The surgeon must de-
cide upon direct reduction or indirect reduction. Direct reduction refers to the classical method of fracture re-
duction whereby fragments are anatomically reduced; indirect reduction refers to the technique whereby the
bone and limb are spatially aligned without the need for anatomic reduction of fragments. The advantage of di-
rect reduction is that anatomic reconstruction of the bone column creates load sharing between the implant and
bone. This lowers stress on the implant system and therefore, has fewer implant related complications (loosen-
ing, failure). However, to apply the technique of direct reduction, a number of criterions must be fulfilled. First,
the fracture configuration must be such that anatomic reduction and interfragmentary stabilization are possible.
Second, the surgeon must be able to achieve anatomic reduction and stabilization without significant injury to
the surrounding soft tissue. If the soft tissues are excessively damaged, the biologic response needed for bone
union will be delayed. This prolongs bone healing and increases the likelihood of complications. Fracture con-
figurations amendable to anatomic reduction are those with single fracture lines (transverse, obligue) or com-
minuted fractures having one or two large fragments. These fracture configurations also allow relatively easy in-
terfragmentary stabilization of all fracture planes without significant disruption of the surrounding soft tissue en-
velope. When using direct reduction, a bone plate will serve as a compression plate or a neutralization plate.
If the fracture configuration is such that anatomic reconstruction and stabilization of fracture planes of the bone
column are not possible, the surgeon should then use the technique of indirect reduction. Fracture configu-
rations where this method of treatment is commonly employed are highly comminuted diaphyseal fractures.
The use of the implant in this situation is referred to as a bridging or buttress implant since it is crossing an
area of bone fragmentation. The implant must therefore be strong enough and stiff enough to withstand all
weight bearing loads until sufficient callus is formed. Implant systems useful for bridging osteosynthesis are
bone plates, plate/IM pin combination, interlocking nails, external skeletal fixators. Since the goal is to achieve
rapid callus (biobutress) formation to unload the implant, the surgeon must preserve an environment to accel-
erate callus formation.There are a number of advantages of indirect reduction that help create an environ-
FIXIN
ment conducive to rapid callus formation. First, indirect reduction preserves the biology (soft tissue) because
there is no attempt to reduce small fragments in the area of comminution. Preserving the injured site conserves
remaining vasculature, hematoma, and various peptides needed for induction of bone formation. Second, in-
terfragmentary strain is low within the area of comminution. Recall that the level of interfragmentary strain
will vary depending on the length of the original fracture gap. Small fracture gaps (single fracture lines) con-
centrate strain, but longer fracture gaps (comminuted fractures) lower interfragmentary strain by distributing
motion over a larger area. Spatial realignment of the bone (rotation, length, varus-valgus) rather than anatom-
ic reduction of fragments maintaines a fracture environment which distributes strain (motion) over a larger
area. This therefore, lowers strain within the fragmented zone favoring rapid bone formation.
Minimally invasive plate osteosynthesis (MIPO) is an open technique where application of a plate is
achieved through soft tissue windows (portals). Each portal is strategically located to allow proper reduction
and application of the plate and screws. With direct reduction, two or three portals are commonly used de-
pending on the type of fracture (transverse, oblique) and location of the fracture plane relative to the prox-
imal and distal metaphyseal region of the bone. An incision (1-2cm) is made overlying the metaphyseal-epi-
physeal area of the proximal and distal parent bone. Soft tissue is reflected to expose the bone surface where
the implant will be applied. An additional small portal may be necessary to expose the transverse (short
oblique) fracture site. A periosteal elevator is
used to create an avenue on the surface of
the bone for positioning the implant. The
fracture is anatomically reduced and the
bone plate slid beneath the soft tissue into
the previously created avenue on the surface
of the bone. One proximal and distal screw
is applied to hold fixation while alignment is
examined. The remainder of screws are then
inserted; screws may be loaded on either
side of the fracture to achieve compression
of the fracture plane. As a generally rule, 3
screws are inserted into each fragment.

Minimally invasive technique using indirect
reduction also uses two or three portals de-
pending on the location of the zone of com-
minution relative to the proximal and distal
eiphysis. An alignment pin or external fixa-
tor is applied initially to facilitate axial align-
ment and maintain reduction of the proxi-
mal and distal parent bones. If an external
fixator is used, transfixation pins are placed
in the proximal and distal metaphysis. The
external fixator is removed after plate inser-
tion or may be left in place until early callus
formation is present. If an IM pin is used,
the pin is normograged in the femur and tib-
ia but may be retrograded in the humerus.
The pin is placed in the ulna for radius and
ulna fractures. A retractor may be used to lift
the incision and soft tissue of the distal or
proximal portal in order to observe the pin
as it exits the marrow cavity at the fracture
site and entry of the pin into the distal (or
proximal) parent bone. Once in place, the
pin maintains alignment as the plate is read-
ied for insertion. The plate is contoured to
the shape of the bone and slid into position
via a tunnel made with a periosteal elevator.
Plate screws are then inserted proximally

and distally through the soft tissue portals.
The pin can remain in place to create a plate/
FIXIN
rod construct. In general with a plate/rod con-

struct, two screws proximal and two screws
distal are all that is needed. MIS Fixin / rod
293 • WVOC 2010, Bologna (Italy), 15th - 18th September S. Lozier
Fractures of the pelvic limb

Scott Lozier DVM MS DACVS
Northwest Veterinary Specialists, Portland, Oregon USA
General indications and application methodology for the Fixin locking plate system have been described ear-
lier in this lecture series. In the pelvic limb these considerations similarly apply. In this lecture several ex-
amples using the Fixin straight plates on the ilium, femur and tibia will be shown. Aside from the general
purpose straight plates, Trauma Vet has designed several Fixin plates specifically for use in the pelvic limb.
These include plates for pelvic osteotomy, acetabular plates, distal femoral plates, proximal tibial ”T” or
“TPLO” plates and tarsal arthrodesis plates. Osteotomy and arthrodesis with the Fixin system will be cov-
ered elsewhere in these lectures.
Nowhere is precise articular reduction more critical and challenging than with acetabular fractures. With the
Fixin system, precision machining, close tolerances, adequate guide length and ease of use of the drill/ pin
guide’s taper lock mechanism allow the surgeon to consistently achieve screw insertion “normal” (perpen-
dicular) to the bushing hole. This is of critical importance in preventing altered reduction as the final screws
are tightened. Initial stabilization of the plate and fracture with 2 drill guides, 2 pins and stoppers is impor-
tant to maintain fracture reduction and accurate placement of the remaining screws. This, combined with
the strength and thin profile, makes the Fixin system my preferred choice for acetabular fracture repair.
These mini acetabular plates may also be useful in certain fractures of the extreme distal femur and some il-
ial body/ wing fracture configurations.
However, when using the 1.9 screws of Fixin mini system there is only one drill size guide for the two screw
sizes that can be used. This drill guide accepts a 5/64 inch pin with zero tolerance. The 5/64 inch pin is equal
to the diameter of the 2.0 mm drill bit and appropriate is for the 2.5 mm screw. A 1/16 inch pin equals the
diameter of the 1.5 mm drill bit necessary for the pilot hole for the 1.9 mm screw. Unfortunately the 1/16
inch pin is undersized and does not fit the drill guide with close tolerance. The Fixin 1.5 mm drill bit has short
drill flutes machined into a 5/64 inch shaft so the drill bit still has zero tolerance in the guide. Yet, if 1/16 inch
pins are used as the initial stabilizing pins for an acetabular or other “reduction critical” repair, final screw
placement can result in slight fracture malalignment since the screw may not be exactly “normal” to the bush-
FIXIN
ing. If you can’t upsize to the 2.5 screw you can avoid this problem by using 2 of the Fixin 1.5 mm drill bits
in the guides as initial plate stabilizers. A third Fixin 1.5 mm drill bit can then be used to drill the final holes.
The distal femoral “L” plates are produced in several sizes. They are designed such that the distal three
screws will fit distal to the most proximal aspect of the trochlear groove. Applied in this fashion the plate
and screw heads of the distal 3-4 screws will be intra-articular. The thin profile of the Fixin plates is likely
to be less irritating in the joint than larger profile systems. Caution must be used so that the screw tips are
not directed through cartilage surfaces or cruciate origins. Though the tension surface of the femur is gen-
erally lateral, these plates may also be placed medially. If an inverted “L” ( ⎦ ) shape is required, the bushings
must be removed and replaced on the opposite side of the plate to make the plate suitable for the opposite
limb or opposite side of the femur. Addition of a distal to
proximal intramedullary pin can add greatly to strength and
stiffness of the stabilization. (Figure 1) This is of particular im-
portance in larger breeds and when anatomic reconstruction
and ideal load sharing cannot be established.
The 4 and 5 hole T Plates and the 6 hole Y (V3004) Plates
are ideal for proximal tibial fractures or osteotomies. Once
again, care must be exercised not to enter the joint. Contour-
ing the plate to avoid this is often necessary. This can result
in mild elevation of the plate from the proximal tibial cortex.
While the thin profile of the Fixin system is beneficial in
many aspects, it is more susceptible to bending on a perpen-
dicular plane. An IM pin or orthogonal plane plating should
also be considered with large dogs or fractures with signifi-
cant cortical defects.
On a rare occasion The T plates may be useful for extreme-
ly distal tibial fractures such that the “wings” of the T are con- Figure 1 - Infected previously operated femoral fracture.
toured around the tibia. Examples of these applications will a) pre-op, b) Immediate post-op with vancomycin impre-
be given during the lecture. gnated PMMA, c) 8weeks post-op.
New products
Massimo Petazzoni, DVM, Milano
The following new implants and instruments will be introduced:
- TPLO plate for giant dogs. - Pre-bended anatomical TPLO plates for medium and large dogs.
FIXIN
- TPLO plate for small dogs (5-10 kg). - L TPLO plate for toy dogs (3-5 Kg).
- Bending pliers to allow plate bending preserving the bushings.
- Plugs. They make the plate stronger when

bushings are removed from the plate.
cTTA (circular Tibial Tuberosity Advancement)

Milano
INTRODUCTION
CCL injuries are the most common orthopedic injuries in dogs and are commonly dynamically stabilized
with either a TPLO (Tibial Plateau Leveling Osteotomy) or TTA (Tibial Tuberosity Transposition) proce-
dure. Both procedures dynamically stabilize the CCL deficient stifle by neutralizing the cranial tibial thrust
motion. The TPLO procedure achieves this neutralization with a radial osteotomy of the proximal tibia and
rotation of the tibial plateau. The radial osteotomy has the benefit of a continuous degree of tibial correc-
tion with compression improving stability and healing. The TTA procedure however, neutralizes the cranial
tibial thrust with a frontal plane tibial osteotomy advancing the tibial tuberosity and patella ligament cra-
nially until perpendicular to the tibial plateau. The TTA has the disadvantages of creating an opening os-
teotomy and bone defect as well as requiring pre-sized spacers for an incremental correction. The (cTTA) is
a technique which integrates the principles of a TTA with the advantage of a radial osteotomy. The objec-
tive is to describe the surgical technique of the cTTA procedure and report on the early results and com-
plications associated with the cTTA procedure in a series of clinical cases.

In a prospective clinical study, 86 client owned dogs, 3 bilateral and 83 unilateral, with CCL tears were treat-
ed with the cTTA procedure (89 cTTA). History and pre-operative assessments were made of each dog pri-
or to surgery including degree of lameness, presence and severity of radiographic osteoarthritis, patellar lig-
ament–tibial plateau angle, and tibial dimensions and conformation for surgical planning. A cranio-medial
approach was made to the stifle and a radial osteotomy was performed oriented parallel to the long axis of
the tibia at the level of the tibial tuberosity. The tuberosity was rotated, cranially and proximally along the
tibia, the amount of rotation based on pre-operative measurements. The osteotomy was reduced in com-
pression and secured with a Fixin locking plate. Pre-operative and post-operative measurements of the patel-
lar ligament – tibial plateau angle were compared to assess if expected correction was achieved. An initial
FIXIN
evaluation was performed at 2 weeks post-operatively and examinations at 4 and 8 weeks post-operatively
to assess radiographic evidence of bone healing, complications and clinical response.
RESULTS
89 dogs were in the study comprised of various breeds, most commonly mixed breed dogs. The mean age
of the dogs was 5,5 years, (range 1-12 years) with a mean weight of 32 kg, (range 9 to 70kg). Eighty-two cT-
TA had a 4-hole Fixin plate applied to secure the osteotomy. In Seven dogs a 5-hole plate was applied. All
dogs were weight bearing on the limb at the time of discharge and minimal lameness was apparent at the
time of radiographic healing. Mean time to radiographic healing of the osteotomy site was 8 weeks. Com-
cTTA: preop planning cTTA. Epagneul Breton, F, 16 Kg

plications occurred in 9 of the 89 stifles (10%) including 2 dogs with a tibial fracture, 1 dog with a combined
tibia and tibial crest fracture, and 3 dogs with a fracture along the proximal screw in the tibial tuberosity and
2 dogs with a fracture along the distal screw in the tibial tuberosity, 1 dog with a fracture along a tibial
tuberosity reduction pin. All dogs with complications healed uneventfully after surgical revision.
DISCUSSION/CONCLUSION
The cTTA is an alternative to the traditional TTA procedure which provides dynamic stabilization of CCL
deficient stifles. The cTTA has the benefit over the traditional TTA of creating an osteotomy that allows for
compression and increased stability of the osteotomy site. Most of the complications that were incurred in
these early clinical cases may be the result of single stage bilateral corrections. The cases with complications
may also be the result of intra-operative technical error where the screws were placed too close to the os-
teotomy site (cranially and distally) or from a tibial tuberosity reduction pin was placed and left for increased
stabilization when the osteotomy cut was too cranial. At present there are no defined limitations to the
amount of correction that can be achieved, however, we recommend cTTA correction for dogs that have a
TPA (Tibial Plateau Angle) less than 28 degrees. This recommendation minimizes the occurrence of tibial
crest and tibial fractures as the result of stress risers from excessive tuberosity rotation and inadequate bony
contact at the osteotomy site. The cTTA procedure in comparison to the traditional TTA does not require
specific spacers and implants for stabilization for defined correction degrees, but relies on traditional plating
methods for continuous correction. The size, shape and location of the osteotomy and plating system em-
ployed with the cTTA also results in a less invasive technique compared to the TTA or TPLO. The cTTA
procedure provides adequate stabilization of CCL deficient stifles with minimal complications and a good
to excellent clinical outcome.
ACKNOWLEDGEMENTS
Bart Verdonck, Gayle H. Jaeger.
FIXIN
Corrective osteotomies
Milano
The Fixin internal fixator system is a fixation device characterized by a locking conical coupling between
screw heads and titanium alloy inserts that are screwed into a stainless steel plate construct. Mechanics, im-
plants, instruments, surgical technique and application principles of the Fixin system have been described1.
Specific plates have been designed by Traumavet for use in limb alignments for the pelvic and the thoracic
limb (Fig. 1,2). They are produced in several sizes. Bushings can be removed and screwed on the opposite
side of an asymmetric plate (for example the distal femoral osteotomy plate) to make a left plate from a right
one or to make the same plate suitable for the opposite side of the same femur. A minimum of two or three
bicortical screws are recommended in each bone segment for osteotomy healing depending on the osteoto-
my (closing wedge or opening wedge), dog’s size and bone side of application (medial, lateral, dorsal, ven-
tral) etc. The screw diameter should not exceed 25% of the bone diameter. Large bicortical screws can min-
imize the occurrence of a rake or plough phenomenon, which results from loss of reduction and stability of
the plate construct as the screws slice through thin bone cortices or more likely through poor quality bone
especially in soft epiphyseal or metaphyseal bone of young dogs. In metaphyseal regions of young dogs care
must be taken in placing angle-stable screws because this can result in injury to the physeal plate. In juxta-
articular regions, apply of angle-stable screws can be difficult and may result in intra-articular implant place-
FIXIN
Figure 1 - First row: Labrador retriever, male, 1 year, 37Kg affected by medial patellar luxation lateral femoral torsion, excessive distal
femoral varus and CCL rupture. a) AP preop view; b) AP postop; c) ML postop; d) 5 months postop.
Second row: miniature poodle, male, 7 months, 4kg, affected by lateral patellar luxation sec to external tibial rotation. e,f) AP and ML pre-
op; g,h) AP and ML postop; i) 1 year follow up.

Figure 2 - First row: Beagle, Female, 5 months, 14 Kg affected by excessive proximal tibial varus. a) AP preop; b) intraop; c,d) AP and
FIXIN
ML postop; e) 8 months follow up.

Second row: Dachshund, male, 1.5 years, 7 kg. Pes varus f) AP preop; g) intraop; h,i) postop; l) 16 months follow up.
ment. In such instances, a shorter screw can be placed (author’s preferred choice) or alternatively, the bush-
ing-insert can be removed and a standard 3.5 or 4.0 mm screw inserted directly into the hole of the plate.
Screws aiming is achieved through contouring of the locking plate. Fixin thin plates are more easily con-
toured than other larger profile locking systems. Thin plates are ideal for distal extremities treatments where
there is less soft tissue coverage (for example performing distal tibial osteotomy to correct pes varus in dachs-
hunds). For additional stabilization, two Fixin plates can be placed side by side or a second plate can be
added orthogonally to the first although this has been rarely a necessity in my experience performing cor-
rective osteotomies. The locked position of the screws into the plate prevents compression between the bone
segments. Compression can be achieved during surgery by using a Jig (Slocum Enterprises) or the Defor-
mity Reduction Device, DRD, (Hofmann s.r.l. Monza Italy). Implants can easily be removed by unthread-
ing the screws or the inserts from the plate with the screwdriver or the insert device. Several examples us-
ing Fixin plates will be given during this lecture including: proximal radius lengthening, distal radius align-
ment, distal femoral corrective osteotomies, proximal and distal tibial alignments in small, medium, large
and giant dogs (Fig. 1,2).
REFERENCES
1. Petazzoni M.; Urizzi A.; Verdonck B.; Jaeger G. Fixin internal fixator: Concept and technique, VCOT (4), 2010,
250-253.
299 • WVOC 2010, Bologna (Italy), 15th - 18th September R. Properzi
CrCL repair technique (TTO)

Roberto Properzi DVM, libero professionista
Rapallo, Italy
TTO (triple tibial osteotomy) is a surgical technique used to treat partial or total rupture of dogs cranial cru-
ciate ligament.
This technique aims to alter the alignment of the tibial plateau, in order to make it perpendicular to the patel-
la ligament.
The surgical treatment consists in performing three partial osteotomies in the proximal part of the shinbone
to create a caudal wedge in the tibial crest. By closing the wedge and advancing the tibial crest, the tibial
plateau gets perpendicular to the patella ligament. This prevents the shinbone from cranial trust during the
leaning gait.
In order to achieve tibial stabilization, after bone wedge removal, big or mini FIXIN T-supports have been
used. In particular these supports were provided with 3.5 – 3 – 2.5 mm self-threading screws, depending on
patient’s body weight.
Between 2008 and 2010 forty-two dogs have been operated, four of which bilaterally, aged two to eight (av-
erage 5.3) and body weight ranging between 10 and 53 (average 27.7); 25 were male and 17 were female
subjects, while operation procedures take about 90 minutes.
To carry out the operations, an amount of 46 T-supports provided with self-threading screws was used. Go-
ing into detail, 13 of them were mini-series supports with a screw diameter of 2.5 mm; 13 were big-series
supports with a screw diameter of 3 mm and the remaining 20 big-series supports had a screw diameter of
3.5 mm.
Due to FIXIN technology features, which join external fixators flexibility to osteosynthesis plates advan-
tages, it was possible to employ smaller supports with a consequently lower amount of screws comparing to
traditional internal fixation systems.
It should be highlighted that the FIXIN system allows a relative perform-
ing ease and a remarkable versatility of the implant itself, making it possi-
ble to choose the most fitting to the bone dimension and to the subsequent
FIXIN
loads. No implant breakage nor screw mobilization was recorded in the fol-
low-ups, thanks to the screw-support conical coupling system which allows
distribution of the loads on the whole structure.
In only one case it has been necessary to remove the implant after eight
months from the operation, because of a lameness depending on an oste-
olysis around the proximal screw of the support.
In the controls films taken four weeks af-
ter the operation a good definitive callus
is noticed, while within twelve weeks the
restitutio ad integrum of the osteotomies is
generally achieved.
Between 3 and 5 days from the surgical
treatment a partial load of the operated
limb is already clear, mostly in patients
affected by partial or total acute rupture
of the cranial cruciate ligament, while af-
ter 4/5 weeks the normal gait is achieved
or, in some case, a first degree lameness is
noticed.
In long term follow-ups (24 to 36 weeks)
patients show generally a normal gait.
It’s remarkable that using the FIXIN sys-
tem in TTO to treat partial or total cranial
cruciate ligament rupture ensures in almost
all cases a full functional recovery of the
limb, with no breakage nor mobilization
of the support and no or little arthrosic
evolution on the concerned joint.
U. Reif WVOC 2010, Bologna (Italy), 15th - 18th September • 300
Non-Union Mal-Union
Ullrich Reif, Dr., Dipl. ACVS/ECVS
Tierklinik Dr. Reif, Schönhardterstr. 36, 73560 Böbingen, Germany
Poor decision making and technical failure of the osteosyn-

thesis, rather than a failure that can be attributed to the ani-
mal or its owner, are the most common mistakes that lead to
nonunions. Inadequate fracture fixation results in instability
and the subsequent motion at the fracture site creates inter-
fragmentary strain. If this strain exceeds tissue tolerance, tis-
sue will not form within the gap. The same sequence of
events that leads to the formation of a delayed union is usu-
ally responsible for the development of a nonunion, particu-
larly if the former is left untreated. They are different stages
of the same process with the same predisposing factors. The
most common local factor is a fracture gap, with or without
interposition of soft tissues, which exceeds the regenerative
capacity of the bone. Soft tissue trauma is also an important
local factor and the significance of the transient extraosseous
blood supply is important. Biologically viable nonunions
have a variable amount of callus but this callus fails to bridge
the fracture gap. Unmineralized fibrocartilage is the main tis-
sue present in the zone between the fracture ends. Biologi-
cally viable nonunions are further classified as hypertrophic,
slightly hypertrophic, or oligotrophic, depending on the
amount of callus present. Hypertrophic nonunions usually
show well marked signs of healing, but the process has

ceased. The bone ends are enlarged due to bone apposition
on either the side of the fracture gap, and the nonunion
FIXIN
is usually referred to as an “elephant foot”. Nonviable

nonunions are further classified as dystrophic, necrotic,
defect, and atrophic. Nonunion is an end result of a delayed
union. The reasons for delayed union are problems such as
inadequate reduction, inadequate immobilization, distrac-
tion, loss of blood supply, and infection.
Treatment of nonunion is directed toward improving the
local physiological and mechanical environment to allow
fracture healing to proceed. This is done in part by ad-
dressing all of the problems that cause delayed union and
nonunion. Locking implants such as the Fixin system can
in part address the problems of fracture fixation leading to
nonunion. The greatest improvement is the increased sta-
bility of fixation. This is especially true in situations where
only a limited amount of screws can be placed in the fragments or in situations where poor bone quality is
present and screw purchase is questionable. However the Fixin system does not allow compression of the
fracture at the level of the fracture site. Locked plates are best used for indirect fracture reduction, diaphy-
seal/metaphyseal fractures in osteoporotic bone, bridging severely comminuted fractures, and the plating of
fractures where anatomical constraints prevent plating on the tension side of the bone. Conventional plates
however, continue to be the fixation method of choice for periarticular fractures which demand perfect
anatomical reduction and to certain types of nonunions which require increased stability for union. Malu-
nion is defined as a healing of the bones in an abnormal position. If the deviations from normal axes are se-
vere and the animal cannot use the leg properly, they are classified as nonfunctional malunions. The cor-
rection of a malunion involves an osteotomy, which can have all the serious sequela of bone fractures such
as delayed union, nonunion, and infection. Corrective osteotomies are often performed at the extremities
close to a joint where fragments are short. Locked implants have to be versatile, fit a variety of patient sizes,
and allow screw placement in short fragments. The possibility to have a stable fixation with a very limited
number of screws makes these systems also suitable for difficult situations such as corrective osteotomies.
301 • WVOC 2010, Bologna (Italy), 15th - 18th September U. Reif
Implant removal
Ullrich Reif, Dr., Dipl. ACVS/ECVS
Tierklinik Dr. Reif, Schönhardterstr. 36, 73560 Böbingen, Germany
Indications for implant removal after uneventful bone

healing are not well defined and depend on different fac-
tors. In some animals pain can be elicited on palpation of
the plated bone or the surrounding soft tissues. This is
most evident in distal long bone fractures, with only lim-
ited soft tissue coverage. In areas where tendons and mus-
cles are running close to the surface of the bone, the bone
plate may interfere with the function of the tendons and
the periarticular structures. Common locations where the
plate interferes with the soft tissues are dorsally plated dis-
tal radius-ulna fractures, distal femur fractures, metacarpal/
metatarsal, or phalangeal fractures. Occasionally, the
lameness is associated with cold transmission through the
metal when the implants have only a thin soft tissue cov-
erage. In addition to symptomatic implants after bone
union indications for implant removal also include non-
union requiring additional fixation, early loss of fixation,
infection, or peri-implant fracture after bone union.
The above mentioned problems are valid for all orthope-
dic implants. Hoverer, locked plates and conventional
plates rely on completely different mechanical principles to
provide fracture fixation. In doing so, they provide differ-
ent biological environments for healing.
Construct stability for conventional plates relies on friction
FIXIN
between the bone plate and the bone surface. This friction
is created by the screw head compressing the plate onto the
bone surface. As healing and bone remodeling continues,
bone resorption around the screws can decrease the stabil-
ity of the construct. Screws may back out from the plate
holes while the plate is integrated in the periosteal tissues.
In contrast angular stable systems do not rely on friction
between the bone plate and the bone surface. Similar to
external skeletal fixators, the forces bridging the fracture
site are transmitted from the screws to the plate which is
bridging the fracture site. With locking systems screw loos-
ening within the plate is practically impossible, unless cor-
rect locking of the implant could not be achieved. There-
fore the locking implants remain stable unless there is
bone resorption around the screws or there is acute pull out (subsidence, rake effect) of the implants.
With the Fixin system screws can be removed in two ways. Using the screw driver, the screw can be backed
out of the plate by unscrewing the screw. Usually the screw head will uncouple form the bushing, while the
screw is being pushed out of the bone. In some cases the bushing will not uncouple from the screw head,
but will unscrew form the plate during screw removal. Screw removal with the screwdriver may be difficult
when a high intentional torque was used and the screw is securely locked, or when the hexagonal recess for
the screwdriver has been stripped. Then the second way of screw removal has to be used. A specially de-
signed instrument (bushing extractor) is used to unscrew the bushing with the locked screw from the plate.
A. Urizzi WVOC 2010, Bologna (Italy), 15th - 18th September • 302
Mechanics: recent novelties and improvements

Andrea Urizzi, DVM
San Michele Al Tagliamento (Ve)
The biomechanical role of an orthopedic implant is to secure the bone fragments and segments in position
to promote healing. The stability of conventional plating is directly proportional to the pressure of the plate
against the bone, caused by the lag force of the screws compressing the plate to the bone. As a result some
of the main complications associated with conventional plate fixation are loosening of the screws, impaired
periosteal blood supply and excessive shielding of stresses from the bone. Because of these potential adverse
results, methods of fracture treatment continue to evolve and the recent use of non-contact locking plates is
a technique that is becoming increasingly popular because these systems offer certain advantages in fracture
repair and osteotomy fixation over conventional plating methods. Locking systems achieve their stability by
locking the screws into the plate and the screws into the bone minimizing contact of the plate with the bone
decreasing the potential of stress-protection at the fracture site and impairment of periosteal blood supply.
The non-contact locking plates or angle-stable plates have also been termed “internal skeletal fixators”.
Anatomical reduction is not required for bone healing with the use of locking plates and an adequate toler-
able strain can promote secondary bone healing with callus formation. Locking systems work in a buttress
fashion even in anatomically reconstructed fractures so healing by callus formation is to be expected. These
implants have the biological advantage similar to external fixators and employ the principles of dynamic os-
teosynthesis with internal placement of the implants. The locking mechanism of the Fixin device is based
on a conical coupling mechanism where the conical head of the screw is locked in the corresponding coni-
cal hole of a titanium alloy bushing that is screwed into the stainless steel locking plate. The stability of the
coupling is achieved by friction, micro-welding and elastic deformation between the contact surfaces of the
screw and the bushing. The stability of this coupling is achieved by “welding” the male and female surfaces
of a truncated cone, and requires an axial force Fa. This axial force, Fa, induces a tangential frictional force
Ft that resists slipping and gliding between the two surfaces. Because of a small conic angle of this coupling
mechanism, only a minimal axial force is needed to achieve a strong bond. The axial force, Fa, is created by
the screw-threads converting the screw driver torque in axial translation of the screw.
FIXIN
Similar to external fixators, the stability of the locking plates is influenced by several factors including: loads,
implant strength, micro movements, fracture reduction, bone contact, bone defects, working length, screw
design, number of fixation screws, the screw diameter, the geometry of the implant, the shape and cross-sec-
tion of the connecting plate, the distance of the connecting plate to the bone and many others.
The following topics will be covered during the lecture:

The conical coupling
• Loads and micro movements behavior at the fracture site
• Elastic and plastic deformation of the implant
• Load sharing
• Influence of bone defects
• Force and its effect on long bones and implants
• Correct implant working length
• Number, size and design of screws
• Screws positioning
• Locking screws into the fracture site
Fixin device is based on a conical coupling mechanism where the conical head
of the screw is locked in the corresponding conical hole of a titanium
alloy bushing that is screwed into the stainless steel locking plate.
303 • WVOC 2010, Bologna (Italy), 15th - 18th September B. Verdonck
Fracture repair in cats with implants for angular stability fixin

Bart Verdonck, Dr., DVM
Practice for referral surgery www.huisdierchirurgie.be, Boechout, Belgium, dogdoc@skynet.be
INTRODUCTION
Fixed-angle implants (“locking plates and screws” or “internal fixators”) are being increasingly used in vet-
erinary orthopaedic surgery, because of their biological and mechanical advantages.
In our experience, probably due to the morphologic structure of feline bones and the nature of the fracture
cause (car accidents and high rise falls), our feline patients tend to have more comminuted fractures than
dogs. Apart from the already mentioned advantages, internal fixators will make it easier to reconstruct these
fractures with respect to the correct anatomical alignment, will permit early weight bearing and will avoid
disadvantages of external fixators such as pin tract infections, intensive postoperative care and discomfort
to the patient.
A disadvantage on first sight might be the inability to aim screws, which could be necessary in peri-articu-
lar fractures, but this problem can easily be overcome with the technique and materials we developed.

Medical records of several types of fractures in cats, according to their classification and anatomical location,
are shown with their follow-up. All procedures were performed by the same surgeon, all cats were clinical
cases referred to us. We developed a bending device which permits the surgeon to bend Fixin implants of
all sizes with preservation of the inserts, so the locking capacity is not lost.
CONCLUSION
Fixed-angle implants have a high value in veterinary feline orthopaedics. The presentation illustrates the
high success rates of procedures and advantages in comparison with traditional fracture repair.
FIXIN
CE, mc, 5,5kg, 5yr, R limb postop 5 months postop

B. Verdonck WVOC 2010, Bologna (Italy), 15th - 18th September • 304
Locking plates can increase the possibilities of even experienced surgeons and
reduce morbidity. In simple fractures their use can depend on economical con-
siderations, but in comminuted and complicated fractures, they can offer more
stability with less materials, ending up with a lower cost.
This presentation will also discuss the difference in surgical technique and
possible errors.
Surgeons are encouraged to take profit of the advantages of fixed-angle sys-
tems, being: less invasive systems because of the use of shorter and thinner
implants and less screws, periosteum vascularization preservation because
plate contact and pressure are no longer necessary, shorter surgery time be-
cause implants do not necessitate to be precisely contoured to the bone,
greater mechanical stability and as a consequence lower morbidity.
bending device
FIXIN
305 • WVOC 2010, Bologna (Italy), 15th - 18th September B. Verdonck
Sliding Humeral Osteotomy, my experience with Fixin

Bart Verdonck, Dr., DVM
Practice for referral surgery www.huisdierchirurgie.be, Boechout, Belgium, dogdoc@skynet.be
INTRODUCTION
It is not the purpose of this presentation to discuss the indications, case selection or scientific backgrounds
of the SHO procedure. Apart from the economical aspect of needing another instrument set and implant
stock for each new procedure, being able to perform a lot of different procedures with basically the same set
of plates and screws, will decrease the risk of instrument-related technical errors and stock problems.

A technique for bending a Fixin plate in the appropriate angle, needed to perform SHO with a 25% over-
lap of the fragments as measured on preoperative X-Rays is described. The technical details during surgery,
adapted to Fixin, are shown. Mechanical differences between SHO using Fixin or the originally developed
New Generation SHO-plate are discussed. Medical records of patients are shown with their follow-up. All
procedures were performed by the same surgeon, all dogs were clinical cases referred to us.
CONCLUSION
Fixin can safely be used to perform SHO with fast callus formation and identical clinical outcome and of-
fers the above mentioned advantages.
REFERENCES
Effect of Humeral Osteotomy on joint surface contact in canine elbow joints (Mason,Kurt Schulz e.a. AJVR, Vol64, No4,
April 2003, 506-511).
Measurement of Humeroradial and Humero- ulnar Transarticular Joint Forces in the canine elbow joint after humeral
wedge and humeral slide osteotomies (Mason, Schulz, e.a. Vet. Surg. 37:63-70, 2008).
Mason DR, Schulz KS, Fujita Y, et al: In vitro force mapping of the normal canine humero-radial and humero-ulnar joints.
AJVR 66(1): 132-135, 2005.
FIXIN
Preston CA, Schulz KS, Kass Treatment of Medial Compartment Disease of the Canine Elbow, Noel Fitzpatrick, Russell
Yeadon,Thomas Smith, Kurt Schulz.
PH: In vitro determination of contact areas in the normal elbow joint of dogs. AJVR 61(10): 1315-1321, 2000.
Techniques of Application and Initial Clinical Experience with Sliding Humeral Osteotomy for Treatment of Medial Com-
partment Disease of the Canine Elbow JVS Vol38,Is2, P261-278.
Bauke, Springer Spaniel, m, 3ys, 18kg BAZIEL, Golden Retriever, m, 8yrs, 38kg
TPLO in small dogs

Clinica Veterinaria, Cremona, Italy
INTRODUCTION
The advantages of locking plates over conventional plates are still on debate both in human and in veteri-
nary medicine; nevertheless their use in several conditions are very useful providing more quick and stable
fixation. Fixin plates for TPLO have been shown to be very practical and safe; in most dogs they require
only two screws proximally and two distally. This feature is very useful in small dogs with a small tibial
plateau.
TPLO IN SMALL DOGS

Cranial cruciate rupture is quite common in small breed dogs too, usually at their mid to old age and is fre-
quently associated to overweight. Forty two Dogs of several small breeds has been treated with TPLO in
our practice using small Fixin plates, Yorkshire Terrier, West Highland White Terrier, Jack Russell, Poodle,
Cairn Terrier, Cavalier King Charles Spaniel, and mongrels, with a body weight ranging from 2 to 10 kg.
While in the past we were used to treat cruciate rupture with extracapsular stabilization, since we start do-
ing TPLO in small breed dogs too, we had more consistent results in terms of early return to full function
and of client satisfaction.
The average tibial plateau angle (TPA) is higher in small breed dogs than in standard and large breed dogs,
ranging from 27° to 40°. Because of this high TPA, TPLO can provide a more efficient joint stabilization.
At the follow-up after healing of the TPLO, the realignment of the femur condyle and the tibial plateau is
achieved and preserved, while in most dogs previously treated with extracapsular stabilization the tibial
plateau was maintained in a cranial subluxation with a bone spur forming caudally to compensate for such
a permanent dislocation.
SURGICAL TECHNIQUE
The surgical technique is similar to the standard TPLO technique; the small sizes of the tibia and tibial
FIXIN
plateau require more delicate instruments and smaller implants. For the small jig we used 2.0 pins and for
the osteotomy 10 mm, 12 mm and 15 mm crescentic saw blades. The 10 mm saw blade is produced by NGD
(new Generation Devices). Special Fixin plates are available with different design to fit in the osteotomized
tibial plateau. The main advantage of small Fixin plates is that they need only two horizontal screws proxi-
mally and two vertical screws distally. Screws for the small TPLO plates are available in two sizes, 2.5 and
1.9. In very small dogs the two proximal screws can be inserted in a convergent direction by bending the
plate accordingly to purchase in the small tibial plateau. To avoid interference with the jig pin and the cau-
dal screw, the pin can be inserted cranial to the collateral ligament. Sometimes, to be able to insert the drill
sleeve into the proximal plate holes, the removal of the jig could be required, providing stability of the fixa-
tion with the temporary pin and a pointed reduction forceps. In very small dogs the L shape of the smaller
Fixin plate keeps the plate aligned with tibia.
Figure 1 - From left to right: plate

V2003, V2007, V2031.
Figure 2 - Yorkshire, M, 6 yrs, 5 kg, 3

months after failed extracapsular stabiliza-
tion (nylon band), with permanent cranial
tibial subluxation. TPA 37°. TPLO to 6°,
fixed with a Fixin plate, V2003. Follow-up
three months after surgery with a regained
FIXIN
joint alignment between femoral condyle and
tibial plateau.
DPO and bilateral DPO

INTRODUCTION
Double pelvic osteotomy (DPO) was first described in an in-vitro experimental study by P. H. Haudiquet
and J. F. Guillon at the ESVOT Congress, Munich, in September 2006. This method produced significant
ventral acetabular rotation by osteotomy of the ilium and pubis, while leaving the ischium intact. The re-
sults of DPO were encouraging with regard to acetabular coverage of the femoral head; DPO with 25° ac-
etabular ventral rotation appeared to have the same radiographic effect as triple pelvic osteotomy (TPO)
with 20° of rotation. The rotation of the acetabular segment was dependent on deformation of the ischial
table and appeared to be about 5° less than the amount of rotation at the level of the ilial osteotomy.
Since its introduction by Slocum in 1986, TPO has been modified and new plates have been designed in an
effort to reduce complications. The most common complications include implant loosening, reduction of the
pelvic inlet diameter, excessive head coverage by the acetabular roof, delayed healing of the iliac and ischial
osteotomies and high morbidity, especially in cases of simultaneous bilateral surgery. Unfortunately, there
is often a need to treat both hips at the same time even though the associated morbidity is high. Although
surgery may be better tolerated by delaying the second procedure by one month, the time frame for the on-
set of osteoarthritis (OA) is short and a delay could result in a poor surgical outcome. Instability of the is-
chium can be particularly painful when the dog sits or walks; furthermore, attempts to stabilize the ischial
osteotomy with cerclage wire do not usually work. Instability of the ischium is often followed by implant
failure, collapse of the pelvis and narrowing of the inlet diameter. These conditions may also contribute to
abnormal gait because the loss of normal pelvic geometry increases the dorsal acetabular coverage with ex-
cessive head insertion. This limits extension and abduction of the hip, even with a 20° plate. Based on the
results of studies from France, we switched from TPO to DPO for all suitable candidates. Since after DPO
the implants appeared to undergo increased stress with a tendency for the ilium to return to its original
anatomic position in the first days postoperatively, due to the elastic memory of the rotated bone, the use of
locking plates appeared to be safer than using conventional plates and screws.
FIXIN
CASE SELECTION AND

PREOPERATIVE PLANNING
The inclusion criteria for DPO, which
are critical for achieving an optimal
clinical outcome and preventing OA,
were similar to those for TPO. Candi-
dates for DPO were five- to eight-
month-old dogs that had joint sublux-
ation and laxity, which are indicative
of future hip dysplasia (HD), no OA,
no or very minimal acetabular filling,
a preserved lateral border of the dor-
sal acetabular rim (DAR), an angle of
subluxation (AS) not > 20° and a dis-
traction index (DI) <1.
Figure 1 - Preoperative evaluation of a German

Shepherd, M, 5.5 months old, 24 kg.
Right hip: Angle of Reduction 30°, Angle of Sub-
luxaion 15°, Distraction Index 0.5 and DAR an-
gle 6.
Left hip: Angle of Reduction 30°, Angle of Sub-
luxaion 15°, Distraction Index 0.68 and DAR
angle 6.
Figure 2 - Surgical field; right hip at

left and left hip at right were the stan-
dard screw used to help in the rotation is
shown; at left the standard screw has al-
ready been replaced by a locking screw.
Below, postoperative radiographs and
Ortolani’sign evaluation.
FIXIN
Figure 3 - One month and 2.5
months follow up, with progression of
bone healing, including the pubic os-
teotomy, preservation of pelvic morhol-
ogy and restored joint congruity.
The degree of acetabular rotation was determined using the criteria set out for TPO. A reference of 5°
more than the measured AS was used, and the correction was increased an additional 5° based on Haudi-
quet’s in-vitro results.
SURGICAL TECHNIQUE
Pubic osteotomy was conducted as described for TPO. This was followed by ilial osteotomy, which was car-
ried out using the method described by Slocum for TPO. Because the ischium was not cut, there was de-
creased mobility of the distal segment. It was therefore necessary to gently elevate this segment with a long
chisel to fix the plate. Rotation of the acetabular ilium segment at the level of the ilial osteotomy required
more effort than the standard TPO. Once distal fixation of the plate was completed, reduction forceps were
applied over the plate and the ilium and used to rotate the ilium ventrally while the most distal and ventral
hole of the plate in the proximal ilium segment was drilled and the screw tightened using a special screw
with a standard head, not conical, to achieve traction on the plate. The combined action of the reduction
forceps and screw traction allowed the desired rotation. A variety of bone plates, typical TPO plates or new
plates recently designed for DPO, were used to stabilize the ilial osteotomy. In the new DPO plates, in-
cluding the Fixin, at least two screws per each side of the plate are locking and are divergent to increase the
bone purchase and avoid the risk of implant failure. In very active and heavy dogs, an additional 4 holes
plate was placed ventrally to increase the stability of the fixation. When required, bilateral DPO was always
performed simultaneously, doing the worst side first, requiring more rotation, because the second side was
always more difficult to rotate. The bending of the pubic symphysis already occurred and hence further
bending was mainly due to ischiatic table torsion.
POSTOPERATIVE CARE
Dogs were discharged from the hospital 24 to 48 hours after surgery as ambulatory. Close confinement was
required for one month after surgery, allowing only short walks on a leash, but prohibiting free walks, free
stairs clumping, playing and jumping. Administration of mild sedatives was recommended in exuberant pup-
pies. In the second month after surgery progressive increase of walks on a leash was recommended to pro-
mote muscular tone and two months after surgery free physical activity was allowed. Clinical and radi-
ographic assessment was recommended at 1, 2 and 6 months after surgery and than every 1-2 years.
FIXIN
DISCUSSION AND CONCLUSIONS

Restored joint congruity, in which 50 to 72% of the femoral head was covered by the acetabular roof, was
the most interesting feature of DPO. In our experience; TPO results in more than 90% femoral head cov-
erage. Femoral head coverage of 50 to 72% is the amount seen in normal hips with good to excellent con-
formation. Preservation of the pelvic geometry was an additional advantage of DPO compared with TPO,
and when combined with restoration of normal joint congruity, resulted in normal gait and joint function in
operated dogs. The reduction of postoperative complications was an important advantage of DPO, even
though a more stable fixation of the iliac osteotomy was required. The surgical technique of DPO is a little
more demanding than TPO because of the difficulty in handling and rotating the acetabular ilial segment,
but this difficulty is compensated by elimination of the need for ischial osteotomy. In conclusion, DPO ap-
peared to be a better surgical technique than TPO for pelvic corrective osteotomy in dogs with early HD,
and we propose that the clinical indications for pelvic corrective osteotomy be revisited.
REFERENCES
1. Haudiquet P H: Other strategies for HD - DPO vs TPO. Proceedings of 14th ESVOT Congress, Munich, 10th-
14th September 2008
2. Haudiquet PH, Guillon JF: Radiographic evaluation of double pelvic osteotomy versus triple pelvic osteotomy in
the dog: an in vitro experimental study. Proceedings of 13th ESVOT Congress, Munich, 7th-10th September 2006
3. Slocum B, Devine Slocum T: Triple pelvic osteotomy. In: Current Techniques in Small Animal Surgery, 4th Edi-
tion. Bojrab M.J., Ellison G.W.Slocum B. 1998, P 1159-1165
4. Vezzoni A., Baroni E., Petazzoni M. “TPO: retrospective multicentric study in 218 cases”, Proceedings SCIVAC
Congress, Montecatini 2000.
5. Vezzoni A, Dravelli G et al.: Comparison of conservative management and juvenile pubic symphysiodesis in the
early treatment of canine hip dysplasia. VCOT 2008;21(3):267-79.
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SEMINAR
313 • WVOC 2010, Bologna (Italy), 15th - 18th September S.J. Butterworth
Injuries in working sheepdogs

Steven J. Butterworth MA, VetMB, CertVR, DSAO, MRCVS
RCVS Specialist in Small Animal Orthopaedics
Weighbridge Referral Centre, Swansea, Wales, UK SA6 8QF
Injuries in working sheepdogs are similar to those seen in pet dogs in terms of their aetiology, i.e. there are no
“work specific” injuries. However, their management options are perhaps more limited, with specific require-
ments, if good function and a likely return to work is to be achieved. The types of injuries seen can be broadly
divided into fractures, luxations and muscle/tendon/ligament sprains/strains. Management of fractures in these
patients follows the standard principles that have been established as “good practice” over several decades, pos-
sibly with adjunct physiotherapy to further help recovery. Management of sprains/strains is the preserve of the
veterinary physiotherapist and such conditions are not within the remit of the paper presented here.
The focus of this paper will be the field of luxations. Over the past few decades a great deal of attention has
been given to the healing of bone and the concept of allowing this to take place whilst controlled limb function
is to be encouraged so that the soft tissue related consequences of limb immobilisation are avoided and a more
rapid and complete return to function is achieved. Luxation of a joint is a catastrophic injury to that organ sys-
tem and successful recovery from such a catastrophe requires attention to more than just reduction and stabil-
isation, though of course these are important requirements, particularly if early mobilisation is to be achieved.
For some luxations, arthrodesis is the best option, for example intertarsal or tarsocrural luxation. In such cas-
es there is no intent on restoring function to the injured joint. However, stabilisation that allows early mobili-
sation of related joints (tarsocrural) will help to avoid unnecessary complications. For those luxated joints
where regaining normal function is the goal there are two major considerations, above and beyond reduction
and stabilisation. Firstly, the quality/strength of the healed tissues, particularly the ligaments. Secondly, restora-
tion of proprioception. The healing of the connective tissues injured as a result of joint luxation are sequential
and predictable. It is the Regeneration Phase that is most crucial since it is at this time that the ultimate tensile
strength of a ligament or tendon can be influenced. This phase occurs during days 5-21 post injury but can
continue for up to 15 weeks. The collagen fibres being formed by the fibroblasts or tenoblasts are laid down
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in a disorganised fashion and the application of appropriate stresses during this phase will allow them to align
themselves in the most appropriate way to resist the forces that will ultimately be applied to them during nor-
mal activity. Collagen synthesis is at its optimum at 2 weeks post injury (Sharma & Maffuli, 2005) and it is at
this point that small degrees of stress should be applied to the healing tissues. Focus is on regaining any lost
range of motion and early strengthening exercises. As pain subsides the strengthening exercises are developed
with inclusion of modalities to enhance circulation and encourage tissue regeneration (though the latter are
aimed more at tendon / muscle injuries associated with the luxation rather than the joint injury per se).
Following injury to or surgery on a joint, a diminished sense of propriocetion is frequently reported by hu-
man patients (Lephart et al, 1997). Regaining proprioception and neuromotor control is important to regain
normal function and to avoid reinjury. Exercises to restore this generally focus on balancing activities and
coordination training (e.g. walking over poles, uneven surfaces, weaving poles etc).
From a surgical point of view, the goal with management of luxations is to achieve good anatomical reduc-
tion and stabilisation that allows early remobilisation, i.e. does not compromise movement of the joint but
adequately protects the joint from reluxation. The techniques that tend to be used by the author for this in
the various joints will be discussed. An interesting compromise may have to be reached in cases where there
is difficulty avoiding external coaptation. For a period of time in South Wales there seemed to be an in-
creased incidence of tarsocrural luxations (and distal tibial fractures) associated with increasing use of All
Terrain Vehicles (ATV’s) by farmers. The sheepdogs tended to travel on a luggage rack at the back of the
vehicle with an “open grill” top. Presumably they tended to catch the limb in the grill as they jumped from
the vehicle. The incidence of injury has reduced since the tops have been replaced with a solid table (often
with a rubberised surface). Although the majority of such tarsocrural injuries were treated with internal sta-
bilisation, the “repair” was protected by external coaptation. However, based on the need to try and remo-
bilise the joints fairly early there was a trend to remove the external support within 4 weeks, though some-
times this was replaced with a brace if the injury was considered severe.
BIBLIOGRAPHY
Lephart, S.M., Pincivero, D.M., Giraldo, J.L. et al 1997. The role of proprioception in the management and rehabilitation
of athletic injuries. Am. J. Sports Med. 25, 130-137.
Sharma, P. & Maffuli, N. 2005. Tendon injury and tendinopathy: Healing and repair. J. Bone and Joint Surgery 87, 187-202.
E.J. Comerford WVOC 2010, Bologna (Italy), 15th - 18th September • 314
Cruciate injuries - Are performance dogs different?

Eithne J. Comerford, MVB PhD CertVR CertSAS PGCertHE DipECVS MRCVS
Senior lecturer in Small Animal Orthopaedics, School of Veterinary Science, University of Liverpool,
Chester High Rd, Neston, CH64 7TE
INTRODUCTION
Cruciate ligament injuries, namely cranial cruciate ligament (CCL) injuries, rarely occur in dogs such as
the racing greyhound. Performance dogs such as the racing greyhounds perform activities intended to
achieve an acquired result e.g. hunting, racing, and agility. Therefore a full overview of performance dogs
would include working (e.g. gun, herding, hunting, hauling), agility and racing dogs. However to date
there is a paucity of information on the epidemiology of CCL injuries in most of these groups except in
sight-hounds e.g. racing greyhound.
The general design of sight hounds; long legs with a flexible, wiry body and large chest for aerobic effi-
ciency make them ideal for capturing agile prey. Their ideal design may also explain why they rarely suf-
fer injuries to their CLs and this lecture will review how hindlimb conformation, stifle joint mechanics
and cruciate ligament composition contribute to the paucity of these injuries compared to other high risk
breeds to CCL injury.
EPIDEMIOLOGY OF CRUCIATE INJURIES IN PERFORMANCE DOGS

1) General
To date a large epidemiological study on cruciate injuries in performance dogs has not been published how-
ever the greyhound had a reported prevalence of CCL rupture of 0.51%1. Other sight hounds such as the
Afghan and Irish wolfhound had prevalences of 0.41 and 0.35% respectively. Common agility breeds such
as the border collie had a prevalence of 1.89% and gundogs such as the English springer spaniel and point-
er had prevalences of 1.37 and 1.51%. A recent study examining orthopaedic injuries to gundogs during the
shooting seasons of 2005-2007 found most of the injuries to be either pad related or wounds with only 8
labrador retrievers and 7 springer spaniels suffering joint injuries2.
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2) Trauma
Most cruciate ligament injuries in performance dogs tend to occur secondary to trauma. These tend to
be multilgamentous injuries involving at least 2-3 ligamentous stabilisers of the canine knee joint such
as the CCL, caudal cruciate ligament (CaCL) and lateral collateral ligament. Border collies tend to be
overrepresented in this group and the injury is usually secondary to the affected limb being trapped or
suspended3.
3) Immature/maturity
Avulsion of the CCL at its tibial attachment has been reported in young puppies4. Partial or full avulsion of
the tibial tuberosity in a litter of greyhound puppies has also been reported and histopathological examina-
tion suggested that this was likely to be secondary to osteochondrosis5.
4) Non-contact injury
Non- contact CCL injury secondary to progressive degeneration (disease) of the CCL (CCLD) is the main
method of eventual ligament rupture in most dogs6. Progressive CCL degeneration leading to rupture does
not appear to occur in the racing greyhound and to date there is little information on non-contact CCL in-
jury in other performance dogs particularly those in the breeds at a high risk to CCL rupture, such as the
Labrador retriever.
5) Exercise
It is currently unknown how exercise, particularly in performance dogs, may contribute to ligament protec-
tion or failure. In tendon it has been shown that overstimulation of tendon cells through repetitive loading
may initiate a degenerative cascade leading to tendinopathy7. However, understimulation of tendon cells can
also produce a pattern of catabolic gene expression that results in loss of tendon material properties8. Very
little research has examined the effect of exercise on the biochemical properties of the canine CCL. An ex-
perimental study examining the effect of regular consistent exercise on canine stifle joints, its associated lig-
aments and cartilage found no injuries in these tissues or any evidence of erosions or osteophytes in the
joints after lifetime exercise9.
315 • WVOC 2010, Bologna (Italy), 15th - 18th September E.J. Comerford
STIFLE JOINT
1) Mechanics
The craniocaudal stifle joint laxity, structural and material properties have been compared in two breeds of
dogs at a high risk of CCLD (Rottweiler and Labrador retriever) to the racing greyhound10-11. Craniocau-
dal stifle joint laxity was less in the greyhound stifles compared to those of the high risk breeds and the struc-
tural (load to failure) and material (ultimate stress and tangent modulus) properties were being significantly
higher in greyhound stifle joint during cranial tibial loading compared with those in Rottweiler12. The in-
creased craniocaudal laxity in the normal Labrador retriever stifle joint appeared to be related to altered
CCL extracellular matrix (ECM) ligament composition.
2) Conformational Variation
Conformational variation of canine hindlimbs such as a straight stifle joint, narrow distal femoral inter-
condylar notch, and steep tibial plateau slope have been associated with CCLD. Altered gait, as demon-
strated by gross differences in kinematic patterns, between greyhound and Labradors retriever hindlimbs
has been shown13. A recent study has documented the functional anatomy and muscle moment arms in
the greyhound compared to a generalised canid model and two other athletic species. The hip muscles were
larger than those of the general canid model. The moment arms of the muscles around the stifle had a sim-
ilar adaptation to that of the hip extensors in the greyhound and this may contribute to maximal propulsion
in the limb when the stifle is extended14.
Intercondylar notch (ICN) stenosis and its association with CCL has been well described15. ICN width in-
dices were found to be greater in the stifle joints of greyhounds compared to those of high risk of CCLD
(Labrador and golden retrievers)16. The authors concluded that impingement by the intercondylar notch on
the CCLs of the high risk breeds may result in altered biochemical composition predisposing the ligament
to increased laxity and degeneration. There have been numerous studies evaluating the association of tib-
ial plateau angle (TPA) and CCL rupture17-18. Studies have shown that the TPAs are not significantly dif-
ferent between greyhounds and Labrador retrievers19.
CRUCIATE LIGAMENT
1) Cells
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Cells in the annulus fibrosus and ovine anterior cruciate ligament have cytoplasmic processes which may be
long and extend in all directions through the collagen fibres suggesting the potential for cell-to-cell commu-
nication20. Recent unpublished observations describe cells of similar morphology in intact CLs of grey-
hounds and Labrador retrievers (Smith unpublished 2010). Cells with long processes were more common-
ly noted in the CLs of the greyhounds than the Labrador retriever. These findings suggest the possibility of
communication between cells (particularly in the greyhound) which, if disrupted, may result in altered me-
tabolism of the ECM ultimately leading to CCLD in other dog breeds.
2) Extracellular matrix (ECM)- collagen, elastin

Collagen: It has been shown recently that macroscopically normal CCLs from Labrador retrievers com-
pared to greyhounds have altered ECM collagen turnover and structural properties. This study also sug-
gested that the different metabolism of the collagenous matrix in the CCLs from a high risk breed may be
related to greater knee joint laxity and lower ligament material properties10.
An ultrastructural study of normal CCLs in these two breeds of dog revealed that the collagen fibril diam-
eters of greyhounds were larger than those of Labrador retrievers, reflecting ligament maturity and better
mechanical properties21. Histology revealed increased “fibrocartilaginous” areas (rounding cell nuclei and in-
creased staining for proteoglycans) in both breeds. The formation of fibrocartilage is clearly not a disad-
vantage to the healthy racing greyhounds and cannot be regarded as a purely pathological degeneration in
this breed. Therefore is currently unclear whether fibrocartilaginous change is a adaptive condition in exer-
cising and/or low risk breeds to CCLD, but a pathologic change (with the fibrocartilaginous change induc-
ing an inflammatory response) in high risk breeds resulting in eventual CCLD.
Elastin: Elastin has always been considered to form a minor component of ligament ECM. Recent work
has compared the biochemical and histological levels of elastin in the canine CL complex in the Grey-
hound (Smith, unpublished 2010). All ligaments were also scored with a modification of the Vasseur scale
of CCL degeneration22 and stained for elastin fibres and microfibrils. All ligaments with evidence of “de-
generation” or fibrocartilaginous change according to the modified Vasseur scale stained very positively
for microfibrils. This has not been shown in degenerative CCLs from Labrador retrievers (Smith, un-
published observations) suggesting that elastin may play an important role in the functional anatomy of
the greyhound CCL.
CONCLUSION
Performance dogs such as the greyhound very rarely rupture their CCLs- this is due to their ideal design in
terms of mechanics, ligament composition, CCL cell communication and gait. However epidemiological da-
ta on these injuries in other performance dogs is sparse and it the effect of exercise and training on pre-
venting CCL injuries in dogs at a high risk to CCLD, such as the Labrador retriever, is still unknown.
REFERENCES
1. Whitehair, J.G., Vasseur, P.B, Willits, N.H., Epidemiology of cranial cruciate ligament rupture in dogs. JAVMA,
1993. 203(7): p. 1016-1020.
2. Houlton, J.E., A survey of gundog lameness and injuries in Great Britain in the shooting seasons 2005/2006 and
2006/2007. Vet Comp Orthop Traumatol, 2008. 21(3): p. 231-7.
3. Bruce, W.J., Multiple ligamentous injuries of the canine stifle joint: a study of 12 cases. Journal of Small Animal
Practice, 1998. 39(7): p. 333-340.
4. Reinke, J.D., Cruciate Ligament Avulsion Injury in the Dog. Journal of the American Animal Hospital Association,
1982. 18(2): p. 257-264.
5. Skelly, C.M., et al., Avulsion of the tibial tuberosity in a litter of greyhound puppies. Journal of Small Animal prac-
tice, 1997. 38(10): p. 445-449.
6. Bennett, D.T., B., Lewis, D.G, et al, A reappraisal of anterior cruciate ligament disease in the dog. Journal of Small
Animal Practice, 1988. 29: p. 275-297.
7. Jones, G.C., et al., Expression profiling of metalloproteinases and tissue inhibitors of metalloproteinases in normal
and degenerate human achilles tendon. Arthritis Rheum, 2006. 54(3): p. 832-42.
8. Egerbacher, M., et al., Loss of homeostatic tension induces apoptosis in tendon cells: an in vitro study. Clin Orthop
Relat Res, 2008. 466(7): p. 1562-8.
9. Newton, P.M., et al., Winner of the 1996 Cabaud Award. The effect of lifelong exercise on canine articular carti-
lage. Am J Sports Med, 1997. 25(3): p. 282-7.
10. Comerford, E.J., et al., Metabolism and composition of the canine anterior cruciate ligament relate to differences in
knee joint mechanics and predisposition to ligament rupture. J Orthop Res, 2005. 23(1): p. 61-6.
11. Wingfield, C., et al., Cranial cruciate stability in the rottweiler and racing greyhound: an in vitro study. J Small An-
im Pract, 2000. 41(5): p. 193-7.
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12. Wingfield, C., et al., Comparison of the biomechanical properties of rottweiler and racing greyhound cranial cru-
ciate ligaments. J Small Anim Pract, 2000. 41(7): p. 303-7.
13. Colborne, G.R., et al., Distribution of power across the hind limb joints in Labrador Retrievers and Greyhounds.
Am J Vet Res, 2005. 66(9): p. 1563-71.
14. Williams, S.B., et al., Functional anatomy and muscle moment arms of the pelvic limb of an elite sprinting athlete:
the racing greyhound (Canis familiaris). J Anat, 2008. 213(4): p. 361-72.
15. Aiken, S.W., Kass, P.H., Toombs, J.P., Intercondylar notch width in dogs with and without cranial cruciate ligament
injuries. Veterinary and Comparative Orthopaedics and Traumatology, 1995. 8: p. 128-132.
16. Comerford, E.J., et al., Distal femoral intercondylar notch dimensions and their relationship to composition and
metabolism of the canine anterior cruciate ligament. Osteoarthritis Cartilage, 2006. 14(3): p. 273-8.
17. Duerr, F.M., et al., Risk factors for excessive tibial plateau angle in large-breed dogs with cranial cruciate ligament
disease. J Am Vet Med Assoc, 2007. 231(11): p. 1688-91.
18. Macias, C., et al., Caudal proximal tibial deformity and cranial cruciate ligament rupture in small-breed dogs. J
Small Anim Pract, 2002. 43(10): p. 433-8.
19. Wilke, V.L., et al., Comparison of tibial plateau angle between clinically normal Greyhounds and Labrador Re-
trievers with and without rupture of the cranial cruciate ligament. J Am Vet Med Assoc, 2002. 221(10): p. 1426-9.
20. Lo, I.K., et al., The cellular networks of normal ovine medial collateral and anterior cruciate ligaments are not ac-
curately recapitulated in scar tissue. J Anat, 2002. 200(Pt 3): p. 283-96.
21. Comerford, E.J., et al., Ultrastructural differences in cranial cruciate ligaments from dogs of two breeds with a dif-
fering predisposition to ligament degeneration and rupture. J Comp Pathol, 2006. 134(1): p. 8-16.
22. Vasseur, P.B., et al., Correlative biomechanical and histologic study of the cranial cruciate ligament in dogs. Am. J.
Veterinary Res., 1985. 46(9): p. 1842-1854.
Physiotherapy
Physiotherapy can be utilized to help restore patient function after disease, illness, or injury. In veterinary
medicine much of the focus on is joint surgery in the dog however, the principals apply to many orthopedic
surgeries. With respect to restoration of function I’ll draw your attention to the scientific literature and con-
trast that to the many opinions that have now been voiced regarding this topic.
Prolonged immobilization after joint surgery is closely associated with degenerative alterations in connective
tissue, cartilage, ligaments, muscles, and bone-ligament complexes, while allowing for hypertrophy of peri-
articular fibrous tissue. Restricted knee motion after anterior cruciate ligament (ACL) reconstruction in peo-
ple contributes to joint pain, muscle atrophy, decreased joint mobility, increased arthrofibrosis, soft tissue
weakness and functional impairment. Loss of joint mobility and joint instability disrupt normal joint kine-
matics and can lead to osteoarthritis (OA). Loss of mobility causes pain and effusion after prolonged weight
bearing, crepitus during extension, altered gait, decreased knee function, and reduces the likelihood of re-
turn to pre-injury function.
Alternatively, early motion and aggressive postoperative physical therapy after ACL surgery in people has
been reported to improve prognosis. Early physical therapy results in earlier and more complete return to
function, often by 4-6 months after surgery, reduces re-injury rates while not increasing intra-articular graft
failure rates. In athletes recovering from ACL surgery, it has been reported to reduce pain, joint effusion,
capsular contraction, and periarticular fibrosis while increasing range of motion, muscle mass and limb
strength. Finally, Shelbourne et al. have suggested that early postoperative physical therapy reduced the de-
velopment of arthrofibrosis and OA. More recent evidence has suggested that focuses on training muscles
that require use of proprioceptive skills is advantageous.
This can be performed in dogs by using cavalettis.
In animals, physical therapy has been suggested to decrease muscle spasm, promote tissue healing and re-
pair, increase ROM, decrease edema, and increase muscle strength and endurance. Improved range of mo-
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tion, cartilage nutrition, and orientation and strength of collagen fibers in the ACL grafts are additional ben-
eficial effects of early motion following joint surgery. Millis et al. have suggested that low impact exercises,
including swimming and walking, avoid worsening of OA while maintaining muscle strength, joint mobili-
ty, and function. Finally, it has been reported that physical therapy after joint surgery decreases adhesions,
is valuable for maintenance of muscle mass, bone, cartilage and ligaments, and provides the stress needed
for reorganization of transplanted tissues.
Rupture of the cranial cruciate ligament (RCCL) is a common cause of lameness and the number one di-
agnosed stifle injury in the dog. While much attention has been given to the role of various surgical tech-
niques for repair of RCCL, peer-reviewed literature addressing the role of postoperative management for
dogs is scarce. Anecdotal reports several text books and manuscripts addressing surgical techniques for the
ruptured cranial cruciate ligament suggest postoperative management should include application of a Robert
Jones bandage for up to 14 days and activity restricted to a leash for up to 12 weeks. Much of this man-
agement is seemingly geared towards increasing the strength of periarticular fibrous tissue and mechanical-
ly protecting the repair technique. One could argue that this approach may actually increase the likelihood
of a poor outcome for patients.
One of the first investigations in veterinary medicine looked at the effect of early postoperative physical ther-
apy on limb function in dogs after surgery for RCCL. In this study, twenty-five dogs were included in a
postoperative physical therapy group and twenty-six dogs were included in an exercise restriction group. Re-
habilitation in this report focused on swimming, stretching and range of motion exercises and leash walk-
ing. Rehabilitation began 10-14 days following arthrotomy. Vertical forces were measured using force plate
gait analysis preoperatively and six months after surgery. Prior to surgery vertical forces were statistically
similar between groups.
Six months after surgery, vertical forces in dogs in the physical therapy group were significantly greater than
in dogs in the exercise restriction group. Peak vertical force (PVF) in dogs in the physical therapy group was
18.5% greater than dogs in the exercise restriction group, vertical impulse (VI) was 13.9% greater, and dogs
in the physical therapy treatment group reached vertical forces that were statistically identical to that of the
opposite normal limb. Considering these findings, it is reasonable to suggest that the after surgery for RC-
CL dogs benefit from postoperative physical therapy and that it should be considered as part of the care pro-
vided to these patients.
Perhaps one of the main benefits to physical therapy after joint surgery is limiting the development of peri-
articular fibrosis. Limiting arthrofibrosis not only allows for maintenance of range of motion and improved
limb function but also reduces periarticular pain. A recent study investigated the range of motion in normal
dogs and in dogs after surgery for a cranial cruciate ligament injury when they participated in terrestrial and
aquatic activities. This investigation found that the range of motion in the hip, knee, and hock joints was
dramatically greater during aquatic activities when compared to terrestrial activities. The principal benefit
was seen with an increase in flexion of the joints during swimming. During walking and trotting dogs still
had near normal extension even after joint surgery. A recommendation from this study is that after joint sur-
gery dogs should not only participate in postoperative physical therapy but that therapy should include both
walking and swimming.
The greatest benefit of aquatic rehabilitation is that it provides for buoyancy, which decreases the effect of
gravity. On land, joint reactive forces can reach several times body weight. In water the effects of gravity
and axial loading can be significantly diminished or can be entirely eliminated if the patient floats. This does
not mean that joint reaction forces are decreased. An alternation to swimming is the use of an underwater
treadmill. One, however, must be cautious when expecting a reduction in ground reaction forces from buoy-
ancy when using this method. Harrison et al. reported that in people at a fast walk the water level needed
to be at the level of the neck in order to reduce ground reaction forces to <25% of that found on land. When
the water level was at the level of the waist, ground reaction forces were still 75-100% of normal. This fact
likely limits the benefits of most low water level aquatic activities. Additionally, muscle activation has been
demonstrated to be decreased during aquatic exercise, allowing for earlier return to active motion while de-
creasing the risk of reinjury. During swimming viscosity provides for a multiplanar passive resistance that is
equal to the force exerted by the movement. Slower movements exhibit lower resistive forces while faster
movements are met with equally increased forces. Additional benefits of water include the effects of hydro-
static pressure and specific heat. It has been suggested that hydrostatic pressure can reduce joint edema and
warm pools can promote relaxation of the patient, increase blood flow to the muscles, and decrease pain.
The veterinary literature consists of few peer-reviewed manuscripts addressing post-operative rehabilitation.
Although much of what is suggested in proceedings and at meetings may be true only evidence-based med-
icine should dictate the techniques we use to manage our patients.

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REFERENCES
1. Marsolais GS, McLean S, Derrick T, Conzemius MG. 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 Mar 15;222(6):739-43.
2. Marsolais GS, Dvorak G, Conzemius MG. Effects of postoperative rehabilitation on limb function after cranial cru-
ciate ligament repair in dogs. J Am Vet Med Assoc 2002 May 1;220(9):1325-30.
3. Akeson WH, Amiel D, Woo SL-Y. Immobility Effects on Synovial Joints. The Pathomechanics of Joint Contrac-
ture. Biorheology 1980; 17:95-110.
4. Noyes FR, Torvik PJ, Hyde WB, DeLucas JL. Biomechanics of Ligament Failure. II. An Analysis of Immobiliza-
tion, Exercise, and Reconditioning Effects in Primates. J Bone Joint Surg [Am] 1974; 56(7): 1406-1418.
5. Noyes FR. Functional Properties of the Knee Ligaments and Alterations Induced by Immobilization. Clin Orthop
1977; 123:210-42.
6. Mooney V, Ferguson AB. The influence of Immobilization and Motion on the Formation of Fibrocartilage in the
Repair Granuloma after Joint Resection in the Rabbit. J Bone Joint Surg [Am] 1966; 48(6): 1145-1155.
7. Sachs RA, Daniel DM, Stone ML, Garfein RF. Patellofemoral Problems after Anterior Cruciate Ligament Recon-
struction. Am J Sports Med 1989; 17:760-765.
8. Shelbourne KD, Patel DV. Treatment of Limited Motion after Anterior Cruciate Ligament Reconstruction. Knee
Surg, Sports Traumatol, Arthrosc 1999; 7:85-92.
9. Graf B, Uhr F. Complications of Intraarticular Anterior Cruciate Ligament Reconstruction. Clin Sports Med 1988;
7:835-848.
10. Vilensky JA, O'Connor BL, Brandt KD, Dunn EA, Rogers PI, DeLong CA. Serial Kinematic Analysis of the Un-
stable Knee After Transection of the Anterior Cruciate Ligament: Temporal and Angular Changes in a Canine
Model of Osteoarthritis. J Orthop Res 1994; 12:229-237.
Shoulder injuries – is treatment a realistic option?

Recent data would suggest that forelimb lameness in dogs may often be attributable to shoulder pathology.
While comprehensive epidemiologic studies in this area have not been reported in the literature to the au-
thor’s knowledge, available evidence indicates that signalment and certain activities may be significant risk
factors for shoulder problems in dogs. The recognized disorders reported to cause lameness in adult dogs
include shoulder instability, biceps tendon injury and inflammation, and pathology of the supraspinatus, in-
fraspinatus, subscapularis, and teres muscle-tendon units. For each of these causes, dogs are most common-
ly middle-aged, large breed dogs that have an intended purpose of work, performance, or very active pet-
level function with a history of unilateral forelimb lameness, which can be acute or chronic.
Physical examination of dogs with shoulder pathology can often be very similar regardless of specific cause.
The examination findings most consistent with shoulder causes for forelimb lameness reported include mild
to moderate atrophy of the spinatus muscles, pain on shoulder extension, flexion, and/or abduction, and
pain on direct palpation of the biceps tendon and/or manual tensioning of the biceps muscle. The author rec-
ommends complete neurologic examination, comprehensive palpation of the forelimb, evaluation of gait at
a walk and trot, and assessment of shoulder range of motion, cranial-caudal and medial-lateral laxity, inter-
nal and external rotation, and abduction angles. Definitive diagnosis and characterization of type of pathol-
ogy typically requires careful ruling out of other possible causes for the lameness including elbow patholo-
gy, neurologic abnormalities, neoplasia, and trauma; more advanced imaging modalities such as ultra-
sonography, CT, and MRI; and/or arthroscopic visualization. Ultrasonography is helpful for determining
the type and severity of the pathology in the majority of cases, in our experience. Exciting and encouraging
work is also currently being done using MRI of the shoulder. Arthroscopic evaluation of the shoulder joint
allows for visualization and assessment of all intra-articular structures. The author recommends arthroscopic
evaluation of the shoulder joint as the diagnostic modality of choice as it allows for visualization, “palpa-
tion”, biopsy, and when necessary, treatment, of pathology.
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Treatment indications and options will be dependent on type, extent, and severity of the pathology. Non-
surgical management, including dedicated physical rehabilitation, should always be considered as an initial
treatment option in these cases, in the author’s opinion. In working dogs, careful preoperative considera-
tion and discussion with the owner and trainer are critical for determining appropriate treatment options
based on goals for return to intended purpose. It is important to point out that we are in the infancy of un-
derstanding the causes of shoulder pathology and the clinical relevance of abnormalities we are now see-
ing. Therefore, it is critical that we carefully investigate and document epidemiological aspects, diagnostic
algorithms with likelihood ratios, treatment algorithms using validated outcomes instruments, and long-
term follow-up so that we can progress in our understanding, delivery of care, and accurate communica-
tion with owners.
The results of one study of 19 dogs showed that forelimb lameness could be localized to shoulders (8), el-
bows (6), or both (5). Preoperative localization was correct in 79% of patients. Orthopedic examination,
spinatus muscle atrophy, abduction angles, elbow joint effusion, and radiographic assessment were clinical-
ly useful for preoperatively determining pathology. Eleven shoulders and 20 elbows were surgically treated.
Dogs were significantly (P < .001) less lame at follow-up (mean ±SD lameness score, 1.1 ± 1.1) 6-24 months
postoperatively compared with admission (4.2 ± 2.8). Dogs with shoulder involvement only were signifi-
cantly (P = .038) less lame than dogs with shoulder and elbow involvement after treatment.
Clinically, we have experienced variable long term outcomes depending on type, duration, and severity of
the injuries. Unidirectional (medial or lateral) instabilities and single muscle-tendon injuries have typically
resulted in fully functional long term outcomes following surgery, while multidirectional instabilities and
multi-muscle-tendon injuries have been associated with less favorable outcomes in the author’s experience.
So, treatment of shoulder injuries is realistic and can be associated with full return to function in working
dogs as well as pets. However, some degree of residual lameness may be present and owners should be
warned about this possibility, especially in more chronic and more severe cases.
Management of various tendon/ligament injuries

in working/sporting dogs
INTRODUCTION
Ligaments hold bones in their normal anatomical relationship and hence maintain the integrity and contact
relationships of articular cartilage. Injuries of ligaments (sprains) cause an increase in length with resultant
increase in motion, yielding abnormal wear with subsequent damage to cartilage resulting in pain and loss
of function.
Tendons join muscles to bone and transmit the force of the muscles to the bone. Injuries to muscle tendon
units (strains) can result in an increase in length or contracture, with subsequent increase or decrease in
ROM (range of motion). Both result in a decrease in function.
Both ligaments and tendons need time and protection during healing so that biomechanical function may
be restored. Injury severity dictates the amount of support needed for healing. The following is not an in-
depth literature review, but simply one man’s thoughts based on four decades of dealing with orthopedic in-
juries of working and sporting dogs.
INJURIES OF THE DIGITAL COLLATERALS

Injuries to the collateral ligaments of the digits consist of mild, moderate or severe (grade I, II, or III) sprains
of the proximal or distal interphalangeal joint. Mild sprains (few fibers torn) may be managed by coaptation
or “strapping” the affected digit to its adjacent member. Healing may be hastened by suture placement. Mod-
erate and severe (partial/complete) tears are best managed by removal of any small avulsed fragments and
suture reconstruction followed by supportive coaptation. Joints with bilateral collateral ligament instability
are completely unstable and although they may occasionally be reconstructed they frequently end up with
amputation or arthrodesis as a salvage procedure. Amputation is at the joint or through the distal end of P1
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or of P2 respectively. The pad is saved. Attempts to protect a surgical repair of a P1-2 instability include a
“cutting back” of the nail and or nail amputation. Nail amputation as described by Richard Eaton-Wells is
particularly useful for instabilities involving the second or fifth digit to decrease the amount of stress that the
repair would be encounter.
INJURIES OF THE FLEXORS OF THE DIGITS

An injury, that creates a loss of the normal acute functional angle of the proximal interphalangeal joint (P1-
2) results in a so-called “flat toe”. This is caused by: (1) a trans-section of the superficial digital flexor ten-
don, (2) an avulsion of the SDF from the proximal palmar/plantar aspect of P2 or, (3) an avulsion fracture
of the proximal palmar/plantar aspect of P2. This injury results in a conformational rather than a function-
al defect. Working performance is not significantly impaired. Reconstruction is by suture capture of the ten-
don and reattachment via A-P trans-osseous tunnels located at the proximal end of P2, or by reattachment
of the osseous avulsion to P2 via similar trans-osseous tunnels.
Trans-section of the deep digital flexor (DDF) or an avulsion fracture of the insertion of the DDF from P3
results in an elevation of the nail from the ground. This results in a “kicked up toe” a change in the nor-
mal position of P3 to the pad. This is of greater clinical significance than a “flat toe”. Some of these indi-
viduals will develop a painful “corn” of the involved pad. Resolution is achieved by resection of the “corn”
and amputation through the distal end of P2 or at the junction of P2-3. The pad is saved in both instances.
You will see the odd patient that has acutely transected both the SDF & DDF secondarily to a glass cut in
the area of the more proximal webbing. These cases should be managed based on the “clinical” rather the
visual presentation.
INJURIES OF THE CARPUS

Horizontal tears in the superficial fascia over the apex of the accessory carpal bone occur in the sporting
breeds. It may be confused with and/or associated with strain injuries to the insertion of the humeral head
of the flexor carpi ulnaris tendon.
On a clinical level it is reminiscent of the tears of the superficial digital flexor as it courses over the tuber cal-
canei, in that both injuries are readily diagnosed on palpation, relatively non-painful, and respond readily to
suture repair.
ACUTE CARPAL INSTABILITY

Depending on the level of the instability and severity of the instability, repair techniques may include: 1) pri-
mary reconstruction of bone and ligaments, 2) autogenous reconstruction with tendon or fascia, 3) synthet-
ic suture, and 4) varying degrees of arthrodesis. Primary reconstruction of isolated antebrachiocarpal luxa-
tion/subluxation consists of 1) pin and fig-of-eight wire for styloid avulsions. 2) use bone plate fixation for
distal portion of ulna fractures 3) divergent K-wires or lag screw for palmar avulsions and 4) possible “cap-
ture” techniques for palmar tears. Failed (or anticipated failure of) reconstructions are addressed by a sec-
ondary or primary arthrodesis.
TARSOCRURAL INSTABILITY
These injuries have predominately involved the medial collateral ligaments and have been addressed via
transosseous bone tunnels, often in conjunction with soft tissue anchors to provide support for the healing
process. These have been supplemented with temporary utilization of Type I external fixators, with a grad-
uated return to activity.
MEDIAL TARSAL INSTABILITIES

These instabilities can generally be managed with plate fixation to obtain the appropriate partial arthrode-
sis. Some cases may be successfully coapted.
PROXIMAL PLANTAR INTERTARSAL & PLANTAR TARSOMETATARSAL

SUBLUXATIONS
Both are generally managed by pin and tension band wire fixation with partial or complete arthrodesis.
ANTERIOR TIBIALIS INJURY

As far as I know this has been an un-described condition seen in adult working German Shepherd dogs.
Owners may say that “they bunny hop, have difficulty getting up, don’t want to jump up or stand on the
hind limbs, or don’t want to search the overhead storage bin on the plane if they are airplane search dogs”.
On visual exam, no obvious gait abnormality is readily apparent, and no obvious limb deformity or stance
is readily apparent. However, a visually subtle (to the casual observer) but readily apparent thickening of the
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tendon of insertion of the anterior tibialis muscle is appreciated upon palpation. This thickening or “cord-
ing” is often present bilaterally, although one side is usually more severe than the other. The tendon does
not appear to be contracted with a secondary mechanical gait such as you might see in the Shepherd with
a gracilis or semitendinosis contracture. These patients usually present at a subacute/chronic stage. There is
sometimes a history of a previous pivotal event.
The m. tibialis cranialis originates on the lateral cranial border of the proximal tibia, medial to the sulcus
muscularis and passes over the craniomedial surface of the crus before becoming a thin flat tendon that pass-
es under the broad proximal extensor retinaculum. The tendon courses distally and obliquely across the tar-
sus to insert on the rudiment of MTI and the proximal base of MTII. The terminal portion of the mm. tib-
ialis cranialis and the threadlike tendon of the extensor hallucis longus are purported to be surrounded by
a synovial sheath between the proximal extensor retinaculum and the middle of the tarsus. This now patho-
logical tendon runs in its oblique path over the central tarsal bone and has a cylindrical rather than flat con-
formation.
These working dogs upon orthopedic exam are generally found to have a normal ROM of hips and stifles
and have usually have no L-S or neurological disease. The tarsocrural joint may appear to have a good
ROM but, upon extreme extension to the end point of ROM, they are exquisitely painful. Dorsiflexion is
normal and, unlike man, there seems to be no loss of functional dorsiflexion.
Standard lab work ups are within normal limits, as are joint taps. Radiology is rather unsurprising. CT,
MR and ultrasound have unfortunately not been utilized to date. One patient had an open biopsy. The
tendon was thickened, cylindrical, swollen and appeared somewhat gelatinous.
Chronic fibrosis and inflammation was present much as you might expect to see at sites of partial tendon
rupture/tear or as a response to localized/repetitive trauma. Normal architecture is disrupted due to fi-
broplasia, angioplasia, and mild fibrosis. To date, treatment has been limited to medical management, re-
stricted activity, physical therapy and rest. Recoveries have been slow, but patients have gone back to full
activity.
Injuries of the Achilles’ Tendon (see revisions lecture stream) “Failed tendon repair”
Chronic pain of chronic strain (see revisions lecture stream) “Failed tendon repair”
SOME EXAMPLES OF SUCCESS

Igor von Lowenfels, SchH III won the Schutzhund nationals in California and then the world Schutzhund
in Germany after a medial tarsal instability (centro-distal and MTII-III) managed via partial arthrodesis.
Greyhounds with elbow luxations that required open reduction have won grade A races.
After a carpal panarthrodesis, secondary to a deranged carpus and a failed primary reconstruction, “Kaze”
a Brittany Spaniel was #1 Brittany in 2004, #2 in 2007, #3 in 2008 before retiring at age 12 ½. Agility is a
timed event.
Hunting dogs after multiple failed ACL attempts have returned to productive work after revision.
Working Police dogs, (bomb, search, street, protection) with tarsocrural instability, or proximal plantar in-
tertarsal subluxation, or tarso-metatarsal instabilities have led productive professional lives after appropriate
reconstruction or arthrodesis.
REFERENCES
Evans HE, Christensen GC: Muscles: Miller’s Anatomy of the Dog (ed 2). Philadelphia, PA, Saunders, 1979, pp 392.
Eaton-Wells RD: personal communications-May 2010.
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323 • WVOC 2010, Bologna (Italy), 15th - 18th September R. Eaton-Wells
Injuries in working dogs in the southern hemisphere

Richard Eaton-Wells, BVSc., MACVSc.
Queensland Veterinary Specialists, Brisbane, Queensland Australia
What constitutes a working dog? And what is different in the Southern hemisphere? 2 questions that are
difficult to answer, as everyone has a different concept of working dogs.
This talk will cover injuries sheep and cattle dogs and the diverse range of cross breeds that are used to chase
and catch feral pigs. A form of weekend recreation for many people “out west”. All of these breeds are re-
quired to work long hours in extreme conditions.
One thing that is immediately obvious is their weight; they are just skin, muscle and bone. Heat stress is a
common in overweight dogs when temperatures are in excess of 35 degrees C.
Their injuries are often related to their work. Cattle dogs are jumping in and out of vehicles and yards, plus
getting kicked. While the working sheep dog is jumping in and out of yards, over fences and fallen trees plus
running over the backs of yarded sheep. Pig dogs are subjected to a multitude of lacerations, from barbed
wire fences as well as pig tusks.
BICEPS ORIGIN INJURIES

Avulsion of the origin of the biceps results in a chronic lameness in working or racing dogs. There is a sub-
tle loss of co-ordination in the elbow action when the dog is walked, this may be associated with some “scuff-
ing” of the nails or abduction of the limb during the anterior phase of the stride. On palpation there is loss
of tension in the tendon of insertion and the dog resents hyper-extension of the elbow, especially if the shoul-
der is flexed. There may or may not be pain on palpation of the bicipital tendon on the medial aspect of the
shoulder.
Diagnosis is by physical examination. Partial tears can be confirmed with MRI.
TREATMENT
The treatment of choice is re-attachment of the biceps origin. In young dogs that have suffered an avulsion
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fracture of the supra glenoid tubercle this can be re-attached with a pin and tension band. Those dogs which
are suffering from a chronic origin rupture can be treated by re-attaching the tendon of origin to the proxi-
mal humerus using a screw and spiked washer. In long standing cases this may be several centimetres down
the humerus.
In acute cases the limb must be supported in flexion, in more chronic cases where the tendon has shortened
and thickened this may not be necessary. However, I feel that the repair should always be supported for the
first 10-14 days.
BICEPS INSERTION AVULSIONS

Although a quite devastating muscle injury there are usually minimal clinical signs of dysfunction apart from
the classic “dis-associated” gait. In an acute injury this is best observed when the dog is walked on a lead.
There is an exaggerated anterior phase of the stride with either scuffing the fore limb nails or abduction of
the limb, during this anterior phase. When stationary the dog has a pathognomonic elbow hyper extension.
Partial tears may be more difficult to palpate and diagnose, but are readily visualised on MRI examination.
Surgical intervention is necessary to return these dogs to full function. Failure to re-attach the insertion to
either the radius or the ulna results in loss of function and working ability.
If an avulsion off the bone has occurred this can be re-attached using a screw and spiked washer, If, how-
ever as more commonly occurs, the tendon of insertion has failed leaving some tendon attached, repair us-
ing a tendon suture of choice can be performed. All repairs should be supported immediately post surgery.
Failure to do this will result in a high proportion of failures in the first 24-48 hrs.
CARPAL HYPEREXTENSION INJURIES

Where possible the radio-carpal joint should be maintained. The high impact nature of the working dog’s
environment means that pan carpal arthrodesis, PCA, has a higher complication rate then partial carpal
arthrodesis. With this in mind, injuries to the collateral ligaments should be repaired primarily with screws
and figure 8 wires, rather than a PCA. Careful examination of the carpus is also necessary and appropriate
stress views taken to confirm the level of injury.
Intercarpal and carpo-metacarpal instabilities can be treated by debriding the articular cartilage with either
a suitable curette or a high speed burr. Care should be taken if a burr is used not to deform the joint sur-
faces too much and hence slow fusion of the intercarpal and carpo-metacarpal joints. Cancellous bone, har-
vested from the proximal humerus, and packed into the various joint levels will aid in bony union. The
joints are then stabilised with IM K wires inserted up the metacarpal medullary canals, through the num-
bered carpal bones and seated into the radial and ulna carpal bones. I usually find that numbers 3&4 are
sufficient but all 4 can be pinned if necessary.
To prevent the pin passing through the post cortex the anterior cortex is “slotted” with a high speed burr,
and the blunt end of the pin inserted initially to reduce the risk of damage to the posterior cortex. This pin
is then removed and reinserted sharp end first utilising an appropriate oscillating pin driver or Jacobs chuck.
Soft tissues and skin are closed routinely and the area protected with a padded dressing with some form of
solid protection during anaesthetic recovery.
Once the post op swelling has subsided the distal limb may be cast. This cast should be applied with the dig-
its in a normal walking position.
MULTIPLE METACARPAL FRACTURES

If these are not open and not too badly displaced external support is sufficient. If grossly displaced some
form of open reduction and internal fixation is necessary. I prefer plating.
If the wound is grossly contaminated, i.e. the foot has been run over or caught in a grass cutter the wounds
should be treated by primary debridement and daily dressing changes. Support can be achieved with an ex-
ternal walking bar. Two transverse pins are placed in the distal radius a walking boot fashioned and holes
drilled in the nails of the 3rd phalanx and wired to the external frame. This allows access for daily treatment
of the wound while providing support for the fractures and soft tissues. Care should be taken not to put too
much tension on the digits as the nails will slough.
LONG BONE FRACTURES

The distal long bones of dogs that jump out of moving vehicles are subjected to considerable rotational
forces. They are a relatively common injury in the working dog and in one western practice spiral tibial frac-
tures were called “Tieri tibias” due to the high incidence from one particular pastoral area with dogs jump-
ing from the back of vehicles.

These fractures can be treated by open reduction and internal fixation with a plate or closed reduction and
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the application of an external fixator. Both have advantages and disadvantages.
STRAIGHT PATELLA LIGAMENT INJURIES (SPL)

These are usually caused by direct trauma, either the dog has hit a stationary object at speed or has jumped
out of a vehicle and slid along the road. In the formed the straight patella ligament can be ruptured, in the
latter the classic “Street Pizza” or mechanical debridement causes the ligament to be injured.
The SPL deficient dog is best handled by surgical debridement of the area, drilling 2 holes in the patella and
placing 2 suitable sized wire sutures through these holes and anchoring them to the proximal tibia. It is bet-
ter to place 2 as 1 invariably breaks prior to re-establishment of the SPL.
STREET PIZZAS
Injuries as a result of falling off a vehicle, while tied on, can vary from mild skin abrasions to gross loss of
skin, muscle and bone.
Minor injuries can be handled with a conservative approach, more severe injuries can be handled either ag-
gressively or conservatively. My preference is for removal of all definitely dead tissue under heavy sedation
/ anaesthesia initially, then twice daily dressing changes while traumatised tissues either re-establish a blood
supply or die from ischaemia. Once the extent of the dead tissue is readily visible it is easily removed and a
primary treatment modality developed. This may or may not include skin grafting, however, the extra down
time and cost associated with skin grafting make it a less used treatment option in working dogs.
STICK AND OTHER FOREIGN BODIES

Penetrating wounds associated with sticks and other rigid material are relatively common sequelae for dogs
working in uncleared paddocks, with fallen trees and fences in dis-repair. Occasionally they are fatal but it
is remarkable how little internal damage is caused.
325 • WVOC 2010, Bologna (Italy), 15th - 18th September L. Ferasin
Exercise induced collapse (EIC) in labrador retrievers

Luca Ferasin DVM PhD CertVC DipECVIM-CA (Cardiology) MRCVS
Specialist Veterinary Cardiology Consultancy Ltd, Newbury, UK
(www.cardiospecialist.co.uk; luca@cardiospecialist.co.uk)
Exercise induced collapse (EIC) is a term that describes a form of exercise intolerance seen in young
Labrador retrievers after strenuous exercise. Although the first report of EIC dates back to 1993, the first
citation in the veterinary literature is very recent (2008).1 According to the authors, affected dogs sometimes
develop an abnormal gait or collapse when subjected to strenuous exercise, but the underlying cause has not
been well established. Affected dogs usually tolerate mild-moderate exercise but occasionally become ataxic
and collapse after 5 to 15 minutes of intense exercise, especially when accompanied by excessive excitement
or stress.2
The pattern of the clinical signs (described by the
Table 1 - Owner description of clinical signs1
aforementioned authors as “collapse”) is poorly
characterised, as demonstrated in a survey car- Description % of dogs
ried out by 225 owners of dogs with a history of
Rear limbs floppy/dragged 78
EIC (Table 1)1.
The physical activity that appears to trigger the Wobbly, uncoordinated 60
event is also poorly defined and includes retriev-
Falling to side/ balance problem ≥1 episode 68
ing toys (46%), retrieval training on land (43%),
upland hunting (25%), excitement during play Rear limbs only affected 82
with other dogs (22%), retrieval training in wa-
All four limbs affected ≥1 episode 18
ter (12%) and waterfowl hunting (2%).1
Some factors seem to contribute to the onset Forelimb rigidity ≥1 episode 18
and development of clinical signs, including ex-
Dazed/disoriented ≥1 episode 23
citement (83%), heat and humidity (31%), use
of live birds in training or hunting (25%), stress Loud/excessive panting ≥1 episode
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19
during training (13%) and competition with oth-
Generalised seizure during 1 episode 3
er dogs (9%).1
In the examination of the pedigree of 326 dogs,
169 individuals appeared to be affected, with nine of these appearing to have an affected parent. Males and
females were equally represented, excluding an X-linked mode of inheritance. Six of the nine affected par-
ents had full phenotypic information. One affected parent mated with another affected parent producing two
affected and two unaffected offspring. In three families, an affected dog produced multiple affected second
and third generation offspring. The pedigree analysis was most consistent with an autosomal recessive mode
of inheritance, although a dominant disorder with partial penetrance or a polygenic disorder could not be
excluded.1
Median age of dogs when they presented the first episode of collapse was 12 months. 10% of dogs had ex-
perienced more than 25 episodes of collapse and seven had died during a collapsing episode. Three of these
individuals had generalised seizure just before death.1 However, the authors do not report whether or not
these dogs underwent a cardio-vascular investigation to rule out, for example, episodic arrhythmias or a
right-to-left shunting persistent ductus arteriosus (reversed PDA).
Although the authors failed to report in their first paper that most EIC dogs will experience spontaneous
resolution of the clinical signs and will not show any further collapsing episodes during adult life, in a most
recent publication they state: “Five years have passed since the 14 dogs with EIC were evaluated. One dog
was euthanized immediately following evaluation.
Six dogs were adopted to pet homes where they no longer participate in the trigger activities associated with
the collapse, and five dogs have not collapsed since relocation. Three dogs remained with their owners and
episodes of collapse reportedly occur if they are allowed to engage in trigger activities. One dog has not had
activity limited, but episodes of collapse have become very infrequent. Three dogs were lost on follow-up.
No dogs have developed progressive systemic or neurological disorders and all are considered by their own-
ers to be healthy aside from the EIC”.2
The mechanism of EIC has not been determined yet, although “a mutation in dynamin 1 gene (DNM1)
was recently suggested as the causal mutation of EIC in Labrador retrievers. A genetic test for the mutation
is now available through the Veterinary Diagnostic Laboratory at the University of Minnesota”.2 The
DNM1 mutation has been described in an elegant study published in 2008 by the same research group.3
L. Ferasin WVOC 2010, Bologna (Italy), 15th - 18th September • 326
My major criticism about the above discoveries is about the arbitrary stratification operated by the authors
to achieve a significant association. Dogs were divided into six groups (presumed EIC, recurrent collapse,
single collapse, atypical collapse, alternative collapse, and no collapse). Further arbitrary selection is ob-
served in the alternative collapse group where “other potential causes of repeated collapse” were listed, such
as cardiac arrhythmia, laryngeal paralysis, lactic acidaemia, and metabolic myopathy. Moreover, 9% of dogs
without a history of collapse resulted homozygous for the mutation, which was explained by the owners as
insufficient exercise or excitement to trigger collapse.
An important limitation in these types of study originates from the lack of objective parameters to assess the
physical condition of these dogs. It is well known that exercise causes significant acute alterations in rectal
temperature (BT), pulse rate (HR), blood lactate (BL) and other physiological parameters in healthy dogs.4-7
However, until recently, there were no available data originating from standardised studies where test–retest
reliability has been assessed.
In our recent publication, Dr Marcora and I assessed the reproducibility of a non-invasive exercise test in
healthy Labrador retrievers and evaluated BL, HR and BT responses that occur during and after incre-
mental exercise in this breed.8 In this study, we demonstrated that differences between tests may exist even
under the strictest controlled conditions, such as environmental temperature, humidity, intensity of exercise,
diet, time of the day, etc. Therefore, the standardised field tests conducted by other groups present several
limitations, with little scientific accuracy and clinical utility.
Another important finding in our study was a prolonged recumbency and temporary inability to regain
the quadrupedal posture in most dogs during the recovery period. This resembled the typical features of
exercise-induced collapse described by Taylor et al. We interpreted these signs as an extreme physiologi-
cal condition (exertional fatigue or exhaustion). This could be attributed to a variety of reasons. Exercise-
induced changes in muscle action potential, extracellular and intracellular ions, and intracellular metabo-
lites reduce the ability to produce force (peripheral fatigue).
Changes at spinal and supraspinal level due to alterations in brain metabolism and neurotransmitters, or
inhibitory afferent feedback from type III and IV muscle afferents can also reduce the ability of the CNS
to activate the locomotor muscles (central fatigue). It is also possible that, in these dogs, the increased pul-
monary blood flow and capillary pressure during intense exercise induced the activation of pulmonary C
fibers (or J receptors). This activation can evoke a somatomotor reflex (the J reflex) that provides potent
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inhibition of limb muscles in animals but not humans. In contrast with what has been observed in peo-
ple, incremental exercise did not appear to induce abrupt increases in BL concentration in Labrador re-
trievers, although significant variation was observed between test stages. Moreover, in humans, BL con-
centrations would be expected to decrease during recovery after intense exercise. However, in our study,
BL values remained stable after a 20-min recovery period in all dogs. Blood lactate concentration during
exercise is the result of lactate production by the contracting muscle, lactate transport from the muscle to
the vascular bed, as well as intracellular and hepatic clearance. Assuming that lactate clearance would con-
tinue during recovery and that lactate production in the muscle would cease after termination of the ex-
ercise, it can be speculated that the modest increase of lactate values observed in Labradors depends on
a slow transport of this compound from muscle to blood. This could be caused by a low muscular den-
sity of proteins involved in lactate transport (i.e., monocarboxylate transporter) and/or intracellular lac-
tate clearance.
According to the EIC test patent owners, breeders need to be selective in their breeding, avoiding the pro-
duction of dogs that actually have EIC. They advise that all breeding dogs should be tested, and if carrier
dogs are bred they should only be bred to dogs that are genetically clear of EIC so that affected puppies will
not be produced. They also advocate avoidance of intensive exercise and, in some cases, the use of pheno-
barbital to decrease the dog’s level of excitement or anxiety.
I kindly (but strongly) disagree with the above approach. I have now managed to successfully treat dozens
of Labrador (and non Labrador) dogs with a history of EIC. First of all, it is necessary to rule out an un-
derlying cardiac abnormality. Afterwards, the exercise capacity should be assessed on a validated treadmill
test to obtain baseline values of BL, HR and BT.
A field test would offer limited value due to its poor repeatability. Furthermore, a well-designed exercise pre-
scription, primarily based on interval training, is normally sufficient to improve the physical ability of the
dog to undergo intense training. The exercise prescription can be designed based on the results of the ex-
ercise test. It is mandatory to maintain a good communication with the dog’s owners and make sure that
the prescribed exercise is recorded on a diary. Finally, owners’ expectations need to be carefully evaluated.
Sometimes, owners force their dogs to undergo exhausting exercise even several times a day. Under these
circumstances, young excitable dogs are at higher risk of “collapse” because they tend to exercise above their
physical capacity.
327 • WVOC 2010, Bologna (Italy), 15th - 18th September L. Ferasin
REFERENCES
1. Taylor SM, Shmon CL, Shelton GD, et al. Exercise-induced collapse of Labrador retrievers: survey results and pre-
liminary investigation of heritability. J Am Anim Hosp Assoc 2008;44:295-301.
2. Taylor SM, Shmon CL, Adams VJ, et al. Evaluations of labrador retrievers with exercise-induced collapse, includ-
ing response to a standardized strenuous exercise protocol. J Am Anim Hosp Assoc 2009;45:3-13.
3. Patterson EE, Minor KM, Tchernatynskaia AV, et al. A canine DNM1 mutation is highly associated with the syn-
drome of exercise-induced collapse. Nat Genet 2008;40:1235-1239.
4. Hinchcliff KW, Olson J, Crusberg C, et al. Serum biochemical changes in dogs competing in a long-distance sled
race. J Am Vet Med Assoc 1993;202:401-405.
5. Ilkiw JE, Davis PE, Church DB. Hematologic, biochemical, blood-gas, and acid-base values in greyhounds before
and after exercise. Am J Vet Res 1989;50:583-586.
6. Matwichuk CL, Taylor S, Shmon CL, et al. Changes in rectal temperature and hematologic, biochemical, blood
gas, and acid-base values in healthy Labrador Retrievers before and after strenuous exercise. Am J Vet Res
1999;60:88-92.
7. Steiss J, Ahmad HA, Cooper P, et al. Physiologic responses in healthy Labrador Retrievers during field trial train-
ing and competition. J Vet Intern Med 2004;18:147-151.
8. Ferasin L, Marcora S. Reliability of an incremental exercise test to evaluate acute blood lactate, heart rate and body
temperature responses in Labrador retrievers. J Comp Physiol B 2009;179:839-845.
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M.H. Herrtage WVOC 2010, Bologna (Italy), 15th - 18th September • 328
Exercise associated collapse - metabolic causes

Michael E. Herrtage MA BVSc DVSc DVR DVD DSAM DECVIM DECVDI
Department of Veterinary Medicine, University of Cambridge
Episodic weakness and collapse is a prominent clinical sign in a large variety of diseases. It can be defined as
a waxing and waning weakness interspersed with periods of apparent normality. The degree of weakness may
vary from mild hindlimb ataxia to total collapse or syncope. Syncope or fainting is defined as a sudden, brief
loss of consciousness. It is caused by a temporary lapse in cerebral function, usually as a result of reduced
cerebral blood flow, inadequate oxygen delivery or inadequate glucose availability. Syncopal episodes are
most frequently seen with cardiovascular, respiratory, metabolic or endocrine abnormalities. The same patho-
physiological mechanisms may cause episodic hindlimb weakness or ataxia, but other conditions, for exam-
ple, neuromuscular disorders, can also produce these clinical signs.
The differential diagnosis of episodic weakness presents a major diagnostic challenge to the clinician. Most
of the animals appear normal when they are initially presented to the veterinarian, thus meticulous atten-
tion to the information contained in the signalment, history and physical examination is important. Access
to routine and sometimes specialised diagnostic aids is usually necessary to confirm a diagnosis. The meta-
bolic and endocrine causes of collapse are listed in Table 1.
Table 1
Metabolic disorders Hypercalcaemia Endocrine disorders

Hepatic encephalopathy Hypocalcaemia Insulinoma
Uremic encephalopathy Hypermagnaesemia Hyperadrenocorticism - myotonia
Hyperglycaemia Hypomagnaesemia Hypoadrenocorticism
Hypoglycaemia Acidosis Hypoparathyroidism

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Hyponatraemia Hyperthermia (heatstroke) Hypothyroidism

Hyperkalaemia Hypoxia Phaeochromocytoma
Hypokalaemia Shock Diabetic ketoacidosis
DIAGNOSTIC APPROACH
Signalment. Certain breeds are associated with diseases which cause episodic weakness. However, some
breeds are associated with more than one condition and the association is by no means exclusive. Age and
sex may limit the diagnostic possibilities or increase the index of suspicion in certain conditions.
History. An accurate and detailed history is often critical to the eventual diagnostic success of a case. Ques-
tions concerning the episodes of weakness are of paramount importance, since the veterinarian may never
actually witness an episode. Many observant owners can relate sufficient information to allow the clinician
to reduce the number of possible differential diagnoses. A detailed description of the episode should be
gleaned from the information provided from the answers to the following questions:
• How many episodes has the animal suffered?
• Do the episodes follow a similar pattern?
• What time of the day do the episodes occur?
• Are there any associations with the onset of an episode?
• Does the animal lose consciousness?
• What does the animal do during the actual episode?
• Does the owner notice any change in the colour of the mucous membrane or in heart rate?
• How long does an episode last?
• Is the animal normal after the episode?
From this information the clinician should be able to piece together a clear impression of the episode. Al-
though most animals appear normal between episodes, it is still important to ask about the general health
of the patient.
329 • WVOC 2010, Bologna (Italy), 15th - 18th September M.H. Herrtage
Physical examination. A complete physical examination including a full neurological assessment should be
carried out in every case even if the clinician feels there are limited diagnostic possibilities. Animals with pain
or discomfort due to orthopaedic or spinal conditions may be reluctant to move or incapable of walking nor-
mally and the owner may incorrectly assess this as weakness. Most of these animals will still be experienc-
ing pain when they are presented for examination.
Clinical experience, history and physical examination may allow the clinician to differentiate or characterise
the disorder so that only confirmation of the diagnosis is required. However, many cases of episodic weak-
ness require careful and logical investigation to confirm the cause. This is particularly true when no abnor-
malities are found on physical examination. Further investigation will require some or all of the following
examinations:
Laboratory tests. Routine haematology and a biochemical profile including electrolytes (sodium, potassi-
um, calcium and magnesium), blood glucose, urea, liver enzymes (ALT, AP) and muscle enzymes (CK,
AST) should be considered the minimum data base. In some cases this minimum data base will provide the
diagnosis but in other selected cases further laboratory investigations are indicated:
• Liver function tests.
• Adrenocortical function tests.
• Other hormone estimations –
- If hypothyroidism is suspected, a basal thyroxine (T4) concentration should be measured together
with a canine TSH concentration.
- Insulin concentrations may be useful in cases of functional pancreatic islet cell tumour (insulinoma),
but can only be interpreted if simultaneous measurements of blood glucose are performed.
- PTH assays can also be helpful in cases with abnormal plasma calcium concentrations.
• Blood gas and acid-base estimations - Blood gas analysis may be useful in obstructive pulmonary disease,
upper respiratory tract obstruction, right to left cardiac shunts, diabetic ketoacidosis and mitochondrial
myopathies.
Diagnostic imaging. Thoracic radiographs are useful for ruling out significant cardiopulmonary disease.
Particular attention should be paid to the shape and size of the cardiac silhouette and the clarity and radio-
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logical pattern of the lung fields. Radiographs of the abdomen, spine, skull and limbs may be indicated from
the findings of the physical examination. Contrast studies may be required in selected cases.
Ultrasonography of the abdomen and particularly of the endocrine glands are useful for providing addi-
tional data in specific cases. CT or MRI scans may also be indicated.
Electrocardiography (ECG). An ECG should be performed in all cases in which a cardiac cause is sus-
pected. The rate and rhythm should be carefully assessed since conduction abnormalities and arrhythmias
are a major cause of episodic weakness and syncope. When the arrhythmias are continuous, as in atrial fib-
rillation or third degree atrioventricular block, the diagnosis is relatively straightforward and may be made
from a single recording. However, certain types of arrhythmia, such as premature contractions, paroxysmal
tachycardias or sinoatrial block, may be intermittent.
Gundog injuries
John E. F. Houlton, MA, VetMB, DVR, DSAO, MRCVS, DECVS
Claims Consultant, The Veterinary Defence Society, Empshill, Robins Lane, Lolworth, Cambridge
Gun dogs perform a number of quite distinct types of work and for the sake of this presentation, these have
been subdivided into beating, picking up, peg dogs and the work performed by Pointers and Setters. Rough
shooting and wild fowling have been excluded, as have the numerically more minor activities such as grouse
counting and falconry.
As veterinarians, we are not necessarily the most informed about the type and incidence of gun dog injuries
since many are treated by knowledgeable and experienced owners/trainers. The study was based on a ques-
tionnaire completed by the owners of dogs at the end of the 2005/2006 and 2006/2007 seasons respective-
ly. Owners were identified through personal contacts, those of colleagues with working gundogs, through
the National Organisation of Beaters & Pickers Up (NOBS) (2), veterinary surgeons with clients who owned
working dogs and through contacts provided by the Kennel Club List of Field Trial Judges. Inclusion crite-
ria were dogs that had worked either one or both the shooting seasons of the years 2005/06 and 2006/07 in
England, Scotland or Wales. Where data was incomplete, all the dogs of that owner were excluded for the
year concerned.
Table 1 - Breed distribution of the number of dogs recorded

Breed No. of dogs worked 2005/2006 No. of dogs worked 2006/2007
Labrador Retriever 316 300
Springer Spaniel 124 133

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Cocker Spaniel 87 87
Golden Retriever 38 30
Flat Coat Retriever 24 42
Eng. Pointer/Setters 45 44
Others 26 16
Total 660 652
Table 2 - Amount of work performed /dog/season

Days worked/season No. of dogs 2005/2006 No. of dogs 2006/2007
0 – 10 days 80 55
11 – 25 days 202 181
26 – 40 days 146 154
41 – 60 days 134 156
61+ days 98 106
Total 660 652
The geographic area where the majority of the work was performed was recorded (Table 3). Those dogs
that worked in more than three of these areas were excluded from any subsequent statistical analysis in-
volving geographic location.
Table 3 - Geographic area worked in England, Wales & Scotland

Area No. of dogs 2005/2006 No. of dogs 2006/2007
More than 3 areas 56 38
East Anglia/Lincs. 142 139
Midlands 89 84
South East England 77 69
South West England 66 68
North England 87 81
Wales 64 80
Scotland 79 93
Total 660 652
The same dog incurring two injuries, but on different occasions during the same season, was recorded in 26
(2005/06) and 16 (2006/07) dogs. In 2005/06, two dogs incurred three injuries on separate occasions. For
subsequent statistical purposes these were recorded as separate cases.
While most dogs only performed one type of work, there were many that undertook a variety. When this
was so, they were placed in the category that best suited the majority of their work (Table 4).
Table 4 - Type of work performed
Type of work No. of dogs 2005/2006 No. of dogs 2006/2007
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Beating 107 102
Picking up 501 494
Peg Dog 36 28
Pointers/Setters 46 44
Total 690 668
The incidence of injuries and whether veterinary attention was sought was noted (Table 5). There were
many minor injuries that owners did not deem worthy of recording and this is a limitation of the data. How-
ever, of those recorded, 47% required veterinary attention.
Table 5 - Number of injuries/season including percentage where veterinary treatment was sought
No. No. of % age of dogs No. of injuries % of injuries
Season
of dogs injuries injured/season treated by V/S treated by V/S
2005/2006 690 192 28% 89 46%
2006/2007 668 145 22% 69 48%
Total 1358 337 25% 158 47%
Injuries were recorded under 14 categories but were then placed into one of four groups for ease of data
handling (Tables 6 & 7). These groups were:
Group 1: soft tissue injuries of the pads, nails and webbing of the feet
Group 2: wounds (lacerations/punctures) & tail injuries
Group 3: articular injuries (inc. fractures) & muscle injuries
Group 4: ocular injuries and miscellaneous conditions
Table 6 - Type of injuries in 2005/2006

Group 1 Group 2 Group 3 Group 4 Not injured Total no. of dogs
Labrador Retriever 28 38 8 11 240 325
Springer Spaniel 23 21 7 6 84 141
Cocker Spaniel 2 13 0 5 67 87
Golden Retriever 3 3 1 1 31 39
Flat Coat Retriever 5 1 0 0 20 26
Eng. Pointer/Setters 1 3 1 1 40 46
Others 4 5 1 0 16 26
Total 66 84 18 24 498 690
Table 7 - Type of injuries in 2006/2007

Group 1 Group 2 Group 3 Group 4 Not injured Total no. of dogs
Labrador Retriever 17 33 16 4 236 306
Springer Spaniel 6 21 2 5 105 139
Cocker Spaniel 5 9 0 1 74 89
Golden Retriever 3 2 1 1 23 30
Flat Coat Retriever 5 6 0 1 31 43
Eng. Pointer/Setters 1 0 1 0 42 44
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Others 1 3 1 0 12 17
Total 38 74 21 12 523 668
In Group 1, injuries of the pads and nails were typically lacerations of the former and splits of the latter.
Blackthorn injuries comprised the other significant group of foot injuries.
Group 2 injuries were mainly lacerations due to barbed wire. They generally involved the groin, sheath and
ventral abdomen, although facial wounds and wounds to the ears also featured. Puncture wounds involved
mainly stake penetrations of areas such as the groin, chest and pharynx.
In addition, there were 26 recorded tail injuries in 2005/2006 and 15 in 2006/2007. The majority were re-
current injuries to the tip of the tail while 3 fractures and 4 cases of water tail were noted (Table 8). There
were ten tail injuries in 268 docked Springer Spaniels and three injuries, including one fracture, in twelve
undocked dogs of that breed. The corresponding figures for Cocker Spaniels were five injuries in 166
docked dogs and three injuries in ten undocked dogs. Both breeds had a highly significant association be-
tween tail injuries and undocked dogs (p=0.008 for Springer Spaniels and p=0.004 for Cocker Spaniels).
Group 3 injuries in 2005/2006 included 2 elbow fractures due to incomplete ossification of the humeral
condyle (IOHC), 4 cruciate ruptures, 4 muscle strains and 3 sprains (carpus, distal interphalangeal joint
(DIPJ) of the thoracic limb and hock). In 2006/2007, there were 3 fractures, (cervical spine, olecranon, and
a toe), one elbow lameness due to IOHC, 3 cruciate ruptures, 5 muscle strains all thought to involve the
shoulder, 2 luxations (hip and DIPJ of the pelvic limb), 4 sprains, (carpus, stifle and DIPJ [2]) and 3 shoul-
der injuries (ruptured biceps tendon [2] and torn glenohumeral ligament).
In group 4, miscellaneous conditions included lameness due to elbow dysplasia (4), snake bites (1), poison-
ing (1), internal haemorrhage due to being run over by a Land Rover (1), neck pain (1), intermittent col-
lapse (1) and death (2). One dog collapsed and died while in the beating line and a Cocker Spaniel picking
up fell over the edge of a cliff and had to be destroyed.
Table 8 - Combined tail injuries for 2005/06 & 2006/07

Total Docked Docked status of all dogs
Breed Pathology
injuries status within the breed
11 tail tips
Labrador Retriever 15 n/a 3 water tails n/a
1 fracture
10 docked 12 tail tips 268 docked
Springer Spaniel 13
3 undocked 1 fracture 12 undocked
5 docked 166 docked
Cocker Spaniel 8 8 tail tips
3 undocked 10 undocked
1 tail tip
Golden Retriever 2 n/a n/a
1 fracture
Flat Coat Retriever 1 n/a 1 water tail n/a
English Pointer 1 n/a 1 tail tip n/a
German W.H. Pointer 1 1 undocked 1 tail tip 1 undocked
There was no correlation between the incidence of injury and breed in either year, nor between the number
of days worked. The region in which the dog worked was not significant in 2005/2006 but significance was
noted (p<0.05) in 2006/2007. The most significant correlation was between the type of work performed and
the incidence of injury. Dogs in the beating line were most likely to be injured while Pointers and Setters
had the lowest rate of injury. Peg dogs were more likely to be injured than Pointers and Setters, but less like-
ly than those picking up.
From a diagnostic viewpoint, there is little challenge with pelvic limb injuries. A notable absent injury was
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total stifle disruption. In the thoracic limb, injuries of the proximal limb prove more of a challenge and the
aetiology of some of the so called muscular injuries of the shoulder is speculative since veterinary treatment
was often not sought.
REFERENCES
Houlton, J.E.F., A survey of gundog lameness and injuries in Great Britain in the shooting seasons 2005/2006 and
2006/2007. Vet Comp Orthop Traumatol, 2008. 21(3): p. 231-7.
K.A. Johnson WVOC 2010, Bologna (Italy), 15th - 18th September • 334
Carpal injuries -
Can we extrapolate greyhound information?
Kenneth A. Johnson, MVSc, PhD, FACVSc, Dipl. ECVS and ACVS
The University of Sydney, Sydney, Australia
The accurate diagnosis of injuries of the canine carpus can be difficult due to the complexity of this joint
and its associated structures. This problem is compounded by our poor understanding of the anatomy and
biomechanics of this joint, as well as the subtle nature of many significant carpal injuries. Compared to oth-
er joints such the hip, stifle and elbow, the carpus is an ‘unfashionable’ joint, judging by the amount of at-
tention it receives in the literature. Perhaps this is because arthrodesis is a highly successful salvage proce-
dure for managing debilitating carpal injuries, and so we have not been challenged to acquire a more thor-
oughly detailed knowledge of the carpus.
If we compare carpal injuries of the greyhound with those in other dog breeds, we can make a few gener-
alizations about similarities and differences. In racing greyhounds, the most commonly recognized and best
documented serious injury of the carpus is fracture of the accessory carpal bone. By contrast, carpal hy-
perextension injury with associated disruption of the palmar fibrocartilage would be one of the most com-
mon carpal injuries in other non racing breeds of dogs. However, in greyhounds hyperextension injury of
the palmar fibrocartilage is very uncommon. Quite paradoxically, greyhounds at full gallop routinely hy-
perextend the carpus to almost 90 degrees so that the metacarpus is completely palmar-grade. How such
an extreme degree of joint flexibility can be accommodated without resulting in a carpal sprain injury has
never been elucidated. Indeed, this degree of carpal hyperextension cannot be reproduced in an anaes-
thetised greyhound, or greyhound cadaver. On the other hand, fractures of accessory carpal bone are not
so unusual in non-greyhound breed dogs, but they tend to occur in conjunction with other fractures, lux-
ations and sprains.
Approximately 80% of accessory carpal bones fractures in greyhounds occur in the right bone. This distri-
bution is probably due to the stress of racing on circular or elliptical tracks in an anti-clockwise direction.
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They are classified into five types. Type I involve the distal articular surface of the accessory carpal bone;
Type II are of the proximal articular margin; Type III are at the origin of the accessoro-metacarpal liga-
ments; Type IV are avulsion fractures at the tendon of insertion of the flexor carpi ulnaris muscle; Type V
are comminuted. Most are Type I, with avulsion of a bone fragment by the accessoro-ulnar ligament insert-
ing in this region. Large fracture fragments are reattached by 1.5 or 2.0 mm cortical lag screws. This stabi-
lizes the fracture, as well as restores ligament function and joint stability. It has been suggested that these in-
juries of the accessory carpal bone in racing greyhounds are a stress fracture, and similar to fractures of the
central tarsal bone. In other breeds, they are often due to a fall or some severe trauma. Falls and hyperex-
tension injuries to the carpus may result in disruption of the palmar carpal ligaments and fibrocartilage, es-
pecially of the middle carpal and carpometacarpal joints. Therefore it is critically important to gain a full ap-
preciation of the extent of carpal injury by physical examination, radiology, stressed radiology, CT and
MRI. Failure to detect concurrent injuries can have a huge impact on the prognosis. Isolated fractures of the
accessory carpal bone in non-greyhounds can certainly be managed by lag screw repair. However, the small
size of fragments, or the degree of comminution can make open reduction and internal fixation unrealistic.
In these cases, splinting of the carpus in flexion for 2-3 weeks, followed by progressive straightening, is of-
ten successful in achieving fracture healing although development of secondary osteoarthritis of the acces-
soro-ulnar carpal joint may adversely affect the outcome.
Fracture of the body of the radial carpal bone was originally recognized in greyhounds by Jon Dee. On ex-
amination of dogs with this fracture, there is reduced range of carpal flexion and pain. Radiographically, the
fracture is seen on the dorso-palmar view as a hairline oblique fracture, but the diagnosis may be delayed.
Initially the fracture line may be incomplete and difficult to diagnose until there has been resorption and
widening of the fracture gap or complete propagation of the fracture line. Although internal fixation with
lag screw fixation of this fracture in greyhounds had been proposed, there is very little information about
the long-term outcome for dogs returning to racing. Indeed it seems that fractures of this bone are possibly
more common in non greyhounds. Comminuted T-shaped fractures that apparently develop without obvi-
ous trauma, especially in Boxer, Irish setter and Spaniel breed dogs, may result from incomplete fusion of
the three ossification centres of this bone. Recently, repair of these fractures with headless, self compressing
screws has been reported (Perry et al, 2010). This report suggests that the outcome of such a treatment car-
ries a better prognosis than was previously believed.
335 • WVOC 2010, Bologna (Italy), 15th - 18th September K.A. Johnson
Although partial or pan carpal arthrodesis are effective surgical options for salvage of severe, chronic or de-
bilitating carpal injuries, these procedures have never been considered as being appropriate for racing grey-
hounds, unless they have been retired. It has been suggested that carpal hyperextension injury in some
breeds of dogs like the Shetland sheepdog, follows pre-existing degeneration of the ligamentus support of
the carpus due to inflammatory or immune-mediated joint disease. This scenario is not something that is
recognized in greyhounds.
Although carpal injuries in greyhounds are somewhat different to those in other breeds of dogs, our expe-
rience with greyhounds has unquestionably resulted in a better overall understanding of canine carpal in-
juries. However this is still much to more to learn.
REFERENCES
Perry K, Fitzpatrick N, Johnson J, Yeadon R. Headless self-compressing cannulated screw fixation for treatment of radial
carpal bone fracture or fissure in dogs. Vet Comp Orthop Traumatol 2010; 23:84-101.
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D. Morgan WVOC 2010, Bologna (Italy), 15th - 18th September • 336
Feeding for performance

David Morgan BSc, MA, VetMB, CertVR, MRCVS
Scientific Communications Manager, P&G Pet Care, Geneva
INTRODUCTION
The ideal dog for working and racing will combine its natural potential, as determined by genetics, along-
side its training regime and nutrition. Dogs have mainly two types of muscles: one for sprinting and one for
endurance. These muscles differ in their power, endurance, blood supply, as well as their preferential type
of nutrient that fuels them. Nutrition is central to providing energy for muscles.
SPRINTING MUSCLES
The ability of dogs to sprint is provided by fast-twitch type IIa muscles (oxidative-glycolytic cells). This het-
erogeneous group of cells have a good blood supply and they are very powerful and are described as fatigue
resistant. Greyhounds have almost 100% of type IIa cells in the muscles deltoideus, triceps brachii caput longum,
vastus lateralis, gluteus medius, biceps femoris and semitendinosus.1 Type IIa cell content in these Greyhound muscles
is significantly higher than in crossbreeds and Foxhounds.1 Type IIa energy mainly comes from an anaero-
bic pathway and the principal fuel source is carbohydrate; glycogen is broken down (glycogenolysis) to pro-
duce glucose which is then metabolised anaerobically via glycolysis.
However, up to 30% of type IIa muscle energy supply can come from aerobic metabolism. Both carbohy-
drates and fat can supply this energy and this looks to be an important energy pathway for sprinters.2 The
aerobic pathway is the citric acid cycle (Krebs Cycle).
ENDURANCE MUSCLES
The ability of dogs to have long distance endurance is provided by slow-twitch type I muscles. These mus-
cles have an increased blood supply, they are not as powerful as the sprinting type IIa muscles and are de-
scribed as non-fatiguing. Their energy comes from aerobic pathways and fat is the principal energy supply
via the citric acid cycle which is an efficient pathway, glucose can also be aerobically metabolised with a 45%
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energy efficiency. Greyhounds have only between 0 and 20% type I endurance muscles whereas other
breeds of dogs can have 20-100%.
NUTRITION NEEDED FOR SPRINTING AND ENDURANCE DOGS

In humans, high carbohydrate diets increase stamina because they increase muscle glycogen.3 However, in
dogs a high fat/low carbohydrate diet increases stamina.4-6
Greyhounds: we typically think of Greyhounds requiring a high carbohydrate diet as they represent our
sprinter, covering 500 metres in 33 seconds reaching an average speed of 55 km/h. While their limb mus-
cles are predominantly fast-twitch type IIa, they have a high oxidative capacity2 and we now look at diets
that are moderately high in fat, protein and carbohydrate.
One publication showed that over 500 m, Greyhounds were 0.18 seconds slower (equivalent to 0.08 m/s or
2.6 m) when fed a diet with increased protein (37% of energy) and decreased carbohydrate (30% of energy)
compared to moderate protein (24% of energy) and higher carbohydrate (43% of energy), both diets had fat
providing 33% of energy.7 The increase in dietary protein or decrease in dietary carbohydrate or a change
in minor nutrient content between diets could have been responsible. It is also possible that changes in two
or more nutrients acted synergistically. In a similar study, Greyhounds ran faster when dietary protein in-
creased from 21 to 25% of energy and dietary fat increased from 25 to 32% of energy with a concurrent de-
crease in carbohydrate from 54 to 43% of energy.8 Taken together, the results of these studies suggest that
excess amounts of protein and inadequate amounts of fat and carbohydrates may be detrimental to per-
formance in sprinting dogs. One explanation for fat being beneficial at moderate levels is that in dogs, mus-
cle fat stores are larger than in humans, albumin binds more free fatty acids, the concentration of free fatty
acids in the blood is higher, delivery of free fatty acids to the tissue is enhanced, and the amount of energy
from fat oxidation at rest and during exercise is greater than in less aerobic species such as humans and
goats. Even though glucose oxidation is the principal source of energy at high rates of energy expenditure
(80% of energy at 85% of VO2 max), fat oxidation still provides some energy and may affect maximal en-
ergy expenditure. But the optimal proportions of protein, fat, and carbohydrates and the way they interact
with each other to affect performance needs further evaluation. Greyhounds appear to require a moderate-
ly high fat and moderate protein diet with a good supply of carbohydrates (Table 1).
337 • WVOC 2010, Bologna (Italy), 15th - 18th September D. Morgan
Table 1 - Nutrient recommendation for sporting dogs

Nutrient Greyhound Sled Dog
Fat* 30-50% 50-65%
Protein* 25% 30-35%
animal based protein
Carbohydrate* 45% 10-15%
Fatty acid profile Omega-6:3 ratio 5-10:1 Omega-6:3 ratio 5-10:1
Fibre yes yes
beet pulp
prebiotics e.g. FOS for gastrointestinal health for gastrointestinal health
Vitamin E 100 IU? additional, but avoid 200IU per day over what they are
alpha-tocopherol high (1000IU) receiving in their typical diet
Vitamin C lower dose than 1g ?
* Percentage of calories.
Beagles: ran for 32kms (140 minutes) when fed a high fat diet: fat 53-67% of energy, but became exhaust-
ed after only 24kms (100 minutes) when fed a moderate fat diet: fat 29% of energy.6
Sled Dogs: A high fat/high protein diet containing no carbohydrate resulted in better performance and less
evidence of exertional rhabdomyolysis.9 In dogs, as in other species, fat oxidation provides most of the ener-
gy, 70 to 90%, at low rates of energy expenditure: i.e. at 60 to 40% of maximal oxygen uptake; VO2 max.10
As exercise intensity increases, glucose oxidation increases, whereas fat oxidation remains constant so that
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glucose oxidation is the principal source of energy expenditure; i.e. 80% of energy at 85% VO2 max. How-
ever, in both sled dogs4,5 and Beagles,6 the ability to use fatty acids through aerobic pathways for energy is
more important for performance than the use of muscle glycogen through anaerobic pathways. Alaskan
Huskies fed a high fat diet (60% fat, 25% protein, 15% carbohydrate on an energy basis) had significantly
higher levels of circulating free fatty acids (FFA) during aerobic exercise after 1 month of feeding compared
to being fed a high carbohydrate diet (15% fat, 25% protein, 60% carbohydrate on an energy basis).11 One of
the major determinants of the amount of fat used for muscle contraction is the concentration of FFA in the
bloodstream. By increasing plasma FFA levels, the high fat diet facilitated FFA utilisation during exercise. This
has also been seen in physically trained Labrador Retrievers which had a 45% increase in maximal fat oxi-
dation when switched to being fed a high-fat (65% of energy) compared to low-fat (25% of energy) diet.12 And,
these dogs had nearly a 50% increase in VO2 max and a 40% increase in mitochondrial volume in biopsies
of the Triceps brachii when fed the high-fat diet. In essence, feeding a high-fat diet alone to physically trained
Labrador Retriever produces an animal that has an aerobic capacity and mitochondrial volume density in-
distinguishable from that of a sled dog. Such data again highlights the central role of nutrition in stamina and
performance since training is typically associated with only a 15-20% increase in VO2 max and maximal fat
oxidation. Racing sled dogs require a high protein diet as anaemia develops if dogs are fed a low protein di-
et during training. The haematocrit declined in dogs fed a diet containing 28% of energy as protein but not
when fed ≥32% of energy as protein.13 And, greater plasma volume and red blood cell mass were maintained
in racing sled dogs fed a very high protein (40% of energy) diet compared to diets with 16, 24 or 32% ener-
gy from protein.14 Additionally, all dogs consuming the 16% diet had a least one injury during the racing sea-
son that resulted in it being removed from training for a minimum of one week. Only 2 out of 8 dogs fed the
24% protein energy diet had serious injuries while none of the 32 and 40% diets had injuries.14 Taken alto-
gether, the data shows that sled dogs benefit from a high protein high fat diet (table 1).
Energy. The energy required for movement is proportional to distance travelled rather than speed; therefore a
500 m greyhound race should require far less energy than a 490 km sled dog race. Greyhounds have main-
tained their body weight during a racing season at ∼600W0.75 kJ/d (equivalent of 6700 kJ [1600kcal] per day for
a 25 kg dog) whereas racing sled dogs consumed 4200W0.75 kJ/d during a 3 day race, running at an average of
7 km/h (equivalent of 47000 kJ [11200kcal] per day for a 25 kg dog).15 To match such energy demands in a sled
dog then fat is the ideal nutrient as it is ∼2.5 as energy dense gram for gram as protein or carbohydrate.
D. Morgan WVOC 2010, Bologna (Italy), 15th - 18th September • 338
Water. In sled dogs, water turnover increases dramatically from 1 L/d in kennels to 5 L/d during a 490 km
race.15 Hydration status before racing will be important, sled dogs not well hydrated may ‘snow-dip’ (drop
their heads to scoop up snow as they race) which can disrupt the team. Rehydration following a race is al-
so important and small fluid volumes can be offered every 10-15 minutes.
Antioxidants; Vitamin E and Vitamin C

During aerobic exercise, oxidative stress and oxidative damage are elevated. Sled dogs have increased lipid
peroxidation and reduced serum antioxidant concentrations. Iditarod sled dogs, which race 1800 kms in 10-
12 days, can develop exertional rhabdomyolysis and they have been found to have low tissue vitamin E con-
centrations. Sled dogs with higher pre-race vitamin E levels were 1.9 times more likely to finish this 1800
kms race.16 The data did not suggest a direct benefit of antioxidant status and the likelihood of developing
exertional rhabdomyolysis. In racing Greyhounds serum vitamin E also declines and oxidative stress in-
crease after a short sprint race. However, supplementing with high vitamin E (1000 IU), but not moderate
(100 IU), actually appears to slow them down.17 In another study daily supplementation with a high dose
(1g) of vitamin C resulted in dogs running, on average, 0.2 seconds slower over a 500 m race, which equates
to a deficit of 3 m at the finish.18 It is possible that the effect on performance of high doses of vitamin C is
due to it acting as a prooxidant and increasing muscle damage or by interfering with force production with-
in muscle. It could also exacerbate the post-race metabolic acidosis observed in Greyhounds.
SUMMARY
The canine athlete requires specially formulated nutrition to bring out the very best in its ability. By using
knowledge and experience, and through a careful blend of nutrients, diets can be balanced to meet the ex-
ceptional nutritional needs of the canine athlete and allow them to perform at their true potential.
REFERENCES
1. Guy PS, Snow DH. (1981). Skeletal muscle fibre composition in the dog and its relationship to athletic ability. Res
Vet Sci 31, 244-248.
2. Hill RC. (1998). The nutritional requirements of exercising dogs. J Nutr 128, 2686S-2690S.
3. Hultman E, Harris RC & Spriet LL. (1994). Work and exercise. In: Modern Nutrition in Health and Disease, 1994.
SPORTS MEDICINE
Eds; Shils ME, Olson JA & Shike M. Lea & Febiger, Philadelphia, PA, 663-685.
4. Hammel EP, Kronfeld DS, et al. (1976). Metabolic responses to exhaustive exercise in racing sled dogs fed diets
containing, medium, lo or zero carbohydrate. Am J Clin Nutr 30, 409-418.
5. Reynolds AJ, Fuhrer L, et al. (1995). Effect of diet and training on muscle glycogen storage and utilisation in sled
dogs. J Appl Physiol 79, 1601-1607.
6. Downey RL, Kronfeld DS, et al. (1980). Diet of beagles affects stamina. JAAHA 16, 273-277.
7. Hill RC, Lewis DD, et al. (2001). Effect of increased dietary protein and decreased dietary carbohydrate on per-
formance and body composition in racing Greyhounds. Am J Vet Res 62, 440-447.
8. Hill RC, Bloomberg MS, et al. (2000). Maintenance energy requirements and the effect of diet on performance of
racing Greyhounds. Am J Vet Res 61, 1566-1573.
9. Kronfeld DS. (1973). Diet and the performance of racing sled dogs. JAVMA 162, 470-473.
10. Theriault DG, Bellar GA, et al. (1973). Intramuscular energy sources in dogs during physical work. J Lipid Res 14,
54-61.
11. Reynolds AJ, Fuhrer L, et al. (1994). Lipid metabolic responses to diet and training in sled dogs. J Nutr 124, 2754S-
2759S.
12. Reynolds AJ, Hoppeler H, et al. (1995). Sled dog endurance: a result of high fat diet or selective breeding? FASEB
J 9, A996.
13. Kronfeld DS, Hammel EP, et al. (1977). Hematological and metabolic responses to training in racing sled dogs fed
diets containing medium, low, or zero carbohydrate. Am J Clin Nutr 30, 419-430.
14. Reynolds AJ, Taylor CR, et al. (1996). The effect of diet on sled dog performance, oxidative capacity, skeletal mus-
cle microstructure, and muscle glycogen metabolism. In: Recent Advances in Canine and Feline Nutritional Re-
search; Proceedings of the 1996 Iams International Nutrition Symposium. Eds, Carey DP, Norten SA, Bolser SM;
1996; Orange Fraser Press, Wilmington, OH: 181-198.
15. Hinchcliff KW & Reinhart GA. (1996). Energy metabolism, and water turnover in Alaskan sled dogs during running.
In: Recent Advances in Canine and Feline Nutritional Research; Proceedings of the 1996 Iams International Nutrition
Symposium. Eds, Carey DP, Norten SA, Bolser SM; 1996; Orange Fraser Press, Wilmington, OH: 199-206.
16. Piercy RJ, Hinchcliff KW, et al. (2001). Association between vitamin E and enhanced athletic performance in sled
dogs. Med Sci Sports Exerc 33, 826-833.
17. Hill RC, Armstrong D, et al. (2001). Chronic administration of high doses of vitamin E appear to slow racing grey-
hounds. FASEB J 15, A990.
18. Marshall RJ, Scott KC, et al. (2002). Supplemental vitamin C appears to slow racing Greyhounds. J Nutr 132,
1616S-1621S.
NEW STRATEGIES IN PAIN CONTROL

SEMINAR
Cerebrum
Primary
somatic
sensory
cortex
Ventral posterior
Midbrain lateral nucleus of
the thalamus
Spinothalamic
tract
Mid-pons
Middle
medulla
Long-term NSAID use for canine OA: is it more effective?

John Innes, James Clayton, Duncan Lascelles
Osteoarthritis (OA) is a disease process where symptoms include pain, inflammation and lameness. It is as-
sociated with pathological changes in tissue in the affected synovial joint. These pathological changes include
a partial or total loss of articular cartilage. The disease is very common, with reports estimating up to 20%
of dogs over one year of age developing the disease (Johnston 1997).
One of the most common treatments is symptom-modifying pharmacotherapy (NSAIDs [Non-Steroidal An-
ti-Inflammatory Drugs], analgesics). Although technically animals cannot have “symptoms”, for the purpos-
es of consistency with human medicine, the term symptom-modification will be used in this report. NSAIDs
are anti-inflammatory agents aimed at inhibiting the COX enzyme (cyclooxygenase) which catalyses the
conversion of arachidonic acid to prostaglandins and thromboxane. The FDA (United States Food and Drug
Administration) have approved six NSAIDs for use in dogs. These being carprofen, meloxicam, tepoxalin,
firocoxib, deracoxib and etodolac. For canine NSAIDs, the annual costs for medications in the United States
exceeds $130 million a year and is growing about 13% a year (Schmit 2005).
Recommendations on prescribing practices for NSAIDs in the management of canine OA vary greatly, with
some authors recommending intermittent ‘as needed’ therapy, and others recommending continuous therapy.
The potential benefits of continuous therapy include better control of pain and greater improvements in mo-
bility, and potential slowing of the disease process through improved joint usage (e.g. reduction in disuse mus-
cle atrophy). The potential adverse effects from continuous therapy include tolerance over time to the drug, an
increased incidence of adverse events associated with the use of the drug, as well as compliance issues.
A potential, and potentially serious, effect of practising continuous NSAID therapy for the control of OA
pain is an increase in the incidence of adverse events. Gastrointestinal complications may occur in some in-

dividuals with the use of NSAIDs and it is most likely that it is the perception of this risk that restricts long
term use of NSAIDs. However, there are no accurate and controlled estimates for adverse event rates with
long-term use of NSAIDs in dogs.
The aim of this review was to collate all the information on long-term (greater than 28 days) NSAID ther-
apy and evaluate the evidence for the safety and efficacy of long-term NSAID use for the treatment of os-
teoarthritis in dogs and humans. In addition, secondary aims were to evaluate the evidence for progressive
decreases in pain, or progressive tolerance (increase in pain) over time; to evaluate the evidence for altered
disease progression with long-term continuous use; and to evaluate the evidence for an increase (or decrease)
in the incidence of adverse events with long-term NSAID use.
METHODS
Five online databases were identified covering the veterinary literature in the English language. These were:
Intute: Veterinary, Journals@Ovid Full Text, MEDLINE(Ovid), Veterinary Science Database, and Webof-
knowledge. The disease term identified was ‘Osteoarthritis’. Three species terms were identified for the
search within the veterinary databases, ‘dog’, ‘dogs’ and ‘canine’. As well as these terms, “NSAID” and “non-
steroidal” were terms used along with the generic names of a number of common NSAIDs including the
U.S. Food and Drug Administration (US FDA 2007) or EMEA-approved drugs were included in the search.
These included ‘carprofen’, ‘meloxicam’, ‘tepoxalin’, ‘firocoxib’, ‘deracoxib’, ‘etodolac’ and ‘phenylbutazone’.
All terms were then combined using Boolean operators; firstly in an ‘AND’ combination and then in an ‘OR’
combination
Included studies were those evaluating canine osteoarthritis affecting synovial joints of the appendicular
skeleton only. Papers were only included if the NSAID therapy was continued for 28 days or more. All ar-
ticles from the database searches were reviewed and included if they assessed either the safety or efficacy of
prolonged NSAID use, or a combination of safety and efficacy. Efficacy was defined as any study which
evaluated the functional or structure-modifying effects of NSAIDs on osteoarthritis in dogs.
Evaluation criteria were based on the system for scientific data produced by the US Food and Drug Ad-
ministration with minor modification. This system is based on the Institute for Clinical Systems Improve-
ment as adapted by the American Dietetic Association (Myers and others 2001) and was designed to rate
the strength of scientific evidence. For efficacy we aimed to calculate estimates for “number needed to treat”
(NNT)(Laupacis and others 1988) and for safety we aimed to calculate estimates for “number needed to
harm” (NNH).
RESULTS
In the summer of 2008, comprehensive literature searches were carried out using 5 different online data-
bases. This resulted in 15 papers that finally met all of the inclusion criteria for use of NSAIDs in dogs. Of
these, five studies looked solely into the use of carprofen, one solely into each of firocoxib, meloxicam and
licofelone, and the other seven studies were comparator studies using a combination of two or more treat-
ments, including carprofen (5), firocoxib (2), meloxicam (2), etodolac (2), buffered aspirin (1) and deracox-
ib (1). Nine were rated as type I studies, five as type III and one as a type IV quality study. Fourteen stud-
ies addressed functional safety in clinical cases of canine osteoarthritis and, of these, eight investigated func-
tional efficacy.
Seven studies were identified that included data on short-term (less than 28 days) efficacy of NSAIDs com-
pared to long term (more than 28 days) treatment. Of these, six reported results showing better outcome at
28 days or more compared to before 28 days. In addition, this difference was statistically significant in two
studies.
We were not able to identify dichotomous primary outcome variable data to calculate NNT estimates for
long-term NSAID treatment. For the one short-term study (14 days) with suitable data identified (Vasseur
and others 1995a), NNT for carprofen compared to placebo was 5 (95% confidence interval [CI], 2-7)
Across the papers identified, there were a total of 1589 canine patients entered in to studies. However, there
was inconsistency in the manner in which adverse events were reported. In addition, the lack of placebo con-
trol in the majority of studies limited our ability to calculate number needed to harm estimates. The only
study (Raekallio and others 2006) with placebo control for treatment greater than 28 days was a small study
which contained an EER of 0.31 and a control event rate (CER) of 0.33 producing a NNH estimate of -39
(equivalent to number needed to treat=39). The odds ratio was not significant and confidence intervals for
NNH were therefore not calculated. This result was compared to short-term treatment with carprofen
(Vasseur and others 1995b) which reported a EER of 0.17 and a CER of 0.12 with a NNH of 21 (95% CI,
19-23). Only one adverse event probably linked to treatment and considered serious was reported in all the
papers reviewed; this was a Labrador with an episode of toxic idiosyncratic hepatitis; this dog was treated
and survived. Overall, studies reported EERs between 0 and 0.31 (mean 0.11) but there was not a signifi-
cant correlation between study length and EER (rs=-0.109 [p=0.793]).
DISCUSSION
Of the seven studies reporting efficacy at sampling points less than and greater than 28 days, six reported
results in favour of long-term therapy for additional efficacy over short-term therapy and the remaining
study indicated no difference. Taken together, there is a moderate level of comfort in recommending long-
term use of NSAIDs for additional beneficial treatment effects for dogs with chronic osteoarthritis. Howev-
er, this issue deserves further exploration. There was no information in the literature on whether this addi-
tional benefit was the result of peripheral or central changes in pain processing. Additionally, it is presently
not known whether the additional benefit was indeed related to a reduction in pain, but in fact a progres-
sive functional improvement due to increased muscle strength and greater range of motion effected by the
initial pain relief-induced greater mobility.
The review of safety was more challenging. Although 14 of 15 papers included data on safety, the majority
was of moderate-low quality, again because of the lack of CER data. Thus we were unable to calculate re-
liable estimates of NNH; much larger numbers are required to provide such estimates with an acceptable
degree of confidence. However, EER data did not indicate an increase in this parameter with duration of
treatment. In addition, out of 1589 dogs entered in to these studies, only one serious adverse event was iden-
tified that probably related to NSAID treatment; this dog was treated and survived. Thus it seems the inci-
dence of serious adverse events with NSAID use of 28 days or longer is low. The authors might suggest that
adverse events may be more related to individual animal’s inherent response to NSAIDs. Such a view sug-
gests that adherence to a protocol of only short-term therapy does not make sense in the face of continued
chronic pain from the underlying condition, in particular when there appears to be increased efficacy with
longer-term therapy.
In summary, whilst the current literature has shortcomings in the objective evaluation of long-term use of
NSAIDs and notwithstanding the limitations of this systematic review discussed above, the current evidence
suggests there is clinical benefit from longer-term NSAID use for dogs with chronic osteoarthritis and that
this is associated with a very low risk of serious adverse events.
ACKNOWLEDGEMENTS
James Clayton was funded by a Pfizer Summer Studentship Award.
Dose reduction or dose maintenance for NSAIDs

administered to dogs with DJD-associated pain?
Recommendations on prescribing practices for NSAIDs in the management of canine OA vary greatly,
with some authors recommending intermittent ‘as needed’ therapy, and others recommending continuous
therapy. The potential benefits of continuous therapy include better control of pain and greater improve-
ments in mobility, and potential slowing of the disease process through improved joint usage (e.g. reduc-
tion in disuse muscle atrophy). The potential adverse effects from continuous therapy include tolerance
over time to the drug, an increased incidence of adverse events associated with the use of the drug, as well
as compliance issues.
There is evidence that joint pain results in the development of central sensitization1,2 which is one of the
mechanisms leading to increased pain. Further, it has been demonstrated that the COX enzymes play a
role in central sensitization3,4 and that COX inhibitors can prevent the establishment of central sensitiza-
tion 4. If a reduction in central sensitization occurred over time with continuous NSAID therapy, there
should be a progressive reduction in pain perceived in the patient. There is a growing body of evidence
that central sensitization can actually drive the progression of disease in the periphery (joints), and that
downward modulation of central sensitization can result in decreased joint pathology5,6. In addition, a di-
rect effect of NSAIDs at the level of the joint may result in a reduction in disease progression7,8. Thus, a
number of lines of evidence suggest potential theoretical benefits of continuous versus intermittent
NSAID analgesic therapy in OA.

A potentially serious or even life-threatening effect of practising continuous NSAID therapy for the control
of OA pain is an increase in the incidence of adverse events. Gastrointestinal complications may occur in
some individuals with the use of NSAIDs and it is most likely that it is the perception of this risk that re-
stricts long-term use of NSAIDs. However, there are no accurate and controlled estimates for adverse event
rates with long-term use of NSAIDs in dogs. A recent review suggested that adverse event rates were no
greater with long-term over short-term NSAID therapy in dogs with OA-associated pain.9 However, the au-
thors indicated that there was not really enough data in the literature to come to a strong conclusion. So,
there are arguments both for and against the continuous use of NSAIDs in dogs with DJD-associated pain.
To date, there are no studies that have evaluated the comparative efficacy of every-day versus intermittent
NSAID therapy in dogs with OA, and only one recent study in human medicine10. In that study, there were
no significant differences between patients randomized to continuous or intermittent treatment except for
the intake of rescue analgesia for ‘flares’ which was less in the continuous treatment group.
Relative overdose is a common feature of cases where problems due to toxicity occur in dogs11,12 and dose
reduction allows for continued efficacy with, presumably, a greater safety margin. Although such an ap-
proach is in line with most current recommendations for clinical use of NSAIDs, there is currently no evi-
dence-based medicine to support the concept of dose reduction on the basis of improved safety. If dose re-
duction is practised, an important question is “is efficacy maintained?”
The author’s research group has recently completed a study evaluating efficacy in dose reduction of
NSAIDs. Dogs that had impaired mobility due to pain associated with appendicular joint OA and did not
have any clinically significant systemic disease were recruited. Dogs were randomized, based on degree of
impairment and fore or hind limb involvement, to recieve a reducing dose of meloxicam (group A; n=30)
or full dose meloxicam (group B; n=29). After a 14 day wash-out, group A received a reducing dose of
meloxicam and group B received full dose meloxicam (0.1mg/kg after a dose of 0.2mg/kg on day 1). In
group A the meloxicam dose was reduced by 15% each 2 weeks starting at D28 down to 40% of original
dose, then 20% of the original dose was administered for 2 weeks; then to 0% of original dose for 2 weeks.
Volumes of drug administered were kept the same across both groups using appropriate dilution with place-
bo to achieve dose reduction in group A and maintain administered volume at 0.67ml/kg in all dogs. Out-
come measures were assessed every 14 days, at D14, 28, 42, 56, 70, 84, 98 and 112. Primary outcome meas-
ures were: number of dogs dropping out due to pain control being insufficient; subjective owner assessments
(Canine Brief Pain Inventory [CBPI] scores; Helsinki Chronic Pain Index [HCPI] scores); accelerometry
(activity ‘counts’); percent standing body weight (%BW) distribution to the index (most affected) limb
as measured on a pressure sensitive walkway. Secondary outcome measures were Client Specific Outcome
Measures (CSOM). Owners were asked to assess the last 7 days prior to each visit; accelerometry counts
were analyzed for the 7 day periods prior to each visit; %BW was measured on the visit day. At each visit,
the owners were asked if the pain control was sufficient. If they answered ‘no’, the dog was removed from
the study at that point and treated appropriately.
Age, weight, sex, degree of impairment (CBPI), fore or hind involvement, CBPI and HCPI were not dif-
ferent between the groups at day (D) 0 or D14. Significantly more dogs in group A dropped out due to in-
sufficient pain control (13) compared to group B (5) over the duration of the study, P=0.029; Odds ratio:
3.67. The median time for dropout in each group was 84 days, corresponding to a dose of 40% of the orig-
inal having been administered for the previous 2 weeks in group A.
Other results will be presented in the lecture, and the implications of these to clinical practice discussed.
REFERENCES
1. Menetrey D, Besson JM. Electrophysiological characteristics of dorsal horn cells in rats with cutaneous inflamma-
tion resulting from chronic arthritis. Pain 1982;13:343-364.
2. Neugebauer V, Schaible HG. Evidence for a central component in the sensitization of spinal neurons with joint in-
put during development of acute arthritis in cat’s knee. Journal of Neurophysiology 1990;64:299-311.
3. Samad TA, Moore KA, Sapirstein A, et al. Interleukin-1 beta-mediated induction of Cox-2 in the CNS contributes
to inflammatory pain hypersensitivity. Nature 2001;410:471-475.
4. Veiga APC, Duarte IDG, Avila MN, et al. Prevention by celecoxib of secondary hyperalgesia induced by formalin
in rats. Life Sciences 2004;75:2807-2817.
5. Sluka KA, Jordan HH, Westlund KN. Reduction in joint swelling and hyperalgesia following posttreatment with a
non-nmda glutamate-receptor antagonist. Pain 1994;59:95-100.
6. Fiorentino PM, Tallents RH, Miller JNH, et al. Spinal Interleukin-1 beta in a Mouse Model of Arthritis and Joint
Pain. Arthritis and Rheumatism 2008;58:3100-3109.
7. Pelletier JP, Lajeunesse D, Hilal G, et al. Carprofen reduces the structural changes and the abnormal subchondral
bone metabolism of experimental osteoarthritis. Osteo and Cart 1999;7:327-328.
8. Pelletier JP, Boileau C, Brunet J, et al. The inhibition of subchondral bone resorption in the early phase of experi-
mental dog osteoarthritis by licofelone is associated with a reduction of MMP-13 and cathepsin K synthesis. Ann
Rheum Dis 2004;63:145-145.
9. Innes JF, Clayton J, Lascelles BD. Review of the safety and efficacy of long-term NSAID use in the treatment of ca-
nine osteoarthritis. Vet Rec 166:226-230.
10. Luyten FP, Geusens P, Malaise M, et al. A prospective randomised multicentre study comparing continuous and in-
termittent treatment with celecoxib in patients with osteoarthritis of the knee or hip. Ann Rheum Dis 2007;66:99-106.
11. Enberg TB, Braun LD, Kuzma AB. Gastrointestinal perforation in five dogs associated with the administration of
meloxicam. Journal of Veterinary Emergency and Critical Care 2006;16:34-43.
12. Lascelles BD, Blikslager AT, Fox SM, et al. Gastrointestinal tract perforation in dogs treated with a selective cy-
clooxygenase-2 inhibitor: 29 cases (2002-2003). J Am Vet Med Assoc 2005;227:1112-1117.
NSAIDs for feline DJD: new developments

These proceedings provide an update to the 2007 review of NSAIDs in cats,1 highlighting new information
that has implications for the use of NSAIDs in the clinical setting in cats, in particular in relation to feline
degenerative joint disease (DJD). The review cited review highlighted several clinically relevant questions
and gaps in our knowledge regarding NSAIDs in cats – particularly regarding efficacy and safety in the
chronic administration setting. Since the 2007 review, a lot of new, clinically relevant and useful information
has been published, and these proceedings summarise that.
Pertinent exciting developments since that publication are the approval in Europe and other countries in-
cluding Australia of meloxicam to treat chronic musculoskeletal pain. The approval is for an unlimited time
at a dose of 0.05mg/kg/day. An additional development is that the first coxib class of NSAID, robenacoxib,2-
4
has been granted approval in Europe for use in cats. In cats with musculoskeletal pain the indication is for
up to 6 days therapy, at a dose of 1mg/kg once daily. Robenacoxib has shown efficacy in a model of paw in-
flammation, and was shown to be COX-2 selective in the cat. As yet, there are no clinical reports of its use.
SAFETY OF NSAIDs
In a small study, using 7 healthy cats, Steagall et al9 found no adverse effects on gastrointestinal, hemato-
logical or serum biochemical parameters of daily administration of carprofen. The administration regimen
was 4mg/kg day 1; 2mg/kg days 2 and 3; and 1mg/kg days 4 and 6. The investigators did not assess effica-
cy, and did indicate that the numbers were too low to draw strong conclusions on the overall safety of this
therapeutic regimen.

In a study on the long-term administration of meloxicam to cats with osteoarthritis, Gunew et al 10 re-
ported that meloxicam at 0.01-0.03mg/kg PO daily (0.1mg per cat PO) was well tolerated. 40 cats were
treated for a mean of 5.8 months, and 40 age, breed, sex and pre-existing disease matched controls were
also followed. There did not appear to be any differences between the groups in illnesses occurring over
time. 4 cats in the meloxicam group vomited and 2 of these were removed from the study; one cat in the
control group was reported to vomit and one have diarrhea. The group sizes of cats were likely too small
to really determine if there was a difference between the groups due to treatment with meloxicam, but it
does give a broad idea of the clinical tolerance of these doses. Only the first 10 enrolled pairs of cats with-
out concurrent disease has serum creatinine measurements (no other values) at enrollment and 1 month
later. There were no differences between the treated and control groups, however, from a clinical point of
view it would have been interesting to have had full blood work performed in all cases. Although effica-
cy was suggested in this report, it was not comprehensively evaluated. In the only placebo-controlled
study to date, there were significant placebo effects,11 and blinded, placebo controlled studies using vali-
dated assessment systems are needed to determine if the ‘low’ doses used (0.01-0.03mg/kg/day) are truly
effective (see later). In an interesting abstract reported at ECVIM, Gowan12 reported the effects of a me-
dian maintenance dose (after dose titration) of 0.02mg/kg daily on the progression of renal disease in aged
cats both with (n=22) and without (n=16) renal disease (IRIS stage I-III). They reported that this dose
of meloxicam did not hasten the progression of renal disease in aged cats, or aged cats with pre-existing
renal disease.
In a small masked, randomized, crossover study, 6 research cats were treated with meloxicam at 0.2mg/kg
day 1, followed by 0.1mg/kg daily on days 2 to 5. All cats were crossed over with no treatment in a ran-
domized manner. The results indicated that short-term administration of meloxicam did not measurably al-
ter the GFR in healthy, euvolemic, conscious cats as assessed by plasma clearance of iohexol.
That NSAIDs and steroids can be associated with serious adverse effects was highlighted by a report of 3
cats (2 that had received meloxicam and 1 that had received steroids) with gastro-intestinal perforation.13 Al-
though the authors do implicate the NSAID or steroid, the authors do state that it is impossible to ascertain
that the primary disease processes (OA and bladder inflammation) and stress related to this due to discom-
fort, visits to the vet and reduced appetite, did not play a role in the etiology of the gastric ulceration.
An interesting study evaluated the role of dietary fiber, intestinal hypermotility and leukotrienes in the
pathogenesis of small intestinal ulcers in cats.14 Based on the finding that small intestinal ulcers induced by
NSAIDs in humans are often more frequent and severe than previously thought, the investigators used in-
domethacin administration to induce ulcers. Interestingly, the administration of indomethacin in fasted cats
produced ulcers in the gastric antrum and duodenum, but administration in fed cats produced severe lesions
in the duodenum and more distal small intestine. It is not known if such a similar phenomenon exists in clin-
ical feline patients being administered preferential or selective COX-2 inhibitors. Other interesting findings
were the effects of dietary fiber on lesions, and the protective effect of a 5-lipoxygenase inhibitor (AA 861).
5-LOX inhibition and a LT receptor antagonist significantly inhibited hypermotility and lesion formation.14
The 2007 review1 indicated there was no information on tepoxalin (a dual [COX and LOX] inhibitor in
dogs) in cats, but interestingly in a 2008 article, Papich15 indicates that pharmacokinetic studies have been
performed, and show that for both the parent drug and the main metabolite, safe dosing might be able to
be performed in the cat at 10mg/kg/day. However, this single piece of information is the only available on
tepoxalin in the cat.
EFFICACY FOR CHRONIC PAIN

Since the 2007 review,1 there have been several publications evaluating the efficacy of meloxicam. In a mod-
el of arthritic pain (that probably models the inflammatory component of OA), Carroll et al16 used 3 trained
cats in a randomized, cross-over design and found that meloxicam at 0.1mg/kg PO for three days before,
and on the day of, intraarticular injection of the short-duration irritant sodium urate, significantly improved
hind limb use as measured using objective pressure-mat data. Elegant work evaluating behaviors thought to
be associated with OA pain in cats used meloxicam at 0.1mg/kg day 1, and 0.05mg/kg thereafter for a total
of 28 days.17,18 These non-blinded studies reported clinical improvement in certain behaviors in cats admin-
istered meloxicam. However, the placebo effect was not accounted for. One placebo-controlled, blinded
study using both subjective and objective evaluations to evaluate the efficacy of meloxicam in cats with OA
found a mobility-enhancing effect meloxicam.11 The dosing regimen was 0.1mg/kg meloxicam on day 1 fol-
lowed by 0.05mg/kg on days 2-5. In this study there was a significant placebo effect, indicating that more
placebo-controlled blinded studies are needed in feline OA where there are, as yet, no validated assessment
systems. Unpublished work indicates such systems are being developed.19 Many clinicians use ‘low’ doses
of various NSAIDs for longer-term administration to cats with DJD (presumably to circumvent the possi-
ble adverse effects of NSAIDs), but as yet, it is not clear whether these ‘low’ doses are effective.
REFERENCES
1. Lascelles BD, Court MH, Hardie EM, et al. Nonsteroidal anti-inflammatory drugs in cats: a review. Vet Anaesth
Analg 2007;34:228-250.
2. Giraudel JM, King JN, Jeunesse EC, et al. Use of a pharmacokinetic/pharmacodynamic approach in the cat to de-
termine a dosage regimen for the COX-2 selective drug robenacoxib. J Vet Pharmacol Ther 2009;32:18-30.
3. Giraudel JM, Toutain PL, King JN, et al. Differential inhibition of cyclooxygenase isoenzymes in the cat by the
NSAID robenacoxib. J Vet Pharmacol Ther 2009;32:31-40.
4. King JN, Dawson J, Esser RE, et al. Preclinical pharmacology of robenacoxib: a novel selective inhibitor of cy-
clooxygenase-2. J Vet Pharmacol Ther 2009;32:1-17.
5. Benito-de-la-Vibora J, Lascelles BD, Garcia-Fernandez P, et al. Efficacy of tolfenamic acid and meloxicam in the con-
trol of postoperative pain following ovariohysterectomy in the cat. Vet Anaesth Analg 2008;35:501-510.
6. Steagall PV, Taylor PM, Rodrigues LC, et al. Analgesia for cats after ovariohysterectomy with either buprenorphine
or carprofen alone or in combination. Vet Rec 2009;164:359-363.
7. Brondani JT, Loureiro Luna SP, Beier SL, et al. Analgesic efficacy of perioperative use of vedaprofen, tramadol or
their combination in cats undergoing ovariohysterectomy. J Feline Med Surg 2009;11:420-429.
8. Brondani JT, Luna SP, Marcello GC, et al. Perioperative administration of vedaprofen, tramadol or their combina-
tion does not interfere with platelet aggregation, bleeding time and biochemical variables in cats. J Feline Med Surg
2009;11:503-509.
9. Steagall PV, Moutinho FQ, Mantovani FB, et al. Evaluation of the adverse effects of subcutaneous carprofen over
six days in healthy cats. Res Vet Sci 2009;86:115-120.
10. Gunew MN, Menrath VH, Marshall RD. Long-term safety, efficacy and palatability of oral meloxicam at 0.01-0.03
mg/kg for treatment of osteoarthritic pain in cats. J Feline Med Surg 2008;10:235-241.
11. Lascelles BD, Hansen BD, Roe S, et al. Evaluation of client-specific outcome measures and activity monitoring to
measure pain relief in cats with osteoarthritis. J Vet Intern Med 2007;21:410-416.
12. Gowan R. Retrospective analysis of long-term use of meloxicam in aged cats with musculoskeletal disorders ind the
effect on renal function. J Vet Intern Med 2009;23:1347 (Abstr).
13. Cariou MP, Halfacree ZJ, Lee KC, et al. Successful surgical management of spontaneous gastric perforations in
three cats. J Feline Med Surg 12:36-41.
14. Satoh H, Shiotani S, Otsuka N, et al. Role of dietary fibres, intestinal hypermotility and leukotrienes in the patho-
genesis of NSAID-induced small intestinal ulcers in cats. Gut 2009;58:1590-1596.
15. Papich MG. An update on nonsteroidal anti-inflammatory drugs (NSAIDs) in small animals. Vet Clin North Am
Small Anim Pract 2008;38:1243-1266, vi.
16. Carroll GL, Narbe R, Peterson K, et al. A pilot study: sodium urate synovitis as an acute model of inflammatory
response using objective and subjective criteria to evaluate arthritic pain in cats. J Vet Pharmacol Ther 2008;31:456-
465.
17. Bennett D, Morton C. A study of owner observed behavioural and lifestyle changes in cats with musculoskeletal
disease before and after analgesic therapy. J Feline Med Surg 2009;11:997-1004.
18. Clarke SP, Bennett D. Feline osteoarthritis: a prospective study of 28 cases. J Small Anim Pract 2006;47:439-445.
19. Zamprogno H, Hansen BD, Bondell HD, et al. Development of a questionnaire to assess degenerative joint disease-
associated pain in cats: Item generation and questionnaire format. American Journal of Veterinary Research ac-
cepted for publication.

P. Lees WVOC 2010, Bologna (Italy), 15th - 18th September • 348
Long-acting and tissue targeting NSAIDs:

a pharmacokinetic and pharmacodynamic view
Peter Lees, C.B.E., B.Pharm. Ph.D., D.Sc., Emeritus Professor of Veterinary Pharmacology
The Royal Veterinary College, Hawkshead Campus, Hatfield, Herts, AL9 7TA, U.K.
Non-steroidal anti-inflammatory drugs (NSAIDs) have been used widely as analgesics in companion ani-
mal medicine for more than 50 years. Their principal mechanism of action at the molecular level is inhi-
bition of cyclooxygenase (COX), an enzyme which exists in two isoforms, COX-1 and COX-2. The for-
mer is constitutive in most cell types and inhibition is responsible for ulcerogenic g.i.t. side-effects. The lat-
ter isoform is induced at sites of inflammation and is present constitutively in the C.N.S.; it catalyses the
synthesis of pro-inflammatory mediators such as prostaglandin E2. The older drugs of the NSAID group
are predominantly non-selective COX inhibitors, although there are exceptions. Thus, carprofen is prefer-
ential/selective for inhibition of COX-2 in the dog and cat1,2,3, whereas ketoprofen is preferential/selective
for COX-1 in the cat4.
Introduction of the selective COX-2 group of inhibitors (COXibs) has provided a major advance in pain
control in domestic animal species; four drugs of this class (deracoxib, firocoxib, mavacoxib and robena-
coxib) have been licensed in various countries. It was anticipated that these drugs might comprise a new
generation of efficacious NSAIDs with lesser side-effects than non-selective inhibitors. However, it is now
recognised that: (a) even selective COX-2 inhibitors may not be entirely free of COX-1 inhibitory activity
at therapeutic dose rates; and (b) COX-2 is now known to be not only inducible at sites of tissue damage
but also constitutive in some organs/tissue e.g. kidney and C.N.S. Nevertheless, introduction of the COX-
ibs represents a major advance in veterinary therapeutics, through provision of pain relief with minimal side-
effects on the upper gastrointestinal tract, in the absence of pre-existing lesions5,6. This presentation sum-
marises pharmacokinetic (PK) and pharmacodynamic (PD) data on the two most recently licensed COX-
ibs, mavacoxib (Trocoxil, Pfizer Animal Health) and robenacoxib (Onsior, Novartis Animal Health). The ef-
ficacy of both drugs has been established in several models of soft tissue and joint inflammation in the dog
(mavacoxib) and dog and cat (robenacoxib). Both drugs are licensed for use for the treatment of musculo-
skeletal disorders, such as osteoarthritis (OA), mavacoxib in the dog7 and robenacoxib in the dog and cat8,9.
The PK of mavacoxib is characterised by a high degree (98%) of binding to plasma protein, high bioavail-
ability (87%) in fed dogs, very slow body clearance (2.7 mL.h/kg) and a correspondingly long elimination
half-life (17 days after oral dosing in pre-clinical studies in Beagle dogs and 44 days clinically in several ca-
nine breeds)10,11. The longer t½ in OA dogs is likely attributable to greater age and body weight of some an-
imals. Mavacoxib exhibited dose proportional pharmacokinetics for doses up to 25 mg/kg in mongrel dogs.
Canine whole blood in vitro assays indicated inhibitory plasma concentrations of 2.46 µg/mL (IC20 COX-1)
and 1.28 µg/mL (IC80 COX-2)12. The IC50 COX-1:COX-2 ratio was 21.2:1. The trough concentration of
mavacoxib in OA dogs of 1.11 µg/mL after 5 doses of 2 mg/kg was less than the IC20 for COX-1 inhibition
and almost identical to the IC80 for COX-212, 13. These properties justify a clinical “jump start” dosage regi-
men of 2 mg/kg administered once monthly, following an initial shorter interval of 14 days between first and
second doses (total of 7 doses), providing plasma concentrations which exceed 400 ng/mL throughout the
6.5 month treatment period.
The PK of robenacoxib in the dog and cat is characterised by a high degree (> 98%) of binding to plasma
protein, moderate or high bioavailability in fasted animals (84% dogs, 49% cats), rapid body clearance (810
mL.h/kg dog, 440 mL.h/kg cat) and correspondingly short elimination half-lives (0.63h dog, 1.49h cats) in
pre-clinical studies after intravenous dosing14, 15. Robenacoxib was non-cumulative on repeat daily dosing.
Feline and canine whole blood in vitro assays indicated the high selectivity of robenacoxib for COX-2; IC50
ratios were 502:1 (cat) and 129:1 (dog)3,16. The blood concentration exceeded IC50 for COX-2 for 9.4h af-
ter oral dosing of 2 mg/kg (the clinically recommended dose) in a population of OA dogs compared to a
time of 2.8h in fasted healthy laboratory beagles. In a feline tissue cage model of acute inflammation, robe-
nacoxib 2 mg/kg intravenously had mean elimination half lives of 2.1 and 23.6h from blood and tissue case
exudate, respectively17. Prostaglandin E2 synthesis in exudate (COX-2) was inhibited significantly at 6, 9, 12
and 24h after dosing, whilst in serum TxB2 (COX-1) was inhibited only slightly and transiently. Similar da-
ta in the tissue cage model were obtained after oral or subcutaneous dosing of robenacoxib (Pelligand et al.,
unpublished).
In summary, studies on the pre-clinical and clinical pharmacology of the novel COXibs, mavacoxib and
robenacoxib, indicate that similar PD properties (preferential or selective COX-2 inhibition) and differing
349 • WVOC 2010, Bologna (Italy), 15th - 18th September P. Lees
PK properties (slow and rapid clearance of mavacoxib and robenacoxib, respectively) can be used to design
effective and safe dosing schedules7,8,9,12. In optimising dosage regimens of both drugs, it is necessary to al-
low for PK differences between healthy, young laboratory animals and generally older animals in the clini-
cal populations of dogs and cats with musculo-skeletal disorders, including OA. Both drugs have been
shown to be well tolerated in clinical use. Mavacoxib provides the advantage of COX-2 preferential selec-
tivity plus once per month dosing and hence infrequent direct (luminal) exposure of the g.i.t. Moreover, the
long terminal half-life ensures that the peaks and troughs of plasma and tissue concentrations, which char-
acterise the PK of many drugs, are avoided. Robenacoxib, on the other hand, provides the advantage of
COX-2 selectivity, rapid clearance from and hence reduced exposure of well perfused tissues (e.g. liver, kid-
ney) and slow clearance from a site of induced inflammation, where action is required. It may be described
as both tissue and COX-2 selective.
ACKNOWLEDGEMENTS
This presentation is based on unpublished and published data generated by J.M. Giraudel, J.N. King et al.
(Novartis Animal Health) and L. Pelligand (Royal Veterinary College) and published data generated by S.
Cox, M. Stegemann et al. (Pfizer Animal Health). Studies on robenacoxib were supported by Novartis An-
imal Health and BBSRC.
BIBLIOGRAPHY
1. Streppa, H.K. et al. (2002). A.J.V.R., 63, 91.
2. Giraudel, J.M. et al. (2005). A.J.V.R., 66, 700.
3. King, J.N. et al. (2010). Res. Vet. Sci., 88, 497.
4. Schmid, V.B. et al. (2010). J.V.P.T., in press.
5. Hanson, P.D. et al. (2006). Vet. Ther., 7, 127.
6. Goodman, L. et al. (2009). J. Vet. Internal Med., 23, 56.
7. Payne-Johnson, M. et al. (2009). J.V.P.T., 32, Suppl. 1, 106.
8. Giraudel, J.M. et al. (2010). A.J.V.R., in press.

9. Gruet, P. et al. (2010). A.J.V.R., in press.
10. Cox, S. et al. (2009a). J.V.P.T., 32, Suppl. 1, 106.
11. Cox, S. et al. (2010). J.V.P.T., 33, in press.
12. Lees, P. et al. (2009). J.V.P.T., 32, Suppl. 1, 105.
13. Cox, S., et al. (2009b). J.V.P.T., 32, Suppl. 1, 107.
14. Jung, M. et al. (2009). J.V.P.T., 32, 41.
15. King, J.N. et al. (2010). Vet. J., submitted.
16. Giraudel, J.M. et al. (2009). J.V.P.T., 32, 31.
17. Pelligand, L. et al. (2009). J.V.P.T., 32, Suppl. 1, 103.
18. Lees, P. et al. (2009). J.V.P.T., 32, Suppl. 1, 33.
L. Novello WVOC 2010, Bologna (Italy), 15th - 18th September • 350
Forelimb blocks in orthopaedics:

what is the evidence and what is new?
Lorenzo Novello, Med Vet, Dip ESRA, MRCVS
President of the Italian Society of Veterinary Regional Anaesthesia and Pain Medicine (ISVRA, at www.isvra.org),
and clinical anaesthetist at Referenza Carobbi Novello, novello@isvra.org
In humans, several different techniques for brachial plexus blockade have been described, aiming to provide
the best operating conditions for different types of surgery. Reported techniques are interscalene, supra-
clavicular, infraclavicular and axillary, including many variations aiming to improve the success rate and de-
crease the incidence of complications.
In general, complete anaesthesia of the arm except for the shoulder is best achieved with the infraclavicular
block, while the interscalene block provides anaesthesia of the shoulder, but not always of the ulnar parts of
the lower forearm and the hand. However, they rarely provide anaesthesia of caudal roots of the brachial
plexus. With the axillary block anaesthetic gaps are expected in the region of the radial and muscolocuta-
neous nerves. In small animals, different anatomy has limited the application and/or modification of the tech-
niques in common use in humans.
The success of a peripheral nerve block depends on how close to the appropriate nerve the local anaesthet-
ic is placed. In humans, the administration of peripheral blocks has traditionally involved search for paraes-
thesia, which restricts the technique to awake and cooperative patient. The introduction into clinical prac-
tice of the nerve stimulator has offered a series of advantages during difficult blocks, teaching, and selective
blocks with small amounts of local anaesthetics. In addition, the nerve stimulator facilitates the location of
peripheral nerves in anaesthetized, deeply sedated and uncooperative patients, and reduces discomfort dur-
ing nerve localization.
Recently, however, ultrasound-guided techniques are becoming increasingly popular as an aid or an alter-
native to electrolocation. Ultrasound guidance uses anatomic landmarks rather than a neurophysiologic end-
point (i.e. electroneurostimulation) to facilitate peripheral blocks, and it has been suggested that the combi-
nation of ultrasound guidance and electrolocation may offer the advantage of both the anatomical and elec-
trophysiological confirmation of nerve identification and needle placement. Furthermore, some case series
have demonstrated shortened procedure time and faster block onset compared with conventional tech-
niques. Although not clearly demonstrated yet, potential benefits of ultrasound guidance include reduction
in block-related complication and incidence of systemic local anaesthetic toxicity, and improvement in suc-
cess rate and patient satisfaction.
In small animals regional anaesthesia is usually described as an adjunct rather than an alternative to gen-
eral anaesthesia, providing a sparing effect on other anaesthetic agents and long term postoperative anal-
gesia. In addition, peripheral nerve blocks are usually performed in an anaesthetized patient due to poor
tolerance to proper positioning, needle insertion and advancement, and high current outputs (e.g. about
1mA) required by electrolocation. However, since its introduction the nerve stimulator has dramatically
improved the success rate of many peripheral blocks in the dog and the cat, and has allowed for new blocks
to be performed.
The recently introduced ultrasound guidance is promising in small animals as well. It may allow the veteri-
nary anaesthetist to perform peripheral blocks with stimulated needles in an awake or slightly sedated co-
operative patient, as the initial current output is much lower (i.e. 0.4mA) during a combined ultrasound-
guided/ electrolocation technique than during standard electrolocation (i.e about 1mA). It should also be
considered that electrical stimulation may become unnecessary with experience, although in people a motor
response at or below 0.5 mA could only be elicited in 42% of successful blocks despite ultrasonographic ev-
idence of close proximity to the targeted nerve.
Although different techniques for brachial plexus blockade have been described in small animals as well,
very little scientific evidence is available. Brachial plexus block was first reported in 1951.1 Since then blind
injection of local anaesthetics into the axillary space at the level of the shoulder joint has been described and
clinically used, although to date no clinical studies have investigated success rate, indications, contraindica-
tion, side effects and complications for this technique. According to unpublished data, however, some in-
vestigators have concluded that the onset time and quality of anaesthesia following a blind brachial plexus
block are unpredictable.2,3 It should also be noted that neither careful description of patient positioning,
anatomical landmarks and surface markings used to locate the injection site has been made available, nor
their influence on the success rate of a blind block assessed.
351 • WVOC 2010, Bologna (Italy), 15th - 18th September L. Novello
In 2000 Moens and Caulkett reported a 70% success rate in 10 research beagles receiving 0.78 ml kg-1 of 2%
lidocaine through a feeding tube blindly placed in the axillary space for continuous brachial plexus block-
ade.4 It was not until 2004 that peripheral nerve stimulator aided brachial plexus blockade was reported in
small animals.5
Twelve research dogs undergoing surgery of the humerus were used. The insertion point was located using
anatomical landmarks (i.e. axillary artery and costochondral junction of the first rib), and the anaesthetic so-
lution (i.e. 1.1 ml kg-1 of 0.375% bupivacaine) was delivered in the axillary space using an insulated needle
and a multiple stimulation technique. Although the authors claimed a 91.6% success rate, in actual fact suc-
cess rate was 83.4% because two dogs did not underwent surgery and were withdrawn from the study due
to block failure and severe hypotension respectively.
Using the same technique, Wenger and others enrolled 20 clinical dogs undergoing orthopaedic surgery of the
forearm and carpus in a prospective, blind, placebo-controlled, randomized study.6 They claimed a 100%
success rate in dogs maintained with isoflurane (ET 1.3-1.4%) anaesthesia, and administered 0.25 ml kg-1 of
a mixture of 2% lidocaine and 0.5% bupivacaine in the axillary space using a multiple stimulation technique.
However, some dogs in the brachial plexus block responded to surgical stimulation despite 1 MAC isoflu-
rane, and received intraoperative fentanyl. In addition, 1 dog required rescue analgesia (i.e. methadone) dur-
ing the 8-hour postoperative monitoring period.
Anatomical landmarks to perform multiple stimulation technique at the axilla, and clinical use of commer-
cially available set for continuous, nerve stimulator aided, brachial plexus blockade have been reported.7,8
Furthermore, using the axillary approach and a single stimulation technique (i.e. flexion of the elbow) 0.3
ml kg-1 of solution was required to adequately stain the brachial plexus in a canine experimental model.9 Re-
cently, the use of ultrasound to approach the canine plexus in the axillary space has been reported in a
prospective experimental trial.10
A posterior approach to the brachial plexus was introduced into clinical use in humans by Pippa in the
1990s.11 It is a cervical paravertebral approach using the loss-of-resistance technique and a single injection of
local anaesthetic, and has been shown to provide a wider area of analgesia compared to Winnie’s lateral (i.e.
interscalene) approach.12 Although epidural spread is still possible, this approach has minimal chance to en-

ter the neuraxis. A modified Pippa posterior approach (dorsal approach) to the brachial plexus has been suc-
cessfully reported in a dog in 2006,13 although first used by this author in 2001.
A lateral paravertebral approach to the canine brachial plexus has been described by Lemke.3,14 Using the
transverse process of the 6th cervical vertebra and 1st rib as anatomical landmarks, the ventral branches of
C6, C7, C8 and T1 are individually blocked. The local anaesthetic is administered via a needle entering the
lateral side of the neck and directed medially, and a multiple injection technique is used. Although the tech-
nique has been described twice, no clinical trial has reported its use. Unintended neuraxial (subarachnoid,
subdural, epidural) anaesthesia is a potential complication of such a block, as well as unintentional spinal
cord puncture through the intervertebral foramen, as already reported in humans for the interscalene and
the Boezaart’s modified posterior approach.
A similar approach, i.e. a craniolateral to caudomedial direction of the needle, using ultrasound-guided low-
volume (i.e. 0.3 ml per site) vs high-volume (i.e. 1 ml per site) injections provided staining of all nerve routes
in 11 canine cadavers.15 However, staining of the epidural space and intervertebral foramen was noted in
both low and high volume injections, and staining of the phrenic nerve in high-volume injections only. Such
staining should be regarded as possible source of complications in a clinical setting, and might be related to
the lateral approach, use of a standard needle, and targeting ultrasonographic landmarks rather than the in-
dividual nerve root.
As an alternative, Hofmaeister and Read described a dorsal approach in 9 canine cadavers using Lemke’s
anatomical landmarks, a multiple injection technique and a methylene blue solution.16 At dissection, all in-
dividual nerves were successfully stained using 3 ml of staining solution in 3 out of 9 cadavers (33%), while
C7 was stained in all cadavers. Indications, success rate and complications for this technique have never
been investigated clinically.
The individual blockade of the radial, ulnar, musculocutaneous and median nerves (RUMM block) at the
distal humerus has been suggested as an alternative to the axillary brachial plexus block, however no clini-
cal reports of the technique have been published.
Recently, a RUMM block at the level of the midhumerus failed to provide complete simultaneous block of
all nerves in all but one dogs,17 although in people it provided a greater success rate than the traditional ax-
illary approach.18
In conclusion, although regional anaesthesia may provide a sparing effect and long term postoperative anal-
gesia during front limb surgery in dogs and cats, scientific evidence to support the use of a specific block for
any specific procedure is currently lacking.
REFERENCES
1. Tufvesson G. Anestesi av plexus brachialis. Nord Vet Med 1951; 3:183-193.
2. Skarda RT. Local and regional anesthetic and analgesic techniques: Dogs. In: Thurmon JC, Tranquilli WJ, Benson
GJ, eds. Lumb & Jones’ Veterinary Anesthesia. 3rd ed. Baltimore: Williams & Wilkins, 1996:426-447.
3. Lemke KA, Creighton CM. Paravertebral blockade of the brachial plexus in dogs. Vet Clin Small Anim 2008;
38,1231-1241.
4. Moens NM, Caulkett NA. The use of a catheter to provide brachial plexus block in dogs. Can Vet J 2000; 41:685-
689.
5. Futema et al. A new brachial plexus block technique in dogs. Vet Anaesth Analg 2002; 29, 133-139.
6. Wenger S, Moens Y, Jaggin N, Schatzmann U. Evaluation of the analgesic effect of lidocaine and bupivacaine used
to provide a brachial plexus block for forelimb surgery in 10 dogs. Vet Rec 2005; 156:639-642.
7. Mahler SP, Reece JLM. Electrical nerve stimulation to facilitate placement of an indwelling catheter for repeated
brachial plexus block in a traumatized dog. Vet Anaesth Analg 2007; Vet Anaesth Analg 2007; 34:365-370.
8. Mahler SP, Adogwa AO. Anatomical and experimental studies of brachial plexus, sciatic, and femoral nerve-loca-
tion using peripheral nerve stimulation in the dog. Vet Anaesth Analg 2008; 35:80-89.
9. Campoy L, Martin-Flores M, Looney AL, et al. Distribution of a lidocaine-methylene blue solution staining in
brachial plexus, lumbar plexus and sciatic nerve blocks in the dog. Vet Anaesth Analg 2008; 35:348-354.
10. Campoy L et al. Ultrasound-guided approach for axillary brachial plexus, femoral nerve, and sciatic nerve blocks
in dogs. Vet Anaesth Analg 2010; 37:144-153.
11. Pippa P, Cominelli E, Marinelli C, Aito S. Brachial Plexus block using the posterior approach. Eur J Anaesthesiol
1990; 7:411-420.
12. Rucci FS, Pippa P, Barbagli R, Doni L. How many interscalenic blocks are there? a comparison between the later-
al and posterior approach. Eur J Anaesthesiol 1993; 10:303-307.
13. Panti A, Novello L. Nerve locator aided brachial plexus block in puppy using a dorsal access (abstract). Proceed-
ings of 3rd ISVRA Annual Conference – Pordenone – Italy, September 23rd-24th 2006. VRA 2006; 4(2):27-33.
14. Lemke KA, Dawson SD. Local and regional anesthesia. Vet Clin North Am Small Anim Pract 2000;30:839-57.
15. Bagshaw HS, Larenza MP, Seiler GS. A technique for ultrasound-guided paravertebral brachial plexus injections in
dogs. Vet Radiol Ultrasound 2009; 50:649-654.

16. Hofmeister HE, Kent m, Read MR. Paravertebral block for forelimb anesthesia in the dog – an anatomic study. Vet
Anaesth Analg 2007, 34, 139-142.
17. Trumpatori BJ, Carter JE, Hash J, Davidson GS, MathewsKG, Roe SC, Lascelles BDX. Evaluation of a mid-
humeral block of the radial, ulnar, musculocutaneous and median (RUMM Block) nerves for analgesia of the dis-
tal aspect of the thoracic limb in dogs. Vet Surg, in press..
18. Bouaziz H, Narchi P, Mercier FJ, Labaille T, Zerrouk N, Girod J, Benhamou D. Comparison between convention-
al axillary block and a new approach at the midhumeral level. Anesth Analg 1997;84:1058-1062.
Pros and cons of epidurals with local

for orthopaedic surgery
Lorenzo Novello, Med Vet, Dip ESRA, MRCVS
President of the Italian Society of Veterinary Regional Anaesthesia and Pain Medicine (ISVRA, at www.isvra.org),
and clinical anaesthetist at Referenza Carobbi Novello, novello@isvra.org
Epidural administration of analgesics has proven to be effective in relieving pain confined to the inferior/
caudal part of the body in both humans and small animals. In addition, many studies have pointed out ben-
efits of using the epidural route to provide analgesia in surgical and trauma patients. Epidurally adminis-
tered analgesics provide longer and more effective analgesia with less side effects compared to systemic ad-
ministration. The somatic and autonomic blockade provided by high doses of local anaesthetics blunts the
catabolic response to surgery, preventing stimulation of the hypothalamic-pituitary-adrenal axis and attenu-
ating the cortisol and catecholamine response. However, this depends upon the concentration of local anes-
thetic and the extent of the block. Despite providing complete analgesia, epidural opioids are less effective
than local anaesthetics in blunting the stress response to surgery. Although a significant reduction in corti-
sol occurs, circulating concentrations of catecholamine and metabolites are not modified. In the postopera-
tive period combinations of local anaesthetics and opioids are more effective than opioids alone.
Epidural anaesthesia is a common technique in veterinary patients undergoing surgery of the pelvis, pelvic
limb, perineum and caudal abdomen. Local anaesthetics (e.g. lidocaine, bupivacaine and ropivacaine), opi-
oids (i.e. morphine, fentanyl, butorphanol and buprenorphine-) and alpha-2 agonists (i.e. medetomidine, xy-
lazine, romifidine and clonidine) have been shown to provide effective antinociception/analgesia when ad-
ministered epidurally to dogs and cats.
Although epidural anaesthesia has been reported in awake or sedated animals, it is usually associated with
general anaesthesia. This association allows the surgical procedure to be carried out without causing stress

to the patient, and offers the advantage of a rapid and less painful recovery compared to general anaes-
thesia alone. However, it may result in a greater degree and incidence of hypotension compared to the
epidural block alone. Such hypotension is mainly due to a decrease in venous return, and to attenuation
of the compensatory vasoconstriction of nonanaesthetized sympathetic tone via central depressant effects
of general anaesthetics on the vasomotor center.
Reported side effects and complications of epidural anaesthesia in small animals include urinary retention,
delayed recovery of motor function and/or proprioception, hypotension, hypothermia, local anaesthetic tox-
icity and inadvertent dural (subarachnoid) puncture.
Opioids are often used in preference to local anesthetic agents because side effects possibly are less severe,
duration of analgesia is longer, motor function is preserved, and sympathetic blockade does not occur. How-
ever, current evidence in dogs suggests that local anaesthetics exert beneficial effects on stress response to
surgery, postoperative analgesia, splanchnic circulation, gastrointestinal motility, early oral intake and func-
tional recovery.
Strategies to decrease the incidence of side effects and complications related to epidural administration of lo-
cal anaesthetics and opioids include the following:
PROPER NEEDLE AND TECHNIQUE

An epidural needle (e.g. Thuohy) and a loss-of-resistance (LOR) syringe should be used. The ‘standard’
Tuohy needle has a long, curved tip, but with a rather sharp point at the end, and a close-fitting removable
stylet. The curved needle end permits easier identification of the ligamentum flavum, and is less likely to
puncture the dura compared to spinal needles. A close-fitting stylet is essential to prevent plugging of the
needle tip with skin and failure to recognize loss of resistance. It also decreases the risk of depositing plugs
of skin into the epidural space. Specific LOR syringe, filled with either air or saline, allows reliable recogni-
tion of the epidural space. Although very popular in veterinary anaesthesia, spinal needles (e.g. Quincke,
Yale) and ‘standard’ syringes should be avoided.
In small animals a paramedian, ‘paraspinous’ (lateral) approach to lumbar epidural space and the loss of re-
sistance technique should be used. The Tuohy needle is inserted lateral to the midline at the level of the cau-
dal edge of the spinous process of the vertebra (e.g. L6) next to the interspace of intended level of entry
through ligamentum flavum (e.g. L5-6). Depending on patient characteristics, cranial angulation is 45 to 55
degrees to long axis of the spine below. The needle is walked until the tip hits the ligamentum flavum. Then
the epidural space is identified using the Bromage grip and the loss-of-resistance technique with an air-filled
LOR syringe. The Bromage grip is a vice-like grip of the needle between the thumb and fist. Metacarpal
heads are braced against the back of the patient, and the needle is advanced by gentle, but firm rotation of
the entire hand around the metacarpal heads. As a result, only small, highly controlled movement is possi-
ble without repositioning the hand on the needle. Whilst advancing the needle, a continual compression of
the syringe plunger with a ‘bouncing’ movement is exerted. As soon as the ligamentum flavum is pierced,
resistance to syringe plunger is lost and the needle is halted.
SEGMENTAL EPIDURAL ANAESTHESIA

Segmental epidural anaesthesia was first described by Dogliotti in 1933.1 ‘The space between the vertebrae into
which injection is to be made will be chosen approximately according to the level at which anesthesia is desired. A difference of
two or three spaces up or down will not matter. We know that the injected fluid spreads up and down for a considerable dis-
tance so that it is unnecessary in a given operation to adhere rigidly to one fixed point of injection.’ He also stated that ‘ac-
cording to the height [i.e. level] at which the injection is made and the amount of solution used, so will the extent of the anes-
thetised area vary’. Using a Tuohy needle and the technique described above epidural puncture has been per-
formed safely and effectively at different lumbar interspaces in small animals as well.2-6 In the dog and the
cat segmental epidural anaesthesia allows the administration of smaller doses of local anaesthetic, so that on-
ly the nerve roots supplying a specific area are affected.
DOSE, VOLUME, CONCENTRATION

According to studies with contrast media or dye, epidural solutions tend to spread more in a cranial than
caudal direction.7 However, these studies have limited value because access to the CSF is important in de-
termining the clinical effect of local anaesthetics. Clinically, the blockade tends to be more intense and more
rapid in onset close to the site of injection. In humans, time-segment diagrams reveal that L2 injection re-
sults in a somewhat greater cranial than caudal spread. A delay in L5 and S1 segments is also possible, and
it is likely to be due to large size of these nerve roots. Very little data are available in dogs and cats.
The dose of the local anaesthetic (concentration x volume) determines the spread of the sensory block, as
shown by Bromage. However, providing that the same total dose (mg) of local anaesthetic is administered,
a greater volume of a less concentrated solution produces a more cranial sensory block than a smaller vol-
ume of a more concentrated solution. With regard to motor blockade, dose becomes less important when
diluted solutions are used (e.g. bupivacaine 0.125% or 0.065%), although the intensity of sensory and mo-
tor block will increase with each additional injection. Conversely, increasing concentration will result in re-
duction in onset time and intense motor blockade.
WHICH LOCAL ANAESTHETIC?

In dogs administered 0.5 ml kg-1 of local anaesthetic with adrenaline at L6, duration of action of 0.5% bupi-
vacaine is about double that of 2% lidocaine, although onset of block is similar.8 In addition, lidocaine has
a greater spreading propensity and central effect as reflected by higher incidence of front limb paresis and
sedation.8
In dogs administered 0.3 ml kg-1 of bupivacaine (0.5% and 0.75%) or ropivacaine (0.5% and 0.75%) at lum-
bar level (L3-L7), the motor and sensory block are dose-dependent, with 0.5% ropivacaine producing the
shortest lasting and 0.75% bupivacaine the longest.2 Ropivacaine is slightly less potent, according to lower
incidence of motor block with the 0.5% solution. In addition, 0.5% ropivacaine provides a sensory block that
persists significantly longer than motor block, as reported in humans.2
FLUID RESTRICTION
Fluid administration should be restricted to maintenance rate (2-4 ml kg-1 h-1). In humans, prophylactic treat-
ment with intravenous fluids do not prevent the decrease in arterial pressure after combined lumbar epidur-
al and isoflurane general anaesthesia. Large amounts of intravenous fluids can cause urinary retention by
producing overdistension of the wall of the bladder.
VASOACTIVE DRUGS TO TREAT HYPOTENSION

Hypotension results from a decrease in venous return. In humans, prophylactic administration of ephedrine
may decrease its incidence by maintaining systemic vascular resistance. In addition, atropine has been sug-
gested to maintain heart rate, and phenylephrine has been shown to restore mean arterial pressure during
combined epidural and general anaesthesia. Careful titration of general anaesthetics to maintain a light plane
of anaesthesia is likely to be most effective in preventing hypotension during segmental epidural anaesthe-
sia in dogs and cats. Correction of preoperative hypovolaemia, limiting the extent of sensory block and pro-
moting venous return by patient positioning (e.g. Trendelenburg) are most significant preventing measures.
MONITORING OF NEURAL BLOCKADE

Careful monitoring of onset time, duration and characteristics of each block will help with the definition of
the dose providing the best perioperative conditions with minimal incidence of side effects for any given sur-
gery.
BLADDER EXPRESSION OR TEMPORARY URETHRAL CATHETERIZATION

Urinary retention is the inability to void with a distended bladder. Epidural local anaesthetics cause tempo-
rary atonia of the bladder and loss of bladder sensation, which are usually short-lived. Spinal opioids de-
crease detrusor muscle tone by decreasing sacral parasympathetic outflow, and this results in an increased
bladder capacity. Urinary disturbances are frequently reported after intrathecal or epidural morphine, and
reversed by intravenous naloxone.
Because overfilling affects detrusor contractility, postoperative distension of the urinary bladder should be
avoided to prevent urinary retention. At end of surgery the bladder should be checked, and emptied by man-
ual expression or urethral catheterization if necessary.
REFERENCES
1. Dogliotti AM (1933) A new method of block anesthesia. Segmental peridural spinal anesthesia. Am J Surg 20:107-
118.
2. Feldman HS, Dvoskin S, Arthur GR, Doucette AM (1996) Antinociceptive and motor-blocking efficacy of ropiva-
caine and bupivacaine after epidural administration in the dog. Reg Anesth 21:318-326.
3. Novello L, Stefanelli E, Carobbi B, Scandone M (2005) Doppia osteosintesi in anestesia regionale in paziente ASA
4 (Abstract). Proceedings of 50th Società Culturale Italiana Veterinari Animali da Compagnia (SCIVAC), Rimini,
p.368.
4. Franci P, Brearley JC (2006). Congress of Epidural catheter placement using the paravertebral approach with cepha-
lad angulation: a preliminary study (Abstract). Proceedings of AVA Spring Meeting, Liverpool, p.69.
5. Gamba D (2006) Convulsions after administration of ropivacaine through an epidural catheter in a dog (Abstract).
Veterinary Regional Anaesthesia 2006; 4:27-33 (www.isvra.org).

6. Novello L, Corletto F (2006) Combined spinal-epidural anaesthesia in a dog. Veterinary Surgery; 35:191-197.
7. Hirabayashi Y, Shimizu R, Fukuda H, Saitoh K, Igarashi T (1996) Effects of thoracic vs lumbar epidural anaesthe-
sia on systemic haemodynamics and coronary circulation in sevoflurane anaesthetized dogs. Acta Anaesthesiol
Scand 40:1127-1131.
8. Lebeaux M (1973) Experimental epidural anaesthesia in the dog with lignocaine and bupivacaine. Brit J Anaesth
45:549-555.
R.G. Wiley WVOC 2010, Bologna (Italy), 15th - 18th September • 356
Neural ablation in control of pain

Ronald G. Wiley, M.D., Ph.D.
Professor of Neurology and Pharmacology, Researcher, Vanderbilt University Medical Center 4A-105D,
Veterans Administration Medical Center, Nashville, TN 37232
Traditionally, patients failing pharmacological control of severe pain due to malignancy have been offered
such alternatives as ablative neurosurgical procedures. However, conventional neurosurgical lesions (de-
struction of ascending nerve fibers in the ventrolateral spinal cord) have a checkered track record and sig-
nificant associated morbidity. Recently, molecular neurosurgical techniques have been developed that selec-
tively destroy specific types of neurons in peripheral nerve (resiniferatoxin) or dorsal horn of the spinal cord
(substance P-saporin). Resinifertoxin destroys the cell bodies and/or the processes of primary afferent noci-
ceptor neurons that express the capsaicin receptor (TRPV-1). Substance P-saporin selectively destroys noci-
ceptive neurons in the superficial dorsal horn of the spinal cord that express receptors for the neuropeptide,
substance P. Both agents have been shown clinically effective in dogs with pain due to bone malignancy, pro-
viding pain relief until they succumb to systemic metastatic disease. Given the excellent side effect profile in
pre-clinical testing, substance P-saporin is a promising agent for a wide range of chronic pain problems not
adequately relieved by more conventional treatments.
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SEMINAR
359 • WVOC 2010, Bologna (Italy), 15th - 18th September J.F. Bardet
Can we prevent medial comportment disease

using a proximal ulnar osteotomy?
Jean François Bardet, DVM, Ms, DECVS
32 Rue Pierret, 92200 Neuilly sur Seine - France
Medial Comportment Disease (MCD) was recently recognized as a full thickness erosion of the coronoid
process and medial humeral condyle associated with elbow dysplasia1. The incidence of MCD is not known
but MDC is rarely recognized under arthroscopy when treating fragmented coronoid process (FCP) in young
dogs but almost systematicly with advanced stages of osteoarthritis of the elbow. The patophysiology of MDC
is not known exactly but elbow incongruity such as radioulnar step defects, humeroulnar incongruence, varus
deformity, or imbalance between skeletal and muscular mechanics may contribute to MDC.
The proximal dynamic ulnar osteotmy (PDUO) was initialy designed to treat radial shortening associated
with FCP and elbow dysplasia2 described by Wind in 19863. Further study compared the clinical and radi-
ographic resutls between the surgical treatment alone of FCP with those of the surgical treatment associat-
ed with the PDUO4.
OBJECTIVE
To evaluate the clinical and radiographic outcomes of dogs with elbow dyplasia and fragmentation of the
medial coronoid process (FCP) treated with surgical excision of a fragmented médial coronoid procès (SE-
FCP) and dynamic ulnar osteotomy (DUO) or treated with SEFCP alone.
STUDY DESIGN
Retrospective analysis of medical records and radiographs from patients treated between 1990 and 2000.
ANIMAL POPULATION
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One hundred nineteen dogs that underwent unilateral (n=64) or bilateral (n=55) SEFCP for a total of 174
elbow joints. Forty-five of these joints were operated consecutively with SEFCP and DUO. The other 129
joints only underwent SEFCP.
METHODS
Gait observation and orthopedic examination were conducted before surgery, at two and six mouths after
surgery, and yearly thereafter. The amout of degenerative joint disease was evaluated on radiographs made
before and six months after surgery. Outcomes in the two treatment groups were compared using Chi
Square, Fisher exact test, and Kaplan-Meier survival analysis.
RESULTS
Follow-up evaluations were available at two months, and at one year or more after surgery for 60, 75, and
83 patients, respectively. The clinical outcome after SEFCP and SEFCP and DUO did not differ at two and
six months (P=0.192 and 0,439) but was better after SEFCP and DUO (100% good outcome) compared to
SEFCP (88% good outcome, P=0.032) at one year or more after surgery. The clinical outcome after SE-
FCP was better when dogs were operated before eight mouths of age (92% good outcome) than after eight
mouths of age (68% good outcome, P=0,022). Anconeal process osteophytes did not differ between treat-
ment groups before surgery (P=0.238) but were larger in SEFCP group than in the SEFCP and DUO
group after surgery (P=0.046).
CONCLUSIONS
The clinical and radiographic outcomes after SEFCP and DUO were beter than the clinical outcome after
SEFCP only. The clinical outcomes were improved when dogs were had SEFCP before eight month of age
compared to after eight mouths age.
DISCUSSION
The cause of elbow dysplasia remains controversial but incongruency is currently believed to be a a major
factor. Diagnosis of elbow joint incongruency can be difficult. Plain radiography is unreliable for the detec-
tion of subtle incongruency. Incongruency can be identified by arthroscopy. However, the technique is in-
vasive, limiting its usefuleness as a screening tool. Computed tomography (CT) became the standard to eval-
J.F. Bardet WVOC 2010, Bologna (Italy), 15th - 18th September • 360
Preosteotomy Postosteotomy
uate joint incongrency althougth it is not always present at the time of diagnosis. Recent research showed
no correlation between elbow joint incongrency and MCD5. Because of unproven, measurable cause of
MCD, PDUO is not currently recomanded as a preventive procedure of MDC. We currently reserve it to
treat refractory lamenesses in dogs with obvious elbow incongrueny not responding to conventional teatm-
nent using arthroscopy.
REFERENCES
1. Schulz KS: Diagnostic assessment of the elbow (when in doubt, scope the elbow). Proc 14th Annual American Col-
lege of Veterinary Surgeons Symposium, Denver, CO, October 2004.
2. Bardet JF et al. La fragmentation du processus coronoïde chez le chien. Prat Med Chir Anim 1996; 31: 451-63.
3. Wind AP et al. Elbow incongruity and developmental elbow diseases in the dog: Part II. J Am Anim Hosp Assoc
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1986; 22: 725-30.

4. Bardet JF: Dynamic Ulnar Osteotomy for Treatment OFMCP: outcome for 45 canine elbow joints. Proc 11th ES-
VOT Symposium, Munchen, Germany, Sep 2003.
5. KramerA et al. Computed Tomographic evaluation of Canine Radioulnar Incongruence In Vivo. Vet Surg; 2006:
35;24-29, 2006.
The role of arthroscopy in the treatment of cartilage erosion

Arthroscopy plays a number of key roles in the treatment of cartilage erosion. The first and most critical
role is that of definitive diagnosis and comprehensive assessment of the nature and extent of the joint pathol-
ogy. The author recommends that each joint undergoing arthroscopy should be assessed in a “compart-
mental” method where each anatomic compartment of the joint of interest is evaluated and each structure
in the compartment scored or graded for pathologic changes. These changes should then be recorded in the
medical record using a data sheet and via arthroscopic imaging. With respect to cartilage pathology, we use
the following system:
Smooth surface – Outerbridge 0 0

Slightly fibrillated/roughened surface – Outerbridge 1 1
Fibrillated surface with focal partial thickness lesions – Outerbridge 2 2
Deep lesions with surrounding damage – Outerbridge 3 3
Large areas of severe damage – Outerbridge 4 4
Macroscopic cartilage scoring for each compartment, based on original Outerbridge

Classification (Outerbridge 1961) and Mastbergen et al Rheumatology 2
Because “the joint is an organ” comprised of many tissues that all play integral roles in health and disease,
it is critical that all other tissues be assessed in each compartment as well.
With respect to treatment of cartilage erosion, there are a number of arthroscopic-assisted methods that can
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be beneficial to veterinary patients. The first arthroscopic-assisted treatment that is done in essentially all
cases is that of lavage or joint “washout.” Lavage alone can have lasting beneficial effects on joints with car-
tilage erosions. Abrasion arthroplasty is another treatment option to consider. Abrasion arthroplasty is most
helpful for “smoothing” severely fibrillated areas to address mechanical factors associated with the cartilage
lesion and for removing abnormal cartilage and bone such as in cases of OCD. Microfracture or microp-
icking can be done in conjunction with abrasion arthroplasty or as a separate treatment. Microfracture is de-
signed to allow connective tissue progenitor cells from bone marrow to infiltrate the cartilage defect and help
create a fibrocartilaginous repair tissue. This treatment is best suited for contained lesions with good sub-
chondral bone architecture.
There are new cell, tissue, scaffold and tissue-engineering treatments for cartilage erosions being developed
that may have clinical application for veterinary patients. Arthroscopy will play a major role in determining
candidates for various procedures as well as providing the mechanism by which these treatments are deliv-
ered.
Lastly, second-look arthroscopy is an important outcome measure for assessing the progression of cartilage
pathology, the effects of treatments employed, and the need for further intervention in patients with carti-
lage injury and disease. At the current stage of knowledge and imaging capabilities in veterinary medicine,
second-look arthroscopy is irreplaceable in my opinion and experience for postoperative assessment of pa-
tients with cartilage erosion.
How would I treat MCD in dogs?

Medial Compartment Disease (MCD) of the canine elbow is a common problem for which there are many treat-
ment options. Unfortunately, none of these current therapeutic options are consistently successful in re-
turning patients to full function and retarding the progression of disease in affected elbows. In addition, there
have been few, if any, cohort or controlled studies comparing outcomes among the various treatments. As
such, treatment algorithms for MCD are based entirely on individual clinician’s experiences and opinions.
The algorithm I currently use based on my experiences and opinion is as follows:
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The specifics for each component of the algorithm will be outlined in the presentation. Of course, a patient-
specific, client-specific approach is recommended and the algorithm may have to be altered accordingly
based on a number of different factors. These will be discussed with examples presented.
How I treat Medial Compartment Disease

Noel Fitzpatrick, DUniv MVB CSAO CVR MRCVS
INTRODUCTION
Various independent primary disease manifestations may contribute to pathology of the medial compart-
ment of the canine elbow joint - Medial Compartment Disease (MCD). These include disease of the medi-
al aspect of the coronoid process, osteochondrosis (OC) / osteochondritis dissecans (OCD) of the medial
humeral condyle, and elbow incongruity (EI). These primary disease processes may occur alone or in com-
bination, and through a range of severity or locations, leading to a diverse spectrum of identifiable primary
and secondary pathological features. This spectrum intuitively necessitates an equally diverse armory of
therapeutic options for their management.
Disease of the medial aspect of the coronoid process

Various diagnostic imaging modalities may be of merit. However, diagnosis of medial coronoid disease is fre-
quently based on identification of secondary markers of degenerative joint disease in the absence of other
overt primary pathologies. Thorough clinical evaluation may be as important as subsequent diagnostic im-
aging techniques, especially since a proportion of elbows with medial coronoid disease may be radiographi-
cally normal. Evaluation of discomfort on elbow manipulation, particularly on firm supination of the ante-
brachium while the elbow is held in moderate flexion, is highly specific to disease of the medial compartment
of the canine elbow. Application of deep digital pressure in the region of the insertion of the bicep brachii mus-
cle over the medial aspect of the coronoid process may also be helpful. A positive result to these tests alone
in the absence of any other identified source of lameness or pain may represent adequate justification for in-
tervention by arthroscopy or arthrotomy. In my hands, clinical decision making is primarily based on a com-
bination of clinical findings (including historical and signalment data), detailed radiography of bilateral elbows
(to determine likely chronicity, severity of subchondral disease and presence of osteochondrosis), CT in se-
lected cases and thorough arthroscopic evaluation of all cases. The spectrum of arthroscopic changes associ-
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ated with medial coronoid disease may include fragmentation, cartilage fissures, chondromalacia and cartilage
fibrillation but these are all manifestations of a common underlying disease process, specifically that of me-
chanical overload and resultant microfracture of the medial aspect of the coronoid process.
NON-SURGICAL MANAGEMENT
Non-surgical management is based on a moderated exercise routine, body weight control, judicious use of
NSAIDs or other analgesics, and provision of “nutraceuticals” or “disease modifying compounds” (e.g. glu-
cosamine and chondroitin sulfate, pentosan polysulphate). Adjunctive therapies such as hydrotherapy, mas-
sage, Trans-cutaneous Electrical Nerve Stimulation – TENS, acupuncture and holistic, magnetic and “alter-
native” therapies may play a role in some patients. In my hands, non-surgical management is typically re-
served for elbows with minimal clinical, radiographic and arthroscopic anomalies, or in cases where logisti-
cal, financial or systemic disease processes preclude surgical intervention. However, I routinely recommend
consideration of these modalities as beneficial adjuncts to surgical management.
BICEPS ULNAR RELEASE PROCEDURE (BURP)

BURP involves tenotomy of the distal insertion of the biceps brachii/brachialis complex. I consider BURP
when rotational instability with excessive supination loading force (one of several etiopathogenic hypothe-
ses) is suspected based on focal subchondral pathology of the medial aspect of the coronoid process in the
region of the radial incisure. Clinically, this includes limited fissure formation in this region without overt
fragmentation or osseous incongruity, or where there is a high index of suspicion that dynamic incongruity
is the underlying cause of MCD (typically juvenile dogs with bilateral elbow pain/lameness and minimal
arthroscopic changes bilaterally, or with minimal arthroscopic changes affecting the elbow contralateral to
an elbow overtly affected by fragmentation). The biomechanical effects of BURP, whether it can alter dis-
ease progression, or reduce persistent frictional abrasion of the medial compartment remain to be elucidat-
ed, but clinical outcomes in a substantial number of cases to date have been rewarding.
SUBTOTAL CORONOID OSTECTOMY (SCO)

Since visible cartilage pathology does not accurately reflect subchondral pathology, and since pain and lame-
ness can occur without breach of the cartilaginous barrier, there is a strong argument that treatment should
be targeted toward addressing subchondral pathology, rather than at removal of loose fragments or stimu-
lating fibrocartilage infilling of superficial lesions. My preference for local treatment of “end stage” medial
coronoid disease where the subchondral changes are sufficiently severe as to be considered irreversible
(based on presence of major fissures, fragmentation, full thickness cartilage eburnation) is SCO – removal
of a pyramidal portion of the medial aspect of the coronoid process extending to include the entirety of the
articular portion distal to the level of the radial incisure. This includes the full extent of commonly recog-
nized cartilage pathology and the areas of most dense subchondral pathology based on previous histomor-
phometric studies. Positive clinical outcomes have been documented in a recently published large case se-
ries. I consider SCO alone to be appropriate even in the presence of some degree of focal cartilage lesions
of the medial humeral condyle (modified Outerbridge grade <III).
PROXIMAL ULNAR OSTEOTOMY

There is some argument to address perceived joint incongruency or abnormal dynamic loading underlying
medial coronoid disease by techniques such as corrective ulnar osteotomy. However, the optimal configura-
tion and location of osteotomy remains unknown and the biomechanics of such osteotomies are complex.
Where there are relatively focal lesions of frictional abrasion associated with the medial aspect of the humer-
al condyle (“humero-ulnar conflict”) of modified Outerbridge grades III-V, or where definitive humero-ra-
dial incongruity is evident on CT or arthroscopic assessment, I perform a double-oblique (caudo-proximal
to cranio-distal) proximal ulnar osteotomy which in my hands is associated with minimal morbidity beyond
the inevitable increased lameness for the first several weeks after the procedure. In such cases, focal treat-
ment of the medial aspect of the coronoid process such as by SCO is invariably also indicated by the irre-
versible severity of subchondral or cartilage pathology present. I do not perform ulnar ostectomy unless
>4mm humero-radial incongruity is definitively identified.
Disease of the medial humeral condyle

OC/OCD is a well recognized disease of the medial compartment of the elbow, and concomitance with me-
dial coronoid disease is frequent (>90% of all cases with OC/OCD), perhaps reflecting a potential role for
incongruity in aetiopathogenesis of both diseases. Varying degrees of cartilage erosion (“kissing lesions”) of
the adjacent medial humeral condyle are also common. Perceived ongoing mechanical overload and the fric-
SA ARTHROSCOPY
tional environment of the medial joint compartment makes it unlikely that fibrocartilage ingrowth from sub-
chondral bone in this region (such as that stimulated by local osteostixis) would be able to provide sub-
stantial or durable protection of the subchondral bone plate. This has been supported by second-look arthro-
scopic imaging performed in a number of “locally treated” cases.
DÉBRIDEMENT / OSTEOSTIXIS
I still apply conventional local treatments (including non-surgical management, curettage, microfracture and
micropicking) aimed at stimulation of fibrocartilage ingrowth for treatment of small (typically <5mm diam-
eter), shallow (typically <1mm subchondral bone depth defect) or abaxial OCD lesions where prognosis is
anecdotally considered positive. Treatment of medial coronoid disease is simultaneously performed as
above.
OSTEOCHONDRAL AUTOGRAFT TRANSFER (OAT) /

SYNTHETIC OSTEOCHONDRAL CORE (SOC)
For treatment of larger OCD lesions, particularly those >5mm diameter or with a deep subchondral defect,
I aim to reconstruct articular topography using OAT procedures (osteochondral donor core from the stifle
joint) or polyurethane SOCs. Both have documented positive clinical outcomes including to > 3 years in the
case of OAT procedures. In rare instances where medial coronoid disease is not identified or suspected by
any imaging modality, OAT/SOC will be performed in isolation. However, suboptimal clinical and arthro-
scopic outcomes, associated with ongoing cartilage eburnation throughout the medial joint compartment
(further indication of underlying mechanical aetiopathogenesis), have been documented where concomitant
medial coronoid disease is identified, even where SCO is performed. I therefore routinely protect the OAT
graft / SOC by simultaneous performance of both SCO and a double-oblique proximal ulnar osteotomy as
above.
SLIDING HUMERAL OSTEOTOMY (SHO)

In a small but significant proportion of dogs, medial coronoid disease is associated with severe lesions asso-
ciated with “humero-ulnar conflict”. The typical appearance is of full thickness (modified Outerbridge grade
V) cartilage pathology across the major portion of the medial joint compartment, affecting both the medial
humeral condyle and the corresponding disto-medial ulnar contact area. These patients invariably exhibit
severe, chronic lameness and elbow pain and long-term prognosis is considered severely guarded following
local treatment. Even if underlying incongruity could be reliably corrected, formation of a durable fibrocar-
tilage barrier between synovial fluid and subchondral bone, or reconstruction of articular contour would be
improbable due to the severity of preexisting changes.
In this circumstance, I use SHO (featuring a stepped, medially-applied locking plate construct to the humer-
al diaphysis) to transfer load bearing forces away from the medial joint compartment toward the relatively
healthy lateral joint compartment. Outcomes of short-, medium- and long-term clinical application in >140
elbows to date (including across a wide range of patient ages and body weights) have been positive with on-
going assessments being continually performed. Arthroscopic and histological documentation of novel fi-
brocartilaginous cover of previously eburnated regions, in combination with in vitro data, provides evidence
of efficacious unloading of the medial compartment. More recently, return of mean Peak Vertical Force at
forceplate gait analysis to 97.5% of the contralateral limb within 12 weeks post-operatively has been docu-
mented. While the initial learning curve for this salvage procedure may be steep, overall complication rate
in recent cases has been low, with only 1/30 recent cases requiring surgical revision (implant removal due to
infection).
TOTAL ELBOW ARTHROPLASTY (TEA)

In a very small proportion of dogs, both medial and lateral joint compartments may be severely diseased,
with extensive eburnation of cartilage and subchondral bone of all major articular structures. In this cir-
cumstance, salvage procedures such as TEA or joint arthrodesis may represent the only viable options for
restoration of comfortable limb function. Following experiences with both the Biomedtrix™ and TATE™
arthroplasty systems, I currently favour the TATE system although the incidence of major complications or
failure for all commercially available systems remains of concern.
BIBLIOGRAPHY
1. Danielson KC, Fitzpatrick N, Muir P, et al: Histomorphometry of fragmented medial coronoid process in dogs: a
comparison of affected and normal coronoid processes. Vet Surg 35: 501-509, 2006.
2. Fitzpatrick N, Smith TJ, Evans RB, et al: Radiographic and arthroscopic findings in the elbow joints of 263 dogs
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with medial coronoid disease. Vet Surg 38: 213-223, 2009.
3. Fitzpatrick N, Smith TJ, Evans RB, et al: Subtotal coronoid ostectomy for treatment of medial coronoid disease in
263 dogs. Vet Surg 38: 233-245, 2009.
4. Fitzpatrick N, Yeadon R, Smith TJ: Early clinical experience with osteochondral autograft transfer for treatment of
osteochondritis dissecans of the medial humeral condyle in dogs. Vet Surg 38: 246-60, 2009.
5. Fitzpatrick N, Yeadon R, Smith T, et al: Techniques of application and initial clinical experience with sliding humer-
al osteotomy for treatment of medial compartment disease of the canine elbow. Vet Surg 38:261-278, 2009.
6. Fitzpatrick N, Yeadon R: Working algorithm for treatment decision making for developmental disease of the medi-
al compartment of the elbow in dogs. Vet Surg 38: 285-300, 2009.
C. Grußendorf WVOC 2010, Bologna (Italy), 15th - 18th September • 366
Can we prevent MCD: personal experiences with mid-shaft

ulna osteotomy
C. Grußendorf, I. Gröngröft
Tiergesundheitszentrum Grüssendorf, Bramsche Germany
In medium to large breed dogs medial compartment disease is often seen. In severe cases a step between
the articular surface of the ulna and the articular surface of the radius can be noticed on radiographs of the
elbow and a marked joint effusion of the elbow is palpable. In less severe cases no step can be noticed on
the radiographs but a slight sclerosis of the ulna is visible as well as discomfort of the dog while using the
stress test of the medial ulna coronoid. In these cases a very small step might be visible only during
arthroscopy of the elbow. Usually, the articular surface of the ulna stands slightly above the articular sur-
face of the radius. In theses case we use a mid-shaft ulna osteotomy to create more space in the joint. Af-
ter a diagnostic arthroscopy and taking out possible fragmented coronoid processes an approximately 8 to
12mm piece, depending on the size of the dog, is cut out of the mid-shaft of the ulna by using an oscillat-
ing bone saw. No fixation of the ulna is used. While walking on the leg the ulna does not shorten by the
length of the bone piece like we expected in the first place but the distal tip of proximal part of the ulna is
shifting laterally and caudally. With this movement a wider joint space is created at the medial compart-
ment and the articular surfaces of both bones reach approximately the same level and in the long term the
dog is able to walk lame free.
If necessary we perform this surgery on both legs at the same time and the patients are able to leave the hos-
pital the same evening with only slight discomfort. Depending on the height of the joint step the dogs are
allowed different grades of activity after surgery: if the step was big quite some exercise is needed directly
after surgery to allow enough movement of the ulna to widen the joint space sufficiently. In general the ul-
na has healed completely within four to six weeks. Usually we see the patients after four and eight weeks
post op for control radiographs.

The risk of too much movement of the ulna can be reduced by calculating the cut out bone piece not too
SA ARTHROSCOPY
long as well as taking care not to cut the ulna too low as in this case the pull of the triceps gets too strong
and the leverage force grows too strong.
In our hands 60 of the dogs presented early enough, meaning at the age of six to eight month with medial
compartment disease benefit greatly from this surgery.
367 • WVOC 2010, Bologna (Italy), 15th - 18th September H. Kriegleder
Acute medial coronoid disease in older dogs:

diagnostic and therapeutic difficulties
Hannes Kriegleder, Dr.med.vet.
Dipl. ECVS, BVEtSc(Hons), Fta f.Kleintiere, Unterbrunnerstr. 31, 82131 Gauting, kleintierpraxis@kriegleder.net
Medial coronoid disease is a cause of lameness mainly in young large breed dogs.
It comprises various types of defects of the cartilage and subchondral bone on the medial coronoid.
Acute medial coronoid disease without secondary arthrosis is rarely seen in older dogs and in clinical prac-
tise it is difficult to diagnose without advanced imaging since oftentimes clinical and radiographic exami-
nation is not diagnostic.
Four dogs (labrador, 2 mix breed, münsterlander) with a mean weight of 28 kg and a mean age of 8 years
are presented with acute medial coronoid disease.
2 dogs had coxarthrosis, in 2 dogs a trauma was noticed by the owner before the onset of the lameness.
Lameness was seen mainly after exercise and rest and could be localized clearly to one side by the owner.
Its duration was chronic (mean: 4 months) and all dogs received longterm nonsteroidal and steroidal med-
ication with no response.
Clinical examination was not diagnostic in all cases. In 2 dogs only strong digital pinpoint pressure on the
medial coronoid could elicit a slight pain reaction.
Radiographic examination of both forelimbs including the cervical spine was normal in 3 dogs. 1 dog had
arthosis of the shoulder at the ipsilateral side. Elbows were normal in all four dogs with no signs of arthro-
sis or subtrochlear sklerosis.
Since owners declined further special diagnostic imaging diagnostic arthroscopy of the elbow was per-
formed for exclusion of a coronoid lesion .
In all dogs a transverse fissure in the cranial third of medial coronoid was seen. The cartilage cranial to it
until the tip of the coronoid appeared malacic and curettage revealed also malacic subchondral bone ( Os-
teochondromalacia). A partial coronoidectomie was performed arthroscopically. The dogs were sound with-
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in a period of 3 weeks. Arthroscopic second look in one dog after 12 months showed medial compartment
sydrome of the elbow.
Histology of the medial coronoid in two cases showed fibrosis and hyperplasia of the subchondral bone:
CLINICAL RELEVANCE / DISCUSSION

1. In older dogs acute medial coronoid disease is a possible cause of persistent forelimb lameness which is
nonresponsive to antiinflammatory medication. Clinical examination is inconclusive, radiographs of the
elbow are normal
2. A traumatic origin due to overload (coxarthrosis) or jumping is suspected.
3. diagnostic arthroscopy shows osteochondromalacia of the medial coronoid
4. Partial coronoidectomy results in resolution of the lameness shortterm
5. Longterm secondary arthrosis and medial compartment disease is seen
6. The author questions if longterm nonsteroidal resp. steroidal medication might lead to increased sub-
chondral bone bleeding and thus promote osteochondromalacia of the medial coronoid.
H. Kriegleder WVOC 2010, Bologna (Italy), 15th - 18th September • 368
Rupture of the biceps tendon:

difficulties in diagnosis, treatment and outcome
Hannes Kriegleder, Dr.med.vet.
Dipl. ECVS, BVEtSc(Hons), Fta f.Kleintiere, Unterbrunnerstr. 31, 82131 Gauting, kleintierpraxis@kriegleder.net
Partial or complete rupture of the biceps tendon (RBT) is a possible cause of forelimb lameness (FL), main-
ly in large breed dogs. Diagnosis is established through a combination of clinical examination (bizeps-test),
ultrasound, radiography, arthrography and arthroscopy. Current treatment of partial RBT is arthroscopic
tenotomy.
Various difficulties at diagnosis and treatment of partial, resp. complete RBT are presented in 3 dogs.
1. GSD, 6y, mcast, 45 kg, history: acute FL right, diagnosis: clinical exam
Difficulty in arthroscopic diagnosis: at arthroscopy all joint structures including the biceps tendon (BT)
were normal during inspection of the shoulder joint in a standard lateral position. A partial rupture of BT
could only be visualized in the distal part after repeated palpation of the BT and extension of the shoulder
joint. Tenotomy of the BT was curative.
2. Bernese mountain dog, 2 y, m, 55 kg, history: acute FL right, diagnosis: clinical exam, ultrasound,
Difficulty in arthroscopic treatment: a partial (50%) RBT was diagnosed at arthroscopy, Tenotomy of the
remaining half was unsucessful after repeated attempts with hocked scissors and a straight knife due to close-
ness of the instrumental portal to the tendon and failure to grasp the tendon firmly. The tendon had to be
transected through an open approach.
3. Bernese mountain dog, 8 y, 40 kg, m, history: chronic FL right for 3 months after an acute onset. diag-
nosis: clinical examination, radiography: arthrosis of the shoulder joint
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Difficulty in outcome: At arthroscopy a complete rupture of the biceps tendon was diagnosed. The stump
of the tendon was firmly adhered to the joint capsule and after freeing it surgically through an open ap-
proach the dog was sound.
CLINICAL RELEVANCE
1. Arthroscopic diagnosis: distal partial tears in the biceps tendon can be overlooked at arthroscopy of the
shoulder joint in a standard lateral position and can only be visualized after thorough inspection of the
BT in extension of the joint.
2. For arthroscopic tenotomy of the biceps tendon it is important to have the instrumental portal proximal
and distant to the BT
3. After transection of the BT persistent lameness can be caused by adheasion of the tendon stump to the
joint capsule which should be freed surgically
369 • WVOC 2010, Bologna (Italy), 15th - 18th September M. Olivieri
Clinical experiences about treatment of medial

compartment disease with proximal ulnar osteotomy
Massimo Olivieri, DVM, PhD
Malpensa Small Animal Veterinary Clinic, Varese (Italy)
INTRODUCTION
Medial Compartment Disease (MCD) is a condition affecting the elbow of dysplastic dogs. It can be isolat-
ed or associated to FCP and / or OCD. In the past many treatments have been used for this condition with-
out significant results.
The study started by the preliminary arthroscopic observation that in dogs affected by MCD during weight-
bearing simulation the pathologic cartilages of the humerus and ulna interfere during normal joint move-
ment (humero-ulnar conflict)1. According to this evidence, the author decided to approach this conflict with
a proximal Dynamic Ulnar Osteotomy (DUO).
The aim of the study is to evaluate the clinical long term functional results of 94 dogs with MCD treated
with DUO. In the initial 18 cases a second arthroscopy was performed 2.5 months following initial surgery.

The clinical records of 94 cases of MCD submitted for arthroscopic evaluation between January 2001 and
January 2009 were selected. Criteria for inclusion in this study were clinical and radiographical signs of El-
bow Dysplasia (ED), the arthroscopic evidence of MCD, no treatment of the erosion but its handling by a
DUO. All the dogs had a Robert Jones bandage in the first 7 days, and than a splint was applied until con-
solidation of the osteotomy. In the first 18 cases a second look arthroscopy was performed after 2.5 months
from the osteotomy.
Criteria for exclusion were cartilage lesion of the radial head and sclerosis of the subchondral bone.
RESULTS
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Arthroscopic inspection showed the presence of cartilage erosion of the under surface of the medial humer-
al condyle and opposing surface of the medial coronoid of the ulna . By simulating weightbearing1 it was
possible to demonstrate in all the joints that the pathologic joint cartilages interfere during normal joint
movements, creating a “conflict area” (humero-ulnar conflict). Regarding the time necessary to reach con-
solidation of the osteotomy, it was obtained in a range of time between 30 and 120 days.
At second look arthroscopy, good fibrocartilage regeneration was present in all the 18 cases, showing a cov-
ering of nearly 100% of the surface where the subchondral bone was originally exposed. The clinical follow
up showed normal gait and pain free in 86 cases between 30 and 60 days after consolidation of the os-
teotomy while 8 cases remained lame. The same results were confirmed after 6 months and 1 year.
After 6 months a second look arthroscopy was performed in 4 of the 8 cases with persistent lameness. In
these cases fibrocartilage regeneration was very irregular, with areas without fibrocartilage.
DISCUSSION
In this study 94 dogs diagnosed of MCD by an arthroscopic exam were treated by means of DUO. The au-
thors hypothesize that DUO would release the articular “conflict”, allowing to optimize the joint between
the semilunar notch and the medial condyle. This hypothesis was confirmed by the presence of fibrocarti-
lage in all the second look arthroscopies and by normal gait evident after 1 year in 86 out of 94 dogs.
In the present study only 18 of the 68 dogs diagnosed of MCD by an arthroscopic exam performed a sec-
ond look arthroscopy. After the similar results obtained by the author in the 18 cases, it seemed unmotivat-
ed to propose a second look to the other 50 cases. In fact also in the largest group of dogs the clinical results
were similar. Regarding the 8 lame cases it is important to observe that they all had consolidation of the os-
teotomy before 60 days. Comparing these dogs to the others with the same consolidation time, it must be
taken into consideration that these 8 cases were very active dogs, with the owner not able to control their
activity. The author hypothesizes that this could lead to the destroyment of most of the regenerated and ini-
tially delicate fibrocartilage.
REFERENCES
1. Olivieri M. et al.: “Preliminary results of arthroscopic diagnosis and treatment of elbow humero-ulnar conflict (car-
tilage erosion) through proximal ulnar osteotomy”. ESVOT Munich 2006.
M. Olivieri WVOC 2010, Bologna (Italy), 15th - 18th September • 370
Clinical study on shoulder OCD failure

Massimo Olivieri, DVM, PhD
Malpensa Small Animal Veterinary Clinic, Varese (Italy)
INTRODUCTION
Osteochondritis of the humeral head (OCD) is a frequent cause of shoulder lameness in young medium-
large breed dogs.
From the author’s experience, arthroscopy is the treatment of choice as it permits a complete exploration of
the joint, it identifies the location of the flap, its possibile migration and allows to perform a magnified ex-
ploration of the subchondral bed. At the same time, in the cases where the dogs don’t have a complete func-
tional recovery, arthroscopy is very useful diagnostic technique to study the origin of the failure.
Regarding the prognosis of dogs undergoing treatment of OCD of the shoulder, there are few papers avail-
able with scarce indication about the possibile origin of failure.
In the present study, the author analizes the origin of failure of the cases treated between 2002 and 2009.
All these cases underwent a long term clinical evaluation and second look arthroscopy.

The clinical records of 140 cases of OCD of the shoulder joint were examined concerning 140 patients treat-
ed by arthroscopy in the period between January 2002 and January 2009. In this study, the author includes
only the cases with persistent lameness after treatment. These cases underwent clinical follow ups and sec-
ond look arthroscopy. In the present study are not included dogs treated bilaterally.
In all cases a standard lateral arthroscopic approach to the shoulder joint was used and a complete explo-
ration of the joint cavity was carried out, with particular attention to the area where the OCD lesion was
originally present and to the caudal compartment of the joint.
RESULTS
In the present work, lameness completely disappeared within 10-20 days in 9 cases, 21-40 days in 58 cases
SA ARTHROSCOPY
and finally 41-60 days in 61 cases. In 12 cases lameness was still present after 4 to 5 months after surgery.
In all these 12 cases arthroscopic inspection showed the absence of fibrocartilage regeneration in the area of
OCD lesion. In 3 cases chronic villonodular iperemic synovitis was present while the subchondral bed had
chondromalacic fibrocartilage with vascularized subchondral bone. The lesions were curetted while the syn-
ovium vaporized. These dogs recovered after 2 months. In the other 9 cases arthroscopic signs of caudal
shoulder instability were found, with cartilage erosion of the caudal part of the humeral head and of the cor-
responding part of the caudal glenoid. In the 12 dogs affected by persistent lameness, it was also pointed out
that all the cases presented a caudo - central (type I) lesion1.
DISCUSSION
In the present work, the author studied the possible causes of OCD treatment failure. In the literature, there
are few reports about OCD treatment of the shoulder joint, with few indications about the possible origin
of failure2-3. In a previous study1 the author noticed that, in some cases in the first weeks after surgery, after
OCD removal, the absence of cartilage in the presence of load directly on the subchondral bone constitutes
a negative factor: as a result, during load, the new growing and soft fibrocartilage is in continuous friction
with the caudal rim of the glenoid cavity. According to this consideration, with the second look of this study,
the author hypothesize that this is the main predisposing factor in the failure of fibrocartilage regeneration
and soon after, in more complicated cases, caudal instability could begin. It is important to observe that all
these 12 dogs were hyperactive, living free in the garden. This can predispose the failure.
At the end, in the author’s experience, the use of carpal flexion bandage can help most of these cases if used
at the beginning. It prevents active dangerous loading, and at the same time, allows the execution of passive
joint movements and other physiatric procedures.
REFERENCES
1. Olivieri M et all “Arthroscopic treatment of osteochondritis dissecans of the shoulder in 126 dogs” VCOT 2007;
20(1) 65-69.
2. Van Bree H.J.,Van Ryssen B. Diagnostic and surgical arthroscopy in osteochondrosis lesions. Veterinary Clinics of
North America 1998; 28:161-168.
3. Johnston S.A. Osteochondritis dissecans of the humeral head. Veterinary Clinic of North America 1998; 28,1:33-49.
371 • WVOC 2010, Bologna (Italy), 15th - 18th September J. Rial Cels
Arthroscopy in a case of synovial chondromatosis

in the stifle of a presa canario
Jose Rial Cels
Hospital Veterinario Marina Baixa, Passeig mitja llegua 17 03580 Alfaz del Pi Alicante Spain
jrial@cvmarinabaixa.e.telefonica.net
The synovial chrondromatosis is a rare pathology and with uncertain ethi-

ology in dogs. Radiographic diagnosis is not always possible and it s sim-
ple by arthroscopy. The disease is characterised for the presence of carti-
laginous nodules within the joint. The treatment consistes in removing the
nodules and synovectomy. In case of scarce and small nodules it is possi-
ble arthroscopic loose body removal and synovectomy. If the loose bodies
are large arthrotomy is necessary. The total synovectomy is difficult and
the partial synovectomy produces only a temporary improvement and re-
currence is almost certain. Sometimes, arthrodesis is necessary.
Case: A 6 years old intact female presa canario was presented to our prac-
tice with a 3 weeks history of right hindleg lameness. Swelling and slight
craneal drawer of the knee was observed. Radiographies show intra-artic-
ular radiodensity mostly proximal and distal to the patella. Arthroscopy Synovial Chondromatosis in knee.
reveals multiple loose bodies with different sizes and CrCL partial rup-
ture. Because the size and number of cartilaginous nodules, we decide to
make an arthrotomy, partial synovectomy and an extracapsular technique for the CrCL rupture. The dog
dismissed the day after surgery with bandage for 1 week and instructions for leash walking for 4 weeks. The
lameness improved over 5 weeks after surgery.
In biopsy of synovial membrane were observed signs of metaplasia: fibrosis and cartilaginous infiltration and
mineralization of the synovial membrane. According the owner 3 years after surgery he was satisfied with
SA ARTHROSCOPY
results and the dog needs sporadically antiinflamatory drugs.
Comments: In these case, the synovial chondromatosis is secundary to a degenerative joint disease and Cr-
CL rupture.
J. Rial Cels WVOC 2010, Bologna (Italy), 15th - 18th September • 372
Shoulder instability and glenoid fisure in a small breed dog

Jose Rial Cels
Hospital Veterinario Marina Baixa, Passeig mitja llegua 17 03580 Alfaz del Pi Alicante Spain
jrial@cvmarinabaixa.e.telefonica.net
Shoulder instability is caused by injury of joint capsule, collateral ligaments

and surrounding cuff muscles.
Case: A mixed breed female years old is presented with a history of two
weeks lameness of right forelimb and no response to antiinflamtory drugs.
Painfull shoulder palpation was found. After sedation increase of abduc-
tion range and craneal drawer was observed. Radiographic and CT scan
findings were unremarkable. During arthroscopic examination we noticed
a slight synovitis and a fisure of caudal and lateral glenoid rim and intact
medial glenohumeral ligament and subescapular tendon. With the palpa-
tion hook the attachment of the fragment was checked. The patient was
dismissed the day after surgery with a Velpeau bandage for 7 days and an-
tiinflamatory drugs 21 days (Rimadyl, caprofen 4mg/kg). Instructions of
Glenoid cartilage fisure.
strict excercise restriction for 1 month and gradual increase in controlled
activity was given to the owner. Improvement in lameness was observed
3 weeks after that and 3 years follow up without lameness.
Comments: Without arthroscopic assistance, these intra-articular lesion may been overlooked. Swelling of
the shoulder can cause abduction test without injury of passive and active factors of shoulder stability.
SA ARTHROSCOPY
373 • WVOC 2010, Bologna (Italy), 15th - 18th September G.L. Rovesti
Caudal detachment of the medial meniscus in dogs

with CCL-deficient stifle
Gian Luca Rovesti, drMedVet, dipl. ECVS
Via della Costituzione 10, 42025 Cavriago, Italy
CCL-deficient stifle is subjected to many biomechanical changes. Particularly, menisci are loaded by shear
forces, which make them prone to damage. The caudal horn of the medial meniscus is at high risk, because
of its connection with the tibial plateau.
Animal population: dogs that underwent stifle arthroscopy before CCL procedures.
Arthroscopic procedure: the menisci where explored. When a large bucket handle or caudal detachment of
the medial meniscus was found, the stifle was distracted, and the lesion thoroughly evaluated. When the le-
sion was located in the “red zone”, it was sutured by the outside-inside-outside suturing technique.
Follow up: no arthroscopic follow up was possible. The clinical rechecks were performed, but it is not pos-
sible to differentiate the impact of the meniscal suture from the overall procedure performed for the CCL
disease.
SA ARTHROSCOPY
G.L. Rovesti WVOC 2010, Bologna (Italy), 15th - 18th September • 374
Subtotal coronoidectomy performed arthroscopically

Gian Luca Rovesti, drMedVet, dipl. ECVS
Via della Costituzione 10, 42025 Cavriago, Italy
Fragmentation of the coronoid process (FCP) is one of the most frequent diseases affecting the elbow of mid-
dle to large size dogs. Beyond the removal of the detached fragments, the removal of the whole coronoid
process (subtotal coronoidectomy: SCO) has been advocated under specific circumstances.
Animal population: dogs that underwent elbow arthroscopy for FCP.
Arthroscopic procedure: the joint was explored, and fragments present in the coronoid area were removed.
When the conditions for SCO were met, the procedure was performed under arthroscopic guidance. The
osteotomy line was always judged correct. Fibrous attachment prevented the possibility to free osteotomized
process from its area, and it was too big to be removed by arthroscopic portals. The cranio-medial portal
was then enlarged to 1-2 cm, to be able to retrieve it from the joint by an arthroscopic-assisted arthrotomy.
SA ARTHROSCOPY
375 • WVOC 2010, Bologna (Italy), 15th - 18th September Y. Samoy
Case report: elbow lameness in a young Golden Retriever

Y. Samoy, H. Seghers, I. Gielen, B. Van Ryssen
Department of Medical Imaging and Small Animal Orthopaedics, Faculty of Veterinary Medicine
Ghent University, Salisburylaan 133, 9820 Merelbeke, Belgium, yves.samoy@ugent.be
INTRODUCTION
Elbow OCD is a frequently diagnosed condition in the Golden Retriever. This case report discusses an atyp-
ical evolution of elbow OCD after arthroscopic treatment.
HISTORY
A 5 month old male Golden Retriever was presented with left front limb lameness. The complaints were go-
ing on for 1.5 months. The local veterinarian started with NSAID treatment, without improvement.
Clinical examination demonstrated moderate left front limb lameness, moderate muscle atrophy and mild
to moderate distention of both elbows. The elbows had a mildly limited range of motion. A moderate pain
reaction was noticed when extending both elbows.
RADIOGRAPHIC EXAMINATION
Both elbows were examined.
Both elbows were suspected for ocd.
SA ARTHROSCOPY
COMPUTED TOMOGRAPHY
Computed tomography (CT) showed a bilateral elbow OCD lesion without indications for a fragmented
coronoid process (FCP).
Above: left elbow: OCD lesion on the

medial humeral condyle(left image),
normal medial coronoid process
(right image).
Below: right elbow: sclerotic region on

the medial humeral condyle (left image),
normal medial coronoid process
(right image).
Y. Samoy WVOC 2010, Bologna (Italy), 15th - 18th September • 376
ARTHROSCOPY
Both elbows looked similar: A moderate degree of synovitis was present. The medial coronoid process had
a normal aspect. In general the cartilage was white and smooth, except for the OCD lesion on the medial
humeral condyle. Treatment existed in removal of this OCD flap.
Left elbow
OCD lesion removal with a bor end result

Right elbow
SA ARTHROSCOPY
Three months after arthroscopic treatment, the dog had not improved. At this point a second arthroscopy
was performed.
SECOND ARTHROSCOPY
Both left and right the medial coronoid process was fragmented. FCP was bilaterally treated.
Left elbow Right elbow
CONCLUSION
Some lesions lesions are not present or visible in an early stage of the disease. Second look arthroscopy can
be of great help in cases with continuous lameness after treatment.
REFERENCES
1. Gemmill, T. (2004). Completing the picture: use of CT to investigate elbow dysplasia. Journal of Small Animal
Practice 45, 429-430.
2. Reichle, J.K., Park, R.D., Bahr, A.M. (2000). Computed tomographic findings of dogs with cubital joint lameness.
Veterinary Radiology and Ultrasound 41, 125-130.
3. van Bree, H., Van Ryssen, B. (1995). Arthroscopy in the diagnosis and treatment of front leg lameness. Veterinary
Quarterly 17 Suppl 1, S32-S34.
4. Van Ryssen, B., van Bree, H. (1997). Arthroscopic findings in 100 dogs with elbow lameness. Veterinary Record
140, 360-362.
377 • WVOC 2010, Bologna (Italy), 15th - 18th September B. Van Ryssen
Definition and occurence of medial compartment disease

B. Van Ryssen, K. Vermote, H. Seghers, I. Gielen, H. van Bree
Department of Veterinary Medical Imaging & Small Animal Orthopedics
Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820 Merelbeke, Belgium
bernadette.vanryssen@ugent.be, www.orsami.com
Medial compartment disease is understood as extended erosions of the medial compartment of the elbow
joint. In the author’s experience, there are three types:
1. extended erosions in the presence of a fragmented coronoid process (FCP) or medial coronoid disease
(MCD): this type is secondary to the primary lesion of the medial coronoid process and is often seen in
combination with large displaced fragments or chronic lesions. (ps. Better than FCP, the term MCD in-
dicates all lesions of the medial coronoid process: fragment, fissure, chondromalacia.)
2. extended erosions of the medial compartment without an obvious FCP: this type could be called ‘prima-
ry MCD’. Typically this type of MCD is diagnosed as a primary elbow problem in old dogs, but also in
young dogs large erosions can be present without a typical coronoid fragment.
3. extended erosions of the medial compartment after surgical treatment of FCP. Several factors could be
held responsible for the dramatic degeneration of the cartilage: size of the primary lesion, age of the dog
at the time of treatment, treatment method, chronicity of the initial problem, presence of erosions at first
treatment, presence of incongruity, presence of OCD.
Several questions rise:

1. What is the cause of primary MCD?
2. What can we do to prevent MCD after treatment of FCP? Can ulnar osteotomy, humeral osteotomy, bi-
ceps release or other methods help to prevent MCD? (question for J.F. Bardet, C. Grussendorf)
3. How can we treat large cartilage defects? (question for J. Cook)
4. What can we do when MCD has occured after treatment of FCP? (question for M. Olivieri, J. Cook, N.
Fitzpatrick)
SA ARTHROSCOPY
CLINICAL EXAMPLES OF MCD
1. MCD in a 1 year old male Great Munsterlander with a chronic right frontlimb lameness.
Right elbow: a: moderate

arthrosis (degree 2 IEWG);
b-c: extended erosions with
small coronoid fragment
(image before and after
treatment)
a b c
2. MCD in a 10 year old male labrador retriever with a lameness of 2 months duration.
Left elbow: a-b: light arthrosis (degree

1 IEWG), irregular outline of the
mediale condyle and minimal sclerosis;
c: the arthroscopic image shows a
complete erosion of the medial
compartment and a mini-fragment
a b c
of 2 mm.
05) In-depth Seminar_05) In-depth Seminars 02/09/10 12.26 Pagina 379
ABSTRACTS
of
IN-DEPTH SEMINARS
Challenging fractures
Limb deformities
Juvenile HD
Biomedtrix: current concepts in total joint replacement
Physiotherapy
Kyon news
Case based ultrasound-arthroscopy correlation
Surgical revisions in THR
Arthrex news
Pathogenesis of cruciate disease
IN-DEPTH SEMINARS
Limb alignment in patellar luxation
Distal limb trauma
CHALLENGING FRACTURES
IN-DEPTH SEMINAR
Challenging acetabular (and pelvic) fractures

The principles of anatomic restoration of the articular surface, stable fixation, and early joint motion are
the optimal treatment goals of acetabular fracture management. Application of these surgical principles
minimizes the subsequent development of osteoarthritis (OA). The technique that is most consistently suc-
cessful for stabilization of acetabular fractures includes anatomic reduction and plate fixation. All acetabu-
lar fractures are complex. Exposure of the entire joint and manipulation of the fracture fragments are not
easy to perform; furthermore, because of the curved surface anatomic reduction, and subsequent rigidity
– regardless of the fixation technique – is difficult to perform. The surgical approach must be atraumatic;
additionally, the exposure must be extensive so that all components of the injury can be visualized and become fully acces-
sible to manipulation and fixation. The surgical reconstruction begins with anatomical reconstruction of the ar-
ticular surface. Finally, secure fixation of the articular components is obtained with a plate that bridges this
entire area, and secured to the ilium (and ischium). Such rigid fixation thereby allows initiation of early
postoperative motion.
APPROACH/EXPOSURE (OSTEOTOMY OF THE GREATER TROCHANTER

± EXTERNAL HIP ROTATORS)
A standard craniolateral approach is
performed to provide the exposure
necessary. Dorsal retraction of the
greater trochanter, which includes the
insertion of the deep and middle
gluteal muscles, provides exposure of
the cranial and mid-acetabulum. Fur-
ther exposure of the caudal acetabu-
lum is achieved by transection of the
insertion of the combined tendon of
the internal obturator and gemelli
muscles at the trochanteric fossa. Retracting these lat-
ter structures caudally protects the sciatic nerve and
provides a cushion of muscle between the nerve and
any retractor placed to expose the caudal acetabular
IN-DEPTH SEMINARS
rim and cranial aspect of the ischium. The sciatic
nerve must be protected at all times from iatrogenic
injury due to this retraction.
In many cases a separate second surgical exposure is
made over the caudal aspect of the ischium to provide
access to the caudal bone fragment. This mini ap-
proach includes elevating the internal obturator mus-
cle dorsally and the semimembranosus and quadratus
femoris muscles ventrally from the caudal aspect of the
ischiatic tuberosity. A Kern forceps then is placed di-
rectly onto the bone at this location, thereby facilitat-
ing direct manipulation of the caudal bone fragment.
It often is difficult to obtain accurate fracture reduc-
tion and maintain that reduction during application of
the plate. Temporary reduction can be achieved with bone holding forceps and/or by insertion of Kirschn-
er-wires (K-wires) across the fracture site. Standard bone reduction clamps may be used to span the fracture,
but may be difficult to position and secure into place, and therefore may not be successful at holding the re-
duction adequately. Temporary screws may be used as fixation points for the tips of these forceps (using the
screw heads as anchoring points).
Some recommendations include manually holding the fracture in position, but requires an assistant to main-
tain the reduction, and rarely are adequate or successfully performed. Regardless of the reduction method,
accurate plate contouring must be performed. These conventional methods for reducing acetabular fractures,
however, may not permit consistent, accurate contouring of a plate. Failure to accurately contour the plate
results in distraction of the fracture with a resultant step in the articular surface upon tightening of the screws
(as the bone attempts to match the plate contour). Theoretically, a locking plate would circumvent these is-
sues, with better maintenance of both primary and secondary reduction. There are no specialized plates
available at this time for this specific anatomic location; nevertheless, some locking plate designs have been
used with mixed success. One recently reported ex vivo biomechanical study evaluating a comparison be-
tween locking and non-locking screw fixation, however, failed to show any advantage of the locking con-
structs. Specialized bone holding instrumentation (as has been developed in humans) may allow for im-
proved reduction and maintenance of this reduction while applying the final fixation.
Synthes® Mandibular Reduction Forceps (MRF)

The MRF are designed for use in humans to aid in the temporary reduction
and stabilization of mandibular fractures before final implant application is
performed. The small size of the forceps allows them to be used for the iden-
tical purpose with acetabular fractures in small animals. The forceps have hol-
low removable sleeves that screw onto the tips of the instrument (arrows).
To apply the forceps to the bone, screws are inserted into these sleeves and
into the bone, after which they are replaced onto the MRF. In simple two-
piece fractures the MRF is applied to the cranial and caudal bone fragments.
In comminuted fractures the comminution is first addressed with appropriate
interfragmentary fixation devices such as screws (1.5 or 2.0 mm) and/or K-
wires – allowing subsequent plate positioning over these implants. Once a two-
piece fracture has been obtained, the MRF is applied as described to the in-
tact bone spanning the fracture site. The MRF position in the bone must be
such that unimpeded access to the dorsal acetabular rim, for subsequent plate
application, is obtained. In caudal acetabular fractures, or in cases in which
the plate is placed around the entire caudal acetabular rim, the surgical expo-
sure must be sufficiently caudal to include identification of the ischiatic spine.
The landmark for caudal MRF placement is just below the caudal-most aspect
of the lateral ridge of the ischiatic spine.
This ridge can be palpated with the tip of a periosteal elevator; therefore, it is
not necessary to elevate the attachments of the gemelli muscles from the ridge.
The landmark for the cranial tip of the MRF is placed approximately 1.75 cm
away from the acetabular rim. These landmarks will prevent subsequent in-
terference of the MRF with plate application. The forceps can directly control
each side of the fracture and aid with the fracture reduction. Shear and com-
IN-DEPTH SEMINARS
pression are controlled directly with the forceps: each side of the forceps (and
attached bone) can be maneuvered in
three planes: cranial and caudal, lat-
eral and medial, and dorsal and ven-
tral. Rotation and bending are not
controlled directly with the forceps; a
second instrument (e.g., Kern for-
ceps) placed on the ischium controls
these maneuvers if necessary. Inter-
fragmentary K-wires and/or 1.5 mm
or 2.0 mm bone screws may be
placed across the reduced bone frag-
ments as an aid to aligning and hold-
ing the fracture in reduction and se-
cured into position by use of the lock-
ing slide and wing nut (arrowhead).
Once secured into position, the MRF
temporarily holds the fracture in re-
duction while simultaneously provid-
ing access to the entire dorsal acetab-
ular rim for plate fixation. A plate (ac-
etabular/reconstruction) is contoured
appropriately and placed onto the dorsal acetabular rim using standard ASIF technique. Once at least two
screws are secured though the plate on each side of the fracture, the mandibular reduction forceps may be
removed to facilitate further screw insertion.
The joint capsule is closed in standard fashion. The combined tendon of the internal obturator and gemel-
li muscles is replaced within the trochanteric fossa with a locking loop suture passed through two small drill
holes in the proximal femur. The greater trochanter is replaced with two 0.062” K-wires and an 18-gauge
figure-of-eight tension band wire. The remaining closure is performed in routine fashion.
The basic principles of intra-articular fracture repair, which include anatomic fracture reduction, stable skele-
tal fixation, and early joint mobilization are well documented in both the human and veterinary literature.
A definitive correlation has been shown between the accuracy of fracture reduction and the prevention of
OA. Articular cartilage does, however, have a limited ability to respond to alterations in intra-articular stress,
as has been demonstrated by clinically satisfactory results in humans with acetabular fractures that have im-
perfect reduction with minor joint incongruities. Severe joint incongruity causes marked changes in stress
applied across the joint and results in rapid breakdown of the articular cartilage. The success reported in hu-
mans, despite small articular cartilage incongruities in intra-articular fractures (including acetabular frac-
tures), has led to a classification system in most publications defining either satisfactory or unsatisfactory
amounts of incongruity present after fracture repair, and also includes a definition of anatomic reduction. A
similar definition in the dog has been proposed (Boswell et al. Vet Surg 2001) based upon an experimental
study of an acetabular osteotomy model in dogs where residual incongruity and the subsequent develop-
ment of OA were examined.
The most common errors responsible for failure of repair of intra-articular fractures are technical failures by
the surgeon, and therefore are preventable:
The #1 error is incomplete reduction of the fracture. The inaccuracy of the reduction fails to restore structural
continuity, thus losing the ability to re-establish the inherent stability of the fragment, and the bone does not par-
ticipate in load-sharing with the implant. Under these conditions, the implant frequently fails since it must neu-
tralize all bending, compressive, shear, and torsional loads. Inaccurate reduction also results in joint surface in-
congruity, and therefore, the rapid development of OA. The quality of the functional and clinical result is relat-
ed to the exactness of the operative reduction. It has been demonstrated that these results are directly depend-
ent on the surgeon performing a wide surgical approach, and ultimately, the experience level of the surgeon.
Furthermore, prevention of OA has been shown to be directly dependent on the ability to obtain an anatomic
reduction and stable fixation of the articular fragments in order to restore joint congruity.
The #2 error is insufficient overall rigidity which does not allow early mobilization, thereby resulting in joint
stiffness and other soft-tissue problems (e.g., contracture). Certainly, immobilization of intra-articular frac-
tures results in joint stiffness; conversely, immediate motion is necessary to prevent joint stiffness and ensure
articular cartilage healing and recovery. Accordingly, such joint repairs must require absolutely stable (rigid!)
internal fixation.
A stable repair from time of operation, and without signs of OA for a period of 1 year, i.e., a clinically and
IN-DEPTH SEMINARS
radiographically good or excellent result, has a continued long-term outcome that usually will not change.
REFERENCES
1. Amato NS, Richards A, Knight TA, et al: Ex vivo biomechanical comparison of the 2.4-mm UniLOCK® recon-
struction plate using 2.4 mm locking versus standard screws for fixation of acetabular osteotomy in dogs. Vet Surg
37:741-748, 2008.
2. Anson LW, DeYoung DJ, Richardson DC, et al: Clinical evaluation of canine acetabular fractures stabilized with an
acetabular plate. Vet Surg 17:220-225, 1988.
3. Tomlinson JL: Fractures of the pelvic, in Slatter DH (ed): Textbook of Small Animal Surgery, vol. 2, (ed 3). Philadel-
phia, PA, Saunders, 2003, pp 1989-2001.
4. Boswell KA, Boone EG, Boudrieau RJ: Reduction and temporary stabilization of acetabular fractures using the ASIF
mandibular reduction forceps: Technique and operative results using plate fixation in 25 dogs. Vet Surg 30:1-10, 2001.
5. Boudrieau RJ, Kleine LJ. Non-surgically treated caudal acetabular fractures in dogs: 15 cases (1979-1984). J Am Vet
Med Assoc 193:701-705, 1988.
6. Dyce J, Houlton JEF: Use of reconstruction plates for repair of acetabular fractures in 16 dogs. J Small Anim Pract
34:547-553, 1993.
7. Ost DA, Kaderly RE: Use of reconstruction plates for the repair of segmental ilial fractures involving acetabular
comminution in four dogs. Vet Surg 15:259-264, 1986.
8. Lewis DD, Stubbs WP, Neuwirth L, et al: Results of screw/wire/polymethylmethacrylate composite fixation for ac-
etabular fracture repair in 14 dogs. Vet Surg 26:223-234, 1997.
9. Stubbs WP, Lewis DD, Miller GJ, et al: A biomechanical evaluation and assessment of reduction of two methods
of acetabular osteotomy fixation in dogs. Vet Surg 27:429-437, 1998.
Challenging elbow fractures

Noel Fitzpatrick, DUniv MVB CVR CSAO MRCVS
INTRODUCTION
The elbow joint is a ginglymoid (hinge like) joint that includes three articulations with a common joint cav-
ity; the humero-radial articulation, the humero-ulnar articulation, and the radio-ulnar articulation. The dis-
tal humerus forms a bony triangle comprised of a medial and lateral ramus (crest), and a condyle that is
comprised of the trochlea medially and the capitulum laterally. The humero-radial articulation exists be-
tween the radial head and the humeral capitulum. The trochlea humeri articulates with the trochlear notch
of the ulna and the medial aspect of the coronoid process.
Fractures of the humeral component of the elbow are the most common type of elbow fractures encoun-
tered in clinical practice and can be either unicondylar (more commonly affecting the capitulum in com-
parison to the trochlea), or bicondylar (affecting both portions of the humeral condyle). All humeral elbow
fractures have an intra-articular (intercondylar) and a juxta-articular (supracondylar) component. Radial
head, trochlear notch and coronoid fractures are far less common. Sixty per cent of distal humeral fractures
involve the condyle in dogs. Ninety percent of unicondylar fractures of the distal humerus are reported to
occur in association with minor trauma. Eighty percent of bicondylar fractures occur in association with
severe trauma1. A report on distribution of distal humeral fractures found 53% of condylar fractures in-
volved the lateral aspect of the condyle, 10% the medial aspect of the condyle, and 37% were bicondylar.
One study reported a peak incidence of unicondylar fractures after minor trauma at 4 months of age1.
The presence of incomplete ossification of the humeral condyle (IOHC) is considered an important pre-dis-
posing factor in the development of unicondylar humeral fracture and the disparate sizes of the medial and
lateral rami predisposes the capitulum to detachment from the humerus by comparison with the trochlea.
The role of the radial head in increasing the force that the capitulum sustains in a traumatic incident is pos-
tulated but not proven.
The humeral condyle in the normal developing dog has two (medial and lateral) centres of ossification,
which are separated by a cartilaginous intermediate zone, and appear at a mean (±SD) of 14 ± 8 days af-
ter birth. These ossification centres are reported to unite by 70 ± 14 days of age with completion of ossifi-
cation by 32 weeks of age. Incomplete ossification of the humeral condyle (IOHC) is over-represented in
the cocker spaniel, in which a recessive mode of inheritance as been proposed. The author and others have
seen the condition in several breeds, including the Labrador Retriever, Labradoodle and Germal Short-
haired Pointer.
IOHC may be a subclinical condition, and has been reported as an uncommon cause of forelimb lameness
IN-DEPTH SEMINARS
in dogs. Lameness may be mild and intermittent to non-weight bearing in nature and may precede complete
humeral condylar fracture. IOHC may decrease stability of the humeral condyle predisposing to complete
fracture often after a minimally traumatic event.
IOHC may be diagnosed radiographically as a linear sagittal radiolucency in the humeral condyle in the re-
gion of the developmental cartilage zone separating the two condylar centers of ossification. Bone scintigra-
phy and arthroscopic examination have been reported useful in establishing a diagnosis but it is now ap-
preciated that diagnosis may prove elusive using these modalities. Magnetic resonance imaging (MRI) or
computed tomography (CT) may be necessary for definitive diagnosis. The author has found that both
modalities are sensitive and accurate. The author has also found that cases which are clinically affected by
lameness generally tend to have intercondylar fissures propagated into the joint itself, and are readily seen
arthroscopically, with relative motion of the two condylar segments on pronation and supination.
GENERAL PRINCIPLES OF ELBOW FRACTURE REPAIR

Maintenance of a healthy bone articulation is dependent on joint motion and repetitive loading. Disruption
of any component of the joint can result in fibrosis and osteoarthritis. Displaced intra-articular fractures can
affect joint stability, cause pain, and disrupt effective joint motion. Gaps in the articular surface can fill with
fibrocartilage, but this repair tissue has inferior mechanical properties and durability in comparison to artic-
ular cartilage.
Accepted guidelines for joint fracture management include anatomical reduction and rigid fracture fixation.
Decreased range of elbow joint motion is a common complication associated with elbow fracture repair and
minimizing the degree of periarticular fibrosis by utilizing optimal surgical technique and early post-opera-
tive mobilization of joint movement including active and passive physical therapy is imperative.
PREOPERATIVE PATIENT ASSESSMENT AND PLANNING

Thorough evaluation of the cardiovascular, respiratory, urinary, gastrointestinal and neurologic systems pri-
or to fracture fixation is imperative. The presence of concurrent injury, particularly in patients that have sus-
tained major trauma is common. Undiagnosed, the presence of pulmonary injury, myocardial dysfunction,
intestinal rupture, urinary tract trauma and neurological deficits will adversely affect patient safety and sur-
gical outcome and the clinician must initially prioritize the complete assessment of these organ systems and
continue to re-assess their function during the post-operative period.
A significant number of dogs and cats with humeral fractures have partial temporary or permanent nerve
dysfunction. The ulnar, median and radial nerves are in close proximity to the distal humerus and a sound
knowledge of their location and peripheral distribution is needed for a complete pre-surgical evaluation of
the limb function. In cats this is especially relevant because the radial nerve passes through the supra-
condylar foramen. Partial temporary nerve injuries typically resolve quickly once the fracture is stabilized.
The presence of cutaneous sensation and spontaneous motor function is commonly used as a positive pre-
dictive finding for intact neurological function.
Temporary stabilization and support of elbow fractures requires placement of a spica splint. In most cases,
splinting is unnecessary prior to surgery unless a delay is anticipated before fracture repair. Incorrect band-
age application may have significant consequences and should be carefully avoided. Patient confinement and
appropriate analgesic administration is required.
Thorough preoperative planning is a prerequisite for successful management of elbow fractures. Pre-opera-
tive imaging should include compete radiographic examination and computer tomography is indicated if
available. The presence of small bone fragments and fissure lines in complex comminuted fractures can be
difficult to identify with plain radiography alone. Failure to identify the anatomic characteristics of the frac-
ture present will adversely affect surgical planning and may adversely affect the post-surgical results
achieved. An added caveat is that aciduous attention should be paid to examination of radiographs for any
evidence of neoplastic disease, particularly since pathologic fractures can be masked by proliferative new
bone secondary to elbow arthrosis.
SURGICAL TECHNIQUE
On the lateral aspect of the distal one-third of the humerus, the radial nerve emerges from deep to the tri-
ceps muscle to lie superficial to the brachialis muscle. On the medial aspect of the distal humerus the medi-
an, musculocutaneous and ulnar nerves are present along with the brachial artery and vein. Meticulous
anatomic dissection during the surgical approach is necessary to avoid damaging these important structures.
Fractures of the lateral and medial aspect of the condyle are exposed by an approach to the lateral or medi-
al aspect of the humeral condyle respectively. A tenotomy of the triceps tendon2, 3 or osteotomy of the tuber
olecrani4 may prove helpful in long-standing fractures that can be a challenge to reduce. The olecranon os-
teotomy approach has been associated with high morbidity and complication incidence5 and is rarely em-
ployed by the author.
IN-DEPTH SEMINARS
Positioning the animal in dorsal recumbence with a mild tilt to the operated side facilitates exposure and re-
duces operating time. A transcondylar screw and anti-rotational K-wires or screws are the principle means
of unicondylar fracture fixation. Reduction maintenance pre-implantation is achieved using appropriate
bone holding forceps. A minimally invasive technique using fluoroscopy to reduce the fragments and posi-
tion the implants has been previously described6.
A glide hole can be started from the fracture surface or from the epicondyle before fracture reduction or
from the epicondyle after fracture reduction. Whatever method is chosen, the hole is drilled so that it exits
or enters craniodistally to the epicondyle and in the centre of the fracture surface. These two points define
the axis of the hole. After fracture reduction has been secured, a drill sleeve is typically inserted into the glide
hole and a thread hole is drilled into the opposite part of the condyle. The author prefers to drill the frac-
ture fragment from the condylar isthmus to the epicondyle, then reversing the drill bit through this frag-
ment, reducing the fracture and driving the drill into the opposing aspect of the humeral condyle. In im-
mature animals a washer can be used to prevent penetration of the head of the screw into the bone while
tightening of the screw. In this patient group a bone clamp can be used to compress the fragments during
insertion of a positional screw.
Partially threaded cancellous screws or fully threaded cortical screws can be used. Cannulated headless ta-
pered screws can are also a valid implant option and have been successfully used in human, equine, canine
and feline articular fracture cases. In small dogs a self-compressing threaded pin system has also been re-
ported as successful7. The author has employed headless screws in both canine and feline humeral condylar
fractures, but generally reserves their use to parallel a transcondylar bone dowel in fixation of cases of in-
complete ossification of the humeral condyle.8
Complications are not uncommon with unicondylar fracture repair8 but can be minimized with careful sur-
gical dissection, appropriate placement of implants, excellent post-operative care and the early and judicious
use of physical therapy. Particular attention must be applied to make sure that the epicondylar region is ac-
curately reconstructed, otherwise mismatch at the intercondylar area is inevitable and fragments with short
epicondylar segments are prone to rotate around the condylar screw and become malaligned. Augmentation
of the medial epicondylar ridge using locking plates such as the 2.0 or 2.4 mm Synthes LCP™ or the 2.0
mm or 2.7 mm string-of-pearls SOP™ plate may be beneficial and as a general guideline, if the author feels
that there is any possibility of aberrant healing or tenuous implant purchase, an epicondylar plate is applied.
Bicondylar fractures can be exposed with a combined lateral and medial approach9 (favoured by the author)
or with an approach to the caudal aspect of the elbow joint after an osteotomy of the tuber olecrani or a tri-
ceps tenotomy. The intercondylar component of the fracture is managed similarly to the unicondylar frac-
tures. Two approaches are valid – either reconstruction of a unicondylar fracture first, with subsequent re-
pair of the opposing aspect of the condylar fracture; or repair of the humeral condyle first and then recon-
struction of the humerus. The author favours the latter approach and frequently employs a fracture dis-
tractor to overcome muscle contracture prohibiting satisfactory reduction. Fixation can be applied using
standard or locking plates or plate-rod techniques. The author previously used hybrid 3.5/2.7 pancarpal
arthrodesis plates applied medially and laterally but now favours 2.7mm and 3.5mm SOP™ plates. Lag
screws are a helpful adjunct, but rarely used in isolation by the author who favours more robust recon-
struction support. An intramedullary pin placed in the medial epicondyle and exiting the proximal humerus
via the subtubercular region can facilitate realignment and may obviate requirement for two plates, facilitat-
ing a plate-rod technique. Cerclage wire can be important or vital for re-apposition and stabilisation of spi-
ral fragments, and can be used to sequentially realign long spiral fragments under guidance of a fracture dis-
tractor. Lateral bone plating with the transcondylar screw incorporated into the plate construct has been ex-
amined clinically and found to be a successful technique that limits micromotion of the fracture site more
effectively in comparison to caudal plate position11.
In case of severe comminution perfect reduction of the supracondylar fracture is not necessary as long as
correct bone alignment and sufficient bone buttressing with two bone plates have been achieved. Commin-
uted fragment recruitment can be facilitated using lassos of polydioxanone suture material. Accurate plate
contouring is a pre-requisite for perfect reduction of the bone fragments as compressing the bone fragments
onto the plate will lead to secondary loss of reduction if the shape of the plate and that of the bone are not
an accurate match. Locking plate technology allows decreased dependence on plate contouring, as the fixa-
tion is not dependent on the friction between the bone and the plate, secondary loss of reduction is less of
an issue compared with conventional plates12.
Ensuring that no implants cross the intercondylar fossa is of vital importance and the surgeon must be alert-
ed when normal range of motion cannot be achieved or crepitus is apparent after reconstruction of the bone
fragments. A technique utilizing trans-condylar implants incorporated in a modified Type I external fixation
has been described but is not favoured by the author. Hybrid linear-arch fixators have also been described13.
IN-DEPTH SEMINARS
In small fragments or comminuted juxtaarticular fractures of cats or dogs, external skeletal fixation may be
very useful including application of small half-pins, self-compressing threaded pins or olive wires on arches
distally to facilitate condylar reconstruction. Such arches and stretch-rings mounted with linear components
further proximally and constituting hybrid fixation systems offer tangible advantages over conventional lin-
ear frames and where conventional circular frames cannot be mounted on the proximal thoracic limb. How-
ever, external skeletal fixation of the humerus in dogs is a high-maintenance technique in that pin tract dis-
charge and prolonged healing times may be issues. Therefore the author prefers internal fixation unless there
is very valid rationale to choose fixator constructs.
Although in each study regarding condylar fractures published to date, a different subjective means of clin-
ical outcome has been used, it is generally accepted that unicondylar fractures enjoy a better prognosis than
bicondylar fractures.
Where IOHC is present or fracture has yielded a paucity of bone stock for implant purchase, elbow frac-
tures can be difficult to treat because of general inability to achieve osseous union at the intercondylar in-
terface, such that epicondylar structural integrity is important. Non-union is common and can give rise to
transcondylar implant loosening and resorption of bone around the implant. In recalcitrant cases this can be
overcome using a transcondylar threaded rod and nuts on either side of the humeral condyle (Webb Bolt).
Tissue glue may be applied to prevent nut loosening.
SURGICAL TREATMENT OF IOHC

Management of IOHC remains controversial. Conservative treatment of IOHC is associated with HCF.
Marcellin-Little reported that 3/7 condyles (43%) with a partial radiolucent line and 1/12 condyles (8%) with
a complete radiolucent line fractured 11days to 18 months after diagnosis. The author has anecdotally ob-
served high rates of fracture of untreated intercondylar fissures. Surgical treatment aims to prevent HCF, to
encourage osseous fusion of the transcondylar fissure and to resolve lameness in the long-term. Current sur-
gical treatment of IOHC generally involves use of a transcondylar screw, either fully or partially threaded,
applied in either a position or in lag fashion. Screw placement may be combined with transcondylar bone
tunnels created by drilling (forage) to allow vascular in-growth. A single case report prior to the author’s
own work on transcondylar bone graft, suggested use of such a graft but this was not performed because of
concerns about potential for the bone graft to communicate with the joint via the transcondylar fissure.
After transcondylar screw application, resolution of lameness usually occurs; however, complications include
failure to achieve bone union, recurrence of lameness, fissure widening, loss of transcondylar compression,
implant failure, and HCF. Failure to achieve bone union and condylar stability may result in cyclic loading
of the screw with bending, stress fatigue, and failure. Some surgeons advocate changing the screw at regu-
lar intervals such as every other year and others advocate re-examination if lameness recurs, in an effort to
prevent osseous fracture if the screw cycles to failure at the non-ossified interface. What is clear is that with-
out biologic augmentation, union is never achieved. Some surgeons therefore advocate placement of screws
of significantly large diameter (5.5 or even 6.5 mm).
Histologic features of the fissure site were consistent with atrophic non-union fracture in an English Pointer and
were composed of fibrous tissue in two Cocker Spaniels with no evidence of chondrocytes or cartilage matrix.
These findings may suggest that IOHC might be approached similarly to treatment of atrophic non-union frac-
tures, so treatment modalities promoting transcondylar bone osseous union are worthy of consideration. Au-
togenous cancellous bone graft application in the area of incomplete ossification has been proposed to optimize
bone formation and remodeling by providing trabeculae necessary for bone conduction and osteoprogenitor
cells, as well as cytokines and growth factors for osteoinduction and osteogenesis. No study has reported the
effect of IOHC on condylar stability but resultant instability may be in part or wholly responsible for observed
lameness. In such cases, use of bone graft alone may not promote bone healing because of the effects of ex-
cessive movement at the fissure site inhibiting healing, similar to unstable atrophic non-unions where AO prin-
ciples support the combination of a graft with rigid internal fixation to promote bony union.
The Acutrak™ bone screw (AT screw, AcutrakTM, Acumed, Beaverton, OR) used since 1992 in human pa-
tients, is composed of titanium alloy (ASTM F136), and is a cannulated, headless, tapered, variably-pitched,
self tapping and fully threaded compression screw. The AT screw is inserted using a customized cannulated
application system. The osteochondral autograft transfer system (OATS™, Arthrex, Naples, FL) has been
used in humans for treatment of articular cartilage defects including osteochondritis dissecans. The author
reasoned that both systems had features that might facilitate graft collection and treatment of IOHC.
Direct visibility of the cranial and caudal aspects of the humeral condyle is achieved and the narrowest isth-
mus of the articular surface is marked by 2 temporary 1.1mm Kirchner (K)-wires placed within the joint
contiguous with the articular surface. A calibrated K-wire (Acumed, Beaverton, OR) is driven medial to
lateral across the humeral condyle at its most distal extent, using an inverted AT screw placed over the K-
IN-DEPTH SEMINARS
wire as a spacing guide to ensure that the maximal diameter of the screw would not encroach on the ar-
ticular cartilage at the narrowest part of the isthmus. When the wire has penetrated the trans cortex, bone
depth is measured using the etch mark on the calibrated K-wire held against the scale on a customized
depth gauge. The base of the inverted AT screw placed over the K-wire acts as a spacer allowing an
OATS™ reamer (OATS™, Arthrex, Naples, FL) of maximal diameter to be centralized proximal to the AT
screw on the medial aspect of the humeral condyle without encroaching on the intended screw position.
The reamer position is maintained by advancing a guide drill across the condyle through the cannulated
reamer. Parallelism of the drill guide/reamer and the wire/screw is desirable, but in some dogs with limit-
ed humeral condylar bone stock it is necessary to drive the screw parallel to the medial humeral joint sur-
face rather than parallel to the transverse axis of the condyle. In these dogs, the screw passes obliquely
from distomedial to proximolateral, craniodistal to the position of the intended bone core as marked by the
guide drill. A hole is prepared for the AT screw using the customized AT insertion system (Acumed,
Beaverton, OR). The guide K-wire is advanced through the trans cortex, soft tissues and skin and is se-
cured with wire graspers on the lateral aspect of the condyle to minimize wire movement. A customized
drill bit is advanced over the guide wire in increments of 3-4 mm and intermittently removed to allow re-
moval of bone debris. External drill calibrated markings measured against the cis cortex allows advance-
ment of the drill tip to within 2-6 mm of the trans-cortex. The reamer is then repositioned on the central
guide drill. The intended socket depth is 75% of condylar width and is estimated from preoperative radi-
ographs. Calibrated markings on the external barrel of the reamer allow socket depth measurement dur-
ing reaming. An AT screw 2 mm shorter than the drill hole depth was threaded over the guide wire and
inserted to finger tightness using a customized screw driver.
Core socket depth and alignment are confirmed using a calibrated alignment rod before cancellous bone
dowel collection. When free autogenous cancellous bone is used, it may be collected from the proximal
aspect of the ipsilateral humerus through a small fenestration created using a bone curette. Corticocan-
cellous bone dowels of appropriate length may also be collected from the proximal aspect of the tibia or
distal femur using an OATS™ core harvesting chisel 1mm wider than the transcondylar recipient socket.
The core harvester is a calibrated, cylindrical cutting chisel with louvered grooves at 4 equidistant points
on the circumference. The louvers engage the bone core when hammer-tapped into the donor site and the
bone dowel is extirpated by a twisting motion axial to the harvester, or by slight rocking (‘toggling’)
whereupon the louvers engage the cancellous bone and break the dowel off at its base, which is subse-
quently removed within the chisel. Graft dowels are trimmed to fit recipient socket length where neces-
sary. Grafts are transferred to the recipient socket by packing the free cancellous graft firmly with a tamp-
ing rod to the level of the cis-cortex or placing a dowel as a press fit using the OATS™ system. Humeral
epicondylar augmentation may be performed with pin(s) or plates if the intercondylar fissure is deemed
significantly unstable.
In a study population of eight dogs operated by the author, time to resolution of lameness ranged from 4 -
84 days (mean, 35 days). Partial (≥50% width of central portion of condyle) or complete bone union was
identified in 7/9 elbows by CT examination, 11 – 16 weeks postoperatively. Failure of bone union was ob-
served in one dog where free cancellous graft was employed and the author therefore generally recommends
application of trabecular bone dowel cores. 8 of 9 operated limbs in this series were deemed free of lame-
ness up to 45 months postoperatively and several had returned to function as working dogs. Trabecular
‘spot-weld’ was consistently observed in all elbows with corticocancellous dowel grafts evaluated by CT. In
contrast to an inert metallic implant which is susceptible to cyclic fatigue, the dowel should theoretically func-
tion as a biologically active transcondylar bridge capable of responding to chronic stress by active regener-
ation, repair, and remodelling in keeping with Wolff’s law.
Bone dowel diameter is intrinsically limited by humeral condylar isthmus dimension and by the concurrent
use of a transcondylar screw. Use of an AT screw allows placement of a mechanically robust but narrow im-
plant whilst maximizing bone dowel diameter.
The cannulated system allows accurate insertion, using the guide wire of the screw and the reamer central-
izer as trajectory guides for the screw and bone dowel respectively, without need for fluoroscopy, although
fluoroscopic guidance may further facilitate accurate screw placement. The fully threaded, tapered nature of
the screw provides constant new bone purchase as it is inserted, minimizing strip-out and maximizing pull-
out strength, providing strong internal fixation.
Where it is perceived that a transcondylar bone dowel of diameter 5mm or greater cannot be placed in ad-
dition to a screw, the author’s preference is to use a screw only as he does not perceive that a bone graft
alone provides adequate structural resilience, in the face of unstable motion of the two condylar segments
in a clinically affected patient. Screw diameter is important and where possible the author employs at least
a 4.5mm diameter cortical screw, since structural resilience will be dependant on the core diameter of this
IN-DEPTH SEMINARS
screw indefinitely. The author prefers to place this screw in a minimally invasive fashion by arthroscopic
guidance. Other transcondylar implants are currently being investigated to try preventing cycling to failure
in future iterations of technique.
RADIAL AND ULNAR FRACTURES

Radial fractures involving the articular surface of the radial head, when reconstructable, are usually fixed
with lag screws or K-wires. These fracture repairs are rare, challenging and optimal results are difficult to
achieve due to the small size of the fragments involved, the difficulties with accurate anatomic reduction of
the joint surfaces and stable implant placement and fixation. Ulnar notch fractures can be treated either with
K-wires and figure-of-eight cerclage wire functioning as a tension band device or with a bone plate placed
laterally or caudally. Medial coronoid fractures are normally treated by subtotal coronoid ostectomy as the
fracture size normally precludes fracture reduction and stabilization. With patience and tenacity even se-
verely comminuted proximal ulnar and radial fractures can be effectively reconstructed and the author has
temporarily supported such repairs using static and hinged transarticular external skeletal fixation with ap-
propriate physiotherapy.
SALVAGE PROCEDURES
In cases of severe comminution or when fixation methods have failed resulting in severe osteoarthritis and
irreparable alteration of joint biomechanics, joint arthrodesis, replacement or limb amputation can provide
a salvage choice. Elbow arthrodesis has in the author’s hands provided surprisingly satisfactory results in
terms of pain-free functional ambulatory capability.
POST-OPERATIVE MANAGEMENT
Limiting postoperative limb swelling ensuring the surgical incisions are not interfered with, protecting the
limb from excessive force, controlling post-operative pain and early ROM exercises are essential for estab-
lishing uninterrupted soft tissue and bone healing. Bicondylar fractures are more challenging and joint stiff-
ness and reduced function is common in the absence of correct rehabilitation. Cryotherapy and pressure
bandaging help limit early postoperative swelling. ROM and stretching exercises need to be initiated in the
early post-operative period and excessive support bandage duration should be avoided particularly in juve-
nile patients. Swimming or underwater treadmill are particularly helpful as they provide patient buoyancy
in combination with resistance to limb motion which is an effective technique to minimize peri-articular mus-
cle atrophy and encourage re-establishment of adequate range of motion in the affected elbow joint. Early
and ongoing adequate pain management is of vital importance for early limb usage and avoidance of reflex
inhibition.
SPECIAL CONSIDERATIONS FOR ELBOW FRACTURES IN CATS

Elbow fractures in cats are less commonly presented in the author’s facility than canine elbow fractures with
published data suggesting that humeral fractures generally represent 4.4% of all fractures in cats. Most are
in the mid-shaft region (87%), approximately 70% of which are comminuted. Where fractures are simple,
they are typically oblique or spiral in configuration and follow the “musculo-spiral groove” toward the supra-
condylar region. A range of fixation techniques are reported and selection largely depends on precise frac-
ture configuration and availability of bone stock for implant placement. Presence of the supracondylar fora-
men which contains the radial nerve makes repair more challenging, not least because in most cats it ren-
ders introduction of an intramedullary pin into the medial epicondyle impossible. Where possible in this re-
gion, pin diameter has been reported as being limited to 1.6mm maximum. If the pin tip is left in the prox-
imal supracondylar region, it has been suggested that up to 2.4mm pin diameter can be applied. However,
additional fixation is always required to provide rotational and often compressional stability which may be
compromised by inclusion of a large intramedullary device. Intramedullary nails up to 5mm in diameter
have been reported but require specialist skills and inventory and may be inappropriate for many fracture
configurations. Cerclage wire is seldom appropriate for common fracture configurations and since the
humerus tends to taper toward the supracondylar region (and has the closely constrained radial nerve), wire
placement is challenging to maintain safely.
Plate and screw fixation is commonly applicable although contouring to match the three-dimensional shape
of the humerus may be challenging except for the most cranio-lateral portion, while the proximity of neu-
rovascular structures, close association with musculature and variable fracture configuration distally makes
surgical approach challenging. External fixation with or without a tied-in intramedullary pin may be appli-
cable to the majority of fractures and hybrid circular/arch systems may optimize limited distal bone stock by
allowing placement of fine wires or half-pins in the region of the humeral condyle. A significant proportion
of other fractures involve the humeral condyle with the lateral condyle most commonly affected. Simple lat-
IN-DEPTH SEMINARS
eral or medial condylar fractures may be stabilized by transcondylar screw and antirotational epicondylar
implant placement. An alternative to standard compression screw placement is the titanium Acutrak screw.
Benefits include cannulation which increases reliability of placement within the relatively narrow humeral
condyle and its headless design which minimizes soft tissue irritation and eliminates the risk of splitting small
bone fragments during countersinking. The variably-pitched, tapered design means that the screw is self-
compressing, while allowing for purchase in new bone for each rotation during insertion.
Y, T and comminuted elbow fracture configurations may necessitate either complex screw and double plate
application or advanced external fixation techniques with circular or hybrid components and olive/stopper
wire fixation to achieve intercondylar compression.
Radius and ulna fractures are also common with wide variation in location and configuration although com-
minuted fractures appear overrepresented. It is rare for radial fractures to occur so far proximally as to com-
promise the elbow joint, but fractures of the ulnar notch and olecranon are more common. Anatomic re-
construction is essential and “drift” of the fracture interface during implant application can easily occur and
careful attention is required in this regard. An intramedullary pin and tension band may be adequate or a
compression plate with a hook fashioned from one of the plate holes over the olecranon may be applied for
extra purchase in small olecranon segments.
Application of bone graft or biologic augmentation agents may be beneficial, particularly in more geriatric
patients or where fracture configuration is anticipated to delay healing. The proximal humeri may provide
small amounts of good quality graft, particularly in younger patients, but for more substantial quantities of
autogenous graft material or in older patients, cortico-cancellous bone from the iliac crest may be harvested
and morcellised. Freeze dried allograft feline bone chips (Veterinary Transplant Services®, Kent, WA) may
be highly advantageous in this circumstance, and are worthy of consideration in all circumstances where
graft is required, including arthrodesis in cats. Elbow arthrodesis is a consideration for unreconstructable ar-
ticular trauma in cats but indications are rare and it is worth mentioning that salvage joint replacement is
now a reality including trabecular metal mesh reattachment of ligament avulsion, but again indications are
rare and experience limited at this point.
REFERENCES
1. Vannini R, Olmstead ML, Smeak DD. An epidemiological study of 151 distal fractures in dogs and cats. J Am An-
im Hosp Assoc 24:531-536,1988.
2. Dueland R. Triceps tenotomy approach for distal fractures of the canine humerus. J Am Vet Med Assoc 165(1):82-
86, 1974.
3. Sturgeon C, Wilson AM, McGuigan P, et al. Triceps tenotomy and double plate stabilization of “Y-T” fracture of
the distal humeral condyle in three dogs. Vet Comp Orthop Traumatol 13:34-38, 2000.
4. Piermattei DL. Approach to the humeroulnar part of the elbow joint by osteotomy of the tuber olecrani. In Pier-
mattei DL, (ed): An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. 3rd ed. WB Saun-
ders Co, Philadelphia, 1993, pp 158-163.
5. Halling KB, Lewis DD, Cross AR, et al. Complication rate and factors affecting outcome of olecranon osteotomies
repaired with pin and tension-band fixation in dogs. Can Vet J. 2002 Jul;43(7):528-34.
6. Cook JL, Tomlinson JL, Reed AL. Fluoroscopically guided closed reduction and internal fixation of fractures of the
lateral portion of the humeral condyle: prospective clinical study of the technique and results in ten dogs. Vet Surg
28:315-321, 1999.
7. Guille AE, Lewis DD, Anderson TP, et al. Evaluation of surgical repair of humeral condylar fractures using self-
compressing orthofix pins in 23 dogs. Vet Surg. 2004 Jul-Aug;33(4):314-22.
8. Fitzpatrick N, Smith TJ, O’Riordan J, Yeadon R: Treatment of incomplete ossification of the humeral condyle with
autogenous bone grafting techniques. Veterinary Surgery 38(2): 173-184, 2009.
9. Morgan OD, Reetz JA, Brown DC, et al. Complication rate, outcome, and risk factors associated with surgical repair
of fractures of the lateral aspect of the humeral condyle in dogs. Vet Comp Orthop Traumatol. 2008;21(5):400-5.
10. McKee WM, Macias C, Innes JF. Bilateral fixation of Y-T humeral condyle fractures via medial and lateral ap-
proaches in 29 dogs. J Small Anim Pract. 2005 May;46(5):217-26.
11. McCartney WT, Comiskey DP, Mac Donald B, et al. Fixation of humeral intercondylar fractures using a lateral
plate in 14 dogs supported by finite element analysis of repair. Vet Comp Orthop Traumatol. 2007;20(4):285-90.
12. Ness MG. Repair of Y-T humeral fractures in the dog using paired ‘String of Pearls’ locking plates. Vet Comp Or-
thop Traumatol. 2009;22(6):492-7. Epub 2009.
13. Kirkby KA, Lewis DD, Lafuente MP, Radasch RM, Fitzpatrick N, Farese JP, Wheeler JL, Hernandez JA: Man-
agement of humeral and femoral fractures in dogs and cats with linear-circular hybrid external skeletal fixators.
Journal of the American Animal Hospital Association 44(4): 180-197, 2008.
IN-DEPTH SEMINARS
393 • WVOC 2010, Bologna (Italy), 15th - 18th September S.J. Langley-Hobbs
Challenging feline fractures including the patella

Sorrel J. Langley-Hobbs, M.A., B.Vet.Med., DSAS(O), Dipl. ECVS, MRCVS
The Queens Veterinary School Hospital, University of Cambridge, United Kingdom
Most surgeons will realise that the old adage that cat fractures will heal if they
are in the same room does not always hold true and non and delayed unions do
occur in cats. Fractures of the ulna, radius, tibia and patella have all been re-
ported to have a high non-union rate1,2,3,5. The incidence of non-union is re-
ported to be between 0.85% (2 of 233 fractures) to 5.25% (188 of 344 fractures).
Tibia - In the tibia the incidence of non-union was 2 of 1003 and 2 of 984 tib-
ial fractures. The fractures are often very distal, comminuted and open. It is
not unusual for distal tibial comminuted fractures to take 4-6 months to heal.
This is likely to be related to the minimal soft tissue in this area meaning there
is poor vascularity. Rotational forces are also high close to the foot. These neg-
ative factors can be overcome by meticulous surgical technique, stable fixation
and cancellous bone grafting. Implants should be placed with the anticipation
that healing will take a long time. Figure 1 - Failure of pin and ten-
sion band wire for a cat patellar
Radius and ulna - Feline diaphyseal radius and ulna fractures were reviewed in a fracture.
retrospective study of cases presented to two university teaching hospitals. A
high incidence of complications was noted, with 6/26 (23.1%) of cases requiring
revision surgery. Open fractures were significantly more likely to require revi-
sion surgery. Compared to dogs where most problems are seen with distal ra-
dial fractures the highest number of complications were seen with middle and
proximal diaphyseal fractures. The two main repair methods were external
skeletal fixation (ESF) or radial plating. More complications were seen with ESF
usage, however, ESF tended to be applied to the more complicated fractures.
Stabilisation of both bones proved an effective repair strategy with only 1/8 cas-
es (12.5%) requiring revision versus 5/18 cases (27.8%) where only one bone
was stabilised. Proximal ulna fractures are associated with a high non-union
rate3. The risk for non-union can be reduced by meticulous surgical technique,
knowledge of feline ulnar anatomy4 and stable fixation.
Patella - Most patellar fractures in cats are transverse stress fractures and in Figure 2 - Non union of a conser-
IN-DEPTH SEMINARS
over fifty percent of cats the condition is bilateral with the second patella frac- vatively treated patellar fracture in
turing several months after the first fracture. a cat.
The patella will very rarely heal whether treated surgically or conservatively.
In a report on 52 fractures in 34 cats there was only radiographic evidence that one fracture healed. Pin and
tension band wire fixation particularly was associated with a very high complication rate and therefore can-
not be recommended. Circumferential wiring maintained reduction in most cases in which it was used. Fol-
low up radiographs often showed further fragmentation, implant loosening, excessive mineralisation and
non-union. Conservative treatment may give a similar or even better outcome than surgical stabilisation of
the fracture fragments. Further work is needed in this area to determine what is the best treatment method.
Older cats may present with non-union patellar fractures as incidental findings.
REFERENCES
1. Langley-Hobbs SJ. Survey of 52 fractures of the patella in 34 cats. Veterinary Record Jan 2009 164, 80-86.
2. McCartney WM MacDonald BJ Incidence of Non-union in long bone fractures in 233 cats. Intern Journal Applied
Research Veterinary Science 2006, 4:209-212.
3. Nolte DM, Fusco JV, Peterson ME Incidence of and predisposing factors for nonunion of fractures involving the
appendicular skeleton in cats: 18 cases (1998-2002) JAVMA 2005.
4. Voss K, Langley-Hobbs SJ, Montavon PM, Radius and Ulna. Feline orthopedic surgery and musculoskeletal dis-
ease. Saunders Elsevier. Edinburgh,2009, 371-384.
5. Wallace AM, De La Puerta B, Trayhorn D, Moores AP, Langley-Hobbs SJ Feline combined diaphyseal radial and
ulnar fractures - A retrospective study of 28 cases Radius and Ulna fractures in cats. VCOT 2009 22: 38-46.
R.H. Palmer WVOC 2010, Bologna (Italy), 15th - 18th September • 394
Challenging polytrauma cases

Ross H. Palmer, DVM, MS, Dipl. ACVS
Associate Professor, Orthopaedic Surgery, Affiliate Faculty, School of Biomedical Engineering, Colorado State University
PRINCIPLES OF MANAGING POLYTRAUMA PATIENTS

“Polytrauma” refers to traumatic injury to multiple regions of the body, in contrast to a single isolated trau-
matic injury. The basic principles of managing victims of polytrauma are summarized in Table 1.
Since polytrauma is usually the result of a high-energy trauma, any temptation to focus upon the readily
identifiable injury or injuries increases the risk of missing other important injuries that may be life-threaten-
ing or have serious impact upon the prognosis and/or cost of the medical care. “Preserve life before limb” is a
particularly appropriate adage for such cases. Injuries to the cardiovascular, pulmonary, urogenital and gas-
trointestinal systems as well as body walls and diaphragm must be identified and managed prior to pursu-
ing aggressive surgical treatment of orthopedic injuries. As an example, many experienced orthopedists can
recall the pelvic fracture patient for whom they eagerly pursued surgical stabilization before recognizing the
ruptured urinary tract or diaphragmatic hernia. Such errors, typically the result of rushing to surgery and
failing to thoroughly examine and observe the patient, cause undue financial burden to the committed pet
owner at the very least and may risk the life of the patient at the very worst. “Don’t just do something….stand
there” may be an appropriate reminder for surgeons, who, by our very nature, are action-oriented.
Once thorough patient assessment is completed, it is important to manage the patient as a whole rather than
as a list of individual injuries. That is to say, injuries to one area of the body may have serious impact up-
on the prognosis for injuries elsewhere in the body. The most obvious clinical example is treatment of a pa-
tient with fractures in more than one limb where it is often not advisable to manage each injury in the way
that one would if it were an isolated injury.
Finally, preoperative client communication must be carefully performed with polytrauma cases. Use of the
Fracture Assessment Scoring (FAS) system1,2 is helpful, amongst other things, to communicate the relative
challenge to the pet owner (“On a trauma score of 1-10 with 1 representing the most severely traumatized patients, your
pet, unfortunately, scores a 2…so as you can tell, the risk of complications, likelihood of revision surgical procedures, and a less
than complete recovery is relatively high. I need you to be aware of this before we begin down the path of orthopedic treatments.
Take time to digest what I have told you to be sure that you wish to proceed with the plans we discuss”). It is also impor-
tant to specifically define the endpoint of discussions on prognosis (ie, does the prognosis discussed pertain
to bone healing, or to restoration of pre-injury mobility, comfort and function or is it for return to a lifestyle
that differs from the pre-injury state?). If the relative likelihood of revision procedures is high, that should
be communicated before the pet owner invests finances, time and emotional energy in the first surgical pro-
cedure. At times, the complexity of a case is such that a realistic “top end” to the total estimated costs can-
IN-DEPTH SEMINARS
not predicted – when that is the case, it should be stated clearly to the pet owner. It may be helpful to dis-
cuss both the “best case” and “worst case” scenarios with the pet owner so that they have a realistic expec-
tation of possible outcomes.
Table 1 - Basic Principles of managing polytrauma cases

1. Treat life before limb
2. Examine and observe the patient closely to detect occult injuries
• Cardiovascular, pulmonary, urogenital, gastrointestinal, neuorologic, body wall, orthopedic, etc
3. Manage the whole orthopedic patient rather than the individual injuries
4. Preoperative pet owner communications must be clear
• Fracture Assessment Scoring System
• Define the specific endpoint for discussions of prognosis
• Define the relatively likelihood for revision procedures, complications, etc
• Define the level of certainty regarding estimated total cost of health care of the injuries
• Discuss “best case” and “worst case” outcomes
395 • WVOC 2010, Bologna (Italy), 15th - 18th September R.H. Palmer
CASE EXAMPLE: RETRIEVER MIXED

BREED, 6 YEARS OLD, CASTRATED MALE,
30 KG - “GUINNESS”
Presenting Concern: Vehicular trauma, “is he dead?”
Past History: Previous femur fracture, previous left TP-
LO, previous right TTA and subsequent tibial fracture
Exam Findings (Figs 1 and 2):
• Severe trauma to both pelvic limbs (not able to am-
bulate even with assistance)
• Type III open fractures of left pes
• Multiple abrasions and moderate swelling over right
tibia
• Severe instability palpable at right tibial fracture zone
Preoperative Patient Assessment:

Left Pes: Figure 1 - Preoperative images (left pes).
Mechanical & Clinical factors (FAS = 3):
• Large breed dog
• Non-load-sharing fixation
• Bilateral pelvic limb disability
• Severe instability of fracture zone
• Active dog
• Poor owner compliance
Biological factors (FAS = 2):

• Middle aged patient
• Type III open injury
• Severe soft tissue injury
• Severe polytrauma
This type III open fracture has a guarded prognosis of

uncomplicated fracture healing and the prognosis for
early restoration of weight-bearing function of the limb
is guarded to poor with fracture treatment. Full limb
Figure 2 - Preoperative images (right crus).
amputation would shift all pelvic limb weight-bearing to
IN-DEPTH SEMINARS
the contra-lateral limb. Distal amputation at the tarso-
metatarsal joint will permit early restoration of weight-
bearing through application of an exo-prosthetic foot.
Right Tibia:
Mechanical & Clinical Factors (FAS = 3):
• Large breed dog
• Non-load-sharing fixation
• Bilateral disability
• Active dog
• Poor owner compliance
Biological Factors (FAS = 5):

• Middle aged patient
• Severe soft tissue injury
• Severe fracture zone instability
• Severe polytrauma
The non-reconstructable fracture of right tibial diaphysis extends distally to very near the tarsal joint (dor-
sal slab fracture of distal tibia extends into tibio-tarsal joint). Non-reconstructable classification of this frac-
ture shifts the surgical treatment priorities from perfect anatomic reconstruction to proper spatial alignment
R.H. Palmer WVOC 2010, Bologna (Italy), 15th - 18th September • 396
of the tibia, preservation of maximal biologic potential for fracture healing and application of an orthopedic
device that is capable of the mechanical demands non-load-sharing fixation. Owner must be aware that mul-
tiple surgical procedures may be required and, ultimate loss of limb may still occur.
Surgical Treatment Plan:

Left Pes –
• Distal amputation at tarso-metatarsal joint and construction of exo-prosthesis (transfer of foot pads to
chest wall as free graft for later use if needed to protect the stump from exo-prosthesis socket)
Right Tibia
• Remove previous bone plate
• Closed application IMEX-SK Hybrid fixator
• Add temporary hinged trans-tarsal component (locked initially)
• Use cranial olive to compress dorsal slab segment
• Use the hanging limb position to facilitate spatial alignment
• Use positive profile pins
• Use pre-drill technique for pin insertion
• Use intra-operative radiography
Postoperative Assessment:
Performed surgical treatment as planned. Locked the
trans-tarsal portion of frame initially. Will temporarily
“un-lock” the hinge during weekly recheck exams for
passive range of motion therapy. Hope to permanent-
ly un-lock the hinge at 4 weeks and remove the trans-
articular component at 6 weeks. Consider delayed can-
cellous bone graft or percutaneous stem cell injection
based upon radiographic appearance at 6 weeks.
Long-term outcome:
Distal amputation of the left
pelvic was performed at the tar-
so-metatarsal joint as a strategy
IN-DEPTH SEMINARS
to allow early weight-bearing

on that limb to protect the right
tibial fracture stabilization. An
exo-prosthesis was promptly
designed and fitted to protect
repair of right tibial fracture.
The patient was ambulating
very well on both pelvic limbs
at 28-day recheck examination.
At day 56, fractures of right
tibia were healing nicely and
the trans-articular component
of ESF was removed. The fractures were fully healed by 28 weeks after surgery and the ESF was completely
removed. More than one year after surgery, the patient is active and fully ambulatory on both pelvic limbs
with aid of the left exoprosthesis.
BIBLIOGRAPHY
1. Palmer RH. Decision making in fracture treatment: the Fracture Patient Scoring System. In Proceedings of (Small
Animal) ACVS Veterinary Symposium, Washington DC, 1994, pp 388-90.
2. Palmer RH, Hulse DA, Aron DN. A proposed fracture patient scoring system used to develop fracture treatment
plans. In Proceedings of the 20th Annual Conference of the Veterinary Orthopedic Society, 1993 (abstract).
Management of juxta-articular fractures

Alessandro Piras, DVM MRCVS ISVS
Newry - Northern Ireland - UK
Juxta-articular fractures are fractures occurring near the joint surface. The prefix “juxta-” comes from the
Latin preposition meaning near, nearby, close. Juxta-articular is composed of juxta, near + articular, from
the Latin “articulus”, a joint = near a joint. These fractures may be intra- or extra-articular.
Juxta-articular fractures are very challenging because of the short length of one of the bone segments, the
relative softness of bone and because of the presence of articular surfaces or physes near the fracture site.
Although many juxta-articular fractures are two-piece fractures, when comminuted, intra/juxta-articular frac-
tures are among the most difficult to achieve return of function and cosmesis.
These challenging fractures can be treated with a variety of methods according to their anatomical location,
degree of comminution, availability of implants and surgeon’s experience.Most of the pitfalls in the treat-
ment of juxta-articular fractures can be avoided if the surgeon has made a correct diagnosis of the fracture
type, has thoroughly analyzed the indications and the contraindications and has a profound knowledge of
the anatomy of the area. Furthermore, before attempting to treat these fractures, the surgeon should be very
familiar with both external and internal fixation techniques. High quality standard and oblique views x-rays
are necessary in order to assess the degree of comminution and the direction of the fracture lines. In order
to avoid diagnostic pitfalls, special imaging, as CT, should be undertaken whenever the fracture study is not
clear in the standard X-rays.
Major decisions in the preoperative planning should include the type of surgical approach and on the fixa-
tion technique. Open approach or minimally invasive plating and trans-cutaneous lag screwing should be
considered when the fracture is reducible and a stable fixation with appropriate size implants is possible. Ex-
ternal fixation with closed or minimally invasive approach should be considered for irreducible fractures and
when opening the fracture site will not add any objective advantage to the reduction and fixation of the frac-
ture. Preoperative evaluation should also include the investigation of associated soft tissue lesion that in se-
lected cases can dictate the choice of the technique and the timing for surgery.
EXTERNAL SKELETAL FIXATION

External skeletal fixation (ESF) is a valid surgical option for the management of some juxta-articular frac-
tures. Pins with positive profile threads or negative profile pins with a progressive thread should be used
when planning the stabilization of juxta-articular fractures with ESF. The size of the pins is usually chosen
based on pin core size, not based on the size of the outer diameter of the thread. The stiffness of a pin is pro-
portional to the 4th power of its diameter. Increasing core diameter by 33% will increase bending stiffness
IN-DEPTH SEMINARS
more than three times. Because space is always limited in juxta-articular fractures, it would be advisable to
use pins with cortical threads rather than cancellous threads because cortically threaded pins have a higher
core to outer diameter ratio.
Using relatively stiffer pins with a smaller outer thread diameter may facilitate the placement of three pins
(rather than two) in a small bone fragment. Since most of the strength of the pin bone interface comes from
the interaction of the pin with cortical bone, rather than cancellous bone, using cortical pins does not appear
to present a mechanical disadvantage, even in very young patients. Half-pins are usually recommended over
full pins because they are less invasive and allow more geometric flexibility. Whenever possible, try to place
three half-pins at different angles in the short fracture fragment in order to improve the overall mechanical
properties of fixation (i.e., bending stiffness). Four pins in the long fragment are usually sufficient. For ex-
ample, for distal radial fractures, it is possible to place two pins in a medial to lateral direction and one pin
in a cranio-medial to caudo-lateral direction. For distal femoral fractures, one pin can be placed in a medio-
lateral direction, one in a latero-medial direction (a full pin may be used as an alternative) a pin can be placed
in a cranio-medial to caudo-lateral direction and a pin placed in a cranio-lateral to caudo-medial direction.
In the distal tibia one pin can be placed in a medio-lateral direction, in a cranio-medial to caudo-lateral di-
rection, in a cranio-lateral to caudo-medial direction, in a caudo-medial to craniolateral direction. Pins are
usually inserted 2 to 3 mm from joint surfaces after predrilling with a drill bit measuring 0.1 mm less than
the core diameter of the pin. In most instances, it is possible to place the ESF pins in closed fashion, pro-
vided that they do not include articular fractures. During surgery, anatomic landmarks are used to precise-
ly locate bone fragments. Useful landmarks include the medial and lateral styloid processes for the distal ra-
dius and ulna, medial and lateral humeral epicondyles, radial head (laterally), and the medial and lateral
malleoli for the tibia The placement of a 25 gauge (0.5 mm) needles helps mapping the joint edges.
Free-form fixation, circular and hybrid are the type of ESF that better adapt to the geometrically variable
and the necessity of multidirectional fixation. Free-form fixation with epoxy putty has the advantage of be-
ing rapid, light and fully flexible with regard to frame geometry. Half, three-quarter, or full rings may are
used for hybrid stabilization of juxta-articular fractures. They have the slight disadvantage of being more
complex, more costly, and heavier than free-form frames. However, they have the significant advantage of
being adjustable after the procedure is complete. Adjustability includes adding or removing pins and chang-
ing the position of the distal fragment in relation of the proximal fragment. When using full rings, two ten-
sioned trans-osseous wires can be connected to the ring. Tensioned wires have the advantage of providing
rigid fixation for a short bone segment. For the long bone segment, linear connecting rods are connected to
the ring with hemispheric washers.
Temporary trans-articular fixation may be used in instances where the short juxta-articular segment does not
permit adequate fixation. Trans-articular hinged frames are preferred over fixed angle frames as they allow
some controlled unidirectional motion at the joint that has been bridged. Hinged frames may be linear, cir-
cular, or free-form frames with a simple hinge embedded in the epoxy. It is usually possible limit the motion
during the first 2 weeks by tightening the hinge. The hinge can be adjusted to allow increased joint motion
over time. Limb use has been shown to lead to a significant increase in strength and stiffness of healing lig-
aments.
OPEN REDUCTION AND INTERNAL FIXATION

Juxta – articular fractures can be treated with open reduction and internal fixation with screws and plates.
The fracture is usually reduced with bone reduction forceps, the fragments are fixed with lag screws and the
implant is applied and secured in a neutralization or buttress function. If lag screws are inserted through the
implant, it is possible to provisionally maintain the reduction with K wires. K wires can also be used as a
“joy stick” to manipulate and provisionally secure in place small fragments.
One of the major limiting factors in plating juxta-articular fractures, is that the distance between the plate
holes of the 2.0/2.7/3.5 DCP or LC DCP plates, allow placement of a limited number of screws for a rela-
tively short fragment. The surgeon should keep in mind that the distance between the plate holes in a DCP
is smaller than an LC-DCP, so, for a given length, the first implant can accommodate more screws. On the
other side, the LC-DCP can compensate with a greater range of screw angulation through the new designed
hole. The Veterinary Cuttable Plate (VCP) is a very versatile implant because it can accommodate the high-
er number of screws per length of plate as compared to most other plates in the veterinary market. The rel-
atively small size in thickness of the VCP can be overcome by stacking two plates. The development of the
new veterinary line of LC-DCP and LCP plates brought some improvement in the design consisting of an
end round hole on one side of the plate that is very close to the second last hole (LC DCP hole or Combi
LCP hole). Round hole, 3.5/2.7 Synthes T plates are very useful allowing placement of two screws in the
head and 5 to 7 screws in the shaft. These plates are usually indicated for dorsal application in juxta-articu-
lar fractures of the radius where they can be associated to medial plating with straight plates. Limitations of
IN-DEPTH SEMINARS
these implants are the relatively short stack portion between the shaft and the head, the thickness (only
2.0mm compared to the 3.3 mm of a 3.5 LC-DCP plate) and the round holes that do not allow interfrag-
mentary compression.
In recent years we assisted to the development of the locking technology that represent a real innovation in
fracture treatment. Locking plates are an ideal implant to treat juxta-articular fractures. The anatomical
shape of some specifically designed model, the fixed screw trajectory, and high surface quality take into ac-
count the current demands of orthopedic surgeons for appropriate fixation, high fatigue strength, and min-
imal invasive applications. One of the major disadvantages that an orthopedic surgeon has to face in treat-
ing juxta-articular fractures in small animals, is the scarcity of specifically anatomically designed implants.
In the human field there is a variety of locking and non-locking implants that are designed to address frac-
tures in proximity of the joints of every bone segment. In the last years some manufacturers started to pro-
duce “special” plates like the club plate for distal femural fracture and dedicated locking plates systems.
SUGGESTED READINGS
Management of Juxta articular fractures with external skeletal fixation. D. J. Marcellin little. ACVS Annual Symposium
2005.
Use of IMEX SK-circular external fixator hybrid constructs for fracture stabilization in dogs and cats. Farese JP, Lewis
DD, Cross AR, Collins KE, Anderson GM, Halling KB. J Am Anim Hosp Assoc. 2002 May-Jun;38(3):279-89.
Tibia: distal (pilon) fractures, Chapter 4.8.3 – Distal Radius/wrist fractures, Chapter 4.33.
AO Principles of Fracture Management. Ruedi, Murphy, AO Publishing 2000.
LIMB DEFORMITIES
IN-DEPTH SEMINAR
401 • WVOC 2010, Bologna (Italy), 15th - 18th September D.B. Fox
CORA method of planning corrective osteotomies

as applied to veterinary orthopedics
Derek B. Fox, DVM, PhD, Dipl. ACVS
Associate Professor, Small Animal Orthopedic Surgery
The CORA methodology of localizing and quantifying deformities within long bones was so named by a
surgeon named Dr. Dror Paley and was based upon his own work in this area in addition to the research of
a number of other surgeons (both human and veterinary) studying angular limb deformities (ALD). It is a
system by which axes and joint lines are assessed within an affected bone and then compared to a normal
standard to allow appropriate surgical planning. There is a challenge in discussing and teaching concepts of
ALD planning and treatment in reducing the subjectivity of individual assessment, and through the CORA
methodology, these investigators have sought to develop a vocabulary of terms, a deformity classification
scheme, and a planning technique adapted to the veterinary patient to allow a more accurate, repeatable and
objective methodology by which ALDS can be addressed.
The intersection of anatomic or mechanical axes defines positions of CORAs within an angulated bone. The
term CORA stand for center of rotation of angulation. This is a very accurate description for a deformity if one
considers the correction of the deformity to require the rotation of one segment of bone around a specific
point to reestablish alignment of both segments. However, what we will find is that CORAs possess more
complexity than just existing as a single point.
Every CORA possesses three elements that we must understand if we are to ac-
curately correct the deformity present: location, magnitude, and plane. Further-
more, we must appreciate that different kinds of CORAs exist – there are clos-
ing, neutral and opening CORAs. This lecture will focus on the definition of the
types of CORAs present and also determination of CORA location and magni-
tude. The next lecture will focus on determination of the CORA plane. If we
consider this diagram, we can see that two bone segments exist, and that each
possesses an individual anatomic axis. Thus the anatomic axis of the proximal
segment can be referred to as the PAA and distal anatomic axis the DAA. The
point at which the PAA and DAA intersect is the CORA. Notice that the inter-
section of these two axis results in angles: two acute, proximally and distally and
two obtuse, medially and laterally. If we find the bisector of the medial-lateral
IN-DEPTH SEMINARS
LIMB DEFORMITIES
obtuse angles, this line can be called a transverse bisecting line (tBL).
The transverse bisecting line is made up of an infinite number of CORAs as

the definition of a line is an infinite number of points. Depending on which side
of the tBL the points reside, they may constitute either closing, neutral or open-
ing CORAs. If the CORA we are identifying is at the exact point where the
two axes intersect, this is referred to as the neutral CORA. CORAs on the con-
cave side of the bone will be closing CORAs and CORAs on the convex sur-
face then will be opening CORAs. The terms opening, neutral and closing
should be familiar as osteotomy types are named after them which will be de-
scribed later.
Obviously, each CORA possesses a location within the bone. When we describe a CORA’s location, we
typically describe this within context to its proximity to an anatomic landmark that we can find surgically.
This becomes specifically important when it comes to complete the osteotomy so that our surgical execu-
tion matches our pre-operative plan.
D.B. Fox WVOC 2010, Bologna (Italy), 15th - 18th September • 402
As each CORA possesses a location, it also possesses a magnitude. The magnitude is defined simply as the
angular difference between the two axes that are intersecting to result in the CORA’s formation. This an-
gular magnitude will be used to determine how much of a correction will be made surgically to realign the
two segments of bone. Lastly, every CORA possesses a plane that it exists within. The plane is always in
the direction opposite of the actual bone deviation. This is a theme you will hear repeated over and over
again over the course of these lectures. The determination of the plane will dictate the plane in which the
corrective osteotomy must be made to optimize surgical correction of the deformity.
A multi-level angular deformity, or multiapical deformity, simply describes a situation in which a bone pos-
sesses more than one level of deformity. It is more accurately defined by a bone which possesses segments
with proximal and distal anatomic axes that do not intersect with one another within the cortical confines
of the bone. Thus, additional axes of intermediate sections of bone between the proximal and distal-most
anatomic axes must be derived resulting in additional CORAs.
In a recent retrospective study completed at the University of Missouri – Columbia in which dogs present-
ing with angular limb deformities were evaluated, it was determined that multiapical deformities are quite
common and may be more prevalent in chondrodystrophic breeds. The relationship that multiple deformi-
ties have to one another can be studied and documented. This allows deformities of this nature to be clas-
sified. For example, deformities which occur in opposite directions are considered to be “partially-compen-
sated” meaning that the bone has angled itself secondarily to offset some of the initial diversion from the
normal axis. Multiple deformities in the same direction are considered to be non-compensated as the diver-
sion from the normal axis worsens with each successive deformity. The most common kind of multiapical
deformity is the partially-compensated, biapical deformity.
This figure represents a partially-compensated biapical deformity. Note that

the PAA and DAA do not intersect one another. Thus, the segment of bone
between the two ends (an intermediate segment) must have its anatomic axis
calculated (IAA1). Note that this results in the presence of two CORAs (mak-
ing it biapical). The magnitude of each (α and β) occur on opposite sides of
the intermediate anatomic axis. Thus the joint orientation lines at the proxi-
mal and distal extents of the bone are relatively parallel. In this way, a proxi-
mal vaurs deformity is offset by a distal valgus, (or vice versa.) The resulting
deformity is mostly a translational deformity such that the distal joint is not
in the direct weight bearing axis (or mechanical axis) of the proximal joint.
This type of deformity frequently occurs in chondrodystrophic breeds.
IN-DEPTH SEMINARS
This figure represents a non-compensated biapical deformity. Again, where-

LIMB DEFORMITIES
as the PAA and DAA would eventually intersect if they were extended out
far enough, they would not do so within the cortical confines of the bone.
Thus, the intermediate bone segment has its anatomic axis calculated
(IAA1). Two CORAs (making it biapical) again result from this; the mag-
nitude of each (α and β) occurring on the same side of the anatomic axis of
the intermediate segment of bone (IAA1). In this case, the joints are not par-
allel. Thus the resulting deformity is either a doubly compounded varus or
valgus deviation in addition to a translational deformity.
The figures above only illustrate biapical deformities in the frontal plane.
However, deformities in the sagital plane, and rotational place can also oc-
cur either concurrently with the frontal plane deformities or on their own.
In addition, we have documented cases with as many as 4 CORAs in se-
verely affected limbs. Each CORA is derived from the intersection of best fit anatomic axes of the various
segments of bone and are required to allow the intersections of the various axes to intersect within the cor-
tical confines of the bone.
ADDITIONAL READING
Paley D. Osteotomy Concepts and Frontal Plane Realignment in: Principles of Deformity Correction, Springer-Verlagg,
Berlin. 2002. p 99.
Fox DB, Tomlinson JL, Breshears LB. Vet Surg. 2006;35:67-77.
403 • WVOC 2010, Bologna (Italy), 15th - 18th September D.B. Fox
Oblique plane closing wedge osteotomy of the radius and ulna

Associate Professor, Small Animal Orthopedic Surgery - University of Missouri - Columbia
Angular limb deformities of the canine forelimb arise predominantly from the antebrachium which is more
frequently affected because of the necessity of both the radius and ulna to develop and lengthen in syn-
chrony despite the fact that 100% of longitudinal bone growth of the ulna distal to the elbow arises from the
distal ulnar physis, whereas longitudinal growth of the radius comes from both the proximal and distal ra-
dial physes. A number of factors can frequently result in premature closure of the distal ulnar physis result-
ing in subsequent and significant angulation of the radius with loss of elbow congruity. Humeral angulation
may also occur and only recently have studies been completed to establish the normal parameters of the ca-
nine humerus in the frontal and sagital planes. In the interest of space, the following description is offered
as a way to utilize the CORA methodology to assess the most common clinical ALD of the canine forelimb,
the oblique planed radioulnar deformity:
Orthogonal radiographs of the affected antebrachium are taken. If the patient’s opposite limb is determined
to be normal based on function and orthopedic examination, radiographs of that side are also completed.
Joint orientation lines are determined for the elbow and carpus both in the frontal and sagital planes. Using
the normal (or referenced) aMPRA and aDLRA, the radial anatomic axes are determined in the frontal
plane. Using normal aCPRA and aCDRA, the radial anatomic axes are determined in the sagital plane.
If two axes are apparent which intersect in the frontal plane within the cortical confines of the bone, the site
of their intersection is considered to be a uniapical CORA. Two anatomic axes should be delineated in the
sagital plane as the radius normally has some procurvatum. The amount of procurvatum from the normal
side should be measured and compared to the affected side. If deviation from the normal procurvatum is al-
so evident and excessive in the affected side, then a deformity exists that possesses deformation both in the
frontal and sagital planes as we measure it from the orthogonal radiographs. However, returning to what we
have already learned, this deformity is not in fact biplanar but exists in one single plane between the or-
thogonal dimensions represented in our radiographs. Thus, it is an obliquely-planed deformity. This is im-
portant to recognize so that a single osteotomy can be completed to correct both frontal and sagital compo-
nents of the oblique uniplanar deformity.
The CORA is localized by examining for the site of intersection of the anatomic axes, and magnitude of the
deformity determined in both frontal and sagital planes. These magnitudes (typically represented by degrees
of angulation) are converted to linear units so that the graphical method of CORA plane determination can
be employed.
As previously discussed, the graphical method is employed charting the frontal plane CORA magnitude vec-
IN-DEPTH SEMINARS
tor on the x-axis, and the sagital plane CORA magnitude vector on the y-axis; both vectors starting at the
LIMB DEFORMITIES
graph’s origin. The two vectors are resolved with a third vector which comprises the hypotenuse of the rec-
tangle that the two orthogonal vectors make. The length of this vector is measured or trigonometrically cal-
culated and represents the magnitude of the CORA in the oblique plane. The angular relationship of this
oblique vector from the orthogonal dimensions defines the obliquity of the CORA. Remember to first eval-
uate which quadrant this resides in (cranio-medial, cranio-lateral, caudal-medial, caudal-lateral) and then try
to determine the angular obliquity more accurately.
To complete a closing CORA at the level of the obliquely-planed CORA, the ACA must be based on a clos-
ing CORA of the tBL that passes through this CORA. Notice that this ACA is perpendicular to the CO-
RA’s plane and exists on the concave side of the bone. The execution of an osteotomy in an oblique plane
is more challenging than if the CORA’s plane is simply in the frontal or sagital plane. To plan a closing
wedge osteotomy in the oblique plane, the dimensions of the proposed wedge cannot be easily determined
from a single radiographic projection. Rather, both planes must be used to determine the dimensions of the
bone at the level of the CORA. Then an illustrative facsimile of the bone’s cross section is drawn so that
the diameter (y) of the bone, on the oblique plane can be determined. This diameter is measured. A right
triangle is then planned with the base of a dimension (y) equivalent to the cross section of the bone at the
oblique CORA. The angle (θ) between the hypotenuse and base of this triangle is represented by the oblique
CORA’s magnitude. Then the height (x) of the triangle is solved for by the formula tanθ = y/x where x is
solved for and will represent the height of the wedge to be removed. It is important to remember that the
saw blade making the two cuts need to be ‘coplanar’ or only offset from each other by the angle of the pro-
posed CORA magnitude. Removal of this single oblique wedge should result in correction of the deformi-
ty both in frontal and sagital dimensions.
J. Tomlinson WVOC 2010, Bologna (Italy), 15th - 18th September • 404
Normal bone angles and malalignment

James Tomlinson, DVM, MVSc, Dipl. ACVS
University of Missouri
In the foreleg, the radius is the bone that is meas-

ured to establish normal joint relationships, to
document abnormalities, and to then determine
the degree of correction needed. In the frontal
plane, the reference points on the proximal joint
surface are the most proximolateral aspect of the
radial head to the most proximomedial aspect of
the medial cornonoid process or distal aspect of
the humeral condyles (Figure 1). These points
are connected to form the proximal joint refer-
ence line. As an alternative if there is a malalign-
ment of the proximal radial and ulnar joint sur-
faces, a line can be drawn across the distal aspect
of the humeral condyle.
For the distal radial joint surface, the reference
points are the lateral articular surface face to the
medial articular face ignoring the styloid
process (Figure 1). These points are connected
to form the distal joint reference line. The
anatomic axis is drawn by connecting three
points that bisect the radius (Figure 1). In the
normal radius, these reference points can be
marked at the midpoints of radial diaphysis at
25%, 50%, and 75% along its length from the
proximal end. The intersection of an anatomic
axis (or mechanical axis) and a joint reference Figure 1
line produces an angle that can be measured.
The angle that is measured for the proximal
end of the radius is the anatomic medial proximal radial angle (aMPRA)
(Figure 1). The angle that is measured for the distal end of the radius is the
IN-DEPTH SEMINARS
anatomic lateral distal radial angle (aLDRA) (Figure 1).

LIMB DEFORMITIES
In the sagittal plane, the reference points for the joint reference line for
the proximal aspect of the radius are the most proximal extent of the cra-
nial and caudal part of the radial head (Figure 2). The line that connects
these reference points is the proximal joint reference line in the sagittal
plane. For the distal end of the radius, the reference points are the cranial
and caudal aspect of the radial articular face. A line that connects these
points is the distal joint reference line (Figure 2). The radius has a normal
procurvatum. As a result the radius does not have a single anatomic axis.
The radius has two anatomic axes, one for the proximal ½ of the bone and
one for the distal ½ of the bone. To draw the two anatomic axes, find 2
points that bisect the radius in both the proximal and distal one-half of the
diaphysis of the bone. Connect the respective reference points in both
halves of the bone to form the two anatomic axes. The intersection of the
anatomic axes with their respective joint reference line produces an angle
that can be measured. For the proximal end of the bone, the anatomic cau-
dal proximal radial angle (aCdPRA) is measured (Figure 2). For the distal
aspect of the bone, the anatomic caudal distal radial angle (aCdDRA) is
measured (Figure 2). The intersection of the two anatomic axes produces
an angle (sagittal plane anatomic axes angle – SPA) that represents the de-
gree of normal procurvatum of the radius (25-26 degrees). Figure 2
405 • WVOC 2010, Bologna (Italy), 15th - 18th September J. Tomlinson
Table 1 - Normal reference values for the radial angles in degrees

aMPRA aLDRA mMPRUA mLDRUA aPCdRA aDCdRA mPCdRA mDCdRA
Labs 82.50±2.83 86.00±3.32 83.60±2.75 89.40±1.83 85.08±3.56 76.92±3.69 78.17±3.08 74.71±3.73
95%CI 81.72-83.28 85.08-86.92 82.83-84.73 88.89-89.91 84.09-86.07 75.89-77.95 77.32-79.03 73.67-75.75
Non-Labs 81.11±3.38 87.77±2.60 83.40±2.1 89.30±1.64 88.00±3.68 75.90±3.57 80.58±3.79 74.10±3.12
95% CI 80.17-82.05 87.05-88.49 82.81-83.99 88.84-89.76 86.98-89.02 74.91-76.90 79.53-81.63 73.21-74.99
Femur - A standardize method to measure the anatomic and

mechanical axis of the femur in the frontal plane will be de-
scribed. The femur must be positioned in a true craniocau-
dal orientation on the radiograph to be measured. The dis-
tal joint reference line is determined by a line that just touch-
es the distal most aspect of the lateral and medial femoral
condyles (line A-B). The proximal joint reference line runs
from the center of the femoral head to the dorsal most aspect
of the greater trochanter of the femur. The anatomical axis
is determined by a line that bisects the proximal one-half of
the femur. A point is selected 33% and 50% below the prox-
imal aspect of the femoral neck in the middle of the femur
and connected by a line that runs from the proximal to dis-
tal aspect of the femur (line X-Y). The anatomical lateral dis-
tal femoral angle (aLDFA) is measured as the angle that is
formed by the anatomic axis and distal femoral joint ref-
erence line (Figure 3A). The anatomical lateral proximal
femoral angle (aLPFA) is measured as the angle that is
formed by the anatomic axis and proximal femoral joint ref-
erence line (Figure 3A). The mechanical axis is determined
by a line that runs from the center of the femoral head to the
center of the intercondylar notch of the femur (line C-E). Figure 3 A, B
The mechanical lateral distal femoral angle (mLDFA) is
measured as the angle that is formed by the mechanical axis
and distal femoral joint reference line (Figure 3B). The mechanical lateral proximal femoral angle (mLPFA)
is measured as the angle that is formed by the mechanical axis and proximal femoral joint reference line (Fig-
IN-DEPTH SEMINARS
ure 3B). Normal angles vary by breed.
LIMB DEFORMITIES
Table 2 - Mean of femoral joint angles
aLDFA mLDFA aLPFA mLPFA Inclination Angle
Labrador Retriever 97±3.2 100±2.6 103±6.4 100±6.0 134±5.3
Golden Retriever 97±2.8 100±2.3 98±5.7 95±5.2 134±5.2
German Shepherd 94±3.3 97±3.1 101±5.0 97±4.5 132±5.9
Rottweiler 98±3.5 100±2.7 96±5.3 93±4.7 137±5.4
Table 3 - 95% Confidence intervals for femoral joint angles for individuals in a population
aLDFA mLDFA aLPFA mLPFA Inclination Angle
Labrador Retriever 90.8-103.4 95.4-105.6 90.6-115.7 88.0-111.4 123.5-144.2
Golden Retriever 91.7-102.7 95.6-104.5 86.4-108.9 84.6-105.0 124.2-144.4
German Shepherd 87.4-100.4 91.1-103.4 90.7-110.5 88.2-105.8 120.7-143.8
Rottweiler 90.9-104.4 94.8-105.5 85.6-106.5 84.1-102.7 126.2-147.5
Tibia - Information about the tibial plateau angle, femoral

inclination angle, and femoral antiversion angle has been
documented. Standard methods of measurement and cor-
responding angles of the relationship of the angles that de-
fine the normal tibia and femur are important in deter-
mining if an angular abnormality exists and the degree of
correction that is needed.
A standardized method to measure the tibial joint surface
angles, in relation to the mechanical axis, in the frontal
plane will be described. The most distal points of the sub-
chondral bone concavities of the medial and lateral tibial
condyles (points A and B on drawing A) are used as land-
marks for the proximal tibial joint orientation line (Fig. 4).
The most proximal points (points A and B on drawing 4B)
of the subchondral bone of the two arciform grooves of the
cochlea tibiae are used as landmarks for the distal tibial Figure 4 A, B, C
joint orientation line (Fig. 4). The mechanical axis of the
tibia is defined by a point in the center of the proximal most
aspect of the intercondylar fossa of the femur (point C in drawing 4A) and at the most distal point (point C in
drawing 4B) of the subchondral bone of the distal intermediate tibial ridge (Fig. 4). The angles between the
mechanical axis and the joint orientation lines are measured on the proximomedial and distomedial aspects to
determine the mMPTA (mechanical medial proximal tibial angle) and mMDTA (mechanical medial distal tib-
ial angle), respectively (Fig. 4C). The tibial plateau angle has been reported in a number of studies.
Table 4. Canine Tibial Angle Measurements - Frontal Plane Data for 105 dogs
All (n=105) Labradors Retriever (n=70) Non-Labradors (n=35)
Mean mMPTA ± SD (degrees) 93.30 ± 1.78 93.38 ± 1.81 93.14 ± 1.73
Mean mMDTA ± SD (degrees) 95.99 ± 2.70 96.34 ± 2.51 95.29 ± 2.95
mMPTA(95% confidence interval) 89.74 - 96.86 89.76 - 97.00 89.68 - 96.6
mMDTA (95% confidence interval) 90.59 - 101.39 91.32 - 101.36 89.39 - 101.19
Table 5. Mean Data for 150 Canine Tibial Angle Measurements – Sagittal Plane
IN-DEPTH SEMINARS
LIMB DEFORMITIES
All (n=150) Labrador Retriever (n=104) Non-Labrador (n=46)

Mean mCrDTA ± SD (°) 81.6 ± 4.2 81.7 ± 4.2 81.5 ± 4.1
Mean mCaPTA ± SD(°) 63.6 ± 3.7 63.8 ± 3.7 63 ± 3.9
mCrDTA 95% confidence intervals 73.3-89.9 73.2-90.1 73.4-89.7
mCaPTA 95% confidence intervals 56.1-71 56.5-71.1 55.2-70.9
REFERENCES
Tomlinson J, Fox D, Cook JL, Keller GG.Measurement of femoral angles in four dog breeds.Vet Surg. 2007;36(6):593-8
Dismukes DI, Tomlinson JL, Fox DB, Cook JL, Song KJ. Radiographic measurement of the proximal and distal me-
chanical joint angles in the canine tibia.Vet Surg. 2007;36(7):699-704.
Dismukes DI, Tomlinson JL, Fox DB, Cook JL, Witsberger T. Radiographic measurement of canine tibial angles in the
sagittal plane. Vet Surg. 2008 Apr;37(3):300-5.
Dismukes DI, Fox DB, Tomlinson JL, Cook JL, Essman SC. Determination of pelvic limb alignment in the large-breed
dog: a cadaveric radiographic study in the frontal plane. Vet Surg. 2008 Oct;37(7):674-82.
Fasanella FJ, Tomlinson JL, Welihozkiy A, Fox DB. Radiographic measurements of the axes and joint angles of the ca-
nine radius and ulna. VOS 2010.
Rear limb deformities

James Tomlinson, DVM, MVSc, Dipl. ACVS
University of Missouri
CORRECTION OF
FEMORAL DEFORMITY
The femur is measured to de-
termine the degree of angular
deformity present. Figure 1 il-
lustrates a method of measure-
ment for this purpose. The
anatomical axis of the femur is
determined by marking a
point 1/3 and 1/2 way down the
femur from the proximal as-
pect of the femoral neck. At
these 2 points, the center of
the femoral shaft (from lateral
to medial) is marked and a
line (X-Y) is drawn through
these points and runs from the
proximal to distal end of the
femur (Figure 1). The distal Figure 1 Figure 2 Figure 3
femoral joint reference line A-
B is drawn across the distal aspect of the femoral condyles so
that the line just touches the distal most aspect of the each
condyle (Figure 1). The angle formed by the intersection of the
femoral axis and the joint reference line represents the distal
femoral joint angle. It is named the anatomical lateral distal
femoral angle (aLDFA) (Figure 1). The mean aLDFA is ~97 de-
grees for most normal dogs. It is important that the femur is po-
sitioned in as true a cranial-to-caudal position as possible for
measurement.
On the radiograph of an abnormal femur, draw the anatomical
IN-DEPTH SEMINARS
axis of the femur and the distal femoral joint reference line
LIMB DEFORMITIES
(JRL). Measure the aLDFA (Figure 2). The angle of the wedge
will be the difference between the measured angle and the refer-
ence angle for aLDFA (~97 degrees).
Draw a line that angles 97 degrees from the distal joint reference Figure 4
line of the distal femur alng the medial aspect of the lateral
trochlear ridge (line aA2). The intersection of this line with the
line aA1 (anatomical axis of the proximal femur) is the level of Angle Tangent Angle Tangent
the CORA where the osteotomy should be performed (Figure
3). If the CORA is located in the trochlear groove, move the os- 5 0.09 11 0.19
teotomy up to just proximal to the trochlear groove. 6 0.11 12 0.21
Draw line X perpendicular to the lateral cortex of the femur at
the level of the osteotomy. Measure the length of line X. The 7 0.12 13 0.23
length of line Y is determined by multiplying the length of line 8 0.14 14 0.25
X by the tangent of the degree of angular correction that was
measured in step #2. Draw line Y on the drawing of the femur. 9 0.16 15 0.27
Line Y must be perpendicular to line X. Finish the triangle by 10 0.18
drawing line Z. This triangle of bone of the wedge that needs to
be removed (Figure 4).
On the abnormal femur, the dimensions of the wedge are marked on the bone the correct distance from the
proximal aspect of the trochlear ridge of the femur. A TPLO jig or a type I Ex Fix apparatus is applied on
the femur to help control the bone once the osteotomy has been performed. The fixation pins will be in-
serted from cranial to caudal. The distal fix-

ation pin will be placed just proximal to the
trochlear sulcus.
The proximal fixation pin is place proximal
to the intended osteotomy site far enough to
be out of the way (Figure 5).
Using the oscillating saw, a cut is made about
½ way across the femur at the first osteoto-
my line. The cut should be perpendicular to
the bone proximal to distal. The second bone
cut is made keeping the saw blade in a coax-
ial plane to the first cut in the cranial-to-cau-
dal axis (Figure 6). A second saw blade (or
metal ruler) can be placed into the first saw
cut and used as a visual reference to make Figure 5 Figure 6
sure the 2 cuts are coaxial planes, with the
common axis at the medial femoral cortex.
Complete the first osteotomy and remove the wedge. The wedge is measured to
confirm that it is the desired size.
The clamps on the TPLO jig (ESF) are loosened and the distal femoral segment
rotated until the osteotomy gap is closed and the femur is in reduction (Figure 7).
The TPLO jig is tighten to maintain reduction of the femur.
Lateral torsion of the distal femur is present in a lot of femurs. Figure 8 demon-
strates how anteversion is measured. The normal anteversion angle is ~27 de-
grees. To correct the anteversion angle to 27 degrees, mark a line that runs prox-
imal to distal across the osteotomy line. This line is a reference points for meas-
urement of the degree of rotation that has been achieved. The bone is not a per-
fect circle but the calculation is a reasonable estimate of the amount of rotation
that is needed. To calculate the circumference of the bone, use the formula for the
circumference of a circle which is circumference = Pi*d where d is the diameter of
the circle (bone) and Pi is 3.14. Measure the diameter of the bone. Calculate the Figure 7
circumference of the circle. Divide the circumference of the bone by 360 degrees
to provide the distance that every degree
equals of the diameter of the circle. Multi-
ple the number of degrees of correction
that is required by the distance that every
degree equals of the diameter of the circle.
IN-DEPTH SEMINARS
Distance of rotation = circumference/360 *

LIMB DEFORMITIES
degrees of rotational correction required. As

an example if the circumference of the bone
is 34.5 mm and the anteversion angle is 0,
divide 34.5 by 360 which equals 0.096. Mul- Figure 8
tiple 0.096 by 27 degrees (degrees of rota-
tional correction required) which equals 2.6 mm. Mark a line 2.6 mm medial to
the reference line and rotate the distal segment of bone until the distal reference
line lines up with the proximal rotation line. Clinically, a simple method to achieve
the same thing is to bend the distal TPLO pin and then confirm the angle with a
goniometer. Cross pin the osteotomy with 1.25 mm K-wires placed from medial
to lateral and cranial to caudal; ensure that the K-wires will not interfere with sub-
sequent plate application.
The appropriate size bone plate is contoured and applied to the lateral aspect of the
distal femur (Figure 9).
CORRECTION OF A TIBIAL DEFORMITY

The tibia can have a compensatory deformity associated with a femoral deformity
that may need to be corrected. Figures 10 shows how the tibia is measured. Nor-
mal value for the mechanical medial proximal tibial angles is 93 degrees and the
normal value for the mechanical medial distal tibial angle is 96 degrees. Figure 9
Draw the proximal and distal joint

reference lines on the tibia. Draw the
mechanical axis of the proximal and
distal tibial segment. The proximal
mechanical axis should be drawn so
that is makes a 93 degree angle to the
joint reference line. The distal me-
chanical axis should be drawn so that
is makes a 96 degree angle to the
joint reference line. Measure the an-
gle formed by the intersection of the
proximal and distal mechanical axes
of the tibia. Where these two lines
cross is the level where the osteotomy
should be performed (Figure 11).
The length of line X is measured and Figure 10
should run perpendicular to the medi-
al cortex of the bone. The length of
line Y is calculated by multiplying the
tan of the correction angle times the
length of line X. Mark line Y on the
drawing of the bone. Complete the tri-
angle by marking line Z (Figure 12).
On the bone, draw the wedge at the
appropriate level on the tibia (CO-
RA). Using the sagittal saw, cut and
remove the wedge. Remember to
make the two osteotomies in coaxial
planes based on the lateral cortex of
the tibia. Do not osteotomize the fibu-
la unless necessary to allow reduction
of the tibia. Reduce the osteotomy
gap and cross pin the osteotomy with
1.5 mm K wires. A bone plate is aAp-
plied to the medial side of the tibia in
a compression manner (Figure 13). Figure 11 Figure 12 Figure 13
IN-DEPTH SEMINARS
LIMB DEFORMITIES
PES VARUS
Pes varus is a bone deformity typically seem in Dachshunds and is thought to be due to closure of the medi-
al aspect of the distal tibial growth plate which then causes varus angulation of the distal tibia. The affected leg
is abducted at the stifle to try to place the foot on the ground in a normal manner causing a bow legged ap-
pearance. Visual examination of the leg demonstrates the varus deformity of the distal tibia. Lameness is a
characteristic finding in affected dogs. Surgical correction is required to resolve the lameness and restore more
normal ambulation. The articular surfaces must be realigned to a normal relationship and is done by either an
opening or closing wedge osteotomy. Since the CORA of the deformity is centered over the distal tibial meta-
physis, little bone is available distal to the osteotomy which can make fixation of the bone difficult. Stabiliza-
tion of the osteotomy can be done with a bone plate, modified external fixator, or circular fixator.
REFERENCES
Tomlinson J, Fox D, Cook JL, Keller GG.Measurement of femoral angles in four dog breeds.Vet Surg. 2007;36(6):593-8.
Dismukes DI, Tomlinson JL, Fox DB, Cook JL, Song KJ. Radiographic measurement of the proximal and distal me-
chanical joint angles in the canine tibia.Vet Surg. 2007;36(7):699-704.
Dismukes DI, Tomlinson JL, Fox DB, Cook JL, Witsberger T. Radiographic measurement of canine tibial angles in the
sagittal plane. Vet Surg. 2008 Apr;37(3):300-5.
Dismukes DI, Fox DB, Tomlinson JL, Cook JL, Essman SC. Determination of pelvic limb alignment in the large-breed
dog: a cadaveric radiographic study in the frontal plane. Vet Surg. 2008 Oct;37(7):674-82.
Radasch R, Lewis DF et al. Pes Varus Correction in Dachshunds Using a Hybrid External Fixator Veterinary Surgery
2008;37:71-81.
JUVENILE HD
IN-DEPTH SEMINAR
413 • WVOC 2010, Bologna (Italy), 15th - 18th September R.T. Dueland
CHD treated by JPS: median 7.6 year results

R.T. Dueland, W.M. Adams, A.J. Patricelli, P.M. Manley, P.M. Crump
University of Wisconsin, Madison, Wisconsin, U.S.A.
This study was initiated to analyze JPS dogs & controls at multiple-years post-operative & compare results
by: hip laxity, age at surgery, owners functional gait analysis & hip arthritic (DJD) medication use.
HYPOTHESES
1. JPS dogs with pre-operative Distraction Index ≤ 0.70 would have improved DJD, DI, functional gait score
and decreased DJD medication usage vs. DI ≥ 0.71; 2. Early aged JPS surgery dogs (≤ 17 weeks) vs. later
aged JPS dogs (≥ 18 weeks) would have similar trends.
MATERIALS & METHODS

Thirty-five previously studied dysplastic-prone dogs (preop DI range 0.46 - 1.26), privately-owned dogs, uni-
versity approved, median age 7.6 years (mean 6.9 years, range 5-11 years), were radiographed for blinded
DJD grading with preop, 1, 2 &7 year DJD & 1-2 year DI statistical comparisons. Cohorts: DI ≤ 0.70 dogs,
n =15; DI ≥ 0.71, n =16; controls, DI 0.71, n= 4; young surgical ages 15-17 wks, n= 10; and older aged JPS
dogs 18-23 wks, n=21. Owner-surveys (n=35) used to evaluate 6 gait functions for disability incidence,
severity scores & hip DJD medication usage.
ANALYSES
* = p<.05, ** = trend (p=0.06-0.09), ns = not significant.
RESULTS
At 7 years: DI ≤ 0.70 JPS dogs decreased DJD by 35% ** vs. preop. value; DI ≥ 0.71 increased DJD by
76%*. Young aged JPS decreased DJD by 6% (ns); the ≥ 18 wk JPS dogs incr DJD by 50%*. DJD Controls
incr. DJD by 125%**. In DI all dog cohorts improved by ~ 19% by 2 years. In owner gait survey: DI ≥ 0.71
dogs & older dogs had highest gait incidence* and severity.*
COMPLICATIONS
Revision rate 1.6% (1/64 hips). All hypotheses were confirmed.
CONCLUSIONS
DI ≤ 0.70 is most important and ≤ 17 wks of age aids JPS success in limiting DJD and for better gait func-
IN-DEPTH SEMINARS
tions.
JUVENILE HD
REFERENCES
1. Dueland, et al. Vet Surg ’01:30:201.
2. Patricelli, et al, Vet Surg ’02; 31:435.
3. Henry DVM Newsmagazine Oct/Nov ’09,32-33, 26-27.
4. Dejardin et al, Vet Surg ’98; 25:194.
5. Vezzoni, VCOT ’08; 21:267.
6. Manley, et al, JAVMA ’07; 230:1-5.
7. Dueland, et al, JPS: Objective & subjective two year results. In press-VCOT.
FUNDING
UW Foundation.
PROPRIETARY
none 6.4.10.
D.B. Fox WVOC 2010, Bologna (Italy), 15th - 18th September • 414
Double Pelvic Osteotomy: mechanisms of action

Associate Professor, Small Animal Orthopedic Surgery - University of Missouri - Columbia
INTRODUCTION
Triple Pelvic Osteotomy (TPO) was developed to increase the dorsal acetabular coverage of the femoral
head in young dogs to improve the biomechanics of dysplastic coxofemoral joints. With TPO, there is a risk
of implant-related complications. Screw loosening and implant failure have been reported to occur in up to
70% of cases. In an effort to reduce the rate of implant-related TPO complications and decrease patient mor-
bidity, a modification of the TPO has been developed in which the hemipelvis is osteotomized only at the
pubis and ilium. Because the DPO causes ventroversion of the canine acetabulum by torsion and plastic de-
formation of the ischium, the magnitude of rotation necessary at the ilial osteotomy required to produce the
same degree of acetabular vetroversion achieved with TPO is not currently known. The purpose of this
study was to compare the acetabular ventroversion achieved by the DPO technique at 20, 25 and 30 de-
grees to the standard TPO at 20 degrees. Secondarily, anatomic angles in six transverse planes of the pelvis
pre- and postoperatively for each technique were compared in an effort to identify the relative anatomic lo-
cation of the hemipelvic torsion or flexion caused by the DPO technique.
Eight large breed dogs between 12 and 20 kilograms, with no history of trauma or disease, and from 6 to 8
months of age were obtained after euthanasia for reasons unrelated to this study. The entire pelvis was dissect-
ed free from each cadaver. Each pelvis and sacrum was cleaned of all musculature, but sacroiliac and lumbosacral
articulations were undisturbed. The specimens were hung in a custom jig to standardize positioning for com-
puted tomography (CT). Baseline CT and radiographs were performed and designated as NoSx. The specimens
had the double pelvic osteotomy procedure (DPO20) with a 20 degree TPO plate (NGD, Glen Rock, NJ) per-
formed similar to a standard triple pelvic osteotomy except the sacrotuberous ligament was transected and the
ischial osteotomy not completed. Computed tomography was repeated in identical fashion being careful to po-
sition the pelvis as before. The ilial plate was replaced with a 25 degree plate (DPO25) using the same cortical
screw holes and CT performed. The procedure was repeated once again with a 30 degree plate (DPO30) and
CT performed. Finally, an ischial osteotomy was performed and the 20 degree plate replaced to mimic a clini-
cal TPO of 20 degrees (TPO20). Selected images from the CTs were obtained. The angles of the medial cortex
of the specimen to the same anatomic midline were measured in six transverse planes: ilial crest (IlCr), pre-ac-
etabular (PreAce), acetabular (AA), post-acetabular (PostAce), cranial ischial (CrIs) and caudal ischial (CdIs). For
change in ventroversion measurements between CTs, an increase in ventroversion was deemed to be a positive
change. All 6 measurements were made bilaterally (operated and unoperated hemipelvis) for each CT. The val-
IN-DEPTH SEMINARS
ues of each angle were compared for the 3 DPO techniques to the TPO20 via concordance correlation in order
JUVENILE HD
to determine which of the three DPOs results in the acetabular ventroversion angle closest to the TPO20 value.
A concordance correlation of 1 indicates perfect concordance; 0.8 is considered good concordance.
RESULTS
The average acetabular angles (±SD) in degrees were: NoSx- 32.89 ± 2.23, DPO20- 47.39 ± 4.39, DPO25-
51.43 ± 5.06, DPO30- 54.75 ± 4.38, and TPO20- 50.20 ± 5.76. Concordance correlations compared to
TPO20 were: NoSx- 0.027, DPO20- 0.721, DPO25- 0.902, and DPO30- 0.593. The average change in ven-
troversion compared to baseline between each portion of the anatomy (PreAce, AA, PostAce, CrIs, and
CdIs) was similar (18.80 ± 4.86, 18.55 ±3.05, 17.32 ±5.62, 16.43 ±5.06, and 18.17 ±5.90 respectively for
the DPO25, for example) with a gradual 2.37 degree decrease in ventroversion between PreAce and CrIs.
DISCUSSION AND CONCLUSION
These data suggest that a DPO at 25 degrees results in the most similar acetabular ventroversion compared
with the traditional TPO of 20 degrees, as indicated by a concordance correlation of 0.902. Thus, in order
to obtain similar results from the DPO as a TPO of 20 degrees, this study supports the use of a 25 degree
plate. Additionally, we found that the ventroversion resulting from the DPO came mostly as a result of ven-
tral flexion of the symphysis pubis. This can be seen in the 2.37 degree decrease in average change from
baseline ventroversion angle between PreAce and CrIs for DPO25.
DISCLOSURE
The implants used in this study were donated by New Generation Devices, Glen Rock, New Jersey. The re-
mainder of the study was funded by an institutional research grant.
415 • WVOC 2010, Bologna (Italy), 15th - 18th September R.H. Palmer
Mechanical comparison of locked and non-locked plate

fixation applied to rotational osteotomies in cadaveric
canine ilia
R.H. Palmer, J.B. Case, C. Dean, D.M. Wilson, J.M. Knudsen, S.P. James
Objective - To compare the mechanical behaviors of two locked (parallel and diverging screws) and one
non-locked version of triple pelvic osteotomy (TPO) plate/screw fixation.
Study Design - In vitro biomechanical evaluation.
Methods- Cadaveric canine hemi-pelves.
Comparison #1 - Non-Locked 20° (NL-20) vs. Locked Parallel screws 20° (LP-20) TPO construct, n = 7.
Comparison #2 - LP-20 vs. Locked Diverging screws 20° TPO (LD-20) construct, n = 6.
Condition #1: Non-destructive loading (stiffness).
Condition #2: Cyclic loading (stiffness, osteotomy gap displacement, and screw loosening).
Condition #3: Load to failure (yield load, yield displacement, load to failure, failure mode).
Results - Stiffness was not different for NL-20 versus LP-20 constructs (p=0.48) or for LP-20 versus LD-20
constructs (p=0.83). Screw loosening was significantly more frequent for NL-20 versus LP-20 (p=0.01) and
for LD-20 versus LP-20 constructs (p=0.02). The relative risk for screw loosening with NL-20 versus LP-
20 and LD-20 versus LP-20 constructs was 1.4 (95% CI=1.1-1.8), and 1.6 (95% CI=1.1-2.2), respectively.
Yield load was significantly greater for LP-20 constructs when compared to NL-20 and LD-20 constructs
(p=0.04, p=0.03), respectively.
Conclusions - No TPO constructs tested maintained complete integrity following cyclical loading. Howev-
er, screw loosening was significantly reduced and yield loads were significantly larger with the LP-20
plate/screw fixation.
Clinical Relevance - The use of LP-20 plate/screw fixation for TPO should reduce the incidence of screw
loosening and plastic deformation in the early postoperative period when compared to NL-20 and LD-20
constructs.
Acknowledgements: This project was supported by New Generation Devices, Inc.
IN-DEPTH SEMINARS
JUVENILE HD
Early diagnosis of CHD and case selection

Canine hip dysplasia (CHD) is a progressive disease, which develops during postnatal skeletal growth. A
definitive diagnosis can be made radiographically when secondary signs of osteoarthritis due to joint in-
congruity become evident. At this point it is too late to prevent osteoarthritis. However, if joint incongruity
is diagnosed before the start of degenerative joint changes, osteoarthritis can be prevented. The development
of hip dysplasia can be diagnosed during the growth period; the more severe the hip dysplasia, the earlier
the diagnosis can be made based on the early clinical and radiographic signs of the disease.
Predictive clinical and radiographic signs are related to joint morphology and congruity and to the detection
and measurement of passive joint laxity (Ortolani sign, subluxation and distraction index) and of the slope
and shape of the dorsal acetabular rim. Early diagnosis and proper treatment can arrest and reverse the pro-
gression of disease and change its pathogenesis. Triple pelvic osteotomy (TPO) or, more recently developed
DPO (Double pelvic Osteotomy can be performed in puppies with femoral head subluxation due to in-
creased dorsal acetabular rim slope.6, 11, 12, 13, 14 In puppies without signs of osteoarthritis, these techniques
modify the direction of the forces inside the joint, leading to a redirection of the femoral head inside the ac-
etabulum. During the residual growth period, the femoral head and the acetabulum regain their joint con-
gruity through uniform cartilage loading, thus preventing or limiting osteoarthritis. The juvenile pubic sym-
physiodesis (JPS) described by Mathews and colleagues in 1996 is a technique intended to modify the slope
of the acetabular roofs in a more ventral direction during skeletal growth in puppies with signs that indicate
the start of hip dysplasia. Limiting the circumferential growth of the pelvic canal by arresting the pubic sym-
physis results in bilateral acetabular rotation, which improves femoral head coverage by the acetabular roofs.
In the residual growth period, joint congruity is improved, thus allowing more favourable joint biomechan-
ics and preventing or limiting osteoarthritis.2
PROTOCOL FOR PREOPERATIVE EVALUATION

AND PATIENT ASSESSMENT
To be consistent, the protocol for preoperative evaluation and patient
assessment must be performed in a systematic manner. A thorough
examination of the hips, consisting of orthopaedic examination and
several radiographic views, is necessary to obtain reliable and predic-
tive results from the selected treatments5. Clinical and radiographic
findings should be compared with each other and contrasting data
IN-DEPTH SEMINARS
should be further scrutinized. Incomplete evaluations, such as exami-

nation of only a standard ventrodorsal radiographic view, lead to un-
JUVENILE HD
reliable results.
Ortolani Sign: In the anaesthetized or deeply sedated dog, the stabili-
ty of the femoral head in the acetabulum, the amount of joint laxity Figure 1 - Measurement of angles of reduc-
and the features of femoral head subluxation, if present, are evaluated. tion and of subluxation with the Slocum
Measurement and evaluation of the angles at which subluxation and Electronic Goniometer ã.
reduction occur are recommended to obtain reference values, which
are very useful for planning treatment when indicated. To measure these angles precisely, we use the Canine
Electronic Goniometer designed for by Slocum for this purpose. The angle of reduction is indicative of joint
capsule laxity. The angle of subluxation is indicative of the dorsal acetabular rim (DAR) slope and of ac-
etabular filling: the DAR slope is the inclination of the weight-bearing dorsal part of the acetabulum. To be
perfectly functional, the DAR slope should be almost perpendicular to the direction of the weight-bearing
forces; in normal dogs the slope is less than 7.5° from a line perpendicular to the long axis of the pelvis. As
the DAR slope increases, so does the angle of subluxation. Filling of the acetabulum with osteophytes and
thickening of the round ligament can also increase the angle of subluxation.
Static radiographic hip study: Using orthogonal views, lateral, ventrodorsal and anteroposterior, a three
dimensional study of the hip can be done to evaluate the bone morphology of both the pelvis and femur.
Because correct positioning and muscle relaxation are essential to carry out this study, the dog must be
anaesthetized. In the standard ventrodorsal view joint incongruity is evaluated and signs of osteoarthritis
are identified by examining the craniolateral acetabular rim, the dorsal acetabular rim and the femoral head
and neck. In the standard frog view any filling of the acetabular fossa caused by a permanently displaced
Figure 2 - Positioning
for the DAR
radiographic view.
femoral head or hypertrophied round ligament will widen the articular rim. The lateral view is useful to
evaluate the lumbosacral joint thereby differentiating other skeletal problems. The dorsal acetabular rim
view, described by B. Slocum in 1990, is the most informative view to evaluate the integrity and slope of
the dorsal acetabular rim, to evaluate the functional laxity and to select the best treatment. With this view,
it is possible to see and evaluate most of the weight-bearing portion of the acetabulum in cross section. In
the dysplastic dog, the lateral aspect of the DAR is blunted and rounded because of erosion and its slope
is increased to 20° or more; the femoral head moves dorsally and laterally along the inclined plane of the
sloped DAR. By combining the DAR study to passive joint laxity measurement the functional joint laxity
is evaluated.
Distraction view: With a distraction device to push the femoral heads apart, a dynamic evaluation of pas-
sive joint laxity is carried out. In a study conducted by R. Badertscher at the University of Georgia in 1977,
the half-axial position was used to improve the radiographic visualization of subluxation in dogs with hip
dysplasia; the results were similar to those described later by Smith in 1990. We have used the procedure
described by Badertscher since 1994 because it is simple, rapid and provides reliable; the only modifica-
tion we made has been improvement of the device used to distract the hips. The dog is positioned ven-
trodorsally with the femurs slightly extended at approximately 95°-105° to the table surface and the tibiae
parallel to the plane of the table surface. For this purpose, we developed an S-shaped teflon table-device
that is 2 cm thick, 5 to 12 cm wide and 50 cm long; the S-shape provides good adaption to the pubic area.
The device has a hinged base to keep it in contact with, and parallel to, the table, and is placed on the ven-
tral surface of the pelvis. Pressure applied to the medial aspects of the proximal femurs through the hand-
held tibiae results in the fulcrum to subluxate the femoral heads from the acetabula. To calculate the pas-
sive joint laxity, the distraction index (DI) described in by G. Smith and colleagues at the University of
Pennsylvania in 1990 was used.
IN-DEPTH SEMINARS
Figure 3 - Distraction
JUVENILE HD
device and positioning
for the distraction
radiographic view.
CASE SELECTION FOR PROPHYLACTIC TREATMENT

When hip dysplasia is detected at an early age, it is possible to alter the progression of the disease with ap-
propriate treatment before the onset of osteoarthritis, which would prevent a favourable outcome. The suc-
cess of preventive treatment is measured by its ability to prevent osteoarthritis in clinical cases with patho-
logical joint conditions. The time-window to correct developing hip dysplasia by surgical treatments is lim-
ited and is lost once cartilage damage, DAR microfractures and acetabular filling have occurred.6,9, 14 With
the most commonly used techniques aimed at altering the course of developing hip dysplasia in the grow-
ing dog, the best results are obtained when lameness and other signs of disease have not yet occurred. Case
selection for prophylactic treatment is accomplished according to the following criteria:
Double Pelvic Osteotomy (DPO) or Triple Pelvic Osteotomy (TPO): they are indicated in dogs 5 to 12
months old with no or minimal signs of osteoarthritis and joint subluxation, an angle of reduction between
20° and 40°, an angle of subluxation between 10° and 20° and a DAR slope between 10° and 20° with its
lateral border preserved. The degree of acetabular rotation, i.e. the degree of torsion of the canine pelvic os-
teotomy plate, is determined according to the DAR slope, whereby excessive correction that would limit ab-
duction of the leg must be avoided and to the angle of subluxation. After correction, the DAR slope should
be 0° to -5° and the angle of subluxation under 0° to 5°. With the indications described above, the most suc-
cessful degree of correction is 20° for TPO and 25° to 30° for DPO ; with this correction, the DAR does
not impinge upon the femoral neck and the gait is not altered. When the angles of reduction and subluxa-
tion are very close (less than 15°), acetabular filling and blunting of the dorsolateral acetabular rim are pres-
ent, indicating loss of dorsal coverage; in these cases, TPO or DPO are contraindicated.6,9, 14 When the dis-
traction index is very high (i.e. over 0.9), capsulorrhaphy should be performed in addition to TPO.9 When
properly performed and with the right indications, TPO and DPO can reverse CHD, prevent the develop-
ment of osteoarthritis and provide full joint function.9 When performed in less than ideal candidates with
mild osteoarthritis, TPO and DPO will not prevent further development of osteoarthritis and for that rea-
son it is not indicated.6, 9, 14
Juvenile Pubic Symphysiodesis: JPS is performed at an early age and the most favourable results are
achieved in 3.5- to 4-month-old puppies. Indications for pubic symphysiodesis are signs that predict the fu-
ture development of CHD: a positive Ortolani sign with an angle of reduction of 20° to 40°, an angle of
subluxation of 0° to 15°, DI from 0.4 to 0.8 and DAR angles of 7° to 12°.10 The procedure is not effective
in puppies with more severe signs or with established osteoarthritis and clinical signs; the degenerative
process cannot be stopped by a slow-effect procedure such as pubic symphysiodesis. While the acetabular
roofs are slowly moving ventrally, the femoral heads slip laterally along the sloped and rounded lateral ac-
etabular border, leading to further erosion of this area. In contrast, when performed in selected cases with
the appropriate indications and post-operative restriction of physical activity (limiting playing and jumping,
promoting swimming), pubic symphysiodesis is effective in improving joint congruity and preventing or lim-
iting the development of osteoarthritis.
CONTRAINDICATIONS FOR PROPHYLACTIC TREATMENT

The disadvantages of preventive surgeries are related to incorrect case selection, such as performing
TPO/DPO or pubic symphysiodesis in dogs with osteoarthritis. These techniques are contraindicated in
such cases because they will not prevent the progression of osteoarthritis. In these cases, palliative sur-
geries such as dorsal acetabular rim plasty (DARthroplasty)7 or, with better outcome, elective surgeries
such as total hip replacement should be suggested instead. In severe early CHD, cementless total hip re-
placement like “Zurich” model can be applied successfully in patients as young as 5 months.10 JPS is a
surgical procedure that modifies the canine phenotype without leaving radiographic evidence of the op-
eration. For this reason, pubic symphysiodesis has a strong ethical implication that must be discussed thor-
IN-DEPTH SEMINARS
oughly with puppy owners to gain their understanding and compliance. We strongly recommended that
JUVENILE HD
puppies undergoing pubic symphysiodesis be neutered at the same time. We believe that the life-long ben-
efits provided by successful pubic symphysiodesis would justify this procedure, provided that the ethical
aspects are well understood.
CONCLUSIONS
The predictive value of early diagnosis and treatment of CHD can be substantiated by monitoring cases that
receive conservative treatment. Early and reliable diagnosis of CHD allows timely surgery that is intended
to modify joint morphology, restore joint congruity and prevent or limit osteoarthritis.
REFERENCES
1. Badertscher RR: The half-axial position: improved radiographic visualization of subluxation in canine hip dyspla-
sia. MS Thesys, Athens, Georgia, 1977.
2. Dueland RT, Adams WM, Fialkowski JP et al.: Effect of pubic symphysiodesis in dysplstic puppies. Vet Surg 30:
201-217, 2001.
3. Mathews KG, Stover SM, Kass PH: Effect of pubic symphysiodesis on acetabular rotation and pelvic development
in guinea pigs. Am J Vet Res 57:1427-1433, 1996.
4. Slocum B, Devine TM: Dorsal acetabular rim radiographic view for the evaluation of the canine hip. J Am An Hosp
Assoc 26: 289, 1990.
5. Slocum B & Devine Slocum T: Hip: Diagnostic Tests, in Bojrab MJ, Ellison GW, Slocum B (editors): Current Tech-
niques in Small Animal Surgery, (4th Ed.). Baltimore, Williams & Wilkins, 1998, pp 1127-1145.
6. Slocum B & Devine Slocum T: Pelvic Osteotomy, in Bojrab MJ, Ellison GW, Slocum B, (editors): Current Tech-
niques in Small Animal Surgery, (4th Ed.). Baltimore, Williams & Wilkins, 1998, pp 1159-1165.
7. Slocum B & Devine Slocum T: DARthroplasty, in Bojrab MJ, Ellison GW, Slocum B, (editors): Current Techniques
in Small Animal Surgery, (4th Ed.). Baltimore, Williams & Wilkins, 1998, pp 1168-1170.
8. Smith GK, Biery DN, Gregor TP: New concepts of coxofemoral joint stability and the development of a clinical
stress-radiographic method for quantitating hip joint laxity in the dog. J Am Vet Med Ass 196: 59-70, 1990.
9. Vezzoni A. Complications in Triple Pelvic Osteotomy. Proceedings 11th ECVS Annual Scientific Meeting, Vienna
2002: 289-294.
10. Vezzoni A, Dravelli G, Vezzoni L, De Lorenzi M, Corbari A, Cirla A, Nassauto C, Tranquillo V; Comparison of
conservative management and juvenile pubic symphysiodesis in the early treatment of canine hip dysplasia. VCOT
2008; 21: 267-279.
14th September 2008.
the dog: an in vitro experimental study. Proceedings of 13th ESVOT Congress, Munich, 7th-10th September
2006.
13. Vezzoni A, Boiocchi S, Vezzoni L, Bohorquez Vanelli A, Corbari A, De Lorenzi M: Double Pelvic Osteotomy
(DPO) as tretament option for hip dysplasia in growing dogs: preliminary results. Poster presentation, VOS, 2009.
14. Vezzoni A, Boiocchi S, Vezzoni L, Bohorquez Vanelli A, Bronzo V: Double Pelvic Osteotomy (DPO) for the treat-
ment of hip dysplasia in young dogs. Accepted for publication VCOT 2010.
IN-DEPTH SEMINARS
JUVENILE HD
DPO: clinical results

INTRODUCTION
Double pelvic osteotomy (DPO) was first described in an in-vitro experimental study by P. H. Haudiquet
and J. F. Guillon at the ESVOT Congress, Munich, in September 2006. This method produced significant
ventral acetabular rotation by osteotomy of the ilium and pubis, while leaving the ischium intact. The re-
sults of DPO were encouraging with regard to acetabular coverage of the femoral head; DPO with 25° ac-
etabular ventral rotation appeared to have the same radiographic effect as triple pelvic osteotomy (TPO)
with 20° of rotation. The rotation of the acetabular segment was dependent on deformation of the ischial
table and appeared to be about 5° less than the amount of rotation at the level of the ilial osteotomy.
Since its introduction by Slocum in 1986, TPO has been modified and new plates have been designed in an
effort to reduce complications. The most common complications include implant loosening, reduction of the
pelvic inlet diameter, excessive head coverage by the acetabular roof, delayed healing of the iliac and ischial
osteotomies and high morbidity, especially in cases of simultaneous bilateral surgery. Unfortunately, there is
often a need to treat both hips at the same time even though the associated morbidity is high. Although sur-
gery may be better tolerated by delaying the second procedure by one month, the time frame for the onset of
osteoarthritis (OA) is short and a delay could result in a poor surgical outcome. Instability of the ischium can
be particularly painful when the dog sits or walks; furthermore, attempts to stabilize the ischial osteotomy
with cerclage wire do not usually work. Instability of the ischium is often followed by implant failure, collapse
of the pelvis and narrowing of the inlet diameter. These conditions may also contribute to abnormal gait be-
cause the loss of normal pelvic geometry increases the dorsal acetabular coverage with excessive head inser-
tion. This limits extension and abduction of the hip, even with a 20° plate.
Based on the results of studies from France, we switched from TPO to DPO for all suitable candidates. From
September 2006 to April 2009, we carried out 68 DPOs in 45 dogs and conducted follow-up examinations
a minimum of two months after surgery in 53 cases (34 dogs). The results of case selection, preoperative
planning, technique, outcome and complications of DPO were compared with those encountered after pre-
viously performed TPOs at our clinic, and with published results.
From September 2006 to April 2009, we carried out 68 DPOs in 45 dogs and conducted follow-up exami-
nations a minimum of two months after surgery in 53 cases (34 dogs). The results of case selection, preop-
erative planning, technique, outcome and complications of DPO were compared with those encountered af-
ter previously performed TPOs at our clinic, and with published results.
IN-DEPTH SEMINARS
CASE SELECTION AND PREOPERATIVE PLANNING

The inclusion criteria for DPO, which are critical for achieving an optimal clinical outcome and prevent-
JUVENILE HD
ing OA, were similar to those for TPO. Candidates for DPO were five- to eight-month-old dogs that had
joint subluxation and laxity, which are indicative of future hip dysplasia (HD), no OA, no or very minimal
acetabular filling, a preserved lateral border of the dorsal acetabular rim (DAR), an angle of subluxation
(AS) not > 20° and a distraction index (DI) < 1. The degree of acetabular rotation was determined using
the criteria set out for TPO. A reference of 5° more than the measured AS was used, and the correction was
increased an additional 5° based on Haudiquet’s in-vitro results.
SURGICAL TECHNIQUE
Pubic osteotomy was conducted as described for TPO. This was followed by ilial osteotomy, which was car-
ried out using the method described by Slocum for TPO. Because the ischium was not cut, there was decreased
mobility of the distal segment. It was therefore necessary to gently elevate this segment with a long chisel to
fix the plate. Rotation of the acetabular ilium segment at the level of the ilial osteotomy required more effort
than the standard TPO. Once distal fixation of the plate was completed, reduction forceps were applied over
the plate and the ilium and used to rotate the ilium ventrally while the most distal and ventral hole of the plate
in the proximal ilium segment was drilled and the screw tightened. The combined action of the reduction for-
ceps and screw traction usually allowed the desired rotation. When rotation was impossible to achieve, release
of the sacrotuberous ligament at its insertion over the ischial tubercle was performed to facilitate pelvic rota-
tion. A short incision was made over the caudal border of the ischial table, and the insertion of the sacro-
tuberous ligament was identified. Tension was applied to the ligament by inserting a smooth periosteal eleva-
tor lateral to the ischial body, and the ligament was partially severed to achieve release. With experience, re-
Figure 1 - Golden retriever, F, 6 months old:

a) preoperative VD view and measurements;
b) postoperative VD view;
c) 2 months postoperative;
d) 6 months postoperative.
IN-DEPTH SEMINARS
lease was usually not necessary, but it was helpful when rotation was difficult. Our preferred method did not JUVENILE HD
include release because a third incision sometimes caused the dog to lick the wound with subsequent dehis-
cence. Preservation of the biomechanical function of the sacrotuberous ligament was also desirable.
A variety of bone plates, typical TPO plates or new plates recently designed for DPO, were used to stabi-
lize the ilial osteotomy. After DPO, the implants appeared to undergo increased stress with a tendency for
the ilium to return to its original anatomic position in the first days postoperatively. This was attributed to
the elastic memory of the rotated bone. However, the stability achieved approximately one week after DPO
was greater than that yielded by TPO because of the pelvic stability afforded by the intact ischium. To
achieve prompt and strong fixation, plates with locking screws and plates with 4 screws per side, which is
an option with the new DPO plates, were used or additional cerclage wire was applied proximally and dis-
tally to the DPO plate. In very active and heavy dogs, an additional small plate was placed ventrally instead
of the cerclage wire to increase the stability of the fixation. However, this additional fixation was carried out
only when indicated by the body weight and activity level of the dog and mostly in bilateral surgery.
POSTOPERATIVE CARE
Dogs were discharged from the hospital 24 to 48 hours after surgery as ambulatory. Close confinement was
required for one month after surgery, allowing only short walks on a leash, but prohibiting free walks, free
stairs clumping, playing and jumping. Administration of mild sedatives was recommended in exuberant pup-
pies. In the second month after surgery progressive increase of walks on a leash was recommended to pro-
mote muscular tone and two months after surgery free physical activity was allowed. Clinical and radi-
ographic assessment was recommended at 1, 2 and 6 months after surgery and than every 1-2 years.
OUTCOME
The morbidity rate after both unilateral and bilateral DPO was much lower than that after TPO. The ability
of the patient to stand and walk without assistance and the neurological responses were assessed in the imme-
diate postoperative period. Dogs that underwent bilateral DPO were able to stand, sit and walk 8 to 18 hours
postoperatively. All the dogs treated with DPO were able to walk the day after surgery and were discharged
from the hospital. Owners reported no restlessness or discomfort in the immediate postoperative period. The
ability to sit without discomfort after DPO was attributed to the stability of the ischium. In contrast, dogs were
reluctant to sit after TPO because of ischial pain. Healing of the osteotomies was faster after DPO than TPO.
The pubic and iliac osteotomies were healed 1 month postoperatively and remodeled 2 months postoperative-
ly. Interestingly, in dogs with DPO, the pubic osteotomies healed completely, restoring the normal anatomy of
the pubic ramus. To assess acetabular coverage, we calculated the percentage of femoral head covered by the
roof of the acetabulum (PC) and the Norberg angle (NA), from ventrodorsal radiographs at four time points:
preoperative, immediate postoperative, first recheck (one month postoperatively) and second recheck (2-3
months postoperatively). When possible, the same measurements were taken at follow-up examinations at six
months and one year postoperatively. The average PC two months after surgery was 60.04% ± 12.1 with a
Norberg angle of 109.5° ± 7.9; this was a significant improvement in joint congruity compared with the preop-
erative data (PC 35.86% ± 10.08 and NA 91.98° ± 7.03). In contrast to TPO, excessive femoral head coverage
did not occur after DPO in any of our patients, even when a 30° plate (corresponding to 25° of rotation) was
used. The Ortolani sign became negative in most cases and the AR and AS decreased in the remaining cases.
To assess the preservation of pelvic morphology after DPO, we calculated the distance between the right and
left iliac wings, the distance between the right and left craniolateral acetabular borders and the distance between
the right and left ischiatic tuberosities. The ratio of those distances remained substantially unchanged before
DPO and in the follow-ups, indicating that there was no collapse of the pelvis and narrowing of the pelvic canal,
which is often observed after TPO. Gait abnormalities such as internal limb rotation during walking, which is
seen after TPO, were not observed after DPO because of the less pronounced acetabular rotation.
COMPLICATIONS
In our preliminary analysis, implant failure was the most frequent complication observed (5 cases, 9.4%), al-
though revision surgery was never required because the desired acetabular orientation was preserved. In one
case, revision surgery was carried out to remove the loose implants only, and joint congruity remained ade-
quate despite failure of the implants. The above-mentioned complications were most often attributable to in-
complete distal plate pull-out without significative effect on the osteotomy healing process or stability, while
screw loosening was observed in only a few cases (3.2% of all screws). Nevertheless, we switched from con-
IN-DEPTH SEMINARS
ventional TPO plates to more stable DPO plates and had better results using DPO plates with two locking di-
JUVENILE HD
vergent screws per side. In high risk dogs (overweight and/or very active), we added a ventral plate to achieve
maximum stability. The osteotomy normally took two months to be completely healed, and delayed union or
non-union did not occur in any of our cases. In two cases (3.7%), there was a transient neurological deficit,
which resolved spontaneously two weeks postoperatively. By leaving the ischium intact, the stability of the
pelvic frame and implant was increased and the healing time and incidence of fixation failure were decreased
compared with TPO. An incomplete fracture of the ischial table was diagnosed in two cases at the one-month
follow-up examination. However, these fractures had healed without any treatment by the next examination
two to three months postoperatively. These fractures may have been spontaneous green stick fractures because
of increased bone tension. At the two-month follow-up examination, a persistent Ortolani sign (AS > 5°) was
present in nine cases (17%), a negative Ortolani sign in 17 cases (32%) and a mild Ortolani sign (AS < 5°) in
27 cases (51%). A persistent positive Ortolani sign could have been avoided by using a higher degree of ac-
etabular rotation or stricter case selection. Nevertheless, in later follow-up examinations (6 months and/or 1
year postoperatively) of 30 cases, the Ortolani sign was negative in an additional six cases, with NA and PC
values similar to those obtained at the two-month follow-up (NA 107.4° ± 7.6 and PC 58% ± 11). With TPO,
a higher rotation using a 30° plate usually resulted in excessive head coverage. This did not occur in DPO with
a 30° plate because the effective acetabular rotation was 5° less, and the type of bone rotation provided by the
preserved ischium differed from that of TPO. One of the complications associated with bilateral TPO is nar-
rowing of the pelvic canal. In DPO the physiologic pelvic geometry was maintained, and pelvic collapse did
not occur, even with a 30° plate. Because we did not encounter side effects using the 30° plate, when deciding
between 25° or 30° of rotation, we selected the latter to better neutralize the Ortolani sign.
DISCUSSION AND CONCLUSIONS

Compared with TPO, there was lower postoperative morbidity after DPO, which allowed bilateral proce-
dures to be carried out simultaneously when indicated.
Restored joint congruity, in which 50 to 72% of the femoral head was covered by the acetabular roof, was
the most interesting feature of DPO. In our experience; TPO results in more than 90% femoral head cov-
erage. Femoral head coverage of 50 to 72% is the amount seen in normal hips with good to excellent con-
formation. Preservation of the pelvic geometry was an additional advantage of DPO compared with TPO,
and when combined with restoration of normal joint congruity, resulted in normal gait and joint function in
operated dogs. The reduction of postoperative complications was an important advantage of DPO, even
though a more stable fixation of the iliac osteotomy was required. The surgical technique of DPO is a little
more demanding than TPO because of the difficulty in handling and rotating the acetabular ilial segment,
but this difficulty is compensated by elimination of the need for ischial osteotomy.
Figure 2 - Comparison of excellent hip conformation in a Borzoi with the hip conformation of a Golden Retriever treated with DPO.
IN-DEPTH SEMINARS
In conclusion, DPO appeared to be the better than TPO for pelvic corrective osteotomy in dogs with early
HD, and we propose that the clinical indications for DPO be revisited.
JUVENILE HD
ACKNOWLEDGMENTS
This study is in the process of being published and I want to thank all the co-authors: Silvia Boiocchi, Lu-
ca Vezzoni, Alejandra Bohorquez Vanelli, and Valerio Bronzo. Moreover I want to acknowledge Philippe
Haudiquet for his input and suggestions regarding DPO and Mike Khowaylo from NGD for his assistance
in designing a new DPO plate.
REFERENCES
14th September 2008.
the dog: an in vitro experimental study. Proceedings of 13th ESVOT Congress, Munich, 7th-10th September 2006.
3. Slocum B, Devine Slocum T: Triple pelvic osteotomy. In: Current Techniques in Small Animal Surgery, 4th Edi-
tion. Bojrab M.J., Ellison G.W.Slocum B. 1998, P 1159-1165.
4. Vezzoni A., Baroni E., Petazzoni M. “TPO: retrospective multicentric study in 218 cases”, Proceedings SCIVAC
Congress, Montecatini 2000.
5. Vezzoni A, Dravelli G et al.: Comparison of conservative management and juvenile pubic symphysiodesis in the
early treatment of canine hip dysplasia. VCOT 2008;21(3):267-79.
6. Vezzoni A, Boiocchi S, Vezzoni L, Bohorquez Vanelli A, Bronzo V: Double Pelvic Osteotomy (DPO) for the treat-
ment of hip dysplasia in young dogs. Accepted for publication VCOT 2010.
BIOMEDTRIX
CURRENT CONCEPTS
IN TOTAL JOINT REPLACEMENT
IN-DEPTH SEMINAR
427 • WVOC 2010, Bologna (Italy), 15th - 18th September R. Acker
TATE elbow development

Randy Acker, DVM
Sun Valley Animal Center
Debilitating canine elbow arthritis is a common condition, and the need for elbow replacement has been
documented1. Despite many attempts with elbow replacement, no system has gained widespread accept-
ance2, 5. This may be due to the complex anatomy of the joint, the changes in the elbow anatomy over time,
or the fact that there is no reliable human model to follow.
The goal of the TATE Elbow™ project is development of an elbow replacement system that will be accept-
ed and used by surgeons. Previous elbow systems were studied. Both the Iowa State and Lewis elbow re-
placement courses were attended. After study of these systems project goals were developed. General guide-
lines included minimal patient morbidity, simple design, and a surgical technique that made the procedure
repeatable.
A medial approach is used to decrease the chances of luxation6. A novel method of joint preparation was de-
veloped using an end mill. The drill and mill technique allows preparation of both sides of the joint simul-
taneously and insertion of the implant as a cartridge (patent pending). Closure of the joint after cartridge in-
sertion is done similar to epicondylar fracture repair. To design and develop the implants and instruments,
an engineer was essential and Greg Van Der Meullen, ME & BME, was hired. Cadavers and sawbones were
used to test approaches implant designs and instruments. A non-linked, semi-constrained, resurfacing arthro-
plasty system was developed3, 4. This system centers on the axis of rotation while preserving the collateral
ligaments as constraints and bone stock.
After a patent was filed, the technique was disclosed to Chris Sidebothum of BioMedtrix who licensed the
use of the patent in canine elbow replacement. A pilot study was done to determine the validity of the sur-
gery. The pilot study began in July of 2007 with client owned dogs. Seven patients were implanted with
acceptable complications, morbidity, and function. After the pilot study, BioMedtrix made a decision to
produce implants, instrumentation, and start courses3. Minor changes in the technique were made based
on the pilot study. Instruments were developed to simplify the surgery and decrease the chances for sur-
gical error.
At Sun Valley Animal Center, 20 elbows have been implanted on 19 patients. The longest case is out 36
months. There have been no explants, fusions or amputations on cases done at SVAC. Two cases had
second surgeries: one for pin removal, and one for a fractured ulna. One case had two surgical errors;
however, the implant is functioning two years post operatively. Data collected includes owner testimo-
nials, radiographs, and goniometry. Recently a force plate was installed and objective data is being col-
lected on all cases.
IN-DEPTH SEMINARS
After attendance of TATE elbow courses, participants were encouraged to have an instructor to participate
in the first clinical cases. Currently, I have assisted in 20 cases out of the clinic. Two cases developed infec-
BIOMEDTRIX
tions, and one case had a fracture. A product certification program was instituted to ensure that surgeons
were prepared for the surgery. It is hoped that the experience with the cadavers will limit complications for
surgeons new to the system.
In May of 2009, Dejardeen reported that approximately 70 cases had been implanted worldwide. A study
of five surgeons with over five cases each reported on 43 elbows implanted in 42 dogs. They reported 7%
severe complications (fracture, infection) and 7% minor complications3.
Continuous refinement of surgical technique, implants, and instruments is in progress. The TATE Elbow™
is showing promise in the patient with global arthritis of the elbow. Future considerations may include a me-
dial compartment implant, an implant that pronates and supinates, and an ankle replacement.
REFERENCES
1. Conzemius MG, Elbow Replacement. Proceedings of the World Veterinary Orthopaedic Congress, Keyston, CO,
Feb. 25th-March 4th, 2006, p 145.
2. Sidebothum Chris, Personal Communication.
3. Acker R, Van Der Meulen G. Resurfacing Arthroplasty of the Canine Elbow. Proceedings of the 34th Annual Vet
Orthop Soc Conf, Sun Valley, ID, March 3-10, 2007, p 55.
4. Schulz KS. Elbow Arthroplasties: Terminology and Designs. Proceedings of the 15th Annual American Coll Vet
Surgeons Symposium, San Diego, CA, October 27th.
5. Lewis RH. Development of Elbow Arthroplasty (Canine) Clinical Trials. Proceedings of the 6th Annual American
College Vet Surgeons Symposium, San Francisco, CA, November 3-6, 1996, p 110.
R. Acker WVOC 2010, Bologna (Italy), 15th - 18th September • 428
6. Piermattei DL, Flo GL, et al. Handbook of Small Animal Orthopedics and Fracture Repair: 3rd Edition, W.B. Saun-
ders Co., Philadelphia, © 1997, p 281: Fig 10-28.
7. Conzemius MG, Aper RL, Corti LB: Short-term Outcome after Total Elbow Arthroplasty in Dogs with Severe Nat-
urally Occurring Osteoarthritis. Vet Surg 32:545-552, 2003.
8. Conzemius MG, Aper RL, Hill CM: Evaluation of a Canine Total-elbow Arthroplasty System: a Preliminary Study
in Normal Dogs. Vet Surg 30:11-20, 2001.
9. Talcott KW, Schulz KS, Kass PH, et al. In Vitro Biomechanical Study of Rotational Stabilizers of the Canine Elbow
Joint. Am J Vet Res 63[11]:1520-6, 2002 Nov.
10. Preston CA, Schulz KS, Kass PH. In Vitro Determination of Contact Areas in the Normal Elbow Joint of Dogs.
Am J Vet Res 61[10]:1315-21, 2000 Oct.
11. Mason DR, Schulz KS, Fujita Y, et al. In Vitro Force Mapping of Normal Canine Humeroradial and Humeroulnar
Joints. Am J Vet Res 66[1]:132-5, 2005 Jan.
12. Conzemius MG, Aper RL. Development and Evaluation of Semiconstrained Arthroplasty for the Treatment of El-
bow Osteoarthritis in the Dog. Vet Comp Orthop Traumatol 11:54A, 1998.
13. Tanaka T, Amadio PC, Zhao C, et al. Effect of Elbow Position on Canine Flexor Digitorum Profundus Tendon
Tension. Journal of Orthop Res, 23(2):249-53, 2005 Mar.
14. Moorey, Bernard F. Joint Replacement Arthroplasty, Churchill-Livingstone, Philidelphia, © 1991, 1192p.
15. B.A. Huibregtse, et al. The Effect of Treatment of Fragmented Coronoid Process on the Developement of Os-
teoarthritis of the Elbow, JAAHA 30:190-195 (Mar./Apr. 1994)
16. Padgett, G.A., Mostosky, U.V., Probst, C.W, et al. The Inheritance of Osteochondritis Dissecans and Fragmented
Coronoid Process of the Elbow Joint in Labrador Retrievers. JAAHA, 31:327-330, 1995.
IN-DEPTH SEMINARS
BIOMEDTRIX
Total Hip Replacement

CFXTM CEMENTED THR

Cemented total hip replacement has been performed in the dog for over 30 years. Because of the consider-
able body of literature and clinical experience related to this procedure, cemented fixation remains the tech-
nique that all others are and for many years will be compared against.
Implant design
Many design improvements have been made since the introduction of the early fixed head prostheses known
as the Richards prosthesis in the early 1970’s. The first innovation was the introduction of a modular canine
total hip system, known as the CFXTM system produced by Biomedtrix〉 in the early 1990’s. This system in-
corporated a series of collared stems, ranging from size #5 through #8, the size related to the diameter of
the stem’s tip in millimeters. The common seventeen-millimeter head was available with a Morse taper at-
tachment socket of various depth including 0, +3, and +6 mm, these various attachment depths allow the
neck length to be adjusted to accommodate the individual patient. The cup is machined from ultra-high mo-
lecular weight polyethylene, features a wire marker ring to aid in identification of the cup’s face, and initial-
ly was available in 23 mm, 25 mm, 27 mm, and 29 mm diameters. The system has been continuously im-
proved since its introduction; those improvements have included changing the stem composition from tita-
nium to cast cobalt-chromium, bead blasting to add surface roughness, and the addition of a lateral flat, as
well as cranial and caudal cement pockets to increase resistance to torsional and axial loads applied to the
stem. Recently the range of implants has been expanded to include a #9, #10 and 31 mm cup for giant breed
dogs, a #4 and #4/5 stem, 20 mm cup and 14 mm head for small sporting dogs, and a #2 and #3 stem and
corresponding cup for toy breeds and cats. With this expansive range of implant choices, the CFXTM sys-
tem can be implanted in a broader range of patient sizes than any other system currently in production; pa-
tients ranging from as little as 3 kg to as more than 100 kg can currently be accommodated.
Cement technique
Although the polymethylmethacrylate cement utilized for fixation of total hip prostheses has changed little
since it was first introduced by Charnely in the 1950’s, significant improvements in cement technique have
resulted in the routine creation of uniform cement mantles devoid of defects with considerable cortico-can-
cellous interlock. The first significant improvement in cement technique was the shift from cement packing
in the dough phase, to cement injection in the liquid phase. Due to the diminished viscosity of cement in the
IN-DEPTH SEMINARS
liquid phase, the cement is more easily driven into the cancellous bone bed when pressurized during injec-
tion and implant insertion. The cement restrictor plug is a plastic, mushroom-shaped device that is inserted
BIOMEDTRIX
into the femoral canal prior to cementing, which restricts distal migration of cement, resulting in improved
pressurization of the cement during injection and stem insertion. The use of a cement injection gun opti-
mizes cement pressurization during injection, and speeds the injection process to ensure cement delivery oc-
curs during the liquid phase. The stem centralizer is essentially a mold that is used to create 1 x 1 x 5 mm
fins on the four surfaces of the stem tip. These fins act as offsets to prevent the stem tip from contacting the
endosteal surface of the femur. The centralizer can be heated in an autoclave to accelerate curing of the cen-
tralizer fins. Heating the centralizer mold also preheats the stem, which results in initiation of final PMMA
curing at the stem surface, resulting in a stronger implant-cement interface. Additional techniques that can
be employed to enhance the cement technique include vacuum mixing and centrifugation that diminish
voids in the cement, and the addition of antibiotics to the cement to aid in bacterial prophylaxis. It should
be noted, however, that the addition of antibiotic powder to the PMMA has been shown to decrease its com-
pressive strength.
Indications
The primary indication for cemented total hip replacement is coxofemoral osteoarthritis secondary to ca-
nine hip dysplasia. Other indications include irreparable fractures of the acetabulum, femoral head and
femoral neck, as well as coxofemoral luxation complicated by acetabular or femoral head/neck fracture, or
other orthopedic disease. Less common indications may include salvage of limb function in cases of acetab-
ular or proximal femoral neoplasia. The decision to utilize cemented fixation is largely surgeon preference,
however, some indications may include cases with poor quality cancellous or cortical bone, such as that fre-
quently encountered in the adult German Shepherd Dog, procedures performed in giant breed or toy breed
dogs, or patients with other significant orthopedic disease in which the initial stability afforded by cement-
ed fixation may be preferred over that achieved with cementless fixation.
Outcome
Cemented total hip replacement provides good to excellent function in 90-95% of cases based on several ret-
rospective analyses. Patients are routinely weight bearing, and may be discharged from the hospital the day
following surgery. Postoperative rehabilitation consists of severe exercise restriction and leash walks outside
to eliminate for the first four weeks. During weeks 5-8 leash walks of progressively increasing duration are
encouraged, and during weeks 9-12 leash walks of 20 minutes are allowed as well as short off leash activi-
ty. At the three month recheck examination, limb function is typically normal or near normal, muscle mass
has returned to normal and is often greater than the non-operated limb in unilateral cases, and radiograph-
ic evidence of acetabular and femoral remodeling is evident. Following a typical three-month recheck ex-
amination, gradual increase in off leash activity is allowed during the next 4 weeks such that unrestricted ac-
tivity is resumed sixteen weeks postoperatively.
Complications
The most frequent complications following cemented total hip replacement include luxation (4.5%), infec-
tion (1.25%), fracture (2.5%), and aseptic loosening (2.25%). Risk factors for luxation include suboptimal ac-
etabular cup position, impingement, and poor soft tissue tension. Acetabular component position has been
shown to be the most important predictor of cranio-dorsal luxation. Position of the cup can be completed
described by reference to three distinct axes. The angle of lateral opening relates the non-truncated portion
of the cup face to the median plane; a zero degree angle of lateral opening describes a cup whose face is per-
pendicular to the median plane (fully closed), while a 90-degree angle of lateral opening refers to a cup
whose face is parallel to the median plane (fully open). Acceptable angles of lateral opening are in the range
of 35-55 degrees. If the cup angle of lateral opening is in excess of 60 degrees, the risk of cranio-dorsal lux-
ation increases eight fold.
The angle of version describes the orientation of the cup face with respect to the transverse plane. A cup
that is perpendicular to the transverse plane is considered to be in neutral version; cups that are directed cra-
nially are considered intenerated, and those that face caudally are considered extroverted. Acceptable ver-
sion of the acetabular component is retroversion of 10-15 degrees.
The angle of inclination describes the orientation of the cup with respect to rotation about an axis perpen-
dicular to its non-truncated face, considering a line from truncation point to truncation point. The appro-
priate angle of inclination is such that the line from truncation to truncation point is directed cranial to cau-
dal or slightly inclined, but not more than a line parallel to the ilio-ischial axis. Orientation of the acetabu-
lar component at an appropriate angle of version and angle of inclination are important in achieving a nor-
mal range of motion in the treated hip, and preventing luxation due to impingement of the femoral neck on
IN-DEPTH SEMINARS
the cup during the normal range of motion.

BIOMEDTRIX
Infection remains the most devastating complication of cemented total hip replacement. Strategies to mini-
mize the risk of infection include avoiding surgery on patients with active skin infection or other sources of
infection, minimizing surgical and anesthetic time, and atraumatic surgical technique. Routine use of peri-
operative, intravenous antibiotic prophylaxis is also recommended, and addition of antibiotics to the bone
cement can be considered.
Fracture of the acetabulum or femur can occur as either an intraoperative or postoperative complication. In-
traoperative fractures most often occur during the reaming process, or due to inadvertent penetration of the
cortex with instrumentation. Rarely, femoral fracture can occur during reduction of the femoral head, if ex-
cessive joint tension is present. The most common type of fracture associated with total hip replacement is
a midshaft, oblique fracture of the femur, centered at the distal tip of the femoral stem; Type B1 according
to the Vancouver Classification. These fractures most commonly occur in the first 4 postoperative weeks,
and are not associated with overt trauma. Repair consists of internal fixation utilizing cerclage, and bone
plate and screws. The bone stock in the greater trochanter is utilized proximally, care is taken to avoid screw
insertion in the cement mantle along the femoral component; cement distal to the tip of the prosthesis may
be used for fixation.
Aseptic loosening results from cytokine mediated osteolysis, in response to wear debris. The genesis of wear
debris can be from the prosthetic articulation, or cement mantle. In response to the accumulation of non-di-
gestable particles of polyethylene or PMMA, macrophages liberate cytokines that result in osteolysis. De-
terioration of the cement bone interface invariably results in progressive implant loosening, and debris gen-
eration.
Summary
Due to the low complication rate, ability to treat a broad range of patient sizes, and complete initial stabili-
ty, cemented fixation remains a very reliable and desirable technique to employ. The largest concern with
cemented fixation is aseptic loosening, however, as cement techniques continue to evolve, the rate of long
term aseptic loosening should continue to diminish.
BFXTM CEMENTLESS THR

Porous coated, press-fit, cementless total hip replacement has become the standard of care in human to-
tal joint arthroplasty over the last 20 years due to concerns regarding long-term stability of cemented fix-
ation, primarily related to aseptic loosening. Recently, a porous coated cementless total hip system, known
as the BFXTM system from Biomedtrix®, has been designed and introduced for veterinary use. Over the
last several years, considerable experience with this system has been gained, and the implant design, im-
plantation technique, indications, complications, and revision strategies have been improved and eluci-
dated.
Implant design
The BFX TM system is composed of a cobalt-chromium stem and titanium cup, each of which is covered with
a porous in-growth surface composed of 200-400 μm titanium beads. The bead size is based on several in-
vestigations in the dog comparing bone in-growth onto several surfaces, which revealed that beads of this
size resulted in the most reliable fixation by osseous tissue, known as osseo-integration. The beads are sin-
tered to the stem and cup in a three layer “stucco” process resulting in considerable porosity to accommo-
date osseous in-growth.
The stem contains a beaded surface in the proximal region that corresponds to the subtrochanteric bone
block region of the femur following implantation, and the cup is beaded on its entire outer surface. The stem
accepts the 14 mm or 17 mm femoral head, with available neck lengths of 0, +3, and +6, and +9 mm.
The cup is a truncated hemi-spherical design similar in shape to the CFXTM cup. This metal backed implant
contains an ultra high molecular weight polyethylene liner insert. Because it relies on a press fit for initial
fixation, it does not contain any screw holes or other areas that allow communication of the joint surface
with the cup backing; this mitigates the likelihood of wear debris migrating to the in-growth surface. The
stem sizes range from #4 – #11, which corresponds to the diameter of the distal tip in millimeters. The cups
range from 22 mm – 32 mm in 2 mm increments. The 22 mm cup accommodates a 14 mm head, while the
other cups utilize a 17 mm head. Since the larger head diameter results in lesser wear debris generation and
a lesser tendency for luxation, the larger cups and 17 mm head are utilized whenever possible.
Indications
The indications for the BFXTM total hip replacement system are essentially the same as those for the CFXTM
total hip system, namely, coxofemoral osteoarthritis secondary to canine hip dysplasia. Other indications in-
IN-DEPTH SEMINARS
clude irreparable fractures of the acetabulum, femoral head and femoral neck, as well as coxofemoral luxa-
BIOMEDTRIX
tion complicated by acetabular or femoral head/neck fracture, or other orthopedic disease. Less common in-
dications may include salvage of limb function in cases of acetabular or proximal femoral neoplasia. The de-
cision to utilize cementless fixation is largely surgeon preference, however, some indications may include
very young patients in which longevity of the implants is a priority. Since the metal backed BFXTM cup does
not require complete dorsal coverage with acetabular bone stock, it has distinct advantages over the CFXTM
system in cases with extreme dorsal rim wear or acetabular malformation. A considerable portion of the dor-
sal aspect of the BFXTM cup can remain exposed without sacrificing initial cup stability, as long as the cra-
nial and caudal aspects of the cup are properly covered with bone. In extreme cases of dorsal rim loss, the
medial acetabular wall can be very carefully penetrated to achieve adequate dorsal coverage. This maneu-
ver must be undertaken with extreme caution, as an overly large medial wall penetration will allow the cup
to protrude through the acetabulum into the pelvic canal.
Investigations into the initial stability of cementless femoral components have revealed that both fit, the sim-
ilarity of the stem’s shape and that of the femoral endosteal shape, and canal fill, the percent of the canal di-
ameter occupied by the stem, are important factors.
Thus, the fit of the stem is evaluated during preoperative templating. The ideal patient for the BFXTM
femoral stem is one in which the femoral canal shape has an abrupt narrowing beginning at the level of the
lesser trochanter, known as a “champagne flute” geometry. Patients with a broad straight sided femur,
known as a “stove pipe” geometry are prone to subsidence, which is distal migration of the stem in the ear-
ly postoperative period. In addition, the properly sized stem should achieve 80-90% canal fill at the lateral
beaded-smooth junction and at the stem tip.
Outcome
Outcome following cementless total hip replacement mirrors that of cemented total hip replacement. Osseo-
integration occurs during the first 6-12 weeks postoperatively, and exercise restriction is imperative during
this time. Following this period, clinical and radiographic examination are performed. Typical findings in-
clude normal or near normal limb usage, return of muscle mass, and stable fixation of the implants at the
twelve week examination. Following this, the patient is gradually allowed to return to normal activities over
the ensuing 4 weeks.
Complications
The typical complications following BFXTM total hip replacement occur during the same time frame and
with the same frequency as those of CFXTM total hip replacement. Intraoperative femoral fissure fracture is
a complication that is virtually exclusive to the BFXTM femoral component, and typically occurs if canal
preparation is not on the femoral centerline, or invades the endosteal diameter. If a fissure fracture occurs,
cerclage is applied, and implantation continues. If the cerclage does not adequately control the fissure, a ce-
mented stem is placed.
Hybridization
With the advent of the BFXTM total hip replacement system, the surgeon is now equipped with a vast array
of interchangeable components with differing fixation. Since the BFXTM and CFXTM systems utilize com-
mon femoral heads, hybrid fixation utilizing one cemented and one cementless component is possible. This
flexibility allows the surgeon to perform intraoperative or postoperative revision with the other system
should the need arise. This represents perhaps the greatest advantage to the utilization of this universal hip
system.
KYON CEMENTLESS TOTAL HIP

The Kyon hip is unique in that it relies on novel fixation methods for both the stem and cup. The cup has
a hydraulically open design that permits fluid flow and tissue ingrowth into a space between the outer tita-
nium shell, and the inner polyethylene liner. The stem relies on screw fixation for stem stability. The lock-
ing screws engage only the medial cortex, and are inserted through access holes placed in the lateral cortex.
In addition, the stem is plasma coated to encourage bony on-growth. Another unique feature is that the stem
has a proximal peg, to which the head and neck attach. An advantage to this design is that the neck can be
removed and thus is not in the way if any revision is required. A disadvantage is that region is an area of
stress concentration, and rarely the peg may break free from the stem.
Schematic line drawing of the modular ce-

mentless prosthesis. The femoral stem is placed
IN-DEPTH SEMINARS
adjacent to the medial femoral cortex and se-

cured with monocortical locking screws (head
BIOMEDTRIX
of each screw locked into the prosthesis) such

that the majority of force transfer is entirely
along the compression surface of the bone (the
arrow indicates this force transfer). {Note: in
the current application, a bicortical screw is
placed in the 1st position.] The acetabular cup
is a shell with multiple drill-holes – with a
space between the shell and the polyethylene
insert (the shell is represented in black, and
the polyethylene insert in dark grey).
The Kyon system has been redesigned in response to limitations identified in the initial design during a
prospective clinical trial. The current system addresses these limitations, and the indications, outcome, and
complications are similar to the BFXTM and CFXTM systems.
The acetabular cups received 5 changes in design: 1) the shell composition was pure titanium; 2) the polar
region of the shell was slightly flattened; 3) 3 parallel ridges (0.3 X 0.7-mm) were added to the periphery of
the shell (and perpendicular grooves added in between each set of ridges); 4) addition of plasma coating to
the shell; and 5) the polyethylene liner was extended 1.6-mm past the equator of the cup. The elimination
of the titanium alloy removed the question of any exposed vanadium. Flattening of the polar region of the
shell reduced the possibility that insufficient seating of the cup occurred within the press-fit as “bottoming-
out” was eliminated. The addition of the ridges and grooves improved the press-fit and initial purchase of
the press-fit, and more readily prevented any possible cup rotation within the bone. The plasma coating was
applied to enhance bony ingrowth to this surface. Finally, extending the polyethylene liner reduced head lux-
ation by requiring a slight pistoning action before any such luxation could occur (identical with the design
of both the Richards® and BioMedtrix® cups).
Prosthetic cup: (left) old design; (right) new design,

flattened pole (top), ridges and grooves at the periph-
ery of the shell, and overlap of the polyethylene liner
(1.6-mm).
The femoral stems also received 4 changes in design: 1) the screw hole depth in the peg was shortened, 2)
the radius of curvature to the base of the peg, at its attachment to the stem, was altered, 3) the position of
the peg was moved 2-mm medially, and 4) the stem was plasma coated. A possible stress riser at the base of
the peg was eliminated by decreasing screw hole length within the peg, although this change in depth only
resulted in an approximate 5% increase of strength. The major change was a re-design of the radius of cur-
vature at the peg base. The original design was determined to have a 60% increase in stress at this locale,
whereas the re-design eliminated this stress-riser: a calculated 0% increase in stress. The medially shifted peg
also decreased the stresses traversing this area, and resulted in a more anatomic position of the subsequent
attachment for the head/neck. Based upon finite element analysis of the re-designed stem, the overall calcu-
lated stem strength (at the base of the peg) was reinforced by an additional 50%. The plasma coating was
applied to enhance bony ingrowth to this surface.
Prosthetic stem:
(left) old design;
(right) new
design, medial
shift of the peg Prosthetic stem: (left) old design; (right) new design, finite element
IN-DEPTH SEMINARS
(2.0-mm) and analysis demonstrating decreased stresses with new radius of curva-
BIOMEDTRIX
new radius of ture at the base of the peg.
curvature at the
base of the peg.
W.D. Liska WVOC 2010, Bologna (Italy), 15th - 18th September • 434
Hip replacement in small patients

William D. Liska, DVM, Dipl. ACVS
Gulf Coast Veterinary Specialists, Houston, Texas, USA
Total hip replacement (THR) is well recognized as an effective treatment for dogs with aseptic hip os-
teoarthritis1 or irreparable pathology, regardless of etiology. The goal of a pain free joint with normal bio-
mechanical function is achievable with a relatively low risk of complications and a high degree of client sat-
isfaction. THR has been used on dogs successfully for over 3 decades. Instrumentation and prosthesis avail-
ability has evolved to modular systems that are implanted with either cemented or cementless fixation. Mul-
tiple implant sizes and appropriate instrumentation are available to accommodate dogs as small as 3 kg. The
results in cats and small dogs in this size range are comparable to results in larger dogs.
Until recently, a femoral head ostectomy was the best surgical option we had to offer. The new micro total
hip replacement system (Micro THR) gives the veterinary surgeon an option to offer a THR as the primary
recommendation for small dogs (and cats) that need surgical intervention.

A modular cemented prosthesis system is available including acetabular components, femoral stem com-
ponents, and femoral heads. The acetabular components are similar in design to the all-polyethylene
(UHMWPE) implant of the BioMedtrix CFX cup (Figure 1). The outside diameter of the acetabular com-
ponent is 16mm, 14mm, or 12mm. All 3 implants have a cup articular surface inside diameter to accept an
8mm femoral head. The profile and design of the femoral stem is similar to that of the BioMedtrix CFX
stem. Two stem sizes are available. The overall stem length from collar to tip is 46mm and 36mm for the
#3 and #2 stems, respectively. The diameter of the stem tip is 3.6mm and 2.6mm, respectively. The femoral
neck accepts the 8mm femoral head with a neutral +0 mm neck length, or an 8mm femoral head with
+2mm of neck lengthening. Templates printed on acetate film are overlaid on radiographs for prosthesis size
selection, or templating can be done using digital templates on digital images. Acetabular and femoral ream-
ers are used to prepare the implant beds. Trial implants confirm adequate bed preparation and implant se-
lection. Alignment guides, inserters, impactors, retractors, and tissue guards have applications similar to
those used on larger dogs – only the instrumentation is smaller.
SURGICAL TECHNIQUE
The surgical technique is similar to that used in larger dogs receiving a cemented THR. Patient positioning
is important as is the use of anatomical landmarks to help insure correct implant position. The approach, ex-
posure, and retraction are routine – except that smaller instruments are used. Acetabulum bed preparation re-
IN-DEPTH SEMINARS
quires attention to details to avoid inadvertent removal of the cranial or caudal pole bone stock, removal of
the dorsal acetabular rim, and penetration of the medial cortical wall. Caution is required when preparing the
BIOMEDTRIX
femoral medullary canal. The canal is opened by hand with an awl, either before or after the femoral head
has been removed. Reamers should be centered in the canal to avoid varus or valgus stem positioning. The
medullary canal can be prepared entirely by hand using a series of awls and reamers. Power instruments
should only be used with extreme caution to avoid cortical penetration, fissures, or fractures. Trial implants
are used to confirm sizing and implant positioning. A trial reduction confirms correct implant positioning, de-
termines femoral neck length selection, and provides insight into the likelihood of postoperative luxation.
Once the beds are prepared, the components are cemented in place with PMMA. Closure is routine.
RESULTS
Sixty six (66) Micro THR procedures were performed on 49 dogs and 8 cats as part of an ongoing prospec-
tive study to evaluate the feasibility and clinical outcome of the procedure. Patient data was recorded includ-
ing: signalment, body weight, diagnosis, surgical technique, implant size, intraoperative comments, and post-
operative complications. Implant positioning and cement mantle quality was evaluated radiographically. Or-
thopedic examinations and client interviews were used during the examinations to obtain follow up infor-
mation. Micro THR was performed unilaterally on 40 dogs, staged bilaterally on 9 dogs, and unilaterally on
8 cats to resolve pain associated with osteoarthritis secondary to either coxofemoral subluxation compatible
with hip dysplasia or of unknown etiology (21), traumatic coxofemoral luxation (17), capital epiphyseal frac-
tures (11), avascular necrosis of the femoral head (13), pelvic fracture malunion (1), femoral head ostectomy
revision (2), and an injury to the round ligament (1) (Figure 2-4). Mean body weight was 7.20 kg (range 2.45
to 15 kg; median 6.4 kg). Access to prepare the acetabular bed and adequate opening of the proximal femoral
435 • WVOC 2010, Bologna (Italy), 15th - 18th September W.D. Liska
Figure 1-4 - Micro THR prosthesis; feline Micro THR; preoperative and postoperative VD views of a 7kg Lhasa Apso with bilateral cox-
ofemoral subluxation treated with bilateral Micro THR.
canal provided technical challenges during the early stage of the learning curve. Excessive coxofemoral laxi-
ty after reduction of the prosthesis was not present in any patients. Postoperative complications included pros-
thesis luxation (9 in 8 dogs and 1 cat). Five of the luxations were managed successfully and 4 resulted in ex-
plantation. Aseptic loosening of an undersized acetabular implant required revision to a larger implant in 1
dog. No femoral fractures occurred even though the femoral cortex was penetrated in 2 dogs during femoral
bed preparation. The mean radiographic follow up time was 96.1 weeks. Ten were followed radiographical-
ly for > 3 years. Sixty of the 66 (91%) Micro THRs had excellent outcomes.
DISCUSSION
There are approximately 122 recognized dog breeds (and a substantial number of mixed breed dogs) that
weigh less than 12 kg. There are approximately 57 cat breeds. It is possible that any dog or cat breed could
have hip pathology (degenerative, traumatic, or otherwise) that requires surgical intervention to resolve pain
and/or dysfunction. Surgeons with THR expertise do not hesitate to recommend the procedure to clients who
own medium and large breed dogs if the proper indications are present and no other medical problems of high-
er priority preclude surgery. The outcomes of the patients in this series indicate that THR should also be con-
sidered for small dogs and cats. The basic principles of implanting the Micro THR are similar to those for the
standard CFX (BioMedtrix, Boonton, NJ) procedure. The only significant difference is that the patient and
prosthesis are smaller and the instrumentation used is designed specifically for the procedure. The outcomes
provide evidence that Micro THR should at least be considered in the treatment of coxofemoral pathology in
small patients in the same way that THR is considered for larger dogs, even if technical challenges and/or con-
IN-DEPTH SEMINARS
comitant problems exist. The complication rate in the patients in this study is acceptable for a new device and
a new procedure, and it can be improved upon through case selection and surgeon experience. The most com-
BIOMEDTRIX
mon complication is recurrent unmanageable luxation of undetermined etiology. This complication, and most
other complications including those caused by technical errors, can be resolved by revision or by salvage to a
FHO pseudoarthrosis. Nothing unique was discovered about the Micro THR technique, outcomes, or com-
plications in cats compared to small dogs or in small dogs compared to large dogs.
CONCLUSION
Based on the study results, Micro THR is considered a satisfactory procedure in small dogs and cats affected
by trauma or coxofemoral osteoarthritis, and it is an alternative to femoral head ostectomy which carries a
relatively high rate of unsatisfactory outcomes based on reported objective data2. Success with twenty three
(23) small dog breeds and with cats3 that have not been previously reported to have received a total hip re-
placement (THR) suggests that Micro THR surgery has widespread application potential. The risk of com-
plications is low, and the complications that arose in this study were manageable. The clinical relevance ap-
pears to be that many small dogs and cats could receive benefit from Micro THR surgery.
REFERENCES
1. Budsberg S, Chambers J, Van Lue S, Foutz T, and Reece L: Prospective evaluation of ground reaction forces in
dogs undergoing unilateral total hip replacement. AJVR 57:1781-1785, 1996.
2. Off W, Matis U: Resektionsarthroplastik des huftgelenkes bei hunden und katzen. Tierarztl Prax 25:379-387, 1997.
3. Liska W, Doyle N, Marcellin-Little D, Osborne J: Total hip replacement in 3 cats: surgical technique, short term
outcome and comparison to femoral head ostectomy. VCOT 6:505-510, 2009.
Total knee replacement

William D. Liska, DVM, Dipl. ACVS
Gulf Coast Veterinary Specialists, Houston, Texas, USA
The instrumentation and a wide range of prosthesis sizes are available for canine total knee replacement
(TKR) surgery. TKR in client owned patients is intended to create a pain free joint and mimic normal bio-
mechanical function. The initial TKR case report was a custom designed prosthesis with a metal augment
to replace lost femoral condyle bone stock1. In a study conducted on the initial group of TKR patients2, se-
vere end-stage osteoarthritis was present in each joint. Statistically significant objective evidence of improved
function based on ground reaction forces with stable implants is presumably a reliable indication of de-
creased joint pain.
INDICATIONS FOR TKR SURGERY

The primary indication for canine TKR is degenera-
tive joint disease, most commonly secondary to cranial
cruciate ligament (CCL) injury (Figure 1). The majori-
ty of dogs present with a history of at least one previ-
ous surgical procedure. Conversion of a failed extra-
capsular repair is relatively straightforward and can be
performed as a onestage procedure. Conversion from a
tibial plateau-leveling osteotomy (TPLO) is best per-
formed as a two-stage procedure with plate/screw re-
moval as stage one several weeks before TKR.
Infection is an absolute contraindication for total knee
replacement. It is recommended that synovial fluid
analysis and tissue cultures be performed on any stifle
joint that has had recent surgery or is suspect of, or has Figure 1 - Typical preoperative osteoarthritis appearance of TKR
confirmed previous sepsis. patients.
TKR SURGICAL TECHNIQUE

Details of the surgical technique can be found in the lit-
erature2. Total knee replacement can be performed
through either a medial or lateral arthrotomy. The
patella is luxated to improve exposure of the distal fe-
IN-DEPTH SEMINARS
mur and proximal tibia. The infrapatellar fat pad, cru-

ciate ligaments, and menisci are removed. Instruments
BIOMEDTRIX
and cutting blocks are designed specifically to guide the

tibial osteotomy and the four femoral osteotomies.
Figure 2 - TKR tibial and femoral prosthesis components.
The osteotomized bone surfaces are prepared to accept
the keel of the tibial implant and the post of the femoral
implant. Upon completion of the bone preparation, the
bone surfaces are cleaned of debris with pulsatile
lavage and suction. Trial components are used to con-
firm proper implant size and position prior to prosthe-
sis fixation. The trials also facilitate evaluation of joint
stability and collateral ligament tension. The current
version all-polyethylene tibial component is implanted
first using PMMA fixation, and the femoral compo-
nent is implanted in cementless press-fit or cemented
fashion (Figure 2). Cementless tibial components are in
trials. Range of motion and collateral ligament tension
are evaluated with the joint rearticulated. The joint
space is lavaged copiously to remove all debris. The
joint capsule, subcutaneous tissue, and skin are closed
in routine fashion while ensuring proper patella track-
ing (Figure 3). Figure 3 - TKR postoperative appearance.
A sterile dressing is applied over the incision. There is no need for a bandage or splint unless complications
(e.g. collateral ligament injury) are encountered during surgery.
TKR POST-OPERATIVE MANAGEMENT

Routine post-operative pain management following TKR includes a combination of opiate analgesics and
nonsteroidal anti-inflammatory agents. Cold packs are applied immediately following surgery and at regu-
lar intervals for 1-2 weeks to reduce pain and swelling. The dog’s activity is restricted for the first 2 weeks,
after which a controlled program of physical rehabilitation and leash exercise can begin. Recommendations
for physical rehabilitation following TKR have been published2. The goal of rehabilitation is to achieve nor-
mal passive range of motion (PROM) in the operated joint.
CLINICAL RESULTS WITH CEMENTED TKR

Outcomes have been published with clinical follow-up on an initial series of client owned dogs that under-
went TKR for end-stage osteoarthritis2. Outcome measures included radiographic assessment, physical ex-
amination (including measurements of stifle joint range of motion and thigh circumference) and force plate
gait analysis of ground reaction forces. Data were recorded pre-operatively and at six weeks, three months,
six months, and one year after surgery. Rehabilitation was provided for each dog.
Joint extension, excursion, peak vertical force, and impulse parameters showed statistically significant im-
provement (P ≤.01) starting at 3-6 months after surgery. At the end of the study, joint extension (152º) and
excursion (115º) were only 9º and 6º less than normal3, respectively. Peak vertical force and impulse were
82% and 103% of the normal contralateral limb, respectively. Video during ambulation at the same inter-
vals confirmed the owner’s subjective evaluation that minimal or no gait abnormalities remained after re-
habilitation in spite of the severity of the preoperative status.
REFERENCES
1. Liska W, Marcellin-Little D, Eskelinen E, et al: Custom total knee replacement in a dog with femoral condyle bone
loss. Vet Surg 2007; 36:293-301.
2. Liska W, Doyle N: Canine total knee replacement: surgical technique and 1-year outcome. Veterinary Surgery
2009; 38:568-582.
3. Jaegger G, Marcellin-Little DJ, Levine D: Reliability of goniometry in Labrador Retrievers. AJVR 2002 63:979-986.
IN-DEPTH SEMINARS
BIOMEDTRIX
PHYSIOTHERAPY
IN-DEPTH SEMINAR
441 • WVOC 2010, Bologna (Italy), 15th - 18th September D.J. Marcellin-Little
Companion animal rehabilitation - Were are we?

An evidence-based review
Denis J. Marcellin-Little, DEDV, Dipl. ACVS, Dipl. ECVS, Dipl. ACVSMR
College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA
ON THE HUMAN SIDE OF THINGS…

Evidence-based medicine is slowly permeating the practice of orthopedics and physical therapy in human
medicine. Guidelines for practice are derived from a variety of sources, including consensus statements,
state-of-the-art reviews and metanalysis published in peer-reviewed publications, medical coverage policy
statements from health maintenance organizations (HMO).
National health organizations (i.e., the National Institutes of Health, in the United States) periodically invite
clinical experts to review the scientific evidence on specific topics. Consensus statements resulting from these
discussions are usually published. Here is a statement excerpted from an NIH consensus statement on
acupuncture1 published in 1998:
There are situations, such as addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia,
myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma, in which acupuncture may be use-
ful as an adjunct treatment or an acceptable alternative or be included in a comprehensive management program.
Specialized clinicians that function under the umbrella of specific private non-profit groups or organizations
also make management recommendations. For example, for the management of osteoarthritis, the Os-
teoarthritis Research Society International (OARSI) regularly updates specific treatment guidelines. The fol-
lowing statement2 was published in 2007:
Twenty-three guidelines have been developed for the treatment of hip and/or knee OA, based on opinion alone, research
evidence or both. Twenty of 51 modalities of therapy are universally recommended by these guidelines. Although this
suggests that a core set of recommendations for treatment exists, critical appraisal shows that the overall quality of ex-
isting guidelines is sub-optimal, and consensus recommendations are not always supported by the best available evi-
dence. Guidelines of optimal quality are most likely to be achieved by combining research evidence with expert consen-
sus and by paying due attention to issues such as editorial independence, stakeholder involvement and applicability.
This review of existing guidelines provides support for the development of new guidelines cognisant of the limitations
in existing guidelines. Recommendations should be revised regularly following systematic review of new research evi-
dence as this becomes available.
IN-DEPTH SEMINARS
PHYSIOTHERAPY
Clinicians develop clinical prediction rules (CPR). CPR identify the best combination of medical signs,
symptoms, and other findings in predicting the probability of a specific disease or intervention outcome.3
For example, with Ottawa ankle rule, radiographs are required only when there is any pain in the malleo-
lar zone and any one of the following is present: 1.) bone tenderness along the distal 6 cm of the posterior
edge of the tibia or tip of the medial malleolus, or 2.) bone tenderness along the distal 6 cm of the posteri-
or edge of the fibula or tip of the lateral malleolus, or 3.) an inability to bear weight both immediately and
in the emergency department for four steps. The sensitivity (true positive detection rate) of the Ottawa an-
kle rule is almost 100% and there are < 2% false negatives.4
The cost of medical procedures and physical rehabilitation programs is most often covered by third party
payers (HMO, health insurances) and these payers often require scientific evidence of efficacy before they
cover the cost of specific therapies. Third party payers often issue medical coverage policy statements that
follow in-depth reviews of the available scientific evidence. Here are two medical coverage policy statements
regarding emerging therapeutic modalities from Cigna, a health maintenance organization based in Philadel-
phia, PA, USA.
Regarding low-level laser therapy, Cigna wrote:
Low-level laser therapy (LLLT) has been proposed for a wide variety of uses, including wound healing, tuberculosis,
and musculoskeletal conditions such as osteoarthritis, rheumatoid arthritis, fibromyalgia and carpal tunnel syndrome.
There is insufficient evidence in the published, peer-reviewed scientific literature to demonstrate that LLLT is effective
for these conditions or other medical conditions. Large, well-designed clinical trials are needed to demonstrate the effec-
tiveness of LLLT for the proposed conditions.
D.J. Marcellin-Little WVOC 2010, Bologna (Italy), 15th - 18th September • 442
Regarding shockwave therapy, Cigna wrote:
Extracorporeal shock wave therapy (ESWT) has been studied in various musculoskeletal applications. Some unan-
swered questions remain, and the data are inconclusive as to the effectiveness of ESWT for the treatment of mus-
culoskeletal conditions. A review of the medical literature shows that the effectiveness of ESWT for the two U.S.
Food and Drug Administration (FDA)-approved conditions (i.e., lateral elbow pain and plantar fasciitis) is un-
clear, as trials have yielded conflicting information. A strong placebo effect has been demonstrated for this technol-
ogy.5 There is insufficient evidence in the peer-reviewed scientific literature to support the use of ESWT for any
musculoskeletal indication. Therefore, the use of ESWT for the treatment of these indications remains unproven at
this time.
ON THE COMPANION ANIMAL SIDE OF THINGS…

There is a paucity of scientific information in companion animal orthopedic and physical rehabilitation.
There are no consensus panels. With few exceptions (i.e. the International Elbow Working Group), there
are no organizations overseeing specific medical issues. There are few evidence-based reviews. There are few
clinical prediction rules.
A current evidence-based review of the management of osteoarthritis (OA) in dogs6 concluded:
A high level of comfort exists for meloxicam that the claimed relationship is scientifically valid and that its use is clin-
ically efficacious for the treatment of osteoarthritis in dogs. A moderate level of comfort exists for carprofen; etodolac;
pentosan polysulphate; green-lipped mussels; P54FP; polysulfated glycosaminoglycans; and a combination of chon-
droitin sulfate, glucosamine hydrochloride, and manganese ascorbate. An extremely low level of comfort exists for
hyaluronan.
An evidence-based review of acupuncture in animals7 concluded:
… On the basis of the findings of this systematic review, there is no compelling evidence to recommend or reject
acupuncture for any condition in domestic animals.
Overall, there are few practice guidelines in companion animals. Our profession needs to organize itself and
address this critical aspect of practice. Here are a few questions that should be addressed in the future. This
list is by no means comprehensive.
Orthopedics
- How impaired are dogs with common orthopedic diseases, including cranial cruciate ligament tears,
patellar luxation, hip dysplasia, elbow dysplasia, osteochondritis dissecans?
IN-DEPTH SEMINARS
- What are the geometric predisposing factors for the occurrence of cranial cruciate ligament injuries?
PHYSIOTHERAPY
- What surgical management options minimize the progression of OA in cranial cruciate ligament (CCL)-
deficient stifle joints?
- Are there effective non-surgical options to manage partial tears of CCL?
- Should low-grade patellar luxations be managed conservatively or surgically?
- Is comfort and limb use better in dogs undergoing femoral head ostectomies compared to dogs under-
going conservative management of hip OA?
Rehabilitation
- Are the acute rehabilitation measures (ice, passive range of motion, massage) beneficial?
- Do therapeutic exercises influence limb use in patients with OA? Do they alleviate pain? Do they influ-
ence the progression of the disease?
- Do low-level lasers have any benefit in OA patients?
- Are water-based exercises more effective than land-based exercises (and more effective than no exercise)
in patients recovering surgical stabilization of CCL-deficient stifle joints?
- Do braces have any benefits in CCL-deficient stifle joints?
- Do therapeutic exercises enhance the recovery after spinal cord injuries?
- Does the use of ambulation assistive devices enhance the speed of independent locomotion in dogs re-
covering from spinal cord injuries?
REFERENCES
1. Acupuncture. NIH consensus development panel on acupuncture. J Am Med Assoc 280:1518-1524, 1998.
2. Zhang W, Moskowitz RW, Nuki G et al. OARSI recommendations for the management of hip and knee os-
teoarthritis, part I: critical appraisal of existing treatment guidelines and systematic review of current research evi-
dence. Osteoarthritis Cartilage 15:981-1000, 2007.
3. Childs JD, Cleland JA. Development and application of clinical prediction rules to improve decision making in phys-
ical therapist practice. Phys Ther 86:122-131, 2006.
4. Rae F. The Ottawa ankle rule. Emerg Med J 18:147, 2001.
5. Buchbinder R, Green S, White M et al. Shock wave therapy for lateral elbow pain. Cochrane Database Syst Rev
CD003524, 2002.
6. Aragon CL, Budsberg SC. Systematic review of clinical trials of treatment of osteoarthritis in dogs. J Am Vet Med
Assoc 230:514-521, 2007.
7. Habacher G, Pittler MH, Ernst E. Effectiveness of acupuncture in veterinary medicine: systematic review. J Vet In-
tern Med 20:430-438, 2006.
IN-DEPTH SEMINARS
PHYSIOTHERAPY
Rehabilitation Engineering - What is it and how does it

apply to companion animal rehabilitation?
Denis J. Marcellin-Little, DEDV, Dipl. ACVS, Dipl. ECVS, Dipl. ACVSMR
College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA
Rehabilitation engineering, as defined in the United States Rehabilitation Act of 1973, is the systematic ap-
plication of engineering sciences to design, develop, adapt, test, evaluate, apply, distribute technological so-
lutions to problems confronted by individuals with disabilities. The Rehabilitation Engineering and Assis-
tive Technology Society of North America (RESNA) oversees this field in the United States. Similar associ-
ations exist in Europe, Australia, and Japan. RESNA’s diverse roles include the influence of policy related
to people with disabilities, the promotion of research, the enhancement of the practice of rehabilitation, for
example through the certification of assistive technology practitioners. Engineering sciences may also be of
benefit to the rehabilitation of patients in veterinary medicine. The purpose of this presentation is to pres-
ent an approach and several applications of rehabilitation engineering to companion animals.
The range of rehabilitation engineering – Engineering may provide assistance for the design, fabrication, and
evaluation of novel objects used for animals with orthopedic and neurologic problems. An engineering approach
usually starts with an accurate capture of a body part, the creation of a virtual or physical replica of that body
part, and the creation of a virtual or physical loading event of that body part under controlled conditions. Vir-
tual models may be tested using finite element analysis, a computer model in 2D or 3D that can be analyzed
and modified before a device is made. The process is cumbersome and heavy in computations, limiting its every-
day use. Physical models may be created and used for testing on materials testing machines. Because of the wide
range of size and the wide variety of clinical problems encountered in veterinary medicine, engineering ap-
proaches are particularly suited to the design and fabrication of splints, braces, orthoses, prostheses, and ambu-
lation assistive devices (slings, hoists, carts) for companion animals, as well as for surgical implants.
Custom splints, braces, orthoses, and prostheses – Engineering methods are particularly helpful for very
small or very large patients who are unlikely to be good candidate for off-the-shelf items. Customization is of-
ten necessary for these patients. Also, engineering methods are useful to replicate the limbs of patients who
need custom rigid orthoses, hinged orthoses, hinged braces, or prostheses. For that purpose, we can perform
a CT scan of the affected and opposite limbs. The cross-sectional images are imported in image-analysis soft-
ware (i.e., Mimics, Materialize, Ann Harbor, MI, USA) that allows the creation of a 3D rendering that will be
used to produce an accurate replica of the limb using free form fabrication. Because most limb replicas are sol-
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id, it is important to image the limbs in a

PHYSIOTHERAPY
position that mimics a weight-bearing

limb position. As an alternative, a 3D re-
construction of a biological structure
may be modified by use of computer-aid-
ed design software (CAD, Figure 1).
Solid replicas may be made of cyano-
acrylate-impregnated plaster, acryloni-
trile butarene styrene (ABS) plastic (Fig-
ure 2), or laser-cured photopolymers, or
other free-form fabrication methods.
These methods produce replicas that
have an excellent accuracy (the lengths
of replicas were approximately 99% ac-
curate in a study from our research Figure 1 - 3D renderings of the pes of a 50-kg Dober- Figure 2 - A CT-based
group – unpublished data). Articulat- man Pinscher demonstrating the correction made to repre- ABS plastic replica of the
ed replicas may be made to support the sent a weight-bearing foot position. That position was forelimb of a cat with
design of hinged orthoses or prostheses. deemed to be necessary for the fabrication of a replica of spina bifida was used to
that pes. The toes were held in neutral position in the make a support orthosis.
These replicas include rigid bone mod- original CT scan (A). Semi-circular cuts, made at the The orthosis, visible on
els connected using artificial ligaments, metarsophalangeal joints (inset), were used to rotate the the image, has padded
covered by ballistic gel (Figure 3). To toes. They were stitched and fixed into an extended posi- inserts that protect areas
replicate the shape of the original limb a tion of 250° (B). susceptible to abrasions.
Figure 3 - A CT-based 3D rendering of the pelvic limb of a mixed Shepherd dog is visible (left). The rendering includes a femur, tibia, and
fibula and the outer skin surface. That rendering has been used to cast a ballistic get replica of the skin surface. Ballistic gel gives a realistic
feel of the elasticity of soft tissues. Inside this replica, the femur and tibia have been articulated. A custom silicone sleeve has been made based
on that ballistic gel replica. The silicone sleeve has a distal locking pin that is secured into a prosthetic shell.
thin replica of the outer skin layer is made and the ballistic get is poured in that mold with the bones already
placed within the mold. Articulated limb replicas may be used to make custom silicone liners and custom
(hinged) shells for prostheses. Prostheses are used in most instances to replace a missing manus or pes. They
are most often designed based on casts (i.e., semi-rigid fiberglass, rigid fiberglass, or plaster of Paris) of the
affected and opposite limb. The contact layer may be a silicone liner or foam adhering to a shell.
Standard pediatric silicone liners may be used for long antebrachia. Custom silicone liners may be used for
smaller or larger patients and for other body parts (i.e., thighs). Liners are secured to shells using locking
pins embedded in their distal portions or are held by friction within the shell (Figure 3). Most prostheses
have custom shells made of rigid thermo-moldable plastic, fiberglass, or carbon fiber. Thermoplastics are
cheapest and their relative lack of
strength and stiffness relative to
other materials does not represent
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a significant drawback in smaller
PHYSIOTHERAPY
patients. Little is known about the
optimal shape of external pros-
theses for partially amputated
forelimbs and pelvic limbs in
companion animals. Adjustable
devices may facilitate the design
of the sole of these prostheses
(Figure 4). The weight-bearing
surface of prostheses is most often
rounded and made of low-wear,
non-skid rubber (Figure 5). The
rubber stiffness is chosen based
on patient size, mobility, and an- Figure 4 - A temporary pros- Figure 5 - A prosthetic foot has been engineered using
ticipated level of activity. Some thesis has been placed on the computer-aided design software. The foot is curved in a cra-
prostheses are hinged at the car- antebrachium of a dog with a nial to caudal and axial to abaxial directions. Grooves on
pus or tarsus. These hinges may mid-antebrachial amputation. its plantar surface enhance traction. The foot has a metal
The base of the prosthesis is core and is rubber coated using injection molding (top). The
be present to enhance the stability adjustable in height and in metal core may be made of spring steel, a hardened, tem-
of the prosthesis on the limb by in- cranio-caudal and medio-lat- pered metal with high yield strength. The foot is connected
creasing the contact area between eral directions. Source: K-9 to a metal tube, adjustable in length. The tube may be made
the shell and the skin without in- Orthotics and Prosthetics, Inc. of aluminum or titanium.
terfering excessively joint motion. Beaver Bank, NS, Canada.
Hinges may also be included in the prosthesis to promote a joint position more
compatible with weight bearing. Hinges add complexity and cost to prostheses
but they may greatly enhance limb function. Custom support braces may be
designed and tested similarly to orthoses and prostheses.
Custom ambulation carts – Ambulation carts have become more established,

primarily to allow independent mobility of paraplegic dogs. Carts may have soft
(i.e., neoprene or nylon mesh) or rigid (i.e. foam-covered tubing) resting surfaces.
Companion animals with orthopedic or neurologic problems in two limbs usual-
ly do well in conventional two-wheeled carts. Animals with problems affecting
their forelimbs or all limbs often require specifically engineered carts. These carts
may be counterbalanced, with an even weight in front and behind the wheels or
may have an additional pivot wheel or four wheels (Figure 6).
Custom metal implants - Custom metal implants have been used successful-
Figure 6 - These three Chi- ly to help patients with limb defects. This includes the use of osseointegrated
huahuas were born without fore- implants that allow the stable fixation of prosthetic extremities to incomplete
limbs. Ambulation carts have limbs. The process used for the creation of these implants include CT scanning,
been prepared. The carts are en- export of the CT sections into CAD software, implant design, implant manu-
gineered to allow dogs to main- facturing using free-form fabrication, implant finishing using CNC machining,
tain a near normal posture during
implant testing using a plastic replica of the patient’s leg, implant placement,
locomotion without excessive stress
placed on the chest. and gait training. The use of free form fabrication (electron-beam melting or
Source: www.eddieswheels.com/ laser sintering) has lead to a significant decrease in the complexity of custom
(accessed July 27, 2008). Eddies’ implant fabrication. Custom titanium implants in dogs and cats have been suc-
Wheels for Pets, Shelburne Falls, cessfully implanted in patients with missing feet (Figure 7). Custom implants
Mass. may also be used for limb sparing procedures (Figure 8).
IN-DEPTH SEMINARS
PHYSIOTHERAPY
Figure 7 - A custom osseointe-

grated implant has been secured
to the proximal portion of the Figure 8 - A custom titanium alloy tibial implant has been designed and fabricated by
tibia of a cat with bilateral the author’s research group. The implant was fabricated by use of electron beam melting
pelvic limb anomalies. The im- (Arcam, Mölndal, Sweden). The implant replaces the proximal portion of the tibia of a
plant is modular and includes a dog with an osseous neoplastic process. The tibial implant is secured in place with five
titanium osseointegrated compo- locking bolts. It has porous portions designed for bone ingrowth. The implant was de-
nent, a rigid tube, and a foot. signed to receive a cemented tibial tray (BioMedtrix, Boonton, NJ). The tray was ce-
The patient will be fitted with the mented in place during the surgical procedure. The tibial implant was paired with a ce-
foot once bone ingrowth into the mentless femoral component for total knee arthroplasty (BioMedtrix, Boonton, NJ). The
osseointegrated implant is stifle joint ligaments were excised during removal of the disease portion of the tibia and
deemed appropriate. Bone in- reconstructed by use of FiberTape (Arthrex, Naples. FL). Cisplastin beads (Matrix III,
growth may be assessed using Royer Biomedical, Frederick, MD, USA) are visible within the soft tissues on the cau-
radiographs. dal aspect of the tibial implant.
KYON NEWS
IN-DEPTH SEMINAR
449 • WVOC 2010, Bologna (Italy), 15th - 18th September I. Pfeif
Elbow incongruency measurements with x-ray

and correction by plated proximal ulnaosteotomie:
clinical experience in 46 dogs
I. Pfeil, P. Böttcher, A. Starke
Tierärztliche Klinik Dresdner Heide, Fischhaustrasse 5, 01099 Dresden, felidog@gmx.de
RADIOLOGICAL METHOD
Incongruency measurements with radiology are at the moment not possible with the normal a.p. or the m.l.
views. As the Coronoid process breaks only when he is loaded, we developed a method to measure incon-
gruency in a standardiced way: The limb of anaesthesiced dog is in a line, the paw hyperextended and
straight, a pressure is put on the olecranon and triceps tendon. The central beam is right into the joint. The
distance of subchondral bone from humerus to radius or Ulna is taken at 6 defined measure points (MP1-
6) from lateral to medial. Measurements are taken with a digital X ray system (Easy vet) with a magnifica-
tion of 500%. MP 1 was termed 100% and MP 2-6 as relative values to MP1. The lateral distance at MP1
was then divided through the distance of MP 6 and the result named loading index. Additionally an angle
was taken: the angle point was the contact point of the most medial coronoid process to the most medial
and distal subchondral bone of the medial epicondyl, one line was taken from this point to the lateral epi-
condyle as a subchondral tangent and the other line to the most lateral, visible, subchondral radial jointsur-
face. We found significant differences to not loaded views. Normal values were evaluated by 50 sound dogs.
In the 50 sound dogs the mean loading index was 2,00 and the mean angle was 3,00°.
IN-DEPTH SEMINARS
KYON NEWS
a b
Figure 1 - a) from left to right Mp 1 – Mp 6. b) The angle measurements.
149 dogs with an FCP were examined in the same way. There where 3 statistically significant groups and
one undefined. (p < 0,05).
PRELIMINARY RESULTS
Short ulna: with a loading index >= 4, and the angle >= 4. 28,86% (n=43)
Short radius: with a loading index < 2 and the angle < then 2 11,41 (n=17)
Short oblique radius: with a loading index < 2 and the angle <= 2 18,12% (n = 27)
and at (Measurepoint 3 > than measurepoint 3
in the normal view)
Group no detectable incongruency 41,6% (n =62)
In a cadaver study where ulna was shortend or lengthend in a two dimensional way with an external fixa-
teur and then taken x-rays, we could not find compare able data. Only tilting, shortening and torsioning the
I. Pfeif WVOC 2010, Bologna (Italy), 15th - 18th September • 450
a b c
d e f
Figure 2 - Upper row shows from left to right not loaded x-ray: a) short Ulna. b) normal elbow. c) short radius. In the second row the same
elbow in a loaded view. d) short ulna. e) normal elbow. f) short radius.
ulna in a three dimensional way showed compare able data to the dogs with a short Ulnasyndrom. In the
radius a two dimensional shortening showed compare able data.
IN-DEPTH SEMINARS
SURGICAL CORRECTION FOR SHORT ULNA

KYON NEWS
(Dogs with short radius were treated with the sliding osteotomie on the radius presented on ESVOT 2004
Proceedings (B.Slocum,I Pfeil).
PLANING
For surgical correction the standardiced views are taken, then a line is drawn from the center of the proxi-
mal olecranon through the highest and medial elevated point of radius to the distal ulna. The difference of
the measured angle to the normal angle is taken and brought to the most medialy elevated point of radius
and signed distally in the ulna bone in the X –ray. 3.5 cm – 4.5 cm below the joint, there is measured where
the distance between the angle is 2 or 3 or 4 mm wide and this determines the osteotomie line for ulna.
SURGERY FOR SHORT ULNA SYNDROME

After arthroscopy of the elbow with removal of all loose fragments the dogs are positioned in dorsal recum-
bency, the paw is fixed cranial so that the back side of the ulna can be reached. The paw is not hyperex-
tended but slightly flexed, the distance for osteotomie is determined by palpating the lateral Radius head
and taken from him the distance distally at the ulna. After a caudal approach, the ulna is there osteotomied
in an right angle. Mostly the ulna creates at once a small gap as tension is reliefed and the proximal bone is
going towards the elbow joint, driven from the capillary forces of the joint. Then the Kyon ulna plate with a
step of 2, 3 or 4 mm according to the previous measurement, is fixed with two bone clamps one at the prox-
imal and one at the distal ulna bone. Two cortical screws at each side are inserted and then the locking screws.
Woundclosure, bandaging after surgery are done, NSAID for 14 -30 days are administered.
451 • WVOC 2010, Bologna (Italy), 15th - 18th September I. Pfeif
a b c d
e f
Figure 3 - German shepherd, male, 10 years. From left to righ: a) pre-op: a.p.view / not loaded. b) pre op x- ray with medial narrow joint
spac/loaded view. c) a.p. view post op: medial joint space is wider/loaded view. d) post op med. lat. view: small gap. e) arthroscopic findings:
whole cartilage erosion on Ulna. f) medial humerus epicondyle: whole cartilage erosion and subchondral bone erosion.
The dogs showed after surgery a severe middlegrad lamness up to 8 – 10 weeks post op. As there is a gap
always a delayed healing was seen and the osteotomie creates pain up to the 12 week. Mostly the joint cre-
ates less pain from the 6 week on. Bone healing was controlled by x- ray and after bone healing the dogs get
IN-DEPTH SEMINARS
a course of prednisolon 0,1 mg / kg for 30 – 45 days.
KYON NEWS
RESULTS
46 dogs were done with this surgery. Only dogs were choosen with a short Ulna syndrome, where the car-
tilage at the ulna was higher degraded or eburnated. 38 dogs were done with this surgery with bending
ALPS 10 or ALPS 8 plate. Which is technically difficult to make it precise. 8 dogs were done with the new
Kyon Ulna step plate. After a time of 16 weeks 87% of the dogs showed a good improvement of lamness,
with no need for NSAID anymore as they had before surgery, they were lame free or showed only a grade
one lamness (grade 1 – 6) mostly when they were standing up after a resting period. Complications were
seen in 6 dogs: 1 was not corrected enough, in 5 dogs we overcorrected them and in 4 of this dogs cycling
and breakage happened to the plate. 3 plates were taken out changing it into a dynamic Ulnaosteotomie two
of them improving and one worsening, one dog was double plated and get healed with good result. One dog
of the overcorrected dogs had problems with impinging osteophytes at the anconeal process. No complica-
tions were seen with the new Kyon ulna step plates which made the surgery much more easier.
CONCLUSION
Radiological measurements for incongruency is possible in 58,4% of cases of FCP with significant differ-
ences under a loaded and standardiced views. There were seen short Ulna and short radius as a cause for
the FCP. The hypothesis of an 3 dimensional movement of the ulna with the short ulna syndrome and the
successfully clinical 3 dimensional surgical correction and improvement of 87% of the dogs is a hint that this
hypothesis might be right. Still more than 41,6% of the cases remain not detectable and require further stud-
ies for loaded standardiced incongruency imaging and improving the method.
S. Tepic WVOC 2010, Bologna (Italy), 15th - 18th September • 452
Various osteotomies for treatement of elbow dysplasia

S. Tepic
Kyon, Technoparkstrasse 1, 8006 Zurich, Switzerland
Elbow dysplasia is a major cause of front limb lameness in dogs -- in a great majority of cases it is initiated
at and/or limited to the medial compartment. A number of different osteotomies have been proposed and
practised to treat the condition, mostly based on observing incongruities within the joint. Looking at the
overall loading of the limb offers another view and may point to the cause of the condition and thus to a
more rational approach to treatments.
In the frontal plane the ground reaction vector, as a rule in straight gait, will pass medially to the elbow. A
simple inspection demonstrates that dogs show a large variety in their front limb conformation and use of
it in gait – some will walk/run hitting the ground with right and left paws near the centre line, while others
will hit the ground at a considerable distance from the centre line. Considering the offset of the ground re-
action with respect to the elbow, a straightforward conclusion follows that a larger offset will generate a larg-
er moment in the frontal plane, which by and large will cause compression of the medial compartment and
tension in the lateral co-lateral ligament. Muscle forces play a minor role in this balance once the ground is
hit. Looking at local incongruency, typically described as short or long ulna vs. radius, may suggest a wrong
intervention.
If the medial offset of the ground reaction is the cause of the problem, can one better plan for a corrective
osteotomy and what are the choices? It turns out that a number of corrections are possible and most have
actually been used, even if based on wrong arguments. A short, probably incomplete list:
1. Prolongation of the radius by an oblique sliding osteotomy, fixed by a plate – will tend to lateralize the
paw and thus decrease the medial offset of the ground reaction and hence to unload the medial com-
partment (planning?);
2. Oblique proximal osteotomy of the ulna, without fixation – will also tend to lateralize the paw (plan-
ning? execution?) and thus unload the medial compartment;
3. Distal shortening of the ulna – as above, but with lesser impact being closer to the ground (planning?
execution?);
4. Proximal osteotomy of the ulna (recently proposed by Pfeil) fixed by a plate, imposing a shift, an an-
gulation and an incidental rotation on the ulna, adding to lateralization of the paw and thus to unload-
ing of the medial compartment. Planning, currently based on the joint condition, is under evaluation;
5. Sliding osteotomy of the humerus (recently proposed by Schulz), originally based on shifting the action
of the triceps, incidentally results in lateralization of the paw (planning?);
6. Rotational osteotomy of the humerus (recently proposed by Tepic) aims at shifting the paw laterally –
IN-DEPTH SEMINARS
in vitro demonstration has yet to be confirmed by surgery.

KYON NEWS
All of these osteotomies could benefit from better, rational, yet straightforward planning and guided execu-
tion. With so many choices available, it is hard to imagine a comparative study being done in the near fu-
ture, if ever. But collective experience of many surgeons may in due time provide an indication of which of
the treatments is more effective, yet less morbid.
CASE BASED ULTRASOUND-

ARTHROSCOPY CORRELATION
IN-DEPTH SEMINAR
455 • WVOC 2010, Bologna (Italy), 15th - 18th September C.R. & J.L. Cook
Case-based presentation of ultrasonograpy and arthroscopy

Cristi R. Cook, DVM, MS, DACVR & James L. Cook, DVM, PhD, DACVS, DACVSMR
This will be a case-based presentation highlighting the usefulness of ultrasonography and arthroscopy in
small animal orthopaedics, as well as the importance of correlation of data from each to the other and to
case outcomes. As such, there is not a true abstract for this presentation. However, information regarding
the use of ultrasonography in small animal orthopaedics is provided below to help aid in the discussion.
Ultrasound is a widely available diagnostic tool in both human and veterinary medicine. It is becoming a
more commonly used modality in veterinary medicine for musculoskeletal imaging. The musculoskeletal
soft tissues, both intra- and extra-articular, as well as the superficial bone, can be imaged with ultrasound.
The advantages of ultrasound include soft tissue differentiation, capabilities for detailed assessment of the
internal architecture of structures, availability, ability to perform without the need for general anesthesia,
relative ease of follow-up examinations, and cost compared to other advanced imaging modalities. Anoth-
er major advantage of ultrasound is the ability to use it for ultrasound guided aspirations, injections, or
biopsies of musculoskeletal-related fluids or tissues. The major disadvantages of musculoskeletal ultra-
sound are related to the required knowledge of normal and abnormal sonographic characteristics of each
tissue in each joint of interest, and the expertise to interpret the findings of the ultrasonographic examina-
tion. It is relatively difficult to become proficient and develop expertise in musculoskeletal ultrasound. In-
terpretation of the lesions may be complicated by imaging artifacts. Artifacts can be created due to the im-
aging plane, position of the transducer with respect to the structure being imaged, orthopaedic implants
causing distal acoustic shadowing over the area of interest, and by remodeling changes surrounding or
within the tissues of interest. In addition, pathology is often bilateral in the orthopaedic disorders we typi-
cally use ultrasound for, so that the contralateral limb is not a valid reference for normal sonographic ap-
pearance for comparison.
For musculoskeletal imaging, no or light sedation, is typically all that is required for well-controlled patients.
Hair is clipped over the area of interest. The patient is positioned on a padded examination table such that
all aspects of the joint or limb of interest are accessible. A 10-14 MHz linear transducer is used for all small
animal musculoskeletal imaging in our hospital. Relevant anatomic structures are evaluated for sonograph-
ic characteristics, and images and data recorded in the patient’s medical record.
Extra-articular soft tissues (ligaments, tendons, muscles) are the easiest structures to image and assess. The
ligaments, tendons and muscles can be imaged for echogenicity, internal architecture, shape, size and loca-
tion (displacement). In acute injuries, these structures may be thickened due to hemorrhage and edema with-
in or surrounding the tissue, and the fibers may be disrupted. In chronic injuries, the fibers may realign or
ULTRASOUND-ARTHROSCOPY
IN-DEPTH SEMINARS
may heal with less organized fibrous tissue. Dystrophic mineralization within or along the surfaces of these
structures may also be noted. The diameter of the structure may be decreased compared to normal due to
replacement with fibrous tissue and contraction of the tissues as it heals.
Our work in sonographic assessment of extra-articular structures has been focused on the shoulder of dogs.
We are able to consistently image and diagnose pathology in biceps muscle-tendons, supraspinatus muscle-
tendons, infraspinatus muscle-tendons, subscapularis muscle-tendons, and the medial glenohumeral liga-
ment. Sonographic assessment of these structures is very sensitive (86%) and specific (91%) for diagnosis of
shoulder disorders (other than primary ligamentous instabilities) causing lameness in adult dogs. Based on
our clinical studies, we have concluded that sonographic evaluation of soft tissues associated with the shoul-
der joint in dogs is clinically useful for ruling in and ruling out shoulder pathology and localizing the source
of forelimb lameness. We have also used ultrasound clinically for imaging of the common calcanean tendon
complex, gracilis and semitendinosis muscle-tendons, iliopsoas muscle-tendons, triceps muscle-tendons, col-
lateral ligaments of the carpus, stifle, and hock, and digital flexor and extensor tendons.
Our work in sonographic assessment of intra-articular structures has been focused on the stifle joint, and
particularly the menisci. In the stifle joint of dogs, we are consistently able to image and diagnose patholo-
gy in patellar and collateral ligaments, infrapatellar fat pad, synovium, lateral and medial menisci, long dig-
ital extensor tendons and cranial cruciate ligaments. In addition, the presence or absence, location, and
amount of joint fluid is often very helpful for indicating the presence and even type of pathology present in
joints. Our work in meniscus has revolutionized the way we handle stifle cases in our practice. We have re-
ported the ability of meniscal ultrasound to accurately determine presence and type of meniscal pathology
in stifles of dogs, concurrent or subsequent to CCL deficiency and surgical treatment of CCL deficiency,
based on evaluation of meniscal echogenecity, shape, and location (displacement), and the presence of peri-
C.R. & J.L. Cook WVOC 2010, Bologna (Italy), 15th - 18th September • 456
meniscal fluid. We reported a sensitivity and specificity for ultrasonographic diagnosis of meniscal patholo-
gy of 90.0% and 92.9%, respectively, and showed that ultrasonography was better than stifle MRI in our
hands for diagnosis of meniscal pathology associated with CCL deficiency in dogs. We have also assessed
changes in sonographic characteristics of menisci following repair, replacement, release, and various types
of CCL surgeries and correlated these findings with second-look arthroscopy, clinical outcomes, and post-
mortem examinations. Based on all of this work, we have found meniscal ultrasound to be very accurate,
reliable, and precise for assessment of canine menisci in all respects.
In other intra-articular applications, we have also found ultrasound useful for assessing OC/OCD of the
humeral head, medial aspect of the humeral condyle, femoral condyles, and talar ridges, FMCP, and vari-
ous chip fractures. Ultrasound is also very sensitive to changes in superficial bone in or about joints. Early
remodeling changes in bone may be detected with ultrasound prior to visualization with standard radiogra-
phy. Early osteomyelitis or neoplasia may be identified with ultrasound as irregular bone margins or loss of
the normal cortical echo, and a soft tissue mass effect within or adjacent to the cortex with surrounding cor-
tical edema are findings that suggest further diagnostics should be performed to investigate a potentially ma-
jor problem.
In our hospital, ultrasound is an excellent tool for comprehensive assessment of patients. We use it routine-
ly for diagnosis, clinical decision making, treatment monitoring, and prognostication for our orthopaedic
cases. The time it takes to attain expertise in this area is certainly worth it in the long run based on the nu-
merous clinical benefits of musculoskeletal ultrasonography.
ULTRASOUND-ARTHROSCOPY
IN-DEPTH SEMINARS
SURGICAL REVISIONS IN THR

IN-DEPTH SEMINAR
Revision of BFXTM Total Hip Replacement

Porous coated, press-fit, cementless total hip replacement has become the standard of care in human total
joint arthroplasty over the last 20 years due to concerns regarding long-term stability of cemented fixation,
primarily related to aseptic loosening. Recently, a porous coated cementless total hip system, known as the
BFXTM system from Biomedtrix〉, has been designed and introduced for veterinary use.
Over the last several years, considerable experience with this system has been gained, and the implant de-
sign, implantation technique, indications, complications, and revision strategies have been improved and elu-
cidated.
IMPLANT DESIGN
The BFX TM system is composed of a cobalt-chromium stem and titanium cup, each of which is covered with
a porous in-growth surface composed of 200-400 μm titanium beads. The bead size is based on several in-
vestigations in the dog comparing bone in-growth onto several surfaces, which revealed that beads of this
size resulted in the most reliable fixation by osseous tissue, known as osseo-integration. The beads are sin-
tered to the stem and cup in a three layer “stucco” process resulting in considerable porosity to accommo-
date osseous in-growth.
The stem contains a beaded surface in the proximal region that corresponds to the subtrochanteric bone
block region of the femur following implantation, and the cup is beaded on its entire outer surface. The stem
accepts the 14 mm or 17 mm femoral head, with available neck lengths of 0, +3, and +6, and +9 mm.
The cup is a truncated hemi-spherical design similar in shape to the CFXTM cup. This metal backed implant
contains an ultra high molecular weight polyethylene liner insert. Because it relies on a press fit for initial
fixation, it does not contain any screw holes or other areas that allow communication of the joint surface
with the cup backing; this mitigates the likelihood of wear debris migrating to the in-growth surface. The
stem sizes range from #4 – #11, which corresponds to the diameter of the distal tip in millimeters. The cups
range from 22 mm – 32 mm in 2 mm increments.
The 22 mm cup accommodates a 14 mm head, while the other cups utilize a 17 mm head. Since the larger
head diameter results in lesser wear debris generation and a lesser tendency for luxation, the larger cups and
17 mm head are utilized whenever possible.
INDICATIONS

IN-DEPTH SEMINARS
The indications for the BFXTM total hip replacement system are essentially the same as those for the CFXTM
total hip system, namely, coxofemoral osteoarthritis secondary to canine hip dysplasia. Other indications in-
clude irreparable fractures of the acetabulum, femoral head and femoral neck, as well as coxofemoral luxa-
tion complicated by acetabular or femoral head/neck fracture, or other orthopedic disease. Less common in-
dications may include salvage of limb function in cases of acetabular or proximal femoral neoplasia. The de-
cision to utilize cementless fixation is largely surgeon preference, however, some indications may include
very young patients in which longevity of the implants is a priority. Since the metal backed BFXTM cup does
not require complete dorsal coverage with acetabular bone stock, it has distinct advantages over the CFXTM
system in cases with extreme dorsal rim wear or acetabular malformation. A considerable portion of the dor-
sal aspect of the BFXTM cup can remain exposed without sacrificing initial cup stability, as long as the cra-
nial and caudal aspects of the cup are properly covered with bone. In extreme cases of dorsal rim loss, the
medial acetabular wall can be very carefully penetrated to achieve adequate dorsal coverage. This maneu-
ver must be undertaken with extreme caution, as an overly large medial wall penetration will allow the cup
to protrude through the acetabulum into the pelvic canal.
Investigations into the initial stability of cementless femoral components have revealed that both fit, the sim-
ilarity of the stem’s shape and that of the femoral endosteal shape, and canal fill, the percent of the canal di-
ameter occupied by the stem, are important factors. Thus, the fit of the stem is evaluated during preopera-
tive templating. The ideal patient for the BFXTM femoral stem is one in which the femoral canal shape has
an abrupt narrowing beginning at the level of the lesser trochanter, known as a “champagne flute” geome-
try. Patients with a broad straight sided femur, known as a “stove pipe” geometry are prone to subsidence,
which is distal migration of the stem in the early postoperative period. In addition, the properly sized stem
should achieve 80-90% canal fill at the lateral beaded-smooth junction and at the stem tip.
OUTCOME
Outcome following cementless total hip replacement mirrors that of cemented total hip replacement. Osseo-
integration occurs during the first 6-12 weeks postoperatively, and exercise restriction is imperative during
this time. Following this period, clinical and radiographic examination are performed. Typical findings in-
clude normal or near normal limb usage, return of muscle mass, and stable fixation of the implants at the
twelve week examination. Following this, the patient is gradually allowed to return to normal activities over
the ensuing 4 weeks.
COMPLICATIONS
The typical complications following BFXTM total hip replacement occur during the same time frame and
with the same frequency as those of CFXTM total hip replacement. Intraoperative femoral fissure fracture is
a complication that is virtually exclusive to the BFXTM femoral component, and typically occurs if canal
preparation is not on the femoral centerline, or invades the endosteal diameter. If a fissure fracture occurs,
cerclage is applied, and implantation continues. If the cerclage does not adequately control the fissure, a ce-
mented stem is placed.
HYBRIDIZATION
With the advent of the BFXTM total hip replacement system, the surgeon is now equipped with a vast array
of interchangeable components with differing fixation. Since the BFXTM and CFXTM systems utilize com-
mon femoral heads, hybrid fixation utilizing one cemented and one cementless component is possible. This
flexibility allows the surgeon to perform intraoperative or postoperative revision with the other system
should the need arise. This represents perhaps the greatest advantage to the utilization of this universal hip
system.
REVISION
Indications for revision include luxation, significant stem subsidence with or without retroversion and/or
femoral fracture, failure of ingrowth or aseptic loosening and infection.
Cup revision for luxation is generally undertaken shortly after the index procedure. In this case, removal of
the cup is relatively straightforward, as osseointegration has not yet occurred. Firm tapping with a mallet
and punch at the 12 o’clock position generally will rotate the cup out of the prep. If osseointegration or fi-
brous tissue integration prevents easy removal, a thin osteotome can be used to gently undermine the im-
plant bone interface around the cup, allowing removal with the mallet and punch. Once the cup is removed,
the acetabular preparation is reamed deeper for the same size cup, or enlarged to the next size cup, and a
new cup is implanted.
Stem revision prior to osseointegration is generally straightforward, requiring stem extraction, broaching to
the appropriate size, and re-implantation of a new stem. If osseointegration has occurred, the implant-bone
interface can be undermined with a thin osteotome introduced at the implant bone interface at the neck re-
IN-DEPTH SEMINARS
section, to allow stem extraction. Care must be taken to prevent damage to the cortical bone, particularly if
implantation of another cementless stem is planned. If the implant bone interface cannot be adequately un-
dermined, or the stem cannot be extracted, an extended femoral window including the greater trochanter
can be performed, allowing access to the implant bone interface cranial and caudal to the implant. The win-
dow is secured with multiple cerclage wires, and a new cementless or cemented stem is implanted. Addition
of a lateral bone plate extending from the trochanter to the distal femur will improve fixation strength. In
cases of catastrophic fracture, or cortical bone loss during extraction, a cemented stem may offer improved
initial stability.
Revision of the cemented THR

William D Liska, DVM, DACVS
Gulf Coast Veterinary Specialists, Houston, Texas USA
Revision of the cemented THR prosthesis (CFX = cemented fixation) may involve the acetabular compo-
nent, femoral stem, femoral neck length, or any combination when using the BioMedtrix modular implants.
The most common reasons for performing revision surgery of CFX components are prosthesis luxation,
aseptic loosening, infection, and surgeon misjudgement. One-stage revision with direct exchange is preferred
in the absence of infection. Revision may include component repositioning or re-sizing. CFX revision may
be to a cementless THR prosthesis (BFX = biological fixation). If infection is present, the surgeon must de-
cide between a direct-exchange or delayed reconstruction. The ultimate “revision” is explantation and re-
version to what in essence is a femoral head ostectomy.
ACETABULAR CUP REVISION

The acetabular component should be revised intraoperatively during the primary surgery if there is improp-
er cementing technique or component malposition. Proper preoperative patient positioning, use of instrument
positioning guides, and referencing anatomical landmarks minimizes the risk of malpositioned implants and
thus the overall need for revision. One of the most common postoperative indications for acetabular direct-
exchange revision is technical error resulting in luxation from component malposition – either with excessive
(dorsal luxation) or inadequate (ventral luxation) angle of lateral opening. Assuming the femoral component
is properly positioned and stable, the acetabular component can be replaced with either another CFX cup, or
with a BFX component. Removal of the femoral head during the exchange facilitates access to the acetabu-
lar area. Bone stock loss is usually present when aseptic loosening is present. A direct exchange procedure is
relatively straight forward. However, the acetabular bed is typically devoid of cancellous bone for cement in-
trusion for long term implant fixation to maintain stability. When cancellous bone is not present in the ac-
etabular bed, impaction grafting and replacement with a BFX cup may be a better option.
In the presence of sepsis, cup revision is feasible either as a one-stage direct-exchange or delayed revision us-
ing a cementless or CFX component. However, the risk of persistent infection is high with one-stage CFX
revision. The success of revision in the face of infection using the cementless cup may be higher, but little
information is available in the veterinary literature. The risk of persistent infection must be compared to
complication resolution treated with prosthesis explantation.
Repositioning a malpositioned acetabular component by repositioning the pelvic segment via a triple pelvic
osteotomy (TPO) is feasible but has not been as successful as femoral neck lengthening or revision of the
cup position. Following TPO, repeated cranial dorsal luxation, as well as ventral luxation due to over-cor-

IN-DEPTH SEMINARS
rection, has occurred so this option has been abandoned.
FEMORAL STEM REVISION

Revision of the CFX stem due to aseptic loosening, under-sizing, or malposition leading to luxation is per-
formed by either stem extraction followed by cement reaming, or by cement removal through an osteotomy,
and reimplantation with window closure. Cement removal hand instruments (Moreland Cemented Hip Revi-
sion Instrumentation, DePuy Orthopedics, Warsaw, Indiana) (Figure 1) designed for human surgery can be
placed down the medullary canal to aid cement removal.
Another cement removal system uses ultrasonic technolo-
gy to transform ultrasonic energy into mechanical energy.
The system (Ultra Drive 3, Biomet Orthopedics, Warsaw,
Indiana) produces pulsations at a speed of 40,000 cycles
per second at the tool tip that generates heat allowing it to
“glide” into the cement and “grasp” the cement after cool-
ing. Discontinuing the pulsations allows the cement to
quickly cool and harden around the tool tip. Extraction is
accomplished by using a slap hammer-like device to re-
move the cement with the tool tip. This instrumentation
penetrates cement easily. However, extreme caution must
be exercised when using this instrument in small diameter
medullary canals of dogs and cats because contact of the Figure 1 - Hand instruments can be used to enter the medullary
tool tips with canine cortical bone will melt or vaporize canal to remove cement.
Figure 2 - Aseptic loosening (left) and postoperatively after femoral stem direct ex- Figure 3 - An aseptically loose femoral stem (left) 5
change revision (center). Even though the implant was stable, recurrent aseptic loos- years after surgery was revised using a BFX stem
ening recurred long term (7 years) with loose femoral and acetabular components, with grafting (right). It is not necessary to remove all
osteolysis, and exostosis. of the cement distal to the tip of the BFX stem.
bone similar to cement. This complication may be more avoidable in human cases with larger medullary canals
and tactile and audible sense emitted when cortical bone is contacted. Regardless of the technique used, revision
of the CFX prosthesis with another CFX prosthesis can be successful, but it is some times disappointing long
term. The severity of the pre-existing pathology requiring the revision may influence the prognosis, but other fac-
tors such as wear debris and the associated inflammatory response also play a role in the outcome (Figure 2). Re-
vision of an aseptically loose CFX to a BFX stem in combination with impaction grafting provides a stable im-
plant with excellent long term stability (Figure 3). Revision of a BFX to a CFX stem is also possible due to the
modularity and interchangeability of the BioMedtrix system. BFX to CFX revision indications include compli-
cations such as subsidence (Figure 4) or femur fracture (Figure 5). Multiple revision options such are these are
valuable tools for the THR surgeon when complications arise. Infected femoral stem revision, like acetabular cup
revision, is also feasible using either CFX or BFX components. A single direct-exchange revision using anoth-
er CFX prosthesis must be preceded by organism identification, antibiotic sensitivity, speculated virulence
of the causative organism obtained from periprosthesis tissue, and efficacious antibiotic therapy preopera-
tively. Revision using another CFX prosthesis via direct-exchange has limited indications, requires antibiot-
ic impregnated cement, and may require the use of systemic antibiotics indefinitely. As with septic cup revi-
sion, the high risk of persistent infection using another CFX stem is discouraging. Revision using a ce-
mentless component may improve success, but little information is available in the veterinary literature.
IN-DEPTH SEMINARS
Figure 4 - Subsidence of the BFX femoral stem should Figure 5 - Following implantation of a BFX femoral stem (left), a femur frac-
be a rare event, but can occur with poor preoperative plan- ture (center) occurred during a stormy recovery from anesthesia. An open reduc-
ning. Revision to a CFX stem with a collar prohibits sub- tion internal fixation was performed and a CFX stem was implanted (right).
sidence of the stable well fixed stem. Full cerclage wires
were used only as a precaution to prevent propagation of
possible invisible fissures created during stem extraction.
FEMORAL NECK LENGTH REVISION

Prosthesis luxation due to joint laxity with well-positioned components can be revised by extending the
femoral neck length. Inadequate neck length can be the result of surgeon misjudgment. However, more fre-
quently laxity results when severe preoperative subluxation is present which makes intraoperative rearticu-
lation of the prosthesis difficult. Within several weeks, joint laxity leading to luxation can develop as the pre-
and intra-operative muscle contracture resolves. The femoral neck is easily lengthened with the modular sys-
tem by removing the head and using longer neck lengths until
the rearticulation is tight. In this scenario, assuming proper im-
plant positioning, extending the femoral neck length by ex-
changing the femoral head is highly successful.
EXPLANTATION
The ultimate revision is prosthesis explantation and reversion
to a femoral head and neck ostectomy. With the cemented
prosthesis, the acetabular component is typically visibly loose
in the presence of prolonged aseptic loosening or infection. An
osteotome aids in opening the bone-cement interface. Removal
is accomplished by levering the implant around its perimeter
with the osteotome (or other instrument), or by cutting the cup
and cement into several pieces. Removal of the femoral stem
with all of the cement usually necessitates a cranial and caudal
beveled tapered extended trochanteric osteotomy to a point be- Figure 6 - The cement mantle can be removed through
yond the tip of the cement mantle. the proximal femur if severe aseptic loosening is present
The osteotomized bone segment is replaced and secured with (left). Full cerclage wires are used to maintain reduction
cerclage wires 1-2 cm apart (Figure 6). If no sepsis is present, re- of the cortical window (right) if the medullary canal is
moval of the cement is optional. opened.

IN-DEPTH SEMINARS
Revisions of Kyon THR

Aldo Vezzoni, Med.Vet, S.C.M.P.A., Dipl. ECVS
The Kyon Hip Prosthesis, also known as the “Zurich Cementless total hip replacement (THR)”, was first ce-
mentless THR prosthesis introduced to the veterinary market 12 years ago. In this system, immediate fixa-
tion of the cup is provided by a press-fit insertion, and long-term stability is achieved by bone in-growth
through the holes in the cup surface. Locking screws are used for immediate fixation of the stem, and in-
growth of bone along the rough titanium surface of the implant provides long-term stability. The Kyon cup
is made of pure titanium and the Kyon stem, head and neck unit and screws are composed of titanium alloy.
Of 753 Zurich cementless THR operations carried out at our clinic from 2001 to 2009, complications (one
or more) occurred in 79 (10.5%) cases. Of these, 72 were successfully revised and 7 (0.9%) required explan-
tation of the prosthesis. The type and incidence of complications associated with THR are time related; lux-
ation, fracture and early cup loosening usually occur within six months of surgery (short term), whereas oth-
er complications including stem loosening, late cup loosening and implant breakage occur later on (long
term). The likelihood of encountering long-term complications increases with time. Thus, long-term compli-
cations are more likely to be seen in cases that are followed for extended periods of time. In the present study,
which spanned eight years, more complications were seen in cases that were followed for long periods of time
than in recent cases. Although the surgeon endeavours to keep complications to a minimum, a major advan-
tage of this surgical technique is the feasibility of successful surgical revision if complications occur.
SHORT-TERM REVISIONS
Luxation: Luxation of the prosthesis is the most common complication in all types of hip prostheses. In our
study, luxation was the single most frequent complication (41.8% of all complications) with an incidence of
4.4% (33 cases). Some luxations occurred in the first few weeks after surgery, but they always occurred be-
fore the end of the 7th week postoperatively. After this time, healing of the joint capsule and periarticular tis-
sues prevented this complication. Surgical revision usually required increasing the neck length by one size to
provide a stable reduction. When poor cup orientation was the cause, the cup was removed and re-implant-
ed in the correct position. A bigger cup was sometimes required to achieve a proper press fit. The possibility
of luxation should always be considered when choosing the size of head and neck, and the shortest neck that
provides stability should be used so that it can be replaced with a longer neck should luxation occur. Os-
teotomy of the femoral neck must be adjusted to accommodate a short prosthetic neck. The same principle
applies to the prosthetic cup: the smallest cup (≥ 23.5 mm) that provides a good press fit should be used, pro-
vided that healthy cancellous bone is contacted for bone in-growth, and the size corresponds to the body
IN-DEPTH SEMINARS
weight of the patient. This allows the opportunity for re-implantation of a larger cup should revision be nec-
essary. This course of action is also useful when revision is required for other reasons because once the joint
is re-opened, a longer neck is usually required to obtain sufficient stability. In giant breeds, the 29.5-mm or
the 32.5-mm cup with the polyethylene insert for a 19-mm head should be used to provide a more stable re-
Figure 1 - An 8-year-old, 48-kg, Italian Cane Corso with a femoral fracture 7 days after THR surgery; Reduction with cerclage wires and
fixation with a neutralization plate (Synthes broad 3.5 LCP); Bone healing at 4 months postoperatively.
duction. The 19-mm head resists luxation

better than the regular 16-mm head be-
cause of its larger diameter. In the majori-
ty of cases (31 of 33), reduction of the lux-
ation was effective and permanent. In 3
cases, recurrence of the luxation and re-
peated revisions led to septic cup loosening
and explantation of the implants.
Femoral fracture: This complication oc-

curred in 9 (1.2%) cases during the first
two weeks after surgery. In 7 cases, surgi-
cal repair of the fracture with a plate was
successful. In one patient, a very obese
Newfoundland dog, it was necessary to
explant the prosthesis because of bone
weakness and stem instability, and in an- Figure 2 - A preventive buttress plate was used in this 9-year-old, 43-kg, Ger-
other dog, the fracture healed but the stem man shepherd dog to prevent postoperative fracture.
become loose and was explanted. The
fractures were repaired with cerclage wires and neutralization plates with locking screws. Monocortical
screws were mainly used in the proximal femur to avoid interference with the stem.
Risk factors for femoral fracture appeared to be excessive weight of the patient in association with severe
chronic osteoarthritis (OA), and advanced age in association with severe OA. We have used the ALPS tita-
nium buttress plate with locking monocortical screws since June 2007, when it first became available, to pre-
vent femoral fracture by distributing the loading forces over a wider area. The plate is S-shaped and twists
proximally behind the stem and distally over the lateral aspect of the femur. In 52 high-risk cases in which
we applied the preventive buttress plate, femoral fracture or other complications associated with the plate
were not encountered. To date we have applied the preventive plate in 310 cases and have experienced on-
ly two (0.6%) fractures; one occurred in a 10-year-old female Labrador retriever and the other in an 8-year-
old German shepherd dog.
Early cup loosening: Lack of bone in-growth or infection with loosening of the cup occurred in 8 (1.1%) cases.
In 3 cases, cup loosening was aseptic based on the results of culture of the fibrous membrane behind the
cup. The cause was thought to be lack of bone in-growth during the first 2 to 3 months postoperatively and
premature limb loading in the very active young dogs. All 3 cases were successfully revised by implanting a
larger cup. In the remaining 5 cases, culture revealed low-grade infection. Septic loosening of the cup was
related to previous revision(s) for other reasons (recurrent luxation) and to subsequent infection with Staphy-

IN-DEPTH SEMINARS
lococcus intermedius in 3 cases. In 1 other, it was related to stem loosening and Leishmania infection, and in the
last case it was because of preoperative infection with Serratia marcescens. Four of the 5 cases were explanted
(Staphylococcus and Leishmania infection) and the case with Serratia marcescens was successfully revised with pe-
riarticular curettage, acetabular reaming to provide space for a cup that was one size larger, multiple os-
teostixis and implantation of a special revision cup. The latter is a special disassembled cup in which the out-
er shell is predrilled with several holes for 2.4-mm titanium screws with flat head, which increase the im-
mediate stability of the cup when the acetabular bone is in poor condition. The inner component (inner ti-
tanium shell and polyethylene liner) is then inserted inside the outer shell using the impactor and hammer
to achieve a full press fit. The gap between the outer and the inner shell is about 1 mm, which means that
the screw flat heads must be well seated to avoid impingement. Because the acetabulum has a deep location,
the holes are drilled using a 1.5-mm Kirschner wire, which allows some bending so that the screws are as
Figure 3 - Revision cup with disassembled

components and outer shell perforations for
multiple screw fixation.
perpendicular to the holes as possible and the screw heads are well centred and seated. The use of a drill bit
would risk its breakage. Before suturing the joint capsule, a gentamicin-impregnated equine collagen sponge
was inserted into the joint space to provide slow-release local antibiosis.
Risk factors for early cup loosening were related to premature weight bearing, particularly in young active
dogs, and to infection associated with multiple revisions. Leishmania infection can result in implant loosen-
ing and should be ruled out before surgery. In our patient with this infection, the preoperative ELISA test
was negative but a test one month later was positive.
LONG-TERM REVISIONS
Late cup loosening: 17 patients (2.3%) developed late cup loosening. In 5 cases, the loosening was aseptic and
occurred 2 to 4 years postoperatively, for unknown reason. In 2 more cases (26.5-mm cup and 29.5-mm
cup), in which the cups appeared well integrated at previous follow-ups, the onset of cup loosening was as-
sociated with a known trauma, after which lameness started. These 7 cases were revised successfully with
new cups, which were one size larger. In a further 7 cases (all 21.5-mm cups), cup loosening was caused by
wear of the polyethylene liner, with excessive production of polyethylene particles, macrophage and osteo-
clast activation and bone resorption. When the liner was completely worn out, the friction created by the
head rubbing against the titanium of the cup produced titanium debris which increased bone resorption
around the cup. In the 21.5-mm cup, the polyethylene liner has a thickness of about 1 mm and in young
and active dogs this thin liner may be worn out in a few years. All cases of aseptic late cup loosening were
successfully revised using 23.5-mm cups. From this experience, we learned that the 21.5-mm cup should not
be used in young dogs because of their high activity level, or in dogs weighing more than 20 kg. When un-
dertaking THR in growing dogs, in which a 21.5-mm cup appears appropriate for the size of the acetabu-
lum, one must consider the residual growth of that dog and implant a larger cup that corresponds to the
adult size of the dog. Newly designed double shell cups with an inner titanium cup supporting the polyeth-
ylene liner came on the market in early 2010. This supporting cup prevents liner deformation, which oc-
curred toward the gap between the outer titanium shell and the liner, particularly in the 21.5-mm cup in
which the liner thickness was limited to 1 mm.
In the remaining 3 cases, loosening was septic and occurred 10 months to 2 years postoperatively because of
low-grade infection, which may have occurred haematogenously. One case was a German shepherd dog that
had a sudden onset of fever and lameness 10 months postoperatively. Haematogenous infection was suspect-
ed, even if the culture was negative, and loosening of the cup developed slowly in the following months; ex-
plantation was required because septic loosening involved the stem as well. In the other 2 cases of septic cup
loosening, without stem involvement, revision with a bigger cup and antibiotic treatment were successful. Lo-
cal antibiosis was provided by a collagen sponge impregnated with slow-release gentamicin, and systemic an-
tibiotics were administered for 3 to 6 months based on culture and sensitivity results (Streptococcus epidermidis).
Cup breakage: In 7 (0.9%) cases, the cup broke 2 to 5 years postoperatively. The 23.5-mm cup broke in 3 cas-
IN-DEPTH SEMINARS
es and the 21.5-mm cup in 4. After the 23.5-mm cup failures, the manufacturer modified the design of this
size cup to increase the strength by reducing the number of holes in the shell. The 21.5-mm cups failed be-
cause of excessive loading in our patients, which were very active young dogs (Border collies). All these cas-
es were successfully revised with new larger cups. Based on these results, we discontinued using the 21.5-
mm cups in young and active dogs until the new double shell cup became available.
Stem loosening: Long term loosening of the stem was seen in 6 (0.8%) cases; 4 had aseptic loosening and 2
had septic loosening. Aseptic loosening was associated with excessive stem loading in 2 dogs that were over-
ly active in the early postoperative period. In another case of aseptic loosening, the stem size used was too
small in relation to body size, and in the remaining dog, an extra-long head and neck unit was used. These
4 cases were successfully revised by using a bigger stem. The 2 cases of septic stem loosening had septic cup
loosening as well, with positive culture for Staphylococcus intermedius, and were explanted. To remove the loose
stem, access holes were created in the lateral cortex using a high-speed burr and a trial stem as a template
to locate the screws. The screws were unscrewed using a sharp screwdriver, which was well seated inside
the hexagonal recess of the screw. When cold metal welding of the screw had occurred (one or more screws
in 3 cases), which prevented screw removal because of stripped hexagonal ribs, the screw was destroyed by
over-drilling using an HSS drill bit. Attempts to remove stripped screws by hammering from a medial ap-
proach after cutting the bone all around the tip of the screw may result in femoral fracture. For the bicorti-
cal screws with stripped hexagonal recesses, special tools for removal of broken screws were required. The
new stem was inserted after canal preparation. It was fixed slightly proximal to the previous one (to avoid
the need for a longer head/neck unit) and with a slightly different anteversion to avoid the old screw holes.
Figure 4 - A 6-year-old, 21-kg, Border collie with breakage of the extra-small stem 2.5 years after surgery; Bone window on the lateral
side; Implantation of a regular small stem and protection of the femoral window with a buttress plate (locking ALPS); The radiograph on the
far right was taken at follow-up 4 months postoperatively.
Stem breakage: In 7 cases, the stem broke 15 months to 5 years after implantation. In all these cases, the im-
planted stem was too small in relation to body size (4 extra-small stems and 3 small stems). We did not en-
counter this complication with medium and large stem sizes. All cases of stem breakage were successfully re-
vised by implanting a larger stem. To remove the distal part of the broken stem, a lateral window in the femur
was created and its repair was then protected by an advanced locking plate system (ALPS) plate. The ALPS
plate was ideal for this purpose because of its metal compatibility (titanium), its versatility (it can be bent in the
two planes) and its stiff fixation with monocortical locking screws. The plate was bent in an S shape before fix-
ing it proximally on the caudolateral side of the femur to avoid the stem and distally on the lateral side.
Infection: Infection occurred in 8 (1.1%) cases, 5 with cup loosening alone and 3 with cup and stem loosening.
The 3 cases in which both components were loose, and 2 other cases with cup loosening were explanted, and
the remaining 3 cases of septic cup loosening were successfully revised. Staphylococcus intermedius (4 cases) and
Leishmania (1 case) were isolated in the 5 explanted cases. Streptococcus epidermidis and Serratia marcescens were iso-
lated in the revised 3 cases.
GENERAL STRATEGIES IN THR SURGICAL REVISIONS

IN-DEPTH SEMINARS
It must be remembered that the risk of infection increases with each revision because of interference with
vascularisation. Asepsis and antisepsis are therefore critical. Gentamicin-impregnated equine collagen
sponges are a useful tool for providing a slow release of local antibiotics for several days. We leave the
sponge inside the joint capsule before closure in every revision. Each revision may require a longer neck to
achieve a stable reduction, but longer necks apply more stress on the stem. Therefore, the use of long necks
in primary surgeries should be avoided. Protection of the weakened femur after stem revision is required to
avoid the risk of post-revision femoral fracture. High-speed burrs and tools for removing broken screws
should be available for THR revision surgery.
CONCLUSIONS
Complications in THR can be frustrating and lead to failure and explantation of the prosthesis. Minimizing com-
plications is a major concern. With good technique, it should be possible to keep the complication rate at less than
10% and the failure rate at less than 1%, which would render the surgical procedure reliable and acceptable. In
our experience, the most interesting aspect of the Kyon system was the high rate of successful revisions in cases
with complications. Understanding the risk factors for complications will help in further reduction of their inci-
dence by using appropriate preventive measures and improving both the implants and the surgical technique.
REFERENCES
Tepic S, Montavon PM. Concepts of Zurich Cementless Prosthesis. E.S.V.O.T. September 2004, Munich.
Hanson SP, Peck JN, Berry CR, Graham J, Stevens G. Radiographic evaluation of the Zurich cementless total hip ac-
etabular component. Vet Surg. 2006 Aug;35(6):550-8.
Guerrero TG, Montavon PM. Zurich cementless total hip replacement: retrospective evaluation of 2nd generation im-
plants in 60 dogs. Vet Surg. 2009 Jan; 38(1):70-80.
ARTHREX NEWS
IN-DEPTH SEMINAR
2.8mm FasTak with #2 Fiberwire 5mm Corkscrew with #5 Fiberwire
4.75 SwiveLock with 2mm FiberTape TightRope with 2mm FiberTape

Arthrex swivel lock suture anchor for CrCL

and MCL repair
Brian S. Beale1, DVM, Dipl. ACVS; Don Hulse2, DVM, Dipl. ACVS
1
Gulf Coast Veterinary Specialists, Houston, TX - 2 Capital Area Veterinary Specialists, Austin, TX
The Swivel Lock anchor is a PEEK implant made by Arthrex Vet Systems that provides knotless fixation
of a prosthetic ligament or soft tissue to bone. The device has a removable aperture at the end of the im-
plant that can be used to capture the suture and position it in a bone tunnel at the desired site. A cannulat-
ed PEEK interference screw is screwed into the bone tunnel, tightly securing the suture. The ends of the su-
ture are cut flush with the bone. No knot tying is required. The Swivel Lock suture anchor is used to attach
FiberWire or FiberTape to bone. This anchor can be used effectively for extracapsular reconstruction of the
CrCL in the stifle or the MCL in various joints of dogs.
CRANIAL CRUCIATE LIGAMENT REPAIR

Extra-articular suture placement for stabilization of
the CCL deficient stifle joint has been an accepted
method of treatment for many years. Recently, im-
provement in attachment site location for suture
placement coupled with superior suture materials
and suture fixation methods have improved out-
come. Suture anchors preloaded with Arthrex Fiber-
Wire and the TightRope coupled with 2mm Fiber-
Tape have been successfully applied over the past 3
years. Choice of system is based upon size and ac-
tivity level of the dog and surgeon preference. Suture
anchors preloaded with #2 or #5 FiberWire are re-
served for small and medium size dogs and cats (up
to 35 – 40 lbs). Beyond this weight, two strand or
four strand 2mm FiberTape is suggested. Two strand
or four strand FiberTape can be effectively applied
with the Arthrex Tight Rope system.
Another method of applying 2 mm FiberTape is with
a knotless Arthrex system used for rotator cuff repair
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in man referred to as the Swivel Lock method. Two
strands stands of 2mm FiberTape in dogs 40 – 60 lbs
ARTHREX NEWS
or four strands of FiberTape are recommended in
dogs over 60 lbs. The Swivel Lock is a knotless sys-
tem based on a PEEK interference screw fixation of The Arthrex Swivel Lock Anchor can be used to attach FiberTape
the FiberTape. Femoral and tibial sites for the Swiv- suture material to bone in a predrilled bone tunnel using a knotless
el Lock Repair technique for stabilization of the Cr- PEEK suture anchor.
CL deficient stifle are identical to that used for the
Corkscrew Anchor or Tightrope systems. The
femoral site (F2) is located caudally in the lateral femoral condyle at the level of the distal pole of the fabel-
la; the tibial site (T3) is located at the bony protuberance just caudal to the sulcus of the long digital exten-
sor groove. The tibial site is prepared first.
Two Strand Application: First locate the protuberances cranial and caudal to the long digital extensor
groove. Make a vertical incision through the capsular tissue overlying the extensor groove. Palpate and lo-
cate the protuberance just caudal to the extensor groove; this is the site for placement of the tibial drill hole.
At this site beginning as proximal as is possible without entering the joint, insert a .045 k-wire. The K-wire
is directed to glide beneath the extensor groove to exit through the medial cortex of the proximal tibia. With
the K-wire in place, place a 2.5mm cannulated drill bit over the wire to create the drill hole. Drill over the
K-wire to exit through the medial cortex. Leave the drill bit in place and remove the K-wire. Through the
cannulated hole in the drill bit, place a nytinol Arthrex suture passer such that the loop is medial. Remove
the drill bit and leave the suture passer in the drill hole.
Load the 2mm FiberTape onto a 2-hole Arthrex SS button. Place the free ends of the FiberTape through the
loop of the Nytinol suture passer and pull the ends from medial to lateral exiting the drill hole laterally at
the T3 site. Pull the FiberTape taught so the SS button lies snug against the medial cortex.
Pre-drill a hole at the F2 site using the appropriate size drill bit (3.2, 3.5); load the Fibertape into the eyelet
and pull the FiberTape through the eyelet until the slack in the FiberTape equals the depth of the drill hole.
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Push the eyelet with loaded FiberTape into the drill hole until the eyelet contacts the bone at the depth of
ARTHREX NEWS
the drill hole. Check the stability and if appropriate (2-4mm translation) tap the interference screw into the
drill hole. Cut suture flush with interference screw.
The FiberTape is cut flush with the bone once

the PEEK anchor is delivered into the bone
tunnel, tightly securing the FiberTape at the
F2 attachment site of the femur.
Drill a hole with an appropriate drill bit Slack is left in the suture during insertion into the
at the F2 site bone tunnel equal to the depth of drill hole
Four Strand Application: Use identical femoral (F2) and Tibial (T3) sites. The tibial drill hole is made with
a 2.7mm drill bit. Use a 4-hole SS button medially loaded with two strands of FiberTape. This creates 4 free
ends exiting T3. Pull all 4 free ends through the femoral bone tunnel in a lateral to medial direction using
a nytinol passing wire. The aperture of the Swivel Lock is not used. Apply desired tension to the 4 strands
of FiberTape using manual tensioning or the Arthrex tensioning device. Insert the interference screw as be-
fore trapping the 4 strands of FiberTape in the F2 drill hole. Cut these strands flush to the bone.
MEDIAL COLLATERAL LIGAMENT REPAIR

The Swivel Lock or Push Lock anchor can be used to reconstruct the MCL of the stifle or collateral liga-
ments of other joints including the shoulder, elbow, carpus and tarsus. The Push Lock anchor is introduced
into the bone tunnel by impaction rather than screwing into place. One end of the FiberWire or FiberTape
is attached to bone using a suture anchor or suture button. The suture is tightened to the desired tension
and securely fastened into a bone tunnel using a Peek Swivel Lock or Push Lock anchor, reconstructing the
collateral ligament.
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ARTHREX NEWS
Use of ACP in dogs

Autogenous Conditioned Plasma (ACP) (Arthrex, Naples, FL USA) is one of the platelet-based therapies
for musculoskeletal disorders in use currently. The platelet-based therapies are based on the principles of
growth factor supplementation, chemotaxis, and function as a tissue scaffold. Several studies have shown
efficacy of these treatments for several musculoskeletal disorders in humans and they are being used with
increased frequency for augmentation of tendon and ligament healing, and adjunctive therapy for epi-
condylitis, fasciitis, tendinosis, and osteoarthritis. Anecdotal evidence in veterinary medicine has been re-
ported for use in similar conditions.
We are currently performing two studies to evaluate the efficacy of ACP for treatment of osteoarthritis sec-
ondary to elbow dysplasia in dogs and augmentation of healing and amelioration of inflammation after sur-
gery for cruciate ligament disease in dogs. These are prospective, randomized, blinded, controlled studies.
This presentation with cover the background and mechanisms of action with respect to use of platelet-based
therapies in orthopaedics and show anecdotal information regarding its use in our practice for select cases,
as well as cover preliminary results from our research.
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ARTHREX NEWS
Canine Unicompartmental Elbow (CUE)

arthroplasty in dogs
James L. Cook, DVM, PhD, DACVS, DACVSMR, Kurt Schulz, DVM, MS, DACVS, Josh Karnes
Burlington Veterinary Specialists, Williston, VT USA
Arthrex, Naples, FL USA
Osteoarthritis of the canine elbow is a common problem for which there are many treatment options. Un-
fortunately, none of these current therapeutic options are consistently successful in returning patients to full
function and retarding the progression of disease in affected elbows. Based on the perception that the ma-
jority dogs with symptomatic elbow disease are primarily affected on the medial aspect of the humeral
condyle and medial coronoid process, the term Medial Compartment Disease (MCD) has gained popularity and
efforts toward treating this cohort of patients are a focus for veterinary surgeons. As such, the authors have
worked together in conjunction with Arthrex Vet Systems to attempt to develop a safe and effective method
for surgical treatment of MCD in dogs.
The Canine Unicompartmental Elbow (CUE) arthroplasty system has undergone initial design and proto-
type generation, cadaveric testing, imaging assessment, and revision and repetition of all of these steps
through several generations of implants and instrumentation to derive a system for initial in vivo testing.
When all ex vivo testing was complete, a limited clinical trial was initiated.
This study falls within the guidelines of the University of Missouri’s Animal Care and Use Committee with
respect to privately-owned canine patients. Fully informed consent was obtained and documented in the
medical record for each patient. Clients did receive a financial incentive for enrollment of their dogs in the
study in terms of reduced costs for the procedure and follow-up appointments. Dogs were included when
the client agreed to the conditions of the study, had documented (arthroscopic and/or radiographic) evidence
of MCD of one or both elbows, were between 20 and 40 kg, and were considered amenable to postopera-
tive restrictions and rehabilitation. Dogs with metabolic disorders, other symptomatic orthopaedic disorders,
and/or diseases of one or both elbows other than MCD were excluded. Examination of each dog including
assessment of lameness, pain, range of motion, and radiographic appearance of the elbow joints was per-
formed prior to enrollment.
Three dogs meeting the inclusion criteria were enrolled for initial study. The CUE implants were success-
fully placed in one elbow of each dog via medial approach with tenotomy, desmotomy, and arthrotomy. One
intraoperative complication was encountered with respect to initial placement of the humeral component ne-
cessitating autogenous cancellous bone grafting and replacement of the prosthesis in a more cranial location.
Postoperative radiographs showed appropriate implant placement and alignment in all 3 dogs. Soft-padded
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bandages were maintained on the limbs for 1 week following surgery and the patients were hospitalized dur-
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ing this time for initial monitoring and care including NSAIDs, analgesics, and cage rest. Patients were dis-
charged ~1 week after surgery and clients were instructed to restrict their dogs to short leash walks or cage
rest only for 6 weeks after surgery. Passive range of motion exercises were demonstrated to the clients and
they were instructed to perform them on the operated limb 2-3 times daily.
A recheck examination was performed on each dog 6-8 weeks after surgery and included assessment of
lameness, pain, range of motion, and radiographic appearance of the elbow joint. A recheck examination in-
cluding the same outcome measures was performed ~6 months postoperatively. No major or minor post-
operative complications were noted or reported by the owners for any of the three dogs. Subjective assess-
ment of lameness showed improvement in all patients. Patient 1 went from a preoperative lameness grade
of 4 (5 pt scale) to 3 at recheck 1 to 2 at recheck 2. Patient 2 went from a preoperative lameness grade of 4
(5 pt scale) to 2 at recheck 1 to 1 at recheck 2. Patient 3 went from a preoperative lameness grade of 3 (5 pt
scale) to 1 at recheck 1 to 0 at recheck 2. Range of motion improved with elbow flexion maintained at more
than 90o after CUE in all dogs. Radiographic assessments revealed no evidence of implant displacement,
subsidence, or loosening in any dog at either time point.
These data provide initial evidence for the safety and efficacy of the Arthrex Canine Unicompartmental El-
bow arthroplasty system and justify further clinical study which is ongoing.
Disclosure: JLC and KS are patent-holders for the Arthrex CUE and will receive royalties associated with
CUE sales. JK is an Arthrex employee.
Isometric suture placement for stabilization of the CCL

deficient stifle
Don Hulse DVM, Dip ACVS, ECVS
Capital Area Veterinary Specialists, Austin, TX
Complete or partial rupture of the cranial cruciate ligament (CCL) is a common injury of the canine stifle.
Injury of the CCL allows cranial translation of the tibia resulting in stifle instability and hind limb lameness.
It has been demonstrated that dogs with CCL deficient stifles cannot prevent cranial translation of the tib-
ia either by altering hind limb gait or muscle forces across the stifle. As such, conservative treatment of CCL
injury is generally unsuccessful leading to surgical stabilization as the preferred method of treatment. Nu-
merous surgical techniques have been developed including placement of intra-articular grafts, insertion of
suture material and/or advancement of periarticular structures outside the joint (extracapsular), and tibial
osteotomies that alter joint mechanics. Although hind limb function and lameness can be improved with sur-
gical intervention, to date, no one technique has been proven to be superior. Procedures that require place-
ment of extracapsular sutures are technically less demanding than intra-articular or mechanic altering tech-
niques and remain popular with veterinary surgeons and veterinary practitioners. The optimal extra-articu-
lar suture would be one which eliminated abnormal craniocaudal translation and was placed such that the
distance between the two points of attachment (femur and tibia) did not change through flexion and exten-
sion (isometric placement). Femoral and tibial sites commonly used for suture placement have increased su-
ture tension through flexion. The method discussed here includes placement of an isometric prosthetic lig-
ament. Isometric placement of sutures. new suture materials, and new suture anchors have become avail-
able to increase the chance of success and simplify the surgical technique.
Prosthetic ligament placement:

The prosthetic ligament must be
placed as isometrically as possible.
Isometric positioning maintains sim-
ilar tension on the ligament through-
out the range of motion, decreases
the chance of stretching or break-
ing the ligament, and allows more
normal stifle movement. The color
graph below shows change in dis-
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tance between attachment points

ARTHREX NEWS
on the femur and tibia for different

paired femoral/tibial sites. The bone
model shows the location of attach-
ment points on the femur and tibia. Clinically the author recommends placement of the suture at the F2-T3
paired site.
Locating the F2 site: The F2 site is located at the level of the distal pole
of the fabella. Placement of the anchor is critical. The anchor must be
placed in the femoral condyle as far distal and as far caudal as is possi-
ble. An anchor placed to far proximal or anterior is at risk for pull out
or suture failure. To locate the correct placement site in the femoral
condyle, palpate the distal pole of the fabella. Make a vertical incision
through the capsular tissue to expose the joint line between the fabella
and caudal margin of the femur. Locate the proper position for the an-
chor just distal to the fabella-femoral jont line and as far caudal as pos-
sible. A hole is pre-drilled at the correct anchor position; the size of hole
is dependent upon the implant being used (FasTak, Corkscrew, SwivaL-
ock, TightRope). The drill hole is directed lateral to medial toward the
patella to eliminate the risk of penetrating the articular surface.
2.8mm FasTak with #2 Fiberwire 5mm Corkscrew with #5 Fiberwire
4.75 SwiveLock with 2mm FiberTape TightRope with 2mm FiberTape
Locate the T3 site at the proximal tibia. First locate the protuber-
ances cranial and caudal to the long digital extensor groove. Make a
vertical incision through the capsular tissue overlying the extensor
groove. Palpate and locate the protuberance just caudal to the extensor
groove; this is the site for placement of the drill hole. The size of drill
hole is dependent upon the implant being used. FasTak 1.5mm,
Corkscrew 2mm, SwivaLock 2.5mm, TightRope 2.7mm) At this site
beginning as proximal as is possible without entering the joint, insert a
guide k-wire. The K-wire is directed to glide beneath the extensor
groove to exit through the medial cortex of the proximal tibia. With the
K-wire in place, place the appropriate cannulated drill bit over the wire
to create the drill hole. Drill over the K-wire to exit through the medi-
al cortex. Leave the drill bit in place and remove the K-wire. Through
the cannulated hole in the drill bit, place a nytinol Arthrex suture passer to facilitate passing the suture. The
suture is anchored against the medial cortex of the tibia with a SS button. Position the limb in normal stand-
ing position (140 degrees). Place the initial double throw of a surgeons knot and check cranial drawer. Do
not over constrain; there should be 2-3mm cranial translation. When satisfied with stability, complete the
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surgeons knot and place 4 additional half throws. Check range of motion and cranial drawer.
ARTHREX NEWS
Clinical update on meniscal repair

BACKGROUND
Meniscal damage is a common sequela to cranial cruciate ligament (CrCL) insufficiency in dogs. Meniscal
injuries are thought to occur due to the inherent instability of the CrCL-deficient stifle. Meniscal lesions have
been categorized into five types based on appearance of the tear. These are radial, vertical longitudinal, hor-
izontal, flap and complex. Variations of each of these tears are common in dogs. The bucket handle is a ver-
tical longitudinal tear with axial displacement of the torn portion of the meniscus.
Considering that our ultimate goal is to alleviate stifle pain while preserving meniscal function, an effort
should be made to preserve or repair tears that do not impair normal stifle contact mechanics. The results
of a recent ex-vivo study suggest that radial and vertical longitudinal meniscal tears could be theoretically
treated with conservative approach or repair, because they have little effect on stifle contact mechanics. We
suspect that these two lesions maintained normal contact mechanics because of their location, the small de-
gree of disruption of the circumferential collagen bundles and the minimal displacement of the torn menis-
cal tissue. It could be argued that longitudinal tears would not need to be repaired.
However, biomechanical testing in human knees has demonstrated that as the stifle flexes and extends, the
axial portion of a vertical longitudinal tear will displace cranially, putting the axial portion of the tear in dan-
ger of becoming crushed between the femoral condyles and the tibia. The continued motion and crushing
of the meniscal tissue may cause progression of a simple tear such as a vertical longitudinal or bucket han-
dle to a complex tear due the chronic femorotibial subluxation. Therefore, consideration should be given to
performing a meniscal repair in order to prevent the progression from a benign tear to a more severe tear
with respect to contact mechanics. Further testing is required to determine the character of progression of
meniscal tears.
PRELIMINARY CLINICAL RESULTS

The results of the clinical cases performed by a group of surgeons (A. Pozzi, J. Cook, C. Devitt, W. Whyt-
ney, GL Rovesti, M. Bauer) is summarized:
# cases 24
Open or arthroscopy 23 scope, 1 open
Medial or Lateral 7 lateral, 17 medial
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Type of tear 11 longitudinal, 4 bucket handle, cr. horn avulsion, menisco-femoral,

complex
CCL status 18 CCLR, 1 isolated, 1 postliminary
Type of repair 7 vertical, 10 horizontal, 4 cruciate
Suture material 2-0 Fiberwire, PDS, Nylon, Byosin, Prolene
Failures 9 (suture pull-through, re-tear)
Outcome (Palpation, U/S) Good in 15 cases
CONCLUSIONS
These preliminary results show that meniscal repair in dogs is feasible and can be successful. However, due
to the low number of cases and the variability in follow-up and outcome measures, the results should be in-
terpreted carefully.
Based on our clinical experience, and the existing experimental studies, we summarized the following points
(work in progress):
1. It is rare to find meniscal tears amenable to repair, due to the chronicity and frequent degenerative
changes present in the meniscus;
2. The ideal tear is a stable peripheral or longitudinal tear (red-red zone). Unstable longitudinal (buck-
et handle tears) may be repairable in some cases, but careful evaluation is recommended because the
torn part is frequently already crushed by the time of the repair; a rule of thumb is that displaced lon-
gitudinal tears are not amenable to repair;
3. Inside-out technique using meniscal needles or spinal needles is effective and feasible in the dog; joint
distraction may facilitate repair;
4. Vertical or cruciate patterns are recommended. However, horizontal suture may be indicated if the
exposure is reduced and allows placement of a single suture;
5. CCL stabilization following repair is crucial to protect the repair. There is no agreement on the best
technique to achieve it. The personal preference of the author is TPLO, or TPLO + extra-capsular
technique (very active dogs) (Tightrope or anchors);
6. The ideal cases may be acute complete or partial CCL rupture with mild DJD;
7. Dogs with advanced DJD and degenerative changes of the meniscus may not be good candidates for
the highly degenerative environment in the joint.
The goal of future clinical studies should be to determine if meniscal repair provides a better outcome than
partial meniscectomy; guidelines for case selection, techniques and suture material are also needed.
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ARTHREX NEWS
A biomechanical perspective to current extracapsular

stabilization techniques
Extracapsular stabilization techniques using prosthetic implants are commonly used to treat cranial cruciate
ligament (CCL) difficiencies. Prosthetic implants function to temporarily mitigate the hyperextension, cra-
nial tibial translation, and internal rotation allowed by loss of the CCL until sufficient periarticular fibrosis
develops to permanently stabilize the stifle joint. Stabilization failure prior to adequate periarticular fibrosis
formation may result from failure/pullout of the femoral or tibial anchor points, prosthetic rupture or stretch-
ing/elongation, or knot or crimp clamp failure.
Early descriptions of extracapsular stabilization involved placement of a circumfabellar suture as the femoral
anchor point. A commonly used modification of this technique is the lateral fabellotibial suture (LFS) tech-
nique. In the LFS technique the suture (typically monofilament nylon leader material) is secured with either
a knot or a crimp clamp. A potential weakness of the LFS technique is the circumfabellar anchor point which
relies on the ligamentous attachment of the fabella to the distal femur to maintain adequate suture tension.
A second weakness of the LFS technique is the use of a relatively low stiffness prothetic (nylon leader ma-
terial). More recently the use of bone anchors or femoral bone tunnels have been reported in place of a cir-
cumfabellar anchor point for extracapsular stabilization. These techniques do not rely on soft tissue struc-
tures to maintain tension and allow the suture material to be anchored in a more isometric location than the
lateral fabella. The Tightrope CCLa technique utilizes FiberTapeb passed through femoral and tibial tunnels
and secured with toggle buttons on the medial aspect of the femur and tibia. A commercially available tog-
gle system (SwiveLockc) utilizes FiberTape secured in a knotless toggle as the femoral condylar anchor point.
Multifilament braided polyethylene suture materials such as FiberWired and FiberTape have been demon-
strated to be stronger, stiffer, and elongate less than nylon leader material or other commonly utilized mul-
tifilament braided materials.
We performed an in vitro biomechanical analysis utilizing load to failure testing of the femoral compo-
nent of five extracapsular stabilization techniques: Lateral fabellotibial suture utilizing double strands of
nylon leader material, Lateral fabellotibial suture utilizing a single strand of FiberWire, Tightrope CCL
utilizing both single and double strands of FiberTape, and the Swivelock knotless bone anchor system uti-
lizing a double strand of FiberTape. Our hypothesis was that constructs utilizing bone anchors or bone
tunnels as the femoral fixation point will exhibit superior load to failure properties compared to the LFS
constructs. Five techniques for extracapular fixation were evaluated in canine cadaveric femurs. The fe-
murs were harvested from animals that were euthanized for reasons unrelated to this study. All soft tis-
IN-DEPTH SEMINARS
sue was removed from the proximal femurs, carefully leaving intact the structures surrounding the fabel-
ARTHREX NEWS
la. After preparation, the femurs were randomized to one of five treatment groups (single-loop Fiberwire
around fabella, double-loop nylon leader line around fabella, single tightrope, double tightrope, or 5.5 mm
SwiveLock with double-loop FiberTape. The double-loop nylon leader line was secured using a commer-
cially available crimp systeme. All other suture materials were secured using standard square knots of
eight throws each. The femurs were secured to a mechanical testing machine (MTS Systems, Eden Prairie,
MN) using a custom jig at an angle of 70 degrees relative to the horizontal plane, which allowed the su-
ture to be tensioned in approximately the same orientation that would be experienced in vivo at a nor-
mal standing angle of 135°. Each construct was preloaded for 100 cycles from 25 N to 250 N at a rate of
1 Hz. Following preload the constructs were loaded to failure at a rate of 1 mm/sec. The ultimate load to
failure for each construct was recorded and analyzed statistically using a univariate ANOVA and tukey
post-hoc test, with p value of 0.05. The preliminary results (load to failure) are presented: the single-loop
Fiberwire around fabella group had the lowest failure load (538 N), which was significantly lower than
a
Tightrope CCL – Innovative Veterinary Products, Rochester, MN, USA.
b
FiberTape – Arthrex Vet Systems, Naples, FL, USA.
c
Swivelock PEEK Corkscrew- Arthrex Inc., Naples, FL, USA.
d
FiberWire – Arthrex Vet Systems, Naples, FL, USA.
e
Securos Inc, Fiskdale, MA, USA.
the single tightrope group (826 N) or the double tightrope group (1246 N). The double tightrope group
had the highest failure load and was significantly higher than all other groups. There was no significant
difference in failure load between the 5.5 mm SwiveLock with double-loop FiberTape (770 N), the dou-
ble-loop nylon leader line around fabella (732 N) or the single tightrope groups.
Failure of extracapsular suture stabilization, when observed in vivo, may be due to many different factors.
In this study an attempt was made to determine the contribution of different types of suture materials and
femoral attachment mechanisms to stability of extracapsular repair. The finding that both single and double
tightrope groups were sustained significantly higher load to failure than the single-loop Fiberwire around fa-
bella group supported our initial hypothesis. Different than our hypothesis, the 5.5 mm SwiveLock with
double-loop FiberTape (bone anchor) and the single tightrope groups were not significantly different in ul-
timate load to failure than the double-loop nylon leader line around fabella group. These findings suggest
that predicting failure trends of extracapsular stabilization techniques is not as simple as merely evaluating
femoral insertion methodology.
Suture material selection would also be expected to play a role in ultimate load to failure values. Nylon
leader line would be expected to fail at a lower ultimate load than FiberWire; however, the nylon leader line
group was constructed using double loops of leader line while the single-loop FiberWire group was con-
structed with only a single loop of FiberWire. This discrepancy between groups may explain the higher load
to failure values noted in the group utilizing nylon leader line over the group utilizing FiberWire (ultimate
load to failure values were not significantly different between groups). The FiberTape utilized in the
tightrope and SwiveLock groups would be expected to have the highest load to failure value of the suture
materials tested. This expectation is realized in the double tightrope group and to a lesser extent in the sin-
gle tightrope group (second highest load to failure values but only significantly higher than the single-loop
FiberWire group). Somewhat unexpectedly the SwiveLock group did not have a significantly higher load to
failure value than any of the other groups. This finding suggests that the anchor system utilized in the Swive-
Lock group may be a weak point for this extracapsular stabilization system. Interestingly, the mechanism of
failure in the SwiveLock group was partial or complete anchor pullout in nine out of ten constructs tested.
Concentrating specifically on the ultimate strength of a suture material and femoral insertion point for ex-
tracapsular stabilization repair should not imply that a construct with the highest load to failure is the most
desirable. Factors such as lateral compartment overload and changes in biomechanical behavior of the sti-
fle joint during range of motion after extracapsular stabilization should be considered in the choice of tech-
nique and may be much more important to a successful outcome than ultimate load to failure. With that
said, this study suggests that if achieving the highest ultimate load to failure is the goal then of the five con-
structs tested the double tightrope would be the technique of choice as it significantly outperformed all oth-
er constructs tested.
The authors would like to Thank Arthrex Vet Systems and Securos for providing materials free of charge
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for this project.
ARTHREX NEWS
PATHOGENESIS
OF CRUCIATE DISEASE
IN-DEPTH SEMINAR
Update on canine cruciate ligament disease:

hormones, immunology and trauma
Eithne J. Comerford, MVB PhD CertVR CertSAS PGCertHE DipECVS MRCVS
Senior lecturer in Small Animal Orthopaedics, School of Veterinary Science, University of Liverpool,
Chester High Rd, Neston, CH64 7TE
GENDER, NEUTER STATUS AND HORMONAL INFLUENCE

The prevalence of CCL rupture has been recognised as being higher in neutered animals, particularly fe-
males1-2. It is unknown if this is secondary to weight gain, as certain authors have reported that neutered fe-
male dogs are twice as likely to be obese than entire female dogs3. In women, increased incidence of ACL
rupture is associated with elevated oestrogen in the pre-ovulatory phase of the menstrual cycle4. However,
as ovariohysterectomy in dogs is associated with persistent hypo-oestrogenaemia, oestrogen may reduce the
incidence of CCLD in the dog5. There have been no conclusive studies determining the effect of systemic
and/ or local hormonal status on CCLD in dogs or man.
White adipose tissue in many species (including the dog) has been shown to be an important endocrine or-
gan, elaborating an array of chemical mediators (adipokines) which may be pro-inflammatory6. It is hy-
pothesised that the adipose tissue of obese individuals is in a state of chronic inflammation7-8 suggesting sys-
temic and/or local adipokine elaboration could be involved in the etiopathogenesis of connective tissue
pathology. However, key proinflammatory adipokines have not been assessed and, a possible role for sys-
temic adipose tissue has not been examined in CCLD.
IMMUNOLOGY
The hostile intra-articular environment created by arthropathies such as immune-mediated arthritis, immune
synovitis and joint sepsis may result in CCLD9-12. Some authors have suggested that there is an immuno-
logic component to rupture of the CCL, because of the demonstration of immune-complexes in synovial flu-
id and sera and immunoglobulin (mainly IgM) in the synovial membrane13. A recent study evaluated anti-
collagen type I antibodies in synovial fluid of the affected stifle joint and the contralateral stifle joint of dogs
with unilateral CCL rupture, and concluded that synovial fluid antibodies against collagen type I alone do
not initiate CCL rupture13.
Inflammatory cells (T and B lymphocytes, CD11c, MHCII dendritic cells and TRAP synovial macrophages)
and molecules with a role in immune cell maturation and antigen presentation (MMP-9 and Cathepsin S)
have been found in the synovium of dogs with CCL rupture14. Increased immunoglobulin deposition and
PATHOGENESIS OF CRUCIATE DISEASE

expression of MHC II in the synovium of dogs with CCL rupture also suggest an immune-mediated com-
IN-DEPTH SEMINARS
ponent. The trigger antigen for the persistent synovitis seen in CCL rupture has not been elucidated and
has been suggested not to be collagen neo-epitopes15. In a recent study, a rat model of ACL injury demon-
strated increased collagenolytic enzymes in synovial fluid16. Of all tissues within the joint, the synovium con-
tributed most to this increase. Thus inflammation of the epiligament may have an influence on the physiol-
ogy of the CLs through release of mediation of growth factors and cytokines and release of collagenolytic
enzymes. Furthermore as the epiligament does not appear to form a barrier to macromolecule passage be-
tween synovium and CCL17, these molecules may be able to act directly on the ligament.
There is also considerable interest in the pro-inflammatory cytokines and their role in the catabolic process-
es occurring in pathological connective tissues but their role in the pathogenesis of CCLD is still unclear13,
18-19
. mRNA expression of cytokines in synovial fluid cells from multiple joints in dogs with unilateral CCL
rupture was measured and this revealed that IL-8 expression tended to be higher in stifle joints that will
rupture their CCL during the next 6 months than in those that will not19. Collagenolytic enzyme expres-
sion has been found in the ruptured CCL and synovial fluid, and synovial macrophage-like cells that pro-
duce matrix-degrading enzymes have been identified14, 20-21. These findings suggest that inflammatory
arthropathy may predispose to CCLD, by release of inflammatory mediators and proteolytic enzymes dur-
ing inflammatory process. Release of collagenolytic proteases from the synovium into the stifle synovial flu-
id can significantly degrade the structural properties of the CCL and increase the likelihood of a patho-
logical rupture14, 20-21.
The CLs are covered by synovial membrane and historically it was thought that they were extra-synovial
and therefore secluded from immune surveillance9. This seclusion may suggest that the cruciate ligaments
could act as self- antigens causing an autoimmune response if damaged due to release of inflammatory me-
diators and degradation products into the synovial fluid. A recent study demonstrated the free passage of
macromolecule markers from synovial fluid to the substance of the CCL and blood17 suggestive of free
movement between the synovial fluid and CCL substance. Therefore a fall in intra-articular osmotic pres-
sure, as may occur in OA, is likely to adversely affect CCL blood flow and this may also affect CL pheno-
type and density. Loss of cells, whether through apoptosis or necrosis, may result in failure to maintain ECM
integrity if they are not replaced and may induce an immunological/inflammatory reaction.
The key to demonstration of an adaptive immune response would be in the demonstration of a specific
peripheral T cell response. There appears to be a proliferative lymphocytic response to collagen type I at
the time of CCL rupture in dogs, but in healthy and sham operated dogs there was also lymphocytic re-
activity, therefore a role of cellular immunity in CCL rupture could not be demonstrated13. The extreme
tissue specificity of CCL rupture would suggest involvement of a systemic adaptive MHC class II re-
sponse in the aetiology unlikely. However mixed MHC class I-autoinflammatory conditions have not
been considered in CCL rupture.
Despite these recent studies, it still remains greatly controversial whether immunological changes are a
secondary phenomenon, in response to the tissue damage during CCL rupture, stifles instability and OA.
To date little work has investigated for evidence of these changes in normal CCLs from dogs at a high
risk to CCLD.
TRAUMA
Trauma has been implicated in around 20% of CCL rupture22 and a force of roughly four times the body
weight of the canine will result in CCL rupture23. Two aetiologies are described: hyperextension and ex-
cessive internal rotation with the stifle in partial flexion24 and tibial compression, where stress is placed
on the CCL through abnormal pressure in the foot transmitted through a flexed hock and contraction
of the gastrocnemius muscle forcing the tibia cranially relative to the femur25. Purely traumatic injuries
are reported in young giant breed dogs25 and in conjunction with multiligamentous stifle injuries in work-
ing dogs26.
REFERENCES
1. Doverspike, M., et al., Contralateral Cranial Cruciate Ligament Rupture: Incidence in 114 dogs. J. Amer. An. Hosp.
Ass., 1993. 29: p. 167-171.
2. Duval, J.M., et al., Breed, sex, and body weight as risk factors for rupture of the cranial cruciate ligament in young
dogs. J Am Vet Med Assoc, 1999. 215(6): p. 811-4.
3. Edney, A.T.B., et al., Study of obesity in dogs visiting veterinary practices in the United Kingdom. Vet. Rec., 1986.
118: p. 391-396.
4. Renstrom, P., et al., Non-contact ACL injuries in female athletes: an International Olympic Committee current con-
cepts statement. Br J Sports Med, 2008. 42(6): p. 394-412.
5. Dannucci, G.A., et al., Ovariectomy and Trabecular Bone Remodeling in the Dog. Calcified Tissue International,
IN-DEPTH SEMINARS
1987. 40(4): p. 194-199.

6. O’Hara, A., et al., Microarray analysis identifies matrix metalloproteinases (MMPs) as key genes whose expression
is up-regulated in human adipocytes by macrophage-conditioned medium. Pflugers Archiv-European Journal of
Physiology, 2009. 458(6): p. 1103-1114.
7. Trayhurn, P., et al., Adipose tissue and adipokines—energy regulation from the human perspective. J Nutr, 2006.
136(7 Suppl): p. 1935S-1939S.
8. Eisele, I., et al., Adipokine gene expression in dog adipose tissues and dog white adipocytes differentiated in pri-
mary culture. Horm Metab Res, 2005. 37(8): p. 474-81.
9. Doom, M., et al., Immunopathological mechanisms in dogs with rupture of the cranial cruciate ligament. Vet Im-
munol Immunopathol, 2008. 125(1-2): p. 143-61.
10. Muir, P., et al., Expression of immune response genes in the stifle joint of dogs with oligoarthritis and degenerative
cranial cruciate ligament rupture. Vet Immunol Immunopathol, 2007. 119(3-4): p. 214-21.
11. Niebauer, G.W., et al., Antibodies to Canine Collagen Types I and II in Dogs with Spontaneous Cruciate Ligament
Rupture and Osetoarthritis. Arthritis and Rheumatism., 1987. 30(3): p. 319-328.
12. Lawrence, D., et al., Elevation of immunoglobulin deposition in the synovial membrane of dogs with cranial cru-
ciate ligament rupture. Veterinary Immunology and Immunopathology, 1998. 65(1): p. 89-96.
13. de Bruin, T., et al., Evaluation of anticollagen type I antibody titers in synovial fluid of both stifle joints and the left
shoulder joint of dogs with unilateral cranial cruciate disease. Am J Vet Res, 2007. 68(3): p. 283-9.
14. Muir, P., et al., Localization of cathepsin K and tartrate-resistant acid phosphatase in synovium and cranial cruciate
ligament in dogs with cruciate disease. Vet Surg, 2005. 34(3): p. 239-46.
15. de Rooster, H., et al., Prevalence and relevance of antibodies to type-I and -II collagen in synovial fluid of dogs with
cranial cruciate ligament damage. Am J Vet Res, 2000. 61(11): p. 1456-61.
16. Tang, Z.Y., et al., Contributions of Different Intraarticular Tissues to the Acute Phase Elevation of Synovial Fluid
MMP-2 following Rat ACL Rupture. Journal of Orthopaedic Research, 2009. 27(2): p. 243-248.
17. Kobayashi, S., et al., Microvascular system of anterior cruciate ligament in dogs. J Orthop Res, 2006. 24(7): p.
1509-20.
18. de Bruin, T., et al., Interleukin-8 mRNA expression in synovial fluid of canine stifle joints with osteoarthritis. Vet
Immunol Immunopathol, 2005. 108(3-4): p. 387-97.
19. de Bruin, T., et al., Cytokine mRNA expression in synovial fluid of affected and contralateral stifle joints and the
left shoulder joint in dogs with unilateral disease of the stifle joint. Am J Vet Res, 2007. 68(9): p. 953-61.
20. Muir, P., et al., Evaluation of tartrate-resistant acid phosphatase and cathepsin K in ruptured cranial cruciate liga-
ments in dogs. Am J Vet Res, 2002. 63(9): p. 1279-84.
21. Muir, P., et al., Collagenolytic protease expression in cranial cruciate ligament and stifle synovial fluid in dogs with
cranial cruciate ligament rupture. Vet Surg, 2005. 34(5): p. 482-90.
22. Paatsama, S., Ligamentous Injuries in the canine stifle joint., in. 1952, Royal Veterinary College, Stockholm.:
Helsinki. p. 80.
23. Gupta, B.N., et al., Breaking strength of cruciate ligaments in the dog. J Am Vet Med Assoc, 1969. 155(10): p.
1586-8.
24. Johnson, J.M., et al., Cranial cruciate ligament rupture. Pathogenesis, diagnosis, and postoperative rehabilitation.
Vet Clin North Am Small Anim Pract, 1993. 23(4): p. 717-33.
25. Bennett, D.T., B., Lewis, D.G, et al, A reappraisal of anterior cruciate ligament disease in the dog. Journal of Small
Animal Practice, 1988. 29: p. 275-297.
26. Bruce, W.J., Multiple ligamentous injuries of the canine stifle joint: a study of 12 cases. Journal of Small Animal
Practice, 1998. 39(7): p. 333-340.

IN-DEPTH SEMINARS
Pathogenesis of cranial cruciate ligament disease in the dog

- genetics and anatomy
The most common cause of lameness on dogs in North America is partial or complete rupture of the Cr-
CL. The annual economic impact of cranial cruciate ligament disease in dogs in the United States was esti-
mated to be 1.2 billion dollars in 2003. Many surgical treatments have sought to restore stifle joint stability
and minimize osteoarthritis through various techniques of replacing the ruptured ligament either inside the
joint, or outside in an extracapsular method. The CrCL is composed of a craniomedial band (CrMB) and
a larger caudolateral band (CLB). The CrMB is taut in flexion and extension, the CLB is taut in extension
but lax in flexion. The CrCL functions to minimize internal rotation and hypertension of the stifle joint and
prevent cranial translation of the tibial plateau relative to the femoral condyles. Full extension of the stifle is
limited by contact between the CrCL and the cranial intercondylar notch of the femur. Mechanisms of trau-
matic rupture of a normal CrCL include: internal rotation of the stifle in 20-50 degrees of flexion or force-
ful hyperextension. Tearing of the CLB alone (most likely from hyperextension) will not produce instabili-
ty because the intact CMB is taut in both flexion and extension; no drawer motion will be present. Injuries
caused by rotation or twisting are more likely to injure the CrMB, producing a small amount of drawer mo-
tion in flexion, but none in extension. Rupture occurs when the ultimate breaking strength of the ligament
is exceeded which is estimated to be 4x the body weight of the dog.
There is no single cause of CrCL rupture in dogs. Acute trauma to a normal CrCL, which is the primary
etiology of CrCL rupture in people, is far less common cause in dogs. Other factors that contribute to the
degeneration and eventual rupture of the CrCL include anatomical factors, such as extreme tibial plateau
angles (>35°), narrowing of the intercondylar notch, and an extended standing angle of the stifle joint; hor-
monal influences, shown to be important in athletic girls; immune mediated disease processes, such as the
production of anti-collagen antibodies or deposition of immune complexes; and heredity in that some breeds
appear to be predispose dogs to CrCL rupture. The genetic basis for hereditability of a predisposition for
CrCL rupture has been shown in Newfoundlands. They have an autosomal recessive mode of inheritance
with a recessive allele frequency of 0.65 and partial penetrance (59%). There may be certain phenotypic ex-
pressions that predispose dogs to developing CrCL rupture. Hyperextension of the stifle joint increases the
standing TPA, which places increased stress on the CrCL. In addition, the stifle joint shifts medial to the
longitudinal axis of vertical load in dogs with a “cow-hocked” stance, which also places greater stress on the
CrCL.
IN-DEPTH SEMINARS
The pathogenesis of CrCL rupture involves the ligamentous changes that occur with disuse, and progress-
ing age that weaken the integrity of the structure. The degenerative changes progress as the animal ages, but
may be less severe in animals less than 15 kilograms in body weight. Degenerative changes associated with
aging may account for 20-40% of dogs that eventually develop bilateral CrCL rupture. It has been postu-
lated that the sedentary lifestyle of the typical middle-aged dog, compounded by obesity, may lead to di-
minished mechanical strength of the CrCL.
CrCL rupture has been identified in all breeds of dogs, but with a higher incidence in obese dogs. Rot-
tweilers, Labrador retrievers, Newfoundlands, bull mastiffs, and chow chows appear to be at particular risk.
Recent studies indicate that younger, larger, more active dogs may be predisposed to CrCL rupture. There
is not a sex predilection for CrCL rupture, but there may be a slightly higher incidence in female spayed
dogs. Although the strength of a dog’s CrCL deteriorates with age, loss of fiber bundle organization and
metaplastic changes of cellular elements in the CrCL may be pronounced at a young age in certain large-
breed dogs.
Patients may present for acute CrCL injury, in which there may be subtle to non-weight bearing lameness
of unknown origin. The lameness often improves somewhat within weeks, but then plateaus especially in
dogs over 15 kg. These larger dogs may never return to pre-injury levels of activity and develop a second,
acute lameness after meniscal injury. The lameness often resolves completely within 1-5 months in dogs less
than 15 kg, although these dogs may also develop meniscal damage later. Chronic, mild lameness is associ-
ated with the development of degenerative joint disease. The acute lameness improves as any hemarthrosis
resolves and fibrous proliferation of the periarticular tissue stabilizes the joint, there is an acute exacerbation
of lameness as a result of a meniscal tear or progression of degenerative joint disease. Partial CrCL tears
may be difficult to diagnose and present as a mild weight-bearing lameness associated with exercise that re-
solves with rest until degenerative joint disease sets in. As the ligament continues to tear, the joint becomes
less stable and degenerative changes exacerbate the lameness until it no longer resolves with rest.
During the examination, a simple visual test is the sit test. Most normal dogs sit with the hock in sufficient
flexion so the patient rests on its haunches. An affected dog may sit with the affected stifle in some degree
of extension. Thickening around the joint or medial buttress, decreased range of motion, pain with stifle hy-
perextension or pressure over the caudomedial joint capsule can be found in dogs with partial or complete
CrCL rupture. Significant atrophy of the quadriceps and hamstring muscles is a common finding in chron-
ic cases. Dogs with angular malformations centered over the stifle, genu varum or valgum, have a higher in-
cidence of CrCL rupture. An audible “clicking” may be heard when the stifle is taken through its range of
motion when a meniscal tear is present. Positive cranial drawer and cranial tibial thrust during a tibial com-
pression test are definitive tests for cruciate instability. To check for cranial drawer, the dog is placed in lat-
eral recumbency with the affected limb up. The examiner places an index finger on the patella and the
thumb of the same hand on the fabella, while the index finger of the opposite hand is placed on the tibial
tubercle and the thumb on the head of the fibula. Cranial translation of the tibia relative to the femur is a
positive drawer sign. This maneuver causes pain, and some dogs may require sedation before this test can
be performed successfully. It is important to remember that dogs less than one year of age have slight laxi-
ty of 1-2 mm of normal drawer movement, and dogs with chronic rupture and joint thickening may have
little or no drawer.
Other differential diagnoses that should be considered are caudal cruciate rupture, which is diagnosed by a
caudal drawer sign or the tibial sag sign, patella luxation that may accompany and/or cause CrCL rupture,
osteochondrosis in young large breed dogs and neoplasia of the stifle that can both be diagnosed with radi-
ography. Avulsion of the long digital extensor tendon, while uncommon, causes a firm swelling on the lat-
eral aspect of the stifle, as well as a radiographic density in the craniolateral aspect of the joint. The exten-
sor fossa may be more prominent, as a radiolucent defect on the lateral aspect of the femoral condyle. Lym-
phocytic plasmocytic synovitis syndrome may cause lameness mimicking CrCL rupture, and has been di-
agnosed in up to 10% of dogs having surgery for CrCL rupture. Less common conditions to consider are
semimembranosus/gracilis contracture, patellar tendon rupture, other arthropathies, and neurological dis-
ease such as cauda equine syndrome.
Synovial fluid analysis may help differentiate partial CrCL rupture, immune-mediated arthropathies, joint
sepsis, and acute trauma. Lateral and craniocaudal (or caudocranial) stifle radiographs are taken to assist in
the diagnosis and to rule out other abnormalities. Radiographic findings (at least 32 have been defined) in
dogs with chronic tears include osteophytes along the femoral trochlear ridges, caudal aspect of the tibial
plateau, and pole of the patella; cranial displacement of the infrapatellar fat pad, and caudal joint capsule
distension. Dogs with an acute or partial rupture may have joint effusion alone as a radiographic abnor-
mality. Stifle exploration via arthroscopy or arthrotomy should confirm the diagnosis of CrCL rupture.

REFERENCES
IN-DEPTH SEMINARS
Vasseur PB: Correlative biochemical and histologic study of the cranial cruciate ligament in dogs. Am J Vet Res 46:1842,
1985.
Henderson RA, Milton JL. The tibial compression mechanism: a diagnostic aid in stifle injuries. J Am Anim Hosp Assoc
14:474-479, 1978.
Vasseur PB: Clinical results following nonoperative management for rupture of the cranial cruciate ligament in dogs. Vet
Surg 13:283, 1979.
Paatsama S: Long-standing and traumatic ligament injuries and meniscal ruptures of the canine stifle. J Small Anim Med
1:329, 1953.
Wilke V, et al. Estimate of the annual economic impact of treatment of cranial cruciate ligament injury in dogs in the Unit-
ed States. J Am Vet Med Assoc 227(10):1604-7, 2005.
Wilke V, et al. Comparison of tibial plateau angle between clinically normal Greyhounds and Labrador retrievers with
and without rupture of the cranial cruciate ligament. J Am Vet Med Assoc 221(10):1426-9, 2002.
Selmi AL, Padhilla Filho JG. Rupture of the cranial cruciate ligament associated with deformity of the proximal tibia in
five dogs. J Small Anim Pract 42(8):390-3, 2001.
Wilke V, et al. Inheritance of rupture of the cranial cruciate ligament in Newfoundlands. J Am Vet Med Assoc 228(1):61-
4, 2006.
K. Hayashi WVOC 2010, Bologna (Italy), 15th - 18th September • 490
Inflammation and bacteria

Kei Hayashi, DVM, PhD, Dipl. ACVS
University of California Davis
BACKGROUND
Cranial cruciate ligament (CrCL) rupture is one of the most common causes of lameness in adult dogs.1 A
number of different surgical interventions have been well described for the treatment of CrCL rupture.
However, the underlying disease mechanism that ultimately leads to structural failure of CrCL remains
poorly understood.2-4
Clinical and epidemiological study results have indicated that CrCL rupture occurs due to intrinsic and pro-
gressive structural deterioration of the normal ligament, and rarely because of a simple traumatic injury.5,6
It has been proposed that chronic degeneration and progressive weakening of the CrCL predisposes the Cr-
CL to rupture during routine daily activities.5-9 In addition, degenerative CrCL appears to rupture initially
at a certain location in the ligament (described as “partial rupture”), which slowly progresses to an eventu-
al “complete rupture” over time.5,6,10
Genetic predisposition, abnormal conformation of the stifle, aging, and inflammatory joint disease have all
been proposed as contributing causes of CrCL degeneration and rupture.11-13 Despite the extensive efforts
put forth in these studies, the instigating causes of CrCL degeneration and its subsequent structural deteri-
oration remain unknown.
TISSUE DEGENERATION
Previous studies have documented that the CrCL experiences chronic and irreversible degeneration re-
gardless of injury and prior to rupture.2,3,7-9 Degenerative changes are generally characterized by a decreased
number of normal ligament fibroblasts, chondroid metaplasia of ligament fibroblasts, and loss of the normal
fibrous collagenous architecture of the extracellular matrix.7-9 Moreover, the transformation does not occur
at the same time throughout the entire ligament. The interior “core region” of the CrCL deteriorates earli-
er than the surface epiligamentous region, and the middle portion of the CrCL deteriorates earlier than ar-
eas close to bony attachments.7,9
In addition, these characteristic histological changes accompany the deterioration of mechanical properties
of grossly intact CrCL.9 The CrCL degeneration appears to begin within the central core portion of the Cr-
CL and may be related to the ischemic nature of the tissue. The observed tissue transformation is believed
to be a successful adaptation to a hypoxic environment.2,3
HISTOLOGICAL FEATURES
IN-DEPTH SEMINARS
Recent histological studies have documented significant quantitative and qualitative cellular changes in rup-
tured CrCL, where the number of typical fibroblasts is decreased with a concomitant increase in chondroid
phenotypic transformation.7 These wholesale cellular changes are associated with extensive disruption of the
highly ordered fibrous extracellular matrix, where ligamentous tissue is transformed into a “cartilage-like”
structure.7
This cartilage-like tissue is believed to be more vulnerable to failure under physiological tensile forces than
is normal ligamentous tissue; therefore the tissue degeneration with cartilaginous transformation in the Cr-
CL may predispose CrCL to a pathological rupture under normal biomechanical activity.14 Interestingly,
cartilaginous tissue transformation in ligaments and tendons has been attributed to altered oxygenation sta-
tus (hypoxia) and altered mechanical environment.15
HYPOVASCULARITY AND CELLULAR HYPOXIA

Based on these previous studies, it has been hypothesized that low vascularity coupled with tissue hypoxia
in the canine CrCL may be important factors contributing to CrCL degeneration. A hypovascular area in
the CrCL may be associated with pathological tissue degeneration and consequent ligament rupture. Vas-
cular anatomy in the normal canine CrCL has been studied 40 years ago using conventional techniques
such as contrast microradiography and ink injection.16,17
More recently, detailed vascular anatomy in the human anterior cruciate ligament (ACL) was studied using
immunohistochemical methods, which revealed distinct hypovascular areas within the core region of the
ACL.18-20 It is currently unknown whether distinct hypovascular areas exist in canine CrCL as reported in
human,18 and whether these areas are associated with the initial rupture site in partial rupture that has been
observed clinically.10
491 • WVOC 2010, Bologna (Italy), 15th - 18th September K. Hayashi
REFERENCES
1. Wilke VL, Robinson DA, Evans RB, et al: Estimate of the annual economic impact of treatment of cranial cruciate
ligament injury in dogs in the United States. J Am Vet Med Assoc 227:1604-7, 2005.
2. Comerford EJ, Innes JF, Tarlton JF, et al: Investigation of the composition, turnover, and thermal properties of rup-
tured cranial cruciate ligaments of dogs. Am J Vet Res 65:1136-1141, 2004.
3. Comerford EJ, Tarlton JF, Innes JF, et al: Metabolism and composition of the canine anterior cruciate ligament re-
late to differences in knee joint mechanics and predisposition to ligament rupture. J Orthop Res 23:61-66, 2005.
4. Hayashi K, Manley PA, Muir P: Cranial cruciate ligament pathophysiology in dogs with cruciate disease: a review.
J Am Anim Hosp Assoc 40:385-90, 2004.
5. Duval JM, Budsberg SC, Flo GL, et al: Breed, sex, and body weight as risk factors for rupture of the cranial cru-
ciate ligament in young dogs. J Am Vet Med Assoc 215:811-814, 1999.
6. Whitehair JG, Vasseur PB, Willits NH: Epidemiology of cranial cruciate ligament rupture in dogs. J Am Vet Med
Assoc 203:1016-1019, 1993.
7. Hayashi K, Frank JD, Dubinsky C, et al: Histologic changes in ruptured canine cranial cruciate ligament. Vet Surg
32:269-277, 2003.
8. Hayashi K, Frank JD, Hao Z: Evaluation of ligament fibroblast viability in ruptured cranial cruciate ligament of
dogs. Am J Vet Res 64:1010-1016, 2003.
9. Vasseur PB, Pool RR, Arnoczky SP, et al: Correlative biomechanical and histologic study of the cranial cruciate lig-
ament in dogs. Am J Veterinary Res 46:1842-1854, 1985.
10. Scavelli TD, Schrader SC, Matthiesen DT, et al: Partial rupture of the cranial cruciate ligament of the stifle in dogs:
25 cases (1982-1988). J Am Vet Med Assoc 196:1135-8, 1990.
11. Wilke VL, Conzemius MC, Rothschild MF: SNP detection and association analysis of candidate genes for rupture
of the cranial cruciate ligament in the dog. Animal Genetics 36:511 542, 2005.
12. Muir P, Oldenhoff WE, Hudson AP, et al: Detection of DNA from a range of bacterial species in the knee joints of
dogs with inflammatory knee arthritis and associated degenerative anterior cruciate ligament rupture. Microb
Pathog 42:47-55, 2007.
13. Comerford EJ, Tarlton JF, Avery NC, et al: Distal femoral intercondylar notch dimensions and their relationship
to composition and metabolism of the canine anterior cruciate ligament. Osteoarthritis Cartilage 14:273-278, 2006.
14. Waggett AD, Kwan APL, Woodnutt DJ, et al: Collagens in firocartilages at the Achilles tendon insertion -a bio-
chemical, molecular biological and immunohistochemical study. Trans Orthop Res Soc 21:25, 1996.
15. Milz S, Benjamin M, Putz R: Molecular parameters indicating adaptation to mechanical stress in fibrous connective
tissue. Adv Anat Embryol Cell Biol 178:1-71, 2005.
16. Alm A, Strömberg B: Vascular anatomy of the patellar and cruciate ligaments. A microangiographic and histolog-
ic investigation in the dog. Acta Chir Scand Suppl 445:25-35, 1974.
17. Arnoczky SP, Rubin RM, Marshall JL: Microvasculature of the cruciate ligaments and its response to injury. An
experimental study in dogs. J Bone Joint Surg Am 61:1221-9, 1979.

18. Petersen W, Tillmann B: Structure and vascularization of the cruciate ligaments of the human knee joint. Anat Em-
IN-DEPTH SEMINARS
bryol 200:325-34, 1999.
19. Duthon VB, Barea C, Abrassart S, et al: Anatomy of the anterior cruciate ligament. Knee Surg Sports Traumatol
Arthrosc 14:204-13, 2006.
20. Scapinelli R: Vascular anatomy of the human cruciate ligaments and surrounding structures. Clin Anat 10:151-62,
1997.
LIMB ALIGNMENT
IN PATELLAR LUXATION
IN-DEPTH SEMINAR
495 • WVOC 2010, Bologna (Italy), 15th - 18th September A. Bruecker
Femoral corrective osteotomy: technique

Kenneth A. Bruecker, DVM, MS, Dipl. ACVS
Veterinary Medical and Surgical Group, Ventura, California USA
INTRODUCTION
Excessive distal femoral varus may preclude successful repair of a medially luxating patella by tibial tuber-
cle transposition and soft tissue techniques alone. Distal femoral osteotomy or ostectomy (DFO) may be re-
quired to accomplish satisfactory quadriceps alignment.
APPROACH
To perform a lateral closing wedge ostectomy of the distal femur, a lateral approach is made to the distal fe-
mur and stifle joint.
SURGICAL TECHNIQUE
Using a parallel jig, the distal jig pin is placed just proximal to the sulcus in a plane perpendicular to the long
axis of the femur and perpendicular to the caudal plane of the femoral condyles. The jig is applied and the
proximal jig pin inserted. (Tip: To avoid a stress riser in the cortical bone, the location of this pin should be such that one
screw will be proximal and one screw will be distal, once the plate is applied.) The ostectomy should be made such that
the distal cut is a few mm proximal to the distal jig
pin and sulcus. (Tip: The plate can be used as a template
to visualize the ideal locations for the osteotomies.) Reference
marks are made on the lateral aspect of the femur
and the ostectomy created with a sagittal saw. (Tip:
Contour the plate and temporarily place one compression screw
in the distal segment prior to completing the ostectomy.) The
soft tissues should be protected using retractors and
gauze sponges. Room temperature irrigation solution
should be used to prevent osteonecrosis from over-
heating by the saw blade. (Tip: Save the ostectomized
wedge of bone for autologous cancellous bone graft.) The
DFO plate should be contoured and applied using
standard AO technique for application of a plate us-
ing compression and locking screws. (Tip: If a combi-
LIMB ALIGNMENT PATELLAR LUXATION

nation of compression and locking screws is to be used, place all
IN-DEPTH SEMINARS
of the compression screws first.) The jig can then be re- Figure 1 - Lateral intra-operative view of jig placement and wedge
moved and additional techniques such as tibial tu- ostectomy.
bercle transposition, medial desmotomy/release and
lateral joint capsule imbrication can be performed.
The bone graft can be placed around the ostectomy
site and routine closure performed.
AFTERCARE
Ice/cold compresses can be applied to the surgery site
for 15-20 minutes. A soft support bandage or modi-
fied Robert Jones bandage can be applied for 24
hours or so. I generally like to begin ROM and walk-
ing exercises as soon as the bandage is removed. I
typically follow-up with radiographs at 3 and 8 weeks
post-operatively. Figure 2 - Lateral intra-operative view of DFO plate in place.
SELECTED REFERENCES
Piermattei DL and Johnson KA: An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat, 4th edi-
tion, WB Saunders, Plates 72 and 73, pages 336-341, 2004.
Computed tomographic planning of distal femoral

ostectomy
Accurate radiological assessment of limb alignment is difficult, and requires heavy sedation or general anes-
thesia and precise patient positioning to avoid positioning artifact. A complete radiographic evaluation in-
cludes at least cranio-caudal and medio-lateral views of the femur and proximal tibia, and an axial view of
the femur for femoral torsion determination. In some cases caudo-cranial and medio-lateral views of the tib-
ia including the stifle and tarsus may be required. Alternatively, a computed tomographic method with
analysis of individual slices (Dudley 2006) or three-dimensional reconstruction of the skeletal elements into
views analogous to the radiographic views can be utilized to quantify the deformities present.
A well-positioned cranio-caudal view of the femur and proximal tibia is the radiographic view that is used
to screen for and quantify femoral varus deformity. It is imperative that the femur is parallel and the radi-
ographic beam perpendicular to the radiographic cassette or detector. In cases in which diminished hip range
of motion limits hip extension, the x-ray beam and cassette or detector can be angled such that the x-ray
beam is perpendicular to the long axis of the femur, and the cassette or detector is perpendicular to the beam.
Alternatively, the patient can be elevated in a v-trough, or a horizontal beam, cranio-caudal femur can be
obtained. In a well-positioned view, the fabellae appear bisected by the femoral cortices, the vertical walls of
the intercondylar notch are distinct parallel lines, and the lesser trochanter is only partially visible; often the
proximal femoral nutrient foramen can be identified as a small, round lucency centered between the femoral
cortices in the proximal diaphysis. The benefit of three-dimensional reconstruction of computed tomo-
graphic images, is that the femoral image can be rapidly manipulated into the appropriate position to simu-
late a cranio-caudal view. In a normal femur, the magnitude of femoral varus (or valgus) is determined by
measuring the anatomic lateral distal femoral angle (aLDFA) at the intersection of the femoral anatomic ax-
is and the distal joint reference line of the femur, using the radiographic method described by Tomlinson
(Tomlinson 2007) or the computed tomographic method described by Dudley (Dudley 2006) or three di-
mensional reconstruction can be employed (Figure 1). In a femur with pathologic femoral varus or valgus,
the femoral deformity is determined at the center of angulation of rotation (CORA) located at the intersec-
tion of the proximal and distal anatomical axes of the femur.
In the radiographic and CT methods, the overall length of the femur is determined, and the center of the
femur at 33% and 50% of its length is identified. A line is drawn connecting these two points; this is the
anatomic axis of the femur. The distal joint reference line is a line connecting the most distal aspect of the
IN-DEPTH SEMINARS
medial and lateral condyles of the femur. The aLDFA is measured at the intersection of the anatomic axis
and the distal joint reference line. Comparison of the aLDFA to a breed specific reference range will deter-
mine if significant femoral varus is present. If a significant femoral varus deformity is present, the location
and magnitude of the deformity must be determined. Measure the overall length of the femur, and identi-
fying the center of the femur at 33% and 50% of its length, draw a line connecting these two points to de-
termine the proximal femoral anatomic axis; in this case, the line is not drawn to the joint level. Draw the
distal joint reference line, set the aLDFA to the breed specific value, and draw the distal anatomic axis such
that the line extends along the lateral aspect of the intercondylar notch. The CORA is located at the inter-
section of the proximal and distal anatomic axes, and its magnitude can be measured at this location. If a
breed specific normal value is not available, then the opposite normal femur can be measured as a reference.
If the opposite femur is affected, the aLDFA can be arbitrarily set to 94-98 degrees, as this is the value for
a number of large breed dogs (Tomlinson, 2007). It should be noted, that in some cases external femoral
torsion (decreased angle of anteversion) is the only identifiable femoral deformity, and in these cases, cor-
rection of torsion should be undertaken.
Femoral torsion can be quantified from the axial view of the femur. To obtain the axial view of the femur,
position the patient in dorsal recumbency and flex the hip joint such that the x-ray beam is directed down
the center of the femoral diaphysis, with the cassette under the hip joint. The femoral torsion angle (antev-
ersion angle) is determined by the intersection of the transcondylar axis and an axis through the center of
the femoral head and neck. The reported range for anteversion angle is quite broad, varies from study to
study, and no breed specific normal values are available at this time. The mean reported in one study was
27 degrees (range 12-40 degrees). This is the value I generally use clinically, since this publication utilized a
similar radiographic method. In the case of medial patellar luxation, if the patient’s femoral torsion angle is
Figure 1 - Cranio-caudal, medio-lateral and

axial three-dimensional reconstruction views of
the femur. These views were reconstructed from
a transverse plane CT scan, 1 mm slice thickness.
less than 27 degrees, I consider correction during corrective osteotomy. If the patient’s angle is greater than
27 degrees, I do not decrease the angle, as this may exacerbate medial patellar luxation. Again, three-di-
mensional reconstruction of the femur and manipulation of the view into the appropriate position is much
more rapid and less labor intensive than obtaining this view with radiographs.
Since these radiographic views are difficult to obtain, and are highly sensitive to radiographic positioning ar-
tifact, several exposures of each view should be obtained. A variation of more than 2-3 degrees between ra-
diographs or between left and right femurs in a symmetrically affected patient suggests positioning or meas-

urement artifact.
IN-DEPTH SEMINARS
In cases in which tibial torsional or angular abnormalities are evident, caudo-cranial and lateral views of the
tibia including the stifle and tarsus should be obtained. Recently, computed tomographic evaluation of tib-
ial torsion has been described, and this technique was found to be more accurate than the radiographic tech-
nique described by Slocum (Aper 2005, Apelt 2005).
REFERENCES
Apelt D, Kowaleski MP, Dyce J: Comparison of computed tomographic and standard radiographic determination of tib-
ial torsion in the dog, Vet Surg 34:457, 2005.
Aper R, Kowaleski MP, Apelt D et al: Computed tomographic determination of tibial torsion in the dog, Vet Radiol Ul-
trasound 46:187, 2005.
Dudley RM, Kowaleski MP, Drost WT et al: Radiographic and computed tomographic determination of femoral varus
and torsion in the dog, Vet Radiol Ultrasound 47:546, 2006.
Tomlinson J, Fox D, Cook JL et al: Measurement of femoral angles in four dog breeds, Vet Surg 36:593, 2007.
Tibial corrective osteotomy for combined MPL

and CrCL rupture
Concurrent medial patellar luxation and cranial cruciate ligament disease in large breed dogs is a common
condition that is challenging to treat. Current best evidence suggests that identification of all abnormalities
in a given patient with individualized treatment results in the best outcomes. A comprehensive clinical eval-
uation including thorough orthopedic examination, gait evaluation, and radiological evaluation serves as
the basis for surgical planning. A thorough physical examination is imperative to guide the clinician in the
interpretation of diagnostic imaging studies, and to select an appropriate treatment plan. Coexisting con-
ditions such as hip dysplasia with subluxation or luxation of the femoral head, partial or complete rupture
of the cranial cruciate ligament, torsional malformation of femur, and torsional or angular malformation of
the tibia must be first identified clinically to ensure appropriate imaging is obtained and a comprehensive
treatment plan is devised. In addition, gait evaluation is critical to assess limb alignment, and determine the
effect of correction on limb alignment and overall appearance of the patient. For instance, in a patient with
genu varum, a femoral corrective osteotomy would improve limb alignment and provide a straight limb for
the patient. In the case of a patient with distal femoral varus and proximal tibial valgus, gross limb align-
ment may appear normal, with the foot placed under the hip during ambulation. In a case such as this, cor-
rection of both the femoral and tibial deformities may be necessary to align the skeletal structures and en-
sure proper overall limb alignment postoperatively.
In cases of concurrent MPL and cranial cruciate ligament rupture, physical examination findings may in-
fluence the choice of the stabilization technique that is employed. Specific factors to consider are rotational
stability or instability of the stifle, tibial tuberosity position (i.e. medial displacement) and patella/patellar ten-
don alignment, pelvic limb alignment, and femoral and/or tibial deformity. To assess patellar tracking, the
hip, stifle and hock are placed in a neutral position, the patella is centered within the trochlear groove, and
the pes is directed vertically. The patellar tendon is traced from the patella to its insertion on the tibial
tuberosity. If the line of action of the patellar tendon is not centered on, and parallel to the trochlear groove,
then a tibial tuberosity transposition is warranted. In cases of medial patellar luxation, the line of action of
the patellar tendon is typically obliquely directed from proximo-lateral to disto-medial with respect to the
trochlear groove. Since the goals of surgery are to align the extensor mechanism and deepen the trochlear
sulcus to create a stable femoro-patellar articulation, the combination of techniques required is dependent
upon the specific abnormalities of each patient. Accurate radiographic assessment of limb alignment is diffi-
IN-DEPTH SEMINARS
cult, and requires general anesthesia and precise patient positioning to avoid positioning artifact. A complete
radiographic evaluation includes at least a lateral and ventro-dorsal view of the pelvis including the femora
and proximal tibia, and an axial view of the femur for femoral torsion angle calculation. In some cases,
cranio-caudal and medio-lateral views of the femur, and caudo-cranial and lateral views of the tibia includ-
ing the stifle and tarsus may be required, particularly if tibial osteotomy is planned. Since these radiograph-
ic views are difficult to obtain, and are highly sensitive to radiographic positioning artifact, several exposures
of each view should be obtained. A variation of more than 2-3 degrees between radiographs or between left
and right femurs in a symmetrically affected patient suggests positioning or measurement artifact.
Utilizing the results of a comprehensive clinical evaluation, the surgical treatment plan is individualized
based on the abnormalities present. In general, cases complicated by femoral varus can be subdivided into
one of several categories, based on the morphology of the tibia. In all cases, significant femoral varus is treat-
ed by distal femoral ostectomy, and the trochlear groove is deepened as needed.
FEMORAL VARUS WITH NO MEDIALIZATION OF THE TIBIAL TUBEROSITY

In this case, the corrections are the most straightforward. Femoral varus is treated with a distal femoral os-
tectomy, the trochlear groove is deepened if necessary, and the stifle is stabilized with the procedure of the
clinician’s choice, such as TPLO, TTA, or extracapsular stabilization.
FEMORAL VARUS WITH MEDIALIZATION OF THE TIBIAL TUBEROSITY

AND INTERNAL TIBIAL TORSION
In cases in which significant torsional or angular deformity exists, the TPLO procedure is best suited for
correction, since TPLO allows for simultaneous correction of limb alignment and stifle stabilization (Figure
A B
Figure 2A and B - Standard TTA (A) and TTTA (B). Note

that the caudal cage ear has been contoured and recessed into the me-
Figure 1A and B - TPLO with internal tibial torsion correction dial tibial cortex, and the plate has been contoured around the me-
resulting in lateralization of the tibial tuberosity and correction of dial tibial cortex to allow lateralization of the tibial tuberosity.
patellar tendon alignment. Reprinted from Langenbach A et al, JS-
AP 2010.
1A and B). Correction of internal tibial torsion at the level of the TPLO results in external rotation of the
distal tibial segment including the tibial tuberosity. Therefore, if the internal torsion correction results in ad-
equate lateralization of the tibial tuberosity, correcting the limb alignment can treat both.
However, if the internal tibial torsion correction results in under correction or over correction of the tuberos-
ity, a TPLO with proximal tibial osteotomy (see Figure 3A and B) is preferred, as this will allow for inde-
pendent and precise tuberosity alignment and tibial torsion correction.
Other procedures such as TTA or extracapsular stabilization can be performed, however, tibial torsion cor-
rection would require an additional tibial osteotomy, thus they are not recommended.
FEMORAL VARUS WITH

MEDIALIZATION OF THE
IN-DEPTH SEMINARS
TIBIAL TUBEROSITY
AND NO TIBIAL TORSION
The tibial tuberosity advancement
(TTA) procedure (Figure 2A) can be
modified to stabilize the stifle and trans-
late the tuberosity laterally; this has
been termed tibial tuberosity transposi-
tion advancement (TTTA) (Figure 2B)
(Fitzpatrick VOS 2008). To perform a
TTTA, the tuberosity is translated to
correct patellar tendon alignment, and
the plate is contoured to match the lat-
eralized position of the tibial tuberosity.
Additionally, the TTA cage must be
placed to match this lateralized position.
Since the medial cortex of the tibial
tuberosity and the tibia no longer lie in Figure 3A, B and C - TPLO with proximal tibial osteotomy (A and B) and
the same plane, the caudal cage ear on ostectomy (C). Utilizing an additional proximal tibial osteotomy, the tibial tuberos-
the tibial side must be contoured and re- ity segment is isolated and translated as needed to align the patellar tendon (A and
cessed into the medial tibial cortex to al- B). A proximal tibial ostectomy can be utilized to correct proximal tibial varus and
low lateralization of the cage. Alterna- valgus with or without excessive plateau angle; in the later case, the ostectomy is a
tively, washer(s) can be placed under cuneiform ostectomy.
the cranial cage ear on the tibial tuberosity. In cases of extreme lateraliza-
tion, both cage ear recession and washers may be needed. It is important
not to deplete the medial cortex of the tibia during cage ear recession, as
the cage ear must be place on cortical bone for adequate implant stability.
The TPLO procedure can be modified to allow lateralization of the tibial
tuberosity by the addition of a transverse proximal tibial osteotomy (Figure
3A and B).
The osteotomy is placed perpendicular to the tibial crest, such that it in-
tersects the TPLO at the caudal cortex. The tibial tuberosity segment can
be translated as needed to correct patellar tendon alignment. Fixation is as
for a TPLO/CCWO (Figure 4).
FEMORAL VARUS WITH TIBIAL ANGULAR DEFORMITY

Correction of complex tibial deformity including eTPA, proximal tibial
varus and proximal tibial valgus with or without tibial torsion and/or me-
dialization of the tibial tuberosity is best addressed with a TPLO and prox-
imal tibial ostectomy (Figure 3C). The ostectomy can be a medial closing
wedge to correct valgus, a lateral closing wedge to correct varus, a cranial
closing wedge to correct eTPA, or a cuneiform closing wedge to correct
both eTPA and angular deformity. Tibial torsion can be corrected at the Figure 4 - Postoperative radiograph
proximal tibial osteotomy. Fixation is the same as for a TPLO with proxi- demonstrating the typical fixation ap-
mal tibial osteotomy (Figure 4). plied to a TPLO with additional prox-
imal tibial osteotomy or ostectomy.
REFERENCES
Boudrieau RJ. Tibial Plateau Leveling Osteotomy or Tibial Tuberosity Advancement? Vet Surg 38:1-22, 2009.
Fitzpatrick N, Yeadon R, and Kowaleski M: Tibial tuberosity transposition-advancement for treatment of medial patellar
luxation and concomitant cranial cruciate ligament disease in the dog. Abstracts of the 34th Annual Conference of
the Veterinary Orthopedic Society, March 3-10, 2007; p 67.
Hoffmann DR, Kowaleski MP, Johnson KA, Evans RB, Boudrieau RJ. In vitro biomechanical evaluation of the canine
CrCL deficient stifle with varying angles of stifle joint flexion and axial loads after TTA. Abstracts of the 18th An-
nual Scientific Meeting of the European College of Veterinary Surgeons. Nantes, France. July 2-4, 2009; pp 557-559.
Langenbach A, Marcellin-Little DJ: Management of concurrent patellar luxation and cranial cruciate ligament rupture us-
ing modified tibial plateau leveling. J Sm Anim Pract 51:97-103, 2010.
Talaat MB, Kowaleski MP, Boudrieau RJ. Combination Tibial Plateau Leveling Osteotomy and Cranial Closing Wedge
Osteotomy of the tibia for the treatment of cranial cruciate ligament-deficient stifles with excessive tibial plateau an-
IN-DEPTH SEMINARS
gle. Vet Surg 35:729-739, 2006.

Weh, JL, Kowaleski MP, Boudrieau RJ. Combination Tibial Plateau Leveling Osteotomy and Transverse Corrective Os-
teotomy of the Proximal Tibia for the Treatment of Complex Tibial Deformities in 12 dogs. Submitted, Vet Surg
May 2010.
Femoral and tibial deformities associated with patellar

luxation (frontal plane, sagittal plane, torsion)
Milano
INTRODUCTION
Patellar luxation is a frequent cause of lameness in the dog and its clinical severity can vary significantly and
be asymptomatic or symptomatic intermittently or be symptomatic continuously up to the fourth grade
where the patella is permanently luxated. Medial patella luxation is the condition that is most frequently di-
agnosed independently from the breed size while lateral luxation is less common in small breed dogs and is
more frequent in large and giant breeds. Patella luxation has been defined as congenital/developmental be-
cause it is diagnosed in the first stages of the development of a puppy. Petalla luxation has been classified in
four degrees but this classification is based solely on clinical findings. Because this classification is inde-
pendent from the kind of anatomical malformations that cause the patella luxation it is useless in the surgi-
cal preoperative planning process. Classically, the main surgical techniques for patellar luxation are trochleo-
plasty, tibial crest transposition, joint capsule imbrication, medial release of the joint capsule retinaculum or
quadriceps muscle group alignment. Following a proper radiographic diagnosis corrective osteotomies allow
to treat hind limb abnormalities.
DEFINITIONS
Anatomic planes: the position of the part of the body of interest can be identified spatially in reference to
three anatomic planes which are perpendicular to each other: the sagittal, the frontal and the transverse plane.
The sagittal plane is oriented in a cranio-caudal position. The frontal plane courses in a lateral-lateral ori-
entation while the transverse plane divides the body (or the limb) into dorsal and ventral parts.
The anatomic axis of a bone segment is a line that passes through the center of the bone through the epi-
physis, methaphysis and the diaphysis. The mechanical axis is a straight line connecting the center of the
proximal and distal joints.
The varus deformity is the deformity in which the bone is deflected inward toward the sagittal median
plane of the body while the valgus deformity is the deformity in which the bone is deflected outward away
from the sagittal median plane of the body.
The procurvatum deformity is the deformi-
ty in which the bone is deflected caudally

while the recurvatum deformity is the de-
formity in which the bone is deflected cra-
IN-DEPTH SEMINARS
Rottweiler, male, 9 months, 30 Kg.

Mechanical and anatomic axes in the frontal plane Lateral patellar luxation. Diagnosis: external rotation of the
tibia. 3D reconstruction. OsiriX.
nially. Torsion is the deviation around the long axis of the bone. In a proximal to distal direction torsion can
be either internal or external. Rotation is the deviation inside the joint.
STANDARD MEASUREMENTS
Femur
The femoral anatomical axis in the frontal plane is represented by a single line, in the center of the me-
dial and lateral cortices throughout the length of the bone. In the dog, the femoral anatomic axis does not
follow a single straight line, but two straight lines, which can be defined as the Proximal Anatomic Axis and
Distal Anatomic Axis.
The femoral anatomical axis in the sagittal plane is a single line coursing through the cranio-caudal mid-
point of the bone, from the center of the head of the femur to the center of the femoral condyles. The
femoral anatomic torsion is the orientation angle of the femoral neck in the transverse plane in relation to
the femoral condyles. The joint orientation line of the proximal femur in the frontal plane is represented
by a line passing through the center of the femoral head and the most proximal tip of the greater trochanter.
The joint orientation line of the distal femur in the frontal plane is represented by a straight line pass-
ing through the most distal convexities of the femoral condyles.
Tibia
The tibial anatomic axis in the frontal plane is represented by a single contoured line centered between
the medial and lateral cortices throughout the length of the tibia. The joint orientation line of the proxi-
mal tibia in the frontal plane is represented by a line passing through the distal points of the concavities
of the tibial condyles. The joint orientation line of the distal tibia in the frontal plane, is represented by
a straight line passing through the proximal points of the medial and lateral concavities of the tibial cochlea.
The tibial anatomic axis in the sagittal plane is represented by a single contoured line centered between
the cranial and caudal cortices. The joint orientation line of the proximal tibia in the sagittal plane is
represented by a line passing through the cranial and caudal extents of the tibial plateau. The joint orien-
tation line of the distal tibia in the sagittal plane is represented by a line connecting the distal most as-
pect of the cranial and caudal cortices of the tibia.
Patellar luxation
The patella is a sesamoid bone that develops inside the tendon of the of the quadriceps muscle. It lies along
the extensor axis of the quadriceps muscle, that is the vector result of the traction force of the 4 muscles that
compose the quadriceps muscle unit (the rectus femoris, the vastus medialis, the vastus lateralis and the vas-
tus intermedius). The rectus femoris inserts distally on the apex of the tibial tuberosity and proximally from
the eminentia ileopubica. The vastus medialis muscle arises in the craniomedial surface of the proximal fifth
of the femur. Vastus intermedius and vastus lateralis arise from the craniolateral part of the proximal fourth
IN-DEPTH SEMINARS
of the femur. Patella is always along the origin and the distal insertion of the quadriceps muscles. For this
reason, in a normal dog, the trochlear sulcus is always on the same sagittal plane of the distal anatomical ax-
is of the femur. During the growing period, because of the traction that these muscles exert, the patella gen-
erates a depression on the metaphyseal curvature of the distal femur, the femoral trochlea. Any modification
to the femur, to the proximal tibia and to the relationship between the femur and the tibia and a combina-
tion of the above mentioned variation bring to a subluxation or to a luxation of the distal portion of the fe-
mur relative to the patella. From these considerations it is clear that the patellar luxations, either medially
or laterally, can be the result of relatively few causes: 1. an internal or an external tibial rotation in respect
to the femur; 2. an internal or an external tibial torsion; 3. a torsion of the distal femoral extremity (inter-
nally or externally) that produces the distal femur subluxating in respect to the patella; 4. a distal axial de-
viation of the femur in varus or valgus 5. a combination of the previous. In general, varus of the distal meta-
physis of the femur brings to the “so called” medial luxation of the patella as well as the external torsion of
the femur while the distal valgus of the femur and the internal torsion of the femur predispose to the “so
called” lateral patella luxation. Malformations of the proximal tibia (varus, valgus or torsion) with or with-
out the femoral malformations mentioned above can cause patella luxation. Torsion indicates a bone mal-
formation in which the distal articular surface is rotated internally or externally along the bone axis. This
means the twisting of one end of the bone while the other end is held fixed. This is generally the result of
an abnormal meta/epiphyseal development or secondary to an abnormal physeal growth during the devel-
opping period or secondary to a bone fracture or to a malunion. Rotation indicates malalignment in which
two contiguous bones rotate one in respect to the other around the joint plane. It can be the result of mus-
cular and tendinous contracture or of ligamentous shortenings or of a bone malformation. Torsion and ro-
tations can be combined contributing to the same malalignment.
The determination of hind limb alignment requires accurate diagnostic imaging evaluations. Radiography,
computed tomography and magnetic resonance were described. In veterinary medicine radiographic survey
was traditionally performed to diagnose hindlimb malformations but few positioning mistakes could deter-
mine significant artifacts or mistakes.
Congenital, developmental malformations can produce an alterate alignment of the femoral axis. To my
knowledge no studies have documented a developmental malformation of the tibial tuberosity alone with-
out a concomitant femoral and/or tibial deformity. For these reasons, surgery should be addressed to re-es-
tablish the anatomy focusing on exactly where the malformation is. Tibial tuberosity transposition should
be performed only when tibial tuberosity is not where it should be.
Acknowledgements: Gayle H. Jaeger

IN-DEPTH SEMINARS
Radiographic planning of femoral and tibial deformities:

CORA method
Milano
RADIOGRAPHIC PLANNING
Radiographic survey of the pelvic alignment is indicated in every case we are considering surgical correc-
tion of a deformity. A complete radiographic survey can include the following projections:
• ventro-dorsal projection of the pelvis. This projection allows for an evaluation of femoral symmetry and
alignment in the frontal plane as well as the potential for concurrent malalignment of the lumbosacral
joint, transitional vertebrae, and hip dysplasia.
• medial-lateral projections of the femurs with superimposition of the femoral condyles. Informations can
be obtained regarding the femur in the sagittal plane. The position of the femoral head and its relation-
ship to the greater trochanter can give an indication of the presence of femoral torsion.
• cranio-caudal femoral projections (sitting dog position) with the femurs parallel with the table top. This
gives information in regards to the frontal plane. Radiographs should be taken of each femur individu-
ally with the distal femoral condyles symmetrical with one another. The relationship between the posi-
tion of the femoral head and greater trochanter can give information regarding femoral torsion. The ob-
jective in positioning for this radiographic projection is not to center the patella within the femoral
trochelar grove (the patella should not be used as a reference point for femoral alignment since it is in-
dependent from the femur) but for the femoral condyles to be symmetric.
• axial projections of the femurs. This projection gives information regarding the degree of femoral torsion.
• mediolateral projections of the tibiae. This projection describes the sagittal plane and information re-
garding the tibial plateau angle.
• caudocranial views of the tibias. This projection give information related to the frontal plane and gives
clues to a potential deformity in the transverse plane.
• caudocranial projections of the tarsus. These are optional views that should be considered in breeds pre-
disposed to metatarsal rotation: Bernese Mountain Dog, Great Dane, Beauceron, Dogue de Bordeaux,
Italian Spinone, Poodle, Rottweiler, Saint Bernard, Napoletan Mastiff, Maremma Shepherd, Briard, Aus-
tralian Shepherd.
• craniocaudal projections of the entire pelvic limb with the dog in a sitting position. This projection gives
information regarding the relationship of the tibia to the femur as well as the mechanical axis of the pelvic
limb.
IN-DEPTH SEMINARS
DEFORMITY PLANNING
There are only normal reference values available for some specific breeds of dog. The ideal case when plan-
ning for a deformity correction, are those that only have one limb affected and the contralateral limb can be
considered normal and can be used as a template for correction. The patient can be affected with a bilater-
al deformity. In these cases we should compare our radiographs to those of normal dogs of the same breed.
In the case of mixed breed dogs with bilateral deformities, we should do our comparisons on dogs from
breeds morphologically close to the dog of interest.
The next step after obtaining the radiographic survey is measuring the radiographs. Measurements can be
made using dedicated software in digital imaging programs or manually from printed or conventional radi-
ographs with the aid of a pencil and eraser, ruler, and goniometer.
The articulation angle is determined from the intersection between the joint orientation line and the anatom-
ic axis of the bone. Joint angles provide information regarding alignment in the frontal plane, sagittal and
transverse plane. They don’t, however, provide information regarding the relationship between two bone
segments. Following the nomenclature proposed by Paley, the angle of articulation is composed of a 5-letter
acronym. The first letter refers to the mechanical (m) or anatomic (a) axis of the bone. The second letter in-
dicates if the angle is medial (M) or lateral (L). The third letter indicates if the angle is Proximal (P) or Dis-
tal (D) in a given bone, the fourth letter indicates the bone of interest (F=Femur, T-Tibia, etc.) while the fi-
nal letter indicates that we are referring to an angle. For example, if we want to refer to the valgus angle of
the proximal tibia, we would use mMPTA (mechanical Medial Proximal Tibial Angle).
Using this nomenclature helps to have a standard way to comunicate and express how a bone is oriented.
The mechanical and anatomic axes are useful to identify the center of rotation and angulation (CORA) of
Joint orientation lines, proximal and distal anatomical axis on the frontal and the sagittal plane. On the right radius and ulna incongruency
measurement.
a bone and determine the plane of deformity. Determining the CORA is useful to locate the origin of the

deformity, how many deformities there are (uniapical, biapical or multiapical), the severity of the deformity
and which direction they occur. The first step to determine the CORA or plane of deformity is to identify
IN-DEPTH SEMINARS
the joint orientation lines and the proximal and distal anatomic axis of the bone of interest. The intersection
between the proximal and distal anatomic axis gives the location of the CORA in that particular plane (in
uniapical deformities). The angle measured at this intersection is the magnitude of the CORA, correspon-
ding to the severity of the deformity. After defining the location of the CORA and its magnitude, we need
to determine its direction of the deformity. In cases where the deformity exists in more than one plane and
the location of the CORA is the same on different planes, a vector method is used to determine the direc-
tion and magnitude of the deformity in order to correct the deformity using a single osteotomy.
When we make an osteotomy for alignment correction, we change the relationship between the proximal
and distal segments. If the corrective osteotomy only changes these angulation between these two segments,
this is referred by Paley as an angulation only osteotomy. This can occur with or without translation of the
two segments relative to each other. The relationship between these two segments is along a single axis,
termed the Angulation Correction Axis (ACA). Paley’s rules of osteotomy state: Rule 1, If the osteotomy
line and the ACA pass through the same CORA, the bone ends will angulate relative to each other without
displacement. Rule 2, When the ACA is through the CORA, but the ostetomy is at a different level, the ax-
is will realign by angulation and translation at the osteotomy site. Rule 3, When the osteotomy and the ACA
are at a level above or below the CORA, a translation deformity will result.
Acknowledgements: Gayle H. Jaeger

DISTAL LIMB TRAUMA

IN-DEPTH SEMINAR
509 • WVOC 2010, Bologna (Italy), 15th - 18th September M.S. Bergh
Stress fractures in high performance athletes:

when advanced diagnostic imaging can tell us a story
Mary Sarah Bergh, DVM, MS, Dipl. ACVS
Assistant Professor, Orthopedic Surgery, Iowa State University College of Veterinary Medicine, Ames, Iowa, USA
Stress fractures can be career-ending injuries in performance athletes. They are considered to be secondary
to cyclic compressive loading of the bone, which leads to microcracks and adaptive bone remodeling and
modeling. Fractures occur when this bone response is inadequate or does not respond fast enough to sup-
port the applied loads. In the racing greyhound, stress fractures frequently occur in the right central tarsal
bone (CTB), metatarsal and metacarpal bones, fibula, and the acetabulum. A thorough diagnostic evalua-
tion allows a comprehensive understanding of the injury so that the treatment regimen may optimize the
outcome for the patient. In many animals with stress fractures, an accurate evaluation of the injury and es-
timated prognosis is important, as the treatment and post-operative decisions can vary greatly based on this
information. Advanced imaging may also give insight to the underlying pathogenesis of these debilitating in-
juries and lead to new investigations into ways that these fractures can be prevented.
DIAGNOSTIC EVALUATION
A presumptive diagnosis of stress fracture may often be made on the basis of physical and orthopedic
examination of the lame performance animal. Initial imaging by way of standard radiography can confirm
the diagnosis and provide some information regarding the severity of the fracture. Adjacent bones must
also be carefully evaluated. Sixty-four percent of greyhounds with a CTB fracture have at least one second-
ary tarsal bone fracture; most common is fracture of the fourth tarsal bone. (Boudrieau 1984)
Computed tomography (CT) is a valuable addition to standard radiography in the evaluation of fractured
bones, particularly those of the carpus and tarsus. Digital reconstruction can create a virtual 3-D model to
aid in evaluation. CT can provide additional information about the fracture(s) including the size of frac-
ture fragments, direction of fracture planes, and incomplete fractures, as well as information about the de-
gree of fracture comminution. Commonly, suspected two or three-piece CTB fractures, are in fact much
more comminuted. (Figure 1) Initial investigation suggests that CT more accurate at identifying the num-
ber of fracture fragments, as compared to standard radiography. (Bergh 2008) CT evaluation is also more
accurate at identifying concurrent tarsal bone fractures among dogs with CTB fractures, compared to stan-
dard radiography.
Although magnetic resonance imaging (MRI) is not commonly used to evaluate bony lesions in veterinary
medicine, there may be great value in this modality for evaluating stress fractures prior to catastrophic fail-
IN-DEPTH SEMINARS
ure. MRI is commonly used for evaluating suspected stress fractures in human athletes. A major advan-
DISTAL LIMB TRAUMA

tage of MRI is spatial resolution and specificity; it can be diagnostic within 24 hours of the onset of symp-
toms. Classic appearance of stress fractures is low signal intensity on T1 and T2 weighted images. Typical-
ly the low signal intensity is a linear band, extending from the cortex, perpendicular to the surface of the
bone. In acute injuries, a high signal region can be seen on T2 weighted images, due to hemorrhage and/or
edema. Fat suppression sequences (i.e. short
T1 inversion recovery (STIR) sequence or a
fat-suppressed T2-weighted fast spin echo
(FSE) sequence) are sensitive for the detec-
tion of edema, and thus can identify bone
bruising, which coincides with multiple mi-
crofractures within the bone itself (rather
than a stress fracture which requires a linear
component to be present).
MRI also has the ability to detect bone
pathology that may lead to bone insufficiency
and fracture in response to otherwise normal
stresses. In addition to information about the Figure 1 - Craniocaudal (A) and mediolateral (B) radiographic projection of
bone and marrow cavity, MRI may provide a racing greyhound that sustained a right central tarsal bone (CTB) fracture.
important information about cartilage dam- The radiographs suggest a dorsal and medial slab fragment, however trans-
age and other soft tissue injury that occur converse computed tomographic (C) imaging identified numerous comminuted
currently with stress fractures. pieces of the CTB in addition to the two large fracture fragments.
M.S. Bergh WVOC 2010, Bologna (Italy), 15th - 18th September • 510
OUTCOMES
Many factors can affect the outcome for an ath-
lete after a stress fracture. Importantly, appro-
priate treatment depends on an accurate diag-
nosis. It has been reported that many suspected
type III CTB fractures (medial slab fracture)
have a non-displaced dorsal slab fracture as
well. (Boudrieau 1984) Additionally, type I and
II CTB fractures (dorsal slab fractures) may
have incomplete fractures that extend in the
plantar direction. (Figure 2)
Complete identification of the fractures in these
cases, is important in order to plan a successful
fracture repair.
Based on literature and the principles of articu-
lar fracture management, if a fracture can be
anatomically reconstructed, open reduction and
internal fixation will likely offer the best prog- Figure 2 - Transverse CT image of the left (A) and right (B) tarsi from
nosis for the animal to return to being a per- a racing greyhound. This dog sustained a complete dorsal slab fracture of
formance athlete. the right central tarsal bone, as well as an incomplete fracture through the
Whereas external coaptation could be utilized as plantar process. Identification of the incomplete fracture is important to
a treatment modality for most stress fractures, it prevent displacement during surgical repair of the dorsal slab fracture.
may be associated with a less favorable outcome.
In one study of greyhounds with CTB fractures,
fewer dogs (58%) treated with external copatation returned to racing, compared to dogs treated surgically
(88%). (Boudrieau 1984)
Additionally, surgically treated dogs had a lesser degree of osteoarthritis. Follow-up on these dogs revealed
that most dogs had radiographic evidence of intertarsal ankylosis, however, this did not appear to adverse-
ly affect post-operative outcome.
Importantly, robust contemporary data on the clinical outcomes of most stress fractures in racing grey-
hounds especially those of the CTB are lacking. Advances in imaging technologies and post-operative re-
habilitation programs may provide new information (and potentially better outcomes) on these dogs prior
to treatment, and in the follow-up period. For example, the prevalence of bone bruising in racing grey-
hounds is unknown, but it may play an important factor in clinical performance both before and after cat-
astrophic stress fracture. In humans, bone bruising is suspected to coincide with pain and have substantial
prognostic implications by affecting the short-term clinical morbidity, time to resolution of clinical signs,
and the long-term outcome.
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DISTAL LIMB TRAUMA
CLUES TO UNDERLYING CAUSE AND PREVENTION OF STRESS FRACTURES

The phenomenon of stress adaptation of bone in both human and animal athletes is well documented.
The mechanisms by which adaptive bone modeling and remodeling becomes insufficient to accommodate
the applied forces remains an area of active investigation. To date, few studies have investigated natural-
ly occurring stress fractures in small animals.
Evaluation of the dorsal slab component of fractured right CTB has revealed large branching arrays of
microcracks. (Tomlin 1999) It has been hypothesized that these microcracks accumulate until catastroph-
ic failure occurs by crack propagation or coalescence. Evaluation of entire fractured right CTB of racing
greyhounds has found that fractures occur through regions of bone that had greater density than both
contralateral left CTB and non-fractured right CTB. (Bergh 2008) It is possible that an adaptive response
resulted in this dense, and possibly more brittle, bone causing it to fail under load. Further evaluation of
the biomechanical properties of this bone is warranted.
Prior to catastrophic failure, early adaptive and pathologic changes may be seen in vivo on CT and MRI. If
an incomplete fracture or region of microfractures is identified, a decrease in the training regimen should be
initiated.
Decreasing the frequency or magnitude the applied cyclic forces on the bone will allow partial to complete
reversal of the changes. (Johnson 1999) Repeat imaging of the animal prior to reintroduction to training is
ideal to confirm resolution of pathologic changes. Training of the animal must begun slowly after prolonged
inactivity, as rest will also cause remodeling and modeling of the bone which may weaken it when large
and/or repetitive forces are applied during training.
511 • WVOC 2010, Bologna (Italy), 15th - 18th September M.S. Bergh
REFERENCES
Bergh MS. Radiographic, computed tomographic, and histologic study of central tarsal bone fractures in racing grey-
hounds. MS thesis, The Ohio State University, Ohio, USA, 2008.
Boudrieau RJ, Dee JF, Dee LG. Central tarsal bone fractures in the racing greyhound: a review of 114 cases. J Am Vet
Med Assoc 184:1486–1491; 1984.
Boudrieau RJ, Dee JF, Dee LG. Treatment of central tarsal bone fractures in the racing greyhound. J Am Vet Med Assoc
184:1492–1500; 1984.
Johnson KA and Muir P. Asymmetric adaptive metacarpal bone remodeling in racing greyhounds. Vet Surg 25:444;
1996.
Johnson KA, Skinner GA, Muir P. Site-specific adaptive remodeling of greyhound metacarpal cortical bone subjected to
asymmetrical cyclic loading. Am J Vet Res 62:787-793; 2001.
Johnson KA, Muir P, Nicoll RG, and Roush JK. Adaptive remodeling of central tarsal bones in racing greyhounds. Vet
Surg 28:203; 1999.
Lee JK, Yao L. Stress fractures: MR imaging. Radiology. 169:217-20;1988.
Tomlin JL, Lawes TJ, Blunn GW, et al. Fractographic study of racing greyhound central tarsal bone failure surfaces us-
ing scanning electron microscopy. Vet Surg 28:217; 1999.
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DISTAL LIMB TRAUMA
Extreme fracture repair: the wise

GUIDELINES
Seemingly similar situations involving the long bones of the distal extremity may be rightfully managed in
quite different ways dictated by sometimes subtle differences in the nature of the fracture. Striving for per-
fection is often purported to be a worthy goal…and it is an ideal goal. However, sometimes in the real
world it is well to remember that the enemy of good is better and “quitting when you are ahead is not the
same thing as quitting” American Gangster – movie line. Occasionally principles will be compromised in def-
erence to the harsh light of reality. The failure to realize one principle may compromise the ability to
achieve another…for example the failure to achieve rigid fixation may impact the important goal of early
range of motion.
COMPLEX FRACTURES OF THE CARPUS AND TARSUS

In general, most fractures of the carpus and tarsus are managed with screws, pins and wires. Virtually every
fracture from the malleoli to the bases of the metatarsals (tarsus) and from the styloids to the bases of the
metacarpals (carpus) may be appropriately managed with a pin, a wire or a screw or some combination
thereof. Don’t make it more difficult than it needs to be. Few instruments are required….generally, no plates
are required. A small inventory is needed and the fractures are generally closed. There is a potential for great
results however, you must know some anatomy.
COMPLEX FRACTURES OF THE DISTAL TIBIA

Different surgical management of comminuted fractures of the distal tibia at/or quite close to the tarsocrur-
al joint, two of which were open fractures. Reconstruction varied from the simple to the more complex: 1)
pin and figure-of-eight wire, 2) plate, 3) hybrid external fixator, 4) reconstruction plus trans-articular exter-
nal fixation, or other external support. Those that are not able to be reconstructed are usually resolved by
arthrodesis.
Case 1) Luxation of the tarsocrural joint with significant instability and soft tissue swelling was present. We
were unable to determine the status of the malleoli and collaterals from the radiographs. The skin
was bruised, but intact. A closed joint reduction was achieved and the limb was re-radiographed.
The medial malleolus had two avulsions and the lateral malleolus was fractured. Anatomic reduc-
tions were maintained via pins and figure-of-eight wires. Patient returned to compete as an elite ath-
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DISTAL LIMB TRAUMA
lete and 30 month post-op films are available.
Case 2) Grade II open comminuted fracture of the distal tibia was sustained secondary to a dog fight.
Wound location and fracture configuration made anatomical reconstruction with cranial plate place-
ment a viable option.
Case 3) Very comminuted open fracture of the distal tibia with excessive soft tissue swelling was presented.
The fracture extended to within 9mm of the tarsocrural joint. This very small distal fragment lends
itself to the utilization of a hybrid fixator. The ring component of the hybrid fixator allows multiple
points of fixation with pins or tensioned wires. The linear component allows the use of half pins.
Case 4) “The pilon fracture, a metaphyseal injury extending into the ankle joint is difficult to treat success-
fully by any method”…Tile. They always seem to be worse than they appear. The “gold standard”
in human orthopedics consists of: 1) anatomic reduction of the articular surface via K-wires 2) graft
metaphyseal defects 3) reduce metaphyseal and diaphyseal components 4) once reduced, secure fix-
ation of the articular components by lag screws and 5) buttress metaphysis and fix diaphysis so that
early motion may begin. The problem is 1) the canine has “no anatomical functional fibula” to act
as an internal strut as is present in man. 2) No “off the shelf” customized (multiple sizes) plate is
available to act as a medial buttress of the tibia. 3) The canine loads the limb immediately after sur-
gery. Therefore, at the expense of early range of motion we may need to protect the repair with
some form of external support.
COMPLEX FRACTURES OF THE DISTAL RADIUS

(comparable to distal tibia)
ACUTE TARSOCRURAL OR ANTEBRACHIOCARPAL INSTABILITY

Current recommendations for acute management would include:
1. Minimize the swelling and discomfort with a modified Robert Jones bandage and splint support for 24
hours, and then reassess under analgesia/anesthesia after the swelling and discomfort has subsided.
2. Repeat the physical and radiographic exam prior to and after any closed joint reduction.
3. Address avulsions and other fracture components via anatomical reduction and internal fixation.
4. Address soft tissue components via “capture techniques”, soft tissue anchors, or anatomically-based tran-
sosseous tunnels in conjunction with the appropriate autogenous or synthetic material.
5. Failed (or anticipated failure of) reconstruction is usually addressed by arthrodesis.
“Watch out for the man who says he can do good work with poor tools. This is a sense of self satisfaction
later to be followed by stiff punishment”… Grecian
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Fracture fixation - the weird

Noel Fitzpatrick, DUniv MVB CVR CSAO MRCVS
‘Weird’ fracture repair in the context of this lecture has been interpreted as situations of repair or salvage of
the appendicular or axial skeleton where conventional methodologies of intervention may be precluded or
deemed unlikely to succeed or where a novel or innovative solution may have salient advantages in the es-
timation of the author. “Weird” solutions for traumatic injury may be justified where treatment by any tech-
nique may be considered exceptionally challenging. The author does not perceive that ability to perform a
particular technique per se validates or vindicates its application, but rather that “weird” fracture manage-
ment techniques should be reserved for situations where tried and tested conventional techniques may be
suboptimal. The technique applied must be in the interests of that individual patient and furthermore should
aim to provide an appropriate balance between optimizing both the biologic and biomechanical environment
most conducive to healing. Many such techniques aim to salvage compromised biologic environments or to
salvage pain free functional quality of life for the patient through limb salvage, if salvage of the biologic el-
ements is precluded by profundity of trauma. The aim is provision of a solution for a challenging environ-
ment with optimization of prognostic variables.
There are unique challenges posed by certain configurations of skeletal trauma and by certain patients due
to biologic or mechanical factors, such as age, activity type or species. In this regard, cats pose challenges
which are fundamentally different to dogs. In the distal limb of cats and small dogs blood vessels are small
and relatively fragile, rendering them highly susceptible to traumatic injury and occlusion. Furthermore, col-
lateral blood supply may be limited and close proximity may result in simultaneous injury. Paucity of soft
tissue cover is a salient issue, particularly over the distal limb in feline patients, and lifestyle may predispose
to relatively high energy traumatic events. Open fractures are common, and bulky internal implants are
commonly associated with major soft tissue morbidity. Small bone size in cats is associated with relatively
thick cortical bone and a narrow medullary cavity. Osteogenic precursor cells from cancellous bone are
therefore limited at fracture sites such as distal tibia and radius in some cats and small breed dogs with poor
quality and size of fracture haematoma for initiation of secondary bone healing. Appropriate implant selec-
tion for small patients may be challenging, with a limited range of available implant sizes commercially avail-
able. This particularly applies to plate and screw fixations. 1.5mm and 2.0mm plates and screws would be
considered applicable for most feline appendicular applications, but due to their relatively small cross-sec-
tional area, they are exponentially less stiff and more susceptible to fatigue failure than equivalent implants
of larger size. 2.7mm plates and screws may be used in many feline applications but their large size carries
an increased risk of bone fissuring during application and the wider spacing of screw holes compared with
IN-DEPTH SEMINARS
smaller plates means that fixation of small bone fragments may be particularly challenging. While external
DISTAL LIMB TRAUMA
fixation techniques may appear more readily applicable in small patients, their relative bulk and weight may
introduce further difficulties in certain circumstances. Furthermore, the narrow limits of stress/strain toler-
ances of healing bone may be challenging to control where implant selection is dictated by bone / fragment
dimensions rather than deliberate surgeon selection. More recently, 2.4 mm implant sizes have proven pop-
ular. External coaptation may be highly challenging to maintain due to limb shape and conformation in
some trauma scenarios in small dogs and cats and even when appropriately maintained, soft tissue morbid-
ity remains a major issue with narrow tolerances for inappropriate pressure or friction, and potentially lim-
ited local vascularity in the region of injuries
Various common, well-documented injury configurations in any small animal patient can pose significant
therapeutic challenges using conventional management techniques. Below is a head-to-toe guide of weird
methodologies that may be used to circumvent these issues.
“WEIRD” METHODOLOGIES FOR “CONVENTIONAL” AXIAL SKELETAL INJURIES

Maxillary, mandibular and skull fractures
Patients affected by trauma of the skull and mandible are frequently concomitantly afflicted by additional soft
tissue trauma including exophthalmus (which may necessitate enucleation), severe intranasal trauma and oc-
casionally significant intracranial swelling with neurological compromise, all of which increase the challenges
associated with successful patient management. Many patients may be unable or reluctant to eat, which can
be contributed by loss of olfactory function in the case of nasal obstruction. As a result, aggressive systemic
stabilization is commonly indicated prior to or concomitant with definitive surgical treatment of osseous in-
jury. Oesophagostomy tube placement is a versatile, technically simple, and time-efficient procedure to per-
form, management of oesophagostomy tubes is straight-forward by comparison with most alternative enter-
al feeding tubes, and may be an extremely helpful short- to medium-term adjunct to patient care. Mandibu-
lar fractures account for about 15% of all feline fractures, with the mandibular symphysis accounting for 73%
of those. Fractures of the body of the mandible account for a further 16% of mandibular fractures. Surgical
management to restore dental occlusion is invariably indicated. Conventional fixation methodologies may be
challenging to apply due to the complex 3-dimensional osseous topography, associated dental and neuro-vas-
cular structures, and variable soft-tissue coverage of the bone within the oral cavity. Fracture comminution,
dental loss and trans-oral placement of endotracheal tubes at general anaesthesia further contribute to chal-
lenges associated with management of these fractures, and may preclude successful application of conven-
tional fixation methdologies such as interfragmentary orthopaedic wire loop placement, reconstruction plate
and screw application, interdental wire placement, and interarcade fixation techniques.
The author’s technique of choice for the majority of mandibular fracture configurations is use of a “free-
form” external fixation device using epoxy resin putty as an external bar. Unilateral or bilateral configura-
tions may be used, while full radial “bumper” bars with a cranial component may prevent “normal” post-
operative eating and drinking, particularly from a standard bowl. IMEX™ miniature interface pins (Imex™
Vet Inc., Longview, Texas) are ideally suited for this application since they can be placed without pre-drilling,
have threaded portions for bone purchase, and have a roughened shaft for resin putty application. Place-
ment of at least one trans-mandibular pin is recommended during application of this technique, even with
unilateral fractures since this significantly increases construct rigidity. This should usually be performed rel-
atively cranially and ventrally in an effort to avoid compromise of tongue function and to avoid tooth roots.
Placement of multiple small diameter pins provides rigid and durable frame configuration while allowing
versatile pin placement to avoid tooth roots, neurovascular or other soft tissue structures (e.g. salivary tis-
sue) or fracture lines. Frame and pin removal can typically be performed 3-6 weeks post-operatively.
Trans-gnathic external fixation may be rapidly employed for definitive realignment of mandibular fractures
and/or temporo-mandibular luxations, and observes principles of biologic fracture fixation for multiple trau-
ma configurations. One or two threaded pins are placed caudal to the maxillary incisors and two pins are
placed between the mandibles which serve to maintain sagittal plane alignment of the mandibular rami and
to secure appropriate symphyseal alignment. The mandibular pins are attached to one or two pins in the
maxilla, and following temporo-mandibular / maxillo-mandibular alignment, mandibular and maxillary
components are attached using conventional linear, circular or freeform (epoxy resin or acrylic) external fix-
ation apparati.
In minimally displaced maxillary fractures, mucosal suturing may provide adequate stabilization, but more
commonly, transmaxillary implant placement is necessitated and may be most simply achieved using a cross-
pin technique, or by placement of a “free-form” external fixation system similar to that described for the
mandible. Many other fractures of the skull can be managed non-surgically, the exceptions being depressed
fractures of the calvarium associated with cranial neurological signs, and certain sinus fractures which have
the potential to act as a one-way pneumatic valve resulting in progressive subcutaneous emphysema. Orbital
IN-DEPTH SEMINARS
DISTAL LIMB TRAUMA
fractures may also result in complications associated with communication of the airway with the orbital
space, particularly involving development of infection.
Axial skeletal trauma

Thoracic or other systemic injury is particularly common in small animal trauma patients and all patients
should undergo full systemic evaluation and stabilization. Diaphragmatic ruptures are common and may be
associated with progressive dyspnoea over several days and may be a significant cause of mortality, partic-
ularly in feline trauma patients. Tracheal ruptures or avulsions are also occasionally identified associated
with emphysema of the cervical soft tissues, pneumomediastinum, or occasionally pneumothorax and war-
rant immediate investigation with a view to surgical repair. Rib fractures are frequently identified, but only
warrant surgical stabilization if they result in gross thoracic wall instability or cause unmanageable levels of
discomfort. Where surgical treatment is required, placement of fine orthopaedic wire interfragmentary loops
through small drill holes is ideal although the costal bone is typically very soft and is easily fissured or frag-
mented during wire tightening. Polydioxanone interfragmentary sutures, or even primary suture repair of
torn intercostal and overlying musculature may be adequate in many cases and may limit potential mor-
bidity. Attempts at skewer wire and tension band fixation wire fixation may also commonly cause further
fissuring and are not recommended.
Spinal injury is an infrequent but challenging presentation in small animal trauma patients. In the experi-
ence of the author, the most common presentation is of thoraco-lumbar fracture/luxation associated with
moderate to severe bilateral pelvic limb neurological deficits. Fractures of the dorsal lamina and facet regions
are not uncommon, but the most common significant lesions, particularly in cats tend to be fractures in the
region of the vertebral end plate associated with lateral luxation at this level. Orthogonal radiography is crit-
ical to identification of these lesions since many are challenging to identify solely on lateral views, although
CT or MRI are preferred if available. While conservative management may be adequate in some patients,
compliance with appropriate limitation of activity and administration of physical therapies may be chal-
lenging to orchestrate, especially in smaller patients, and appropriate analgesic management can be particu-
larly difficult in some patients. The author has had considerable and reliable success with decompressive
hemilaminectomy followed by surgical reduction and stabilization using a vertebral body pin and bone ce-
ment bolus technique, all conducted on the most “concave” aspect of the spinal column. In larger patients,
locking plate application such as the String-Of-Pearls implant (SOP™, Orthomed, Huddersfield, UK) may
be possible, and may circumvent challenges associated with use of bone cement boluses in this location, but
appropriate contouring to optimize screw placement can be technically challenging. In the case of caudal
lumbar and lumbosacral fracture-luxation configurations, L7-S1 facet screw and transilial-translumbar pin
configurations are easily applied and generally provide satisfactory healing and clinical outcomes. For more
complex fractures in this anatomic location, pins and polymethylmethacrylate cement fixation may also be
efficaciously employed.
“WEIRD” METHODOLOGIES FOR “CONVENTIONAL” APPENDICULAR

SKELETAL INJURIES
Appendicular fractures are particularly common in small animals. Since many are “high energy” impact in-
juries, comminution and disruption of adjacent soft tissues and local biology is common.
THORACIC LIMB
Scapular fractures
Proximal and mid-body scapular fractures are uncommon and seldom necessitate surgical stabilization.
However, infrequently, fractures of the distal scapula or glenoid may be identified and may pose a signif-
icant therapeutic challenge. In many cases, arthrodesis of the shoulder joint may be necessitated by injury
configuration for fractures in this region, particularly for articular glenoid fractures, and may be achieved
by plate and screw application following excision of the articular surfaces. Screw purchase in the feline scapu-
la is poor even at the base of the scapular spine, and accurate plate contouring may be challenging so lock-
ing plate application may be beneficial. In a current retrospective review of 12 dogs undergoing recent shoul-
der arthrodesis by the author, application of the String-of-Pearls plate (SOP™, Orthomed, Huddersfield,
UK) was found to be technically straightforward by comparison with standard dynamic compression or re-
construction plates, and was associated with positive clinical outcomes.
Humeral fractures
Humeral fractures are more common, and range from more simple diaphyseal fractures to complex “Y”
or “T” fractures of the humeral condyle. In the diaphyseal region, fractures are typically oblique or spiral
IN-DEPTH SEMINARS
DISTAL LIMB TRAUMA
in configuration and follow the “musculo-spiral groove” toward the supracondylar region. A range of fixa-
tion techniques are reported and selection largely depends on precise fracture configuration and availability
of bone stock for implant placement. Proximity of neurovascular structures in this region including presence
of the supracondylar foramen in cats (containing the radial nerve and brachial artery) may contribute to de-
cision making for selection of fixation methodology. Intramedullary pins and cerclage wire may be particu-
larly challenging to use appropriately in this location due to the complex osseous anatomy. Plate and screw
fixation is commonly applicable although contouring to match the three-dimensional shape of the humerus
may be challenging except for the most cranio-lateral portion, while the proximity of neurovascular struc-
tures, close association with musculature, and variable fracture configuration distally makes the surgical ap-
proach challenging. External fixation with or without a tied-in intramedullary pin may be applicable to the
majority of fractures, and hybrid circular systems may optimize limited distal bone stock by allowing place-
ment of fine wires in the region of the humeral condyle.
A significant proportion of other fractures involve the humeral condyle with the lateral condyle most com-
monly affected. While simple lateral or medial condylar fractures may be stabilized by transcondylar screw
and antirotational epicondylar implant placement, Y, T and comminuted configurations may necessitate ad-
vanced internal and external fixation techniques. In smaller patients, and particularly cats, application of ad-
equately robust internal fixation implants can be extremely challenging, especially where supracondylar
comminution is present. Circular or hybrid external fixation may be employed with olive/stopper wire fixa-
tion to achieve intracondylar compression and may be useful to circumvent these challenges. Accurate place-
ment of olive wires can be achieved by pre-drilling inside-to-out fashion followed by outside-to-in wire place-
ment to achieve compression.
An additional alternative to standard compression screw placement in medium sized or larger patients is the
titanium Acutrak™ (Acumed, Hillsboro, Oregon, USA) screw. Benefits include cannulation which increases
reliability of placement within the relatively narrow humeral condyle, and its headless design which mini-
mizes soft tissue irritation and eliminates the risk of splitting small bone fragments during countersinking.
The variably-pitched, tapered design means that the screw is self-compressing, while allowing for purchase
in new bone for each rotation during insertion. The author has had considerable success with management
of humeral condylar fractures using this technique, and in conjunction with autogenous bone core dowel
placement for management of Incomplete Ossification of the Humeral Condyle which may predispose to
pathological humeral condylar fracture in some patients.
Radius and ulna fractures

Fractures of the radius and ulna are extremely common with wide variation in location and configuration
and with comminution being a frequent feature. Plate and screw constructs or external skeletal fixation are
the most commonly employed implants. However, in some very small patients, such modalities may be tech-
nically challenging and the author has seen iatrogenic fracture through implant-bone interface sites. Bone
plate application may also be associated with stress protection and ulna resorption as well as loss of carpal
flexion due to interference with the extensor tendons. Plate removal may be indicated necessitating a second
procedure, and re-fracture through a screw hole is not uncommon.
While the published literature reports a high incidence of complications including delayed or non-union, the
author has successfully employed intramedullary pins recessed and countersunk from the distal radial ar-
ticulation with Type 1A external skeletal fixation in small thin-boned dogs and cats with excellent results
and no apparent morbidity associated with the transgression of the most dorsal aspect of the articular sur-
face of the distal radius. The author has also applied the technique to a 700g chinchilla using spinal needles
as intramedullary pins.
Application of bone graft may be beneficial in all but the most biologically robust fracture scenarios. Auto-
genous cancellous bone graft such as from the proximal humeri is ideal, but the available quantity and qual-
ity of graft material in smaller or older patients may be of concern. Autogenous cortico-cancellous bone from
the iliac crest is a viable alternative in such patients. However, adjunctive products such as freeze dried al-
lograft bone chips (Veterinary Transplant Services®, Kent, WA) may be highly advantageous in select cir-
cumstances, as may synthetic or processed osteoinductive agents including collagen based scaffolds (e.g. Col-
loss®, VetCell Bioscience Ltd, Burford, UK) or synthetic bone morphogenic protein agents. Such products
may be a particularly useful addition to fracture management in toy breed dogs where biologic potential for
osseous healing may be suboptimal.
Carpal Bone Fractures

The canine radial carpal bone has three centers of ossification and fracture of the radial carpal bone has been
documented through the fusion planes. Documentation of incomplete radial carpal fracture is consistent
IN-DEPTH SEMINARS
DISTAL LIMB TRAUMA
with aetiopathogenesis of incomplete ossification in some breeds, most notably the Boxer. Pro-dromal lame-
ness may precede overt debilitation. Stabilization of these fractures by means of conventional lagged bone
screws can be problematic due to fracture orientation and interference of the screw head with periarticular
soft tissues. A cannulated, headless, titanium, variable-pitched, tapered, self-compressing screw (Acutrak™,
Acumed, Hillsboro, Oregon, USA) is employed by the author to repair sagittal or single bi-planar fractures
of the radial carpal bone. The screw may be accurately inserted along a guide-wire and may be countersunk
beneath the articular surface of the radial carpal bone to compress the fusion plane. Headless design reduces
the risk of splitting small fragments and core screw size is small compared to conventional alternatives of
similar strength. Osseous union can be achieved with restoration of normal integrity and stability and with-
out residual pain, restriction of motion or lameness. Casting is not required. By contrast, cast immobiliza-
tion alone has been linked with a high incidence of pseudoarthrosis, whilst lag screws may result in reduced
range of motion and fragment removal may decrease carpal stability. In the case of comminuted radial carpal
fractures, pancarpal arthrodesis may still be required to salvage limb use. In this regard the author’s prefer-
ence is minimally invasive application of a hybrid 3.5/2.7 or 2.7/2.0 plate onto one metatarsal after de-
bridement of the radio-carpal and intercarpal joint levels and packing with cancellous graft. The author does
not apply external co-aptation splinting and has experienced success in a large case series.
PELVIC LIMB
Pelvic fractures
Pelvic fractures are common in small animals. Absolute indications for surgical intervention include pelvic
canal narrowing, impairment of urinary or faecal function, neurological compromise and articular fractures,
but surgical stabilization is also beneficial in achieving early analgesic control and early return to ambulato-
ry function, particularly where fractures involve the major weight bearing axis. Conventional repair tech-
niques involve combinations of plate and screw placements with occasional use of interfragmentary pins or
wires. However, surgical exposures required for these techniques are often extensive, particularly where mul-
tiple pelvic fractures necessitate separate repairs, and bone quality may be poor resulting in implant loosen-
ing or migration necessitating later removal.
Several reports published in the 1940s-1970s described the successful use of Kirschner-Ehmer splints for the
stabilization of pelvic fractures. The author has developed and applied external fixation for all configura-
tions of pelvic fracture in both cats and dogs for several years with considerable success. Application can be
performed through minimal approaches to the ilium and ischium, avoiding disruption to the biologic enve-
lope using limited window visibility or digital palpation of fractures including acetabular fractures, and cor-
ridors for optimal pin placement have been established. The technique facilitates sequential realignment of
fracture segments by placing 2-3 pins per major bone segment on separate connecting rods and attaching ad-
jacent segments with link rods (Pin Anchor Realignment Technique, PART), enabling accurate reduction to
be achieved, which may be difficult with convention plating systems. In cats, the techniques are sometimes
more readily applied than in dogs due to relatively superficial pelvic bone prominences, less bulky muscle
mass, and frequent presence of multi-component or comminuted fractures which either require extensive
soft tissue dissection or are un-reconstructable with internal fixation. Fixation has been demonstrated to have
superior mechanical properties to plate and screw fixation in a canine ilial fracture model. Frame design can
be readily modified to incorporate stabilization of hip luxation, and has been applied for revision of a num-
ber of cases with pelvic canal narrowing initially managed conservatively. Frame removal can typically be
performed at 4-6 weeks and bone healing has been consistent.
In a series of 131 cats treated with pelvic fractures 38 acetabular fractures were documented; 15 of 38 were
simple, 10 were mildly comminuted and 13 were highly comminuted. In all cases satisfactory outcome was
achieved due to the formation of a functional fibro-osseus union at the acetabular site. Surgical time in the
author’s hands is almost invariably reduced by comparison with conventional internal fixation methodolo-
gies, with the longest procedure noted in the above series of pelvic ESF being a comminuted acetabular frac-
ture with involvement of the caudal ilium, bilateral SI luxation and contralateral ilial fracture, for which the
surgical time was 92 minutes. ESF for pelvic fractures allows any combination of pelvic injuries to be treat-
ed simultaneously with good outcomes. Pelvic ESF may be ‘weird’, but results in some wonderful outcomes
for cases sometimes conventionally deemed non-operable.
Femoral fractures
Femoral neck fractures can be frustrating to realign and secure in appropriate apposition. Conventional
crossed K-wires can be employed with or without fluoroscopic guidance and the author has found the can-
nulated, variable-pitched, tapered, self-compressing Acutrak™ screw (Acumed, Hillsboro, Oregon, USA)
helpful with respect to apposition and appropriate fixation. Proximal juxta-articular fractures may also be
IN-DEPTH SEMINARS
DISTAL LIMB TRAUMA
challenging and locking plates such as the String-of-Pearls plate (SOP™, Orthomed, Huddersfield, UK)
may be very helpful where there is only room for one or two screws in the proximal segment. Similarly for
comminuted un-reconstructable mid-diaphyseal femoral fractures there is a strong indication for applica-
tion of locking implants. Whether locking or conventional implants are required, special care must be ex-
erted to assure alignment of the distal femoral segment in appropriate orientation to avoid iatrogenic patel-
lar luxation, particularly in cats.
Comminuted mid-diaphyseal segments can be locally recruited by means of polydiaxonanone cerclage las-
so technique and considerably improves healing propensity in the author’s view. String-of-Pearls plate ap-
plication is also particularly helpful for salvage following iatrogenic femoral fracture during placement of the
stem component in total hip replacement. For distal femoral articular fractures particular attention must be
given to anatomic fracture fixation and transarticular external skeletal fixation may be helpful as temporary
ancillary support. TAESF may also be useful in rehabilitation of quadriceps contracture or patellar tendon
rupture following traumatic disruption of the femur and surrounding musculature. Total stifle replacement
with constrained and unconstrained implants is now a viable salvage option for un-reconstructable stifle frac-
ture/traumatic disruption in both cats and dogs.
Tibial fractures
Tibial fractures in cats and toy breed dogs represent a major and perhaps under-estimated orthopaedic chal-
lenge. Very distally located, highly comminuted fractures with overlying soft tissue trauma are not uncom-
mon. The small medullary canal and poor local vascularity in cats and toy breed dogs may predicate slow
bone healing, with risk of delayed or non-unions akin to those more commonly identified in the ante-
brachium in these patient groups. While external fixation, particularly circular hybrid fixation may be ap-
plicable for many fractures, allowing optimization of limited distal bone stock, durability may be insufficient
in some cases, and bulky or heavy frame constructs in this location may hinder normal ambulation. The au-
thor has had most consistent results with a double-plate technique involving application of small sized dy-
namic compression or veterinary cuttable plate application both medially and cranially, allowing multiple
screw placement even in very distal bone segments and excellent multi-planar stability.
Tarso-crural disruption
In extremely distal tibial fractures, and in other cases of tarsal injury (including talo-crural luxations, shear-
ing injuries, articular talar fractures, etc.), pantarsal arthrodesis may be indicated, and this can be techni-
cally challenging, particularly in cats or toy breed dogs. Dorsal plate application is technically simplest and
most amenable for the range of standard implants commercially available for many patients (with standard
L-shaped plates intended for medial application being available only in a limited selection of sizes). How-
ever, dorsal plate application is mechanically unfavourable, being effectively on the compression surface of
the hock. The author has developed a pre-contoured tapered extended length plate with ovoid holes adja-
cent to the talocrural joint allowing for greater screw angulation and aiding placement of at least one screw
through the plate into the calcaneus (FitzPANTA plate - canine). This implant facilitates a minimally inva-
sive approach and appropriate tibio-tarso-metatarsal alignment and clinical outcomes have been good. The
author has experienced challenges with metatarsal anchorage and stress-risers using medially-applied
plates. In cats the author has previously harnessed the biomechanical benefits of plate-rod stabilization by
application of the Acutrak Fusion™ screw (Acumed, Hillsboro, Oregon, USA) as an intra-medullary cal-
caneo-talo-tibial rod in conjunction with dorsal 2.0mm plate and screw application with excellent results in
a large number of cats while avoiding issues with soft tissue implant coverage. Although associated with
good outcomes the procedure can be technically challenging and thus the author has designed a new hy-
brid 2.4/2.0 dorsal hybrid tapered plate (FitzPANTA plate - feline) which is biomechanically resilient and
has yielded very favourable results. Freeze dried allograft bone chips as discussed above provide a useful
augmentation to this surgery.
Metacarpal (MC) and metatarsal (MT) fractures

Successful treatment of multiple juxta-articular MC or MT fractures can be challenging. This is particular-
ly true when the fractures are comminuted, especially in cats and small dogs and cats. Conventional tech-
niques such as normograde intramedullary pin insertion through a separately created “slot” in the dorsal as-
pect of the head of the MT or MC bone risks “splintering” of the bone during pin insertion and has an in-
trinsic risk of transcortex pin penetration. Bending of small diameter pins which are necessitated by this tech-
nique may occur with an increased risk of subsequent fracture malunion. “Dowel” intramedullary pin tech-
nique allows the use of a relatively large diameter pins, however, this technique may be impossible with com-
minuted juxtarticular fractures. Furthermore, in cases of open fractures, concerns regarding implant removal
IN-DEPTH SEMINARS
DISTAL LIMB TRAUMA
for reasons such as infective osteomyelitis are significant. Some authors describe external coaptation follow-
ing failed attempts at internal fixation for what can be devastating injuries.
Application of internal fixation may be precluded by paucity of bone stock for screw application or re-
quirement for multiple bulky fixation elements with limited soft tissue cover. The use of conventional ex-
ternal fixation for such injuries may be considered, however in our experience, application of adequate
numbers of transverse pins may not be possible for juxta-articular fractures where fracture segments are
unusually short or severely comminuted. Placement of fixation pins in the distal row of tarsal or carpal
bones may permit increased bone purchase for proximal juxtarticular fractures, however this is not pos-
sible with fractures of the distal aspects of the MT or MC bones. Additionally, alignment of MC or MT
bones is difficult with conventional ESF and occurrence of synostosis is frequent in the author’s experi-
ence. Currently there are no reported techniques which facilitate reliable and successful treatment of chal-
lenging juxta-articular MC/MT injuries. Such injuries are not uncommon and in a recent series from our
hospital 73 of a total of 112 individual bone fractures affected the proximal or distal thirds of the MC or
MT bones, 23/112 fractures were comminuted in configuration, and the majority of subjects were cats or
small breed dogs.
Secured Pin Intramedullary Dorsal Epoxy Resin (SPIDER) external fixation stabilization offers a viable re-
liably robust stabilization across a range of fracture configurations including juxta-articular fractures with
very small fracture segments or fractures with comminution or bone loss. The techniques entails placement
of intramedullary pins of 50%-75% medullary diameter driven into the distal fracture segment via a limited
open approach directly over the fracture site. The pins are driven distally through the MT-P or MC-P joints
and through the skin, with attempts made to angle the pins such that they exit as far dorsally as possible
through or immediately adjacent to the MT-P or MC-P joints. The pins are then withdrawn until the pin tip
at the fracture site is level with the fracture line. Fractures are then manually reduced using the pins placed
in the distal fracture segment for fragment manipulation and the pins are driven into the corresponding prox-
imal MT or MC fracture segment or in some cases into the distal row of tarsal/carpal bones to improve bone
purchase, particularly for management of proximal juxta-articular fractures.
One or two further pins are placed transversely across the bases of the MT or MC bones and/or across the
distal row of tarsal or carpal bones to create rigid proximal anchors for the frames. All exposed pin ends are
then contoured dorsally such that they converge over the dorsal aspect of the pes or manus and a bolus of
activated epoxy resin putty is compressed over the pin ends and allowed to cure. Risk of thermal injury dur-
ing epoxy putty curing is minimized by placement of a wooden spatula between the epoxy putty bolus and
skin and by lavage of the visible pin segments. Care is taken to ensure an appropriate gap is left between the
skin surface and resin bolus to allow for post operative limb swelling.
In our series of 12 dogs and 19 cats significant changes were not noted in association with any carpo-MC
or tarso-MT joint in any case at long term follow-up of a minimum of 6 months. All patients were reported
to be weight bearing on the operated foot and using it when ambulating within 3 days post-operatively. Mild
to moderate lameness was common while the SPIDER frame was in situ, however lameness typically re-
solved 1-3 weeks after SPIDER frame removal. No significant changes were noted in association with any
carpo-MC or tarso-MT joint in any case and osseous union was noted in all cases in <10 weeks and in most
cases within 4 weeks. Mild to moderate degenerative changes associated with MT-P or MC-P joints was
common, however in most cases this affected only one or two joints. Violation of associated MT-P or MC-
P joints by pin penetration should be considered a potential source of morbidity and requires further study,
but long-term assessments to date suggest that the consequences may be sufficiently limited as to justify clin-
ical application in select cases, where other techniques are unlikely to results in adequate stabilization and a
satisfactory outcome.
WEIRD METHODOLOGIES FOR WEIRD INJURIES

Distraction-Compression Osteo-Integration (DCOI) technique
Non-union following fracture repair is an unfortunate, although thankfully relatively uncommon outcome
following fracture stabilization. In many cases, there is a clear reason for the lack of osseous union such as
inadequate stabilization or infection, however the problem is often one of inadequate blood supply or a com-
bination of these factors. Whatever the cause, successful salvage following non union can be problematic,
with revision surgical procedures often compounding the underlying reason for suboptimal bone healing.
The author has operated a number of cases of fracture non-union or massive traumatic bone loss including
canine and feline femora, canine tibiae and canine mani using a novel biologic stimulation technique fea-
turing sequential distraction and compression in order to stimulate incorporation of large cortico-cancellous
autogenous bone graft blocks. This technique was developed from reports of cyclical distraction and com-
pression in humans for successful treatment of non-unions of femoral fractures.
IN-DEPTH SEMINARS
DISTAL LIMB TRAUMA
The technique, termed DCOI, uses autogenous cortico-cancellous bone blocks to fill the bone defects. The
bone blocks are generally autogenous coccygeal vertebrae (or less commonly blocks from the iliac crest and
wing). These are incorporated into the defect by being “skewered” onto kirschner wires which themselves
are placed as intramedullary pins across the fracture defect. Additional autogenous cancellous bone graft is
placed and the fractures and bone defects stabilized using modified hybrid circular pin-arch external skele-
tal fixator constructs. Dynamic phases of distraction and compression are performed daily for several weeks
to enhance bone regeneration and to promote incorporation of the autogenous cortical bone blocks into the
defects. The majority of the cases that we have treated had undergone multiple previous surgical procedures,
with many associated complications prior to presentation and the DCOI technique was employed as a last
port of call before considering amputation.
Pedal Arch Wire Scaffold (PAWS)

The author has encountered a number of cases of multiple MC- or MT-phalangeal luxation, in conjunction
with either infectious arthritis or severe soft tissue injury. In this circumstance, skewer wires can be used to
facilitate stability or phalangeal arthrodesis and if protection from weight-bearing is required for healing, a
customized wire-arch hybrid frame can be constructed which allows ambulation on metal arches whilst pro-
viding a “tent” for healing, dressing of pad or palmar/plantar lesions or abscess-drainage. This technique has
also been applied for management of trophic ulceration of bilateral pelvic limb pads secondary to spinal dis-
ease, and by a colleague for management of severe acid burns of all paw pads of three feet of a dog as a
walking external fixation frame, transmitting load bearing forces directly to the appendicular skeleton, by-
passing the pads and other soft tissues of the paw.
Intraosseous Transcutaneous Amputation Prosthesis (ITAP™)

Where irreparable neuro-vascular trauma accompanies osseous compromise and amputation is required, re-
cent advances in prostheses now prompt consideration of partial limb amputation and application of ITAP.
The ITAP was developed for use in the human digit to circumvent challenges associated with stump-socket
prostheses or with skin-implant interfaces and was inspired by deer antler, where the bone-pedicle continu-
ously remodels throughout the antler cycle whilst the dermal tissues are adherent to the osseous structure
with sufficient strength to prevent infection, marsupialization and ultimate failure of the soft-hard tissue in-
terface. ITAP successfully applied ultrastructural geometry gleaned from this natural biomimetic model to
create a soft tissue-implant interface which acts as a barrier to exogenous agents, and in particular may pre-
vent epithelial down growth and marsupialization.
ITAP comprises a titanium alloy stem for intraosseous (intramedullary) press-fit placement, a perforated um-
brella-shaped flange seated subcutaneously for skin in-growth and a distal extracutaneous peg that functions
as a link between the stem and flange portion and the exoprosthesis attachment. The three ITAP compo-
nents are custom manufactured on an individual-patient basis as a single integrated unit and each subunit
has specialized biological and/or mechanical properties to meet their required functions.
The author has had success in application of these prostheses in distal thoracic and pelvic limbs in both cats
and dogs. Iterations of exoprostheses are rapidly evolving for both human and canine limb-salvage, and sub-
sequent to our initial case series, application of the endoprosthesis in select human amputees is now under-
way. In fact, upsizing of the technology from human digit to human arm which was first performed in 2007
on a survivor of the “7/7” London terrorist attack in 2005 would not have been possible without applica-
tion to an animal model, and due to regional legislation, this was not possible in an experimental animal. As
a result, the ITAP –exoprosthesis evolution experienced in small animals has considerably expedited and en-
hanced possibilities for human application. This paradigm of cross-pollination and symbiosis of ideas be-
tween human and veterinary patients is a specific goal of the author’s clinical practice and a good example
of how ‘weird’ fracture fixation can transform the lives of veterinary and human patients.
In conclusion, whilst all of the biologic and biomechanical principles of conventional fracture fixation con-
tinue to remain the basis of and the standard of care within the author’s clinical practice and should remain
so, there is a role every now and then for considering ‘weird’ options as long as they are in the best inter-
ests of the individual patient with individual circumstances. It warrants re-iteration that being able to per-
form a technique does not in itself justify application; there must be an ethically sound basis for application.
The general dictum that the rules of biology must be obeyed holds true and all ‘weird’ techniques must have
a rational basis which optimizes the biologic and mechanical environment for healing. Some live their lives
in a box, some think outside the box, and some never knew there was a box. It may be good sometimes to
think without limits, but biology will always humble the arrogant surgeon and a surgical tool-box which ig-
nores the well-established boundaries of biology will fail. Success must learn from the past, must not linger
in the present and must look to the future. We will not be measured by the magnitude of our failure, but by
the magnitude of our response to that failure. Sometimes ‘weird’ fracture management may resolve or pre-
IN-DEPTH SEMINARS
DISTAL LIMB TRAUMA
vent failure but should be applied with justified caution and careful deliberation of all available options.
“An awareness of my limitations pervades me all the time. I have no special talents. I am only motivated by
an irresistible longing to understand and translate the secrets of nature” Albert Einstein.
Use of the fixin locking system for carpal

and tarsal arthrodesis
Milano
FIXIN FEATURES AND MECHANICAL PRINCIPLES

The main complications associated with plate fixation are loosening/failure of the screws, impaired pe-
riosteal and cortical blood supply directly beneath the plate and excessive shielding of stresses from the
bone. Non-contact locking plates could offer certain advantages in arthrodesis fixation over conventional
plating methods.
Locking plates work as an internal skeletal fixator. Screws are locked into the plate as they are inserted in-
to the bone. Because of this fixed screw mechanism, bone’s threads are unlikely to become stripped dur-
ing screw insertion and are more resistant to implant failure. The locked position of the screws into the
plate negates screw angulation and compression between bone fragments. The locking mechanism of the
Fixin system is achieved by a conical coupling between the screw head and a bushing insert which is
screwed into the plate. The outer surface of the screw head is conically shaped, corresponding with the in-
ternal surface of the bushing.
The stability of the screw-bushing coupling is achieved by friction, micro-welding and elastic deformation
between the head of the screw and the bushing. The presence of the bushings allows for easy implant re-
moval by either removing the screw from the insert or unthreading the bushing from the plate. This inter-
mediary fixation negates concerns of implant removal difficulties secondary to cold-welding, cross thread-
ing or damage to the screw hexagonal recess as has been reported with other locking plate systems. The
Fixin plate is composed of AISI 316LVM stainless-steel. Straight plates of various thickness ranging from
1.2mm to 3mm are available ranging from four to eight holes with varying lengths. The bushings are made
of titanium alloy Ti6Al4V. Fixin screws are made of titanium alloy Ti-6Al-4V; they are self-tapping locking
screws. Fixin Angled plates for dorsal pancarpal arthrodesis, (Fig. 1) medial pancarpal arthrodesis (Fig. 2),
dorsal pantarsal arthrodesis (Fig. 3) and medial pantarsal arthrodesis (Fig. 4) were developed. The aim of
this presentation was to review advantages and disadvantages of these implants in clinical cases without
any external coaptation.
IN-DEPTH SEMINARS
DISTAL LIMB TRAUMA
Figure 1 - Pancarpal arhtrodesis plates for dorsal application with 10° Figure 2 - Pancarpal arhtrodesis plates for
angle. medial application with 10° angle.
(a) Distal bushing can accomodate 1.9mm or 2.5mm screws. Proximal bush- (a) Distal bushing can accomodate 1.9mm
ings can accomodate 3.0 or 3.5mm screws. or 2.5mm screws. Proximal bushings can ac-
(b) Bushings can accomodate 3.0mm or 3.5mm screws. comodate 3.0 or 3.5mm screws.
(b) Bushings can accomodate 3.0mm or
3.5mm screws.
Figure 3 - Pantarsal arhtrodesis plates for dorsal applica- Figure 4 - Pantarsal arhtrodesis plates for medial applica-
tion with 135° angle. tion with 135° angle.
(a) Distal bushing can accomodate 1.9mm or 2.5mm screws. (a) Distal bushing can accomodate 1.9mm or 2.5mm screws.
Proximal bushings can accomodate 3.0 or 3.5mm screws. Proximal bushings can accomodate 3.0 or 3.5mm screws.
(b) Bushings can accomodate 3.0mm or 3.5mm screws. (b) Bushings can accomodate 3.0mm or 3.5mm screws.
ARTHRODESIS
An arthrodesis is a pain relieving procedure where an induction of joint fusion (ankylosis) is performed via
surgery.
Partial or Pancarpal and Pantarsal Arthrodesis are salvage procedures for canine joint hyperextension in-
juries, irreparable multiple ligament damage, severe osteoarthritis, irreparable intrarticular fractures, chron-
ic luxations or subluxations, shearing injuries and malformations. Either a pantarsal or a partial tarsal and
a pancarpal or a partial carpal arthrodesis can be performed, depending on the localization of the lesion. An
arthrodesis involves debridement of the joint cartilage, application of a bone autograft (cancellous bone), and
a stable fixation, either with a bone plate or with an external skeletal fixator (linear or circular). Plate appli-
cation combined with a period of adjunctive external coaptation is the conventional methodology treating
partial or pancarpal and pantarsal arthrodesis. Because a dorsal plate is positioned on the biomechanically
weak compression side of the limb and it is more prone to failure, medial plating has been evaluated lately
and it is considered biomechanically superior. High postoperative complication rates have been described
with carpal and tarsal arthrodeses, and they are more common with pancarpal/tarsal than with partial
IN-DEPTH SEMINARS
carpal/tarsal arthrodesis. Complications of partial and pancarpal-tarsal arthrodesis include failure to fuse, im-
DISTAL LIMB TRAUMA

plant/fixation failure (screw loosening/breakage), metacarpals and metatarsals fractures, infection, skin
necrosis and bandage/cast related complications.
Our hypothesis was that the Fixin system would provide sufficient support to allow healing of arthrodesis
without additional external reinforcement (cast or splint).
Records of twenty-four dogs undergoing unilateral arthrodesis by using the Fixin system were reviewed. In-
dications included acute or chronic radio-carpal subluxations or luxations (6), revision of a previous failed
pancarpal arthrodesis (1), severe carpal osteoarthritis (1), radio/carpal subluxation in addition to a fracture
of the stiloid process of the radius (1), carpal-metacarpal chronic subluxation (1), malformation of the radio-
carpal joint (1), acute or chronic tarsometatarsal subluxations or luxations (4), severe tarsal osteoarthritis (5),
tarsal-metatarsal luxation in addition to fractures of the base of the metatarsal bones (3), tarsal acute luxa-
tion (1). Time to presentation was one day to eight months from injury. Age range was 1.2 to 6 years (mean
3.5); weight range was 4.7 to 103 kg (mean 24 kg). Seven patients were female, seventeen were male.
Arthrodesis performed: pancarpal arthrodesis (11), pantarsal arthrodesis (5), partial tarsal arthrodesis (8).
Carpal cranial approach and plating (2), carpal medial approach and plating (7), carpal dorsal approach and
double plating (1), carpal cranial and medial and craniolateral triple plating (1), tarsal dorsal approach and
plating (1), tarsal medial approach and plating (11), tarsal lateral approach and plating (1). Time to follow-
up was 56 days to 1460 days (mean 370 days).
Meticulous debridement of articular cartilage was performed and joint spaces were packed with cancellous
autograft harvested from the proximal humerus or from the proximal tibia or from the wing of the ilium.
Different plates were applied: straight plates or arthrodesis plates or custom made plates. A modified Robert
Jones bandage was applied for 48 hours. An external support (cast or splint) during the post-op period was
never used. Cage confinement was suggested for eight weeks and in-door confinement for a further four
weeks with leash walking four times a day for 15 minutes each. All patients were re-examined for follow-up
at least at two weeks and eight weeks post-op.
Complications included fistulae (2). Incomplete union at the carpal-metacarpal joint (1). Screws breakage
with incomplete bone fusion (1). Screws breakage after bone fusion (1). No metacarpal fractures at the dis-
tal plate height were observed. All dogs but one showed satisfactory function without pain.
Collie male, 4 years old, 23 Kg. Carpal panarthrodesis medial approach and plating.
These results indicate that using Fixin plates can result in excellent limb function without the need for ad-
ditional external coaptation.
IN-DEPTH SEMINARS
DISTAL LIMB TRAUMA
Acknowledgements: Andrea Urizzi.

Extreme fracture repair: the wild

Alessandro Piras DVM, MRCVS, ISVS
Oakland Small Animal Veterinary Clinic Newry, Northern Ireland, UK
THE CARPUS
Carpal fractures are almost invariably avulsion fractures of ligaments (origin or insertion) and tendons in-
sertion or the result of the combination of shearing and compressive forces acting on the bones during the
hyperextension. All these fractures are intra articular with the exception of two types of accessory carpal
bone lesions. The clinical examination consists of accurate palpation to localize pain, soft tissue swelling, in-
stability and crepitius. The range of motion of the joint should be tested in flexion, extension, intra and ex-
tra rotation in extension and 90 degrees flexion, cranial translation with carpus flexed at 90 degrees.
Radiographic examination consists of standard views together with oblique views and skyline views.
Stress views are indicated to evaluate the degree of avulsion of some bone fragment and the stability of
the joint. High detail screens as rare earths and mammography mono-emulsion films are recommended
to achieve perfect detail. Whenever doubts about the radiographic anatomy exist, it is extremely useful
to x-ray the controlateral normal limb. In cases of strong clinical suspicion and difficulty in localizing the
injury, it is possible to prescribe an anti-inflammatory treatment and rest for 2/ 3 days, than repeat the
radiographs; in case of some hair-line or incomplete fractures the osteolysis can highlight the fracture
line. Failure to recognize an injury at this level can have serious consequences and in sporting dogs can
terminate their career. In case of non-surgical treatment, as for any other intra-articular fractures, the de-
velopment of osteoarthritis due to fracture instability is expected. Open reduction and internal fixation
with K. wires, tension band wiring and small size screws is the treatment of choice to achieve results com-
patible with the joint function.
Complex fractures of the carpal bones are generally associated with ligament damage, severe comminution
and variable degrees of subluxation. Therefore a careful preoperative planning should consciously consider
the typology of the fracture in relation to the age, breed and the expected level of physical activity of the
dog, the level of expertise of the surgeon and the availability of mini implants; according to this, arthrode-
sis could be the best choice.
Radial Carpal Bone (RCB): Fractures of the body of the RCB are uncommon injuries and are usually
caused by compressive forces acting during the hyperextension of the carpal joint. Different types of frac-
tures have been identified: midbody saggital and saggital oblique (this fracture can be either complete with
displacement or an hair-line fracture), comminuted T shaped compound generally by three fragments and
fracture of the dorsal margin (usually a small chip). Mid-body fractures, often incomplete have been de-
scribed in racing Greyhounds; some Authors suggest that they are more common in the right leg but in-
IN-DEPTH SEMINARS
sufficient numbers (Dee, personal communications: 6 cases) are available yet to define this type of predis-
DISTAL LIMB TRAUMA

position. The clinical signs are variable; in case of complete fracture, the dog is lame and often non weight
bearing, swelling of the joint, pain at palpation, decrease range of motion in flexion and crepitius are usu-
ally present.
In case of hair-line fractures the diagnosis could be very difficult as this type of injury is subtle, showing min-
imal clinical signs, minimal joint effusion and pain only on forced flexion. Radiographic examination con-
sists of dorso palmar, dorso palmar oblique and latero medial views. In case of incomplete fractures, the frac-
ture line may not be detectable for several weeks until bone resorption creates some widening at the frac-
ture gap.
These fractures are intra-articular and are treated with open reduction and internal fixation.
According to the type, the fracture can be approached surgically either with a standard dorsal or a palmaro
medial approach or a combination of the two.
Mid-body fractures are accurately reduced and stabilized with lag screws, generally 2.0 or 2.7 cortical, in-
serted from the palmaro medial aspect of the bone in an oblique dorso lateral direction. Accurate counter-
sinking of the screw head and precise measuring of the screw length are vital to avoid interferences of the
implants with other bones or soft tissues.
Some authors suggest that T shaped type fractures of the RCB occurring without history of trauma, share
a common ethiopatogenesis.
Considering that the two main fracture lines recognized radiographically and with CT scan, correspond ap-
proximately to the fusion plans of the three ossification centers of the bone, has been hypothesized that an
incomplete fusion of this areas could have predisposed to this injury. According to this Authors the breeds
most commonly represented are Boxers, Labrador Retriever, English Setter, English Springer Spaniel and
Pointer, presenting often a bilateral involvement. Due to their nature this fractures tend to respond poorly
to internal fixation, the tendency of the fragments to the non union predispose to implant failure, and os-
teoarthritis. These fractures are best managed with pan carpal arthrodesis.
The fracture of the palmar process has been described as a sprain avulsion of the palmar radial carpo
metacarpal ligament and is treated with open reduction and internal fixation with lag screws or K. wire and
tension band wire.
Dorsal RCB chip fractures are extremely common in racing Greyhounds consisting in most of a case of a
small chip. They are likely to be the result of the impingement of the distal dorsal margin of the radius over
the RCB. during hyperextension of the joint. The history is variable with the trainer reporting poor per-
formance and the dog checking and running wide in the bends. Lameness, when present, usually disappears
from few hours to 12 hours after intense exercise. Clinical examination reveals often but not always pain in
flexion, joint effusion could be from minimal to absent, direct finger pressure on the dorsal aspect of the car-
pus not necessarily elicit a pain response. Diagnostic radiographic views are usually the medio lateral and
medio lateral oblique. In many cases skyline views are of invaluable help to define tridimensionaly the frag-
ment location, this decreasing the size of the surgical approach and the surgical time. In case of a small chip,
surgical removal is the treatment of choice, larger slabs can be reduced and stabilized with 1.0 titanium
screws or 1.5 screws applied in a lag fashion.
Ulnar Carpal Bone: complete fractures are very rare injuries, dorsal chip fractures are more common.
They have been observed in conjunction with other carpal fractures and luxations, as an isolated fracture.
The author recalls 1 case and two cases reported as personal communication (Dee). Dorsal chip share the
same ethiopatogenesis, diagnostic approach and treatment seen in the RCB dorsal chip.
Second and Third Carpal Bones: uncommon and isolated fractures consist of a minute chip or a dorsal
slab. Treatment consists of surgical excision of the small chips and lag screw fixation for larger dorsal slabs.
Accessory Carpal Bone (ACB) is one of the most common carpal fractures in racing Greyhounds and they
can easily terminate the racing career of the dog.
Bateman, in 1950, has firstly reported these fractures and K. Johnson et al have classified them in 5 Types
on the basis of their radiological and pathological features in 1988. The ACB withstands the severe tensile
stress that develops as the carpal joint hyperextend during the weight-bearing phase of the stride. The result
of vectorial forces, acting along the long axis of the bone create a compression of its articular surface on the
other carpal bones contributing probably to the ethiopatogenesis of some of this injuries. The avulsion frac-
tures of the ACB may affect either limb and may involve the proximal dorsal or ventral border of the bone
(intra articular) or the distal dorsal or ventral border (extra articular). According to some Authors the right
ACB is involved in 80% of the dogs sustaining this injury.
Type I is an avulsion fracture of the distal articular margin involving the insertion of the accessoro-ulnar lig-
ament (type IB: pamaromedial). It is the most common of the five types; the fragment may vary in size, from
a single large slab to multiple chips. A variation of the type I involving the lateral articular prominence of
the bone (type IA: palmarolateral) have been recently described and its diagnosis can be quite challenging
IN-DEPTH SEMINARS
DISTAL LIMB TRAUMA
as is only visible in the dorso lateral palmaro dorsal oblique radiographic view.
Type II is an avulsion fracture of the proximal articular margin at the insertion of the palmar ulnocarpal and
radio carpal ligaments. The fragment is usually well defined, single and of the shape of a wedge.
Type III is an avulsion fracture of the distal palmar border of the bone involving the origins of the acces-
soro metacarpal ligaments that inserts on the fourth and fifth metacarpal bones. The fragment can be a sin-
gle slab involving one ligament or multiple fragments involving both ligaments. This fracture can be seen
in conjunction with type I and IV.
Type IV is a strain avulsion fracture of the insertion of the flexor carpi ulnaris on the proximal surface of
the palmar border of the bone. Fragments are usually small.
Type V is a comminuted fracture of the bone. The fracture can involve the articular surface with a combi-
nation of Type I and II and Type III and IV or split the bone along the transverse plane.
Clinical signs are variable; in acute type I and II injuries the area of the ACB is interested by edematous
swelling that create a lack of definition of the fovea between the flexor carpi ulnaris and the bone, decrease
range of motion with pain in flexion and direct palpation. In types III and V is possible to detect crepitius
during palpation.
In chronic cases the swelling may be from minimal to absent and pain is elicited only with firm pressure dur-
ing forced flexion of the carpus.
Radiographic examination is imperative to determine the type of fracture. Medio lateral views in semi flex-
ion and extension are usually diagnostic although dorso palmar and oblique view can be, in type I and II,
very useful in the identification of the fragments.
Treatment for type I fracture consist of fragment excision for small chips and whenever possible lag screw fixa-
tion. The operative space is very restricted by the small surgical approach and the fragment fixation could be
technically demanding. Fixation of the chip offer the best prognosis according to published data and to this Au-
thor’s experience, unfortunately the technique requires a long learning curve and the complications are numer-
ous. Small fragments can be excised taking care to not further damage the intact portions of the ligament.
In type II fractures, small avulsed fragments are generally excised and internal fixation of large fragments
may be attempted. Type IV fractures are best treated with fragment excision and tendon repair. Type V frac-
tures are so devastating and variable that usually are career ending, although in selected cases an attempt to
surgically repair this fractures may worth.
palmar aspect. After 3 weeks is possible to gradually extend the carpus changing the splint or bandage un-
til an extended weight bearing position is reached. After 6 weeks bandage or cast are removed and accord-
ing to the radiographic signs of healing, physiotherapy and controlled exercise are started. Full training can
start between 12 and 16 weeks post operatively. There are insufficient data yet published to define a prop-
er prognosis for the ACB fractures. Probably in the future there will be the necessity of a revision of the clas-
sification with the aid of CT scan images and tridimentional reconstruction, and a reevaluation of the prog-
nosis for each type of fractures based on larger numbers of cases.
THE TARSUS
The hock is a complex joint composed of 13 bones distributed in rows and joined by several ligaments. In-
juries of the tarsus are more common in the canine athletes and involve fractures of one or more bones, lig-
aments sprain or a combination of these.
Central Tarsal Bone (CTB) in racing greyhounds: the highest incidence of these fractures (96%) occurs
in the right leg and some of these can be so devastating to terminate the patient’s racing career.
There are several factors to consider for a thorough understanding of how this fractures occurs. During the
anti-clockwise racing in the bends the right hind leg is procuring propulsion but is also counteracting the
centrifugal forces. In this situation the central tarsal bone is acting as the buttress for the medial aspect of
the tarsus where all the greatest compressive forces are applied as the dog is negotiating the curves. It has
also been theorized by K. Johnson and others that adaptative remodeling due to cycling loading can pro-
duce changes of the bone mineral density with micro cracks, predisposing to catastrophic fracture.
According to the shape and severity, fractures of the CTB have been classified into five types:
• Type I: dorsal slab fragment with no displacement
• Type II: dorsal slab fragment displaced
• Type III: medial fragment displaced
• Type IV: combination of dorsal slab fragment and medial slab fragment more or less displaced
• Type V: comminuted fracture with several fragments
Types I – II and IV are the most common.
Clinical findings vary according with the severity of the fracture; the tarsus can present a mild swelling on
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DISTAL LIMB TRAUMA
its dorsal aspect in types I and II; severe swelling with crepitius and evident varus with deformity are com-
mon findings in types IV and V.
Flexion of the hock elicits pain and slow return to weight bearing.
Radiographic examination is mandatory to establish the severity and type of fracture. Plantaro dorsal medio
lateral and latero medial views are usually diagnostic; in type I fractures it is useful to apply stress in exten-
sion in the latero-medial view to evaluate the degree of dislodgement of the slab; in type IV and IV it is use-
ful to take oblique views to better determine the amount of comminution and shape of the fragments.
With very few exceptions, CTB. fractures require open reduction and internal fixation to achieve anatomi-
cal reconstruction and realignment of the tarsus to improve post injury prognosis.
The CTB is approached by a dorso medial incision, surgical fixation consists of repair using lag or positional
screws. Single dorsal slabs as in type I and II are repaired with the insertion of a dorso plantar lag screw,
usually 2.7 mm or 2.0 mm. The rare type III fractures are repaired with a single medio lateral screw, al-
though non visible at X-ray examination, a non displaced dorsal slab is often detected at time of surgery and
should be repaired with an appropriate size lag screw inserted in dorso plantar direction. In hundreds of frac-
tures of the CTB., the author can only recall one genuine Type III. Type IV are traditionally repaired with
a medio lateral 4.0 mm partially treaded cancellous screw and a dorso plantar 2.7 mm or 2.0 mm lag screws.
The medio lateral screw is inserted ensuring that the treaded portion is sunk deep in the fourth tarsal bone.
Type V fractures can be repaired with insertion of multiple lag screws, small washers or a single hole piece
of Veterinary Cuttable plate could be used to contain very small unfixable fragments. With the surgeon’s
increased expertise and the flattening of the learning curve together with the use appropriate instrumenta-
tion and mini implants the number of Type V fractures considered non reparable is decreasing.
Although these fractures tend to be quite similar as reported in the classification by Dee, et al, in 1976, the
variability of the shape and position of the fragments can complicate the surgery leading to unpleasant sur-
prises. Recent preliminary data indicate that the degree of comminution detectable with CT scan is greater
than could be appreciated radiographically suggesting that it will probably be necessary to review the clas-
sification and the prognosis of this fractures.
Prognosis is usually very good for types I, II and III, good to fair for type IV and fair to poor for Type V
non associated to other tarsal bones fractures.
Although the author’s preference is always surgical repair there are some reports that casting of some C.T.B.
fractures has been successful, with some dogs returning to the full performance.
After the surgery the dog is confined and the tarsus is supported with a cast or a splint for a period variable
from 3 to 4 weeks. The cast should be removed as soon as the radiographic control shows signs of healing,
starting a physiotherapy protocol to reduce the recovery time.
The usual program consists of controlled activity, massages, passive range of motion, electrical stimulation,
treadmill and swimming. Ultrasounds are contraindicated, as they will interfere with the metal of the im-
plants.
Calcaneus: fractures of the calcaneal bone can be seen as solitary injuries or can be associated with other
tarsal injuries, most often CTB fractures.
Two different mechanisms of calcaneal fracture have been advocated in adult greyhounds. In most of the
cases it is an indirect consequence of the fracture of the CTB. As the CTB fractures, the dorsal and medial
fragments dislocates with the collapse of the talo central joint space, the head of the talus move distally with
consequent lack of support for the calcaneus, this create instability and dorso medial tilt of the bone that un-
der the enormous pulling action of the Achilles tendon, fractures over the talus that act as a fulcrum. In oth-
er cases the calcaneus fractures as the bone is unable to withstand the extreme tension that develops along
its plantar aspect during the race, in this case the fracture is not associated with fracture of the CTB.
Different types of fractures of the calcaneus have been described.
Fracture avulsion of a small lateral or medial portion of the tuber calcis at the insertion of the retinaculum
of the SDFT. Surgical management consist of removal of small fragments with repair of the retinaculum or
in case of large fragments open reduction and internal fixation with small lag screw or K. wire and figure of
eight tension band wire.
The avulsion of the tuber calcis is an uncommon injury of immature dogs. Open reduction and internal fix-
ation with K wires and figure of eight tension band wire is the treatment of choice. Early removal of the ten-
sion band is recommended to avoid premature closure of the growing plate.
Fractures of the shaft can be simple or present different degrees of comminution.
Methods of repair, dependent on the choice of the surgeon, include pins and cerclage and hemi cerclage
wires, lag screws, or a combination of this techniques.
Simple fractures of the shaft are generally repaired by pin and figure of eight cerclage wire, comminut-
ed shaft fractures can be repaired by combination of lag screws and pin with tension band wire. In se-
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DISTAL LIMB TRAUMA
lected cases, comminuted calcaneal fractures can be repaired with a plate. Case selection depend on sur-
geon’s preference. A laterally applied plate can be used to support the repair of a comminuted fracture.
The fracture is first reduced with pointed reduction forceps and with the aid of small size K wires, lag
screws are inserted and finally the plate is applied to support the repair. In alternative, when allowed by
the fracture configuration, the lag screws are inserted through the plate holes. Some authors suggest to
supplement the repair with application of tension band wire. When the fracture involves the base of the
bone, is recommended to extend the plate to the fourth tarsal bone. If a damage to the plantar fibro car-
tilage is detected or suspected, the plate need to be extended to the proximal metatarsal fifth following
the principles of arthrodesis. The plates that are generally used for this anatomical area are 2.7 DCP or
LCDCP (allows less screw holes for length compared with DCP) and Veterinary Cuttable Plates 2.0/2.7
or 1.5/2.0 (allow maximum amount of screw holes for length compared to any other plate) according to
the patient size.
Lateral saggital slab fractures extend usually from the shaft to the joint space of the base. The repair is
achieved with lag screws usually applied from lateral to medial.
Distal fractures of the calcaneus can either or not involve the joint space. Oblique proximo plantar dorso
distal slabs with intact plantar ligaments are repaired with K wires inserted from distal to proximal in the
body of the bone and figure of eight cerclage wire. Large oblique plantaro distal dorso proximal slabs are
repaired with a pin in the calcaneus that seat deep in the fourth tarsal bone and a figure of eight tension band
wire from the bone to the body of the fourth tarsal bone. The same technique as a support for a calcaneo-
quartal arthrodesis can be used for the fractures of the base in witch the origin of the middle plantar liga-
ment avulse with a plantaro distal fragment.
A dorso medial axial slab can be detected in the dorso lateral plantaro medial X-ray view, usually associat-
ed with CTB. fracture. If undetected or non-treated this little slab can go to non union and therefore its fix-
ation with a lag screw is recommended.
After surgery a cast is applied for three to five weeks. As the cast is removed physiotherapy and controlled
exercise is encouraged for another four or five weeks, with a gradual reintroduction to activity during the
next four weeks. With appropriate repair and postoperative care and rehabilitation, the prognosis could be
from fear to good.
Talus: fracture of the talus are indeed very rare injuries and can be associated to fracture of the CTB in rac-
ing Greyhounds. This fractures are generally classified as intra articular involving the lateral or medial
trochlear ridges or the base, or extra articular involving the neck and the body. Proximal intra articular frac-
tures are usually a diagnostic challenge and they require multiple and special radiographic views for best ap-
preciation. They are treated by open reduction and internal fixation of large fragments and excision of small
chips. To increase the surgical exposure is often necessary to perform a fibular osteotomy. Fractures of the
body, neck and base can be repaired with a combination of K wires, lag screws and\or mini plates. Fractures
of the talar neck with minimal displacement can be managed conservatively.
Second Tarsal Bone: fractures of the second tarsal bone. are quite rare and usually associated to a fracture
of the third tarsal bone. Dorso plantar or plantaro dorsal views are usually diagnostic showing an increased
joint space between the second and third tarsal bones. Open reduction and internal fixation with lag screws
is usually the treatment of choice. As for third tarsal bone fractures, postoperative coaptation may be re-
quired. Third Tarsal Bone: fractures of the third tarsal bone can be a solitary lesion, or associated with the
fracture of the Second T B.. This injury can be quite subtle and must be confirmed by X-ray findings in
medio lateral and plantaro dorsal (or DP) views. Open reduction and internal fixation with a lag screw in-
serted in dorso plantar direction is usually the best option of treatment.
Fourth Tarsal Bone: fourth tarsal bone fractures are almost invariably associated with the fractures of the
CTB and are a consequence of the collapse of the joint space due to the compressive forces. Diagnosis is by
clinical and radiographic examination. The repair of the fourth tarsal bone is achieved indirectly by repair-
ing the CTB and the prognosis is strictly related to the CTB. Postoperative care is similar to the above de-
scribed for the CTB.
References available from the author upon request.
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DISTAL LIMB TRAUMA
06A) Free_commun_2010_04) Free_commun_2010 02/09/10 12.28 Pagina 531
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& POSTERS
ABSTRACTS
Small & Large Animals
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533 • WVOC 2010, Bologna (Italy), 15th - 18th September Z. Adamiak
Treatmet of tibia fractures with half-circular external

fixator in sheep
Z. Adamiak PhD, P. Holak PhD, M. Jalynski PhD, M. Chyczewski PhD,
M. Lew PhD, H. Matyjasik BSc
Department of Surgery, Faculty of Veterinary Medicine, Olsztyn, Poland
INTRODUCTION
The objective of this study was to evaluate the applicability of half-circular external fixator in own modifi-
cation in the treatment of tibia bone fractures eleven sheep and to estimate the surgical time, the time heal-
ing, and complications associated with the use of the examined external fixators.

Between 2004 and 2009, eleven sheep affected with tibia fractures were treated with half-circular external
fixator.
In eight sheep short oblique and in three cases transversal fracture types, located in the middle diaphysis
were determined according to preoperative radiographs. The surgery was performed under general anaes-
thesia by presented stabilization system. The fixators with 4 half circular rings and rods, and Kirschner pins
2,2 mm diameter were applied in all sheep. External fixator was applied with a cranio-medial approach the
tibia. The same system was applied in all cases. After surgery completion, in order to evaluate fracture re-
duction control X-ray examinations were made by taking pictures in lateral and cranio-caudal views. Daily
care of the pins was made with chlorhexidinium gluconicum solution.
RESULTS
Mean age of the sheep was 12 months. Sheep were operated on first two days after the fracture occurred.
All treated animal tolerated the apparatus very well. The technique was simple and did not consume a long
time. The sheep began weight bearing on 2nd, 3rd 3x 5th, 6th, 2x9th, 11th, 13th, 14th days, respectively.
Follow up radiographic examination showed complete bone healing on the postoperative radiographs be-
tween 46th - 56rth days. The external fixators were removed after six-eight weeks, when X-ray bone union
was achieved and sufficient callus was formed in the treated tibia. The only complication, which was noted
in all sheep, was tract discharges on Kirschner pins.
CONCLUSION
In all treated sheep bone union was satisfied. However, due to small number of clinical cases treated with
described fixators, further studies are needed.
REFERENCES
1. Beck, A.L, Pead, M.J. (2003) The use of Ellis pins (negative profile tip-threaded pins) in external skeletal fixation
in dogs and cats. Vet Comp Orthop Traumatol 16, 223-231.
2. Anderson, D.E., ST Jean, G. (1996) External skeletal fixation in ruminants. Vet Clin North Am Food Anim Pract
12, 117-122.
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Corresponding Address:
Prof. Zbigniew Adamiak - University of Warmia and Mazury Department of Surgery,
Ul. Oczapowskiego 14, 10-957 Olsztyn, Poland - E-mail zbigniew.adamiak@wp.pl
A. Aliabadi WVOC 2010, Bologna (Italy), 15th - 18th September • 534
Evaluation of the effects of bovine demineralized bone

matrix and coralline hydroxyapatite on radial fracture
healing in rabbit
A. Aliabadi, DVM, PhD1, M. Farahmand, MSc2, A. Hojati, DVM1, A. Mohebi, DVM1
1
Department of clinical studies, faculty of veterinary medicine, Islamic Azad University, Kazeroon branch, kazeroon, Iran
2
Department of biology, faculty of basic science, Islamic Azad University, Kazeroon branch, kazeroon, Iran
INTRODUCTION
Over the last decades, a great deal of research has focused on therapies for enhancing bone repair. Stimu-
lating bone production may be applied to the management of fractures, non-unions, and osteomyelitis. Au-
togenous bone graft has been the implant of choice for most of the orthopaedic procedures. However, au-
togenous and allogenic bone grafts have several limitations, such as donor-site infection, pain, and disease
transfer. Because of these limitations, biosynthetic bone graft substitutes are being investigated. Bone graft
substitutes should possess one or more of the characteristics typical of autograft: osteoconductivity, os-
teoinductivity, and osteogenicity. Demineralized bone matrix (DBM) has been used for several decades in
human surgery for the treatment of nonunions, facial deformities, osteomyelitis, and large defects resulting
from benign tumor removal. Hydroxyapatite is compatible and osteoconductive for bone regeneration. A
combination of DBM and HA mixture would probably create a composite with both osteoconductive and
osteoinductive properties.This study was conducted to evaluate the effect of osteoinductive activity of
xenogenic DBM in combination with osteoconductive hydroxyapatite in osseous location.

Twenty four skeletally mature New Zealand white rabbits were used in this study (male, weight: 2.5 – 3.0
kg), all obtained from the same source, in order to decrease genetic variability. All rabbits were anesthetized
with intramuscular administration of ketamin (40 mg/kg; Alfasan International, Woerden, Holland) and xy-
lazine (13mg/kg; Alfasan International, Woerden, Holland). After preparing the operation site, the right ra-
dius was exposed, and an approximately 5-mm full thickness bone defect was created in the middle dia-
physeal region in the radius of right forearm. Rabbits were divided into four groups, Group I was the con-
trol group, and the rabbits in this group received no treatment. The segmental defects in group II were im-
planted with DBM alone, and group III were implanted with HA. Group IV were implanted with DBM
and HA mixture combination with equal parts. Following implantation, the fascial incisions were closed with
3-0 absorbable suture and the skin was closed with 2-0 absorbable suture and sealed with Vetbond. The
DBM used for this study was prepared from the long bones of rabbits in a similar manner as that of human
BioSet_ RT. The demineralization process was similar to that employed by Urist. Osteoinductivity of each
lot was determined in the rabbit ectopic pouch model. Coralline hydroxyapatite (ProOsteon_ 500R; Inter-
pore Cross International, Irvine, CA) was prepared using aseptic technique for extrusion from a syringe in
0.5 cc doses. The formation and healing of bone were determined by radiographic, histological, and me-
chanical analysis during 8 weeks. For radiographic evaluation, anteroposterior and lateral radiographs of the
forelimb were made immediately after surgery and at the time that the animals were sacrificed during 8
weeks. For histological examination, the harvested tissues were decalcified with 10% formic acid solution
which was changed daily. The samples were embedded in paraffin, and 5 µm-thick sections cut through the
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long axis and stained with hematoxylin and eosin. During the histological examination, the pathologist was
unaware of the group to which each specimen belonged. For biomechanical evaluation, the samples had un-
dergone the three-point bending test (Amsler FM 2750, Roell + Korthaus, Schaffhausen, Switzerland).and
we compared structural stiffness and ultimate load in all groups.Data was analysed with SPSS 11.0 software
for Windows with the paired sample test and the Wilcoxon non-parametric two-related sample test.
RESULTS
Implantation of combination of DBM and hydroxyapatite yielded significant (p < 0.05) bone formation re-
sulting in radiographic, histological, and mechanical evidence of union compare to other groups. Radi-
ographic evaluation revealed that in the control group there was no significant bone healing in any of the
limbs. In the DBM+HA group, five of six defects healed completely, and one of them showed high degree
of healing. In the DBM group, radiography showed increase in radiodensity and changes, but there were
no bridged defects on medial and lateral sides. There was a statistically significant difference between the
535 • WVOC 2010, Bologna (Italy), 15th - 18th September A. Aliabadi
DBM+HA group and the control group (p<0.05). Further analyses showed no significant difference be-
tween the HA group and the control group (p=0.124) Meanwhile, the DBM+HA group was radiologically
evaluated to show better characteristics of fracture healing when compared to both the HA and the DBM
groups (p<0.05), As a result, the DBM+HA group was found to be providing significantly better radiolog-
ical healing when compared to the other three groups, including the control group. DBM group showed sig-
nificant difference when compare to HA and control Groups. Histopathological evaluation was shown that
Quality of the fracture union, Cortex development and remodelling, Bone-graft incorporation and newbone
formation were significantly better (p<0.05) when compared to the other groups. Three other groups turned
out to show no significant differenc but DBM group shows better healing in some histologic slide compare
to HA and control group. Biomechanichal evaluation revealed better result in DBM + HA gruop compare
to other groups. Structural stiffness and ultimate load was significantly increased (p<0.05) in DBM + HA
group compare to three other groups. There was no significant difference between HA group and control
group but DBM group showed significant (p<0.05) difference when compare to HA and control Groups.
CONCLUSION
As an osteoinductive agent, DBM has been proved to establish good results for the healing of fractures and
bone defects. Taking this into account, delivering this material to the defect site through the use of an scaf-
folding synthetic material seems logical. One of the most popular mixtures is the mixture of DBM and HA,
which has demonstrated variable results in different studies. In our study, DBM and the HA mixture were
combined to provide better fracture healing. Different results were obtained in similar research projects,
whilst some of them supported our results. In our study, the best fracture healing was observed in the mix-
ture of DBM and HA group, and there were no significant differences between the HA and the control
group whereas DBM group showed significantly better healing when compare to HA and control
Groups.Good healing in DBM+HA group may dou to osteoconductive properties of HA in combination
with Osteoinductive DBM. These data illustrate the osteoconductive properties of HA and also the os-
teoinductive capacity of DBM has been well-documented. Ragni and Lindholm found similar results. They
designed an experiment in which they aimed to create lumbar intervertebral fusion in rats, they used HA
and DBM in combination, and compared the outcomes with three other groups which consisted of HA,
DBM and autogenous grafting. At the end of the second month, the HA/DBM group provided better fu-
sion than the plain HA and plain DBM groups. we concluded that bovine DBM may be more useful in com-
bination with hydroxyapatite as a therapeutic adjuvant in clinical situations when local formation of bone is
needed.
REFERENCES
Chesmel, K.D., Branger, J., Wertheim, H. and Scarborough, N. (1998). Healing Response to Various Forms of Human
Demineralized Bone Matrix in Athymic Rat Cranial.
Finkemeier CG (2002) Bone-grafting and bone-graft substitutes. J Bone Joint Surg Am 84(3):454-464.
Kurz, L.T., Garfin, S.R. and Booth Jr, R.E. (1989). Harvesting Autogenous Iliac Bone Grafts. A Review of Complications
and Techniques, Spine, 14: 1324–1331.
Ragni P, Lindholm TS (1991) Interaction of allogeneic demineralized bone matrix and porous hydroxyapatite bioceram-
ics in lumbar interbody fusion in rabbits. Clin Orthop 272:292-299.
Dr. Ali Aliabadi, Shahid Rajaee Blvd- 6Th Str, #309, Shiraz/ Fars/ 71879-73966, Iran - E-mail aaliabadi@gmail.com
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K. Ash WVOC 2010, Bologna (Italy), 15th - 18th September • 536
Minimally invasive plate osteosynthesis using two

perpendicularly oriented plates for the treatment of tibial
fractures in 23 cats
N. Fitzpatrick, DUniv CSAO CVR MVB, V. Wavrille, DVM, P. Buttin, DVM,
R. Amis, DVM, K. Ash, BSc BVMS
Fitzpatrick Referrals, Eashing, UK
INTRODUCTION
Minimally invasive plate osteosynthesis (MIPO) involves application of internal fixation devices through
stab incisions at the proximal and distal extents of long bone fractures. Indirect fracture reduction is achieved
by distraction of bone fragments with or without fluoroscopic guidance. Limited dissection results in re-
duced patient morbidity, minimal disruption of the soft tissue envelope and encourages expeditious fracture
healing.
Adequate stabilisation of distal juxta-articular fractures can be challenging due to paucity of bone stock of
the juxta-articular segment. Adherence to the AO principle of engaging six cortices in each major bone seg-
ment may be impossible with conventional plating techniques. In addition, such fractures are often com-
minuted, requiring the relatively bulky plates to provide adequate stability which may compromise subse-
quent skin closure. We hypothesized that the concurrent application of 2mm veterinary cuttable plates
(VCPs) to the cranial and medial aspects of the tibia would provide adequate stability to promote rapid bone
healing, facilitate fracture reduction and functional limb alignment without the need for implant pre-con-
touring, minimise soft-tissue complications and allow early weight-bearing. We report the results of this dou-
ble technique for the repair of tibial fractures in 23 cats.

Medical records between April 2007 and August 2009 were reviewed. Inclusion criteria were that all feline
tibial fractures had been repaired with 2mm VCPs applied to both the cranial and medial aspects of the tib-
ia via MIPO technique, and that complete clinical and radiographic follow up records were available. Ani-
mals with concomitant orthopaedic injuries or articular fractures were excluded. Small incisions of 1-2cm
were made at the most proximo-medial and disto-medial extents of the fractured tibia in all cases, and plates
were cut to span the length of the bone based on radiographs of the contralateral limb. The medial plate
was placed first through the proximal incision, and passed along the medial aspect of the tibal diaphysis as
far distally as the medial malleolus.
The major tibial segments were then manually distracted to appropriate length and bicortical 2.0mm screws
were loosely placed in the most proximal and most distal screw holes. The distal drill hole was placed 2-3
mm from the tibial articular surface. The cranial plate was placed in a similar fashion and bicortical 2.0mm
screws loosely placed in the most proximal and distal screw holes. The most proximal screw of the cranial
plate was placed through the proximal aspect of the tibial tuberosity and the most distal screw centrally
placed 2-3mm from the articular surface to avoid the medially placed distal screw. These four screws were
then sequentially tightened to realign the major segments by virtue of the perpendicularity of the plates, en-
suring that segmental translation did not occur. Remaining screw holes were filled to attain screw purchase
in a minimum of at least six cortices in each major bone segment.
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Post-operative limb alignment was subjectively graded as good, fair or poor. Repeat clinical examination was
performed two and six weeks post-operatively and every three weeks thereafter until full recovery. Radi-
ographic examination was performed at six weeks post-operatively and if necessary, repeated every 3 weeks
until bone healing was confirmed. Fracture healing was defined as radiographic evidence of bridging os-
seous callus on orthogonal projections.
RESULTS
A total of 23 cats met the inclusion criteria with median age 36m (range 11-168 m). Fracture configuration
was comminuted (n=21) or segmental (n=4).There were no simple fractures. Fracture location was diaphy-
seal (n= 14), metaphyseal (n=6) or juxtaarticular (n=5) and the median number of screws per construct was
12 (range 8-20). Median time to weight bearing was 2 days (range 1-5) and limb alignment was graded as
good in all cases. Two cats were graded as 3/10 lame by 6 weeks post operatively; all other cases were scored
as lameness-free. Lameness resolved in the former two cases by nine weeks post operatively.
537 • WVOC 2010, Bologna (Italy), 15th - 18th September K. Ash
Radiographic union was documented in 20 cases by six weeks. Two cases took nine weeks to heal and a sin-
gle case took 12 weeks. No peri-operative complications were recorded. Post-operative complications in-
cluded infection (n=6), delayed union (n=1), and wound breakdown (n=2). Self trauma was the suspected
cause of infection in 5/6 patients. Implant removal was required in two cases at 6 weeks post operatively due
to exposure of the distal aspect of the plates.
CONCLUSION
Simultaneous application of 2mm veterinary cuttable plates to the medial and cranial aspects of the tibia fa-
cilitated complete fracture healing in all cases with a return to normal function in all 23 patients. Healing
times were similar to those reported with other fixation techniques. Non union is a commonly reported com-
plication of feline tibial fractures, but this was not seen in any of our cases. The double plate MIPO tech-
nique was particularly helpful for the stabilisation of fractures with small juxta-articular bone segments. In
this series, fracture location was juxtaarticular or metaphyseal in 44% (11/25) of cases. The technique allows
additional screw purchase to be obtained in small distal segments due to the orthogonal positioning of the
two plates and by the increase in screws per unit length afforded by the VCP compared to conventional dy-
namic compression plates. The increased stiffness of the double plate construct also allows placement of
smaller screws than would be required with a single, thicker bone plate.
Despite the low profile of the plates, self trauma was noted in five cases and plate removal was required in
two cases. Preexisting ischemic damage as a result of the original trauma may have contributed and in the
latter two cases there were technical errors; the cranial plate was placed too far medially leading to focal pres-
sure of the overlying skin at the disto-medial extremity of the construct.
The minimally invasive double plate technique described here provides an effective method for stabilization
of tibial fractures in the feline tibia, and should be considered as a viable option for the management of com-
plex tibial fractures in cats, particularly when the proximal or distal bone segments are very small.
REFERENCES
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.
Mr. Noel Fitzpatrick - Fitzpatrick Referrals, Halfway Lane, Eashing, Godalming, Gu72Qq, United Kingdom
E-mail noelf@fitzpatrickreferrals.co.uk
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F. Beccati WVOC 2010, Bologna (Italy), 15th - 18th September • 538
Development of first phalanx osseous cyst-like lesion after

fracture repair: two cases
F. Beccati, DVM1, M. Pepe, DVM PhD MRCVS1, R. Gialletti, DVM1, M. Puccetti, DVM PhD2,
C. Tamantini, DVM PhD1, S. Nannarone, DVM PhD1
1
Dipartimento di Patologia, Diagnostica e Clinica Veterinaria, Sezione di Chirurgia e Radiodiagnostica,
Facoltà di Medicina Veterinaria, Università degli Studi di Perugia, Perugia, Italy
2
Libero Professionista, Perugia, Italy
INTRODUCTION
Subchondral osseous cyst-like lesions (SCLs) in horses are well documented. SCLs at locations other than
the medial femoral condyle have a relatively low incidence. Their aetiopathogenesis is not completely un-
derstood, although developmental factors, sepsis, trauma, and ischemia have been proposed as possible
causes.

Case 1 was a 5-days-old, Warmblood colt foal referred for transverse first phalanx fracture of the left fore-
limb. Case 2 was a 3-months-old Warmblood filly foal referred for complete diaphyseal third metacarpal
bone fracture of the right forelimb. Both fractures were treated by internal fixation under general anaesthe-
sia. Post operatively, foal 1 received amikacina sulphate (25 mg/kg bwt, i.v., s.i.d.) and cefquinome sulphate
(1 mg/kg bwt i.v. b.i.d.) for seven days, whereas foal 2 received the same treatment for fourteen days. In both
cases pain management was provided by administration of phenylbutazone (2.2 mg/kg, bwt, i.v., s.i.d.). Re-
spectively 28 days (foal 1) and 20 days (foal 2) after fracture repair, a diagnosis of implant infection was made
in both patients based on clinical and diagnostic findings. Implants were removed 67 days (foal 1) and 73
days (foal 2) after fracture repair and the infection was resolved in both cases. Forty days after fracture re-
pair foal 2 showed severe lameness (grade 4/5) of the left hind limb, whereas foal 1 showed severe lameness
(grade 4/5) of the right hind limb 20 days after implant removal.
RESULTS
In both foal physical examination revealed soft-tissue swelling of the pastern, severe local pain and a posi-
tive flexion test of the distal limb. Lameness was abolished by plantar digital anaesthesia in both foals. Four
standard radiographic views of the affected proximal interphalangeal joint were taken for each patient (dor-
soplantar, lateromedial, dorso45°lateral-plantaromedial oblique and dorso45°medial-plantarolateral oblique).
A circular, irregular, focal area of subchondral lucency surrounded by mild sclerosis was observed in the dis-
tal medial end of the proximal phalanx on the dorsoplantar and D45°MPLO views in both foals. On the
lateromedial view, marginal osteophytes and periarticular new bone growth were detected in the proximal
end of the middle phalanx and were associated with irregular linear subchondral radiolucency in the dorsal
aspect of the distal end of the PI. For foal 1, radiographic follow-up was obtained 3 months after diagnosis
of the SCL. On dorsoplantar view, the SCL was surrounded by severe sclerosis and showed a strongly ir-
regular outline. On lateromedial view, marginal osteophytes and proliferative bone growth were detected.
The dorsal aspect of the distal end of PI was sclerotic. For foal 2, radiographic follow-up was obtained at 2
and 4 months after diagnosis of the SCL. On dorsoplantar view, the first follow-up examination showed a
sclerotic appearance of the proximal aspect of the SCL and 2 small irregular circular radiolucencies were de-
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tected close to the joint surface.

On the lateromedial view, the subchondral plate and the dorsal cortical rim of the dorsal aspect of the dis-
tal end of PI were sclerotic and had increased in thickness. Radiographic examination showed the presence
of severe remodelling of the distal condyle of PI and flattening of the dorsal aspect of the distal articular sur-
face of PI. At 4 months, the second follow-up examination showed the SCL was completely filled with scle-
rotic bone. On the lateromedial view, the radiolucency had disappeared, whereas the flattening of the artic-
ular surface of PI was still evident. An increase of the cortical rim of the dorsal aspect of the middle phalanx
associated with bone remodelling was still evident.
CONCLUSION
Several of the clinical features found in these two cases suggest that aetiology other than osteochondrosis
may be responsible for the development of the subchondral bone cyst. Given the young age of the foals
(mean age 1 month), failure of endochondral ossification could potentially explain the development of the
539 • WVOC 2010, Bologna (Italy), 15th - 18th September F. Beccati
SCLs, but the radiographic findings (irregular focal area of bone loss) and the acute and severe onset of
lameness in both foals make this unlikely. The severe and sudden onset of lameness and the history of im-
plant infection could suggest a septic aetiology in the development of SCLs. The continued severe lameness
following fracture repair and the consequent overloading of the other limbs may also suggest a traumatic
mechanism in the development of SCLs. In these young horses, the development of SCLs in locations oth-
er than the fractured limb could be considered as a complication of fracture repair and/or implant infection.
Weight-bearing induced laminitis is the most common and devastating complication of fracture repair in
adult horses. In foals, continued severe lameness following fracture repair frequently results in angular limb
deformity and occasionally in contracture deformity. In cases of implant infection and severe lameness, de-
velopment of SCLs could be also potentially considered a severe complication in foals.
REFERENCES
1. Montgomery L.J. and Juzwiak J.S. (2010) Subchondral cyst-like lesion in the talus of four horses. Equine Veterinary
Education 21, 629-637.
2. Garcìa-Lopez J.M., Kirker-Head C.A. (2004) Occult subchondral osseous cyst-like lesions of the equine tarsocrur-
al joint. Veterinary Surgery 33, 557-564.
3. Baxter G.M.: Subchondral Cystic Lesions in Horses, in McIlwraith C.W. and Trotter G.W. (eds): Joint Disease in
the Horse. Philadelphia, WB Saunders Company, 1996, pp 384-396
4. Nixon A.J.: Laminitis and Contracture Deformity, in Nixon A.J. (ed): Equine Fracture Repair. Philadelphia, WB
Saunders Company, 1996, pp 367-370.
5. Trotter G.W., McIlwraith C.W., Norrdin R.W. and Turner A.S. (1982) Degenerative joint disease with osteochon-
drosis of the proximal interphalangeal joint in young horses. Journal of the American Veterinary Medical Associa-
tion 180, 1312-1318.
Dott.ssa Francesca Beccati - Dipartimento di Patologia, Diagnostica e Clinica Veterinaria. Facoltà di Medicina
Veterinaria, Università degli Studi di Perugia, Via San Costanzo 4, 06126 Perugia (PG), Italy
E-mail francescabeccati@hotmail.it
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A. Bertuglia WVOC 2010, Bologna (Italy), 15th - 18th September • 540
A conservative treatment technique for gastrocnemius

muscles rupture in young calves (7 cases)
A. Bertuglia, DVM, PhD, E. Guidi, DVM, PhD, M. Bullone, DVM,
M.C. Greppi, DVM, M.G. Poletto, DVM
Dept. of Animal Pathology, Section of Surgery, Faculty of Veterinary Medicine, University of Turin, Turin, ITA
INTRODUCTION
Gastrocnemius muscles rupture (GMR) and subsequent incompetence of caudal reciprocal apparatus is a
serious injury rarely described in young calves that can occur during a fall with the hindlimb extended un-
der the body, resulting in forced extension of the muscles while it is engaged in contraction. The conse-
quence of the lesion is a severe lameness and occasionally the inability to weight bearing the affected leg,
a severe dropped hock with excessive angulation at the hock joint and the stifle joint maintained in exten-
sion. Untreated animals usually have a poor prognosis because unable to self-repair the condition. These
animals are frequently euthanatized in consequence of prolonged recumbency, severe sore lesions and de-
generative myopathy. Surgical techniques to correct the caudal reciprocal apparatus rupture are rarely de-
scribed in large animals. Some cases in foals had been managed successfully with temporary external skele-
tal fixation or a combination of splint-cast. The purpose of the present case report study is to asses the ef-
fectiveness of conservative treatment of GMR cases in young calves with a Thomas splint bandage to cor-
rect the condition.

All cases of GMR in young calves diagnosed between 2007-2010 were registered and analyzed retrospec-
tively. Diagnosis of GMR was based on description of the referring veterinarian and on clinical observation
of the calf at the time of admission or in the field. Only records of patients with complete follow-up and treat-
ed conservatively were selected. A recorded video tape of the patient was performed at the time of the ad-
mission or at the first clinical examination in the farm and repeated during the follow-up. The initial diag-
nosis of the referring veterinarian never considered the GMR as a differential diagnosis. Generally, suspi-
cion of fracture or luxation was the reason for hospitalization. Diagnosis of GMR has been made on the ba-
sis of the clinical examination. An US examination completed the medical record in two animals. All the
calves have been treated with a standard medical protocol. A short general anesthesia with propofol induc-
tion had to be performed in 2/7 patients. In the other 5 calves a sedation with xylazine was adequate to al-
low the manipulation. All the patients had been positioned in lateral recumbency with the affected leg up-
permost. Affected limb was bandaged from the foot to the stifle with a uniform cotton roll layer. The im-
mobilization was achieved with the stifle, hock and fetlock in a physiological weight bearing position, using
the normal contro-lateral hindlimb as a reference, and the foot slightly flexed, bearing on the toe. The band-
age was completed with a rounded aluminium splint that must be modelled directly on the shape of the leg,
starting from the cranial aspect of the foot up to the stifle, then bending dorso-caudally to the line of the hip
and then ventrally, following an inverse “U” shape, to continue on the caudal aspect of the leg. The alu-
minium splint was fixed to the limb using a self-adhering bandage (Self-Fix) wrapped in a double-8-figure
around the splint dorsal and plantar to the leg. The bandages were protected with a self adhering tape (Ve-
trap). Using this technique the leg had been suspended by the splint in a not-weight bearing position with
the gastrocnemius muscles relaxed, bearing on the toe of the foot and avoiding pressure contacts between
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the splint and the skin. During weight bearing the forces had been transferred from the splint to the tibia
leaving the hock joint in a not-weight-bearing position. Initially, after recovery, the animals were assisted to
help their hindlimb to protract during walk because the cranial phase of the stride of the affected limb is
shortened by the weight of the bandage.
RESULTS
During the observation time 7 medical records of calves with GMR were recorded. 5 animals were Piemon-
tese calves and 2 animal were Belgian Blue. Heavy breeds were significantly more represented than other
breeds. All cases observed were male and in 5/7 it was reported from the owner to be the heaviest newborn
calves in the farm. All patients were 0-15 days old with a mean age at presentation of 3,8 day. In 4/7 patients
a significant swollen leg had been observed at clinical presentation in the plantar aspect of the tibia that di-
minished after 5-8 day of therapy. Animal received 1.0 mg/kg of flunixin meglumine daily for 5 to 8 day af-
ter the trauma to control the pain. All bandages and splint had been well tolerated from the animals. All the
541 • WVOC 2010, Bologna (Italy), 15th - 18th September A. Bertuglia
patients were able to stand up alone after the bandage had been positioned but all the animals needed to be
assisted during the first walk after recovery. In 2/7 cases we treated animals 1d old still unable to walk. In
2/7 animals bandages were maintained 6 weeks, in the others subjects the immobilization protocol duration
was 8 weeks. Calves had been managed in a single box and initially needed assistance by the owner during
nursing. All the patients during the bandage period had been submitted to a controlled exercise programme.
In none of the animal adverse effects related to the splinting technique were observed. Bandage were
changed every three to four weeks and no more than two bandages had been required to obtain a clinical
resolution of the condition. Weight bearing improved in all patient shortly after the bandage had been per-
formed at the recovery from sedation/general anaesthesia. Complication recorded related to the procedure
are pressure sores at the point of the hock, reported in 2 patients, and urine sore at the point of the hock
and on the medial surface of the fetlock, described in 1 animal. A restricted range of motion of the hock
joint after bandage removal was reported in 5/7 patients in which the bandage was maintained for 8 weeks.
The bandages were removed after 6-8 weeks and no further support was necessary. All the treated animals
showed a complete functional recovery of the hock joint and experienced unrestricted use of the hind limb
after recovery for at least one year.
CONCLUSION
GMR affects mainly young and newborn heavy animals in the farm after a traumatic event due to sudden
hyperextension of the hock joint. Clinical diagnosis is straightforward due to the functional limitation of the
lesion and the dramatic dropped hock position during weight-bearing of the affected hindlimb. The combi-
nation of bandage and splinting technique we described in this case report study is an easy and functional
measure to correct the caudal reciprocal apparatus disruption. The functional as well as the cosmetic result
of the described technique is good to excellent. This conservative technique is an effective measure in calves
to correct GMR compared to more radical surgical procedures described in foals, adult horses and dogs.
REFERENCES
Bertuglia A., Puglisi G. (2005). Repair of the Achilles mechanism in a miniature horse. Equine Veterinaty Education 17
(1) pp 3-8.
Lescun T.B., Hawkins J.F., Siems J.J. (1998). Management of rupture of the gastrocnemius and superficial digital flexor
muscles with a modified Thomas splint-cast combination in a horse. Journal American Veterinary Medical Associ-
ation 15; 213(10):1457-9.
Toppins D.S., Lori D.N. (2006). Incomplete rupture of the gastrocnemius and superficial digital flexor muscles in a Quar-
ter Horse stallion. Journal American Veterinary Medical Association 1;229 (11):1790-4.
Jesty S.A., Palmer J.E., Parente E.J., Schaer TP., Wilkins PA.(2005). Rupture of the gastrocnemius muscle in six foals.
Journal American Veterinary Medical Association 15; 227(12): 1965-8.
Dott. Andrea Bertuglia - Università degli Studi di Torino - Facoltà di Medicina Veterinaria - Dip.to Patologia Animale,
Via Leonardo da Vinci 44, 10095 Grugliasco (TO), ITA - E-mail andrea.bertuglia@unito.it
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A. Boero Baroncelli WVOC 2010, Bologna (Italy), 15th - 18th September • 542
Effect of screw insertional torque on push-out strength

in 5 different angular stable systems
A. Boero Baroncelli, DVM1, U. Reif, DVM, ACVS, ECVS2, C. Bignardi, Dipl. Ing3,
V. Tonti, Dipl. Ing3, B. Peirone, DVM, PhD1
1
Department of Animal Pathology, University of Turin, Torino, Italy
2
Tierklinik Dr. Reif, Böbingen, Germany
3
Department of Mechanics, Politecnico di Torino, Torino, Italy
INTRODUCTION
In recent years, a more biological approach, with minimal disturbance of soft tissues in the fracture area, has
been introduced. Biological factors, such as minimized iatrogenic soft tissues disruption, utilization of indi-
rect fracture reduction techniques, provision of stable fixation and promotion of early return to limb func-
tion, has been the goal of internal fixation1. The introduction of angular stable systems by Synthes (PC Fix
and Locking Compression Plate) and their use in veterinary medicine has inspired the development of sev-
eral angular stable systems used exclusively in the veterinary field. Different locking mechanism have been
developed in order to achieve stable fixation of the screw within the plate while still allowing screw removal.
However few biomechanical studies have been performed to compare and validate the mechanical proper-
ties of these systems2. The purpose of this study was to compare the screw push out strength of five differ-
ent angular stable systems. Our hypothesis was that screws insertion torque has an influence on push out
strength of the locking mechanism.

Five different implant systems were evaluated. The Combi Hole of the Synthes Locking Compression Plate,
the conical coupling of the Traumavet Fixin Internal Fixator; the Securos poly-axial angularly-stable screw-
plate locking system, the Orthomed String of Pearls (SOP), the Veterinary Instrumentation round stacked
locking hole. Screws insertion was performed in a standardized fashion using a variable torque limiting de-
vice. Screws were tested in an isolated locking hole. The insertion torque was set to 0.8, 1.5, 2.5, and 3.5
Nm. Screws insertion was performed at 90° (through the use of the factory’s drill guide) using a synthetic
bone support and a specially designed jig. To evaluate the push out strength, the plate was mounted on a
custom made device and a push out force was applied in an axial direction on the screw tip at a constant
displacement rate of 1 mm/min. The loading of the sample was removed after a displacement of more than
2 mm was recorded. Tests were performed by means of a materials testing machine (Q/Test 10, MTS Sys-
tems Corporation). Three screws were tested for each company. Statistical analysis of the push out strength
was performed using analysis of variance (ANOVA). Significance was set to a p-value of 0,05.
RESULTS
Traumavet
An insertion torque of 0,8 Nm (Push-out force 249 +- 33 N) led to a statistically significant difference (p =
0,002) of 80% of the push out strength, compared to the results obtained with 3,5 Nm (1285 +- 98 N). An
insertion torque of 2.5 Nm (1076 +- 86 N) achieved the correct coupling of the screw’s head with the plate’s
insert.
Securos
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An insertion torque of 0,8 Nm (Push-out force 595 +- 87 N) led to a statistically significant difference (p =
0,013)) of 74% compared to 3,5 Nm (2240 +- 282 N). An insertion torque of 2,5 Nm (1729 +- 193) achieved
flush placement of the screw’s head with the plate surface.
Orthomed
Varying the insertion torque did not lead to significant differences in push out strength, which was approx-
imatively 3748 +- 91 N for the Orthomed system.
Synthes and Veterinary Instrumentation
Varying the insertion torque did not lead to significant differences in push out strength, which was approx-
imately 4699 +- 315 N for the Synthes system and 5005 +- 755 N for the Vet Instrumentation system.
CONCLUSION
In the case of the Orthomed, Synthes and Veterinary Instrumentation systems, the higher resistance to push
out was due to their design: in the Orthomed system, up to two revolutions of the standard cortical screw
543 • WVOC 2010, Bologna (Italy), 15th - 18th September A. Boero Baroncelli
threads are engaging the plate hole surface, while the Synthes and Veterinary Instrumentation systems use
a fine-threaded screw head, conceived to engage the threaded plate hole.
The standard cortical screw uses a relatively coarse thread, compared to the very fine thread found in the
Synthes and Veterinary Instrumentation screw heads, and this could explain the different values experi-
enced. These systems could, on average, sustain higher push out strength than either the Traumavet or the
Securos system.
In the use of Traumavet and Securos angular stable systems, the minimum acceptable insertion torque
should be 2,5 Nm, in order to obtain the correct screwing to plate coupling, along with the maximum pos-
sible friction surface.
It should be noted however that a higher push out strength in this series of tests does not necessarily corre-
spond to higher implant performance in real world applications: there is a number of additional factors,
among which the plate hole design, resistance to shear forces at the level of the screw neck or fatigue failure
of the locking mechanism, that intervene mainly, compared to an axially loading push out strength.
Screw removal difficulty was not evaluated, and might be an issue in the higher torque ranges in case of im-
plant removal.
REFERENCES
1. SM Perren: Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixa-
tion: choosing a new balance between stability and biology. J Bone Joint Surg 2002;84-B:1093-110.
2. J Kaab, A Frenk, A Schmeling, K Schaser, M Schutz, N P Haas: Locked Internal Fixator Sensitivity of Screw/Plate
Stability to the Correct Insertion Angle of the Screw. J Orthop Trauma 2004;18, 8, September.
Dott. Alessandro Boero Baroncelli - Department of Animal Pathology, University of Turin (Italy)
Via Nazzario Sauro 13, 12051 Alba (CN), ITALY - E-mail alessandro.boero@unito.it
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C. Burns WVOC 2010, Bologna (Italy), 15th - 18th September • 544
Influence of locking bolt location

(metaphyseal vs. diaphyseal) on the mechanical properties
of an interlocking nail in the canine femur
C. Burns, DVM1, A. Litsky, MD ScD2, M. Allen, Vet MB PhD1, K. Johnson, BVSc PhD3
1
Department of Veterinary Clinical Sciences, The Ohio State University, Columbus, USA
2
Department of Orthopedic Surgery, The Ohio State University, Columbus, USA
3
Faculty of Veterinary Science, University of Sydney, Sydney, Australia
INTRODUCTION
Interlocking nails (ILN) provide an alternative to the use of standard bone plates for the repair of commin-
uted diaphyseal fractures. Complications associated with the use of ILN include bending or breakage of the
locking bolts. We hypothesized that the fatigue properties of locking bolts would in part be determined by
the location of the bolt in diaphyseal versus metaphyseal bone.

20 femoral pairs were harvested from skeletally mature dogs. Femora were implanted with a 6-mm diame-
ter ILN and locked with a 2.7 mm bolt placed in either the diaphysis or metaphysis. Constructs were test-
ed in axial loading (10 pairs) or torsion (10 pairs) to failure (defined as displacement > 2 mm or a total of
500,000 cycles for axial loading, and rotation > 45° degrees for torsional loading.) Outcome measures in-
cluded initial construct stiffness, number of cycles to failure, peak load and peak torque. Microradiography
and histology were used to determine the location and nature of construct failure.
RESULTS
Metaphyseal bolts failed at higher axial loads than diaphyseal bolts (p=0.03), with bolt failure due to bend-
ing at the nail-bolt interface. All metaphyseal constructs survived torsional testing whereas 9 of 10 diaphy-
seal constructs failed catastrophically due to spiral fracture through the adjacent cortical bone.
CONCLUSION
Placement of a locking bolt in metaphyseal bone extends fatigue life under axial loading and decreases the
incidence of catastrophic failure under torsional loading. Whenever possible, efforts should be made to ob-
tain firm seating of at least one bolt in metaphyseal bone.
Dr. Matthew Allen - The Ohio State University Veterinary Clinical Sciences, 601 Vernon Tharp Street, Columbus,
Oh 43210, United States - E-mail allen.1243@osu.edu
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545 • WVOC 2010, Bologna (Italy), 15th - 18th September T. Cachon
Risk for a dog to have simultaneous phenotypic expression

of both hip and elbow dysplasia.
A study based on 1411 radiographic examinations
of both joints sent for official scoring
T. Cachon, DVM, Dipl ECVS, MSc, P. Maitre, DVM, F. Arnault, DVM, D. Remy, Pr, PhD,
D. Fau, Pr, C. Carozzo, DVM, Dipl ECVS, PhD, J. Genevois, Pr, PhD
1
Department of Surgery-VetAgro-Sup-Campus Vétérinaire de Lyon, Marcy L’Etoile, France
INTRODUCTION
Hip dysplasia (HD) and elbow dysplasia (ED) are among the most common orthopaedic diseases of medi-
um to large breed dogs, that are associated with osteoarthrosis in adulthood. As they are encountered in sim-
ilar breeds, many dogs are simultaneously affected by HD and ED.
The purpose of this study based on 1411 official radiographic screening for both elbow and hip dysplasia
is to look, in this population, for the phenotypic correlation between hip and elbow dysplasia and to the risk
ratio linked with the two conditions.

Animals:
From 1999 to 2007, based on radiographs which were submitted for authorative grading, 1411 dogs simul-
taneously screened for HD and ED were included in the study. Radiographic screening was performed by
a unique skilled official panellist. For each dog, breed, age at time radiographs were performed, HD and ED
score were noted.
Radiographic examination:
HD radiographic screening was based on a conventional ventrodorsal hip extended view. The animals were
graded according to the FCI 5 class grading scale protocol (A=no sign of HD; B=near normal); C=mild
HD); D=moderate HD; E=severe HD).
ED radiographic screening was based on three radiographic projections of each elbow joint: true mediolat-
eral with the joint flexed approximately 45° (ML flexed), true mediolateral with the joint extended (ML ex-
tended), and craniolateral-caudomedial oblique (Cr15L-CdMO). ED gradation was based on official ED
french grading system, which is a 5 class modified IEWG (International Elbow Working Group) grading
scale (ED 0=No sign of ED; SL= near normal; ED1=Mild ED; ED 2=Moderate ED; ED 3=Severe ED).
In this grading scale, every dog showing a primary lesion on the radiograph is classified as ED 3.
As they belong to an «intermediate» class, dogs scored as «near normal», either for HD or ED, were ex-
cluded from the study.
Data analysis:
Statistical analysis was performed with a statistical computer software package. A chi2-squared test and a
Spearman’s rank correlation test were performed in order to look for correlation between elbow and hip dys-
plasia. Risk ratio and the corresponding 95% CI was then calculated to look for the risk factor for the ani-
mal to be both HD and ED affected. Risk ratio was also calculated for each class of dysplasia
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RESULTS
1411 dogs were included in this study. Most of them belong to four breeds: Bernese mountain dog (726),
Rottweiler (341), Australian sheepdog (165) and White Swiss sheep dog (139). 41 dogs from 13 other breeds
are also included in the study. There are 894 females and 517 males. Median age was 16 months. Results
of HD and ED score were resumed in table 1. HD prevalence was 7,5% and of ED prevalence 18,4%.
Chi2-squared test showed a significant correlation (p-value < 0.001) between HD and ED. Spearman’s rank
correlation test value was 0,1 (p-value = 0.0005).
Risk ratio for an animal to be simultaneously affected by HD and ED was 1,67 (1,21-2,30) (p-value=0,004).
For a dog with ED, risk ratio to be affected by HD, increases with the grade of ED. Inded, risk ratio, for a
dog with grade 1 ED, to be affected by HD was 1,19 (0,67-2,09). Whereas for a dog with grade 3ED risk
ratio to be affected by HD was 3,60 (2,20-5,90) Similarly, for a dog affected by HD, risk ratio for ED in-
creases with the grade of HD. A dog with a grade C HD get a risk ratio to be affected by ED of 1,30 (0,82-
2,06) whereas risk ratio, for a dog with grade D HD, to be affected by ED was 2,29 (1,53-3,40).
T. Cachon WVOC 2010, Bologna (Italy), 15th - 18th September • 546
CONCLUSION
We found a statistically, though low, significant correlation between HD and ED. To the authors knowledge,
phenotypic correlation beetween HD and ED was so far reported in three study. A Pearson correlation co-
efficient of 0.16 beetween phenotypic traits of HD and ED was found in labrador retrevier in Switzerland.
Another result from an explorative screening program for elbow dysplasia in some breeds of dogs in Italy
show that HD diagnosis was significantly associated with the risk of outbreak of ED, and that dogs affect-
ed by hip dysplasia showed a 41% increased risk on being affected by ED. In Finland, a phenotypic corre-
lation beetween HD and ED was also reported to be 0,24 for the Rottweiler.
On a clinical (or individual) point of view when HD or ED is diagnosed in an animal, the clinician should
look for the second condition. This is particularly pertinent in case of severe ED or HD as the risk ratio for
an animal with severe HD to be also affected of ED is almost 2,3. Similarly, the risk ratio for an animal with
severe ED to present with HD is 3,6. Such correlation between orthopedic conditions has been described
for other orthopedic problems.
On a breeding point of view, finding a positive correlation between HD and ED could bring the hope that
a simultaneous selection for both traits is possible. Unfortuntely, at least in our study and in the studies of
Mäki, the correlation is in a low range. Therefore selection against only one trait will not effect the other
trait sufficiently. As a consequence, selection has to be conducted at reduction of HD as well as reduction
of ED.
REFERENCES
Ohlert, S., et al., Epidemiologische und genetische Untersuchungen zur Hüftgelenksdysplasie an einer Population von
Labrador Retriever: Eine Study über 25 Jahre. Deutsche Tierärztliche Wochenschrift, 1998. 105: p. 378-383.
Sturaro, E., et al., Prevalence and genetic parameters for hip dysplasia in Italian population of purebred dogs. Ital. J. An-
im. Sci., 2006. 5: p. 107-116.
Maki, K., A.E. Liinamo, and M. Ojala, Estimates of genetic parameters for hip and elbow dysplasia in Finnish Rottweil-
ers. J Anim Sci, 2000. 78(5): p. 1141-8.
Dr. Thibaut Cachon - Vetagro-Sup-Campus Vétérinaire de Lyon Department Of Surgery, 1 Avenue Bourgelat,
69280 Marcy L'etoile - France, France - E-mail t.cachon@vetagro-sup.fr
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547 • WVOC 2010, Bologna (Italy), 15th - 18th September I. Calvo
Tibial tuberosity fracture as a complication of tibial

tuberosity advancement. Risk factors and management
I. Calvo, Ldo Vet, CertSAS, R. Yeadon, MA(hons), vetMB, CertSAS,
D. Chase, BVSc, MACVSc (Surgery), K. Zavota, BVMS, D. Bennet, BSc, BVetMed, PhD, DSAO
Division of Companion Animal Sciences, University of Glasgow Veterinary School, Glasgow, UK
INTRODUCTION
Tibial tuberosity (TT) fractures have been reported after TTA, with an incidence ranging from 1- 4%.The
majority (7/8) of fractures previously reported were simple avulsion fractures, with only one having com-
minution. Risk factors have been identified for TT fractures after TPLO. However, to the authors’ knowl-
edge, no reports to date have specifically addressed these risk factors for TTA.
This report describes 7 cases of TT fractures following TTA (3 avulsions, 4 comminiuted), which occurred
during the first 54 operated, stifles at a referral hospital. We aim to retrospectively identify any technical er-
rors, which might have predisposed to these fractures and to report their management and outcome.

Hospital records were searched between October, 2008 and October, 2009 for dogs that had undergone
TTA. Clinical records and radiographs were examined to identify signalment, implant size, fracture pattern,
the presence of technical errors, surgical management and outcome.
Statistical analysis was performed using Minitab Release 14 software (Minitab Inc., Coventry, UK). A bi-
nary logistic regression model was used to identify potential predictors of complications. Candidate vari-
ables included patient age, cranial cage screw orientation, cage size, number of fork tines, contact between
the cranial cage ear and the plate, plate orientation, osteotomy thickness, cage positioning, and osteotomy
contact. P-values <0.05% were considered significant. A Hosmer-Lemeshow goodness-of-fit test was used to
evaluate the logistic regression model.
RESULTS
47 dogs, 54 stifles were operated. Mean age was 5.14 years (range 1-13 years). 14 different breeds were rep-
resented with Labradors being most common (n=10). 28 left, 26 right stifles were operated. 7/54 stifles sus-
tained post-operative peri-implant tibial tuberosity fractures, with 4/7 being comminuted, and 3/7 being
transverse avulsion type fractures. Only reduced thickness of the osteotomised tibial tuberosity (P=0.034)
was found to be a significant predictor of tibial tuberosity fracture (OR = 7.71; 95%CI = 1.17 - 50.80) with-
in the binary logistic regression model. The model fitted the data well (Hosmer-Lemeshow ?2 P=0.80). No
other variables were found to be significant predictors of tibial tuberosity fracture.
All three avulsion-type fracture were incidental findings at 6 weeks post-operative follow up. None of them
were surgically treated, and the 3 dogs are exercising normally (6 month follow-up).
The comminuted TT fracture configuration appeared to follow the same pattern; the major fracture line ex-
tended along the plate tines, extending to the cranial cage screw and caudal aspect of the osteotomized tib-
ial crest. With a second distal fracture line extending from the plate tines towards the cranial aspect of the
osteotomized tibial crest, resulting in a transverse-plane fracture of the osteotomized crest. The degree com-
minution and the amount of proximal displacement of the fractured TT varied slightly among the cases.
One of the comminuted TT fractures was an incidental finding at 6 weeks post-operative follow-up. A mild
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2/10 hind lameness was detected. Stifle range of motion and comfort levels were good. Conservative man-
agement was elected. At 12 weeks post-operatively follow up, healing was evident. At 4 month post-opera-
tively follow-up the dog was reported to be exercising normally with no stiffness or lameness.
The three remaining comminuted TT fractures were treated surgically. All three cases presented with a not-
weight bearing lameness. Significant discomfort was elicited on gentle stifle examination. The cranial cage
screw, plate, fork and plate screws were removed in all cases. The advancement cage and caudal screw were
maintained initially in all cases. The TT was reduced, maintaining the advancement, and fixed with a dou-
ble tension band wire (each of the cerclage wires passed through one of the plate screw holes). In two cases
2 aditional positional k-wires were used.
One of the surgically treated cases underwent an uncomplicated recovery after fracture repair. 6 month fol-
low up revealed the dog to be exercising normally with no stiffness or lameness.
One of the surgically managed TT comminuted fracture case sustained a minimally displaced TT avulsion
fracture, which was incidentally diagnosed at 4 weeks post-fracture rapair follow-up. The avulsion fracture
I. Calvo WVOC 2010, Bologna (Italy), 15th - 18th September • 548
was managed conservatively and 6 months follow up revealed the dog to be exercising normally with no
obvious stiffness or lameness.
In the remaining case, the comminuted TT fracture repair failed. All the implants were removed and the tib-
ial tuberosity was anatomically reduced using two 1.6 mm k-wires and a figure-of-eight tension band wire.
The stifle was stabilised by an extra-capsular technique. At six weeks follow-up there was a 2/10 pelvic limb
lameness and radiographic progression of fracture healing.8 months follow-up afte revealed the dog to be
exercising normally, although stiffness after rest on the affected limb was reported after unrestricted exercise
of more than 45 minutes duration.
CONCLUSION
Lavafer et al (2007) stated that the proximal cage screw should be directed in a cranio-proximal direction.
Directing the screw in such a way maximizes cortical bone purchase. The ideal torque required by the prox-
imal cage screw is unknown, however; it has been previously reported that decreased cortical bone thick-
ness (amongst other factors) negatively affects the screw torque achieved and therefore decreases its resist-
ance to toggle. Intuitively, maximising cranial cage screw cortical bone purchase is an advisable goal. Based
on the same rationale, positioning of the plate as cranial as possible (cranial border of the plate level with
the cranial border of the tibial crest) may provide better cortical bone purchase. Despite of the lack of sta-
tistical significance we recommend aiming the cranial screw in a proximo-cranial direction and positioning
the plate as cranial as possible.
Distal cage positioning leaves an isolated TT without caudal support. This configuration has been hypoth-
esized to increase the risk of TT fracture after TPLO. However, Bergh et al (2008) evaluated the factors pre-
disposing to TT fracture after TPLO and concluded that isolation of the TT with lack of caudal support
was not a risk factor. Our results suggest that low cage position is not associated with tibial tuberosity frac-
ture after TTA.
Narrow osteotomized tibial crest was associated with TT fracture in our study (P=0.034). Our subotimal os-
teotomies were mostly narrow at the level of the distal plate tines; we hypothesize that a thin distal osteotomy
may result in poor purchase of the distal tines and overload of the proximal ones, raising the stress at the prox-
imal part of the osteotomy. Further biomechanical studies are warranted to prove this hypothesis.
Tibial tuberosity fracture repair maintaining the advancement is an ambitious goal. The caudal support is
limited, increasing the stress in the repair and therefore the chances for implant failure or subsequent frac-
ture. We achieved a satisfactory functional outcome whilst maintaining the advancement in 2/3 cases. How-
ever, careful assessment of the fracture configuration, patient and clinical factors on an individual basis is
mandatory. Consideration should be made for implant removal and stabilization of the crest fragment in
their original anatomic position. In this case CrCL deficiency can be treated via extra-capsular repair.
REFERENCES
Lafaver S, Miller NA, Stubbs WP, et al. Tibial tuberosity advancement for stabilization of the cranial cruciate ligament-
deficient stifle joint: surgical technique, early results, and complications in 101 dogs. Vet Surg 2007;36:573-586.
Bergh MS, Rajala-Schultz P, Johnson KA. Risk factors for tibial tuberosity fracture after tibial plateau leveling osteotomy
in dogs. Vet Surg 2008; 37: 374-382.
Mr. Ignacio Calvo - University of Glasgow Small Animal Orthopaedics, Bearsden Road, Bearsden, G61 1Qh,
United Kingdom - E-mail i.calvo@vet.gla.ac.uk
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549 • WVOC 2010, Bologna (Italy), 15th - 18th September F. Cappellari
Surgical correction of antebrachial deformity

in a dog by means of deformity reduction device
F. Cappellari, DVM, PhD1, E. Panichi, DVM, PhD2, L.A. Piras, DVM1,
A. Ferretti, DVM, ECVS3, B. Peirone, DVM, PhD1
1
Department of Animal Pathology, Faculty of Veterinary Medicine, Turin, Italy
2
Libero professionista, Pinerolo, Italy
3
Libero professionista, Legnano, Italy
INTRODUCTION
Antebrachial deformity in dogs may be treated by external or internal fixation. During internal fixation, one
of the most critical issue is bone segments instability following the osteotomy. The aim of this paper is eval-
uated the feasibility of a a new reduction device in order to improve stability and segment apposition before
plating.

A 1-year-old 23 kg female Kurzhaar dog was referred because of intermittent lameness of the left forelimb;
the limb had a visible antebrachial deformity resulting in valgus, procurvatum and external rotation.
At 6 months of age a non dislocated transverse fracture of the distal third of the radius was diagnosed. Con-
servative treatment of the fracture was performed. Three weeks later, radiographs showed fracture healing
progression. Three weeks later the owner observed a slight antebrachial deformity and the radiographic ex-
am showed a premature closure of the distal physis of the ulna. At 8 months of age the dog was treated by
ulnar ostectomy and staple application on the cranio-medial aspect of the distal physis of the radius. No func-
tional improvement was observed and four weeks later the implant was removed.
After four months the owner agreed to correctional deformity treatment. At presentation the dog showed I
degree left forelimb lameness, around 15° external rotation of the paw and carpal flexion reduction (left:
130°, right: 155°).
Orthogonal radiographic views of both forelimb were obtained. Deformity was assessed and quantified ac-
cording to the Center of Rotation of Angulation (CORA) method1, 2.
PCRA right: 91°; left: 91°
DCRA right: 77,6°; left: 59,4°
SPA right: 13,4°; left: 31,6°
MPRA right: 84,1°; left: 83,2°
LDRA right: 87,3°; left: 73,4°
FPA right: -3,2°; left: 9,8°.
Length of the right radius measured 173,3 mm, left 169,6 mm. Based on the small amount of limb shorten-
ing, an acute correction by medial closing wedge osteotomy of the radius was planned. In order to achieve
stabilization of the osteotomy site and precise surgical correction, the use of the Deformity Reduction De-
vice (DRD, Hoffman) was planned.
Methadone (2 mg/kg) and acepromazine (0.015 mg/kg) were administered IM. Anaesthesia was induced
with propofol (3 mg/kg, IV) and maintained during surgery via isoflurane (2%) with 100% oxygen.
Cefazolin sodium (22 mg/kg, IV) was administered at induction and every 90 minutes. A standard hanging
limb preparation was adopted, with the dog in dorsal recumbency.
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The fibrous tissue in the previous ulnar ostectomy site was removed with a bone rongeur through a cau-
dolateral approach to the ulna. A medial approach to the distal shaft of the radius was performed. A 25-
gauge needle was inserted into the radiocarpal joint for reference. Marks were made on the bone to identi-
fy the distomedial closing wedge osteotomy, located at positions 38 mm and 43 mm proximal to the joint
space. A 1,6 mm Kirschner wire was inserted in the lateral cortex, at the level of the CORA. This allows
precise positioning of the DRD’s hinge at the level of the Angulation Correction Axis (ACA). Care was tak-
en to maintain the radius at the center of the DRD’s arc before securing it to the bone with four 2 mm neg-
ative threaded pins. Osteotomies were made with an oscillating saw; the cuts converge on the lateral surface
of the radius to create a 13° wedge.
Deformity corrections on the axial and frontal plane were achieved through the DRD’s correction mecha-
nisms. Correction on the sagittal plane and bone contact at the osteotomy site were obtained by loosening
the Meynard clamps at the proximal part of the DRD, in order to reduce procurvatum. The clamps were
then tightened to stabilize the osteotomy site.
F. Cappellari WVOC 2010, Bologna (Italy), 15th - 18th September • 550
Gross observation of the limb revealed an apparent appropriate correction of the rotational and angular de-
formity. A 7 hole 2,7 mm LCP (Synthes) was applied on the medial aspect of the radius. The DRD was re-
moved and a straight support (Traumavet), with four 1,9 mm screws, was applied on the lateral surface of
the ulna.
RESULTS
In the postoperative x-ray, alignment was as follows: PCRA was 91°, DCRA 77,2° and SPA 13,8°, MPRA
was 83,2°, LDRA 85,5° and FPA -2,3°.
The dog was re-evaluated 40 days after surgery and was clinically free from lameness although reduction in
carpus flexion didn’t improve. A slightly external rotation of the paw was still present. Radiographic evalu-
ation revealed osteotomy bone healing progression, even if exuberant periosteal reaction was noted.
At 12 weeks postoperatively, carpus flexion had improved to 145°. Radiography revealed complete bone
healing of the radial, but not of the ulnar ostectomy.
At 6 months after surgery, the dog was presented with swelling of the medial aspect of the carpus. No lame-
ness or pain was detected during orthopedic evaluation; carpus flexion was still reduced to 145°. Radi-
ographs revealed ulnar ostectomy healing and implant removal was suggested to solve the swelling and pre-
vent osteopenia. One month later both plates were removed.
One year after the procedure, the owner reported satisfaction with the outside appearance of the limb and
the dog’s activity level was normal.
CONCLUSION
Angular deformities of the forelimb are frequently reported in dogs. In 1 study, 75% were attributable to dis-
tal ulnar physis abnormalities. Such abnormalities can be related to different etiologies. However, trauma is
the most common cause of early physis closure3. In this case, delayed diagnosis of premature closure of the
distal ulnar physis led to a delayed treatment of the condition. The first treatment’s poor outcome was prob-
ably due to the inappropriateness of epiphysiodesis at 8 months of age.
With appropriate preoperative planning and careful execution of surgical techniques, resolution of ante-
brachial angular limb deformities is possible with a good-to-excellent clinical outcome2. The DRD device al-
lows good stabilization of the osteotomy site and precise correction: alignment of the limb and reduction of
the osteotomy can be checked and changed during surgery. When alignment and apposition are both satis-
factory, the plate can be easily applied without loss of primary reduction.
In this case, closing wedge osteotomy was chosen to obtain bone to bone contact, decreasing implant stress
in the postoperative phase. Radius shortening was determined as a consequence. Opening wedge osteoto-
my may be considered as an alternative, in fact the use of the DRD guarantees a precise correction on the
frontal plane.
In this case, axial alignment was achieved with translation of the distal fragment of the radius. A decision
was made to offset the osteotomy from the CORA to provide adequate space for implant positioning. The
DRD’s hinge (ACA) was positioned at the level of the CORA. The translation occurred is explained by Pa-
ley’s second osteotomy rule1.
A major limitation of this case report is that the degrees of radius torsion was estimated clinically without
the use of a CT scan. Another limitation is that the degree of the dog’s lameness before and after surgery
was not objectively quantified. Thus, success was defined by the radiographic and gross improvements in
limb alignment and the subjective lameness assessment by the clinicians and owner, which may be biased.
REFERENCES
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1. Paley D. (2002) Frontal plane mechanical and anatomic axis planning. In: Herzenberg JE, ed. Principles of defor-
mity correction. Heidelberg, Germany: Springer-Verlag Berlin Heidelberg, 61-97.
2. Fox DB, Tomlinson JL, Cook JL, et al. (2006) Principles of uniapical and biapical radial deformity correction using
dome osteotomies and the center of rotation of angulation methodology in dogs. Vet Surg 35, 67-77.
3. Dismukes D.I., Fox D.B., Tomlinson J.L., Essman S.C. (2008) Use of radiographic measures and three-dimension-
al computed tomographic imaging in surgical correction of an antebrachial deformity in a dog. JAVMA 232, 68-73.
Dott. Fulvio Cappellari - Department of Animal Pathology, Faculty of Veterinary Medicine, Turin, Corso De Nicola,
62, 10129 Torino (TO), Italy - E-mail fulvio.cappellari@unito.it
551 • WVOC 2010, Bologna (Italy), 15th - 18th September J.U. Carmona
Evaluation of the antibacterial effect of platelet concentrates

and other equine blood components against methicillin
resistant Staphylococcus aureus
M.E. Álvarez, BSc, MSc, C. López, MVZ, C.E. Giraldo, MVZ, MSc,
J.U. Carmona, MVZ, MSc, PhD
Grupo de Investigación Terapia Regenerativa, Departamento de Salud Animal, Universidad de Caldas,
Calle 65 No 26-10, Manizales, Colombia
INTRODUCTION
The clinical (Yuan et al. 2008) and in vitro (Bielecki et al. 2007; Moojen et al. 2008)) antibacterial effect of
human platelet concentrates hPCs have been reported against bacteria such as Staphylococcus aureus (sen-
sible (Moojen et al. 2008) and methicillin resistant -MRSA-) and, Escherichia coli (Bielecki et al. 2007).
Staphylococcus aureus is one of the most commonly bacteria isolated in surgical infections and septic arthri-
tis in horses. These infections are even more serious when produced by MRSA strains (Anderson et al.
2009). To date there is no information about the in vitro antibacterial effect of the equine platelet concen-
trates (ePCs) against MRSA. The aims of this study were 1) to evaluate the antibacterial effect of ePCs (ei-
ther activated or not with calcium gluconate) obtained by the tube method (Arguelles et al. 2006) against
MRSA, and 2) to compare their antibacterial effect with platelet poor plasma (PPP) (activated with calcium
gluconate) and plasma (P).

Forty-five mL of blood were collected in sodium citrate tubes from 7 horses (5 geldings and 2 mares) with
a median age of 7 years (range 4-12 years). Blood samples were processed by the tube method (Arguelles et
al. 2006), and the following components were obtained: 3 mL of PC, 2 mL of PPP and, 1 mL of P. A count
of platelets (PLTs) and leucocytes (WBCs) was performed in duplicate for whole blood (basal count), PCs
and PPPs. The cellular blood products and plasma were allotted into 4 groups to determine the antibacter-
ial effect against MRSA (ATCC® 43300, KS, USA). Group 1: 1 mL of PC (G1), group 2: 0.9 mL of PC
plus 0.1 mL of calcium gluconate (G2), group 3: 0.9 mL of PPP plus 0.1 mL of calcium gluconate (G3) and
group 4: 1 mL of P (G4). One mL of each group was mixed with 33 µL of a MRSA suspension and 4mL
of Müeller-Hinton broth (MHB) to obtain a final concentration of 1X106 colony-forming unit (CFU)/mL.
In addition, a positive control group (PCG) (1mL of PBS+33µL of MRSA suspension +4mL of MHB) and
a negative control group (NCG) (1mL of PBS+4mL of MHB) were included in the study. The samples were
incubated at 37ºC during 1h and then plated in serial 10 µL dilutions (1:10, 1:100, 1:1.000, 1:10.000 y
1:100.000) in plates of sheep blood to 5%. The plates were incubated at 37°C for 4, 8, 12, and 24h, and the
number of colony forming units (CFU) was determined in each plate. The hematological values were pre-
sented as mean (standard deviation) and evaluated with a 1 way ANOVA. A SNK test was used as post-hoc
test. The antibacterial effect of each evaluated group was presented as median (interquartile range) and eval-
uated with a Friedman`s ANOVA. Tests of Wilcoxon and Mann-Whitney U were used as a tests post-hoc.
A Spearman correlation test was also performed. A P<0.05 value was accepted as statistically significant for
the all tests.
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RESULTS
The mean counts of PLTs and WBCs in blood were 210.214 (39.760)/µL and 11600 (1400)/µL, respective-
ly. The mean PLT count for the PCs was 512.928 PLTs/µL and of WBCs was 9.560 (4980) cells/µL. The
mean PLT concentration for PPP was 257.215 (59.511) PLTs/µL and 128 (165) WBCs/µL. The concentra-
tion of PLTs/µL was statistically different (P=0.01) between the basal count of the whole blood and the PC
and between the count of the PC and PPP. There were no statistical differences among the PLT counts of
the whole blood and the PPP. The WBCs concentration in PPP was statistically lower (P=0.01) than in
whole blood and in the PC. There were not statistical differences between the WBCs count in whole blood
or the PC.
The bacterial growth was significantly (P=0.01) inhibited by the G1, G2, G3 and G4 groups in comparison
with the CPG during the first 12h. At 24h only a statistically significant (P=0.01) antibacterial effect was no-
ticed for the G1, G2 and G3 in comparison with the PCG. The most important (global -P=0.01-) antibac-
terial effect was observed for the G2, followed by the G3 and G1, respectively. The G2 and G3 groups pre-
J.U. Carmona WVOC 2010, Bologna (Italy), 15th - 18th September • 552
sented the same antibacterial effect during 8 and 12 h, and this was statistically superior (P=0.01) when com-
pared to G1 and G4 during 8 and 12 h. The time factor statistically influenced (P=0.01) the bacterial growth
among all the evaluated groups (excepting the NCG), but this effect was more pronounced on G4 and PCG.
There were not significant correlations between the concentrations of PLTs or WBCs of each group and the
counts of 10logCFU/mL observed for the 1:10.000 dilution.
CONCLUSION
The global results of this study demonstrated that PC and PPP activated with calcium gluconate provide
the best antibacterial effect against MRSA. Our results are similar to the results described by others (Moo-
jen et al. 2008), who observed an in vitro bactericidal effect of the human platelet gel against Staphylococ-
cus aureus. In our study, as in other (Moojen et al. 2008), a correlation between the concentration of PLTs
or WBCs and the count of 10logCFU/mL was not obtained. Upon activation, platelets release platelet fac-
tor 4 (PF-4), a potent bactericidal peptide against Staphylococcus aureus (Mukhopadhyay et al. 2007).
Platelets can be naturally activated by Staphylococcus aureus, such as in G1; however, it is possible that the
activation with calcium gluconate (G2 and G3) produced a greater release of this peptide during the exper-
iment. On the other hand, is very important to consider that the presence of immunoglobulin against MR-
SA possibly inhibited the bacterial growth during at least the first 4h of the experiment, since G4 (plasma)
presented a strong bactericidal effect during this time and then gradually lost this effect. Our results war-
rantee the measurements of concentrations of PF-4 and immunoglobulin against MRSA in the PCs and the
other blood components evaluated in this study. These results open the possibility of using calcium glu-
conate treated PCs and PPP as “prophylactic antibacterial biodrugs” in soft tissue and orthopedic equine
surgery. PCs and even PPP could be potentially useful as adjuvant treatment of septic arthritis or synovitis
produced by MRSA. However, in vivo and clinical studies should be performed to validate the use of these
substances in equine surgery.
REFERENCES
Anderson, M.E.C., Lefebvre, S.L., Rankin, S.C., Aceto, H., Morley, P.S., Caron, J.P., Welsh, R.D., Holbrook, T.C.,
Moore, B., Taylor, D.R. and Weese, J.S. (2009) Retrospective multicentre study of methicillin-resistant Staphylo-
coccus aureus infections in 115 horses. Equine Veterinary Journal 41, 401-405.
Arguelles, D., Carmona, J.U., Pastor, J., Iborra, A., Vinals, L., Martinez, P., Bach, E. and Prades, M. (2006) Evaluation
of single and double centrifugation tube methods for concentrating equine platelets. Research in Veterinary Science
81, 237-245.
Bielecki, T.M., Gazdzik, T.S., Arendt, J., Szczepanski, T., Krol, W. and Wielkoszynski, T. (2007) Antibacterial effect of
autologous platelet gel enriched with growth factors and other active substances - An in vitro study. J. Bone Joint
Surg.-Br. Vol. 89B, 417-420.
Moojen, D.J.F., Everts, P.A.M., Schure, R.M., Overdevest, E.P., van Zundert, A., Knape, J.T.A., Castelein, R.M.,
Creemers, L.B. and Dhert, W.J.A. (2008) Antimicrobial activity of platelet-leukocyte gel against Staphylococcus au-
reus. Journal of Orthopaedic Research 26, 404-410.
Mukhopadhyay, K., Whitmire, W., Xiong, Y.Q., Molden, J., Jones, T., Peschel, A., Staubitz, P., Adler-Moore, J., McNa-
mara, P.J., Proctor, R.A., Yeaman, M.R. and Bayer, A.S. (2007) In vitro susceptibility of Staphylococcus aureus to
thrombin-induced platelet microbicidal protein-1 (tPMP-1) is influenced by cell membrane phospholipid composi-
tion and asymmetry. Microbiology-Sgm 153, 1187-1197.
Yuan, T., Zhang, C.Q. and Zeng, B.F. (2008) Treatment of chronic femoral osteomyelitis with platelet-rich plasma (PRP):
A case report. Transfusion and Apheresis Science 38, 167-173.
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Dr. Jorge U. Carmona - Universidad de Caldas Departamento de Salud Animal, Calle 65 No 26-10, Manizales,
Caldas, Colombia - E-mail carmona@ucaldas.edu.co
553 • WVOC 2010, Bologna (Italy), 15th - 18th September B. Costa
Effect of glupamid (N-palmitoyl-D-glucosamine)

on knee osteoarthritis pain
B. Costa, PhD1, F. Comelli, Biol1, A. Miolo, BSc2, M.F. della Valle, Biol2
1
Department of Biotechnology and Bioscience, University of Milano-Bicocca, Milano, Italy
2
CeDIS, Science Information and Documentation Centre, Innovet Italia, Milano, Italy
INTRODUCTION
Osteoarthritis (OA) is one of the most common chronic musculoskeletal diseases both in dogs and cats, af-
fecting 20% of dogs over one year of age1 and about 60% of cats aged over 6 years2. OA is a significant
cause of pain and disability. In dogs, it is characterised by lameness and pain with joint manipulation,
whereas in cats joint pain is mainly manifested by behavioural changes, such as less jumping and groom-
ing. One of the main mechanisms responsible for the generation of joint pain is the activation of nocicep-
tors located on the terminal branches of joint type III (A-delta fibre) and type IV (C fibre) primary affer-
ent nerve fibres3. Interestingly, synovial mast cells (MCs) have been identified in close proximity to both
these types of knee joint afferents4. Neuromediators are known to stimulate MC degranulation, resulting
in the local release of proinflammatory and hyperalgesic mediators5,6. Cytological studies have shown that
synovial MC numbers are elevated in OA when compared with normal controls7. Particularly, MCs con-
taining tryptase seems to be strikingly increased in OA synovial tissues8, and tryptase has a crucial role in
the activation of pain pathways9.
An established animal model of OA pain involves the intraarticular injection of the glycolysis inhibitor
monosodium iodoacetate (MIA), which disrupts cartilage metabolism, thus leading to chondrocyte death
and subchondral bone lesions consistent with the pathologic changes seen in naturally occurring OA. Elec-
trophysiologic and behavioural studies have shown that joint nociceptors are sensitized in the MIA model,
leading to the generation of joint pain10.
Glupamid (N-palmitoyl-D-glucosamine) is the amide of palmitic acid and glucosamine, and is thought to in-
corporate both the effects of the aliamide palmitoylethanolamide (PEA) and those of the chondroprotective
compound glucosamine. PEA exerts a significant antinociceptive effect in a model of chronic pain11 and this
effect is mediated, at least in part, by the down-modulation of local MC activity12. Furthermore, Glupamid
has also been shown to fine-tune MC degranulation in vitro13. Given these findings, the aim of the present
study was to investigate the effect of Glupamid on experimentally induced OA pain.

All experiments performed were in accordance with Italian State and European regulations governing the
care and treatment of laboratory animals. Forty male Wistar rats (180-220 g) were housed in cages with free
access to water and rodent food and maintained at room temperature (21 ± 1°C) under a 12-hour light/12-
hour dark cycle. Rats were deeply anesthetized with pentobarbital. A 27-gauge needle was introduced into
the joint cavity through the patellar ligament, and 2 mg MIA in 25 microl saline was injected into the joint.
Control rats were injected 25 microl saline only. Animals were allowed to recover for 7 days and on day 8
received a single administration of Glupamid (10 mg/kg, p.o.).
A time-course study was performed with the nociceptive behaviour evaluated 30, 90, 120 and 180 min af-
ter the single administration. Afterwards, the treatment went on daily for one week. Mechanical allodynia
was assessed using the Dynamic Plantar Aesthesiometer (Ugo Basile, Varese, Italy), an automated appara-
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tus based on the von Frey filament principle. The effect of drugs between animal groups was analyzed by
two-way analysis of variance (ANOVA) with Bonferroni adjustment and by Student’s unpaired t-test. P val-
ues less than 0.05 were considered significant.
RESULTS
As expected, 7 days after the MIA injection, rats developed mechanical allodynia to normally innocuous me-
chanical stimulation with a von Frey filament, as compared to saline injected animals. Treatment of MIA in-
jected rats with a single dose of Glupamid (10 mg/kg, p.o.) resulted in a significant relief of mechanical al-
lodynia. The anti-allodynic effect was maximum 90 min after the acute administration of Glupamid and it
was no more detectable 24 h later. To determine whether the anti-allodynic effect of Glupamid could be en-
hanced by repetitive administration, we subjected MIA injected rats to a 7-day regimen with the same dose
of Glupamid (10 mg/kg, p.o., sid). The repeated administration significantly attenuated mechanical allody-
nia in a time-dependent manner.
B. Costa WVOC 2010, Bologna (Italy), 15th - 18th September • 554
CONCLUSION
Joint pain in canine and feline OA is considered to be of chronic nature14 and quite frustrating to treat, as it
often responds poorly to classic analgesics (eg, opioids, NSAIDs)15. In the present study we demonstrated
that Glupamid is able to reduce mechanical hypersensitivity associated with OA. In particular, we have
shown that Glupamid evoked a significant relief of pain in a murine model of OA after a single oral ad-
ministration, and that the repeated treatment led to a more potent and long-lasting relief. Glupamid belongs
to the aliamide family, i.e. a group of lipid amide compounds acting via the so called ALIA mechanism (Au-
tacoid Local Injury Antagonism), whose main target is considered to be the down-modulation of MC func-
tion16. For this reason, works are in progress to examine the involvement of MCs in the Glupamid-evoked
anti-allodynic effect. In conclusion, the data reported herein suggest that Glupamid may represent a new tool
for controlling OA–associated pain.
REFERENCES
1. Johnston SA. Osteoarthritis. Vet Clin North Am Small Anim Pract. 1997;27(4):699-723.
2. Slingerland LI. et al. Cross-sectional study of the prevalence and clinical features of osteoarthritis in 100 cats. Vet J.
2010; In Press.
3. Schaible HG, Schmidt RF. Activation of groups III and IV sensory units in medial articular nerve by local me-
chanical stimulation of knee joint. J Neurophysiol 1983;49:35-44.
4. Heppelmann B. et al. Fine sensory innervation of the knee joint capsule by group III and group IV nerve fibers in
the cat. J Comp Neurol. 1995;351:415-428.
5. Tore F, Tuncel N. Mast cells: target and source of neuropeptides. Curr Pharm Des. 2009;15:3433-45.
6. Theoharides TC. et al. Differential release of mast cell mediators and the pathogenesis of inflammation. Immunol
Rev. 2007; 217:65-78.
7. Dean G. et al. Mast cells in the synovium and synovial fluid in osteoarthritis. Br J Rheumatol 1993;32:671-675.
8. Buckley MG. et al. Mast cell subpopulations in the synovial tissue of patients with osteoarthritis: selective increase
in numbers of tryptase-positive, chymase-negative mast cells. J Pathol. 1998;186:67-74.
9. Dale C, Vergnolle N. Protease signaling to G protein-coupled receptors: implications for inflammation and pain. J
Recept Signal Transduct Res. 2008;28:29-37.
10. Harvey VL, Dickenson AH. Behavioural and electrophysiological characterisation of experimentally induced os-
teoarthritis and neuropathy in C57Bl/6 mice.Mol Pain. 2009;5:18.
11. Costa B. et al., The endogenous fatty acid amide, palmitoylethanolamide, has anti-allodynic and anti-hyperalgesic
effects in a murine model of neuropathic pain: involvement of CB1, TRPV1 and PPARgamma receptors and neu-
rotrophic factors. Pain. 2008;139:541-50.
12. Costa B. et al. Targeting mast cells in neuropathic pain with the endogenous modulator palmitoylethanolamide. J
Periph Nerv Syst. 2009;14(S1):10.
13. Miolo A. et al., Glupamid: a novel nutraceutical approach to canine and feline osteoarthritis. J Vet Pharmacol Ther.
2006;29(S1):202-3.
14. Hellyer P. et al., AAHA/AAFP Pain Management Guidelines for Dogs & Cats, J Am Anim Hosp Assoc. 2007;
43:235-48.
15. Posner LP. Chronic pain in dogs and cats. Scientific Proceedings, North Am Vet Conf (NAVC), 2008.
16. Re G. et al., Palmitoylethanolamide, endocannabinoids and related cannabimimetic compounds in protection
against tissue inflammation and pain: Potential use in companion animals. Vet J. 2007;173:23-32.
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Prof.ssa Barbara Costa - Department of Biotechnology and Bioscience, University of Milano-Bicocca, Milano, Italy
Piazza della Scienza 2, 20126 Milano (MI), Italy - Tel +39-02-64483436
555 • WVOC 2010, Bologna (Italy), 15th - 18th September A. Crovace
Implantation of autologous bone marrow mononuclear

cells as a minimal invasive therapy of Legg-Calvè-Perthès’
disease in the dog
A. Crovace DVM, Full professor1, F. Staffieri DVM1, G. Rossi DVM Associate professor2,
E. Francioso Technician1
1
DETO, Bari, Italy
2
Dipartimento di Scienze veterinarie, Camerino, Italy
INTRODUCTION
The cell therapy is at present considered a novel solution for the regeneration and also for the treatment of
some disease of many tissues including bone and other mesenchymal derived tissues.
The Legg-Calvè-Perthes (LCP) syndrome is a degenerative disease of the hip joint which is characterized by
idiopatic avascular osteonecrosis of femoral head. This disease typically occurs in young children and for
the distinguishing features it can be comparable to the LCP disease in young small breed dogs.
In the present study, the preliminary results of the use of autologous Bone Marrow Mononuclear Cells
(BMMCs) and cultured Bone Marrow Stromal Cells (cBMSCs) are reported as a possible minimal invasive
therapeutic treatment of Legg-Calvè-Perthes disease in the dog.

Twelve dogs of small size and different breed, six males and six females, aged from 8 to 15 months affected
by monolateral LCP disease were enrolled in this study. The grade of the radiographic features of the dis-
ease was estimated according to the Ljunggren ‘s scale. In eight dogs the BMMCs have been administered
while in the other four the cBMSCs ones, after they were cultured for 3-4 weeks in COON’s Medium at
37°C in a 5% carbon dioxide atmosphere. The bone marrow was collected from each patient from the iliac
crest and the mononuclear fraction was separated by a gradient centrifugation at 2000 rpm for 30 minutes.
The mean number of BMMCs was of 8.9 x 108±3.9 x 108 while the mean number of the cBMSCs was of
8.4x 106± 3.5 x 106. For the BMMCs the Colony Forming Unit (CFU) were evaluated and the mean num-
ber obtained was of 5.5 x102 ±5.2 x 102/ml. The cells were suspended in fibrin glue just before the admin-
istration and then implanted by transcutaneous injection, under CT or RX guide, using a Jamshidi needle
inserted trough the femoral head and neck starting at the basis of the trochanter major.
RESULTS
In ten of the treated dogs the disappearance of pain was observed starting from 3-4 weeks after the cells ad-
ministration and also a gradual weightbearing on the affected limb up to a complete remission of the symp-
tomatology. In the other 2 cases at ten weeks from the treatment a femoral head and neck ostectomy was
performed because the recovery proceeded too slowly and the owners prefered to don’t wait anymore. His-
tological and immunohistochemistry studies were then performed on these samples and had evidenced the
presence of cartilage and subcondral bone of new formation in the area in which the cells have been im-
planted.
CONCLUSION
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As to the results obtained, the cell therapy seems to be an effective and minimal invasive therapeutic treat-
ment of the LCP disease. The efficacy could be due to the osteogenetic and anti-inflammatory capacity of
the stromal cells which could lead first to the disappearance of the pain and then to a more intense repara-
tive activity with a more precocious sclerosis of the femoral head.
REFERENCES
1. Awad H.A., Butler D.L., Boivin G.P., Smith F.N., Malaviya P., Huibregtse B., Caplan A.I. (1999) “Autologous mes-
enchymal stem cell-mediated repair of tendon”. Tissue Eng. Jun; 5(3); 267-77.
2. Banks W.J. (1991) “Istologia ed anatomia microscopica veterinaria”.
3. Brehm W. et al. (2006) “Repair of superficial osteochondral defects with an autologous scaffold free cartilage con-
struct in a caprine model: implantation method and short-term results”. Ostearthritis cartilage. 14; 1214-26.
4. Crovace A., Di Bello A. and Mastronardi M. (1989) “L’osteotomia medio cervicale nel trattamento della malattia
di Legg-Calvè-Perthes nel cane. Veterinaria. 3; 21-25.
A. Crovace WVOC 2010, Bologna (Italy), 15th - 18th September • 556
5. Crovace A., Lacitignola L., De Siena R., Francioso E. (2007) “Cell terapy for tendon repairs in the horse: an ex-
perimental study.” Veterinary research communication. 31 (suppl.1); 281-283.
6. Cuomo A., Pasolini M.P., Meomartino L., Brunetti A., Potena A. (1999) “La trapanazione della testa femorale nel
trattamento nel morbo di Legg-Calvè-Perthes del cane”. Atti VI Congresso nazionale SICV. 138-141.
7. Demko J., McLaughlin R. (2005) “Developmental orthopaedic disease”. Vet. Clin. Small Animal 35;1111-35.
8. Denny H.R. and Butterworth S.J. (2000) “A guide to canine and feline orthopaedic surgery”. IV Edition Blackwell
Science, Oxford.
9. Fossum T. (2004) “Chirurgia dei piccoli animali”. Pp. 963-964.
10. Gambarella P.C. (1993) “Legg-Calvè-Perthes in dogs. Disease mechanisms in small animal surgery.” Bojrab MI.
804-7.
11. Gangji V., Haureur J-P., Lambermont M. (2004) “Treatment of osteonecrosis of the femoral head with implanta-
tion of autologous bone-marrow cells. A pilot study”. J. Bone Joint Surg. Am. 86; 1153-1160.
12. Kraus K.H. and Kirker-Head C. (2006) “Mesenchymal stem cells and bone regeneration”. Vet. Surg. 35; 232-242.
13. Lee J.S., Lee J.S., Roh H.L., Kim C.H., Jung J.S., Suh K.T. (2006) “Alterations in the differentiation ability of mes-
enchymal stem cells in patients with nontraumatic osteonecrosis of the femoral head: comparative analysis accord-
ing to the risk factor”. J. Orthop. Res. 24:604-609.
14. Ljunggren G. (1967) “Legg-Perthes in the dog”. Acta Orthop. Scand. 95; 7-79.
15. Piek C.J. et al. (1996) “Long-term follow-up of avascular necrosis of the femoral head in the dog”. J. Small Anim.
Prac. 37;12.
16. Smith R.K. (2004) “Autogenous stem cells implantation”. Proocedings ACVS symposium, Denver, 199-200.
17. Spitocovsky D. and Hescheler J. (2008) “Adult mesenchymal stromal cells for therapeutic applications”. Minimally
invasive therapy. 17 (2); 79-90.
18. Yamasaki T., Yasunaga Y., Terayama H., Ito Y., Ishikawa M., Adachi N., Ochi M. (2008) “Transplantation of bone
marrow mononuclear cells enables simultaneous treatment with osteotomy for osteonecrosis of the bilateral femoral
head”. Med. Sci. Monit. 14 (4) CS 23-30.
Prof. Antonio Crovace - Università di Bari Dipartimento delle Emergenze e dei Trapianti di Organi (Deto)
Sezione di Chirurgia Veterinaria, Strada Provinciale per Casamassima Km.3, 70010 Valenzano (BA), Italia
E-mail a.crovace@veterinaria.uniba.it
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557 • WVOC 2010, Bologna (Italy), 15th - 18th September M.M. Dehghan
Histopathological evaluation of treatment of superficial

digital flexor tendinitis with autologus mesenchymal
stem cells in horse
M.M. Dehghan, DVM, DVSc1, H. Kazemi, DVM, DVSc2, M.R. Baghban Eslaminejad, PhD3,
D. Sharifi, PhD1, S.H. Mardjanmehr, DVM, DVSc4, M. Masoudifard, DVM, DVSc1,
A. Vajhi, DVM, DVSc1
1
Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Tehran, Tehran, Iran
2
Department of Clinical Sciences, Faculty of Veterinary Medicine, Ferdowsi University of Mashhad, Mashhad, Iran
3
Stem Cells Department, Cell Sciences Research Center, Royan Institute, ACECR, Tehran, Iran
4
Department of Patholgy, Faculty of Veterinary Medicine, University of Tehran, Tehran, Iran
INTRODUCTION
Injuries to the superficial digital flexor tendon (SDFT) in racing horses are common and a significant cause
of wastage. Many treatment modalities have been used to facilitate healing of these lesions, but currently no
treatments enhance healing on a consistent basis. Recently, the potential advantages of mesenchymal stem
cells has been taken into consideration for the healing of different tissue injuries. The aim of the present
study was to evaluate the histopathologic findings after SDF tendonitis treatment with autologus mes-
enchymal stem cells in horse.

Five clinically normal cross bred horses with average age of 4.3 years (2-6) and average weight of 368.5 kg
(350-400) were used. Bone marrow was taken from horse’s sternum and their mesenchymal stem cells were
isolated and cultured in the lab. Experimental tendinitis was induced with injection of 2000 IU collagenase
in the centre of the left and right superficial digital flexor tendons (SDFT) of forelimbs of each horse under
ultrasound guide to confirm intratendineous needle placement. Two weeks later 15×106 autologous mes-
enchymal stem cells with plasma were injected in one limb and the other limb just autologous plasma was
injected as a control group. At day 60 after injection, the animals were euthanized and tendon samples ob-
tained for histopathologic evaluation.
RESULTS
Histopathology showed number of fibroblasts and blood vessels in treated group was fewer than control
group. Total average of reorganization and arrangement and collagen alignment in experimental group were
better than the control group.
CONCLUSION
With regard to the results of this study, it was concluded that mesenchymal stem cell application in acute
and subacute stages of tendonitis helps to improve speed and quality of healing of the SDFT lesions.
REFERENCES
Barry F.P., Murphy J.M. (2004). Mesenchymal stem cells: clinical applications and biological characterization. Interna-
tional. Journal of Biochemistry & Cell Biology 36, 568-584.
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Reef V.B. (2001). Superficial digital flexor tendon healing: ultrasonographic evaluation of therapies. The Veterinary Clin-
icsof North America: Equine Practice 17, 159-178.
Prof. Mohammad Mehdi Dehghan - University of Tehran Department of Clinical Sciences, Faculty of Veterinary
Medicine, Azadi St. Gharib St., Tehran, Iran - E-mail mdehghan@ut.ac.ir
L. Déjardin WVOC 2010, Bologna (Italy), 15th - 18th September • 558
In vivo biomechanical evaluation of a novel angle-stable

interlocking nail design in a canine tibial gap fracture
model
L. Déjardin, DVM, MS, DACVS, DECVS1, J. Cabassu, Dr. Vét.2, R. Guillou, Dr. Vét.1,
M. Villwock, MSc3, H. Zamprogno, DVM, MSc, PhD1, C. Beckett, BSc3, R. Haut, PhD3
1
College of Veterinary Medicine, East Lansing, USA
2
College of Veterinary Medicine, Tufts, USA
3
College of Osteopathic Medicine, East Lansing, USA
INTRODUCTION
Acute construct instability, potentially leading to inter-fragmentary motion and subsequently delayed bone
healing, has been documented experimentally and clinically in long bone fractures repaired with currently
available interlocking nails (ILNs). To circumvent standard ILN shortcomings, an angle-stable ILN (AS-ILN)
was developed1. While in vitro studies have shown that AS-ILN constructs sustain significantly less angular
deformation (AD) than comparable standard ILNs,2 the relative biological benefits of these nails has not been
investigated. This study compares the clinical outcome and final callus biomechanical properties of the AS-
ILN to those of a 6-mm bolted standard ILN (ILN6b) in a canine in vivo tibial gap fracture model. We hy-
pothesize that 1) functional recovery and clinical union occurs earlier in AS-ILN than ILN6b dogs, 2) final
callus initial stiffness, failure torque and energy would be greater in AS-ILN than ILN6b dogs and 3) callus
bone density (BD) and polar moment of inertia (PMI) would be greater in AS-ILN than ILN6b dogs.

Following IACUC approved protocols, a 5-mm mid-diaphyseal tibial-fibular ostectomy was performed in 11
dogs of similar size and weight. Using dedicated instrumentation, dogs were treated with a 185mm-long AS-
ILN (n=6) or ILN6b (n=5) stabilized using four dedicated bolts. The AS-ILN OD varied from 7mm (ex-
tremities) to 5.3mm (center) and featured two threaded conical holes accepting size-matched threaded bolts
at each extremity. The AS-ILN bolts insertion torque was 2.5Nm torque. The ILN6b were secured using
standard 2.7mm partially threaded bolts.
Every two weeks postoperatively, lameness was evaluated on a scale from 1 (absent) to 4 (severe), while
bone healing was evaluated on serial radiographs. All dogs were sacrificed at 18 weeks once clinical union
was achieved in at least three dogs in each group. Paired tibiae were harvested, stored at –80°C then thawed
overnight before testing. After implant extraction, tibial specimens were mounted in an Instron testing ma-
chine following published protocols. Torsion tests were conducted at 1°/s until failure initiation defined as a
6.5% drop from the maximum torque. Initial stiffness, failure torque and energy were computed while lo-
cation and the failure mode were recorded.
Following mechanical testing, five, 1mm-thick transverse CT slices, centered on the initial gap, were ac-
quired to evaluate callus BD and PMI. To compare the entire and cortical calluses, voxels between 0-2000
HU and 900-2000 HU, respectively, were sequentially selected on each CT slice. A custom Matlab code
was then used to compute individual cross-sectional PMI about the center of the medullary cavity in each
group and for each tissue density range. Callus PMIs were averaged over the five slices.
All data were compared using 2-factor repeated measures ANOVA and SNK post-hoc tests, (p<0.05). Fac-
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tors were treatment/time (lameness scores) or treatment/side (biomechanical and imaging data).
RESULTS
All dogs recovered uneventfully. Up to two weeks postoperatively, tibial rotational instability, with an audi-
ble click was present in all ILN6b but none of AS-ILN dogs. Mild rotational instability remained in one of
five INL6b dogs up to six weeks postoperatively.
From four to eight weeks postoperative, lameness scores were significantly lower in the AS-ILN than ILN6b
dogs. Clinical union started at 8 weeks (2/6) and was completed in all AS-ILN dogs at 10 weeks postopera-
tively; in contrast, in the ILN6b group, clinical union was reached in one of five dogs at 12 weeks and three
of five dogs at 18 weeks. Explantation was achieved manually in all specimens; removal of the AS-ILN bolts
required less torque (p<0.05) than at insertion.
All biomechanical data was greater in the AS-ILN than ILN6b specimens (p<0.05). Compared to controls,
initial stiffness was 28% greater in the AS-ILN group (p<0.05) but similar in the ILN6b group. Likewise,
559 • WVOC 2010, Bologna (Italy), 15th - 18th September L. Déjardin
failure torque and energy were not different from controls in AS-ILN specimens but were respectively 28%
and 54% smaller (p<0.05) in ILN6b than in control specimens. All intact and AS-ILN treated tibiae failed
acutely via spiral fractures along the tibial diaphysis. Conversely, ILN6b treated tibiae failed progressively
via transverse fracture through the initial gap.
Callus BD was 19% greater in AS-ILN than in ILN6b specimens (p<0.05). Corresponding PMIs of the en-
tire and cortical calluses were respectively 33% and 77% greater in AS-ILN than ILN6b specimens (p<0.05).
CONCLUSION
This study demonstrates that the healing process in AS-ILN treated specimens led to the formation of a
stiffer, stronger and more mature callus when compared to standard ILNs. The improved AS-ILN specimen
biomechanical properties likely resulted from earlier callus maturation/remodeling (early clinical union, in-
creased BD), suggesting that the bone healed in a more stable environment. Conversely, initial postopera-
tive residual instability in the ILN6b specimens may be responsible for delayed functional recovery and clin-
ical union. This speculation is further supported by the lower callus BD, which suggests higher fibrocarti-
lage content and likely explains the weaker mechanical properties of the callus. This study suggests that an-
gle stable nails may represent a valid alternative to standard nails in the treatment of long bone fractures.
REFERENCES
1. Dejardin LM, Lansdowne JL, et al. (2006). “In vitro mechanical evaluation of torsional loading in simulated canine
tibiae for a novel hourglass-shaped interlocking nail with a self-tapping tapered locking design.” Am J Vet Res 67(4):
678-685.
2. Lansdowne JL, Sinnott MT, et al. (2007). “In vitro mechanical comparison of screwed, bolted, and novel inter-
locking nail systems to buttress plate fixation in torsion and mediolateral bending.” Vet Surg 36(4): 368-377.
Prof. Loic Dejardin - Michigan State University, College of Veterinary Medicine - Small Animal Clinical Sciences,
East Lansing 48824-1314, United States - E-mail dejardin@cvm.msu.edu
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L. Déjardin WVOC 2010, Bologna (Italy), 15th - 18th September • 560
Effect of articular design on rotational constraint

of two unlinked canine total elbow prosthesis
L. Déjardin, DVM, MS, DACVS, DECVS1, R. Guillou, Dr. Vét.1, M. Sawyer, DVM1,
H. Zamprogno, DVM, MS, PhD1, C. Beckett, BSc2, R. Haut, PhD2
1
College of Veterinary Medicine, East Lansing, USA
2
College of Osteopathic Medicine, East Lansing, USA
INTRODUCTION
Limitations of conservative management and non-replacement surgeries for the treatment of end-stage ca-
nine elbow osteoarthritis have recently fueled a growing interest in total elbow replacement (TER). Poor re-
sults seen with early linked (hinge-like) systems led to a paradigm shift toward unlinked designs, which to-
day include the IOWA1, a hybrid fixation stemmed prosthesis and the TATE, a cementless resurfacing de-
sign2. Joint and implant stability of unlinked designs are influenced by the geometry of the articulating sur-
faces, which defines the constraint level of the prosthesis, and by the integrity of the surrounding capsu-
loligamentous and bone structures. While congruent articular surfaces largely contribute to joint stability in
highly constrained systems, relatively higher loads are transferred to the bone/cement/implant interfaces.
This may increase morbidity due to secondary fibrous union and/or aseptic implant loosening. Conversely,
in minimally constrained systems, with less congruent articular surfaces, trans-articular loads are predomi-
nantly absorbed by the collateral ligaments. This spares the implant/cement/bone interfaces from deleteri-
ous shear stresses, which subsequently may enhance bone ingrowth and thus long-term implant stability.
However, by limiting articular congruity, joint stability may be substantially lowered, particularly if liga-
mentous constraints have been compromised as a result of pathology or surgical technique. While trans-ar-
ticular forces in the frontal plane are primarily counteracted by passive capsuloligamentous structures, in-
ternal/external rotation is mainly controlled by articular surfaces geometry. To date, the effect of articular
geometry on the constraints of unlinked TER prostheses in rotation is unknown.
Therefore, the purpose of this study was to characterize and compare the IOWA and TATE systems in in-
ternal/external rotation. Based on their respective articular surface geometry, our hypothesis was that, com-
pared to the TATE, the IOWA system would be more constrained in internal and external rotation.

Four large IOWA and 19mm TATE prostheses were used. Humeral components were mounted to dedicat-
ed fixtures affixed to an x-y table allowing unconstrained planar translation between humeral and radio-ul-
nar (RU) components. The RU components were press-fitted into dedicated custom-designed cradles. Spec-
imen orientation mimicked that of the elbow joint in the middle of stance phase. The RU components were
fastened to a servohydraulic testing machine via a biaxial torque/load cell. Non-destructive torsion tests were
conducted under displacement control for 10 cycles (500N axial load, 10° internal and external rotation).
Tenth cycle data, consisting of resistive torques at 7.5° of rotation and maximum torques, were compared us-
ing 2-factor ANOVA (prosthesis and direction) and SNK post-hoc tests (p<0.05). Testing conditions repli-
cated weight-bearing loads of a trotting ~40kg dog likely to receive either implant, and canine elbow in vi-
vo kinematics showing ~15° of internal/external antebrachium rotation at the trot.
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RESULTS
In both systems, at 7.5° of twist, resistive torques were not statistically different between internal and exter-
nal rotation (2.20+/-0.07Nm vs. 2.20+/-0.10Nm [TATE] and 3.41+/-0.04Nm vs. 3.43+/-0.03Nm [IOWA], re-
spectively). However, torques were ~50% greater in the IOWA than in the TATE system (p<0.001) in both
testing directions. Similarly, there was no difference in maximum torque between internal and external ro-
tation in either system (2.34+/-0.09Nm vs. 2.34+/-0.08Nm [TATE] and 3.93+/-0.09Nm and 3.77+/-0.05Nm
[IOWA], respectively). Maximum torques, however, were at least 60% greater in the IOWA than in the
TATE system (p<0.001) in both testing directions.
CONCLUSION
This study demonstrated that, in torsion, the IOWA is more constrained than the TATE prosthesis. While
optimal constraint of unlinked TER remains unknown, it has been suggested that the risk/type of compli-
cations varies in part with the level of constraint imparted by articular surfaces geometry. In more con-
strained designs, improved joint stability may be offset by the higher risk of fractures and/or aseptic loosen-
561 • WVOC 2010, Bologna (Italy), 15th - 18th September L. Déjardin
ing. Conversely, less constrained designs may spare implant interfaces from deleterious shear stresses to the
detriment of joint stability3. Paradoxically, elbow luxations have been reported in 10% of IOWA clinical cas-
es. This could result from the surgical technique which involves lateral collateral ligament desmotomy, thus
iatrogenic weakening of the joint passive constraints. While the rate of aseptic loosening has not been re-
ported, humeral and/or ulnar fractures have been anecdotally described with the IOWA. This might be ex-
plained by a combination of increased load transmission to the implant/cement/bone interfaces and surgical
weakening of the bone support resulting from the broad wedge resection of the humeral condyle.
Interestingly, while joint instability could be expected in the less constrained TATE, elbow luxation has not
been observed in clinical cases, presumably as a result of the more conservative resurfacing surgical tech-
nique which preserves both collateral ligaments and the humeral condyle. While a potential benefit of less
constrained designs is improved stability of the bone/implant interface, the long term fate of that interface
in TATE prostheses is currently unknown. With more than two years follow-up, however, clinically relevant
aseptic loosening has yet to be documented in TATE cases.
While implant osteointegration could theoretically be improved by reducing articular constraint, profile it-
erations could prove more effective with the TATE than with the IOWA system. To date, the optimal artic-
ular design that would reduce the rate of both complication types remains speculative.
REFERENCES
1. Conzemius MG, Aper RL and Corti LB: Short-term outcome after total elbow arthroplasty in dogs with severe,
naturally occurring osteoarthritis, Vet Surg 32:545, 2003.
2. Acker R and Vandermeulen G: Tate elbow preliminary trials, 35th VOS annual conference 2008.
3. Armstrong AD, King GJW, et al. (2005). Total elbow arthroplasty design. Shoulder and elbow arthroplasty.
Williams, Yamaguchi, Ramsey and Galatz. Philadelphia, PA, Lippincott Williams & Willkins: 297-312.
Prof. Loic Dejardin - Michigan State University, College of Veterinary Medicine - Small Animal Clinical Sciences,
East Lansing 48824-1314, United States - E-mail dejardin@cvm.msu.edu
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I. Dias WVOC 2010, Bologna (Italy), 15th - 18th September • 562
Evaluation of biomarkers of bone formation and serum

minerals variations for prediction of fracture healing versus
non-union process in sheep as a model for orthopedic
research
I. Dias, DVM, PhD1,2, C. Viegas, DVM, MSc, PhD1,2, J. Azevedo, CEng, PhD3, C. Sousa,
DVM,MSc1,2, A. Ferreira, DVM, PhD4, A. Cabrita, MD, PhD5, R. Reis, CEng, MSc, PhD2
1
Dept. of Veterinary Sciences, School of Agrarian and Veterinary Sciences, University of Trás-os-Montes e Alto Douro,
Vila Real, Portugal
2
IBB - Institute for Biotechnology and Bioengineering, 3B’s Research Group - Biomaterials, Biodegradables and
Biomimetics, Dept. of Polymer Engineering, University of Minho, Taipas, Guimarães, Portugal
3
CECAV - Dept. of Animal Sciences, School of Agrarian and Veterinary Sciences, University of Trás-os-Montes e
Alto Douro, Vila Real, Portugal
4
CIISA - Dept. of Morphology and Clinic, Faculty of Veterinary Medicine, University Technical of Lisbon, Lisbon, Portugal
5
Institute of Experimental Pathology, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
INTRODUCTION
The biochemical markers of bone metabolism reflect the bone turnover process and are usually divided in-
to formation and resorption markers. Formation markers are proteins or enzymes secreted by osteoblasts
during the bone formation process, such as serum total (tALP) and bone-specific isoform of alkaline phos-
phatase (BALP), serum osteocalcin (OC) and serum procollagen type I C- and N-terminal propeptides. Bone
resorption markers are those resulting from the breakdown of type I collagen during the bone resorption
process, namely serum carboxyterminal telopeptide of type I collagen, urinary collagen type I cross-linked
C- and N-telopeptide, urinary hydroxyproline, total and free urinary pyridinoline and deoxypyridinoline
(Cremers et al., 2008).
The two most commonly used bone formation markers for clinical and research purposes in human beings
for the study of pathophysiological mechanisms and management of postmenopausal osteoporosis and oth-
er metabolic bone diseases are the BALP and OC. These biomarkers of bone turnover are also used in sev-
eral animal species for clinical and orthopaedic purposes, namely to develop experimental models of post-
menopausal osteoporosis and glucocorticoid osteopenia in sheep (Egermann et al., 2008). Nevertheless,
measurements of biomarkers of bone turnover could possibly also aid in the evaluation of cellular function
in fracture or bone defect healing research, supplying information about the organic response to the lesion
and to the selected treatment (Seebeck et al., 2005).
This study aimed at determining the serum activities of tALP and BALP and of intact serum level of OC
and their correlation with serum minerals – Ca, P and Mg, after carrying out an osteotomy or a critical size
segmental defect (CSD) at the tibia level in sheep, in order to assess the pattern of variation of these bio-
markers as possible indicators with prognostic value either in the normal evolution of the healing process of
fractures or in the development of a non-union process.

After experimental protocol approval by the National Ethical Committee for Laboratory Animals, twelve
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skeletally mature female sheep were maintained under controlled environmental conditions for six weeks be-
fore the collection of the blood samples and the surgeries. The sheep were divided in two experimental
groups, in one of them was performed a standardized osteotomy and in the other one a 3 cm segmental bone
CSD at the mid-diaphysis of the tibia, stabilised by a 4.5 large DCP of eight holes in neutralization function
and a 4.5 large bone lengthening osteosynthesis plate of eight holes, respectively. All biochemical parame-
ters were measured over a 12-week healing period, weekly during the first month and twice monthly dur-
ing the remaining post-operative period. A control group (n=6), subjected to the same conditions of the ex-
perimental groups but not to experimental protocols, was also performed to monitor the various parameters
during the same post-operative period and to obtain a reference baseline value.The tALP serum activity and
serum minerals were measured with commercial kits of BioMérieux and by means of molecular absorbance
spectrophotometry and the BALP serum activity and the serum level of intact OC performed with im-
munoassay kits from Quidel Corporation and by ELISA. The fracture healing and the CSD evolution were
monitored by X-ray exams monthly and by histological analysis at the 12th week post-surgery.
563 • WVOC 2010, Bologna (Italy), 15th - 18th September I. Dias
RESULTS
Total ALP and BALP serum activities and the serum level of Ca were significantly affected by treatment
(p<0.05, p<0.0001 and p<0.05, respectively) and by time (p<0.001, p<0.01 and p<0.0001, respectively).
Serum intact OC was only significantly affected by treatment (p<0.001) while P and ionised Ca2+ serums
were merely by time (p<0.01 and p<0.05, respectively). Mg was not significantly affected by treatment or
time. The maximum peak of tALP activity was achieved between the 3rd and 4th post-operative weeks in
the osteotomy group with respect to the value of the CSD group for the same post-operative time (p<0.05),
and the inflection of the level of serum OC until the 3rd post-operative week followed by subsequent in-
crease in the CSD group (p<0.01) with respect to osteotomy, represented some of the most significant dif-
ferences between groups. There were significant differences between the control and osteotomy groups for
tALP and BALP serum activities and for serum level of Ca at the 3rd week post-operative and between the
control and CSD groups for serum intact OC at the 2nd and 3rd weeks post-surgery.
In this study, a similar pattern of variances for serum activities of tALP and BALP and for serum Ca and P
were observed and these parameters presented similar and simultaneous variations throughout the entire
post-operative period in both groups under study. In general, these parameters underwent an increase in
their values, which began between the 2nd and 3rd weeks and reached a maximum value between the 3rd
and 4th post-operative weeks, followed by a decrease and maintenance of these values at basal levels until
the 12th post-operative week. It was also observed that in the osteotomy group, for all parameters evaluat-
ed, with the exception of the Ca2+ plasma electrolyte, they were nearly always located, throughout the post-
operative period, above the values of the group in which the CSD was carried out. The increase of tALP
and BALP between the post-operative 2nd and 3rd weeks may have been associated with an active synthe-
sis phase and maturation of the bone extracellular matrix (ECM) through osteoblasts in both groups. The
fact that the serum level of OC in the CSD group is maintained generally lower than that of the osteotomy
group may mean depressed osteoblastic activity in the non-union process in progress.
Particularly significant correlations were obtain between tALP and Ca (r=0.5193; p<0.0001), tALP and
BALP (r=0.3482; p<0.01), BALP and Ca (r=0.2806; p<0.01), BALP and P (r=0.3147; p<0.01) and be-
tween serum minerals, which could be explained by the role that BALP and serum minerals play in bone
ECM mineralization, simultaneously supporting the existence of a possible relationship between these pa-
rameters and, at the same time, the involvement of these parameters in the osteoid synthesis and in the min-
eralization phenomenon.
The X-ray exams and the histological analysis demonstrated bone healing in the osteotomy group and the
development of an atrophic non-union process in the CSD group at the 12th week post-operative.
CONCLUSION
Reference to the serum bone turnover parameters in sheep could be of great value in research and could al-
so provide complementary non-invasive information on the fracture healing process, particularly with regard
to obtaining an early prognosis of fracture healing evolution. Accordingly, this study indicates the poten-
tiality of serology applied to the monitoring of the healing of bone fractures which may become an accessi-
ble method, complementary to the X-ray exams, in early prediction of either a normal bone healing process
or an evolution towards a delay or a non-union process, allowing an assessment of the dynamic process of
bone healing and providing a foundation for early decisions during the development of possible disturbances
of the bone healing fracture process.
REFERENCES
Cremers S., Garnero P., Seibel M.J. (2008). Biochemical markers of bone metabolism. In: Principles of Bone Biology
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(Bilezikian J.P., Raisz L.G., John Martin T., eds). 3rd ed., San Diego: Academic Press, 1857-1881.
Egermann M., Goldhahn J., Holz R., Schneider E., Lill C.A. (2008). A sheep model for fracture treatment in osteoporo-
sis: benefits of the model versus animal welfare. Laboratory Animals 42, 453-464.
Seebeck P., Bail H.J., Exner C., Schell H., Michel R., Amthauer H., Bragulla H., Duda G.N. (2005). Do serological tis-
sue turnover markers represent callus formation during fracture healing? Bone 37, 669-677.
Prof. Maria Isabel Ribeiro Dias - University of Trás-os-Montes e Alto Douro, Dept. of Veterinary Sciences,
Quinta de Prados, P.O. Box 1013, Vila Real / 5001-801, Portugal - E-mail idias@utad.pt
Long-term follow-up of lumbosacral distraction-fusion

using combined dorsal and ventral fixation including
a novel intervertebral spacer device (23 dogs)
N. Fitzpatrick, DUniv, CSAO, CVR, MVB, A. Danielski, DVM
INTRODUCTION
Degenerative lumbosacral stenosis (DLSS) is a syndrome of disc, articular fascet, vertebral and soft-tissue
associated dynamic or static compression of the cauda equina and L7 nerve roots. Surgical treatment has
historically targeted specific components of the disease by means of dorsal laminectomy, annulectomy, nu-
clear extirpation, fascectectomy, foraminotomy, fascet stabilisation or application of dorsal stabilising im-
plants. Selection criteria for surgical intervention and long-term outcome data have been poorly defined, par-
ticularly with respect to clinical significance of and mensuration of abaxial neural impingement. This is es-
pecially relevant where the exit zone of the neuroforamen may be encroached by soft tissue or osseous de-
formity and where dynamic instability is present. Medium-term recurrence of clinical signs has variably been
reported as 18-54.5%. We hypothesised (on the basis of a cadaveric pilot study) that application of a novel
tapered, threaded, titanium distraction screw (Fitz Intervertebral Spinal Screw, FISS) between the L7-S1 end-
plates with adjunctive dorsal stabilization, would result in reliable and resilient resolution of clinical signs as-
sociated with documented central and abaxial neural impingement and instability.

The study population consisted of 23 dogs presented January 2007 - December 2008. Signalment, dura-
tion of clinical signs, pre-operative and 12 week post-operative radiography, MRI, complications and one
year post-operative clinical and owner visual analog scale (VAS) scores were recorded. All presented with
clinical signs attributable to lumbo-sacral and sciatic nerve pain and MRI-documented abaxial neuro-
foraminal impingement. Standard T2 sagittal and transverse MRI scans were performed (Siemens Sym-
phony Magnetom, Germany) in addition to 40-45° angled para-sagittal oblique T2 and T1 images of the
neuroforamina. Standard dorsal laminectomy without facetectomy was followed by intervertebral disc an-
nulectomy and nuclear extirpation. The FISS was inserted manually into the IVD space at the site of an-
nulectomy to a level below the course of the cauda equina nerve roots. Negative profile 2-5-3mm thread-
ed pins were placed across the LS fascets (2), into the vertebral body of L7 bilaterally (2) and into the sacro-
iliac junction bilaterally (4). All pins were “notched” with an appropriate cutter and enshrouded in a bolus
of polymethylmethacrylate cement applied dorsal to L7-S1 with the laminectomy site protected using au-
togenous muscle/fat.
RESULTS
Breeds included Labrador Retriver (30.43%), German Shepherd (21.73%) and Rottweiler (17.39%). Male
dogs constituted 60.86%. The median duration of clinical signs was 3months (range 3 weeks-17months).
Lumbo-sacral and sciatic nerve pain were present for all cases, whilst abnormal gait or behaviour, lameness,
reduced myotactic reflexes, altered tail carriage and micturition functionality varied.
All except one dog were able to micturate and defaecate normally by 3 days post-operatively, with one ex-
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ception taking 10 days to voluntarily urinate. Pelvic limb function deterioration was noted in one patient and
resolved over 16 weeks, whilst three others took up to 8 weeks to recover normal ambulation. Mean time
to resolution of pain and lameness in 21 dogs, by clinical examination and owner VAS score was 4.2 weeks
(range 2-16 weeks).
Clinical outcome was evaluated for 15 patients by telephonic interview at mean 495 days post-operatively
(range 300 – 780 days). For exercise level, one owner answered that it was sub-optimal, 66.6% answered
high (n=10) and 26.6% moderate (n=4). For degree of pain by “whole number” scale of 1 to 10 with 1 be-
ing no pain and 10 being severe pain, 60% answered 1 (n=9), 26.66% said 2 (n=4) and 13.3% said 3 (n=2).
Radiography performed at twelve weeks postoperatively for all cases revealed mean magnitude of interver-
tebral distraction 3.4mm (range 2-6mm) and maintenance of distraction position for all cases, with implant
integrity for 20 dogs. Three cases were affected by clinically inconsequential migration of a threaded pin,
which was removed and one further case was affected by a seroma and superficial licking associated with
self-trauma.
CONCLUSION
Surgical intervention for DLSS is indicated when neurologic deficits are present, pain is severe, quality of
life is affected or there is no response to medical management or physical therapy. Addressing exit zone im-
pingement of the L7 nerve roots even with radical foraminotomy and a trans-ilial approach is difficult be-
cause of propensity for iatrogenic trauma and encroaching soft tissue and bone may grow back over time.
Furthermore, without adequate stabilisation, dynamic components of deformity may continue to cause clin-
ically relevant pain, especially with respect to the L7 nerve roots in a definitive subgroup of patients. A pi-
lot cadaver study intimated reliable distraction of neuroforaminal dimension by the FISS implant and this
clinical data supports application of the technique and documents resilient maintenance of distraction and
lasting amelioration of clinical signs. Complications were largely attributable to operator error in that the
tips of the pins should be imbedded within and not traverse the trans-cortex. Further biomechanical studies
are warranted but data presented here supports recommendation for clinical application in DLSS cases
where static or dynamic neuroforaminal impingement is documented.
REFERENCES
Gödde T, Steffen F: Surgical treatment of lumbosacral foraminal stenosis using a lateral approach in twenty dogs with de-
generative lumbosacral stenosis. Vet Surg 36: 705-713, 2007.
Seiler G, Häni H, et al. Staging of lumbar intervertebral disc degeneration in nonchondrodystrophic dogs using low-field
magnetic resonance imaging. Vet Radiol Ultrasound 44:179-184, 2003.
Matoon JS, Koblik PD. Quantitative survey radiographic evaluation of the lumbosacral spine of normal dogs with de-
generative lumbosacral stenosis. Vet Radiol Ultrasound 1993; 34: 194-206.
Van Klaveren NJ, Suwankong N, De Boer S, et al: Force plate analysis before and after dorsal decompression for treat-
ment of degenerative lumbosacral stenosis in dogs. Vet Surg 34:450-456, 2005.
Moens NM, Runyon CL: Fracture of L7 vertebral articular facets and pedicles following dorsal laminectomy in a dog. J
Am Vet Med Assoc 6:807-810, 2002.
Wood B, Lanz O, Jones J, Shires P. Endoscopic-assisted lumbosacral foraminotomy in the dog. Vet Surg 33:221-231,
2004.
Carozzo C, Cachon T, Genevois JP, Fau D, Remy D, Daniaux L, Collard F, Viguier E. Transiliac approach for exposure
of lumbosacral intervertebral disk and foramen: Technique description. Vet Surg. 2008 Jan; 37(1):27-31.
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Constrained total knee replacement, a novel prosthesis

for salvage arthroplasty in the dog and cat
N. Fitzpatrick, MVB, CSAO, CVR, DUniv1, K. Ash, BSc, BVMS1,
J. Meswania, PhD2, G. Blunn, PhD2
1
2
Institute of Orthopaedics and Musculo-Skeletal Science, Stanmore, UK
INTRODUCTION
Total knee replacement (TKR) has to date been limited to canine veterinary patients for the treatment of se-
vere osteoarthritis or juxtaarticular bone loss. TKR has not thus far been reported for feline patients. Cur-
rent salvage options for multi-ligamentous disruption of the canine or feline stifle include mutiple ligament
reconstruction with or without ancillary trans-articular support which is fraught by challenges attaining con-
comitant isometricity of all support structures. Stifle arthrodesis is a legitimate option but limb function is
suboptimal.
Total joint replacement enables early pain free function, but intact collateral periarticular support is prereq-
uisite for commercially available non-constrained prostheses. In humans, uniaxial constrained total knee re-
placement (UCTKR) may be employed when collateral support is not salvageable. We describe application
of a novel UCTKR implant design for four cases. We hypothesized that application of UCTKR would be
feasible in dogs and cats and would provide early and resilient functional recovery.

Prostheses employed for all cases were custom made (OrthoFitz™, Eashing, Surrey, UK) based on comput-
ed tomographic and radiographic mensuration. In all cases, a lateral parapatellar approach facilitated resec-
tion of femoral and tibial epiphyses. The femoral and tibial components articulated by means of a medial to
lateral pin placed perpendicularly to and interfaced with the hinge via ultra high molecular weight
polyurethane bushings to ensure stability and smooth flexion-extension. The medullary canals of both fe-
mur and tibia were prepared for pressurized cementing technique and curved tapered beveled stems on each
of the metallic components were implanted using polymethylmethacrylate cement. In two cases, the femoral
component was elongated to replace tumour resected from the distal femur.
Subjective evaluations of lameness and pain on joint manipulation were performed at 2, 6, 12, and 26 weeks
post operatively where possible. Video recordings were made of all gait analysis in an attempt to standard-
ize assessments. All patients were minimally weight-bearing preoperatively and objective analysis was im-
practical.
Orthogonal plane radiography was obtained preoperatively, immediately post operatively, and at 6, 12, and
26 weeks where possible. Radiographs were assessed for positioning, orientation and implant-cement-bone-
interface of both femoral and tibial components. Complications were recorded and descriptive statistics an-
alyzed.
RESULTS
Case 1
An 8yr 4mos old speyed female 31.2 kg cross breed dog suffered failure of a non-constrained total knee re-
placement (Biomedtrix, Boonton, New Jersey, USA) due to progressive degenerative rupture of the medi-
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al and lateral collateral ligaments. Multiple attempts were made to regain collateral support by means of
autogenous and allogenous facia lata grafts, synthetic prostheses and transarticular external skeletal fixa-
tion, however ultimately collateral support was unachievable. Severe coxofemoral arthrosis associated with
dysplastic luxation affected the contralateral pelvic limb, total elbow arthroplasty had been applied to one
thoracic limb, lumboscaral fusion had been performed and limb amputation was not considered viable. En-
bloc explantation of the non-constrained knee prosthesis preceded implantation of the UCTKR. Pre-dis-
ease ambulatory status was achieved by 6 weeks postoperatively and normal activity was impaired only by
contralateral hip arthrosis by 12 weeks. Full functional activity was maintained without pain by six months
post-operatively.
Case 2
An 8yr 2mos speyed female 3.8kg domestic short-haired cat sustained severe bilateral pelvic limb trauma
following vehicular impact. Left stifle dis-articulation with rupture of both cruciate ligaments, both collater-
al ligaments and both menisci occurred concomitantly with contralateral tarso-metatarsal fracture-luxation
and profound plantar tissue loss. The pedal injury was addressed with epoxy-pin external fixation, but in-
ability to weight-bear and unpredictability of outcome predicated against amputation or arthrodesis for the
stifle injury. UCTKR was employed because of perceived optimization of limb function. Pre-disease ambu-
latory capability for the affected limb was restored by four weeks postoperatively and normal jumping-run-
ning activity was permitted by 12 weeks.
Cases 3 and 4
A 5yr 3mos male neutered 44.4kg Leonberger and a 7yr 11mos female neutered 43.7kg Leonberger were
both diagnosed with stage IIb osteosarcoma of the distal femur. Euthanasia, palliative amputation and
chemotherapy, or limb salvage with neoadjuvant chemotherapy were offered. Based on size and activity lev-
el, the owners both elected for limb salvage. Preoperative MRI was performed to assist planning. To achieve
adequate osseous and periarticular excisional margins, the origin and insertion of the medial and lateral col-
lateral ligaments were sacrificed in the excisional field. Six week functional recovery was deemed satisfacto-
ry by owner and veterinary assessment with comfortable ambulation and limb function albeit that the gait
pattern was significantly suboptimal. However, local tumor recurrence necessitated amputation at 4 months
post-operatively in case 3 and only 6 week follow-up was available for case 4 at time of abstract submission.
In Case 4, a local depot installation of carboplatin 300mg/m2 and pluronic (poloxamer 407) was employed
to ameliorate proclivity for local tumour recurrence. For both cases a systemic chemotherapeutic protocol
of carboplatin was also employed.
Radiography at 6 weeks for all cases, 12 weeks for cases 1, 2 and 3 and 26 weeks for case 1 revealed satis-
factory cement-bone and cement-implant integrity with no periprosthetic radiolucency. Owner satisfaction
at 6 weeks post operatively was excellent for all cases.
CONCLUSION
Early return to pain free function and satisfactory activity level intimated achievement of the objectives of
salvage arthroplasty using this novel device. UCTKR restricts joint motion to flexion-extension but was ad-
equate for short-term function in these cases. The gait pattern in cases 3 and 4 was disturbed by magnitude
of resection precluding appropriate soft tissue reattachment to the moving components of the endoprosthe-
sis and was similar to that of humans with similar joint replacement limb salvage. The function and activi-
ty level of cases 1 and 2 was deemed normal by owners. A salient limitation is lack of longer-term outcome
measures, but feasibility of application has been established.
Tumour recurrence in the region of the popliteal artery confirmed after limb amputation for case 3 sug-
gested that tumour invasiveness caudal to the stifle precluded complete excision. More precise selection
criteria for this indication are therefore warranted. The effect of local installation of chemotherapeutic
agent in case 4 is novel and as yet, efficacy is unknown. Notably however, this was safely achieved with-
out adverse sequelae.
Canine and feline patients affected by multi-ligamentous disruption recalcitrant to stabilization have limit-
ed interventional options and limb-spare for articular neoplasia typically involves amputation or arthrode-
sis. This case series, to our knowledge, documents the first cases of UCTKR reported in the veterinary lit-
erature for limb-spare of distal femoral neoplasia, for a feline patient and for salvage of failed non-con-
strained TKR. Cemented fixation methodology was deemed most practical for all cases operated. Rotat-
ing constrained hinge systems may mitigate bone-cement-implant interface stress more effectively and may
prolong implant survival time, but are more expensive and take longer to manufacture. Encouraging ear-
ly outcomes for these cases have established precedent for further investigation of application of UCTKR
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in dogs and cats.
REFERENCES
Liska WD, and Doyle ND: Canine total knee replacement Vet Surg 38:568-582, 2009.
Novel modular limb salvage endoprostheses for treatment

of primary appendicular tumors in dogs:
short-term outcome
N. Fitzpatrick, DUniv, MVB, CVR, CSAO1, K. Ash, BSc, BVMS1, J. Meswania, PhD2,
G. Blunn, PhD 2
1
2
Institute of Orthopaedics & Musculoskeletal Science, Stanmore, UK
INTRODUCTION
Limb salvage techniques for treatment of primary bone tumors in dogs are increasingly employed. The ob-
jective is to enable complete resection of the malignancy and restore pain free limb function. Techniques in-
clude longitudinal bone transport, microvascular anastomosis of bone transplant, bone transposition (ulna
for radius), cortical allografts, endoprostheses, extracorporeal intraoperative radiation therapy and autograft
pasteurization combined with neo-adjuvant chemotherapy.
Metallic endoprostheses may be technically easier to apply than allografts and do not rely on bone harvest-
ing and banking. Such techniques have been most commonly employed for malignancies of the distal ra-
dius. Clinical outcomes at this site are often positive, with minimal compromise of limb function by pan-
carpal arthrodesis.
To date simple metallic spacers with a single plate anchored to the proximal radius and a single metacarpal
bone have been employed. Limb spare application at other sites including distal tibia and proximal humerus
has been associated with more variable outcomes.
Our hypothesis was that application of novel endoprostheses for distal radial, distal tibial and proximal
humeral osseous malignancy with associated arthrodesis was technically feasible, would result in rapid re-
covery of pain-free limb function, and would prove biomechanically resilient.

Preoperative skeletal imaging included orthogonal plane radiography, computed tomography and magnetic
resonance imaging of affected limbs. Diagnosis was additionally refined using pre-operative cytology,
histopathology and appropriate staging for local or distant metastasis. A novel modular massive endopros-
thesis system was employed in all cases. Endoprostheses were custom manufactured from stainless steel
based on pre-operative imaging parameters
and shared several common design features.
A size-matched spacer featured hydroxyapatite (HA) coating of an intramedullary stem at the long-bone in-
terface for four of six implant constructs, and two of six had a fluted stem cemented by application of an-
tibiotic-impregnated polymethylmethacrylate (PMMA). Cross-hatched notching at the joint interface pro-
vided a mechanically stable platform for arthrodesis (n=6) and osseous in-growth when coated with HA
(n=4). Integrated locking plates were employed proximal and distal to the spacer.
Both distal radius and ulna were resected for malignancy of either bone. Pancarpal or pantarsal arthrodesis
was achieved using contoured tapered locking plates, which integrated with the spacer unit via 3.5 mm link-
screws, and which attached to the metacarpal / metatarsal and carpal / tarsal bones using 2.7 mm or 3.5 mm
locking or standard screws. Two carpo-metacarpal plates were attached to MC 3 and 4 and one tarso-
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metatarsal plate attached to MT 3 or 4. For antebrachial sites, a locking plate was applied to the lateral as-
pect of the proximal ulnar segment and articulated with the spacer using a multidirectional linkage unit. For
proximal humeral limb salvage, shoulder arthrodesis was achieved using 3.5mm string-of-pearls (SOP™)
locking plates cranial and caudal to the scapular spine and locked into the endoprosthesis construct and the
distal humerus.
All osteosarcoma cases received four cycles of intravenous carboplatin at three weekly intervals which be-
gan pre-operatively at the time of imaging and one case received regional infiltration with cisplatin 50mg/m2
and pluronic (poloxamer 407).
Clinical examination and subjective gait analysis was performed and degree of lameness scored on a nomi-
nal scale pre-operatively, and at 2, 6, and 12 weeks post operatively. Repeat radiography was performed im-
mediately, 6 weeks and 12 weeks post-operatively. Clinical, imaging and surgical records were reviewed and
pertinent data including incidence of complications was recorded. Owner satisfaction was graded on an or-
dinal scale at 12 weeks post operatively.
RESULTS
Six client-owned dogs with histologically confirmed primary bone tumors (osteosarcoma [n=4], chon-
drosarcoma [n=1] and osteoblastoma [n=1]) were operated. Anatomic sites included distal radius (n=2), dis-
tal ulna with radial involvement (n=1), distal tibia (n=2), and proximal humerus (n=1). All cases were neg-
ative for grossly discernable pulmonary metastases by radiographic and computed tomographic interroga-
tion at the time of presentation.
Four major but salvageable complications occurred. Loosening of the link-screws between the spacer and
tarsal arthrodesis plate at 6 weeks was successfully addressed in minimally invasive fashion. Plate breakage
and bone fissuring associated with the ulnar plate in two cases was successfully revised by lengthening the
ulnar attachment plate. Local tumour recurrence for one distal antebrachium was successfully resected.
Consistent weight-bearing limb use was achieved by 1 week post-operatively for all cases. Subjective lame-
ness scores were markedly decreased between pre-operative (mean lameness score 7/10) and 12 week post-
operative evaluations (mean lameness score 2/10 for carpal and tarsal arthrodesis cases and 4/10 for shoul-
der arthrodesis). Veterinary and owner assessment perceived resolution of pain by 2 weeks postoperatively
for all cases. Radiographic reassessment revealed implant integrity without periprosthetic osteolysis for all
cases at 12 weeks and owners were universally satisfied.
CONCLUSION
Application of these novel endoprostheses for distal radial, distal tibial and proximal humeral osseous ma-
lignancy with associated arthrodesis resulted in rapid recovery of pain-free limb function and lameness ame-
lioration. Avoidable construct failure occurred in 4/6 and was successfully addressed. At the time of abstract
submission, the patient receiving local resection of recurrence has not required further treatment 5 months
postoperatively. No complication was fulminant, but the failure of two ulnar attachment sites was attributed
to pronation-supination moment and prompted construct re-engineering for subsequent cases.
The relative advantages of HA-coated versus cemented intramedullary stems have not been elucidated to
date, and the advantage may best be realized with less rapidly terminal pathologies such as chondrosarco-
ma or osteoblastoma, where implant-bone construct survival may be required for several years.
However, novel application of an ulnar linkage plate (to the proximal extent of the olecranon) and two rather
than one metacarpal plates may assist early mobilization and promote resilient biomechanical function. In
vitro validation is pending and a salient limitation is lack of long-term outcome data. Infection was not not-
ed in any case, in spite of secondary intervention in 4 cases.
The modular implant design has putative advantages by comparison with existing endoprostheses by dis-
tributing load to all available osseous segments, allowing unrestrained intramedullary implantation and pros-
thesis attachment, precise functional limb axis alignment and optimization of available bone stock in both
proximal and distal segments. This may be particularly pertinent to the antebrachium where elbow disease
as a result of iatrogenic incongruency or malalignment may contribute to poor outcome and where prona-
tion-supination may contribute to implant loosening.
Early clinical outcomes experienced for the modular massive endoprosthesis systems employed here are en-
couraging and warrant further study.
REFERENCES
1. Liptak JM, Dernell WS, Ehrhart N, Lafferty MH, Monteith GJ, and Withrow SJ. Cortical allograft and endopros-
thesis for limb-sparing surgery in dogs with distal radial osteosarcoma: a prospective clinical comparison of two dif-
ferent limb-sparing techniques. Vet Surg 35:518-533, 2006.
2. Blunn GW, Briggs TW, Cannon SR, Walker PS, Unwin PS, Culligan S, Cobb JP. Cementless fixation for primary
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segmental bone tumor endoprostheses. Clin Orthop Relat Res. (372):223-30, Mar 2000.
M. Gatineau WVOC 2010, Bologna (Italy), 15th - 18th September • 570
Palpation and dorsal acetabular rim radiographic view for

early detection of canine hip dysplasia: a prospective study
Matthieu Gatineau, DVM1, Jacques Dupuis, DVM, MSc, DACVS1, Guy Beauregard, DVM2,
Benoit Charette, DVM, MSc, DACVS3, Luc Breton, DMV4, Guy Beauchamp, DMV, PhD4,
Marc-Andre d’Anjou, DMV, DACVR4
1
Centre Veterinaire DMV, Montreal, Canada - 2 Hopital Veterinaire Rive Sud, Montreal, Canada
3
VetSurg and Neurology, Woodland Hills, USA
4
Department of Clinical Sciences - Faculty of Veterinary Medicine, Université de Montréal, Montreal, Canada
INTRODUCTION
In the first part of this study, we standardized a palpation technique which ensured high repeatability in the
reduction angle (RA) measurement in six-months-old dogs,1 and which could consequently be used by vet-
erinarians with the expectation of comparable and consistent results. The purpose of the second part of this
study was to evaluate the validity of two diagnostic methods (the RA from the Ortolani method, and the
dorsal acetabular slope (DAS) from the dorsal acetabular rim (DAR) radiographic method) which could be
available to veterinary practitioners for the early detection of canine hip dysplasia.

Seventy three dogs were evaluated at 6, 12 and 24 months of age and used in this study: 6 Labrador re-
trievers, 16 Bernese mountain dogs and 51 Labrador retriever-Bernese mountain dog mixed-breed dogs. A
complete physical and orthopedic examination was performed on all dogs at 6, 12 and 24 months of age to
detect any signs of CHD and to rule out any other orthopaedic diseases. Under general anesthesia, the fol-
lowing sequence of tests was executed at 6 months of age: the VD hip extended radiographic view (VD), the
measurement of the RA using the Ortolani maneuver in dorsal recumbency, the compression-distraction ra-
diographic views (PennHIP method) and finally the DAR view. The same protocole was used at 12 and 24
months of age with the exception that the PennHIP method was not repeated. Data related to only one cox-
ofemoral joint of each dog, randomly chosen, were used for statistical analysis. Statistical analysis were per-
formed to establish the range of values of normal and abnormal RA and DAS; to document the variation of
the RA and DAS values over time; to compare the ability of the different methods to predict coxofemoral
OA; to determine the influence of pure passive laxity and of the DAS on the occurrence of an Ortolani sign
and on the magnitude of the RA; to establish the relationship between the DAS and subsequent development
of passive laxity and coxofemoral OA; and to evaluate the influence of the DAS and RA on the occurrence
of coxofemoral OA with severe, moderate and minimal coxofemoral passive joint laxity, respectively.
RESULTS
Twenty coxofemoral joints (27%) showed evidence of OA at 24 months of age. None of the coxofemoral joints
with a negative Ortolani sign at 6 months of age developed radiographic signs of OA at 2 years of age. Of the
47 coxofemoral joints with a positive Ortolani sign, 20 (43%) eventually developed OA whereas 27 (57%) were
classified free of OA at 2 years of age. Results of the sensitivity and specificity for the DI, RA and the DAS, cal-
culated for different cut-off values are summarized in Table 1. ROC curve analysis revealed that
AUCRA>AUCDAS>AUCDI suggesting that the RA>DAS>DI for an overall diagnostic performance point
of view. RA values were significantly higher at 6 months of age in coxofemoral joints with OA versus those grad-
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ed as normal at 24 months of age (p=0.0004). There was no time effect on the RA (p=0.56). There was no in-
teraction between time and OA. DAS values were significantly higher at 6 months of age in coxofemoral joints
with OA versus those graded as normal at 24 months of age (p=0.0002). There was a time effect on the DAS
(p<0.0001). DAS values at 6 months of age were significantly lower than those obtained at 12 and 24 months,
while these values did not change between 12 and 24 months of age. There was no interaction between time
and OA. The mean DI was significantly higher in dogs with a positive Ortolani sign as opposed to negative
(p<0.0001). The mean DAS was significantly higher in dogs with a positive Ortolani sign as opposed to nega-
tive (p<0.0001). Both the DI (p=0.0014) and the DAS (p=0.0021) had a positive and independent effect on the
probability of having a positive Ortolani sign. There was a significant positive linear relationship (p=0.015,
r2=0.32) between results of the DI and RA, and this relationship was unchanged regardless of the final diag-
nosis (p=0.15). There was a significant positive linear relationship (p=0.0078, r2=0.38) between results of the
DAS and RA and this relationship was unchanged regardless of the final diagnosis (p=0.26). There was a sig-
nificant positive linear relationship (p=0.015, r2=0.33) between results of the DAS and DI and this relationship
was not influenced by the final diagnosis (p=0.15). The final diagnosis had no effect on the DAS value (p=0.44).
571 • WVOC 2010, Bologna (Italy), 15th - 18th September M. Gatineau
Table 1 - Sensitivity and specificity of DI, RA and DAS when performed

at 6 months of age for occurrence of coxofemoral OA at 24 months of age
Test Cut off value Sensitivity Specificity
(%) (%)
DI Se ~ Sp ≥ 0.68 70 77
High Se ≥ 0.60 95 54
High Sp ≥ 0.80 35 96
Reported cut off value ≥ 0.70 55 78
≥ 0.41* 100 0
RA Se ~ Sp ≥ 12° 80 81
High Se ≥ 8° 90 70
/ ≥ 20° 60 91
High Sp ≥ 25° 40 94
Reported cut off value ≥ 15° 70 85
None 100 49
DAS Se ~ Sp ≥ 7.5° 75 79
High Se ≥ 6.0° 100 64
High Sp ≥ 10.0° 55 91
Reported cut off value ≥ 7.5° 75 79
DI: Distraction Index, RA: Reduction Angle, DAS: Dorsal Acetabular Slope
Se: sensitivity, Sp: specificity, Se ~ Sp: sensitivity similar to specificity
*
None of the hips in this study had a DI ≤ 0.4
Twenty-two (31%) coxofemoral joints had a DI≥0.7. Of these, 11 (50%) developed evidence of OA by 2 years
of age while 11 (50%) remained free of radiographic signs of OA. There was a significant difference between the
normal coxofemoral joints and coxofemoral joints with OA for the RA (p=0.04) and DAS (p=0.0008), but not
for the DI (p=0.03). The DAS was the best predictor of occurrence of coxofemoral OA for a DI≥0.7 (p=0.02).
Forty-eight (69%) coxofemoral joints had a 0.3<DI<0.7. Of these, 9 (19%) developed evidence of coxofemoral
OA and 39 (81%) remained free of radiographic signs of OA by 2 years of age. There was a significant differ-
ence between the normal coxofemoral joints and coxofemoral joints with OA for the RA (p=0.026), the DAS
(p=0.009) and the DI (p=0.037). RA was the best predictor of occurrence of coxofemoral OA in the DI range
of 0.31 to 0.69 (p=0.02). None of the coxofemoral joints in this study had a DI ≤ 0.3. Overall, the RA proved
to be the best occurrence predictor of coxofemoral OA (p= 0.0019). A RA ≥ 20° and a RA ≥ 15°was respec-
tively 91% and 85% reliable for predicting coxofemoral OA and a RA < 10° was 85% reliable for predicting nor-
mal coxofemoral joint. Eight of the 20 (40%) dogs with coxofemoral OA on the standard VD hip extended ra-
diographic view at 24 months of age demonstrated clinical evidence of CHD.
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CONCLUSION
The RA, when evaluated at 6 months of age in dorsal recumbency, was the best predictor of coxofemoral
OA at 2 years of age, and a negative Ortolani sign was at all times predictive of normal coxofemoral joint
at 2 years of age. Despite the presence of passive laxity measured by the DI method, other anatomic factors
such as joint conformation partially assessed by the RA and DAR methods are important for joint stability,
preventing conversion of passive to functional laxity, and subsequent development of coxofemoral OA.
REFERENCES
1. Charette B, Dupuis J, Beauregard G, et al. Palpation and dorsal acetabular rim radiographic view for early detec-
tion of canine hip dysplasia. Vet Comp Orthop Traumatol 14:125-132, 2001.
Corresponding Address: Dr. Matthieu Gatineau - Centre Veterinaire Dmv Surgery, 2300, 54 Avenue, Montreal (Lachine),
Canada - E-mail gatineaumatthieu@hotmail.com
V.A. Grigoropoulou WVOC 2010, Bologna (Italy), 15th - 18th September • 572
The use of canine scrotum as a mesh graft

to cover skin defects
V.A. Grigoropoulou, DVM, PhD candidate1, N.N. Prassinos, DVM, PhD, Assistant Professor2,
L.G. Papazoglou, DVM, PhD, MRCVS, Associate Professor2,
A.D. Galatos, DVM, PhD, Dipl ECVA, Associate Professor1, D.A. Psalla, DVM, PhD, Lecturer3
1
Clinic of Surgery, Faculty of Veterinary Medicine, University of Thessaly, Karditsa, Greece
2
Companion Animal Clinic, Faculty of Veterinary Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
3
Laboratory of Pathology, Faculty of Veterinary Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
INTRODUCTION
Research for the use of novel cutaneous donor sites in small animal reconstructive surgery is in progress.
There is only one clinical report in the literature that describes the use of the scrotum as a free flap for the
coverage of skin defects in the distal limbs in dogs.
The use of the canine scrotal pedicle flap for closure of cutaneous defects of the prepuce, thigh and perineum
has been also reported. The purpose of this experimental work was to evaluate, both clinically and histo-
logically, the use of canine scrotum, as a full thickness mesh graft, for covering skin defects in the thoracic
wall in dogs.

Four adult intact male Beagle dogs were used in the study. Following scrotal ablation and castration, the scro-
tum was prepared as a full thickness mesh skin graft by complete excision of the subcutaneous tissue until
the hair follicles were visible on the dermal side of the graft. Before the creation of mesh slits, the graft was
used as a template to determine the size of the experimentally created skin defect in the left thoracic wall.
Finally, the graft was sutured to the recipient site with simple interrupted sutures.
Bandaging of the graft at the recipient site was performed for one month after surgery. All dogs received
non steroidal anti-inflammatory and antimicrobial drug therapy. Biopsy samples were taken from the graft
at the time of surgery and on the 1st, 2nd, 4th and 6th month after surgery. All dogs were followed for six
months after surgery.
RESULTS
In two dogs, the graft was taken well with formation of a new epidermis within the first month after sur-
gery. By the end of the second month after surgery, complete closure with a durable appearance of the graft-
ed area was evident. Pigmentation of the skin graft was normal four months after surgery, but hair re-growth
was minimal.
Histologic examination of the samples obtained from the scrotal free graft revealed, at all time points of sam-
pling, a thin epidermis of stratified squamous epithelium with epidermal ridges, and normal dermis with the
presence of sebaceous and apocrine sweat glands, few hair follicles and smooth muscle fibers, namely the
dartos muscle. Eventually, a good cosmetic result was evident.
The remaining two dogs showed, two months after surgery, complete healing of the grafted area charac-
terized by a combination of areas with satisfying survival of the scrotal graft and others that presented
wound contraction and epithelialization, as revealed by the reduction of the total grafted area and its pale
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coloration. Six months after surgery, the grafted area showed a durable appearance with pale color, in
combination with small areas of mild pigmentation and the presence of few scattered hair. Histologic ex-
amination of the grafted area revealed the development of scar connective tissue, that had replaced the
meshwork of collagen and sebaceous and sweat glands, covered by a thin single to double layered ep-
ithelium. However, occasionally, areas of the graft had normal epidermis and dermis with few hair folli-
cles and smooth muscle fibers even six months after surgery. A poor but acceptable cosmetic result was
eventually evident.
CONCLUSION
The canine scrotum may be used as a full thickness mesh graft for coverage of skin defects with acceptable
cosmetic results. A meticulous and not over zealous surgical preparation of the fine scrotal skin as a graft is
recommended in order to keep intact all its anatomical structures that may improve the survival rate and the
cosmetic appearance of the graft.
573 • WVOC 2010, Bologna (Italy), 15th - 18th September V.A. Grigoropoulou
REFERENCES
Grigoropoulou V., Prassinos N. N., Galatos A. D., Papazoglou L. (2007). Use of the canine scrotum as a pedicle flap for
closure of skin defects of the prepuce. Proceedings of the 8th Congress of the Hellenic Veterinary Medical Society
on Companion Animal Practice, 111-112.
Grigoropoulou V., Prassinos N. N., Galatos A. D., Papazoglou L. (2007). The canine scrotum as a pedicle flap for closure
of skin defects in the thigh. Scientific Proceedings of the 50th Annual Congress of British Small Animal Veterinary
Association, 529.
Harris J. E., Dhupa S. (2008). Treatment of degloving injuries with autogenous full thickness mesh scrotal free grafts. Vet-
erinary and Comparative Orthopaedics and Traumatology 21, 378-381.
Matera J. M., Tatarunas A. C., Fantoni D. T., De Carvalho Vasconcellos C. H. (2004). Use of the Scrotum as a Trans-
position Flap for Closure of Surgical Wounds in Three Dogs. Veterinary Surgery 33, 99-101.
Ms. Virginia Grigoropoulou, 3, Lambrou Veikou Str., 18547 Neo Faliro/Pireaus, Greece
E-mail virginiagr78@gmail.com
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E. Iacono WVOC 2010, Bologna (Italy), 15th - 18th September • 574
Use of bone marrow mesenchymal stem cells in case

of excision of superficial flexor tendon in the horse:
a case report
N. Romagnoli, DVM, E. Iacono, DVM, B. Merlo, DVM, A. Spadari, DVM
Veterinary Clinical Department- Alma Mater Studiurum University of Bologna, Ozzano dell’Emilia, Italy
INTRODUCTION
Tendon injuries in horses often compromise the return to the same level of activity, despite what is consid-
ered appropriate management (Sharma and Maffulli 2005; Smith and Webbon 2005), because the scar tis-
sue formed in the repair process make the tendon functionally deficient in comparison to normal (Dowling
et al. 2000). A multitude of treatments have been advocated for the management of tendon injuries, includ-
ing the intralesional injection in the lesion of mesenchymal cells and the use of Growth factors (platelet rich
Plasma). In 2003 Smith et al. suggested for the first time the use of autologous mesenchymal cells obtained
from bone marrow in spontaneous tendon lesions in horses (Smith et al. 2003; Smith 2004; Smith and Web-
bon 2005). MSCs achieved optimal regeneration of injured tendon tissue both in experimental and equine
spontaneous lesions. It has been also proposed by the same authors to inject MSC in vehicle with PRP
(Smith, 2006), that it was used alone like treatment for tendon lesion (Spadari, 2006).
To the authors’ knowledge, treatment with stem cells in Platelet Rich Plasma (PRP) medium has not been
used in association with surgical repair after complete tendon severing in the horse. In this study, the au-
thors describe the use of autologous MSC in PRP medium in an Arabian horse to enhance the repair of
severed traumatic superficial digital flexor tendon (SDFT) surface.

A 3-year-old, Arabian horse weighing 400 kg, was admitted because of a right frontlimb 3 cm reverse V
shaped wound between middle and distal third of the palmar metacarpal surface, with few blood lost, caused
by entangled wire fence of the paddock. On presentation, the animal was bright, alert and responsive. All
vital parameters were within normal limits. It was evident from outside the complete tear of the SDFT. The
horse was immediately subjected to surgery under general anesthesia. During surgery, margins of the skin
wound were removed and the opening was enlarged proximally to expose the tendon. After curettage of the
extremities, the two stumps of the tendon was apposed with Bunnell suture using PDS 1. The fascia was
then closed with Poliglicolic 0 in continuous pattern and the skin was closed with monofilament nylon 0 with
interrupted simple suture. In a second surgical field, bone marrow was aspirated from iliac crest by using a
Jamshidi bone marrow biopsy needle under sterile conditions. Immediately after surgery a cast was applied.
Anti-inflammatory and antibiotic drugs were administered for 10 days.
A total of 75 ml of bone marrow aspirate were collected into two 60 ml sterile syringes containing heparin
and sent to the laboratory. All chemicals were obtained from Sigma-Aldrich (St. Louis, MO, USA) unless
otherwise stated; plastic dishes and tubes were from Sarstedt Inc. (Newton, NC, USA). In laboratory, sam-
ple were diluted 1:1 in PBS solution supplemented with antibiotic solution and centrifuged for 15 min at
300g. The pellet was re-suspended in 5ml of culture medium (DMEM and TCM-199, 1:1 plus 10% FBS -
GIBCO®, Invitrogen Corporation, Carlsbad, California, USA-100 IU/mL penicillin and 100 µg/ml strep-
tomycin), placed on 5 ml of 70% Percoll solution and centrifuged at 1200g for 30 min. The interface layer
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was then aspirated and re-suspended in culture medium, washed for three time by centrifugation and seed-
ed into 25 cm2 flasks. In vitro culture was performed in a 5% CO2 incubator at 38.5°C. Medium was re-
freshed after 48 h then twice a week.
After six weeks the cast was removed and an ultrasound examination was performed. A big abnormality of
tendon shape, anaechoic lesion with a cross section area (CSA) of about 75% of tendon volume was evident.
The fiber disruption pattern was along the midline, with the division of tendon into medial and lateral com-
ponents. Therefore, it was decided to make an ultrasound guided inoculum MSC in PRP suspension (11.1
x 106 cells in 4 ml of platelet gel prepared as described by Spadari et al -2006). The patient followed a re-
habilitation protocol for about four months.
RESULTS
Fifteen days after treatment with mesenchymal stem cells and PRP, the flexor right metacarpal area was sig-
nificantly increased in volume compared to the contralateral. The ultrasound examination revealed an ear-
575 • WVOC 2010, Bologna (Italy), 15th - 18th September E. Iacono
ly stage of re-organization of tendon fibers with a less persistent hypoechoic fiber pattern. Four months af-
ter the injection, the overall appearance of the area was still slightly enlarged. At the ultrasound examina-
tion an axially isoechogenic alignment fiber bundle, favorable CSA and textural improvement was evident
and the trend of tendon fibers was normal.
One year after the injury the horse is in sport activity.
CONCLUSION
In this case report autologous bone marrow mesenchymal stem cells in PRP suspension have been used af-
ter tenorraphy in a complete severed tendon injury as enhancing therapy. The result obtained is largely sat-
isfactory starting from four months after inoculation when the tendon showed a reorganization of the fibers
entirely physiological. Such data must be confirmed by treating a significant number of patients with the
same acute lesion and not suffering recurrence during follow up longer than one year.
REFERENCES
Hertel D.J. (2001). Enhanced suspensory ligament healing in 100 horses by stem cells and other bone marrow compo-
nents. Proceedings American Association Equine practioners 47, 319-321.
Smith JJ, Ross MW, Smith KW (2006) Anabolic effects of acellular bone marrow, platelet rich plasma, and serum on
equine suspensory ligament fibroblasts in vitro. VCOT 19 (1), 43-7.
Sharma P. and Maffulli N. (2005). Tendon injury and tendinopathy: healing and repair. Journal of Bone and Joint Sur-
gery-American Volume 87, 187-202.
Smith R.K., Webbon P.M. (2005). Harnessing the stem cell for the treatment of tendon injuries: heralding a new dawn?
British Journal of Sports Medicine 39, 582-584.
Smith R.K., Korda M., Blunn G.W., Goodship A.E. (2003). Isolation and implantation of autologous equine mesenchy-
mal stem cells from bone marrow into the superficial digital flexor tendon as a potential novel treatment. Equine
Veterinary Journal 35, 99-102.
Smith R.K. (2004). Autogenous Stem Cell Implantation. Proceedings of ACVS Veterinary Symposium 204-206.
Spadari, A., Romagnoli, N., Gentilini, F., Agnoli, C. (2006) Use of platelet gel in the horse: preliminary report. Proceed-
ings of XII Annual Congress SIVE, 206.
Prof. Alessandro Spadari - Alma Mater Studiorum - Università di Bologna Dipartimento Clinico Veterinario,
Via Tolara di Sopra 50, 40064 Ozzano dell'emilia (BO), Italia - E-mail alessandro.spadari@unibo.it
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Assessment of the osteoinductive properties of freeze-dried

canine demineralised bone matrix (DBM)
J. Clayton, BSc student1, C. Redmond, BSc1, P. Myint, BVSc PhD2,
J. Innes, BVSc PhD DSAS(orth) MRCVS1,2
1
Musculoskeletal Research Group, University of Liverpool Veterinary School, Liverpool, UK
2
Veterinary Tissue Bank Ltd (www.vtbank.org), Wrexham, UK
INTRODUCTION
Use of bone allograft products is increasing rapidly in both human and veterinary orthopaedics (Innes and
Myint 2010). Demineralised bone matrix (cDBM) is one such product and is used for its osteoinductive
properties in procedures such as arthrodesis, TPLO, fracture repair and spinal fusions (Hoffer and others
2008). DBM is acellular but importantly, unlike synthetic bone products, DBM contains species-specific
growth factors. Although recombinant human bone morphogenic factors (rhBMPs) are available and have
functionality in dogs, the expense of these products has generally precluded their widespread use in veteri-
nary orthopaedics.
To assess the osteoinductive properties of human DBM (hDBM), traditionally, hDBM is implanted in to
epaxial muscles of nude rats and 28 days later histological scoring of bone production is performed; such
data have not been reported for canine DBM (cDBM) products. However, biochemical or in vitro tests
would be preferable to reduce the numbers of experimental animals used for such tests. Previous work on
hDBM has indicated that cell based in vitro assays and measurement of BMP-2 provide good correlations
with osteoinduction observed histologically in nude rats. We hypothesised that the osteoinductive proper-
ties of cDBM could be assessed using a myoblast cell-based in vitro assay or a BMP-2 assay.

To measure the BMP-2 content of different cDBM batches (Canine DBM, Veterinary Tissue Bank, Wrex-
ham, UK), cDBM samples were digested in 4M Guanidine/0.05M Tris-HCl and dialysed against 0.05M
Tris-HCl using a Slide-A-Lyzer G2 dialysis cassette (Thermo Scientific) with a molecular weight cut off
(MWCO) of 10K. A single sample of hDBM was treated similarly and used for comparison. The dialysed
samples were then assayed using an ELISA for BMP-2 (R&D Systems) (canine BMP shows 94% homolo-
gy with human BMP-2). Results were expressed as ngBMP-2/g DBM.
To validate the mouse myoblast cell line (C2C12) based assay, cells were cultured in the presence of in-
creasing concentrations of BMP-2 (10, 20, 50, 100, 300ng) added directly to a monolayer of cells. The
C2C12 cells were seeded at 5x104 in 12 well plates in a medium of Dulbecco’s Modified Enrichment Medi-
um (DMEM) with 10% Fetal Calf Serum (FCS) and given an attachment period of 4 hours. The media was
then changed to one containing 1% FCS and the BMP-2 applied in duplicate to a monolayer of cells. The
plates were incubated for 48 hours at 37oC and 5% CO2 media were assayed for total protein (Thermo Sci-
entific) and for osteoinductive effect by luminescence assay of alkaline phosphatase (ALP) (Anaspec Inc.).
ALP concentrations were expressed as ALP (pg) per (mg) Total Protein.
RESULTS
BMP-2 assay results indicated that BMP-2 was detectable in all five cDBM batches with a mean value of
4.508ngBMP-2/g DBM (SD=6.733). By comparison the hDBM sample contained 34.868ng BMP-2/g
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DBM.
In the C2C12 cell based assay, increasing concentrations of rhBMP-2 produced a positive dose response,
i.e., increasing concentrations of ALP were measured when increasing rhBMP-2 concentrations were added,
validating the cell based assay. Further work will test cDBM in this cell-based assay.
CONCLUSION
The results indicate that cDBM contains BMP-2. On average, BMP-2 concentrations in cDBM were lower
than the single hDBM sample and this may reflect a lower sensitivity of the assay for detection of canine
BMP-2 since the assay is designed for use with human samples. However, it may also indicate that canine
bone inherently has less BMP-2 or that the single human DBM used was unusually high in BMP-2. Fur-
ther work would be required to investigate these possibilities. In addition, it is realised that the osteoinduc-
tive properties of DBM are greater than can be explained by BMP-2 alone because a milieu of growth fac-
tors is present.
The cell based assay was validated with rhBMP-2 which produced a dose response suggesting that this as-
say may be useful for in vitro quality assessment of cDBM batches. Future work will test that hypothesis.
This study supports the view that cDBM possesses osteoinductive properties. These results support the clin-
ical use of DBM in canine patients when support for bone healing is required. Further work on the cell-
based assay may provide a more holistic assessment of osteoinductive properties compared to BMP-2 alone.
REFERENCES
Hoffer, M. J., Griffon, D. J., Schaeffer, D. J., Johnson, A. L. & Thomas, M. W. (2008) Clinical applications of demineral-
ized bone matrix: A retrospective and case-matched study of seventy-five dogs. Veterinary Surgery 37, 639-647.
Innes, JF and Myint PE (2010) Demineralised bone matrix in veterinary orthopaedics: a review. Veterinary and Com-
parative Orthopaedics and Traumatology, in press.
Prof. John Innes - University of Liverpool Comparative Molecular Medicine, Leahurst Campus, Neston
United Kingdom - E-mail j.f.innes@liv.ac.uk
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J.C. Ionita WVOC 2010, Bologna (Italy), 15th - 18th September • 578
Biochemical characteristics of the equine autologous

conditioned plasma (ACP™)
J.C. Ionita¹, C. Kissich¹, P. Böttcher², M. Stief², J. Gottschalk³, W. Brehm¹
¹ Large Animal Clinic for Surgery, University of Leipzig, An den Tierkliniken 21, 04317 Leipzig, Germany
² Department of Small Animal Medicine, University of Leipzig, An den Tierkliniken 23, 04103 Leipzig, Germany
³ Institute of Physiological Chemistry, University of Leipzig, An den Tierkliniken 1, 04103 Leipzig, Germany
INTRODUCTION
The principle of platelet concentrate (PC) therapy is the local application of wound healing promoting, au-
tologous growth factors (GF) that are contained in the patients’ plasma and highly concentrated in their
platelets (Pt). PDGF-BB and TGF-β1are two of these GF that play a central role by controlling important
cellular processes during wound healing. Human and equine studies demonstrated the positive effects of PC
on different aspects of healing in tendon, skin, cornea and bone tissue lesions amongst others. Many stud-
ies recommend the depletion of leucocytes (Lc) from the PC in order to prevent any further intensification
of the local inflammatory process. Numerous kits for human or equine PC production are already available
on the market. “Autologous conditioned plasma” (ACP™, Athrex, USA) represents a new, simplified, low-
priced and attractive technique to prepare a PC. It uses a specially designed, patented double syringe sys-
tem and needs only one relatively soft centrifugation step. This method originates from human sports med-
icine and was successfully introduced in veterinary medicine to treat equine orthopaedic disorders, such as
tendinitis and osteoarthritis. The optimal protocol (relative centrifugation force and duration of centrifuga-
tion) for producing ACP for human patients have been well established by the manufacturer, but data lack
for horses. Our hypothesis was that the best ACP preparation parameters for equine patients differ from
those in humans, as Pt sedimentation, specific gravity of Pt and blood viscosity in horses are different from
those in people. In order to find out the most suitable centrifugation technique in equine patients, we meas-
ured the concentrations of Pt, Lc and GF (PDGF-BB and TGF-β1) in several equine ACP specimen pre-
pared by using different combinations of relative centrifugation forces (expressed as rotations per minute:
U/min) and durations of centrifugation. The aim of this study was to find out the ACP production combi-
nation which showed the relatively highest concentration of thrombocytes and GF in comparison to the Lc
concentration and to define it as the standard preparation method in horses.
MATERIAL AND METHOD

The study was divided in two parts. 9 healthy, adult Warmblood horses were included in the first part. From
each patient 9 ml of venous blood were collected in 1 tube containing 1 ml ACDA (S-Monovette™, Sarst-
edt, Germany) in order to measure their base blood cell concentrations. Moreover 12 ACP syringes con-
taining 1 ml of ACDA were filled with 9 ml of venous blood for each horse. Based on non published pre-
liminary results, the different centrifugation speeds used were 900, 1100, 1300 und 1500 U/min with a du-
ration of 4, 5 and 6 min, respectively. Each syringe was used for only one combination. A blood count was
completed for each ACP sample after centrifugation, with special attention to Pt and Lc counts. 2 aliquots
from the combinations “900X4”, “1100X5” and “1300X6” were frozen at -80°C until measurement of their
TGF-β1 and PDGF-BB concentrations. This was achieved using human specific ELISA kits (R&D Systems,
Minneapolis, USA).
10 other healthy, adult Warmblood horses were included in the second part of the study, in order to vali-
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date the GF measurements. A tube containing 1 ml of ACDA (S-Monovette™, Sarstedt, Germany) was filled
with 9ml of venous blood from every patient and used to prepare conventional plasma (3000g X 10 min)
which served as negative control. ACP prepared with the combination “1100X 5” was processed for each
horse, divided in 3 aliquots and frozen at -80°C before measurement of their TGF-β1 and PDGF-BB con-
centrations using the same ELISA kits as before.
RESULTS
In the first part, the combination “900X4” showed the highest concentration of Pt (160% ±22) compared to
whole blood, followed by the combinations “1100X4”, “900X5” and “1100X5” with 158% ±22, 158% ±21
and 150% ±20, respectively. There were no statistical significant differences between these values. From
these combinations, “1100X5” showed the lowest concentration of Lc (12% ±4) when compared to whole
blood. The absolute concentration of PDGF-BB was 1.88ng/ml ±0.7, 1.58ng/ml ±0.7 and 1.24ng/ml ±0.5
for “900X4”, “1100X5” and “1300X6”, respectively. For TGF-ß1 the concentrations were 1.70ng/ml ±0.8,
579 • WVOC 2010, Bologna (Italy), 15th - 18th September J.C. Ionita
1.40ng/ml ±0.8 and 1.14ng/ml ±0.3 for “900X4”, “1100X5” and “1300X6”, respectively. There were no sig-
nificant differences between the different centrifugations.
In the second part, the combination “1100/5” showed a significantly higher concentration of Pt than con-
ventional plasma when compared to whole blood (180% ±26 for ACP and 15% ±5 for plasma). Moreover
the concentration of TGF-β1 and PDGF-BB were significantly higher in “1100X5” than in conventionally
prepared plasma (411% ±190 and 589% ±240 higher). The concentrations of Pt and GF were highly cor-
related (r=0.97).
CONCLUSION
The combination “900/4” showed the highest concentration of Pt, but on the other side it contained a rela-
tively high amount of Lc. Lc may promote local inflammatory reactions and should be avoided when
platelet concentrates are injected. “1100X5” showed a high amount of Pt with a relative low Lc concentra-
tion and for this reason this combination was chosen as the best protocol for ACP preparation. The meas-
urement of the GF concentration in the 3 different combinations showed a positive correlation between GF
and Pt concentrations as expected. The validation of the results was achieved by measuring the Pt and GF
concentrations in ACP prepared using “1100X5” and “cell depleted” plasma. The GF and Pt concentrations
which were significantly lower in plasma than in ACP confirmed our expectations and the validity of the re-
sults from the first part of the study. ACP prepared using the centrifugation parameters 1100U/min X 5min
is an effective, fast and easy to use technique to obtain a high amount of Pt and a Lc depleted plasma, but
clinical studies are necessary to objectively assess the beneficial effects in equine patients.
REFERENCES
Anitua E, Andía I, Sanchez M, Azofra J, del Mar Zalduendo M, de la Fuente M, Nurden P, Nurden AT (2005). Autolo-
gous preparations rich in growth factors promote proliferation and induce VEGF and HGF production by human
tendon cells in culture. J Orthop Res. 23(2), 281-6.
Argüelles D, Carmona JU, Climent F, Muñoz E, Prades M. (2008). Autologous platelet concentrates as a treatment for
musculoskeletal lesions in five horses. Vet Rec. 162 (7), 208-11.
Bosch G, van Schie HT, de Groot MW, Cadby JA, van de Lest CH, Barneveld A, van Weeren PR (2010). Effects of
platelet-rich plasma on the quality of repair of mechanically induced core lesions in equine superficial digital flexor
tendons: A placebo-controlled experimental study. J Orthop Res., 28(2), 211-7.
DeRossi R, Coelho AC, de Mello GS, Frazílio FO, Leal CR, Facco GG, Brum KB (2009). Effects of platelet-rich plasma
gel on skin healing in surgical wound in horses. Acta Cir Bras. 24 (4), 276-81.
McCarrel T, Fortier L (2009). Temporal growth factor release from platelet-rich plasma, trehalose lyophilized platelets,
and bone marrow aspirate and their effect on tendon and ligament gene expression. J Orthop Res. 27 (8), 1033-42.
Jean-Claude Ionita, Chirurgische Tierklinik, An den Tierkliniken 21, 04103 Leipzig, Germany
E-mail Ionita@vetmed.uni-leipzig.de
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A. Kavaguchi De Grandis WVOC 2010, Bologna (Italy), 15th - 18th September • 580
Radial shock wave therapy for tendon healing and tendon

adhesion prevention: characterisation of surgically induced
goat model of tendonitis
A. Kavaguchi De Grandis, DVM, MSc1, F. Auzas, DVM2, C. Boulocher, DVM, PhD1,
L. David, Professor3, T. Roger, DVM, Prof Dipl ECLAM1, S. Sawaya, DVM, PhD1,2
1
UPSP 2007-03-135 RTI2b - Vetagro-Sup Campus Vétérinaire de Lyon, Marcy l’Etoile, France
2
Unité Physiothérapie-Rééducation-Ostéopatie - Vetagrosup- Campus Vétérinaire de Lyon, Marcy l’Etoile, France
3
UMR CNRS 5223 IMP Laboratoire des Matériaux Polymères et Biomatériaux - Université Lyon 1, Villeurbanne, France
INTRODUCTION
There is no ideal treatment for tendinitis, but physical therapy is often considerate as a useful complementary
treatment (DYSON 1998; BATHE 2005). This study was created to characterize an experimental model of
surgically induced tendonitis in goats and to quantify the effectiveness of Radial Extracorporeal Shock Wave
Therapy (rESWT) on tendon healing and tendon adhesion prevention.
This experimental protocol was approved by the ethical and scientific committees of the author’s Institution.
Fifteen female goats aged from 8 to 12 months were included in the study. Surgical splitting of the deep digi-
tal flexor tendon of the left hind limb was performed at day 0 (D0). The right hind limb was left intact and
used as normal control. Two groups were randomly created: group I formed the control operated group (n=6)
and did not receive any treatment; group II formed the treated group (n= 9) and was treated with rESW at
day 9, 16 and 22 after the surgery (15mm diameter applicator, 1200 shocks, P = 2 bars, 8 to 10 Hz; energy
flux density = 0.12 mJ/mm²). Goats were clinically evaluated for 45 days. Lameness, pain measured by al-
gometry (Sensitivity Threshold to Pressure: STP), and oedema (measurements of width and depth of the ten-
don region) were measured before and at days 5, 14, 21, 30 and 45 after surgery. Ultrasonography was per-
formed before surgery, then at days 7, 21 and 45 after surgery to measure homogeneity, echogenicity and fib-
bers alignment. Fifty days after surgery the goats were euthanized. Gross examination of the left and right ten-
dons was realised. Eight tendons underwent tensiles tests (operated left and intact right tendons from two goats
of each group). Both groups were statistically compared with Wilcoxon tests.
RESULTS
At day 45, group II was statistically limping less than group I (p <0.001). During the treatment period, Group
II tendons showed a lower STP. The difference between the two groups was not signifficative anymore at day
30 (p < 0.05). Oedema was not statistically different between the two groups during all the study (p > 0.05).
At day 45, Group II showed a slightly better ultrasonographic healing score while not statistically significant.
At day 50, gross examination of the operated tendons in Group I showed more inter-tendons and tendon-
sheath adhesions than in Group II (83% vs 44%). The rigidity of the tested tendons varies between 40 and 80
N/mm and the elasticity modulus between 156 and 189 MPa. Only two of operated tendons (one from each
group) showed different mechanical properties than non-operated tendon.
CONCLUSION
Here we present a preliminary study of surgically induced model of tendonitis in goats. We set up a protocol for
clinical, ultrasonographic and mechanical evaluation of tendon healing. Clinical improvement was significantly
higher in the treated group than in the control group 3 weeks after the last session of rESWT. Gross examina-
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tion showed a lower percentage and grade of tendon adhesion for Group II. While the ultrasonographic evalua-
tion scores were in favour of the Group II these results were not statistically different from these of the Group I.
These results have to be completed by the results of the tensiles tests.To characterize this experimental model and
confirm the effectiveness of rESWT at a later stage of healing (GAUTARD et al. 1989), we have already started
a 90 days study involving a greater number of animals and including an immuno-histological evaluation.
REFERENCES
Bathe AP: Results of extracorporeal schockwave therapy for the treatment of superficial digital flexor tendonitis. British
Racing School, NewMarket, Equine Study Medicine Course, 2005: 17-21.
Dyson SJ: Superficial digital flexor tendonitis: a comparison of treatment methods and rehabilitation programmes. Con-
ference du CESMAS, Cordoba, Espagne, 1998.
Gautard R, Fouriner D: Echographie du système musculo-tendineux. Revue Thérapeutique 1989; 46 (3): 152-157.
Corresponding Address: Dr. Serge Sawaya - Vetagro-Sup - Campus Vétérinaire De Lyon Anatomie Comparée, 1,
Avenue Bourgelat, 69280 Marcy L’etoile, France - E-mail s.sawaya@vetagro-sup.fr
581 • WVOC 2010, Bologna (Italy), 15th - 18th September N. Kim
Evaluation of bone healing with using a xenogenic bone

plate and screws in a canine fracture model
N. Kim, MS, PhD1, S. Heo, MS, PhD1, J. Kim, PhD2, H. Lee, MS, PhD1,
M. Kim, MS, PhD1, K. Lee, MS, PhD1, C. Oh, MS, PhD2
1
College of Veterinary Medicine, Chonbuk National University, Jeon city, South Korea
2
College of Engineeting, Chonbuk National University, Jeon city, South Korea
INTRODUCTION
The purse of this study evaluated using a xenogenic bone plate and screws (XBPS) for internal fixation of
bone fractures in a canine model. Metallic plate and screw for internal fixations of bone fracture have been
used a human and veterinary medicine. A main suggested disadvantage of metallic implants is led to corti-
cal porosis, delayed bridging, necessity of removing the plates after healing complete and refracture after
plate removal. The current xenogenic bone plates and screws have been developed for internal fixation de-
vices of possibility of manufacture. However, previous reports were suggested biomechanical assessment by
in vitro study. In addition, our knowledge, xenogenic bone plates and screws for internal fixation system
have not been reported by vivo study in canine fracture model. This study was possibility the xenogenic
bone plate and screw (XBPS) for internal fixation of bone fracture in canine.

The animals were distributed into 3 experimental groups: a XBPS was applied to transverse fracture of the
ulna (Group A), a metallic bone plate and screws were applied to transverse fracture of the ulna (Group B),
and a beagle dog’s cadaveric ulna (Group C). The experiment region underwent radiography for observing
the state of periosteal reaction, bone union and remodeling until 36 weeks. After this, the ulnas were ana-
lyzed by micro-computed tomography. The ulnas were mechanically tested with 3-point bending to assess
failure; selected transverse fracture ulnas from each group were analyzed histologically.
RESULTS
The radiological and histological results show that 70% of the bone fractures healed and fixation of the
XBPS was normal. On the micro–CT, the bone volume was increased in the fracture zone of the Group A
as compared to that of Group B (P < 0.01). The biomechanical test results of group A were similar with
those of normal bone, and the biomechanical test of Group B was 50% lower than that of Group A and nor-
mal bone (P <0.01).
CONCLUSION
The advantage of XBPS is the possibility of its incorporation, which would prevent the need for second sur-
gery to remove the bone plate and screw.
REFERENCES
1. Anderson, K. J., Fry, L. R., Clawson, D. K. & Sakurai, O. (1965) Experimental Comparison of Autogenous, Ho-
mogenous, and Heterogenous Bone Grafts: a Planimetric Measurement Study. Ann Surg 161, 263-271.
2. Choi, I. H., Kim, H. G., Kim, N. S., Sasaki, N. (1996) Effectiveness of freeze-dried bone grafts on the non-union
fracture of dogs. Korean J Vet Res 36(2), 495-511.
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3. Haddad, F. S. & Duncan, C. P. (2003) Cortical onlay allograft struts in the treatment of periprosthetic femoral frac-
tures. Instr Course Lect 52, 291-300.
Prof. Nam Soo Kim - College of Veterinary Medicine, Chonbuk National University Veterinary Surgery, 664-14 Dokjin
Dong, Jeonju City, College of Veetrinary Medicine, Chonbuk National University, Jeon Ju, 561-756, South Korea
E-mail namsoo@chonbuk.ac.kr
J. King WVOC 2010, Bologna (Italy), 15th - 18th September • 582
Preclinical safety of robenacoxib in cats

J. King, BVSc, PhD1, R. Hotz, DVM2, D. Roth, Dr vet med3, W. Seewald, PhD1, P. Lees, PhD, DSc4
1
Novartis Animal Health Inc, Basel, Switzerland - 2 Novartis Animal Health Inc, St Aubin, Switzerland
3
Novartis Pharma AG, Muttenz, Switzerland - 4 Royal Veterinary College, Hawkshead, UK
INTRODUCTION
Robenacoxib is a novel non-steroidal anti-inflammatory drug which possesses analgesic, anti-inflammatory and
anti-pyretic properties (Giraudel et al., 2009; King et al., 2009). It is registered in Europe for cats as Onsior®
as a single subcutaneous injection (at 2 mg/kg) or repeated administration of tablets (1-2.4 mg/kg once daily)
for a maximum of 6 days. The objective of this study was to evaluate the safety of robenacoxib tablets in young
healthy cats when administered at dosages ranging from 4 to 20 mg/kg per day for 42 consecutive days. The
hypothesis for the study was that robenacoxib would have a good safety profile in cats due to a combination
of properties: high selectivity for the cyclooxygenase (COX)-2 isoform of COX; lack of direct gastrointestinal
irritant action (in rats); and short residence time in the blood (Giraudel et al., 2009; King et al., 2009).

The study was a prospective, randomised, placebo-controlled, blinded study in laboratory cats. A total of
32 European short-haired cats weighing a mean of 2.8 kg (females) and 3.7 kg (males) and aged 7.5 to 8
months were used. They were healthy at the start of the study, as evidenced from clinical examination,
haematology, clinical chemistry and urinalyses. Within each sex, the cats were randomised to receive either
placebo or robenacoxib at total daily dosages of 4, 12 or 20 mg/kg for 6 weeks (given in divided doses ap-
proximately 12 hours apart). Each group contained 4 female and 4 male cats. The test article was Onsior®
6 mg tablets or matched placebo (containing the same excipients but no robenacoxib). The tablets were
placed within gelatine capsules to facilitate dosing. Cats were observed at least twice daily. Body weights and
food consumption were measured weekly. Blood samples for haematology and clinical chemistry, and urine
samples, were collected prior to and 2 and 6 weeks after the start of dosing. At the end of the 6 week dos-
ing, the cats were necropsied and organs and tissues were examined macro- and microscopically.
RESULTS
No toxicologically significant effects were recorded in any group through general observations of health,
haematological and clinical chemistry measurements and urinalyses in life, and by post mortem gross pathol-
ogy, organ weight and histopathology assessments. Body weights increased in all cats during dosing, but
body weights and food consumption were not significantly different between the placebo and robenacoxib
groups. There were no differences in groups in the incidence of clinical signs wild mild vomiting and soft
faeces being the most common signs in all groups. There were no biologically relevant differences between
the groups in results of haematology, clinical chemistry or urinalyses. Although there were isolated cases of
statistical significance, there were no consistent effects at repeated time points or with dose-related effects of
robenacoxib. There were no significant differences between groups in gross appearance or weight of organs,
with the exception of thymus weights which were significantly lower in all three robenacoxib groups com-
pared to placebo, but with no dose-related effect. However, thymus weights were not significantly different
between groups when two outliers in the placebo group were excluded from the analysis.
No treatment related effects were detected in microscopic evaluations of any tissue (including the thymus).
CONCLUSION
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At daily dosages up to and including 20 mg/kg for 42 days, representing overdose by 8-20 fold relative to
the recommended tablet dosage of 1-2.4 mg/kg, robenacoxib was well tolerated in healthy young cats. It was
especially notable that no evidence of toxicity was detected in blood clotting parameters, the gastrointestinal
tract, kidney or liver of any cat.
REFERENCES
Giraudel, J.M., Toutain, P.L., King, J.N., Lees P. (2009) Differential inhibition of cyclooxygenase isoenzymes in the cat
by the NSAID robenacoxib. Journal of Veterinary Pharmacology and Therapeutics, 32, 31-40.
King, J.N., Dawson, J., Esser, R.E., Fujimoto, R., Kimble, E.F., Maniara, W., Marshall, P.J., O’Byrne, L., Quadros, E.,
Toutain, P.L., Lees, P. (2009) Preclinical pharmacology of robenacoxib: a novel selective inhibitor of cyclooxyge-
nase-2. Journal of Veterinary Pharmacology and Therapeutics, 32, 1-17.
Corresponding Address: Dr. Jonathan King - Novartis Animal Health Inc Clinical Development, Schwarzwaldalle 215,
Ch-4058 Basel, Switzerland - E-mail jonathan.king@novartis.com
583 • WVOC 2010, Bologna (Italy), 15th - 18th September G.A. Kojouri
Ostrich tendon (new xenogenic) transplantation

in rabbits model
G.A. Kojouri, DVM, PhD1, A. Bigham Sadegh, DVM, PhD2, Z. Shafiei, DVM3,
A. Zamani Moghaddam, DVM, PhD4, H. Nourani, DVM, PhD5
1
Department of Clinical Sciences, School of Veterinary Medicine, Shahrekord University, Shahrekord, Iran
2
Department of Clinical Sciences, School of Veterinary Medicine, Shahrekord University, Shahrekord, Iran
3
Postgraduate Student, School of Veterinary Medicine, Shiraz University, Shiraz, Iran
4
Department of Clinical Sciences, Shahrekord, Shahrekord, Iran
5
Department of Pathobiology, School of Veterinary Medicine, Shahrekord University, Shahrekord, Iran
INTRODUCTION
Since tendons are subjected to repeated motion and degeneration over time, they are prone to both acute
and chronic injuries. In addition, blood supply to the tendon is reported to be poor, thereby healing often
was progressed slowly. Autogenic, allogenic and xenogenic tendon transplantation have been done in re-
constructive tendon surgery.
Karakurum previously (2003) showed that the ostrich has an excellent strength during biomechanical eval-
uations (Karakurum et al., 2003). They showed that flexor tendons of the ostrich are an excellent source of
tendons with good quality and have adequate length. There is no report on ostrich (xenograft) tendon trans-
plantation on the other species. Therefore, the purpose of this study was to evaluation of ostrich flexor ten-
don transplantation in rabbit model.

Seven male New Zealand Albino rabbits 1 year old and weighing 4.0±0.5 kg were used in this study. One
week old ostrich chicken cadavers were referred to the department of poultry science for diagnosis of nutri-
tional deficiency. Digital flexor tendons were retrieved aseptically through a paratendinous incision of ap-
proximately 5cm and then be transferred to a sterile container and cut and shaped immediately and pre-
served in sterile saline solution at -20º C. At the time of transplantation preserved tendons were thawed at
room temperature for about one hour(Scotish National Blood Transfusion Service (SNBTS) Tissue Service,
2005). About 3 cm of the superficial flexor tendon were resected and created defects were filled in all rab-
bits with 3 cm harvested ostrich chicken tendon and sutured with 2/0 polypropylene in a single Modified
Kessler suture pattern. After recovery, the operated leg was bandaged after operation and the rabbits were
kept in a restricted area individually to limit their movement. During the post-operative time, clinical pa-
rameters including appetite, activity, infection, bleeding and wound dehiscence were evaluated daily.
Fifteen weeks after operation the rabbits were euthanized pharmacologically for histopathological evalua-
tion. Histopathological evaluation was carried out on the all of rabbits. The graft tendon unit was resected
then fixed in 10% formalin. Two 5 micron thick sections were cut from the centers of each specimen and
were stained with Hematoxylin and Eosin. The sections were individually evaluated by pathologist blinded
to the treatment.
RESULTS
Clinical evaluation
All rabbits showed normal activity and appetite, and there was no evidence of clinical complications such as
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local infection or wound dehiscence. In all rabbits, the skin was freely movable across the implant site.
Gross evaluation
In the transplanted area, transplanted tendon was difficult to determine, without any continuity and solid
integration, with yellowish color appearance, graft contraction and degeneration
Histopathological finding
The main histopathological findings were observed in the all animals with xenograft consisted of graft necro-
sis and sequestration. A large number of macrophages or epithelioid cells, eosinophiles and foreign body
type giant cells were seen around the necrotic debris. These structures were surrounded with collagenous
connective tissue infiltrated by lymphocytes and plasma cells.
CONCLUSION
In overall, our results showed that ostrich tendon has sever antigenicity and elicit vigorous inflammatory reaction
and it is not recommended to use as a xenogenic tendon graft for the replacement of tendons or ligaments.
G.A. Kojouri WVOC 2010, Bologna (Italy), 15th - 18th September • 584
REFERENCES
1. Karakurum G, G?Le A, B?Y?Kbebeci O and Karadag E (2003) The ostrich: an excellent tendon source for the bio-
mechanical studies. G?Lhane Medical Journal, 45 180 - 181.
2. Scotish National Blood Transfusion Service (SNBTS) Tissue Service, 2005. Instructions for thawing and use of ten-
don products., Edinburgh.
Prof. Gholam Ali Kojouri - School f Veterinary Medicine, Shahrekord University Clinical Sciences, Saman Road,
Shahrekord, Pobox 115, Iran - E-mail drgholam_alikojouri@yahoo.com
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585 • WVOC 2010, Bologna (Italy), 15th - 18th September T. Lescun
Use of hydroxyapatite pin coating for the prevention

of transfixation pin loosening in horses
T. Lescun, BVSc, MS, D. Baird, DVM, PhD, G. Moore, DVM, PhD
Department of Veterinary Clinical Sciences, Purdue University, West Lafayette, IN, USA
INTRODUCTION
Fractures in the horse, despite recent advances, continue to be challenging for veterinarians to treat and re-
sult in significant wastage in the equine industry. Transfixation casting has been used to treat complicated
distal limb fractures in the horse where other methods had previously failed.1 However, pin loosening and
pin hole fractures currently limit its use. Hydroxyapatite (HA) coatings have been used to promote osteoin-
tegration and ultimately prevent loosening of various orthopedic implants, including external fixation pins
in humans,2,3 however their use in horses has not been evaluated. We previously compared the insertion
characteristics of two different HA coatings on large animal transfixation pins during insertion into cadav-
eric equine bone.4 A solution precipitated nanoHA coating was subsequently chosen for in vivo evaluation.
The aim of the present study was to determine the extent to which this HA coating, prepared on standard
stainless steel transfixation pins, promotes osteointegration in the horse during transfixation casting over an
8 week period. We hypothesized that HA coating of transfixation pins would improve pin osteointegration
in the equine third metacarpal bone under full weight-bearing conditions relative to uncoated transfixation
pins over an 8-week period.

Fourteen adult horses were divided into 2 groups - an uncoated (UC) and an HA coated pin group. Three
transcortical pins (either UC or HA) were placed in one third metacarpal bone of each horse and incorpo-
rated into a standard short limb cast. Pin locations were designated 1,2 and 3 from proximal to distal. A
foam spacer was placed beneath the foot to ensure full load bearing on pins. End-insertional torque meas-
urements were made following pin insertion. Radiographs were taken of the third metacarpal bone pre- and
immediately post-operatively and at 4 and 8 weeks. Extraction torque was measured for each pin 8 weeks
following placement. All pins and pin holes were cultured and bone segments from 2 horses in each group
underwent histological evaluation. Insertion torque, extraction torque, torque difference and percentage of
cortical radiolucency data were normally distributed and evaluated using ANOVA. Positive pin culture rate
was compared between groups using Fishers Exact test. Differences between groups were considered signif-
icant when p < 0.05.
RESULTS
All horses used the transfixation casts well following placement and completed the study. Extraction torque
of the UC pins was 64%, 69% and 43% lower than insertion torque at pin locations 1, 2 and 3, respective-
ly. This reduction in torque was significant at pin locations 1 and 2 (p < 0.05). In contrast, in the HA group,
extraction torque was 98% and 180% higher than insertion torque at pin locations 1 and 3, respectively,
while at pin location 2, extraction torque was 54% lower than insertion torque (p < 0.05). A large amount
of variability in the extraction torque data was present in the HA group due to an “all or nothing” effect of
osteointegration, with one-third of pins maintaining or increasing torque (up to 8-fold) and the remaining
two-thirds decreasing torque over the 8 week study period. Obvious radiographic osteopenia was evident
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below the transfixation pins in all horses by week 8. The percentage of cortical radiolucency increased sig-
nificantly from week 0 to week 8 for pin location 2 in the UC group (p<0.05). There was a significant in-
crease in percentage of cortical radiolucency in the HA group at all pin locations (p<0.05). Overall positive
culture rate for the HA group (83%) was not significantly different from the UC group (87%). Histological
results showed no adverse effects of the hydroxyapatite coatings and evidence of pin tract infection of vari-
ous degrees of severity in both groups.
CONCLUSION
Results of this study show that HA coating of transcortical pins in the horse can result in osteointegration
of the pins. Evidence for this was an increase in pin torque measurements from insertion to extraction in
one-third of the HA pins compared to consistent loss of torque in the UC pins. Positive culture rate was not
different between groups and pin tract infections potentially limited the effectiveness of the HA coating to
promote osteointegration at individual pin sites. The “all or nothing” effect observed following an 8 week
T. Lescun WVOC 2010, Bologna (Italy), 15th - 18th September • 586
casting period may also reflect the rigorous nature of the fully weight-bearing equine model used in this
study. Further evaluation of methods to prevent pin tract infections while utilizing HA pin coatings as well
as other pin coating strategies as a method to prevent pin loosening in horses is warranted.
REFERENCES
1. Lescun TB, McClure SR, Ward MP, Downs C, Wilson DA, Adams SB, Hawkins JF, Reinertson EL (2007), Eval-
uation of transfixation casting for treatment of third metacarpal, third metatarsal, and phalangeal fractures in hors-
es: 37 cases (1994-2004), J Am Vet Med Assoc. 230: 1340-1349.
2. Moroni A, Cadossi M, Romagnoli M, Faldini C, Giannini S (2008), A biomechanical and histological analysis of
standard versus hydroxyapatite-coated pins for external fixation, J Biomed Mater Res B Appl Biomater. 86B: 417-
421.
3. Pommer A, Muhr G, David A (2002), Hydroxyapatite-coated Schanz pins in external fixators used for distraction
osteogenesis: a randomized, controlled trial, J Bone Joint Surg Am. 84-A: 1162-1166.
4. Zacharias JR, Lescun TB, Moore GE, Van Sickle DC (2007), Comparison of insertion characteristics of two types
of hydroxyapatite-coated and uncoated positive profile transfixation pins in the third metacarpal bone of horses, Am
J Vet Res 68: 1160-1166.
Dr. Timothy Lescun - Purdue University Veterinary Clinical Sciences, 625 Harrison St,
47907 West Lafayette (IN), United States - E-mail tlescun@purdue.edu
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587 • WVOC 2010, Bologna (Italy), 15th - 18th September D. Lewis
A biomechanical evaluation of the effect of three drop wire

configurations on the stiffness of single ring external
fixator constructs
J. Arango, Veterinary Student1, D. Lewis, DVM, Diplomate ACVS1, C. Hudson, DVM1,
M.B. Horodyski, EdD, ATC2
1
College of Veterinary Medicine, Department of Small Animal Clinical Sciences, University of Florida, Gainesville, FL,
United States
2
College of Medicine, Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, United States
INTRODUCTION
Drop wires are often used when applying circular and hybrid external fixator constructs. Typically two wires
are placed as fixation elements on each ring in any construct, with one wire secured directly to each surface
of the ring. Drop wire is a term used to describe an additional wire (or wires) placed remote to the surface
of the ring. Drop wires are used to improve construct stability, particularly when stabilizing juxta-articular
fracture or osteotomy segments that are too short to accommodate stabilization by a second ring. The pur-
pose of this study was to evaluate three methods of adding a drop wire on a single ring construct and to the
compare axial, bending and torsional stiffness of each drop wire construct to both a single and two ring con-
struct. Our hypotheses were 1) addition of any drop wire would increase the axial, bending and torsional
stiffness of a single ring construct; 2) bending and torsional stiffness would increase as the distance the drop
wire was positioned away from the surface of the ring increased, and; 3) drop wire constructs would have
similar bending and torsional stiffness as the two ring construct.

All constructs were made with 66 mm diameter rings and 1.6 mm olives wires were used as fixation ele-
ments. The wires placed on opposing surfaces of the ring were placed at 60 degrees to one another with
drop wires placed to bisect this angle in the mediolateral plane. All wires were tensioned to 30 kg. A 16
mm diameter Delrin rod, positioned centrally in the ring, was used as a bone model. Eight replicates of
five different fixator constructs were loaded in axial compression, craniocaudal and mediolateral bending
and torsion using a materials testing system.
The five constructs tested were: 1) the base single ring construct with two opposing olive wires attached
directly to opposing surfaces of the ring; 2) the base single ring construct with a drop wire secured by fix-
ation bolts with four washers placed subjacent to the wire, positioning the drop wire 5.5 mm from the sur-
face of the ring; 3) the base single ring construct with a drop wire secured by fixation bolts secured in one-
hole posts, positioning the drop wire 10.5 mm from the surface of the ring; 4) the base single ring construct
with a drop wire secured by fixation bolts secured in two-hole posts, positioning the drop wire 24 mm from
the surface of the ring; and 5) a two ring construct, the distance between the rings being 25 mm, with two
opposing olive wires attached to opposing surfaces of each ring.
The stiffness of each construct was determined by the slope of the linear portion of the load/displacement
curve generated during each loading trial and the mean±SD stiffness was determined for each construct
for each mode of loading. The stiffness for each construct was compared using an analysis of variance with
a p-value ≤ 0.05 considered significant.
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RESULTS
The mean±SD stiffness results for the five constructs tested are summarized below. Parameters for con-
structs subjected to the same mode of loading with different superscripts were found to be significantly dif-
ferent (p≥0.05).
Axial Compression (N/mm): Single Ring 287.08 ± 3.98a; Fixation Bolt Drop Wire 301.15 ± 4.45b; One
Hole Post Drop Wire 300.62 ± 8.12b; Two Hole Post Drop Wire 302.33 ± 4.97b; Two Ring 363.71 ± 7.11c
- Thus all drop wire constructs were significantly stiffer than the single ring construct; however, there was
no significant differences between drop wire constructs. The two ring construct was significantly stiffer than
all other constructs.
Craniocaudal Bending (N*m/degree): Single Ring 0.64 ± 0.03a; Fixation Bolt Drop Wire 0.74 ± 0.04a; One
Hole Post Drop Wire 0.83 ± 0.03a; Two Hole Post Drop Wire 1.38 ± 0.08b; Two Ring 5.73 ± 0.57c - Thus
the single ring, fixation bolt drop wire and one hole post drop wire constructs were not significantly differ-
D. Lewis WVOC 2010, Bologna (Italy), 15th - 18th September • 588
ent; however, the two hole post drop wire construct was significantly stiffer than those three constructs. The
two ring construct was significantly stiffer than all other constructs.
Mediolateral Bending (N*m/degree): Single Ring 0.62 ± 0.05a; Fixation Bolt Drop Wire 1.73 ± 0.31b; One
Hole Post Drop Wire 2.51 ± 0.18c; Two Hole Post Drop Wire 4.78 ± 0.23e; Two Ring 4.34 ± 0.30d – Thus
the one hole post drop wire construct was significantly stiffer than the fixation bolt drop wire construct,
which was significantly stiffer than the single ring construct. The two hole post drop wire construct was sig-
nificantly stiffer than the other four constructs and the two ring construct was significantly stiffer than the
single ring, fixation bolt drop wire and one hole post drop wire constructs.
Torsion (N*m/degree): Single Ring 0.67 ± 0.06a; Fixation Bolt Drop Wire 0.83 ± 0.02b; One Hole Post
Drop Wire 0.85 ± 0.02b; One Hole Post Drop Wire 0.88 ± 0.02b; Two Ring 1.13 ± 0.04c - Thus all drop
wire constructs were significantly stiffer than the single ring construct, but there were no significant differ-
ences between the drop wire constructs. The two ring construct was significantly stiffer than the other four
constructs.
CONCLUSION
Our results corroborate the findings of a prior study reported by Cross et al. which established that addi-
tion of a drop wire, which was secured to a single ring using one hole posts, can improve fixator stiffness.
While the addition of a drop wire improves axial and torsional stiffness, the distance the drop wire was po-
sitioned away from the surface of the ring did not have a significant effect on axial stiffness. To improve cran-
iocaudal bending stiffness of a single ring construct, the drop wire needs to be placed a substantial distance
from the surface of the ring which was only accomplished in this study using a drop wire mounted on two
hole posts. The drop wires were very effective in improving mediolateral bending because the wire was
placed in the plane of bending and there was a significant increase in this effect the further the drop wire
was positioned from the surface of the ring. A drop wire positioned on a two hole post actually provided
greater resistance to mediolateral bending than the two ring construct. The results of this study provide use-
ful information to assist surgeons during the application of circular and hybrid constructs. During testing we
observed that the use and position of olive wires had a substantial effect on resisting the applied force and
we strongly advocate the clinical use of olive wires. Because ring diameter is the most important parameter
effecting the biomechanics of any circular or hybrid construct, further studies should be done using 50, 84
and 118 mm diameter rings to confirm that the findings of this study, which used 66 mm diameter rings,
apply to other diameter rings commonly used in small animal practice.
REFERENCES
1. Lewis DD, et al. Biomechanics of circular external skeletal fixation. Vet Surg 27:454-464, 1998.
2. Lewis DD, et al. Axial characteristics of circular external skeletal fixator single ring constructs. Vet Surg 30:386-
394, 2001.
3. Cross AR, et al. Effect of various distal ring-block configurations on the biomechanical properties of circular exter-
nal skeletal fixators for use in dogs and cats. Am J Vet Res 65:393-398, 2004.
Dr. Daniel Lewis - College of Veterinary Medicine, University of Florida, 2015 SW 16th Ave, Box 100126,
32610 Gainesville (FL), United States - E-mail lewisda@vetmed.ufl.edu
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589 • WVOC 2010, Bologna (Italy), 15th - 18th September D. Millis
Effect of extracorporeal shock wave therapy on elbow

osteoarthritis in dogs
D. Millis, DVM, DACVS, CCRP, DACVSMR, M. Drum, DVM, PhD, D. Whitlock, PT, DVM
University of Tennessee College of Veterinary Medicine, Knoxville, TN, USA
INTRODUCTION
Osteoarthritis (OA) is a progressive degenerative process of synovial joints and management is multifaceted.
New modalities to manage OA are regularly promoted, but there is little objective evidence of efficacy for
many modalities. Extracorporeal shock wave therapy (ESWT) has been used to treat selected muscu-
loskeletal disorders in humans and animals, including OA. There are few studies evaluating the use of
ESWT in clinical canine patients. The purpose of the study reported here was to evaluate the efficacy of
ESWT in the management of canine elbow OA. We hypothesized that ESWT would have a positive effect
on ground reaction forces and clinical parameters of lameness.

Fifteen skeletally mature dogs with elbow OA, confirmed radiographically, were evaluated. Diet, exercise,
and other treatments were maintained the same throughout the study. Dogs were randomly assigned to a
treated or sham treatment group. Evaluations included subjective gait evaluations at a trot and walk; com-
fortable range of motion measurements; and determination of ground reaction forces at a trot. Two baseline
analyses were obtained to be certain that the degree of lameness was stable. If both elbows were arthritic,
only the more affected limb was selected for treatment. ESWT treatments were administered on days 0 and
14 under sedation. Joints received 240 pulses/min for a total of 500 pulses using a 5 mm focused probe, with
the pulses divided and applied equally to the proximomedial, distomedial, proximolateral, and distolateral
joint capsule insertion points. The energy flux density used was 0.13mJ/mm2. All dogs were evaluated on
days 0, 14, and 28. Data were evaluated using ANOVA with treatment and time as factors. Significance was
set at P<0.05.
RESULTS
Dogs generally tolerated treatment well. There were mild improvements in outcome parameters in dogs re-
ceiving treatment. ESWT resulted in a 3.3% increase in peak vertical force (81.5±4.35 to 83.8±4.33, as a
percent body weight) compared with a decrease of 5.4% (80.8±6.02 to 76.4±5.64, as a percent body weight)
in sham treated dogs (P<0.01). There were no differences in vertical impulse. Mean lameness scores im-
proved marginally at the walk with ESWT (2.1±0.3 to 1.7±0.3) versus deterioration with sham treatment
(2.0±0.4 to 2.2±0.5)(P<0.01), and remained mainly unchanged at the trot. Comfortable ROM remained ap-
proximately the same with ESWT, while it decreased 70 in sham treated dogs (P<0.01).
CONCLUSION
ESWT is a relatively new modality in small animal practice to treat OA. Elbow OA is particularly chal-
lenging to manage, and the cases in this series were moderately lame and most dogs were already receiving
standard therapy. The improvement in peak vertical force and lameness scores in this study are similar to
what might be expected with NSAIDs or other treatments. ESWT appears to be an efficacious addition to
the multimodal approach to OA of the elbow.
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REFERENCES
J Dahlberg, G Fitch, RB Evans, SR McClure, M Conzemius. The evaluation of extracorporeal shockwave therapy in nat-
urally occurring osteoarthritis of the stifle joint in dogs. Vet Comp Orthop Traumatol 2005;18:147-52.
M Mueller, B Bockstahler, M Skalicky, E Mlacnik, D Lorinson. Effects of radial shockwave therapy on the limb function
of dogs with hip osteoarthritis. Veterinary Record 2007; 160:762-765.
Dr. Darryl Millis - University of Tennessee College of Veterinary Medicine, 8309 Birch Run Lane,
37919 Knoxville, TN, United States - E-mail boneplate@aol.com
D. Millis WVOC 2010, Bologna (Italy), 15th - 18th September • 590
Kinematic analysis of stair and decline slope walking

of the pelvic limb in healthy dogs
R. Millard, DVM, D. Millis, DVM, DACVS, CCRP, DACVSMR, J. Hearick, DVM
University of Tennessee College of Veterinary Medicine, Knoxville, TN, USA
INTRODUCTION
Joint range of motion (ROM) is important in performing activities of daily living and can be a component
of physical rehabilitation in dogs with orthopedic disease. The purpose of this study was to evaluate range
of motion of the pelvic limb in healthy dogs descending stairs compared to decline slope walking. We hy-
pothesized that ROM would be greater during stair descent than decline slope walking.

A set of custom-made stairs was constructed with the following dimensions: rise of 17.78 cm, run of 25.4 cm
and width of 91.4 cm. A removable ramp was constructed to fit snuggly over the stairs to create a continu-
ous slope equal to that of the stairs. Seven healthy adult dogs free of orthopedic and neurologic disease were
fitted with reflective spheres that were placed on the ischiatic tuberosity, tuber sacrale, greater trochanter, lat-
eral epicondyle, lateral malleolus and head of fifth metatarsal bone of the right pelvic limb. Each dog was
trained to walk down the stairs and ramp at a comfortable pace. Five trials of stair and ramp descent of each
dog were recorded using four 60Hz digital infrared cameras. Maximum and minimum joint angles and range
of motion for the coxofemoral, femorotibial and tibiotarsal joints were calculated using commercially avail-
able software (Vicon, Inc). Data were analyzed using paired t-test with statistical significance set at p < 0.05.
RESULTS
Greater joint extension and flexion occurred in the pelvic limb during stair descent compared to decline
walking. Compared with decline slope walking, dogs walking down stairs had significantly greater stifle flex-
ion (62.1° vs 76.6°, p= 0.001) and hock flexion (61.4° vs 76.7°, p= 0.004) and extension (159.3° vs 152.4°,
p= 0.01). ROM was significantly increased in the stifle (96.2° vs 79.9°, p < 0.001) and hock (97.9° vs 75.7°,
p < 0.001) joints during stair descent compared to decline walking. Maximum extension and flexion of the
hip joint were not significantly different, however, ROM of the hip was significantly greater when descend-
ing stairs (27.2° vs 22.8°, p= 0.04).
CONCLUSION
Healthy dogs walking down stairs generally demonstrated greater ROM in the pelvic limb compared to de-
cline slope walking. The hock and stifle joints play an important role in stair descent. Stair descent may be
a beneficial rehabilitative exercise for dogs with orthopedic disease. Conversely, in dogs with significant dis-
ability, dogs may find it easier to walk down a slope rather than stairs if there is loss of ROM due to con-
ditions such as osteoarthritis. Further studies are needed to evaluate ROM of dogs with orthopedic disease
descending stairs, to demonstrate the effectiveness of stair descent as a rehabilitative exercise. The decline
walking slope used in this study subjectively appeared to be greater than what may be used for rehabilita-
tive exercises; however it was selected because it had a slope equal to that of the stairs. Further studies of
varying degrees of slope are needed to evaluate the effect of descending a more gradual slope.
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REFERENCES
Bennett RL, DeCamp CE, Flo GL, et al. Kinematic gait analysis in dogs with hip dysplasia. Am J Vet Res 1996;57:966-
971.
DeCamp CE, Soutas-Little RW, Hauptman J, et al. Kinematic gait analysis of the trot in healthy greyhounds. Am J Vet
Res1993;54:627-634.
DeCamp CE, Riggs CM, Olivier NB, et al. Kinematic evaluation of gait in dogs with cranial cruciate ligament rupture.
Am J Vet Res 1996;57:120-126.
Tashman S, Anderst W, Kolowich P, Havstad S, Arnoczky S. Kinematics of the ACL-deficient canine knee during gait:
serial changes over two years. Journal of Orthopaedic Research 22 (2004) 931-941.
Dr. Darryl Millis - University of Tennessee College of Veterinary Medicine, 8309 Birch Run Lane,
37919 Knoxville, TN, United States - E-mail boneplate@aol.com
591 • WVOC 2010, Bologna (Italy), 15th - 18th September H.R. Moslemi
Study of the effects of hydroxyapatite on fracture healing

of diabetic rats
H.R. Moslemi, DVM, PhD, B. Tabari, DVM, PhD, M. Ahmadi, DVM
Dept of Surgery and Radiology, Faculty of Veterinary Medicine, Islamic Azad University, Garmsar Branch, Garmsar, Iran
INTRODUCTION
Fracture healing is a process of restoring the structural and biological properties of injured bone. Osteope-
nia is one of the most common complications in diabetic patients. Diabetic osteopenia has been reported in
many clinical human and experimental animal studies. Typical fi ndings in these patients are alterations in
calcium, phosphate and bone metabolism, and reduced bone biomechanical properties The calcium phos-
phate group is the largest, most important inorganic part of the hard tissues constituting bones and dentine
material in vertebrate animals. Synthetic calcium phosphate or hydroxyapatite (HA) has been shown to be
quite similar to the natural component of bone. It has several medical applications, such as the appropriate
replacement of bony and periodontal defects. The purpose of this study was to evaluate the effects of HA
on fracture healing in diabetic rats.

Twenty-four male Sprague Dawley rats (243 ± 17.1 g and 3 months old) were housed at a temperature of
(22 ± 2 ºC) in an airconditioned room and supplied with standard pellet food with tap water ad libitum.
All rats received humane care according to the criteria outlined in the “Guide for the care and use of lab-
oratory animals” prepared by the National Academy of Science and published by the National Institutes of
Health. The rats were divided randomly into four equal groups: a non-diabetic HA treated group
(NDRHA), a non-diabetic non-treated with HA (NDR) group, a diabetic HA treated group (DRHA) and a
diabetic group non-treated with HA (DR). Diabetes mellitus was induced in 2 groups by the intraperitoneal
injection of alloxan at the dose of 165-mg/kg body mass.
RESULTS
Radiographic signs of bone healing of groups DRHA and NDR were relatively same. These signs in group
NDRHA were higher and in groups DR were lower. In histological finding, healing process in non-diabet-
ic HA treated group (NDRHA) was higher rate while in groups DRHA and NDR were moderate and in
diabetic group non-treated with HA was low.
CONCLUSION
In conclusion, this study shows that application of hydroxyapatite has the positive effects on the fracture
healing process of diabetic rats.
REFERENCES
1. Beam HA, Parsons JR, Lin SS. (2002) The effects of blood glucose control upon fracture healing in the BB wistar
rat with diabetes mellitus. J Orthop Res; 20: 1210-1216.
2. Caria PHF, Kawachi EY, Bertran CA, Camilli JA. (2007) Biological assessment of porous-implant hydroxyapatite
combined with periosteal grafting in maxillary defects. J Oral Maxillofac Surg; 65: 847-854.
3. Fang L, Gao P, Leng Y. (2007) High strength and bioactive hydroxyapatite nano-particles reinforced ultrahigh mo-
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lecular weight polyethylene. Composites: Part B; 38: 345-351.

4. Funk JR, Hale JE, Carmines D, Gooch HL, Hurwits SR. (2000) Biomechanical evaluation of early fracture heal-
ing in normal and diabetic rats. J Orthop Res; 18: 126-132.
5. Zhao DM, Liu ZH, Wu SO, Li AM, Zhao JJ, Wang P, Sun KN. (2006). Biocompatibility of carbon nanotubes/hy-
droxyapatite composite with tibia of rabbit. Chinese J Biomed Eng; 25(3): 342-345.
Dr. Hamid Reza Moslemi, Dept of Surgery and Radiology, Faculty of Veterinary Medicine,
Islamic Azad University - Garmsar Branch, Semnan, Garmsar, Iran - E-mail moslemi34@yahoo.com
P. Murison WVOC 2010, Bologna (Italy), 15th - 18th September • 592
Postoperative analgesic efficacy of meloxicam compared to

tolfenamic acid in cats undergoing orthopaedic surgery
P. Murison, BVMS DipECVAA DVA MRCVS1, S. Tacke, PD DVM PhD2, C. Wondratschek,
DVM DrVetMed3, I. MacQueen, BVetMed CertSAO MRCVS4, H. Philipp, DVM DrVetMed5,
R. Narbe, DVM DrVetMed5, L. Brunnberg, PD DVM PhD3
1
Department of Clinical Veterinary Science, University of Bristol, Bristol, UK
2
Department for Veterinary Clinical Sciences, Justus-Liebig-University, Giessen, Germany
3
Clinic of Small Animals, Faculty of Veterinary Medicine, Free University of Berlin, Berlin, Germany
4
MacQueen Veterinary Centre, Devizes, UK
5
Boehringer Ingelheim Vetmedica, Ingelheim-am-Rhein, Germany
INTRODUCTION
Several non-steroidal anti-inflammatory drugs (NSAIDs) are now licensed for use in cats, including meloxi-
cam and tolfenamic acid. NSAIDs inhibit prostaglandin production from arachidonic acid by affecting cy-
clooxygenase (COX) enzymes. Meloxicam and tolfenamic acid have been compared in cats undergoing
ovariohysterectomy (Benito-de-la-Vibora et al, 2008) but not after orthopaedic surgery.
The aim of this study was to compare the efficacy of tolfenamic acid (Tolfedine®) and meloxicam (Meta-
cam®) in cats undergoing surgery for fracture repair, including the immediate post-operative period and four
subsequent days.

This was a positive-controlled, blinded, randomised, multicentre study. Cats 2-12 kg in weight and aged over
6 weeks admitted for fracture repair were eligible for inclusion. A venous blood sample was taken on the
day before or on the day of surgery (day 0 or 1) for measurement of alkaline phosphatase, alanine amino-
transferase, aspartate aminotransferase, bilirubin, urea and creatinine. Cats were randomly allocated to one
of two groups (M or T) according to a pre-prepared protocol, grouping cats with different fracture sites (fore-
limb, hindlimb or pelvic) to ensure even distribution between treatment groups. Before surgery, cats were
assessed by a pain assessor (unaware of treatment group). A pain score was allocated using a visual analogue
scale (VAS) (0mm = “no pain”, 100mm = “worst pain imaginable”). Function of the affected limb was as-
sessed and a score assigned (1 = no signs of lameness, 2 = noticeably lame but weight bearing, 3= only oc-
casionally weight-bearing, 4= non-weight-bearing). In group M, 0.2mg/kg meloxicam (Metacam®) was giv-
en by subcutaneous injection before premedication and anaesthesia. On days two to five group M received
0.05mg/kg meloxicam oral suspension once daily. In group T, tolfenamic acid (Tolfedine®) tablets were ad-
ministered orally at 1.5 - 3 mg/kg twice daily; the first dose was given before premedication and anaesthe-
sia. The investigational product (pre- and post-operatively) was given by a drug administrator separate from
the pain assessor to maintain blinding. Pre-anaesthetic medication and anaesthesia were carried out accord-
ing to the individual hospital protocol. Intravenous fluid therapy and antibiotic cover were provided. The
duration of surgery was recorded.
In recovery, pain assessments of the cats consisted of VAS scoring at 1, 2, 3, 4, 6 and 8 hours after extuba-
tion, with limb function assessed in addition If at any point the cat was deemed to be excessively painful,
‘rescue’ analgesia was given (opioids chosen by individual hospital). Use of rescue analgesia was recorded.
Twice daily assessments included allocating function of limb and VAS pain scores. Palatability of the test
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product was scored (1= excellent [no resistance of the cat to treatment], 2= good [acceptance by the cat with
slight resistance], 3 = satisfactory [moderate resistance to dosing] and 4= poor [ strong resistance]) and food
intake (1= voluntary feed intake, 2= feed intake following stimulation such hand feeding, 3= no feed in-
take). Final pain and feed intake scores were performed on the morning of day 6 and a second blood sam-
ple taken for biochemistry (as before).
Area under the curve (AUC) for VAS was calculated for each cat over time and a mean for each group was
calculated. The AUC for VAS were compared between treatment groups using a one-sided 97.5% confidence
interval approach with analysis of variance (factor ‘group’ and pre-surgery VAS as covariate). Meloxicam
was said to be non-inferior to tolfenamic acid if the upper bound of the one-sided 97.5% confidence interval
for the difference (meloxicam scores – tolfenamic acid) was less than the equivalence margin d= 750 over 5
days. Function of the affected limb, frequency of rescue analgesia, feed intake and palatability of meloxi-
cam/tolfenamic acid were compared using a 2-sided Wilcoxon Mann-Whitney test (p=0.05 taken as signifi-
cant). Data are expressed as mean (standard deviation).
593 • WVOC 2010, Bologna (Italy), 15th - 18th September P. Murison
RESULTS
Data from 66 cats were analysed, excluding those receiving rescue analgesia or prematurely withdrawn from
the study for any reason. Time between fracture occurrence and day of surgery was 4.03 (8.86) days in the
meloxicam group and 3.61 (3.51) days in the tolfenamic acid group. Surgical duration was 1.34 (0.66) hours
and 1.26 (0.58) hours respectively. Time from the end of surgery to extubation was 0.35 (0.16) and 0.41
(0.23) hours respectively. No significant difference in blood analyses between groups were found. Before sur-
gery, VAS scores were similar between treatment groups; M= 79.5 (16.94), T= 78.1 (20.67); and decreased
continuously over the study period in both treatment groups. Significant non-inferiority of meloxicam com-
pared to tolfenamic acid was demonstrated within the 95% confidence interval for all investigated Areas Un-
der the Response Curve (AUC1 – 2 days, AUC1 – 3 days, AUC1 – 4 days, AUC1 – 5 days and AUC1 –
6 days) indicating a similar analgesic effect in both treatment groups. There were no significant differences
in limb function scores between the treatment groups on any day (p varied between 0.909 [Day 1, 8h after
extubation] and 0.151 [Day 2]). In group M, 4 cats required rescue analgesia and in group T, 6 cats required
rescue analgesia. There was no statistically significant difference in feed intake over the study period
[p=0.098 (Day 6) - 0.860 (Day 2)] but palatability was significantly greater in group M (p=0.002-0.039).
CONCLUSION
Treatment with meloxicam or tolfenamic acid pre-operatively and for four days post-operatively provided
effective analgesia for most cats undergoing orthopaedic surgery, with no clinically obvious side effects not-
ed. Meloxicam (Metacam®) may be associated with superior compliance in clinical practice due to the high-
er palatability and once daily treatment, which result in better ease of administration.
REFERENCES
Benito-de-la-Víbora, J., Lascelles, B.D.X., García-Fernández, P., Freire, M. & Gómez de Segura, I. A. (2008) Efficacy of
tolfenamic acid and meloxicam in the control of postoperative pain following ovariohysterectomy in the cat. Vet-
erinary Anaesthesia and Analgesia 35, 501-510.
Ms. Pamela Murison - University of Bristol, Langford House, Langford, Bristol, BS40 5DU, United Kingdom
E-mail pamela.murison@bris.ac.uk
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J. Park WVOC 2010, Bologna (Italy), 15th - 18th September • 594
Cytotoxicity of contrast media iohexol for arthrography

on bovine chondrocytes
G. Hong, BSc, DVM, J. Park, BSc, DVM, S. Choi, PhD, DVM, G. Kim, PhD, DVM
Department of Veterinary Surgery, College of Veterinary Medicine, Chungbuk National University, Cheongju,
Chungbuk, South Korea
INTRODUCTION
Iodinated contrast media is widely used in angiography and computerized tomography. Intra-articular in-
jection of iohexol is the most popular for canine arthrography. The osmolality and ionic condition of con-
trast media are considered to play a role on cytotoxicities. Low osmolality and non-ionic contrast media have
been shown to have fewer toxic effects. In vitro toxic effects of iohexol (Low osmolality and non-ionic) were
however reported in vascular endothelial cells and renal cells recently by Heinrich et al. (2005). Although
there are many different pathogenetic mechanisms of cytotoxicity have been proposed, but none fully ex-
plaining the pathogenesis. The citotoxicity study of iohexol on chondrocytes is not reported in human and
veterinary medicine. The aim of this study was to determine the cytotoxic and metabolic effects of iohexol
on cultured bovine chondrocytes in clinical dose.

Full thickness of articular cartilage was aseptically harvested from the knee of a calf. They were digested
with 1 mg/ml collagenase in DMEM containing 63.5 µg/ml penicillin and 100 µg/ml streptomycin for 18
hours with gentle stirring. Chondrocytes were filtered through sterilized gauze and centrifuged at 200 ? g
for 5 minutes. The pellets were re-suspended and cultured with DMEM containing 10% FBS in a 75 cm2
cell culture dish. Culture medium was changed twice per week. The first passage cells were used in this ex-
periment. Chondrocytes were exposed to 50%, 25% and 12.5% iohexol and 50% mannitol for 2 hours. Os-
molality was measured by Micro-osmometer (Model 3300). Cell proliferation was detected by 3-(4,5-di-
methylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) colorimetric assay. The absorbance was meas-
ured at 570 nm by a microplate reader (Emax, Molecular Devices).
Apoptosis and necrosis of chondrocytes were analyzed with the double staining of Hoechst 33342 and pro-
pidium iodide using fluorescence microscopy. Both blue (hoechst) and red nuclei (propidium iodide) visual-
ized using the same UV filter. Metabolic changes were quantified by real-time PCR measurement of aggre-
can, collagen type I and II gene expression. Total RNA was isolated using Easy Blue (Intron Co.) and cD-
NA was synthesized by commercial kit. Data were presented as the means ± SE and analyzed by one-way
analysis of variance (ANOVA), followed by Tukey’s multiple comparison test. p<0.05 was considered to be
statistically significant.
RESULTS
The synovium facilitates rapid contrast media efflux from the joint. Iohexol was undectable at 3 hours post-
articular injection in a normal condition. Therefore, we decided that the concentration of iohexol was be-
low 50% and the exposure time was set for maximum 2 hours. To evaluate the effect of high osmolality on
chondroctyes, mannitol was applied in this study. Osmolality of iohexol (885 mOsm/kg) was lower than
mannitol (1013 mOsm/kg). Osmolalites of diluted iohexol were 592, 477 and 421 mOsm/kg at 50%, 25%,
12.5% iohexol respectively. Mannitol 50% was 828 mOsm/kg. The first passage cells were used in all ex-
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periments, and chondrocytes specific markers were sufficiently expressed such as aggrecan and collagen
type II in RT-PCR analysis. MTT results expressed as a percentage of control absorbance. The results of
MTT assay showed that 50% iohexol inhibited the proliferation of bovine chondrocytes at 2 hours cul-
turing, however the inhibition effect of mannitol was smaller than those of the 50% and 25% iohexol. The
percentage of live cells were 85.9±5.6, 91.8±4.6, 95.1±3.9 and 94.9±3.3 at 50%, 25%, 12.5% iohexol and
50% mannitol respectively. Dead cells stained with propidium iodide were significantly higher at 50% io-
hexol compared to control.
Propidium positive cells were found in 17.9±12.3%, 7.8±3.8%, 6.3±3.9%, 5.6±2.6% at 50%, 25% and 12.5%
iohexol and 50% mannitol respectively. Control was 2.0±0.6%. No significant iohexol-induced apoptotic
nuclei were observed in Hoechst stained cells at 50% iohexol. Strong mRNA expression of aggrecan and
collagen type II as specific markers of cartilage was observed in RT-PCR. In metabolic changes of chon-
drocytes, aggrecan and collagen type II were not affected by 50% iohexol exposure, as well as the degen-
erative marker of collagen type I.
595 • WVOC 2010, Bologna (Italy), 15th - 18th September J. Park
CONCLUSION
Iohexol induced chondrocytes necrosis rather than apoptosis for 2 hours culturing and showed the cytotoxic
effect with minimum relation to osmolality. Chondrocytes are surrounded by the abundant extracellular ma-
trix, therefore there may be a limitation of cell damages in healthy cartilage. However, the clinical use of io-
hexol should be aware of the risk for patients with cartilage disorders where cells could be exposed to io-
hexol directly.
REFERENCES
Heinrich M.C., Kuhlmann M.K., Grgic A., Heckmann M., Kramann B., Uder M. (2005) Cytotoxic effects of ionic high-
osmolar, nonionic monomeric, and nonionic iso-osmolar dimeric iodinated contrast media on renal tubular cells in
vitro. Radiology 235(3), 843-849.
Prof. Gonhyung Kim - Chungbuk National University Department of Veterinary Surgery, 12 Gaeshin-Dong,
Heungduk-Gu, Cheongju, Chungbuk 361-763, South Korea - E-mail ghkim@cbu.ac.kr
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R. Pandey WVOC 2010, Bologna (Italy), 15th - 18th September • 596
Clinical management of fractured tibia in a bull

with the use of interlocking nail without reaming
R. Pandey, BVSc, MVSc, PhD, D. Kumar, BVSc, MVSc, G. Kumar, BVSc, MVSc,
P. Katiyar, BVSc, MVSc, B. Singh, BVSc, MVSc, PhD
Department of Surgery & Radiology, College of Veterinary Science, Pt. DDU Veterinary and Animal Science University,
Mathura, INDIA
INTRODUCTION
Long bone fracture management in fully grown adult bovine continues to be a frustrating clinical situation.
Successful fracture healing depends on maintaining soft tissue viability, minimizing trauma and stable fixation.
Closed intramedullary interlocking nailing technique under imaging guidance, is claimed to be the method of
choice if proximal and distal extremities of the bone involved are intact. In veterinary subjects, interlocking
nails with or without reaming have been investigated for neonatal bovine femoral and equine humeral and tib-
ial fractures. Similarly, evaluation of intramedullary interlocking nailing for stabilization of transverse femoral
osteotomies has been done in foals (McClure, et al., 1998) but successful implementation of this technique in
fully grown adult bovine has not been done. Successful management and long term follow-up of tibial fracture
in a fully grown adult bull with closed interlocking nailing without reaming is described hereunder.

In vitro feasibility study of immobilizing mid tibial fractures in fully grown adult was done in a specimen of
adult tibia and in freshly died carcasses before implementing the technique in clinical cases. A tubular in-
terlocking nail of 28cm x 12mm dimensions with a prebending at the level of proximal third, 3mm x 62 mm
and 3mm x 52 mm screws were used for management of closed transverse fracture of distal third diaphysis
of the Tibia in a bull aged 4 years. The bull was restrained in right lateral recumbency with the affected left
limb up after attaining epidural anaesthesia using 2% Lignocaine hydrochloride solution and sedation using
Xylazine @ 0.05 mg per Kg body weight. Through a 5 cm incision in the groove between anterior and me-
dial patellar tendons entry portal at the anterior end of the anterior meniscal ligament was made with a
curved awl under C-arm guidance. Using a jig, the tubular nail was introduced in the proximal fractured
segment through the entry portal up to the level of proximal fractured end. Closed reduction of the frac-
tured ends of tibia was achieved by applying manual traction, rotation and translation. After reduction, the
nail was driven further into the distal segment upto distal epiphysis. Proximal locking of the nail was
achieved with a single transcortical screw (3mm x 60mm) with the help of insertion jig and a distal transcor-
tical screw (3mm x 40 mm) locking was achieved with C-arm imaging guided free hand technique.
RESULTS
On the day following surgery, the bull was able to get up unsupported and was partially supporting weight
on the operated limb. Post operatively, only analgesics were administered for three days and the entry por-
tal suture line was cleaned and dressed with povidone iodine. The healing was eventless. The bull was able
to bear weight partially and walk within one week. Normal ambulation occurred within 45 days. Complete
bone healing occurred in about 2 months. The case was followed for a period of eight months. The range
of motion (ROM) of joints was not affected and the tibial axis also remained normal negating any possibil-
ity of bending of the nail or implant failure due to weight of the animal.
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CONCLUSION
Closed interlocking nailing of tibia prevents loss of fracture haematoma, causes minimal changes in the in-
ternal environment at fracture site, low risk of infection, minimum soft tissue surgical trauma, and rigid im-
mobilization thereby ensuring early union. Eventless healing makes the technique worth recommending for
management of similar cases in adult bovines in veterinary practice.
REFERENCES
McClure S.R., Watkins J.P., Ashman R.B. (1998). In vivo evaluation of intramedullary interlocking nail fixation of trans-
verse femoral osteotomies in foals.Vet Surg. Jan-Feb; 27(1): 29-36.
Corresponding Address: Dr. Deepesh Kumar - Pt. Deen Dayal Upadhayaya Veterinary and Animal Science University and
Cattle Research, Institute Department of Surgery & Radiology, College of Veterinary Science, Mathura,
Uttar Pradesh-281001, India - E-mail dr_deepesh@rediffmail.com
597 • WVOC 2010, Bologna (Italy), 15th - 18th September E. Panichi
Deformity reduction device (DRD JIG):

a new device for deformity corrections
E. Panichi, PhD1, A. Ferretti, ECVS3, F. Cappellari, PhD2, B. Peirone, PhD2
1
Libero professionista, Torino, Italy
2
Università, Torino, Italy
3
Libero professionista, Milano, Italy
INTRODUCTION
Distal femoral osteotomy (DFO) is an elective surgical procedure in patients affected by patellar luxation sec-
ondary to femoral deformity. Additional surgical techniques, such as tibial tuberosity transposition, trocleo-
plasty, soft tissue imbrication, can be added as necessary. The DFO is usually performed using a Slocum jig to
provide temporary fixation at the osteotomy site and to maintain the rotational alignment. The most critical is-
sue is bone segments instability following the osteotomy. To achieve stability during plate application, point re-
duction forceps can be used, along with Kirschner wires, temporarily inserted through the osteotomy. Tor-
sional correction can be achieved by Jig pin bending, in a fashion similar to that of the TPLO procedure. Nev-
ertheless the center of rotation will be located outside of the bone with translation of the bone segments.
The purposes of our study are:
1) To design a new jig, named Deformity Reduction Device (DRD), that is basically a hybrid external fix-
ator that can be applied to the bone by means of 4 pins (2 for each bone segment). The aim of the DRD
device is to allow predictable correction of complex deformities in dogs over 20 Kg and to provide ade-
quate temporary reduction of the osteotomy site during plate application.
2) To standardize the DFO surgical technique by means of the DRD.

1) Description of the DRD device:
a. Features and components:
- Length: 13/11cm
- Rod: diameter 4 mm, length 6 cm and 4 cm
- Hinge
- 120 ° slotted arch, inner diameter 70 mm
- Rotational mechanism of the arch
- Meynard clamps that allow placement of 2mm, 3mm and 4mm pins
b. Mechanical movements:
All the DRD components (rod, hinge and arch) can be moved precisely and independently through
the adjustment of micrometric screws.
Hinge: allows 120° of angulation of the rod towards the arch. Can be moved +-60° from neutral po-
sition (arch perpendicular to the rod). When the DRD-jig is applied on the frontal plane of the bone,
the hinge allows correction of varus and valgus deformity. The central screw of the hinge is cannu-
lated to permit the insertion of 1.5 mm K-wire that represent the Angulation Correction Axis (ACA).
Adjusting the dedicated micrometric screw, the hinge can be translated toward the arch medially or
laterally by as much as 3cm (+/-1,5cm), making it possible to change the position of the ACA.
Rod: It supports the two proximal pins, inserted in the femoral diaphyseal segment. Two clamps are
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used to connect the pins to the rod. By adjusting the dedicated retaining screw, the rod can be trans-
lated medially or laterally with a 3cm range of motion (+/-1.5cm). This translation mechanism is use-
ful to adjust fragments apposition before plate application.
Slotted arch: it allows 90° degrees of rotation, 45° clockwise and 45° counterclockwise from neutral. Two
pins are inserted from the arch in the para-throclear zone of the femur. To perform accurate rotational os-
teotomy without any translation, the center of the arch must be aligned with the center of the bone.
2) DFO by means of the DRD: Standardization of the surgical procedure.
Lateral closing wedge osteotomy (10° degrees) and internal torsional correction (10° degrees) has been
performed on 6 normal femurs of canine cadavers, ranging between 20 and 40 kg.
- Preparation of DRD jig: the device is prepared with the same amount of varus estimated upon ra-
diographic examination. Observing the femur on the frontal plane, the hinge must be placed at the
level of the CORA and can be translated medially or laterally to change the position of the ACA.
The rod must overlay the femoral anatomical axis.
E. Panichi WVOC 2010, Bologna (Italy), 15th - 18th September • 598
- Lateral approach to the femur and stifle

- Luxation of the patella
- Insertion of a 1.5 mm Kirschner wire at the the level of the ACA, calculated preoperatively. This pin
must be perpendicular to the cranial surface of the femur. The ACA is located tangent to the medi-
al cortex. For this reason the K-wire must be inserted as medial as possible.
- The DRD jig is positioned by passing the cannulated hinge screw on the K-wire.
- Four threaded pins are inserted through both cortices to achieve temporary fixation of the jig to the
bone: 2 pins proximally, with cranio-caudal direction, and 2 pins distally, on the epiphysis laterally
or medially to the trochlear notch.
- Insertion of the first 2 mm threaded negative profile pin with cranio-caudal direction in the center
of the bone at the level of the mid-shaft of the femur. Before tightening the clamp to secure the first
pin to the DRD, it is mandatory to check the jig’s correct positioning relative to the femur. Looking
at the femur from the axial view, care must be taken to positioning the distal part of the femur in
the center of the arch.
- A second pin is inserted with cranio-caudal direction through the muscles in the proximal part of the
femur. A clamp secures the pin to the rod.
- The third and fourth threaded pins are inserted from the arch to the para-troclear region of the fe-
mur on the same side (lateral or medial to the troclear notch), or one on each side. Clamp applica-
tion secures the pins to the arch.
- The lateral closing wedge osteotomy is performed with an oscillating saw, with entry from the lat-
eral side.
- The amount of correction can be achieved through the micrometric hinge screw and the graduate
scale.
- Rotational correction can be obtained by adjusting the arch screw
- Plate application
- Pins removal
RESULTS
The size of the animals and the surgical approach were both adequate for DRD application. The amount of cor-
rection planned was achieved with satisfactory reduction. The osteotomy site was stable during plate application.
CONCLUSION
This cadaveric study demonstrated the applicability of DRD to achieve predictable correction in the frontal and
axial plane. To avoid a wide surgical approach proximally, we found it preferable to insert a smooth pin through
the skin and muscle, instead of a threaded one. The two pins in the para-trochlearis region can both be applied
on the opposite side of the luxation to evaluate patellar reduction before plate fixation. If the amount of correc-
tion is not satisfactory, it is possible to modify the position of the segments through the use of the regulation
screws of the jig. The arch allow torsional correction while minimizing the translation of the segments because
the center of rotation is superimposed with the center of the bone. The application of the plate was performed
while the osteotomy site was in a stable condition without the use of reduction forceps. We believe that DRD
jig assisted surgery represents an effective alternative to standard techniques, achieving predictable correction of
the deformity. The surgeon can perform corrective ostetotomy to be consistent with the preoperative measure-
ments. Precise torsional correction can be achieved in a simple way through the graduate scale. The DRD can
be potentially applied in all types deformities, and in other anatomic segments as well. Similarly to human med-
icine, we think that the DRD could improve the precision and predictability of deformity correction. It’s known
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that deformity correction can be achieved with internal or external fixation. Both has advantages and disad-
vantages. The external fixation, especially through the Ilizarov method, could be considered more precise, bio-
logical and adjustable, in comparison with plate and screws fixation. On the other hand, the internal fixation
needs less post-operative management and leads to lower patient morbidity after surgery. Using temporary ex-
ternal fixation and definitive internal fixation allows the surgeon to link the advantages of both techniques.
REFERENCES
1. Kowaleski MP: Patellar Luxation - preoperative evaluation and surgical planning for femoral corrective osteotomy.
ESVOT proceedings 2006, pag. 87-90.
2. Brueker KA: Femoral corrective osteotomy for the treatment of medial patellar luxation - surgical technique. ES-
VOT proceedings 2006 pag. 34.
Corresponding Address: Dott. Enrico Panichi - Clinica AVAP Pinerolo, Ospedale Roma Sud, via Madre Teresa 8,
10064 Pinerolo (TO), Italy - E-mail enricopanichi@yahoo.it
599 • WVOC 2010, Bologna (Italy), 15th - 18th September L.A. Piras
Treatment of distal radius and ulna fracture in toy breed

dogs by means of circular external skeletal fixation:
a retrospective study
L.A. Piras, DVM1, B. Peirone, DVM, PhD1, F. Cappellari, DVM, PhD1, A. Ferretti, ECVS2
1
Dept Animal Pathology, University of Turin, Grugliasco, Italy
2
Clinica Ferretti, Castellanza, Italy
INTRODUCTION
Small breed dogs treated for distal radius and ulna fracture present a greater risk for the development of de-
layed union or nonunion, in comparison with larger breeds. The reasons for this impaired healing are both
biomechanical and vascular. Fracture healing is strictly related to the method of treatment. The CESF is a
reasonable and accepted method for fracture management in dogs. To the best of our knowledge there are
no reports regarding treatment of distal radius and ulna fracture by means of Circular External Skeletal Fix-
ation (CESF) in toy breed dogs. The purposes of this retrospective study were to evaluate the effectiveness
of CESF in treating distal radius and ulna fractures in toy breed dogs and to document the type and rate of
complications associated with this technique. Our hypothesis is that CESF is an effective technique in treat-
ment of distal radius and ulna fracture in toy breed dogs.

The medical records of small breed dogs affected by distal radius and ulna fractures admitted to the Veteri-
nary Teaching Hospital of the University of Turin and to the Clinica Ferretti (Castellanza) between 2002
and 2009 were retrospectively reviewed.
The criteria for inclusion in the study were: body weight of 5 kg or less, transverse or short oblique fracture
of the distal third of the radius and ulna, no previous repair attempts and treatment with CESF as the sole
method of fixation. The frame was pre-assembled, with a double-ring block configuration for the proximal
fragment, consisting of an arch and a ring, and a single ring for the distal fragment, due to its small dimen-
sion. An arch with the open portion oriented cranially was used in the proximal part of the antebrachium,
to avoid interference between the skin and frame during limb flexion. In order to achieve adequate stabi-
lization of the distal fragment, either an oblique transosseus wire or a threaded pin was connected to the dis-
tal ring. On postoperative radiographs fracture reduction and limb alignment were judged. Complications,
time of healing and refractures after implants removal were recorded.
RESULTS
Twenty-one fractures in 17 dogs fit the criteria for inclusion into the study. Breeds included 8 Italian Grey-
hounds, 4 Pinscher, 2 Pomeranians, 1 chihuaua, 1 Yorkshire and 1 mix-breed. Mean age was 14.5 months
(range, 4-50 months) and mean body weight was 3 kg (range, 1-4.5 kg). In two cases acute correction of a
pre-existing deformity was performed. All dogs used the treated limb within two days after surgery, with a
moderate degree of lameness. Major complications occurred in one case: three months after surgery, a prox-
imal radial fracture occurred at a wire level. Bone healing was achieved in all cases. Mean time until radi-
ographic evidence of a bridging callus and successive implant removal was 71 days (range, 30-120). No signs
of infection or implant failure were detected in any case. Postoperative minor complications included pin
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tract discharge (n=8) and sudden lameness in three cases, successfully managed with NSAIDs. Three cases
were lately represented for a fracture occurring on the same bone segment: in all cases it was not considered
a refracture because the new fracture line was not in the same site as the previous one nor at the level of the
previous wire hole.
CONCLUSION
The results of this study support the feasibility of fixation by means of the Ilizarov apparatus for distal ra-
dius and ulna fractures in toy breed dogs as an alternative to other methods of fixation. The construct em-
ployed was light and very well tolerated: in our experience all dogs had a fast recovery in limb use and in
none of the cases the apparatus determined walking difficulties other than the expected mild lameness. How-
ever, this technique requires a series of follow-up rechecks to evaluate the stability of the apparatus, the in-
tegrity of the wires and determine the right moment for implant removal, thus requiring more collaboration
on behalf of the owner for a prolonged period of time.
L.A. Piras WVOC 2010, Bologna (Italy), 15th - 18th September • 600
REFERENCES
Vaughan LC (1964): A clinical study of non-union fractures in the dog. J Small Anim Pract 5:173-177.
Sumner-Smith G, Cawley AJ (1970): Nonunion fractures in the dog. J Small Anim Pract 11:311-325.
Sumner-Smith G (1974): A comparative investigation into the healing of fractures in miniature poodles and mongrel dogs.
J Small Anim Pract 15:323-328.
Sumner-Smith G (1974): A histological study of fracture nonunion in small dogs. J Small Anim Pract 15571-578.
Hunt JM, Aitken ML, Denny HR (1980): The complications of diaphyseal fractures in dogs: A review of 100 cases. J
Small Anim Pract 21:103-119.
Herron MR: Repair of distal radio-ulnar fractures in toy breeds of dogs. Canine Pract 1:12-17, 1974.
Waters DJ, Breur GJ, Toombs JP (1983): Treatment of common forelimb fractures in miniature- and toy-breed dogs. J
Am Anim Hosp Assoc 19:643-650.
Ferretti A. The application of the Ilizarov technique to veterinary medicine. In: Branchi-Maiocchi A, Aronson J, eds. Op-
erative principles of Ilizarov. Milan, Italy: Med Surg Vido, 1991:551-570.
Lewis DD, Radasch RM, Beale BS (1999). Initial clinical experience with the IMEX™circular external skeletal fixation
system. Part I: use in fractures of arthrodeses. Vet Comp Ortho Traum 12: 108-117.
Marcellin-Little DJ (1999). Fracture treatment with circular external fixation. Vet Clin North Am Sm Anim Pract, 29:
1153-1170.
Dott.ssa Lisa Adele Piras - Dipartimento di Patologia Animale, Università di Torino,
Via Leonardo Da Vinci 44, 10095 Grugliasco (TO), Italy - E-mail lisa.piras@unito.it
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601 • WVOC 2010, Bologna (Italy), 15th - 18th September R. Rinnovati
Multiple rib fracture repair in a standardbred foal

R. Rinnovati, DVM, N. Romagnoli, DVM, G. Ricciardi, DVM,
C. Castagnetti, DVM, A. Pirrone, DVM, A. Spadari, DVM
Veterinary Clinical Department, Alma Mater Studiorum - University of Bologna, Bologna, Italy
INTRODUCTION
Rib fractures in neonates occur most commonly in Thoroughbred foals born after dystocia, secondary to
natural or iatrogenic trauma, especially in primiparous mares (Jean et al. 1999). The cause of thoracic trau-
ma may be focal pressure on the thorax during passage of the foal through the pelvic canal. Pulmonary con-
tusion, haemothorax, pneumothorax, diaphragmatic herniation, haemoabdomen, haemopericardium and
myocardial laceration are complications associated with rib fractures (Sprayberry et al. 2001) and sudden
death can occur without any previously identified clinical sign. In a study of 760 necropsied neonates, 19 of
the 76 foals diagnosed with rib fractures died as a direct result of rib trauma (Schambourg et al. 2003). The
best method to reveal fractured ribs is ultrasonography, whereas radiographs are not considered as valuable
as diagnostic method (Jean et al. 2007).
The surgical treatments for rib fracture repair have been considered by a few number of papers. Bellezzo
(2004) reduced and fixed the fractured ribs in 14 foals by placing a plate stabilized to the rib with cerclage
wire tightened in single loops, proximally and distally to the fracture line. Kraus (2005) used a nylon strand
to obtain an “8-figure” passing in holes drilled into the thickness of the rib and across the fracture line. Re-
cently Ahern (2009) proposed another method of fixation using stainless steel cerclage wire applied in a “fig-
ure 8” fashion, with the wire crossing and lying on the thoracic surface of the ribs.
The purpose of this study is to describe a new method, easy to perform and as useful as other techniques,
that can provide a stable fixation of fractured ribs, using a tension device that counteracts tension and bend-
ing forces.

A 6 days - old Standardbred colt was admitted because of Perinatal Asphyxia Syndrome. The foal was born
on the breeding farm after dystocic parturition caused by posterior presentation and lateral position. It had
been resuscitated immediately after birth by the referring veterinarian and during the first 5 days of life the
foal was assisted at the breeding farm. On initial physical examination at admission, the animal was de-
pressed but in good body conditions; the only clinical alterations were dyspnea, tachypnea (72 bpm) and
tachycardia (114 bpm). Antimicrobial therapy was started with cefquinome (1 mg/kg IV q12h) and amikacin
sulfate (30 mg/kg IV q24h) and continued for 13 days. Omeprazole (4 mg/kg PO q24h) and probiotics were
also administered throughout the period of hospitalization. After 2 days loud murmurs and paradoxical
movements of the left thorax during respiration became evident and the palpation of the left thorax revealed
crepitus and incongruity of left ribs II–VIII. Fractures and dislocation of the ribs were identified with ultra-
sonography and confirmed with X-Rays.
Diazepam (0.05 mg/kg IV) and butorphanol (0.05 mg/kg IV) were administered for sedation and muscu-
lar relaxation, anesthesia was induced with ketamine (1.5 mg/kg IV) and propofol (0.8 mg/kg IV), and
maintained with isofluorane in oxygen; intermittent positive pressure mechanical ventilation was used.
The foal was positioned in right lateral recumbency and the left hemi-thorax was prepared and draped
for aseptic surgery.
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To approach the most cranial fractures, a 7 cm vertical skin incision was made over the 3rd left rib at the
level of the fracture site and continued through the cutaneous trunci muscle; the serratus ventralis muscle
was dissected bluntly to expose the affected rib.
When the rib fracture was identified, fragments were manipulated using towel clamps applied circumferen-
tially 3–4 cm from the fracture line. The distal fragment was elevated and 2.5 mm drill bit was used to drill
equidistant and parallel holes transversely through the rib, 0.5 cm distant from the fracture line. A 0.8 stain-
less steel cerclage wire was passed through the holes drilled in the proximal fragment and then in those of
the distal fragment in a figure 8 fashion to create a tension band on the external surface of the rib. The ribs
2nd and 4th were approached and treated with the same method using the same incision, moving cranially
and caudally the overlying soft tissues. The ribs 5th – 8th were repaired using the same technique through
two additional incisions made on ribs 5th and 7th.
Cerclage wire was tightened to maintain reduction and to develop maximal stability. In some cases the tight-
ening of the end of the cerclage was not enough to warrant the necessary strength of the 8 figure, thus an
additional tightening of the other loop of the wire was performed to obtain the desired tension and inter-
R. Rinnovati WVOC 2010, Bologna (Italy), 15th - 18th September • 602
fragmentary compression. Muscular layers and subcutaneous tissue were closed using 2-0 Dexon® in a con-
tinuous pattern and the skin was closed using staples.
Postoperatively the foal was maintained on a mattress and assisted for standing and drinking every 2 hours;
it was monitored for respiratory distress by physical examination and blood gas analysis. Flunixin meglu-
mine (1 mg/kg IV q8h) for 3 days was added to the therapies. Ten days after surgery antibiotic therapy was
changed to doxycycline (10 mg/kg PO q12h) and rifampicin (5 mg/kg PO q12h) for 13 days. A X-Ray ex-
amination was performed immediately after surgery and the fracture sites were evaluated ultrasonographi-
cally every week. The post operative period was uneventful and the foal recovered completely. It was dis-
charged after 25 days of hospitalization. Box rest was recommended for 4 more weeks.
RESULTS
The treatment here described is a modification of the cerclage methods proposed by Kraus and Ahern. The
Ahern technique of the bicortical holes drilled in each rib was preferred and adopted because easier, faster
and probably achieving a stronger stabilization after the reduction. Differently to the original technique, the
figure 8 configuration was made with the wire crossing on the external, convex surface of the rib, consider-
ing it more subjected to the tension forces.
In the opinion of the authors, breathing movements could put stress to the whole implantation. Thus the
tension band applied externally, following the principles of compression-tension forces, can counteract all
tension forces, which are remarkable especially during thorax expansion, creating compressive forces better
distributed along the fracture line. It was also considered that the 8 shaped tension band created laterally to
the rib, and not medially, brings the fracture to a better stiffness and distribution of the strength along the
natural tension lines during breathing.
CONCLUSION
This surgical technique should be considered as a modification of others, but in better correspondence with
the internationally recognized standard principles for internal fixation of fractures.
REFERENCES
Ahern B.J., Levine D.G. (2009). Multiple Rib Fracture Repair in a Neonatal Holstein Calf. Vet Surg 38, 787-790.
Bellezzo F., Hunt R.J., Provost P. et al. (2004). Surgical repair of rib fractures in 14 neonatal foals: case selection, surgical
technique and results. Equine Vet J 36, 557-562.
Jean D., Laverty S., Halley J. et al. (1999). Thoracic trauma in newborn foals. Equine Vet J 31, 149-152.
Jean D., Picandet V., Macieira S. et al. (2007). Detection of rib trauma in newborn foals in an equine critical care unit: a
comparison of ultrasonography, radiography and physical examination. Equine Vet J 39, 158-163.
Kraus B.M., Richardson D.W., Sheridan G. et al. (2005). Multiple rib fracture in a neonatal foal using a nylon strand su-
ture repair technique. Vet Surg 34, 399-404.
Schambourg M.A., Laverty S., Mullin S. et al. (2003). Thoracic trauma in foals: post mortem findings. Equine Vet J 35,
78-81.
Sprayberry K.A., Bain F.T., Seahorn T.L. et al. (2001). 56 cases of rib fractures in neonatal foals hospitalized in a refer-
ral center intensive care unit from 1997–2001. Proc Am Assoc Equine Pract 47, 395-399.
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603 • WVOC 2010, Bologna (Italy), 15th - 18th September A. Rizk
The use of xylazine hydrochloride (Rompun®) in the

analgesic protocol for claw treatment in lateral recumbency
on a surgical tipping table in lame dairy cows
A. Rizk, MVSC, DVM1,2, S. Herdtweck, DVM1, H. Meyer, Dr.med.vet1,
A. Zaghloul, Prof Ph.D2, J. Rehage, Prof Dr.med.vet, Dr habil, Dipl ECBHM1
1
Clinic for Cattle, University of Veterinary Medicine Hannover, Hannover, Germany
2
Department of Surgery, Anaesthesiology and Radiology, Faculty of Veterinary Medicine, Mansoura University, Mansoura,
Egypt
INTRODUCTION
Lameness in dairy cows is commonly due to claw lesions (Van Amstel and Shearer 2006). For treatment of
claw disorders commonly surgical intervention with proper analgesia and restraining is important in order
to ensure adequate and safe surgical conditions (VanMetre et al. 2000 and Starke et al. 2007). For or-
thopaedic surgery frequently cows are laid down on a surgical tipping table. Restraining is perceived as stress
by cows (Tagawa et al.1994 and Pesenhofer et al.2006). Although animal welfare is a growing subject of con-
cern in farm animals, adequate analgesic protocols in general and in particular in orthopaedic surgery are
still neglected by field veterinarians and farmers (Hudson et al.2008). This appears under animal welfare as-
pects no longer acceptable (Galindo and Broom 2002).
Results of a previous study showed the alleviation of stress by pre-emptive application of xylazine
(Rompun®) when cows are turned into lateral recumbency (LR) for painless claw trimming with some ad-
ditional effect on respiratory depression of LR in dairy cows. The aim of this study was to investigate the
effect of pre-emptive xylazine treatment in the analgesic protocol for claw treatment in LR in lame dairy
cows on the stress and pain response.

In a prospective, blinded, placebo-controlled clinical case study, 24 lame, German Holstein Frisian cows (not
more than four months pregnant), weighing 531±85.5 kg and aged 4.4±1.5 (mean ± SD) years old were used.
All cows suffered from lameness due to a claw lesion. An indwelling venous catheter was introduced into the
right jugular vein for repeated blood sampling. Cows were randomly allocated into two groups of 12 cows
each and either treated with Xylazine (Rompun®; 0.05 mg kg-1 BW, IM) or an equal volume of sterile saline
(controls) 15 minutes before LR for claw treatment. After initial claw examination in each cow a retrograde
intravenous local anaesthesia (LA) with 20 ml of 2% procaine was performed. At regular preset time intervals
over an observation period of 6 hours (30 min before drug application to 6 hours post-operative) heart rate
(HR), respiratory rate (RR), plasma levels of cortisol, glucose, lactate and non-esterified fatty acids (NEFA)
were determined and signs of behaviour monitored (via video recording and pedometer).
Xylazine or placebo treatments were performed in the stable. Fifteen minutes after drug application cows
were moved to the surgery theatre and turned into LR for initial claw examination, then (20 min after start
of LR) the regional anaesthesia was applied and thereafter the surgical claw treatment performed according
to the type of the claw affection. After turning into standing position cows were moved back to the stable.
Statistical evaluation of results (SAS package 9.1) was performed by means of a two factorial analysis of vari-
ance for repeated measurements. Behaviour signs were tested for group differences either by Fisher’s exact
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or by Wilcoxon rank-sum test.
RESULTS
All cows treated with xylazine showed mild signs of sedation for about one to two hours, and were able to
walk and to stand at all times. No significant (P < 0.05) difference was found for rumen motility in both
groups. In both groups rumen motility ceased during the surgical intervention in LR. Cows of both groups
showed mild signs of ruminal free gas bloat after LR. In the evaluation of behavioural signs xylazine demon-
strated significantly (P < 0.05) additional analgesic effects to LA by reduced pain response on the insertion
of the needle for LA, reduced ear flicking during claw treatment and reduced lameness score. In xylazine
treated cows the evaluation of the pedometer recordings revealed in the first hour after claw treatment in
LR a significantly (P < 0.05) higher percentage of standing than in controls. The average period of activity
(standing and active) was not significantly different between both groups and generally with about 2 – 3%
per hour low. Also the mean number of steps per min during active periods was not significantly different.
A. Rizk WVOC 2010, Bologna (Italy), 15th - 18th September • 604
Coming back from claw treatment in LR to the free stall, xylazine treated cows started to consume offered
feed mostly immediately, while controls preferred to lie down. In average the time period in % of one hour
cows spent feeding was longer in xylazine treated cows than in controls.
Mean HR and RR as well as plasma levels of lactate and NEFA were significantly (P < 0.05) reduced after
xylazine treatment compared to baseline and controls. After xylazine treatment mean plasma glucose was
significantly (P < 0.05) higher after xylazine treatment compared to controls. In placebo treated control cows
plasma glucose increased significantly (P < 0.05) compared to baseline during LR. Mean plasma level of cor-
tisol was significantly (P < 0.05) lower in xylazine treated cows after being turned into LR but raised to lev-
els in controls during the surgical treatment. No difference between groups was seen in plasma cortisol post-
operatively. In each of both groups one cow exhibited with 2 ng ml-1 plasma cortisol concentrations which
were close to the detection limit. In both cows plasma cortisol concentrations stayed at this low level, even
during the entire period of LR.
CONCLUSION
The pre-emptive xylazine treatment in a low dose (0.05 mg kg-1 BW) can reduce hormonal and metabolic
stress response and has short term additional mild analgesic effects to LA in lame cows receiving claw treat-
ment in LR. Thus, xylazine appears to be an appropriate sedative for stress alleviation in cows turned into
LR and can be used as an analgesic in a multimodal analgesic protocol for short term pain management dur-
ing claw surgeries. Since xylazine has as LR depressive effects on cardio-respiratory function the desired ef-
fects of sedation and analgesia have to balanced against the possibility of reduced tissue oxygenation before
the use of xylazine in cows turned in LR, at least we discourage to use higher doses of xylazine under field
conditions.
REFERENCES
Galindo F., Broom D.M. (2002). Effects of lameness of dairy cows. Journal of Applied Animal Welfare Science 5, 193-
201.
Hudson C., Whay H., Huxley J. (2008). Recognition and management of pain in cattle. In practice 30, 126-134.
Pesenhofer G., Palme R., Pesenhofer R.M., Kofler J. (2006). Comparison of two methods of fixation during functional
claws trimming -walk in crush versus tilt table-in dairy cows using faecal cortisol metabolite concentrations and dai-
ly milk yield as parameters. Wiener Tierärztliche Monatsschrift 93, 288-294.
Starke A., Kehler W., Rehage J. (2007). Arthrotomy and arthrodesis in the treatment of complicated arthritis of the fet-
lock joint in adult cattle. (Author reply): Veterinary Record 160, 171-172.
Tagawa M., Okano S., Sako T., Orima H., Steffey E.P. (1994). Effect of change in body position on cardiopulmonary
function and plasma cortisol in cattle. Journal of Veterinary Medical Science 56, 131-134.
Van Amstel S. R., SHEARER J. K. (2006). Review of Pododermatitis circumscripta (ulceration of the sole) in dairy cows.
Journal of Veterinary Internal Medicine 20, 805-811.
VanMetre D.C., Wenz J.R., Garry F.B.(2000). Handling lameness problems in dairy herds. Canadian Veterinary Journal
32, 111-113.
Awad Rizk - Clinic for Cattle, Bischofsholer Damm 15, 30173 Hannover, Germany
E-mail awad_surgery@yahoo.com
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605 • WVOC 2010, Bologna (Italy), 15th - 18th September G.L. Rovesti
Comparative evaluation of two composite materials

for use in circular and hybrid external fixation
G.L. Rovesti, drMedVet, dipl. ECVS - Clinica veterinaria M.E. Miller, Cavriago, Italy
INTRODUCTION
External fixation has been established as an important tool for fracture management in veterinary trauma-
tology. Most of the fixators used in veterinary surgery are made by metals and metallic alloys. Beyond the
problems linked to the surgical technique, one of the major drawbacks inherent to their use is due to the in-
terference of the fixator with radiographic examination. This is particularly true when dealing with periar-
ticular fractures and with circular fixators. The use of radiolucent material for fixator construction could be
very useful, allowing the clinician to better appreciate the development of bone healing. The aim of the study
was to test two different composite materials, both for mechanical performance and for radiolucency.
Two composite materials were tested. The first one was made by braided fabric long carbon fibers (BF) in
epoxy resin, and the second one was made by random short carbon fibers (SCF) in epoxy resin. The BF
were radially oriented, with 36° rotation of each layer compared to the previous one, and ten layers were
used. The SCF were 51x9 mm fibers randomly distributed in the resin mixture. According to the producer
instructions, the fibers were impregnated with the resin mixture, and placed in a mold. Polypropylene sheets
were used as mold releasing film. Composite panels of 6 mm thickness were made for each reinforcement
fiber. Prototypes rings of 115 mm of internal radius, 15 mm wide and 6 mm thick were then produced from
the panels by a water-jet cutting technique. Radiographic evaluation of the rings was performed at different
angles of incidence of the X-ray beam to the ring’s plane. The X-ray beam was oriented parallel to the plane
of the ring, and at 30°, 45° and 90°. The X-ray beam was then oriented parallel to the plane of the ring, but
with rotation of the ring around its center at 45° and 90°. The tests were performed at 25, 30, 32, 34, 36,
38, 40, 45 KV and 30 mAS. The mechanical tests were performed connecting a 1.5 mm-diameter K wire to
one side of the ring, and tensioning it progressively. The loads applied were of 294 N, 490 N, 882 N, and
1.078 N. At each load, the displacement of the ring was measured as a percentage of its starting diameter.
RESULTS
The radiographic test showed similar responses. Both materials were more radiolucent at higher beam en-
ergy, being a higher fraction of the beam transmitted through the material. As expected, the rings were most-
ly visible when the X-ray beam was oriented coplanar with the ring, and less visible when it was perpendi-
cular to it. Both composites were barely visible at 30 KV when the X-ray beam was perpendicular to the
rings’ plane, and at 45 KV when it was coplanar with the rings. No differences were detected when the ring
was rotated on its center, meaning the materials are radiographically isotropic. The mechanical tests showed
similar results, with not statistically significant differences between the materials. The planar displacements
were in average 0.26% at 294 N, 0.26% at 490 N, 0.53% at 882 N, and 0.53% at 1.078 N for the BF. They
were similar for the SCF at lower loads, 0.62% at 882 N, and 0.89% at 1.078 N. Both composite recovered
their original size when the load was released, showing an almost pure elastic behavior.
CONCLUSION
Both the BF and the SCF composites show radiographic and mechanical characteristics that make them
good candidates for developing their use in circular and hybrid external fixation, whenever the possibility
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of assessing radiographically the area of interest could be hindered by the use of metallic frames.
REFERENCES
1. Baydia K.P., Ramakrishna S., Rahman M., Ritchie A. (2001). Advanced textile composite ring for Ilizarov external
fixator system. Proc Instn Mech Engrs, Part H 215, 11-23.
2. Gasser B. (2000). About composite materials and their use in bone surgery. Injury 31, 48-53.
3. Watson M. A., Mathias K. J., Maffulli N. (2000). External ring fixators: an overview. Proc Instn Mech Engrs, Part
H 214, 459-470.
4. Baydia K.P., Ramakrishna S., Rahman M., Ritchie A., Zheng-Ming Huang (2003). An investigation of the polymer
composite medical device – External fixator. J Reinf Plast Comp 22, 563-590.
5. Nele U., Maffulli N., Pintore E. (1994). Biomechanics of radiotransparent circular external fixators. Clin Orth Rel
Res 308, 68-72.
Corresponding Address: Dott. Gian Luca Rovesti - Clinica veterinaria M. E. Miller, Via Costituzione 10,
42025 Cavriago (RE), Italy - E-mail grovesti@clinicamiller.it
S.G. Sawaya WVOC 2010, Bologna (Italy), 15th - 18th September • 606
Clinical and biomechanical evaluations after radial

shockwave therapy in 8 dogs presenting a severe hip
osteoarthritis
S.G. Sawaya1,2 DVM, PhD; E. Demare2 DVM; T. Lequang1,3 DVM, PhD;
E. Viguier1,3 DVM, PhD, Pr, Dipl ECVS
1
UPSP 2007-03-135 RTI2B - Vetagro-Sup; Campus Vétérinaire de Lyon. 1, Avenue Bourgelat,
69280 Marcy l’Etoile, France
2
Unité de Physiothérapie-Rééducation-Ostéopathie; Vetagro-Sup; Campus Vétérinaire de Lyon. 1, Avenue Bourgelat,
3
UP de Chirurgie des Animaux de Compagnie Vetagro-Sup; Campus Vétérinaire de Lyon. 1, Avenue Bourgelat,
OBJECTIVES
Physical therapy is considerate as a useful complementary medicine for hip dysplasia and hip osteoarthritis
treatment. Extracorporeal Radial Shockwave Therapy (rESWT) has been used since almost twenty years
for several tendon problems in Human and Horse. During the last ten years, rESWT emerged in the field
of canine physical therapy, particularly in the treatment of tendonitis and osteoarthritis. Osteoarthritis is not
a known indication for shockwaves in human medicine. Clinical or experimental studies about rESWT in
dogs are still very rare. This clinical and biomechanical study is a contribution to quantify the effectiveness
of radial shockwave therapy for hip osteoarthritis in dogs.

The study included eight client-owned dogs of different breeds, ranging in age from 11 months to 7 years,
with clinical and radiographic signs of severe hip osteoarthritis. The dogs underwent three sessions of radi-
al shock wave therapy (1 session per week) with a Swiss DolorClast Vet® (Electro Medical Systems, Nyon,
Switherland). The lateral aspect of the hip was clipped before the treatment. At each session, 2000 shots with
a pressure of 2 bars and a frequency of 9 Hz were applied. 10 hips were treated. The dogs were evaluated
just before each session (D0, D+1w, D+2w) and four weeks after the last session (D+6w). Lameness at walk
and trot, and hip pain were scored (Millis DL, 2004). Maximal hip flexion and maximal hip extension were
measured by goniometry. Gait analysis was performed with the GaiteRite® system (Le Quang et al. 2007;
Viguier et al. 2007; Maître et al. 2008). The maximal pressure occurring during the stance phase (Pmax)
and the relative stance phase duration (SPD) were measured for each limb. The ratios (symmetry indices)
of the Pmax and of the SPD between the two hindlegs (Left Hindlimb / right hindlimb) and the ratio of the
Pmax between the forelegs and the hindlegs (Forelegs/hindlegs) were calculated. Control radiographies were
taken before treatment and at D+6w. Lameness and pain scores were statistically compared with Wilcoxon
tests, hip angles and biomechanical parameters were compared with Sudent tests (In both tests the difference is
considered statistically significant if p < 0,05).
RESULTS
The treatment was very well tolerated by all the dogs and didn’t need any sedation. At D+1w all the own-
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ers reported a general improvement: their dog was less limping and has recovered its willing to go out for
walks and to play. At D+2w all the clinical and all the biomechanical studied parameters where significant-
ly improved: Mean lameness score and mean pain score were reduced (Respectively: p=0,004 and p =
0,002) and the mean hip extension angle was increased: 135,54±13,81° at Do, 150,09±10,53° à D+2w,
153,45±7,45° at D+6w (p=0,01). Gait analysis results shows:
- An increase of the mean relative Pmax of the treated limbs: 16,11±3,43% at D0, 18,69±2,01% at D+2w,
19,12±2,31% at D+6w (p=0,013) (Relative Pmax of a sound hindlimb: 20%, (Le Quang et al).)
- A favorable evolution of the Pmax ratio for the hindlimbs: 1,44±0,37 at D0, 1,17±0,22 at D+2w, 1,06±0,18
at D+6w (p = 0,031). In sound dogs, the Pmax ratio between left and right hindlimbs = 1 ± 5% (Le Quang et al).
- A favorable evolution of the ratio of the relative stance phase duration for the hindlimbs:0,92±0,08 at D0,
0,98±0,04 at D+2w, 1,02±0,03 at D+6w -; (p=0,005); In sound dogs, the ratio of the relative STD between left
and right hindlimbs = 1 ± 5% (Le Quang et al).
- A decrease in the Pmax ratio between the forelimbs and the hindlimbs, (1,89±0,43 at D0, 1,81±0,36 at D+2W,
1,59±0,11 at D+6w (p=0,03). In sound dogs, the Pmax ratio Forelimbs/hindlimbs = 1,5 ± 5%. (Le Quang et al).
607 • WVOC 2010, Bologna (Italy), 15th - 18th September S.G. Sawaya
The maximal clinical and biomechanical improvements were observed between weeks 2 and 4 after the last
session of rESWT.
Control radiographies didn’t show any notable aggravation nor improvement of the osteoarthritic lesions.
Discomfort or lameness recurred between 3 and 6 months after treatment in 4 dogs, more than 12 months
after treatment in 3 dogs, and 2 months after treatment for 1 dog.

Here we present a clinical study assessing the effectiveness of radial shockwave therapy in 8 dogs suffering
from severe hip osteoarthritis. Clinical and biomechanical parameters were significantly and durably im-
proved after treatment in all the dogs. Lameness and hip pain were significantly reduced and hip range of
motion significantly increased. The relative maximal pressure (Pmax) increased in all the treated hindlimbs,
in relation with a better loading of the leg. This was confirmed by the favourable evolution of the symme-
try indices (ratios), showing less difference in loading and in the stance phase duration between the left and
the right hindlimbs from one hand, and a better distribution of weight-bearing between the forelegs and the
hindlegs with a decrease of the load transfer on the forelegs, on the other hand. These results are in accor-
dance with those of Mueller’s et al (2007) force-plate analysis after rESWT on dogs with hip osteoarthritis.
Radial shockwave therapy is a non invasive technique with a simple protocol (generally 3 sessions, with 1
session per week) and should be considered as an alternative or a complementary treatment for severe hip
osteoarthritis:
- when NSAID are not effective or induce adverse effects;
- or, in the case of hip dysplasia, when a surgical treatment is not indicated or not desired by the owners.
More clinical studies with more animals, control groups and comparison with other therapeutic modalities
are necessary to confirm these observations, and to evaluate the effectiveness of rESWT on other sites of
osteoarthritis in dogs.
BIBLIOGRAPHY
Le Quang T., P. Maitre, T. Roger, E. Viguier. The GAITRite® system for evaluation of the spatial and temporal pa-
rameters of normal dogs at a walk. Comp. Meth. Biomech. Biomed. Eng., 2007, 10 (S1): 109-110.
Maitre P., Le Quang T., Fau D., Genevois J.P, Viguier E.; Hip dysplasia in dogs: correlation between clinical lameness
score, radiographic finding and walkway gait analysis. Comp. Meth. Biomech. Biomed. Eng. 2008 11 (S1): 153-
154.
Millis D.L: Assessing and Measuring Outcomes. In: Millis DL, Levine D, Taylor RA. Canine Rehabilitation and Physi-
cal Therapy. Saunders, USA, 2004; p 211-227
M. Mueller, B. Bockstahler, M. Skalicky, E. Mlacnik, D. Lorinson, Effects of radial shockwave therapy on the limb func-
tion of dogs with hip osteoarthritis. The Veterinary Record, 2007;160(22):762-5.
Viguier E., Le Quang T., Maitre P., Gaudin A., Rawling M., Hass D. The validity and reliability of the GAITRite®
system’s measurement of the walking dog. Comp. Meth. Biomech. Biomed. Eng. 2007, 10 (S1): 113-114.
Dr. Serge Sawaya - Vetagro-Sup - Campus Vétérinaire De Lyon Anatomie Comparée, 1,
Avenue Bourgelat, 69280 Marcy L’etoile, France - E-mail s.sawaya@vetagro-sup.fr
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C.I. Serra WVOC 2010, Bologna (Italy), 15th - 18th September • 608
Determination of the platelets and TGF-β1 concentration,

in the plasma rich in growth factors of the canine species
C.I. Serra, DVM PhD1,2, I. Peris, DVM1, J. Sopena, DVM PhD1, J.I. Redondo, DVM PhD1,
R. Cugat, MD PhD2, C. Soler, DVM PhD1,3
1
Universidad CEU Cardenal Herrera. Animal Medicine and Surgery Department, Valencia, Spain
2
Fundación García Cugat para la Biomedicina, Barcelona, Spain
3
Centro de Investigación Príncipe Felipe, Valencia, Spain
INTRODUCTION
Nowadays, the use of fractions of autologous plasma rich in growth factors (PRGF), as a therapeutic option
in the tissue regeneration, is a reality in human medicine. In veterinary medicine, it is possible to find the
application of this PRGF in isolation case reports, small clinical studies and research works. For the authors,
it is very important to describe an easy, sure and cheap protocol, to increase the PRGF application in the
veterinary medicine. For this, the purpose of this work was to study a new protocol to obtain autologous
PRGF in dogs, comparing it with another two indexed protocols.

Eleven healthy Beagle dogs were used. 3 blood samples from each animal were collected to be centrifuged
with three different protocols: A protocol (the proposal of this work): 210 g 10 min; B protocol: 210 g 10
min + 210 g 15 min (Casati et al., 2007) and C protocol: 475 g 8 min (Anitua et al., 2004). White blood
cells, platelets and TGF-ß1 (ß Quantikine, R & D Systems, USA) in the plasma fraction rich in growth fac-
tors (PRGF), in the plasma fraction poor in growth factors (PPGF) and in the blood sample were obtained.
The 3 protocols were compared among them and everyone with itself (among PRGF, PPPGF and blood
sample). Statistical differences were estimated using a one way ANOVA (p<0,5).
RESULTS
Platelets (1013 ± 431 x103 cel/µl) and TGF-ß1 (40614,45 ± 30259,31 pg/ml) concentrations in PRGF in A
protocol were significantly higher than those obtained in the other two protocols. In the same way, the con-
centration of platelets in PRGF in the A protocol was also higher than the blood (301 ± 53 x103 cel/µl) and
PPGF (128 ± 60 x103 cel/µl) for the same protocol. However, this did not happen for the TGF-ß1 values.
CONCLUSION
The studied protocol, compared to the previous published ones, would be a good option to obtain a plas-
matic fraction rich in platelets and TGF-ß1 in dogs, without white blood cells.
REFERENCES
Anitua E., Andía I., Ardanza B., Nurden P., Nurden AT. (2004). Autologous platelets as a source of proteins for healing
and tissue regeneration. Throm Haemost 91(1): 4-15.
Casati MZ., de Vasconcelos Gurgel B.. Gonçalves P., Pimentel S., da Rocha G., Nacit F. Salem Jr.E. (2007). Platelet rich
plasma does not improve bone regeneration around peri-implant bone defect- apilot study in dogs-. Int J Oral Max-
illofac Surg 36(2): 132-6.
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C. Iván Serra - Uch-Ceu Animal Medicine And Surgery, Avda. D Francia Nº1 1ªt-4B, 46023 Valencia, Spain
E-mail ivaseag@uch.ceu.es
609 • WVOC 2010, Bologna (Italy), 15th - 18th September T.J. Smith
GeneJammer® enhances adenoviral BMP-2 gene delivery

to canine bone marrow-derived mesenchymal stem cells
T.J. Smith1, J. Gandy1, E. Olmsted-Davis2, A. Davis2, L. Sordillo1, T. Zachos1
1
College of Veterinary Medicine, Michigan State University, East Lansing, Michigan 48824, USA
2
Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas 77030, USA
INTRODUCTION
Incidence of long-bone fracture non-union in the dog has been estimated to be 5-8%.1,2 Complications of
fracture healing in dogs result in considerable patient morbidity and owner expense, inconvenience and
emotional distress. Use of autogenous cancellous bone graft to augment bone healing is considered the gold
standard but can be limited by availability, additional anesthetic time required for harvesting and associated
donor site morbidity. Bone morphogenetic proteins induce osteogenic differentiation of mesenchymal stem
cells. Adenoviral (Ad) vector-mediated gene delivery of bone morphogenetic protein-2 (BMP-2) increases
BMP-2 protein expression in human stem cells.3 In our laboratory we have previously achieved successful
Ad-gene delivery to canine bone marrow-derived mesenchymal stem cells (cBMDMSC), resulting in os-
teogenic differentiation.4 However permissiveness of cBMDMSC in our model was lower than reported for
other species. We hypothesized this was attributable to variability in or lack of cellular expression of the Cox-
sackie Ad receptor.3,4 GeneJammer® (GJ; Stratagene, La Jolla, CA, USA), a polyamine transfection reagent,
enhances Ad-BMP-2 gene delivery to human BMDMSC.1 The goal of this study was investigate the effi-
cacy of GJ-enhanced Ad-BMP-2 gene delivery to cBMDMSC in a monolayer culture system. Our hypoth-
esis was that GJ would enhance Ad-BMP-2 gene delivery to canine BMDMSC in monolayer culture re-
sulting in gene and protein expression consistent with osteogenic differentiation.

Following Institutional Animal Care and Use Committee approval, bone marrow was harvested from adult
dogs and cBMDMSC were isolated and expanded in monolayer culture. Cell pluripotentiality was con-
firmed by selected differentiation and expression of cell surface markers consistent with mesenchymal stem
cells. Cells were maintained in osteogenic medium (OM) in 24-well plates in triplicate. Transduction effi-
ciency was optimized using an Ad5-green fluorescent protein (GFP) reporter gene construct with respect to
optimize: (1) viral particles per cell (VPC); (2) GJ concentration; and (3) expression of GFP transgene prod-
ucts. Cellular production of BMP-2 was compared between GJ-enhanced Ad-BMP-2 (Ad-BMP-2-GJ), Ad-
BMP-2 (no enhancement), positive control (BMDMSC cultured in OM supplemented with 100 ng/ml
rhBMP-2) and wild-type control (BMDMSC cultured in OM only) groups. Cell culture media and cells
were harvested on days 0, 3, 6 and 9. Percentage of cells expressing GFP on days 0-5 was assessed. Changes
in gene expression of canine collagen type I (col1); canine collagen type II (col2); canine alkaline phosphatase
(alp); canine aggrecan 1 (agc1); and human BMP-2 (hBMP2) were quantified using real-time RT-PCR. Con-
centrations of canine vascular endothelial growth factor (VEGF) and hBMP-2 in culture media at days 0,
3, 6 and 9 were quantified using ELISA. ALP activity in cell lysate harvested on days 0, 3, 6 and 9 was quan-
tified using a colorimetric kinetic assay (QuantiChromTM BioAssay Systems, Hayward, CA, USA). Expres-
sion of osteopontin was assessed at days 0, 3, 6, 9 and 12 by immunocytochemistry. Increases in gene, pro-
tein and ALP expression were compared using two-way ANOVA with Bonferroni correction; p<0.05 was
considered significant.
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RESULTS
The presence of cell surface markers CD-90, CD-105 and MHC-I, and the absence of CD34 and CD-45;
and pluripotentiality (osteogenic, chondrogenic and adipogenic differentiation) was confirmed. A VPC ra-
tio of 10,000:1 was optimal for transduction. Transduction time of 4 hours, followed by dilution for 48
hours, was optimal for transduction, and significantly greater percentage of cells expressing GFP was seen
beginning at day 3 (p<0.001). At day 6, a 1.25% GJ concentration was optimal for BMP-2 protein expres-
sion compared with no Ad-BMP-2 (no GJ-enhancement) and controls (no Ad-BMP). The hBMP2 gene ex-
pression was significantly greater in the Ad-BMP-2-GJ group compared with the control (p<0.05) and Ad-
BMP-2 (p<0.001) groups, at day 3. The aggrecan (agc1) gene expression in the Ad-BMP-2-GJ group was
significantly greater compared with the control (p<0.001) and Ad-BMP-2 (p<0.001) groups, at day 6. In-
crease in alp gene expression in the Ad-BMP-2-GJ group was significantly greater compared with the con-
trol (p<0.001) and Ad-BMP-2 groups, at days 3 (p<0.001) and 6 (p<0.01) respectively, and between the Ad-
T.J. Smith WVOC 2010, Bologna (Italy), 15th - 18th September • 610
BMP-2 and control group at day 6 (p<0.05). The col1 gene expression in the Ad-BMP-2-GJ group was sig-
nificantly less than in the Ad-BMP-2 group (p<0.05). The col1 gene expression in the AdBMP-2 group was
significantly lower compared with the control group, at days 6 (p<0.05) and 9 (p<0.001), respectively. The
col2 gene expression in the Ad-BMP-2-GJ group was significantly greater compared with the control group
at days 6 (p<0.001) and 9 (p<0.001) and the Ad-BMP-2 group at days 6 (p<0.001) and 9 (p<0.01). The
hBMP-2 protein expression was greatest at day 6 in the Ad-BMP-2-GJ treated group. Expression of VEGF
protein increased across all treatment groups with time (p<0.001). ALP activity was significantly greater in
the Ad-BMP-2-GJ group compared with rhBMP-2 (p<0.001) and control (p<0.001) groups, and between
the rhBMP-2 and control group (p<0.05), at day 9. Osteopontin protein production increased with time in
the Ad-BMP-2-GJ group compared with controls.
CONCLUSION
A 1.25% concentration of GeneJammer® optimized enhancement of Ad-BMP-2 gene delivery to cBMDM-
SC in monolayer culture. The patterns of up-regulation of hBMP2 and alp gene expression, with hBMP-2,
VEGF and osteopontin protein expression, are consistent with osteogenic differentiation, and suggest that
day 6 may be the optimal in vitro time point to utilize cells for in vivo applications to induce osteogenesis.
However, up-regulation of col2 gene expression and decreases in col1 gene expression are consistent with
chondrogenic differentiation. A proposed explanation for this, when considered together with the delay in
ALP protein increase following increases in hBMP-2 and VEGF proteins, is that this chondrogenic differ-
entiation is part of the continuum of osteogenic differentiation of BMDMSC via endochondral ossification
induced by hBMP2 gene delivery. The optimal time point for evaluation of efficacy of osteogenic induction
in vivo applications may be between days 6 and 9. Further studies are warranted prior to initiating in vivo
studies.
REFERENCES
1. Hunt J.M., Aitken M.L., Denny H.R., et al. (1980). The complications of diaphyseal fractures in dogs: a review of
100 cases. J Small Anim Pract 21, 203-119.
2. Dvorak M., Necas A., Zatloukal J. (2000). Complications of long bone fracture healing in dogs: Functional and ra-
diological criteria for their assessment. Acta Vet. Brno, 69,107-114.
3. Fouletier-Dilling C.M., Bosch P., Davis A.R., et al. (2005). Novel compound enables high-level adenovirus trans-
duction in the absence of an adenovirus-specific receptor. Hum Gene Ther 16, 1287-1297.
4. Smith T.J., Davis E.A., Zachos T.A. (2008) Bone morphogenetic protein-2 gene delivery induces osteogenic differ-
entiation of canine bone marrow-derived mesenchymal stem cells in vitro. Proceedings, Veterinary Orthopedic So-
ciety Annual Meeting, Big Sky, Montana, p.54.
Terri Zachos, MD Class of 2014, College of Human Medicine, Michigan State University
A234 Life Sciences Building, Mailbox #132, East Lansing, MI 48824 - E-mail: zachoste@msu.edu
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611 • WVOC 2010, Bologna (Italy), 15th - 18th September A. Spadari
Single injection of autologous platelet rich plasma (PRP)

in suspensory ligament lesions in horses: a clinical trial
A. Spadari, DVM, G. Ricciardi, DVM, R. Rinnovati, DVM, N. Romagnoli, DVM
Veterinary Clinical Department, Alma Mater Studiorum - University of Bologna, Bologna, Italy
INTRODUCTION
Suspensory ligament injuries in horses are a major problem for any kind of discipline and attitude, often de-
manding long periods of rest, introduction in lower classes of competition and sometimes retirement from
the sport activity (Smith, 2008). The site of the lesion, the affected limb and the use of the horse are the main
concerns in assessing the possibility of recovery and the prognosis (Ross & Dyson, 2006). Many are the pos-
sible therapies experimented throughout the years, but none of them ensures to completely restore the
anatomical and functional integrity of the injured tissue. Recently regenerative medicine has risen great ex-
pectations and lesions have been treated with autologous blood derivates and MSCs (Fortier & Smith, 2008).
Platelets concentrates have been in the last decades addressed as possible proper solutions to the problem,
being a substantial source of growth factors potentially boosting the reparative process and improving the
quality of the heal (Borzini & Mazzucco, 2005). Nevertheless there is a general lack of knowledge about the
precise indications, timing, number of applications and minimum number of platelets for the treatment
with PRP and its effectiveness is yet to be clinically investigated. Too many are the possible interactions of
platelets’ growth factors in the site of lesion and each one can affect the outcome of the healing process,
not forgetting that the age, the rehabilitation protocol and the characteristic of the lesion itself play a role
too (Weibich et al., 2002). All of these variables are hard to investigate for importance and far to be de-
coded at the moment.
Clinical trials on large numbers of subjects could better outline the guidelines for the effective and actual use
of blood derivatives. The aim of this study was to verify the effectiveness of a single PRP application in sus-
pensory ligament spontaneous lesions in sport horses.

Ten adult horses different for age (mean 7.7 y), sex, breed and sport discipline (4 trotters, 5 jumpers, and 1
galloper) were referred for lameness and assessed to be affected with a lesion of the suspensory ligament af-
ter a complete lameness investigation and an ultrasonographic exam. To include the horse in the study, the
lesion had to be echographically evident, less than 1 month old, and treated with a single ultrasound-assist-
ed intra-lesional injection of fresh PRP. Fore and hind limbs lesions were included not considering the dif-
ferent sites of lesion (proximal, midbody, distal, branches).The cross sectional area (CSA) of the lesions var-
ied from 10 to 75% of the ligament, and the average alignment of fibres was 1.6.
Four-hundred-fifty ml of whole blood were collected from each horse in CPDA-1 and PRP was obtained
with a double centrifugation in a closed, sterile, blood transfusion double-bag system. The first centrifuga-
tion was performed at 500 g for 20 minutes. The PCV was manually separated from the supernatant which
was then centrifuged at 3000 g for 10 minutes. Eighty% of the supernatant was then eliminated and the
platelets re-suspended in the remaining plasma. Platelets were concentrated 7 to 11 times. Horses were se-
dated with acepromazine (20 microg /kg IV), detomidine (10 microg /kg IV) and butorphanol (20 microg/kg
IV) and a proximal troncular anaesthesia of the palmar/plantar nerve was performed (lidocaine 2%) for the
ultrasound-assisted intra-lesional injection of PRP. A soft simple bandage was applied and horses were hos-
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pitalized for two days. A standardized rehabilitation/training protocol, suitable to the activity of the horse,
was recommended to reintroduce the horse in competition after 6 months. The outcome of the treatment
was evaluated with a lameness investigation and an ultrasonographic control at six months, and on the ba-
sis of the return to the activity.
RESULTS
None of the horses showed any adverse reaction to the treatment. Six horses returned to competition after
the scheduled period of rehabilitation (6 months), whereas other 3 needed an average of 6 more weeks to
get back to the activity. One horse was unable to get back to contests without further treatment due to a re-
lapse of the pathology during rehabilitation. Of the 9 horses that returned to the activity 2 showed a clini-
cal relapse of the pathology within 1 year after treatment.
The ultrasound control showed a reduction of the CSA of the lesion in 9 horses with an average score of
alignment of fibres of 1.
A. Spadari WVOC 2010, Bologna (Italy), 15th - 18th September • 612
CONCLUSION
The results obtained in this clinical trial are encouraging. Seven of the 10 treated horses have had a positive
outcome with a 12 months follow up. This datum is consistent with the literature (Arguelles et al., 2008) but
a longer follow-up is needed to understand whether if the result is long lasting.
The 3 horses with a negative outcome were all trotters, affected in hind limbs. This result might have a cor-
relation both with the discipline itself and with the management and training of such horses, which are of-
ten put back into competition with an urgency potentially undermining a complete recovery.
In this study were considered only horses treated with a single application of PRP, which was demonstrat-
ed to be effective on rats (Virchenko & Aspengerg, 2006) and that has here shown a satisfactory outcome.
In this report we included only the horses in which it was considered, based on an ultrasonographic evi-
dence, that multiple injections might even cause a damage to the fibrils in shaping. Until more consistent da-
ta become available, it is possible to state that the treatment of suspensory ligament lesion with PRP seems
to be effective, uneventful, cheap and easy, and able to accelerate and improve the quality of the heal, thus
it should strongly be considered for these injuries in sport horses.
REFERENCES
Argüelles D. et al. (2008). Autologous platelet concentrates as a treatment for musculoskeletal lesions in five horses. Vet
Record 162, 208-211.
Borzini P., Mazzucco L. (2005). Platelets gels and releasates. Current Opinion in Hematology 12, 473-479.
Fortier L. A., Smith R. K. W. (2008). Regenerative Medicine for Tendinous and Ligamentous Injuries of Sport Horses.
Vet. Clin. Equine 24, 191-201.
Ross M.W., Dyson S.J. Diagnosis and management of lameness in the horse. Saunders, 2006.
Smith R. K. W. (2008). Tendon and Ligament Injury, Proceedings A.A.E.P. 54, 475-501.
Virchenko O., Aspenberg P. (2006). How can one platelet injection after tendon injury lead to a stronger tendon after 4
weeks? Acta Orthopaedica 77 (5): 806-812.
Weibrich G. et al. (2002). Growth factor levels in platelet-rich plasma and correlations with donor age, sex, and platelet
count. J Craniomaxillofac Surg 30, 97-102.
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613 • WVOC 2010, Bologna (Italy), 15th - 18th September T. Sparrow
Treatment of significant bone defects with distraction and

compression using autogenous cortico-cancellous bone graft
in a dynamized external fixator construct in 4 dogs and 1 cat
N. Fitzpatrick, DUniv, CSAO, CVR, MVB, T. Sparrow, BSc (Hons) BVM&S, K. Perry, BVM&S,
T. Smith, VetMB CertSAS, M. Hamilton, BVM&S, CertSAS, DipECVS
INTRODUCTION
Various therapies have been reported for the treatment of segmental bone loss resulting from trauma and
atrophic non-unions in humans and animals. These include the use of vascular or avascular autografts, al-
lografts, xenografts, synthetic materials, bone transport, and distraction osteogenesis. Cyclical distraction
and compression has been described in humans to treat non-unions of femoral fractures. We report the use
of modified circular external fixator constructs with autogenous cortico-cancellous bone block grafts for the
treatment of significant bone defects due to non-unions and traumatic bone loss in 4 dogs and 1 cat. Our
hypothesis was that application of distraction compression osteointegration (DCOI) technique would result
in osseous integration of cortico-cancellous bone blocks into large segmental defects facilitating limb salvage
in clinical patients.

Clinical and radiographic records of four dogs and one cat managed by DCOI between January 2001 and
December 2009 were retrospectively reviewed. Data pertaining to signalment, orthopaedic history, surgical
technique, complications and radiographic findings were recorded.
Cortico-cancellous bone blocks fashioned from coccygeal vertebrae (n=2) or the cranio-dorsal iliae (n=3)
were employed to fill the bone defect. Autogenous cancellous and cortico-cancellous grafts were placed in
all cases. Bone blocks were stabilized with a customized dynamic circular or hybrid external skeletal fixation
frame. In 4/5 cases, intramedullary “skewer” wires were used to anchor the bone blocks and prevent shear.
In the remaining case the blocks were anchored with bicortical wires. Cyclical compression distraction was
instigated following a three day lag period. Cycles comprised alternate days of compression and distraction
for two weeks. Initial rate and rhythm was 0.5mm every six hours. For a further seven days, daily com-
pression/distraction was 1mm, before a final day of 2mm compression prior to the consolidation phase. In
case 4, bilateral pancarpal arthrodesis was performed in conjunction with treatment of the osseous defects.
Post-operatively, orthogonal radiographs were obtained at four week intervals until osteointegration of the
blocks was confirmed by appearance of bridging trabecular bone pattern. All animals underwent intensive,
individually designed, physiotherapy programmes and normal exercise was gradually reintroduced once ra-
diographic evidence of integration had been documented.
RESULTS
The mean length of the consolidation phase following DCOI was 40 days (range 27 – 63 days). Three cas-
es received a single 3-week cycle of DCOI and two cases received two 3-week cycles. Two cases required re-
vision surgery for the removal of non-integrated blocks from a metacarpal shearing injury and femoral at-
rophic non-union respectively. Revision procedures were successful in both cases. Pin and wire-associated
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discharge was treated symptomatically in two cases and femoral shortening of 12mm and 4mm were noted
in a Border Collie and Bengal cat respectively. Four of five cases were sound at 12 month follow-up. The re-
maining case had quadriceps tie-down and contracture and remained significantly lame.
CONCLUSION
Cyclic compression of a fracture can accelerate fracture stiffness by stimulating osteogenesis. Circular exter-
nal fixators provide adequate stability to healing fractures, whilst allowing axial micromotion and facilitat-
ing distraction or compression, which have been demonstrated to be beneficial for osteogenesis. Ilizarov’s
tension-stress theory suggests that biomechanical stimuli may be mediated by tension, stress and strain,
streaming potentials, increased blood flow and fracture stability. The magnitude and frequency of compres-
sion-distraction used here was derived from data established using compression for stimulation of healing in
femoral non-union of human patients, where rates of between 0.5-2.0 mm per day have been shown to re-
sult in enhancement of osteogenesis.
T. Sparrow WVOC 2010, Bologna (Italy), 15th - 18th September • 614
The use of skewer wires allowed axial distraction and compression by “sliding” of the bone blocks axially
along the wires while preventing any lateral / shear movement of the blocks. This principle has been de-
scribed in humans with this technique using IM nails. In addition, skewer wires facilitated osteointegration
of the blocks in regions where plate fixation may have led to further compromise of surrounding soft tissues.
We surmise that the grafts integrated into defects and fused to the adjoining bones by creeping substitution.
Successful osseous bridging of large osseous defects by integration of autogenous bone blocks was achieved
in all cases. DCOI offers a viable treatment option for the treatment of chronic atrophic non-unions and in
other challenging clinical scenarios, where significant bone loss has occurred. Further work is required to es-
tablish optimal parameters for DCOI, however radiological evidence of bridging trabecular pattern with in-
tegration into the grafted cortical bone blocks provides proof of principle and that the mechanobiological
loading schedules employed for these cases were appropriate and merit consideration for application in sim-
ilar clinical scenarios.
REFERENCES
Aronson J. Temporal and spatial increases in blood flow during distraction osteogenesis. Clin Orthop Relat Res 1994;
301: 124-131.
Aronson J. Limb lengthening, skeletal reconstruction and bone transport with the Ilizarov method. Current concepts re-
view. J Bone & Joint Surgery (Am) 1997; 79-A: 1243-58
Cattaneo R, Catagni M, & Johnson EE. The treatment of infected nonunions and segmental defects of the tibia by the
methods of Ilizarov. Clinical Orthopaedics and Related Research 1992; 280(July): 143-152.
Goodship AE, & Kenwright J. The Influence of Induced Micromovement upon the healing of experimental tibial frac-
tures. Journal of Bone and Joint Surgery 1985; 67 B (4): 650-655.
Goodship AE, Cunningham JL, & Kenwright J. Strain rate and timing of stimulation in mechanical modulation of frac-
ture healing. Clinical Orthopaedics and Related Research 1998; 355S: 105-115.
Green SA. Skeletal defects A comparison of bone grafting and bone transport for segmental defects. Clinical Orthopaedics
and Related Research 1994; 301: 111-117.
Ilizarov GA. The tension-stress effect on the genesis and growth of tissues. Clinical Orthopaedics and Related Research
1989; 238(January): 249-281.
Ilizarov GA. Clinical application of the tension-stress effect for limb lengthening. Clinical Orthopaedics and Related Re-
search 1990; 250(January): 8-26.
Ilizarov GA. Principles of the Ilizarov Method. Bulletin Hospital for Joint Diseases 1997; 56(Number 1): 49-53.
Ilizarov GA, & Ledyaev V. The replacement of long tubular bone defects by lengthening distraction osteotomy of one of
the fragments. Clinical Orthopaedics and Related Research 1992; 280(July): 7-10.
Inan M, Karaoglu S, Cilli F, Turk CY, & Harma A. Treatment of femoral nonunions by using cyclic compression and dis-
traction. Clinical Orthopaedics and Related Research. 2005; 436: 222-228.
Kenwright J, Goodship AE, Evans M: The influence of intermittent micromovement upon the healing of experimental
fractures. Orthopaedics 7, 481, 1984
Kirkby KA, Lewis DD, Fitzpatrick N, Farese JP, Radasch RM, Lafuente MP et al. Management of humeral and femoral
fractures in dogs and cats with linear- circular hybrid external skeletal fixators. Journal of the American Animal
Hospital Association 2008; 44(July): 180-197.
Mccartney W T. Limb lengthening in three dogs using distraction rates without a
Paley D, Catagni M, & Argnani F, Ilizarov treatment of tibial nonunions with bone loss. Clinincal Orthopaedics. 1989;
241: 146-166
Patzakis MJ, Scilaris TA, Chon J, (1995) et al Results of bone grafting for infected tibial nonunion. Clin Orthop; (315):
192-198.
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615 • WVOC 2010, Bologna (Italy), 15th - 18th September B. Stapley
Pantarsal arthrodesis in 11 cats using a novel dorsal plate:

technique and complications
N. Fitzpatrick, DUniv, MVB, CSAO, CVR, B. Stapley, BVSc, R. Yeadon, MA, VetMB, CertSAS
INTRODUCTION
Pantarsal arthrodesis (PANTA) is a salvage procedure indicated for intractable degenerative joint disease,
devastating shearing injuries and tarsal fractures, sciatic nerve palsy and irreparable injury of the Achilles
tendon. Various techniques have been described for PANTA including medial plating, dorsal plating with
or without an intramedullary pin, plantar plate application and external skeletal fixation. A specially de-
signed plate is available for medial application, however there is currently no specifically designed plate for
application to the dorsal aspect of the tarsus. We report the technique and complications of dorsal plate ap-
plication for PANTA in 11 cats using a novel PANTA plate (“FitzPANTA”).

The two inclusion criteria for the study were that patients had undergone PANTA with the novel dorsal
plate as the only means of stabilisation of the arthrodesis and that the clinical and radiographic records were
complete. The “FitzPANTA plate” was made of 316L stainless steel, with a pre-contoured angulation of 120
degrees and tapered distally. The plate incorporated four 2.0/2.4 mm dynamic compression screw holes
proximally and distally. The screw holes immediately adjacent to the bend in the plate were ovoid to allow
for 25 degrees of screw angulation proximo-distal in the sagittal plane and 14 degrees axial-abaxial in the
transverse plane. Patients were operated in dorsal recumbency and all articular surfaces of the intertarsal
and tarso-metatarsal joints were debrided and packed with autogenous cancellous graft. The plate was se-
cured to the third metatarsal bone before the tibial screws were inserted, with the limb supported in appro-
priate sagittal plane alignment. The plate contour facilitated tight apposition to the angle of the tarso-crural
joint, thus enforcing appropriate talar positioning. Particular attention was paid to avoid disruption of the
dorsal perforating metatarsal artery. Screws were inserted in the calcaneus through each of the ovoid screw
holes (most proximally thorough the distal tibia) to secure appropriate limb alignment and to improve sta-
bility of the construct. A soft padded bandage was applied postoperatively in all cases for three days to lim-
it post-operative swelling and no further external coaptation was employed throughout the post-operative
period. Data pertaining to body weight, age, indication for surgery, time to radiographic fusion, complica-
tions, screw placement and bandaging were recorded. Radiographic evidence of fusion was determined as
visible trabecular bone bridging and attenuation of formerly definitive tarsal bone subchondral cortical out-
line on orthogonal radiographs. Clinical examination was performed at 2 and 6 weeks post operatively and
follow-up radiographs were obtained after six weeks and as repeated as necessary until fusion was docu-
mented.
RESULTS
Eleven cases met the inclusion criteria. Mean age at surgery was 46 months (range 14 to 173 months) and
mean body weight was 4.2kg (range 3.2 to 5 kg). Indications for surgery included tarsocrural instability
(n=11) and non-reconstructable fractures of the distal tibia and fibula (n=4), talus (n=2), and calcaneus
(n=1). 2.0 mm screws were employed in all holes for all cases. The arthrodeses were stable and pain free on
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palpation by 11 weeks (n=10) or 16 weeks (n=1). Complications occurred in three cases; skin infection
(n=1), skin ulceration over the plate (n=1) and screw loosening (n=1). Infection was managed successfully
with antibiotics and wound management whereas skin breakdown and screw loosening required repeat sur-
geries for wound reconstruction and screw removal respectively. The cat with the skin ulceration had sus-
tained severe soft tissue injury at the time of initial presentation. No instances of metatarsal fracture or plate
breakage were noted. Osseous union was documented by 6-11 weeks with a mean of 7.7 weeks. Time to full
functional limb use was 5.5 – 16 weeks with a mean of 8.6 weeks. All patients were affected by residual low
grade mechanical lameness but no behavioural manifestation of pain. All patients returned to full function
with outdoor free-range exercise capability restored.
CONCLUSION
This is the first study to specifically report the results of PANTA in a significant number of feline patients.
Metatarsal fractures have been associated with dorsal plating in canine PANTA, however this did not occur
B. Stapley WVOC 2010, Bologna (Italy), 15th - 18th September • 616
in any of the cases reported here. Other than a single case of screw loosening, implant failure was not seen
in any of our cases, suggesting that the “FitzPANTA” plate provided adequate stability to facilitate arthrode-
sis in these feline patients without the need for additional external coaptation. Complications only occurred
in 3/11 cases, which were easily resolved. The case of skin ulceration was associated with severe soft tissue
injury at the time of presentation and was deemed not related to the surgery. We feel that application of the
FitzPANTA plate is readily achievable, allows for greater tissue cover than medially applied plates, facilitates
limb alignment assessment and security intra-operatively and is a valid technique for achieving reliable and
robust PANTA in cats.
REFERENCES
DeCamp C, et al. Pantarsal arthrodesis in dogs and a cat: 11 cases. J Am Vet Med Assoc 1993;203:1705-1707.
Theoret M, Moens N.M.M. The use of veterinary cuttable plates for carpal and tarsal arthrodesis in small dogs and cats.
Can Vet J 2007;48:165-168.
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617 • WVOC 2010, Bologna (Italy), 15th - 18th September S. Stein
Computerized measurements of radiographic anatomical

parameters of the elbow joint of bernese mountain dogs
S. Stein, DrMedVet CertSAS1, H. Waibl, DrMedVet Prof2, L. Brunnberg, DrMedVet Prof3
1
Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
2
Department of Anatomy, University of Hannover, Hannover, Germany
3
Small Animal Hospital of the Free University Berlin, Berlin, Germany
INTRODUCTION
Elbow dysplasia (ED) is a common problem in larger and giant breeds of dogs. Disturbances of ossification
of the cartilage and asynchronous growth of the radius and ulna which cause an incongruity of the joint sur-
face have been discussed as causes of ED.
For successful therapy and selection for breeding, early detection of the initially mild changes in the elbow
joint is essential. Radiological parameters to predict the potential development of ED at a very young age,
based on joint anatomy, would be useful for prophylaxis and treatment.
The purpose of the present study was to comparatively evaluate the methods of VIEHMANN (1998) and
MUES (2001), which are designed to measure anatomical features of the elbow joint, in regards to their sen-
sitivity and practicality in diagnostic investigation and selection of breeding stock.

931 radiographs of elbow joints of 305 Bernese Mountain Dogs were available. The elbow joints were ED-
scored by an expert (ED-score 0 to 3 according to the IEWG). The radiographs were divided into 5 groups
on basis of the angle of flexion of the elbow: 0-30°, 31-60°, 61-90°, 91-120° and larger than 120°.
Measurement method according to MUES (modified)
The MUES method was established to characterise the elbow joint with objective measurements for evalu-
ation of genetic parameters in the Rottweiler and German Shepherd Dog. They were created to describe pri-
mary morphologic structures and not secondary osteoarthritic changes (comparative to the Norberg-angle
for hip dysplasia). The centre of the elbow joint/humeral condyle was identified with circles of different di-
ameters. Straight lines were drawn from this centre to landmarks within the elbow joint (most cranial point
of the anconeal process (a), most cranial point of the olecranon (b), joint gap between radius and ulna (c),
most cranial point of the radius (d)) and parallel to the radial diaphysis (e), which extends proximally over
the centre of the condyle.
The following angles were measured as described by MUES:
Angle OL:
The angle OL is measured between the axis-parallel to the radius (e) and the most cranial point of the ole-
cranon (a).
Angle PA:
The angle PA is measured between the most cranial point of the anconeal process (a) and the most cranial
point of the olecranon (b).
Angle UL:
The angle UL is measured between the most cranial point of the olecranon (b) and the joint space between
the head of the radius and the ulna (c).
Angle RA:
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The angle RA is measured between the most cranial (d) and most caudal point of the radial head (c).
Measurement method according to VIEHMANN

The VIEHMANN method was created to identify abnormal formation of elbow joints in Bernese Moun-
tain Dogs and Rhodesian Ridgebacks.
The following parameters were evaluated:

Radius of the humeral condyle:
The radius (R) of the humeral condyle can be regarded as a simple measure for the absolute size of the el-
bow joint.
Opening angle beta:
The size of the angle provides information about the molding of the trochlea notch. The smaller the open-
ing angle beta, the more elliptic is the trochlea notch.
S. Stein WVOC 2010, Bologna (Italy), 15th - 18th September • 618
Quotient Q:
The quotient Q provides information about the molding of the trochlea notch. The greater the quotient Q,
the more elliptic is the trochlea notch.
Quotient Ae:
The quotient Ae describes the molding of the trochlea notch. The greater the quotient Ae, the more elliptic
is the trochlea notch.
Area (X):
The percentage of the area of the humeral condyle that is encompassed by the trochlea notch is determined.
A cranial displacement of the humeral condyle decreases the percentage of the humeral condyle that is en-
compassed by the trochlea notch.
Step between radius and ulna (S1):
The distance between the plateau of the radius and the apex of the lateral coronoid process is measured in mm.
Step between radius and ulna (S2):
The dorsal margin of the radius is marked with a circle. This circle is scrolled up to the lateral coronoid
process and the distance is measured in mm.
RESULTS
The age of the Bernese Mountain Dogs at the time when the radiographs was taken, correlates highly sig-
nificant with the ED-score (p < 0.01; ED 0 = 558.93 days, ED 1 = 567.21 days, ED 2 = 677.60 days, ED
3 = 806.91 days).
MUES method:
The measured values of the angles OL, PA and RA and of the area X, step 1 and step 2 correlate highly
significant with the angle of flexion of the elbow joint (p = 0.004).
There is a significant correlation between angle OL (r = 0.127, p < 0.001), angle PA (r = 0.115, p < 0.001)
and angle RA (r = 0.187, p < 0.001) and the ED-score.
VIEHMANN method:
There is a highly significant correlation between ED-score and size of the radius of the humeral condyle (r
= 0.180, p < 0.001), opening angle beta (r = -0.248, p < 0.001), quotient Q (r = 0.275, p < 0.001) and quo-
tient Ae (r = 0.252, p < 0.001).
There is a significant correlation between step 1 and step 2 and the ED-score.
CONCLUSION
Secondary radiographical changes such as osteophytes and sclerosis of the trochlea notch are good indica-
tors of a FCP but only apparent as the disease progresses. For breeding stock selection at an early stage, ra-
diographic anatomy can be analysed.
The measured values by the method of MUES were significantly dependent on the positioning and the an-
gle of flexion and therefore elbow joints with different angles of flexion should not be compared. Dogs with
moderate to severe osteoarthritis (osteophytes on the proximal radius and anconeal process) could be de-
tected with the measurement methodology of MUES.
The results of this study show that the trochlea notch measured on the radiographs becomes increasingly
ellipsoid, as the ED-score increases. Whether it is the alteration of the shape of the trochlea notch in the
Bernese Mountain Dog to an ellipse as a congenital or developmental underlying cause for the high inci-
dence of elbow dysplasia in this breed, or if it indicates a secondary malformation of the elbow joint relat-
ed to enormous stress because of an ED, cannot be determined by this study. To estimate the predictive pow-
er of the quotient Q and Ae and the opening angle beta for an early selection for breeding, a prospective
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study in a representative population of dogs is necessary.

In conclusion the method of VIEHMANN seems valuable for the evaluation of radiographs of elbow joints
in the Bernese Mountain dog for elbow dysplasia, but further studies are necessary.
REFERENCES
Viehmann,B. (1998): Zur Diagnostik der Ellbogengelenksdysplasie beim Hund: Standardröntgen, Feinfokusröntgen und
computergestützte Auswertung, Vet Med Diss Berlin.
Mues C (2001): Charakterisierung und Vererbung des Arthroserisikos der Ellenbogengelenks-dysplasie (ED) beim Hund,
Vet Med Diss Gießen.
Dr. Silke Stein - University of Cambridge, Madingley Road, CB8 8HW Cambridge, United Kingdom
E-mail silkbat@aol.com
619 • WVOC 2010, Bologna (Italy), 15th - 18th September M. Stewart
The regulation of superficial zone protein/lubricin

expression in equine articular chondrocytes
M. Stewart, BVSc, PhD, FACVSc, E. Rawson, DVM, MS, T. Kuykendall, BS,
A. Stewart, DVM, MS, DiplACVS
Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois, Urbana, Illinois, USA
INTRODUCTION
Lubricin or Superficial Zone protein (SZP) is a highly glycosylated, mucinous protein secreted by synovio-
cytes and chondrocytes within the superficial zone of articular cartilage. SZP participates in boundary lu-
brication of diarthrodial joints. Its importance to normal articular function is reflected by the severe joint ab-
normalities that develop in individuals with SZP mutations (Marcelino et al 1999) and in mice lacking the
SZP gene (Rhee et al). In osteoarthritis (OA), the superficial zone of articular cartilage becomes fibrillated
and depleted of cells. Given the critical importance of SZP activities for normal joint function and the early
involvement of the articular cartilage surface layers in the OA pathology, it is likely that alterations in SZP
expression influence arthritic disease progression. This study was carried out to determine whether SZP ex-
pression is associated with the predominant biomechanical stimuli experienced by articular cartilage surfaces
(compression vs shear), to identify the critical cartilage-associated cytokines and growth factors that impact
SZP expression by articular chondrocytes and to determine the changes in SZP expression that occur in OA
cartilage.

Articular cartilage samples were isolated from the femoral condyles, trochlear ridges and patellar surface of
the stifle joints from skeletally mature horses and were snap-frozen immediately in liquid nitrogen. The car-
tilage was pulverised under liquid nitrogen and homogenized in a GITC-based buffer. Total RNA was iso-
lated using repeated phenol/chloroform extractions, followed by isopropanol precipitation and a column-
based ‘clean-up’, using a commercially available kit (RNeasy, Qiagen), as previously described (Stewart et al
2000). This procedure included a DNAse digestion step that removed any potential genomic contamination
of the final sample.
Articular cartilage was isolated from osteoarthritic and site-matched normal articular cartilage from four
adult horses euthanased with unilateral arthritic disease. The chondrocytes were isolated by sequential
trypsin/EDTA and collagenase digestion and were cultured as non-adherent aggregates (Stewart et al 2000)
for up to eight days. Total RNA was isolated using a similar protocol to that described above (Stewart et al
2004), although only a single phenol/chloroform extraction was required.
Chondrocytes were isolated from normal articular cartilage of skeletally mature horses by sequential
trypsin/EDTA and collagenase digestion and were cultured as non-adherent aggregates (Stewart et al 2000).
The aggregates were treated with the chondro-anabolic factors bone morphogenetic factor 2 (BMP-2;
100ng/ml), BMP-7 (100ng/ml), transforming growth factor b1 (TGF-b1; 10ng/ml) and insulin-like growth
factor 1 (IGF-1; 100ng/ml), or the catabolic agents interleukin 1b (IL-1b), IL-6 and tumor necrosis factor a
(TNFa), all at 10 &100 ng/ml, for up to 8 days. Total RNA isolation was as for the normal/OA chondrocyte
experiments above (Stewart et al 2004).
Changes in SZP mRNA expression in the cartilage specimens and the articular chondrocyte cultures were
assessed by real-time QPCR. SZP mRNA expression in normal and OA cartilage was assessed by QPCR
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(Oshin et al (2007). EF1? was used as a reference gene for these analyses. Statistical analyses of the QPCR
data were carried out using one-way ANOVA, followed, where indicated, by Bonferroni’s post-hoc tests.
RESULTS
SZP mRNA expression reflected the predominant loading forces experienced by the cartilage surfaces in the
equine stifle joint. SZP mRNA levels were approximately 10-fold higher at the patellar surface and femoral
trochlear ridges than at the tibial plateau. The femoral condyle cartilage cells (that experience both shear
and compressive loads) showed an intermediate level of expression.
The osteoarthritic chondrocytes consistently expressed less SZP mRNA than the contra-lateral normal chon-
drocytes after 4 and 8 days in culture; however, the inter-experimental variability was too great for statisti-
cal significance.
SZP expression in normal articular chondrocyte aggregate cultures was stable throughout the 8-day culture
intervals. Of the anabolic factors assayed, only TGF-b1 significantly increased SZP levels above control lev-
M. Stewart WVOC 2010, Bologna (Italy), 15th - 18th September • 620
els (10-fold increase after 4 days, 4-fold after 8 days), while BMP-7 reduced expression by approximately
60% at Day 8. All three catabolic factors significantly reduced SZP expression a both low (10 ng/ml) and
high (100 ng/ml) doses, however TNFa was substantially more suppressive than either interleukin, reducing
mRNA levels by approximately two logs. There was no obvious dosage effect; responses to the low-doses
were statistically equivalent to the high-dose effects.
CONCLUSION
The results indicate that SZP expression reflects the biomechanical loads experienced by articular surfaces,
with the femoral trochlear ridge and patellar surfaces (shear loads) expressing considerable more SZP than
the femoral and tibial condyles (compressive loads). The in vitro studies demonstrated that SZP expression
is not responsive to all recognized cartilage anabolic factors but appears to be selectively up-regulated by
TGF-b signalling. Given that the responsiveness of articular chondrocytes to TGF-b stimuli are reduced with
aging (Blaney Davidson et al 2005, Wei et al 1998), down-regulation of SZP expression might predispose
older individuals to arthritic disease. Of note, the articular pathologies in mice defective in cartilage TGF-b
signalling (Serra et al 1997) are similar in several respects to the changes seen in SZP-null mice (Rhee et al
2005) and may reflect a common role of reduced SZP expression in these transgenic models.
SZP expression was significantly suppressed by all three inflammatory cytokines assayed in this study, al-
though TNFa was noticeably more potent in this respect, reducing expression to near-undetectable levels.
These findings strongly suggest that SZP expression by articular chondrocytes is altered by increased in-
flammatory mediator release in joint disease and support the recent development of SZP as a therapeutic
agent for the treatment of arthritis.
REFERENCES
1. Marcelino J et al (1999). CACP, encoding a secreted proteoglycan, is mutated in camptodactylyarthropathy-coxa
vara-pericarditis syndrome. Nat Genet 23:319–322.
2. Rhee DK et al (2005) The secreted glycoprotein lubricin protects cartilage surfaces and inhibits synovial cell over-
growth. J Clin Invest 115:622-631.
3. Stewart MC et al (2000) Phenotypic stability of articular chondrocytes in vitro: The effects of culture models, BMP-
2 and serum supplementation. J Bone Mine Res 15:166-174.
4. Stewart MC et al (2004) Expression and activity of the CDK inhibitor p57Kip2 in chondrocytes undergoing hy-
pertrophic differentiation. J Bone Miner Res 19:123-132.
5. Oshin AO et al (2007) Phenotypic maintenance of articular chondrocytes in vitro requires BMP activity. Vet Comp
Orthop Trauma 20:185-191.
6. Blaney Davidson EN et al (2005) Reduced transforming growth factor-beta signaling in cartilage of old mice: role
in impaired repair capacity. Arthritis Res Ther 7:R1338-1347.
7. Wei X et al (1998) Age and injury-dependent concentrations of TGF-b1 and proteoglycan fragments in rabbit knee
joint fluid. Osteoarthritis Cart 6:10-18.
8. Serra R et al (1997) Expression of a truncated, kinase-defective TGFb type II receptor in mouse skeletal tissue pro-
motes terminal chondrocyte differentiation and osteoarthritis. J Cell Biol 139:541-552.
Dr. Matthew Stewart - University of Illinois Veterinary Clinical Medicine, 1008W Hazelwood Dr,
Urbana/Illinois/61802, United States - E-mail matt1@illinois.edu
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621 • WVOC 2010, Bologna (Italy), 15th - 18th September M. Stewart
TLR expression and activities in articular chondrocytes

M. Stewart, BVSc, PhD, FACVSc, A. Yates, DVM, A. Love, DYM, T. Kuykendall, BS
Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois, Urbana, Illinois, USA
INTRODUCTION
Septic arthritis follows infection of joint cavities by bacteria. Joint sepsis can result from intra-articular local-
ization of hematogenously disseminated bacteria or direct introduction of bacteria via wounds, arthrocente-
sis or during surgical procedures. In addition to severe pain, joint swelling and synovial inflammation, sep-
tic arthritis leads to rapid depletion of proteoglycans from articular cartilage.
Toll-like receptors (TLR) are critical components of the innate immune system and are activated by a range
of microbial ligands. TLRs 2 and 4 recognize cell wall components of Gram positive (lipoteichoic acid, pep-
tidoglycans) and Gram negative (lipopolysaccharides) bacteria, respectively. Both TLRs 2 and 4 are ex-
pressed by articular chondrocytes (Kim et al 2006), despite the avascular and alymphatic properties of ar-
ticular cartilage.
This study was carried out to determine the capacity of articular chondrocytes to directly respond to TLR
ligands. Specifically, the experiments were designed to determine 1. changes in TLR expression that occur
in joint sepsis, 2. the effects of specific TLR ligands on cartilage matrix turnover, 3. the effects of specific
TLR ligands on expression of putative matrix degradative enzymes by articular chondrocytes, and 4. the ef-
fects of TLR signaling blockade on chondrocyte responses to bacteria.

Articular cartilage was collected from the septic and contralateral uninfected joints of four horses, eu-
thanased because of septic arthritis without having received treatment for the disease. Total RNA was iso-
lated and the expression of TLRs 2 and 4 mRNAs in these septic and matched normal articular cartilage
specimens was determined by quantitative real-time PCR, as previously described (Oshin et al 2007).
Articular cartilage was also collected from several horses euthanased for reasons other than musculoskele-
tal disease, for the TLR ligand challenge experiments. Articular chondrocytes were isolated by collagenase
digestion and cultured as non-adherent aggregates (Stewart et al 2000). The aggregates were cultured in
basal medium for seven days, to allow neo-synthesis of a robust extracellular matrix, then exposed to vary-
ing concentrations of ultra-pure lipopolysaccharide (LPS 1-100 ng/ml), lipoteichoic acid (LTA 10-1000
ng/ml), peptidoglycan G (PepG 0.1-10 ug/ml) preparations, or heat-killed Staph aureus (Sa 106-108/ml) or-
ganisms for up to 72 hours. A neutralizing anti-TLR2 antibody (eBioscience) was used to assess the effects
of TLR2 blockade on chondrocyte responses to Staph aureus.
Changes in expression of collagen type II mRNA were monitored by Northern blot analyses (Stewart et al
2000). Proteoglycan release was assessed by DMMB assays. Changes in the expression of inflammatory me-
diators and degradative enzymes were determined by quantitative real-time PCR. Data were analyzed by
ANOVA.
RESULTS
TLR mRNA expression was consistently higher in septic articular cartilage specimens, when compared to
matched normal samples, indicating that TLR 2 and 4 expression is up-regulated in response to joint sepsis.
TLR expression was also significantly elevated in synovial samples isolated from the same cases.
Treatment of healthy articular chondrocyte aggregates with varying doses of LPS, LTA, PepG and HKSA
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for 72 hours resulted in dose-dependent down-regulation of collagen type II mRNA levels. DMMB analy-
ses showed similar responses, with dose-dependent increases in proteoglycan release from aggregates, fol-
lowing exposure to TLR ligands.
Quantitative PCR analyses of candidate MMP and ADAMTS enzymes induced by TLR ligands demon-
strated significant and dose-dependent increases in MMP 2, 3 and 13, and ADAMTS 1, 4 and 5 expression
following treatment with LPS, LTA and HKSA. In contrast, PepG had little or no effect on expression of
these genes at the doses used in this study. Finally, co-administration of an inhibitory TLR2 antibody to
chondrocyte aggregates exposed to heat-killed Staph aureus significantly attenuated the down-regulation of
collagen type II expression by the bacteria at all three antibody concentrations used.
CONCLUSION
The data indicate that TLR 2 and 4 expression is significantly increased in articular chondrocytes exposed
to clinical articular sepsis. Further, specific TLR ligands are able to directly impact cartilage matrix turnover
M. Stewart WVOC 2010, Bologna (Italy), 15th - 18th September • 622
and induce enzymes capable of degrading cartilage ECM. Finally, inhibition of TLR2 signaling had a pro-
tective effect on articular chondrocytes exposed to heat-killed bacteria. Collectively, these results indicate
that TLRs are major signaling factors involved in the catabolic effects of joint sepsis on articular cartilage,
and suggest that compromise to articular cartilage matrix integrity in septic arthritis could be prevented or
reduced by local TLR signaling inhibition concurrently with antimicrobial therapy to eradicate the primary
infection.
REFERENCES
Kim HA et al (2006) The catabolic pathway mediated by toll-like receptors in human osteoarthritic chondrocytes. Arthri-
tis Rheum 54:2152-2163.
Oshin AO et al (2007) Phenotypic maintenance of articular chondrocytes in vitro requires BMP activity. Vet Comp Or-
thop Trauma 20:185-191.
Stewart MC et al (2000) Phenotypic stability of articular chondrocytes in vitro: The effects of culture models, BMP-2 and
serum supplementation. J Bone Mine Res 15:166-174.
Dr. Matthew Stewart - University of Illinois Veterinary Clinical Medicine, 1008W Hazelwood Dr,
Urbana/Illinois/61802, United States - E-mail matt1@illinois.edu
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623 • WVOC 2010, Bologna (Italy), 15th - 18th September S. Ulusan
Treatment of radius-ulna and tibia fractures using

by circular external skeletal fixation system in 9 cats
O. Ozdemir, PhD, S. Ulusan, PhD Student, D. Mutluay, PhD Student, H. Bilgili, Prof. Dr., PhD
Dept. of Orthopaedics and Traumatology, Faculty of Veterinary Medicine, University of Ankara, Ankara, Turkey
INTRODUCTION
Throughout the second half of the 20th century, Dr Gavriil Abromovich Ilizarov developed a new method
and apparatus in the field of Orthopaedics and Traumatology. He created a new vision for the Orthopaedics
and Traumatology research field with his new method, and made developments in the field of soft tissue
and bone regeneration. The Ilizarov apparatus is a unique external fixation system that can be used in many
different fields (Bilgili et al 2007). The Ilizarov circular external skeletal fixator method has frequently been
used, especially for the last 20 years, for treatment of fractures in dogs (Ferretti 1991, Marcellin-Little 1999,
Lewis et al 1999, Bilgili et al 2006) and cattle (Ferretti 1991, Bilgili et al 2008). It is also used in the correc-
tion of angular deformities (Ferretti 1991), non-union fractures (Ferretti 1991), limb lengthening (Bilgili et al
2008), distraction osteogenesis, arthrodeses (Lewis et al. 1999), and bone transportation after tumour re-
sections.
The purpose of this study is presented Circular External Skeletal Fixation (CESF) System, designed by us,
in treatment of radius-ulna and tibia fractures in cats for first usage and shares all outcomes with our col-
leagues.

This study was carried out on 9 cats with complaint of tibia (7 cases) and radius-ulna (2 cases) fractures,
were brought to Ankara University, Faculty of Veterinary Medicine, Department of Orthopaedics and Trau-
matology. The Ilizarov apparatus was modified from a human type system (CESF, Tipsan, Turkey). The
apparatus was composed of ETAL-74 (94.5% aluminium, 1.5% magnesium, 4.5% copper). For cats, this
CESF System consists of 2 different types (full rings and 5/8 rings), 3 different diameters (35.0 mm, 45.0
mm and 55.0 mm) of rings and connection rods on 4.0 mm diameters together with 1.0 mm, 1.2 mm and
1.5 mm diameters Kirschner wires and 7 number nut-key for wire fixation bolts and nuts. Anterioposterior
and mediolateral radiographs were taken on both limbs of cases. The exact location of the fracture, the num-
ber of fragments in one fracture, the directions and locations of longitudinal fissures, appropriate ring di-
ameters, the number of rings to use, ring types, rod numbers, rod lengths, and suitable rod penetration lev-
els were determined from these radiographs. Vascular, neural, and anatomical structures of the cat radius-
ulna, and tibia were examined and safe pin penetration levels, directions, and suitable ring levels were de-
termined according to previous studies. The apparatus and whole set was prepared according to the case,
was mounted preoperatively, and was sterilized after the rehearsal. In this study, 45.0 mm diameters rings
for 4 cases of tibia fractures, 55.0 mm diameters rings for 3 cases of tibia fractures and 35.0 mm diameters
rings for 2 cases of radius-ulna fractures were used on their treatment. The cats were placed in lateral re-
cumbency. Skin of the fracture sites was shaved and prepared for aseptic surgery. The rings were positioned
perpendicular to the extremity at the center of the ring. For the application of the fixator 3 steps were con-
sidered. Firstly, the pins were located in the same plane i.e. having applied lateral oblique or medial oblique
pins for all rings, the second step was to check the level and position of the apparatus, whether it was posi-
tioned as specified in the preoperative planning, and the third step was the application of divergent pins. Ap-
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paratus, fragment, fixator positions and bone reductions were evaluated by taking radiographs postopera-
tively. Owners were advised to dress the pin penetration surfaces with 10% polyvidon-iode solution twice a
day. Massage and passive exercises on joints from top to bottom direction of the fracture site for 5 minutes
twice a day were also recommended. We contacted owners to obtain achieve information about the im-
provement of the cats clinical status. All cases where radiological consolidation was determined to be com-
plete by checking their two sided radiographs under general anestesia. No bandage was applied to limbs af-
ter the apparatus was removed; however, owners were advised to limit the movements of their cats for the
following 10-15 days.
RESULTS
Seven cases of tibia fractures and 2 cases of radius-ulna fractures were treated with circular external skeletal
fixator. A limited open reduction approach technique was done for all cases. In the postoperative follow-up
period, the cats seemed to tolerate the apparatus and the first usage of treated limb was observed on post-
S. Ulusan WVOC 2010, Bologna (Italy), 15th - 18th September • 624
operative 1st-3rd day for all cases. While the radiological consolidation was shown on postoperative 25th-
48th days, the apparatus was removed on postoperative 35th-55th days. In one case, superficial pin track in-
flammation was observed. None of the cases showed fixator or pin deformation, breakage, or distortion in
the apparatus configuration. According to the clinical and cosmetical outcomes, 7 cases (6 tibia and 2 radius-
ulna fractures) were evaluated “excellent” and a case (1 tibia fracture) was evaluated “good”, excepted for
pin tract infection.
CONCLUSION
As a conclusion, CESF System and its apparatus, designed by us, is determined reliable using on treatment
of radius-ulna and tibia fractures in cats.
REFERENCES
Bilgili, H., Dioszegi, Z., Csebi, P. (2006). Detailed preoperative planning for fracture treatment with Ilizarov method in
three dogs. Vet Comp Orthop Traumatol 3, 162-171.
Bilgili, H., Kurum, B., Captug, O. (2007). Treatment of radius-ulna and tibia fractures with circular external fixator in 19
dogs. Polish Journal of Veterinary Sciences 10, 217-231.
Captug, O., Bilgili, H., Kurum, B. (2008). Unifocal internal and external bone lengthening with circular external skeletal
fixator in 5 dogs. Polish Journal of Veterinary Sciences 11, 155-169.
Bilgili, H., Kurum, B., Captug, O. (2008). Use of a circular external skeletal fixator to treat comminuted metacarpal and
tibial fractures in six calves. Veterinary Record 163, 683-688.
Bilgili, H., Captug, O. (2009). Correction of the antebrachium deformity by using circular external skeletal fixator in 7
dogs. Polish Journal of Veterinary Sciences 12, 45-54.
Ferretti A (1991). The application of the Ilizarov technique to veterinary medicine. In: Bianchi-Maiocchi A and Aronson
J (eds). Operative principles of Ilizarov. Williams & Wilkins, Baltimore, pp 551-570.
Lewis, D.D., Radasch, R.M., Beale, B.S., Stallings, J.T., Lanz, O.I., Welch, R.D., Samchukov, M.L. (1999). Initial clinical
experience with the IMEXTM circular external skeletal fixation system. Part I. Use in fractures and arthrodeses.
Vet Comp Orthop Traumatol 12, 108-117.
Marcellin-Little, D.J. (1999). Fracture treatment with circular external fixation. Vet Clin North Am Small Anim Pract 29,
1153-1170.
Mr. Sinan Ulusan - Ankara University, Faculty of Veterinary Medicine Orthopaedics and Traumatology, Irfan Bastug
Cad. No: 9, Diskapi, 06110 Ankara, Turkey - E-mail sinanulusan@hotmail.com
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625 • WVOC 2010, Bologna (Italy), 15th - 18th September B. Van Thielen
Assessment of maxillofacial fractures in the dog using

cone beam computed tomography; an experimental
ex-vivo study
B. Van Thielen, Engineer in Medical Imaging1, F. Siguenza, Application Specialist2,
A. Gamelin, Veterinary Nurse3, B. Hassan, BDS, MSc4
1
Centre for Interactive MRI Education, Amiens, France
2
SiTech, Society of Medical Imaging Technology, Grenoble, France
3
Clinique Vétérinaire Eurolia, Ham, France
4
Academic Centre for Dentistry (ACTA), Amsterdam, The Netherlands
INTRODUCTION
The diagnosis and pre-operative planning of maxillofacial fractures with radiographs is often difficult due to
the superpositioning of anatomical structures, which makes that several important structures may not be
properly assessed. This is why Panoramic Radiographs have been regarded for a long time as the standard
for pre-operative planning in human craniofacial medicine (Roth et al., 2006). Computed Tomography of
the fractured region is therefore becoming useful due to the application of MultiPlanarReconstructions
(MPR) or Volume Rendering Technique (VRT) images (Markowitz et al., 1999 – Roth et al., 2005). A new
CT technology, Cone Beam Computed Tomography (CBCT), has recently been introduced in human max-
illofacial radiology and this gives the clinician the opportunity to make panoramic, MPR, VRT and dental
reconstructions in one scan. The principle of CBCT is based on a fixed x-ray source and detector with a ro-
tating gantry. The gantry bearing the x-ray source and detector rotates around the patient’s heads in full
360°, or sometimes, partial 180°-270° arcs. This technology has been developed due to the invention of the
practical cone-beam algorithm in the early eighties. These scanners are produced application specific, which
reduces the purchase costs and which makes that no particular radiographer skills are necessary. CBCT is
able to show a larger number of fracture lines and fragments compared with conventional images, and de-
picts precisely the position and orientation of displaced fragments (Shintaku et al., 2009). In comparison with
conventional CT, CBCT is more cost effective, whilst having a comparable image quality for the evaluation
of high-contrast structures (Manson et al., 1990). Panoramic dental reconstructions of the dog, made with a
CBCT device for supine patient positioning, were recently evaluated on image quality and potential utility
(Van Thielen et al., 2010). The aim of this study was to evaluate the assessment of maxillofacial fractures in
dogs using a human CBCT - unit.

A CBCT device for supine patient positioning (NewTom 3G™) was used for scanning ex-vivo the heads
of 4 dogs. The heads were amputated and frozen in the 24 hours after death and defrosted 24 hours prior
scanning. Before scanning artificial maxillofacial fractures were made using a chisel and a hammer. The iso-
lated heads were positioned with the occlusal plane perpendicular to the floor. Scans were performed us-
ing a FOV of 12”, 110 kV and mAs was depending of the dose-reduction system. MPR reconstructions
with a reconstruction width of 0.250 mm were made of all the 4 skulls in the 3 orthogonal planes using the
specific software. VRT reconstructions were made of all the 4 skulls. Panoramic reconstructions with a re-
construction width of 8 mm and in detail parasagittal reconstruction with a reconstruction width of 1 mm
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were made using the specific software. After scanning, radiographs were obtained in profile and face of
each skull using a standardized technique and image quality of the different reconstructions and radi-
ographs was subjectively assessed.
RESULTS
In dog 1 a fracture in the right ramus mandibularus was made, just below the coronoid process and the
condyle. In dog 2, a fracture of the body of the right madibule was made. In dog 3 a symphyseal separation
of the mandibular jaw was created and in dog 4 a fracture of the body of the right mandibule and of the
right maxillar jaw was created.
Panoramic, parasagittal, MPR and VRT reconstructions were obtained of the four dogs’ heads, as well as
radiographs in profile and face. A satisfying image quality was obtained for evaluating the fractured region
using the panoramic, MPR and VRT reconstructions. Concerning the parasagittal reconstructions, in dog
3 and 4, due to the high detail images, anatomical landmarks were lost and these views were less useful. The
B. Van Thielen WVOC 2010, Bologna (Italy), 15th - 18th September • 626
symphyseal separation of dog 3 was difficult to recognize on the radiographs and was only clearly visible
on the scan reconstructions. The fractures of the other 3 heads were clearly identifiable on the radiographs,
but showed increased detail and geometric localisation on the scan reconstructions.
CONCLUSION
A CBCT technology for supine patient positioning in human medicine was experimentally evaluated for the
assessment of mandibular and maxillofacial fractures in dogs. Images with satisfying quality for evaluation
of fractures were obtained of the fractured region. Panoramic, as well as MPR and VRT reconstructions ap-
pear to have a utility in the evaluation of maxillofacial fractures.
Images of the fractures had satisfying detail and contrast, where a recent evaluation of the utility of the same
CBCT device for imaging dental anatomy had some problems, concerning image quality, with the auto-
matically adapted mAs (Van Thielen et al., 2010).
Today CBCT is a commonly used diagnostic tool for human orthodontics, dentistry and it is of great help
in diagnosing and planning surgery in human maxillofacial medicine (Shintaku et al., 2009). Since several
years maxillofacial surgeons try to obtain a more precise reduction and treatment of fractures using intra-
operative CT (Manson et al., 1990) or Computer-Assisted Surgical Treatment (Westendorff et al., 2006).
With this objective CBCT technology was recently evaluated for intraoperative imaging (Heiland et al.,
2005). A major advantage of intraoperative CBCT is the low level of metal artifacts in comparison with CT
(Heiland et al., 2005). The linear and geometric accuracy of CBCT – technology for maxillofacial surgery
was recently evaluated in comparison with MDCT and appeared sufficient to achieve satisfying surgical re-
sults (Mischkowski et al., 2007). Using CBCT – technology for pre-surgical evaluation of maxillofacial frac-
tures in dogs could have a benefit when planning particularly complicated surgeries. Even intraoperative
scanning could be possible because of the manually handled table with laser lights. The huge advantage of
CBCT – technology in comparison with MDCT is the fact that supplementary panoramic reconstructions
can be made using a parabolic curve following the mandibular or maxillar arc. This experiment shows the
potential value of using CBCT – technology for the diagnosis and surgery planning of mandibular and max-
illofacial fractures in dogs.
REFERENCES
Heiland M., Shulze D., Blake F., Schmelzle R. (2005) Intraoperative imaging of zygomaticomaxillary complex fractures
using a 3D C-arm system. Int. J. Oral Maxillofac. Surg. 34, 369–375.
Manson P., Markowitz B., Mirvis S., Dunham M., Yaremchuk M. (1990) Tomward CT – based facial fracture treatment.
Plast. Reconstr. Surg. 85, 202–212.
Markowitz B., Sinow J., Kawamoto H., Shewmake K, Khoumehr F. (1999) Prospective Comparison of Axial Computed
Tomography and Standard and Panoramic Radiographs in the Diagnosis of Mandibular Fractures. Annals of Plas-
tic Surgery 43, 163-169.
Mischkowski R., Pulsfort R., Ritter L., Neugebauer J., Brochhagen H., Keeve E. and Zöller J. (2007) Geometric accura-
cy of a newly developed cone-beam device for maxillofacial imaging.
Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology 104, 551-559.
Roth F., Kokoska M., Awwad E., Martin D., Olson G., Hollier L., Hollenbeak C. (2005) The identification of Mandible
Fractures by Helical Computed Tomography and Panorex Tomography. Journal of Craniofacial Surgery 16, p
394–399.
Shintaku W., Venturin J., Azevedo B., Noujem M. (2009) Applications of cone-beam computed tomography in fractures
of the maxillofacial complex. Dental Traumatology 25, 358-366.
Van Thielen B., Siguenza F., Hassan B. (2010) Primarily results of Cone Beam Computed Tomography for dogs. Pro-
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ceedings of the European Veterinary Conference “De Voorjaarsdagen”, Amsterdam, 22 – 24 th April.

Westendorff C., Gülicher D., Dammann F., Reinert S., Hoffmann J. (2006) Computer-Assisted Surgical Treatment of Or-
bitozygomatic Fractures. Journal of Craniofacial Surgery 17, p 837-842.
Van Thielen Bert - Centre for Interactive MRI Education, 33, rue Philippe Lebon, 80000 Amiens, France
E-mail lafourbure@free.fr
627 • WVOC 2010, Bologna (Italy), 15th - 18th September N. Vecchio
Orthogonal evaluation of changes in tibial plateau angles

after tibial plateau leveling osteotomy in the cranial
cruciate deficient stifle of dogs. A ten-year review
N. Vecchio, DVM1, G. Hosgood, BVSc, MS, PhD, FACVSc, DACVS2,
L. Vecchio, Senior Veterinary Student3, T. Tobias, DVM, MS, DACVS1
1
Surgery Department, MedVet Memphis, Cordova, TN, USA
2
Murdoch University Veterinary Hospital, School of Veterinary and Biomedical Sciences, West Australia, Australia
3
Cátedra de Cirugía, Facultad de Ciencias Veterinarias, Universidad Nacional de La Plata, La Plata, Buenos Aires,
Argentina
INTRODUCTION
Cranial cruciate ligament (CCL) rupture in dogs is a common orthopedic condition. Several procedures
were described for stifle reconstruction. Techniques may be divided into intracapsular, extracapsular, and
techniques aimed at changing the geometry and biomechanics of the stifle regardless of the integrity of
the CCL.
Tibial plateau leveling osteotomy (TPLO) utilizes a curved osteotomy around the tibial plateau with re-
alignment of tibial plateau at a smaller angle relative to the long axis of the tibia. The tibial plateau angle
(TPA) measured from both pre- and post-operative radiographs, as described by Slocum1, is used by the sur-
geon to calculate the amount of rotation needed and to evaluate the angular reduction respectively2. Level-
ing the tibial plateau neutralizes cranial tibial thrust during the stance fase of normal gait3. For neutralization
to take place, the TPA should be reduced to 5 to 6.5°. A more recent report showed that TPAs up to 14° al-
low clinical results comparable to those achieved with TPA in the 5 to 6.5 o range4. We reviewed our ten-
year experience with the TPLO procedure recording postoperative changes in the TPA in orthogonal radi-
ographic views. Host factors, implant characteristics and TPLO technique features were also recorded.

Medical records from January 1st 1999 to December 31st 2008 were reviewed. Information recorded includ-
ed the dog’s age, sex, breed, and body weight, the pre-, postoperative and recheck TPA measured in medio-
lateral (mTPA) and caudo-cranial (cTPA) radiographs, time of recheck, tibial tuberosity pin placement (placed
through the tibial tuberosity at the insertion of the patellar tendon and across the osteotomy), type of implants
used, diameter of the osteotomy blade, and use (yes/no) of the alignment jig during surgery.
All radiographs met the standards described for measurement of the TPA1 and all TPAs were measured by
the same author.
All numerical data was summarized as mean and SD and quartiles. All categorical data was summarized as
frequencies and proportions. Each stifle was assumed an independent event.
For the purpose of statistical analysis, the differences in the mTPA from post mTPA - pre mTPA and from
recheck mTPA - post mTPA were calculated. The differences in the cTPA were calculated similarly. The ef-
fect of plate type, screw size, sex, weight, age (years), jig use (y/n), cranial pin use (y/n) were explored for an
effect on mTPA difference and cTPA difference using regression analysis. Age was rounded down to the
nearest year. Weight was categorized in 10 kg increments. Stepwise selection was used with the effect vari-
ables included at p<0.15 and retained at p<0.05.
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The post mTPA was categorized according to whether it fell within the clinically recommended range of
4-6 degrees. This response was assessed for an effect of plate type, screw size, sex, weight, age, jig (y/n),
cranial pin (y/n) using logistic regression. The estimated odds ratio and its 95% confidence interval was
reported for effect variables with a significant effect. Where a multilevel variable was significant, further
analysis using the same methodology was performed after categorization and comparison to a selected ref-
erence level.
RESULTS
Data from 364 stifles was included, 163 from male dogs (89 left-sided & 69 right-sided) and 201 from female
dogs (112 left-sided & 94 right-sided), 52 of them had bilateral TPLO. Mean weight (+/- SD) was 35.9 kg
(+/-9.8 kg). Mean age 5.4 years (+/-2.6 years). The TPLOs were performed using 4 different plate types:
Slocuma, Olmsteadb, TWOc, and Cobra Headb with various sizes and screw configuration. Tibial tuberosi-
ty pins were used (and left in place) in 289 stifles. Alignment jig was used in 309 stifles.
N. Vecchio WVOC 2010, Bologna (Italy), 15th - 18th September • 628
Overall, the mean pre mTPA (26.2° +/-4.7°) was significantly higher than the post mTPA (4.5+/-3.5°) which
was significantly lower than the recheck mTPA (7.2 +/-4.1°), p<0.001 respectively. The mean recheck time
was 56.5 (+/-73.7) days.
Examining the changes in mTPA according to plate type, this pattern remained for all plate types except the
Cobra and TWO plates where the recheck mTPA was not significantly different to the post mTPA.
Overall, the mean pre cTPA (4.1 +/-2.4o) was significantly higher than the post cTPA (2.7+/-2.2o) which
was significantly lower than the recheck cTPA (3.1+/-2.5o), p<0.001 respectively. Examining the changes
in cTPA according to plate type, this pattern remained for all plate types except the Cobra plate where
there were no differences and the TWO plate where the recheck cTPA was not significantly different to
the pre cTPA.
There was no significant association of any explored effect variables with the response variable mTPA dif-
ference or cTPA difference.
CONCLUSION
Our study shows that both the mTPA and cTPA, as measured by hand according to the description of
Slocum, do change during the recovery period and become on average, significantly higher than that meas-
ured immediately postoperative. This change was described to occur in the medio-lateral plane5. In our
study the mTPA appears to change regardless of the plate type used (although not achieving statistical sig-
nificance for Cobra and TWO plates) and does not appear to be associated with any of possible explanato-
ry variables examined in this study including age, weight, breed, sex, the pre-, postoperative and recheck
mTPA, cTPA, time of recheck, tibial tuberosity pin placement, type of implants used, diameter of the os-
teotomy blade, and use (yes/no) of the alignment jig during surgery.
Regarding the cTPA, there were no changes observed with the Cobra plate and changes did not reach sta-
tistical significance with the TWO plates. This information may be useful if correcting an angular deformi-
ty at the time of a TPLO is a concern.
Since in our study time at recheck (range 15 to 1082 days) did not affect the changes in TPA and a pre-
vious study5 evaluating the healing of the osteotomy did not find a significant difference in mTPA change,
we speculate that the change in TPA is caused by repositioning of the proximal fragment. This takes place
in the immediate post operative period. The absence of changes on mTPA when a fixed-angle fixation de-
vice, such as locking plates, is used6 supports this speculation. The larger the angle the higher the chances
of an operated stifle to have cranial tibial trust, which is recognized to be an indication of failure of the
TPLO procedure.
According to our findings the standardized tables for rotation of the tibial plateau should be adjusted ac-
cordingly to account for the loss of mTPA in the post-operative period depending on the type of plate used
for osteosyntesis.
REFERENCES
1. Slocum Enterprises, Inc. Tibial Plateau Leveling Osteotomy Seminar, 1999.
2. Headrick J, Cook J, Helphrey M, Crouch D, Fox D, Schultz L, Cook C, Kunkel J: A novel radiographic method
to facilitate measurement of the tibial plateau angle in dogs. Vet Comp Orthop Traumatol 2007; 20:24-28.
3. Slocum B, Devine T: Cranial tibial thrust: a primary force in the canine stifle. J Am Med Assoc 183:456-459, 1983.
4. Robinson DA, Mason DR, Evans R, Conzemius MG: The effect of tibial plateau angle on ground reaction forces
4-17 months after tibial plateau leveling osteotomy in Labrador Retrievers. Vet Surg. 2006 Apr;35(3):294-9.
5. Moeller EM, Cross AR, Rapoff AJ: Change in tibial plateau angle after tibial plateau leveling osteotomy in dogs.
Vet Surg 35:460-464, 2006.
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6. Vecchio NE, Vecchio LE, Tobias, TA, Singh A: Influence of locking plates in tibial plateau angle changes after TP-
LO in dogs with cranial cruciate ligament rupture. Proceedings VOS 2010, February 20-27, 2010. Breckenridge,
CO, USA.
Dr. Nicolás Vecchio - Medvet Memphis Surgery, 830 North Germantown Parkway, 38018 Cordova (TN), United States
E-mail nvecchio@medvetmemphis.com
a Slocum Enteprises Inc., Eugene, OR, USA.

b BioMedtrix, LLC. Boonton, NJ, USA.
c Jorgensen Laboratories, Inc. Loveland, CO, USA.
629 • WVOC 2010, Bologna (Italy), 15th - 18th September V. Viateau
Ovine anterior cruciate ligament (ACL) reconstruction

with a new bioactive device: in-vivo study
V. Viateau, DVM, PhD1,2, M. Manassero, DVM, MSc1,2, F. Anagnostou, PhD2,3,
J. Zhou, MSc 4, D. Mitton, PhD5, V. Migonney, PhD4
1
Centre Hospitalier Vétérinaire d’Alfort, Unité de chirurgie, Ecole Nationale Vétérinaire d’Alfort, Maisons Alfort, France
2
Laboratoire de Biomécanique et Biomatériaux Ostéoarticulaire UMR 7052, Paris, France
3
Faculté de Chirurgie Dentaire, Université Paris VII, Paris, France
4
Laboratoire de Biomatériaux et Polymères de Spécialité, CSPBAT CNRS FRE 3043, Université Paris 13, Paris, France
5
Arts et Métiers ParisTech, CNRS, LBM, Paris, France
INTRODUCTION
A multiplicity of surgical operations have been developed in an attempt to achieve satisfactory function af-
ter ACL repair in both human and veterinary surgery. High failure rates of prosthetic ligaments, have been
reported in human and animals and raise doubts about their use in knee stabilization after ACL rupture.
Yet, the use of artificial ligaments to stabilize knees after ACL rupture is an appealing strategy. The harvest
of the autograft which is currently considered in human knee surgery as the gold standard is indeed some-
times associated with significant morbidity at the donor site. The use of autograft has also given variable re-
sults for the stabilization of unstable stifle in dogs.
Tissue engineering strategies based on the elaboration of cell-seeded scaffolds are currently evaluated for
ACL reconstruction.
Surface grafting by a bioactive polymer (polyNaSS) of a polyethylene terephtalate (PET) artificial ligament
have given promising results in an in-vitro study showing that it enhanced human fibroblasts adhesion on
the polymer and allowed homogeneous distribution of cells along the polymer fabrics. However, the impact
of grafting on the intra-articular inflammatory response and on the biomechanical properties of the device
has not been studied in-vivo.
The purpose of the present study was to study the short term in vivo behavior of a grafted PET ligament
in a sheep model of ruptured anterior cruciate ligament (ACL) and compare them to the ones of a non graft-
ed PET ligament. We hypothesized that grafting would optimize in-vivo tissue ingrowth within the device
and subsequently improve its mechanical behaviour without generating an adverse inflammatory response.

29 two year old sheep (60kg) were obtained from a licensed vendor and reared in keeping with the guide-
lines published by the European Committee for Care and Use of Laboratory Animals.
The excision of the proximal third of the ACL and subsequent intra-articular joint stabilization with a 44
strands PET artificial ligament (LARS AC44-TM artifical ligament) (ultimate tensile stress = 2500 N) was
performed in the left stifle of each sheep which received either a PET ligament (Group 1, n=14) or a poly-
NaSS grafted PET ligament (Group 2, n=15). The type of device implanted was randomly assigned. De-
vices were implanted according to the procedure described in human. Briefly, the device was placed intra-
articularly through two 5 mm width femoral and tibial tunnels drilled from inside-out, at the site of the
femoral insertion and immediately behind the tibial insertion of the native ACL. Device fixation was pro-
vided with 6 mm titanium alloy interference screws, knees were ranged to ensure isometry. Once the screws
were secured, drawer sign was checked and the free extremities of the artificial ligament were cut flush with
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the surface of the bone.The joint was copiously lavaged before closure of the capsule with 3dec Polyglactin
interruped sutures. Fascia and skin were closed routinely.
Standard craniocaudal and mediolateral oblique X-rays were taken at the end of the surgical procedure; po-
sitions of the interference screw were noted.
A simple bandage was applied on the surgical wound and changed as needed until removal of the skin su-
tures 14 days after surgery. Animals were left free to ambulate without restriction for the whole length of the
experiment.
Orthopaedic examinations and synovial fluid collections and analysis were performed at monthly intervals
until sacrifice, three months post-operatively. Gait was observed at different strides and when present, lame-
ness was recorded. Animals were then anesthetized and both stifles were palpated for comparison and sev-
eral parameters were recorded: (i) stifle diameters; (ii) thigh circumferences; (iii) angles of mobilization in
flexion-extension; (iv) presence of a positive cranial drawer sign. Synovial fluid samples were collected un-
der aseptic conditions and evaluated for cytology, glucose and protein dosages
V. Viateau WVOC 2010, Bologna (Italy), 15th - 18th September • 630
Specimens were then explanted and processed for either: (i) histology to assess under standard and polar-
ized light microscopy tissue ingrowth, cellularity and presence of wear debris in the intra-articular portion
of the device;(ii) Collagen I and III gene expression by RT-PCR and; (iii) biomechanical tests including load-
ing to failure in tension.
Quantitative data were analyzed by performing a Mann-Whitney-test. The confidence interval was set at
95%, and the significance level at p< 0.05.
RESULTS
Functional recovery was excellent in all animals in which normal weight bearing was observed at all strides
within 15 days of surgery.
Monthly postoperative orthopaedic examinations showed constant normal weight bearing in all but one an-
imals (which showed occasional intermittent lameness at running), at all strides.The stiffle was not painful
when palpated or mobilized. No significant differences between diameter of the thighs could be evidenced
and anterior drawer sign was absent in all but the animal in which lameness was observed.The volume of
synovial fluid collected at different examinations did not differ significatively between groups. In both
groups, cellularity and protein contents in the synovial fluid increased for the first two operative months and
decreased until sacrifice 3 months postoperatively. At that time, they remained above the normal physiologic
values.
At the time of explantation, three months postoperatively, all artificial devices were entirely covered by a thin
connective tissue layer and native ligament’s fibers could not be distinguished from the artificial ligament’s
fibers. Similar capsular hypertrophies were observed in sheep implanted with ungrafted and grafted devices.
Inflammatory reactions were similar and no wear debris were seen. Grafting thus did not generate adverse
inflammatory response.
Cellularity and presence of wear particles (which were few and inconsistently observed) were similar be-
tween grafted and ungrafted devices. More uniform tissue ingrowth and higher collagen III/I expression ra-
tios were found in grafted devices compared to ungrafted devices.
Loading to failure in tension: Failure loads in tension tended to be superior in grafted devices compared to
ungrafted devices (188 ±52N and 113±70N, respectively). However, failure loads of both devices were in-
ferior to the one of native ligament (1276 ± 238N).
CONCLUSION
Ligament modification by grafting polymerization did not generate superior inflammatory response com-
pared to ungrafted ligaments in a sheep model of ACL rupture. More uniform tissue ingrowth and higher
collagen III/I gene expression were obtained 3 months postoperatively. PolyNaSS grafting can be used for
designing ligament tissue-engineered constructs. Use of the grafted LARS AC-TM artificial ligament is an
appealing strategy for intra-articular stabilization of anterior cruciate ligament rupture in dogs. It is current-
ly under evaluation in our faculty.
REFERENCES
Ciobanu, M. et al. (2006). “Radical graft polymerization of styrene sulfonate on poly(ethylene terephthalate) films for
ACL applications: “grafting from” and chemical characterization.” Biomacromolecules 7(3): 755-60.
Migonney, V. et al. (2007). “Bioactive poly(ethylene terephthalate) fibers and fabrics: grafting, chemical characterization,
and biological assessment.” Biomacromolecules 8(11): 3317-25.
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Dr. Véronique Viateau - Centre Hospitalier Vétérinaire d'Alfort, Ecole Nationale Vétérinaire d'Alfort
Unité de Chirurgie, 7 Avenue du Général De Gaulle, 94700 Maisons Alfort, France
631 • WVOC 2010, Bologna (Italy), 15th - 18th September G. Viefhues
The complication rate of the HELICA-HIP-endoprosthesis

is 8.1% in 37 cases
G. Viefhues, Dr., P. Winkels, Resident ECVS
Private Practitioner, Ahlen, Germany
INTRODUCTION
Hip dysplasia, acute or chronic hip luxation and acetabular fractures are common causes of coxarthritis in
dogs.1 An accepted method of treatment is total hip replacement. Different types of total hip replacement
systems, cemented and cementless are available with various complication rates between 3.8-22%.2-4 The
most frequent complications are luxations, infections, septic and aseptic implant loosening, femoral fractures
and bone infarcts.
Recently a screw prosthesis, HELICA-HIP-endoprosthesis (Innoplant, Hannover, GERMANY) (HHE),
for total hip replacement was developed.5 This screw prosthesis is a cementless system, with a threaded cup
component and a threaded stem allowing for high primary stability.
The purpose of this study was to determine and report the complication rate of the HHE.

Medical records (May 2007 – March 2009) of dogs that underwent total hip replacement with the screw
prosthesis were reviewed looking for complications.
The HHE was implanted according to the technique described by HACH and DELFS.5
Clinical and radiographic assessment was routinely performed after 6 weeks and 6 months.
RESULTS
In 34 dogs 37 total hip replacements with HHE were preformed by one single surgeon (GV).
There were 20 females and 14 males. Median weight was 36.8 kg (range, 22.5 – 50.5 kg) and median age
was 4.75 years (range, 1.5 – 10.5 years). Breed distribution was Labrador (n = 10), mixed breed (n = 9),
Golden Retriever (n = 6), German Shepherd (n = 3), Rusian Terrier (n = 2), Rottweiler (n = 2), Canadian
Shepherd (n = 2) and 1 each of Magyar Viszla, Muensterlaender, and Bernese Mountain Dog.
No minor complications were noted like seroma formation, sciatic neuropraxia or delayed wound healing.
Three major complications occurred in three total hip replacements:
- osteomyelitis
- stem loosening,
- stem and cup loosening
All three prosthesis were removed and treated with hip resection arthroplasty.
The overall complication rate was 8.1 % (3/37).
In the remaining 34 cases function has been restored and no signs of radiolucency or osteosclerosis at the 6
week and 6 month follow up were obvious.
CONCLUSION
In 8.1 % of the treated hips with total hip replacement using the HHE major complications were present.
Considering this surgery as an elective procedure the complication rate appears relative high. However, re-
ported complication rates of 23% for cemented (3), 17% for cementless (4) hip systems and 3.8 – 11% of all
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total hip prostheses (2) let this complication rate look reasonable.
One of the most common complications is luxation, which is often contributed to surgical error, inappro-
priate management and trauma. In this study there was no luxation present, which might be due to the spe-
cial design of the acetabular component. A slight undercut in the inlay leads to a certain fixation of the head
within the inlay.
No fracture occurred during or after surgery. In contrast to other stems fixed within the femoral bone canal
the HHE is placed in the centre of the femoral neck and metaphysis and therefore probably reproducing a
closer physiologic force distribution. Furthermore this site of placement and the compatibility to other total
hip replacement systems leaves room for revision surgery with a stem fixed in the proximal femoral bone
canal.
Osteomyelitis occurred in one dog (2.7%), which is comparable to other reports (1 to 4.7%).6, 7
Stem loosening occurred twice and started in both cases at the stem end close to the lateral cortex of the fe-
mur. This could be a particular problem of this kind of prosthesis. When the collar of the stem does not
G. Viefhues WVOC 2010, Bologna (Italy), 15th - 18th September • 632
have uniform contact to the cortex of the osteotomy surface, consequently micromotions at this point might
be possible. At the end of the stem close to the lateral cortex these motions would exacerbate as the stem is
working as a lever arm.
In the case of stem and cup loosening we assume that the cup followed the loosed stem due to the fixation
of the head in the acetabular component.
In all cases the prosthesis were removed. This was an easy and quick procedure compared to the removal
of cemented prosthesis or cementless titanium prosthesis fixed with locking screws.
Limitations of this study were the limited case number and the short term follow up (6 month). The ob-
tained data should be interpreted as preliminary results. Further studies with a higher amount of cases, dif-
ferent surgeons and long term follow up are required to obtain more reliable data.
In our hands the HHE is a quick and relative simple technique as total hip replacement. Due to its screw
mechanism the cup can be adjusted if misplacement occurs. Nevertheless rules for cementless total hip re-
placement, like retroversion, opening of the cup and anteversion of the stem respectively should be impera-
tively respected. The complication rate is comparable with reported complication rates.
REFERENCES
1. Parker RB, Bloomberg MS, BitettoW. Canine total hip arthroplasty: a clinical review of 20 cases. J Am Anim Hosp
Assoc 1984;20:97-104.
2. Conzemius MG, Vanderfoort J. Total Joint Replacement in the Dog. Vet Clin Small Anim. 2005; 35: 1213-1231.
3. Bergh MS, Gilley RS, Shofer FS, Kapatkin AS. Complications and radiographic findings following cemented total
hip replacement. A retrospective evaluation of 97 dogs. V.C.O.T. 2006; 19:172-9
4. Guerrero T, Montavon P. Zurich Cementless Total Hip Replacement: Retrospective Evaluation of 2nd Generation
Implants in 60 Dogs. Vet Surg 2009; 38:70-80
5. Hach V, Delfs G. Initial experience with a newly developed cementless hip endoprosthesis. V.C.O.T. 2009; 22:153-
158.
6. Montgomery RD, Milton JL, Pernell R, et al. Total hip arthroplasty for treatment of canine hipdysplasia. Vet Clin
N Am 1992;22:703-19.
7. Nelson JP, Glassburn AR Jr, Talbott RD, et al. The effect of previous surgery, operating room environment and
preventive antibiotics on postoperative infection following total hip arthroplasty. Clin Orthop Relat Res 1980;
147:167-9.
Gereon Viefhues - Tierärztliche Klinik Ahlen, Bunsenstraße 20, 59229 Ahlen, Germany
E-mail gereon.viefhues@tierklinik.ahlen.de
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633 • WVOC 2010, Bologna (Italy), 15th - 18th September H. Werner
Geometric change of the humeroradial and humeroulnar

articulation following dynamic proximal ulnaosteotomy
in dogs affected by radioulnar incongruence
H. Werner, DVM, S. Bräuer, DVM, G. Oechtering, Professor, P. Böttcher, Diplomate ECVS
Department of Small Animal Medicine, Faculty of Veterinary Medicine, University of Leipzig, Leipzig, Germany
INTRODUCTION
Radioulnar incongruence (RUI) which leads to humeroradial and humeroulnar incongruence is believed to
play a major role in the pathogenesis of elbow dysplasia (ED), mainly fragmentation of the medial coronoid
process (FCP) and / or medial compartment disease. A lot of work has been done, focusing on precise esti-
mation of RUI both in-vitro and in-vivo1-5, attesting high accuracy and reliability at least in vitro for
arthroscopy and CT based three dimensional (3D) image renderings of the radioulnar articulation6-8. De-
tailed appreciation of the present joint deformity is of special relevance in those cases in which osteotomies
are considered to be part of the treatment plan. Such osteotomies aim at unloading the medial aspect of the
elbow joint and at correcting incongruence leading to balanced joint load, improved fit of the opposing joint
surfaces and increased load bearing area. Among the available osteotomies radial lengthening or dynamic
proximal ulna osteotomy (DPUO) have been proposed either in case of severe (> 2mm) RUI or in case of
treatment failure following conservative or surgical treatment, when overloading of the medial compartment
has to be subjected9. Aim of the present study was to characterise the change in geometric shape of the
humeroradial and humeroulnar articulation following DPUO in dogs affected by RUI. Therefore, we meas-
ured the width of the subchondral humeroulnar and humeroradial joint space at each point of the radioul-
nar joint surface using CT based 3D image renderings of the elbow joint before and after healed DPUO.

12 adult middle to large bread dogs with thoracic limb lameness suspicious for ED on physical examination
and orthogonal radiographs of the elbow joint were included. For final inclusion CT and arthroscopy had
to reveal a FCP, eburnation of the cartilage at the medial humeral condyle and the medial coronoid process
(MCP), and a positive RUI = 2mm. Subtotal coronoid ostectomy (SCO) was performed either arthroscop-
ically or via arthrotomy, followed by DPUO via a caudolateral approach to the proximal ulna. No stabili-
sation of the ulna was performed allowing three-dimensional movement of its proximal part. Before DPUO
and after complete bony union of the DPUO a CT scan of the elbow joint was acquired in dorsal recum-
bency with the elbow joint at an angle of ~ 135°. Based on these data, 3D surface models of the elbow joint
pre- and postoperatively were calculated using dedicated image analysis software based on the Visualization
Tool Kit (Kitware Inc., New York, NY, USA). Finally the width of the subchondral humeroulnar and
humeroradial joint space was calculated using a specially developed image algorithm. The resulting values
were projected onto the radioulnar joint surface of the respective 3D models and colour coded using a scalar
from 0.0 to 5.0 mm. Further enhancements as well as inspection of the 3D models were performed using
Para View (Kitware Inc., New York, NY, USA). The 3D image renderings and the given subchondral joint
width pattern were semiquantitatively analysed by two observers (HW, PB) using the following criteria:
- RUI at the MCP and the lateral coronoid process (step)
- width of the subchondral joint space (SJS) of the proximal radioulnar articulation (especially laterally)
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- width of the SJS of the humeroradial and humeroulnar articulation

o at the medial and lateral coronoid process
o at the cranial, caudomedial and caudolateral radial head
o at the medial and lateral aspect of the anconeal process
RESULTS
Following DPUO RUI at the MCP decreased in all cases, while RUI at the lateral coronoid process in-
creased. Therefore the RUI present preoperatively was not completely reduced in any case. Collapse of the
humeroradial and humeroulnar SJS, indicated by a small width (< 0.5 mm), was seen preoperatively at the
cranial and caudolateral aspect of the radial head and the MCP. Following DPUO the SJS width at the
humeroradial articulation was smallest at the cranial and medial aspect of the radial head, while the previ-
ously collapsed caudolateral aspect showed an increased SJS width. Following DPUO the area of focal joint
collapse at the MCP changed to a more homogeneous pattern of moderate SJS width, possibly in return to
H. Werner WVOC 2010, Bologna (Italy), 15th - 18th September • 634
complex tilting of the proximal ulnar segment with subsidence of the MCP and elevation of the lateral coro-
noid process in respect to the radial head. While rotation of the proximal ulna did occur along all three ax-
es, SJS width at the anconeal process decreased medially and increased laterally. In all cases the SJS width
at the proximal radioulnar articulation increased laterally.
CONCLUSION
Semiquantitative evaluation of CT based 3D image renderings in combination with the calculation of the
SJS width of the humeroradial and humeroulnar articulation offer the potential to assess the complex alter-
ation of 3D shape of the elbow joint in dysplastic dogs as well as to evaluate the success of corrective or
modifying osteotomies, such as DPUO. Our preliminary results show that following DPUO the expected
congruent alignment of radius and ulna due to distal translation of the ulna does not take place. However,
areas of SJS collapse present at the MCP preoperatively changed to areas with increased SJS width postop-
eratively. The observed change in joint space width pattern at the radial had indicates a shift and twist of
the humerus in respect to the radius. Medial and cranial tilting of the proximal ulna segment results in a
varus deformation of the elbow. The widening of the SJS width at the lateral proximal radioulnar articula-
tion is the result of rotation of the ulna around its longitudinal axis. Overall DPUO resulted in a complex
rotational movement of the proximal ulna segment whereas we were not able to detect a significant axial
translation, the latter being a prerequisite for restoration of radioulnar joint congruence. Nevertheless, a
more homogeneous distribution of SJS width at the medial coronoid process was detectable following
DPUO. Assuming that the width of the SJS and the area of small SJS correlate with intraarticular load dis-
tribution, an elbow joint with obvious RUI preoperatively seem to be functionally more congruent follow-
ing DPUO, despite persistent or even increased incongruence, when compared to a normal joint.
REFERENCES
1. Mason, D.R., et al., Sensitivity of radiographic evaluation of radio-ulnar incongruence in the dog in vitro. Vet Surg,
2002. 31(2): p. 125-132.
2. Kramer, A., et al., Computed tomographic evaluation of canine radioulnar incongruence in vivo. Vet Surg, 2006.
35(1): p. 24-29.
3. Gemmill, T.J., et al., Evaluation of elbow incongruency using reconstructed CT in dogs suffering fragmented coro-
noid process. J Small Anim Pract, 2005. 46(7): p. 327-333.
4. Gemmill, T.J., et al., Use of reconstructed computed tomography for the assessment of joint spaces in the canine el-
bow. J Small Anim Pract, 2006. 47(2): p. 66-74.
5. Holsworth, I.G., et al., Accuracy of computerized tomographic evaluation of canine radio-ulnar incongruence in vit-
ro. Vet Surg, 2005. 34(2): p. 108-113.
6. Wagner, K., et al., Radiographic, computed tomographic, and arthroscopic evaluation of experimental radio-ulnar
incongruence in the dog. Vet Surg, 2007. 36(7): p. 691-698.
7. Bottcher, P., et al., Visual estimation of radioulnar incongruence in dogs using three-dimensional image rendering:
an in vitro study based on computed tomographic imaging. Vet Surg, 2009. 38(2): p. 161-8.
8. Werner, H., et al., Sensitivity and specificity of arthroscopic estimation of positive and negative radio-ulnar incon-
gruence in dogs. An in vitro study. Vet Comp Orthop Traumatol, 2009. 22(6): p. 437-41.
9. Fitzpatrick, N. and R. Yeadon, Working algorithm for treatment decision making for developmental disease of the
medial compartment of the elbow in dogs. Vet Surg, 2009. 38(2): p. 285-300.
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Mr. Hinnerk Werner - Departement of Small Animal Medicine, University Leipzig, An den Tierkliniken 23,
04103 Leipzig, Germany, Germany - E-mail h.werner@kleintierklinik.uni-leipzig.de
635 • WVOC 2010, Bologna (Italy), 15th - 18th September P. Winkels
Prospective evaluation of the leipzig stifle distractor

in 64 cases – A multicentre study
P. Winkels, Resident ECVS1, A. Pozzi, Dipl. ACVS2, R. Cook, DVM3,
G. Oechtering, Dipl. ECVAA1, P. Böttcher, Dipl. ECVS1
1
Department of Small Animal Medicine, Faculty of Veterinary Medicine, University of Leipzig, Leipzig, Germany
2
College of Veterinary Medicine, University of Florida, Gainesville, Florida, USA
3
Private Practitioner, St Charles, Illinois, USA
INTRODUCTION
The incidence of medial meniscal tears secondary to cranial cruciate ligament (CrCL) insufficiency has been
reported as high as 77%.1 As the exposure of the caudal horn of the medial meniscus (CMM) is often difficult,
probing of the meniscus has been advised to improve diagnostic accuracy of both arthroscopy and arthroto-
my.2 Arthroscopy is considered the diagnostic method of choice for meniscal diagnosis with a sensitivity of
80%.2 Joint manipulation and distraction are recommended to improve the visualization of the CMM.3
The aim of this study was to evaluate the effect of joint distraction using the Leipzig Stifle Distractor (LSD)
(STORZ Endoscopes®, Tuttlingen, Germany) on CMM exposure and on accuracy of meniscal diagnosis
during stifle arthroscopy in dogs with CrCL insufficiency. In each dog the extent of the exposed CMM was
compared between meniscal examination with or without joint distraction.
The number of meniscal tears diagnosed with or without distraction were also recorded. Our hypothesis
was that joint distraction would increase exposure of the CCW and diagnostic accuracy for meniscal tears
compared to manual maneuver.

Dogs
Dogs with hind limb lameness and a tentative diagnosis of CrCL insufficiency presenting to 3 veterinary
hospitals were prospectively enrolled in the study.
Arthroscopy
In all dogs stifle arthroscopy was performed as described using a 2.7 mm or 4.0 mm 30° fore oblique arthro-
scope.4 Debridement of the fat pad and torn CrCL was performed as needed to expose the medial com-
partment. First, the medial meniscus was examined using a manual maneuver to distract the medial com-
partment. Then, the LSD was used to distract the joint and expose the meniscus. This sequence was re-
peated for each dog.
Manual maneuver Procedure
Manual maneuver procedure (MMP) was performed either performing valgus stress on the stifle and ex-
ternal rotation of the tibia or using the tibial compression test.4
Distraction with the Leipzig Stifle Distractor
The LSD is applied on the medial aspect of the joint wih a pin in the femur and a pin in the tibia as de-
scribed by Boettcher et al.3 Pin placement was performed either prior to arthroscopy or prior to LSD appli-
cation up to the surgeon’s preference. Distraction was stopped when the opening of the medial joint space
was judged to be adequate or if the tension applied to the distractor was felt to be excessive.
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Outcome measures
Pin placement
Time was clocked and the subjective level of difficulty was noted when placing the 2 pins for the LSD.
Probe measurements
To extent of the exposed CMM was measured before and after distraction using a meniscal probe (Probe,
Small Joint Hook Tip, Arthrex Vet System®, Naples, Florida, USA) with a 2 mm scale and a 2 mm long tip.
Radial measurements were undertaken perpendicular from the inner rim towards the outer border of the
CMM. Measurement 1 was performed in the craniocaudal middle of the medial meniscus, measurement 3
at the caudal meniscus ligament junction and measurement 2 was done in between measurement 1 and 3.
The largest distance with visible tip from the probe was documented in mm and a picture was taken. The
measurement could be done with the calibrations on the shaft or the tip of the probe. Each of the 3 meas-
urements performed firstly with MMP and in a second step in the distracted joint space using the LSD.
P. Winkels WVOC 2010, Bologna (Italy), 15th - 18th September • 636
Arthroscopic findings
Meniscal tears diagnosed with and without distraction were documented. Partial or complete CrCL tears
were documented and in case of a partial tear it was up to the surgeon to leave the CrCL remnant or re-
move the CrCL remnant.
Statistical Analysis
Measurements 1, 2 and 3 taken during MMP and under distraction were added respectively and the dif-
ference was analyzed using the Wilcoxon signed-rank test, as normal distribution was disapproved.
RESULTS
64 dogs were enrolled in the study. The mean (+/- SD) weight was 35 kg (+/- 11) and mean (+/- SD) age
was 5 years (+/- 2). 30 left and 34 right stifles were examined. 54% (n = 35) of the patients had a complete
CrCL rupture, 2% (n = 1) with intact CrCL and 44% (n= 29) had a partial rupture. In 14% (n = 9) of the
cases a stable remnant of the CrCL was not debrided. Pin placement took in average 1.5 minutes and the
placement was judged to be easy in 90% and moderate in 10% of the cases. The visible part of the medial
meniscus increased significantly (p = 0,000) using the LSD compared using the MMP.
During MMP 31 meniscal tears were detected, whereas using the LSD 40 meniscal tears were noticed. From
these additional 9 meniscal tears in 6 cases there was no meniscal tear visible at the time of MMP but un-
der distraction. In 3 cases there was one type of meniscal tear visible during MMP and 3 additional tears
became obvious during distraction of the medial compartment.
CONCLUSION
This study showed a significant increase in exposure of the CMM when using the LSD compared to limb
manipulation with valgus stress and external rotation alone. The improved exposure of the CMM allowed
increasing diagnostic accuracy of arthroscopy, showed by the greater number of tears that were diagnosed
using LSD. Without distraction 9 meniscal tears (22% of all tears) would have been missed despite probing.
This result is in agreement with a previous ex vivo study that reported an 80% of sensitivity of meniscal di-
agnosis using arthroscopy and probing without distraction. Non-displaced vertical tears in the abaxial region
of the medial meniscus may be missed without distraction if a cranial port is used. By exposing the abaxial
rim, the LSD allowed to visualize peripheral tears more easily.
The study population is representative of the population of dogs undergoing stifle arthroscopy for CrCL in-
sufficiency, as suggested by the mean bodyweight of 35 kg. Partial rupture of the CrCL was detected in 44%
which is more compared to Ralphs and Whitney who had 80% complete and 20% partial tears.5
Placements of the pins were considered simple and quick and no complications occurred in any case.
Beside the mentioned objective measurable parameters all 3 surgeons (PW, AP, RC) reported a much easi-
er and quicker removal of the affected CMM with no or only superficial cartilage damages due to the in-
creased joint space. Besides the possibility using hand instruments and a shaver for meniscus removal with-
in the opened joint space, distraction allowed for easier meniscal repair, which was done in 1 case.
Distraction of the medial compartment of the stifle joint, using the LSD is easy and quick, leads to better
exposure of the CMM, improves meniscus diagnostic accuracy and produces less cartilage damage when
meniscus surgery is performed.
ACKNOWLEDGMENTS
The authors gratefully acknowledge the provision of the Leipzig Stifle Distractors by STORZ endoscopes®.
REFERENCES
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1. Flo GL. Meniscal injuries. Vet Clin North Am Small Anim Pract. 1993 Jul;23(4):831-43.
2. Pozzi A, Hildreth III BE, Rajala-Schultz PJ. Comparison of arthroscopy and arthrotomy for diagnosis of medial
meniscal pathology: an ex vivo study. Vet Surg. 2008;37(8):749-55.
3. Bottcher P, Winkels P, Oechtering G. A novel pin distraction device for arthroscopic assessment of the medial
meniscus in dogs. Vet Surg. 2009 Jul;38(5):595-600.
4. Beale BS, Hulse DA, Schulz KS, Whitney WO. Small animal arthroscopy. Philadelphia, Pennsylvania: Elsevier Sci-
ence; 2003.
5. Ralphs SC, Whitney WO. Arthroscopic evaluation of menisci in dogs with cranial cruciate ligament injuries: 100
cases (1999-2000). J Am Vet Med Assoc. 2002 Dec 1;221(11):1601-4.
Mr. Philipp Winkels - Department of Small Aninmal Medicine, Faculty of Veterinary Medicine, University of Leipzig,
An Den Tierkliniken 44, 04103 Leipzig, Germany - E-mail winkels@kleintierklinik.uni-leipzig.de
637 • WVOC 2010, Bologna (Italy), 15th - 18th September S. Zoi
The effect of titanium mesh in the management

of segmental long bone defect: an experimental study
in a canine model
S. Zoi, DVM1, S. Papadimitriou, DVM, DDS, PhD - Assistant Professor2, A. Galatos, DVM, PhD
- Associate Professor1, N. Prassinos, DVM, PhD - Assistant Professor2, M. Dalstra, MEng, DrMedSc
Associate Professor3, A. Stavropoulos, DDS, PhD, - Associate Professor4,5
1
Clinic of Surgery, Faculty of Veterinary Medicine, University of Thessaly, Trikalon 224,Gr-43100, Karditsa, Greece
2
Companion Animal Clinic, Faculty of Veterinary Medicine, Aristotle University of Thessaloniki, St. Voutyra 11,Gr-54627,
Thessaloniki, Greece
3
Department of Orthodontics, School of Dentistry, University of Aarhus, Vennelyst Boulevard 9 Dk-8000, Aarhus C,
Denmark
4
Department of Periodontology and Oral Gerontology, School of Dentistry, University of Aarhus, Vennelyst Boulevard 9
Dk-8000, Aarhus C, Denmark
5
Center for Experimental and Preclinical Research (CEPBR), Athens, Greece
INTRODUCTION
Titanium mesh cages are in use since the early ’90 for reinforcement of deficient bone and for cement con-
tainment in selected skeletal surgical procedures. Titanium mesh cages filled with bone graft have become
quite popular in spine surgery to replace or fuse, resected vertebral bodies.
More recently a titanium mesh cage was used in restoring bony continuity in two tibial fractures with seg-
mental bone loss in humans (Cobos et al. 2000).
In 2003, Fujibayashi S. et al., used bioactive titanium mesh to reconstruct segmental femoral defects in rab-
bits. Later in 2006, Lindsey R.W. et al., described the efficacy of the titanium mesh cage for the recon-
struction of segmental femoral defects in dogs.
The objective of the present study,-using a newly established critical-size canine ulnar defect model- was to
evaluate the influence of the titanium mesh on bone formation, when used as a space providing device for
guided bone regeneration, either alone or in combination with autogenous bone block graft.

Thirty six, purpose bred, adult (2-5 years old), castrated male, laboratory Beagle dogs (16 ? 4 kg of body
weight) were used in the study.
Under general anesthesia, a unilateral, segmental mid-diaphyseal, ulnar osteo-periosteal critical-size defect
was created in each animal. Defect’s length was calculated individually for each site based on Key’s hy-
pothesis on critical size defect dimensions, i.e., defect length = 2 x ulnar diameter (Toombs et al. 1985, Vi-
ateau et al. 2004). The residual ulnar segments were then stabilized with a veterinary osteosynthesis stain-
less-steel plate and appropriate screws. Each defect was managed with one of the following approaches: a) a
bone block graft harvested from the ipsilateral iliac crest was trimmed and adapted to fit into the defect
achieving continuity and a commercially titanium mesh extending beyond the defect margins was wrapped
around the ulna (Group 4; 9 animals), b) only a titanium mesh was placed similarly to above (Group 3; 11
animals); c) only a bone block graft was placed similarly to above (Group 2; 8 animals), and d) no treatment
(Group 1; 8 animals).
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After six months of healing all animals underwent a second surgical procedure and block biopsies consist-
ing of the experimental sites and portion of the pristine ulnar segments were retrieved without dog’s eu-
thanasia. Following specimen fixation, the blocks were scanned using a µCT table-top scanner, and the da-
ta-sets were exported in TIF-format and imported in special 3D-visualization software. The dimensions of
the original defect and of the residual defect in each specimen were linearly measured after identifying their
margins by browsing the entire stack of images. Then regions-of-interest (ROI), perpendicular to the long-
axis of the specimen and comprising the entire cross-section of the defect space x 0.33 mm thick were de-
termined at a level corresponding to the 20, 40, 60 and 80 percent of defect length. Next, for these ROI,
mineralized bone tissue was isolated by manual segmentation and its volume was automatically calculated
by the software.
Subsequently the specimens were histotechnically processed and qualitative histological evaluation was per-
formed on two non-decalcified longitudinal sections from each block, representing central aspects of the de-
fect space.
S. Zoi WVOC 2010, Bologna (Italy), 15th - 18th September • 638
Statistical evaluation was performed with one way analysis of variance (ANOVA) and the students t-test for
independent samples. The level of significance was set to P<0.05.
RESULTS
No significant complications related to the surgical procedures were observed and all animals were fully am-
bulatory on their operated limb approximately 10 days (range 7-14) post -operatively.
Analysis of the µCT images revealed no significant differences in the originally created defect dimensions
among the four experimental groups. Complete bone bridging had occurred in the two groups where a bone
graft was used. On the contrary, no specimen in the two other groups showed complete bridging and the
residual defect averaged 7.7 mm in the titanium mesh group and 10.5 mm in the no treatment group. The
observed difference between Group 1 & 3 in residual defect length was not statistically significant.
Similarly, no statistically significant differences in terms of mineralized bone volume in the various ROI were
detected between the grafted sites (Group 2 & 4) or between the non-grafted ones (Group 1 & 3). On the
contrary, significantly larger amounts of bone were present at the various ROI in Group 2 & 4 when com-
pared with Group 1 & 3.
The histological evaluation indicated good integration of the bone blocks irrespective the use of a titanium
mesh. In the non-grafted sites, small amount of new bone had formed in the margins of the defect, but a
major portion of the original defect space was occupied by soft fibrovascullar connective tissue. Occasional-
ly, some new bone formation could be observed within the titanium mesh structure, mostly in aspects close
to the original defect margins.
CONCLUSION
The use of titanium mesh does not influence significantly the amount of bone formation, in non-grafted and
grafted long bone critical-size defects.
The described canine ulnar critical size defect model seems to be a reliable model to use in experimental
studies.
REFERENCES
Attias N., Lehman R.E., Bodell L.S., Lindsey R.W.(2005) Surgical management of a long segmental defect of the humer-
ous using a cylindrical titanium mesh cage and plates. A case report. J.Orthop Trauma, 19, 211-216.
Attias N., Lindsey R.W. (2006) Management of large segmental tibial defects using a cylindrical mesh cage. Clinical Or-
thopaedics and Related Research, 450, 259-266.
Barbieri C. H., Mazzer N., Aranda C. A., de O. Pinto M.M. (1997) Use of a bone block graft from the iliac crest with
rigid fixation to correct diaphyseal defects of the radius and ulna. Journal of Hand Surgery (British and European
Volume), 3, 395-401.
Cobos J. A, Lindsey R. W., Gugala Z. (2000) The cylindrical titanium mesh cage for treatment of a long bone segmen-
tal defect: Description of a new technique and report of two cases. J. Orthop. Trauma, 14, 54-59.
Fujibayashi S., Kim H.M., Neo M., Uchida M., Kokubo T., Nakamura T. (2003) Repair of segmental long bone defect
in rabbit femur using bioactive titanium cylindrical mesh cage. Biomaterials 24, 3445-3451.
Kraus K.H., Kadiyala S., Wotton H., Kurth A., Shea M., Hannan M., Hayes W.C., Kirker-Head C.A., Bruder S. (1999)
Critically sized osteo-periosteal femoral defects: A dog model. Journal of Investigative Surgery, 12,115-124.
Lindsey R.W., Gugala Z., Milne E., Sun M., Gannon F.H., Latta L.L. (2006) The efficacy of cylindrical titanium mesh
cage for the reconstruction of a critical-size canine segmental femoral defect. J Orthop Res, 24, 1438-1453.
Toombs J.P, Wallace L.J., Bjorling D.E., Rowland G.N. (1985) Evaluation of Key’s hypothesis in the feline tibia: An ex-
perimental model for augmented bone healing studies. American Journal of Veterinary Research, 46, 513-518.
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Viateau V., Guillemin G., Yu Chien Yang, Bensaid W., Reviron T., Oudina K., Meunier A., Sedel L., Petite H. (2004) A
technique for creating critical – size defects in the metatarsus of sheep for use in investigation of healing of long
bone defects. American Journal of Veterinary Research, 65, 1653-1657.
Ms. Sofia Zoi - Veterinary Clinic of Larissa, Polytchniou 208, GR 41221 Larissa, Greece
E-mail vetcli1@otenet.gr
06B) posterOK_05) poster 02/09/10 12.31 Pagina 639
639 • WVOC 2010, Bologna (Italy), 15th - 18th September F. Arnault
Mandibular reconstruction after partial

hemimandibulectomy in a dog using rhGDF 5
F. Arnault, P. Maitre, D. Watrelot, C. Carozzo, D. Fau, Jp. Genevois, E. Viguier
CHEVAC, Small Animal Department, Veterinary school, Vetagrosup, University of Lyon
INTRODUCTION
Our purpose is to describe a reconstruction of the mandible, after large
complete excision of an achantomatous amelobastoma, with plates fix-
ation and a synthetic graft substitute (recombinant human Growth Dif-
ferentiation Factor 5) delivered in an absorbable collagen sponge im-
pregnated with hydroxyapaptite/tricalcium phosphate granules (Com-
pressive Resistant Matrix).
CLINICAL REPORT
A five year old, 35kg, German wirehaired pointer was admitted with
a right mandibular mass. A 2cm mass was localized between the fourth Figure 1 - CT Reconstruction 1 year after
premolar (P4) and the first molar (M1) of the right mandible. Achan- partial mandibulectomy.
tomatous amelobastoma was diagnosed by biopsy and
histopathology. A partial right hemimandibulectomy was per-
formed from cranial to P3 to caudal to M1. Histopathology
confirmed the nature and complete excision of the tumor.
One year after mandibulectomy, there was no sign of recur-
rence on clinical and CT revaluation (Fig. 1).
Owners reported moderate malocclusion, ptyalism, and diffi-
culty in eating. Because the dog of this report was a hunting
dog, the owner chose mandibular reconstruction in effort to
maintain function. After correct occlusion was obtained, a Vet-
erinary Cuttable Plate (VCP) was contoured and secured to Figure 2 - Applied two perpendicular buttress plates to
the ventral mandibular border with 2mm cortical screws. An the mandibule to bridge the gap.
additional VCP was contoured and secured to the lateral
mandibular border with 2mm cortical screws (Fig. 2).
The defect (5*2.2*1.7) was filled with Compressive Resistant
Matrix (CRM). CRM was soaked with recombinant human
Growth Differentiation Factor 5 (rhGDF5) (Fig. 3). The tissues
were closed routinely.
The dog was discharged 48 hours after surgery with instruc-
tion to continue Cephalexin and Meloxicam. Food intake was
restricted to a soft diet for 8 weeks.
Four weeks after surgery, occlusion was satisfactory. Some sub-
tle remodelling of the cranial resection border was noticed on
radiographs (Fig. 5). Figure 3 - Defect filled with CRM and rhGDF5.
POSTERS
Figure 4 - Immediate post operative view. Figure 5 - Post op radiographic views. Figure 6 - Follow up radiographic view:
8 weeks.
F. Arnault WVOC 2010, Bologna (Italy), 15th - 18th September • 640
Eight weeks after reconstruction, most of bone defect was filled with subtle remodelling (Fig. 6). Revalua-
tions are foreseen 12, 16, 20 and 52 weeks after mandibular reconstruction (not available at this date).
DISCUSSION
Other names used for Acanthomatous amelobastoma include acanthoma-
tous epulis and adamantinoma. It is locally infiltrative but never metasta-
sizes. Surgical excision with histological confirmation of free borders is the
treatment of choice.
P3-M1 resection is an accepted form of therapy for tumors of the mandible
generally with good cosmetic and functional results. Yet despite such per-
ceptions, and owners uniformly satisfied, almost 20% of the dogs have
poorer quality of life and pain in jaw1.
We propose that reconstructive surgery is a more attractive surgical option.
This reconstructive technique would be best used where there is a good Figure 7 - Follow up: 8 weeks.
long term prognosis.
Autogenous cancellous grafts historically have been considered the best
method to fill bony defect. Limited availability of autogenous cancellous
bone graft has stimulated development of other techniques to replace bone
including graft substitutes.
GDF 5 is a member of the bone morphogenetic protein family. Several stud-
ies suggest that GDF 5 is essential for the normal development and forma-
tion of bones, joints, tendons and ligaments in the axial and appendicular
skeleton.
GDF5 induces chondrogenesis and osteogenesis both in vitro and in vivo.
Application of GDF 5 in a variety of carrier systems increased/accelerated
local bone formation, fracture healing, periodontal wound healing, carti-
lage, tendon and ligament formation.
GDF 5 is being evaluated in preclinical (in vivo) studies using small and Figure 8 - 3D rhGDF5.
large animal platforms. Few preclinical studies have evaluated the effect of
GDF 5 on bone formation in a canine model2, 3, however, collectively these
studies reported GDF 5 enhances endosseous implant stability in trabecular bone, accelerates bone forma-
tion and osteointegration in mandibular alveolar defects. Application of GDF5 appears safe as it was asso-
ciated with limited, if any, adverse effect2, 3. To the author knowledge, clinical application of GDF 5 has nev-
er been reported in veterinary literature.
CRM is a matrix substitute; it stimulates osteoconduction and was used for its mechanical support and as
delivery vehicles for ostoinductive factors.
CRM has been used previously in canine mandibular reconstruction reports4, 5.
CONCLUSION
To the author knowledge, the dog in the present report is the first dog with a clinical mandibular defect that
has been reportedly treated with rhGDF5. Use of rhGDF 5 appears to be a promising, viable and safe op-
tion for reconstruction of mandibular defects in dogs, however, clinical data are lacking.
REFERENCES
1. Fox LE, Geoghegan SL, Davis LH, et al: Owner satisfaction with partial mandibulectomy or maxillectomy for treat-
ment of oral tumors in 27 dogs? J Am Anim Hosp Assoc. 1997, 33:25-31.
2. Weng EA, Pöhling S, Pippig S, Bell M, Richter EJ, Zuhr O, Hurzeler M. The effect of recombinant human growth
POSTERS
differentiation factor 5 (rhGDF5) on bone regeneration around titanium dental implants in barrier membrane-pro-
tected defects: a pilot study in the mandible of Beagle dogs. The international Journal of Oral and Maxillofacial Im-
plants. 2009, 24: 31-37.
3. Schwartz F, Rothamel D, Herten M, Ferrai D, Sager M, Becker J. Lateral ridge augmentation using particulated or
block bone substitutes biocoated with rhGDF5 and rhBMP2: an immunohistochemical study in dogs. Clinical Oral
Implants Research. 2008, 19: 642-652.
4. Spector DI, Keating JH, Boudrieau RJ. Immediate mandibular reconstruction of a 5cm defect using rhBMP-2 after
partial mandibulectomy in a dog.
5. Lewis JR, Boudrieau RJ, Reiter AM, Seeherman HJ, Gilley RS. Mandibular reconstruction after gunshot trauma
in a dog by use of recombinant human bone morphogenetic protein 2. JAVMA 2008; 233: 1598-1604.
641 • WVOC 2010, Bologna (Italy), 15th - 18th September F. Arnault
Treatment of a non union, secondary to gunshot fracture,

of the distal radius with circular external fixation
and rhBMP2/ACS in a cat
F. Arnault, P. Maitre, A. Collin, D. Fau, C. Carozzo, Jp. Genevois, E. Viguier
CHEVAC, Small Animal Department, Veterinary school, Vetagrosup, University of Lyon
INTRODUCTION
Shotgun fractures are open contaminated fracture, generally highly comminutive and associated with mas-
sive soft tissues destruction. Gunshot fracture of the distal radius ulna in a cat is a challenging fracture.
Our objective was to describe, to the author knowledge, the first successful treatment of a non union sec-
ondary to gunshot fracture with Circular External Fixation (CEF) and recombinant human Bone Mor-
phogenic Protein 2 (rhBMP 2) in a cat.
CLINICAL REPORT
A 6 year old male, 4.6 kg, British shorthair was referred for a gunshot fracture of the right radius and ulna.
The overall clinical examination, thorax, abdomen x rays and abdomen ultrasonography did not reveal any
abnormal findings. Serum biochemical profile, hematologic profile and urinalysis were within normal limits.
The wound was clipped, lavaged, debrided and protected by a sterile dressing. Antibiotics (Cephalexin,
Marbocyl), and morphine were administered.
The radiographic examina-
tion of the right radius and
ulna revealed a distal com-
munitive fracture (Fig. 1).
Numerous shotgun pellets
and bone fragments were
noticed. Twelve hours after
admission the radius and
ulna were surgically stabi-
lized by a circular external
fixation (CEF).
A two rings frame was
placed in closed fashion
(Fig. 2). Dressings were ap-
plied on skin wounds. Med- Figure 1 - Radiographic views of the gun- Figure 2 - Circular external fixation. Immediate post
ications were prescribed in- shot fracture. opérative radiographic view.
cluding cephalexin, mar-
bofloxacin and meloxicam.
Outpatient revaluations
were frequent for wound
management. Skin wound
healed uneventfully by sec-
ond intention in 21 days.
Follow up: 8 weeks: bone
POSTERS
healing was absent (Fig. 3).

To enhance bone healing a
5 mm compression of the
fracture site was performed.
Follow up: 28 weeks: bone
healing was absent (Fig. 3).
rhBMP2 was used to en-
hance bone healing. Two
absorbable type 1 collagen
sponges (ACS) were cut to
the size of the bone defect Figure 3 - Radiographic follow up 3D rhBMP2.
F. Arnault WVOC 2010, Bologna (Italy), 15th - 18th September • 642
and soaked in rhBMP2 reconstituted with its solvent. 0.6 mL of a solution of rhBMP2
at a concentration of 70 µg/mL were used for each sponge. The sponges were carefully
placed around the radius and ulna wrapping 1cm of each extremity of the fractured
bones.
Follow up: 36 weeks: a good bone healing evolution was noted on X rays and CT scan
revaluation (Fig. 4). CEF was removed and a cast was applied and weekly changed.
Follow up: 44 weeks: fracture union was achieved (Fig. 3), no lameness was present.
DISCUSSION
Few clinical cases on gunshot fractures in cats have been previously published. The
gunshot is capable of generating massive tissue destruction.
Ilizarov method and circular external skeletal fixation

have been used in veterinary surgery over the last 15 years
however very few clinical reports have been published in
its use in the management of fractures in cats.
CEF is particularly indicated when extensive dissection and internal fixation are con- Figure 4 - CT scan 36
traindicated because of soft tissue trauma, bone stock deficiency or comminution. Despite weeks after external fixa-
the occurrence of a non union, CEF was considered a good therapeutic option for this tion (8 weeks after BMP
distal, highly comminutive, contaminated and poorly vascularised radio ulnar gunshot graft).
fracture. Traditionally non-union requires several surgical procedures and the use of fresh
autogenous cancellous bone graft, however cancellous bone graft is limited in cats.
rhBMP2 is a graft substitute that is currently approved by regulatory agencies as an
alternative to bone graft for treatments of fractures and non unions in human1. This
factor has been shown to elicit bone formation in experimental model in dogs2. Sev-
eral successful case reports have been recently published in dogs for the healing of non
union3. The cat is not an experimental model that has been used significantly for
rhBMP2 studies. To the author knowledge, only one author3 has reported clinical cas-
es of cats undergoing treatment for fracture non unions with rhBMP2. This previous
report gives encouraging results.
The carrier matrix ensures the sustained release of rhBMP2 and is highly important
for the effect of BMPs. Absorbable collagen sponge (ACS), used in this report, is cur-
rently used in clinical setting and is the approved carrier for commercially available rhBMP2 products in
several countries.
The dose of rhBMP2/ACS used in this case report was 83 µg (18 µg rhBMP2/kg) and was lower than the dose
reported previously in cats (300 µg BMP2 Fibrin/cat)1. A minimum threshold dose of rhBMP2 is necessary for
a beneficial effect to occur but a higher dose does not necessarily result in better outcome4. The ability to use low-
er concentrations of rhBMP2 may be important because expense is an important limitation for its use in veteri-
nary surgery. The minimum efficient dose of rhBMP2 remains unknown in cats but 18 µgram/kg of rhBMP2/
ACS was enough to lead to clinical success in this report. The bodyweight dose of rhBMP2/ACS selected in this
report reflects estimation of effective dose based on published research trials in dogs2,5.
CONCLUSION
To the author knowledge, the cat in the present report is the first with radial gunshot fracture that have been
reportedly treated with CEF and rhBMP2/ACS. The dose of rhBMP2/ACS, which leaded to bony union,
POSTERS
was lower than the dose reported previously in cats. As an individual case study, this report can not be used
as evidence that rhBMP2 at such a dose is appropriate for use in all cats.
REFERENCES
1. Govender S, Csimma C, Genant HK, et al. Recombinant human bone morphogenetic protein 2 for treatment of
open tibial fractures: a prospective, controlled, randomized study of four hundred and fifty patients. J Bone Jt
Surg[Am] 2002; 84: 2123-2134.
2. Faria MLE, Lu Y, Heaney K, Uthamanthil RK, Muir P, Markel MD. Recombinant human bone morphogenetic protein
2 in absorbable collagen sponge enhances bone healing of tibial osteotomies in dogs. Vet surg 2007; 36: 122-131.
3. Schmoekel HG, Webert FE, Hurter K, Schenset et al. Enhancement of bone healing using non glyosylated rhBMP2
released from a fibrin matrix in dogs and cats. JSAP 2005; 46: 17-21.
4. Schmiedt CW, Lu Y, Heaney K, Muir P, Amodie DM, Markel MD. Comparaison of two doses of recombinat human
bone morphogenetic protein in absorbable collagen sponges for bone healing in dogs. AJVR 2007; 68: 834-840.
643 • WVOC 2010, Bologna (Italy), 15th - 18th September M. Bielecki
Total hip replacement with dorsal acetabular rim

augmentation (DARA) using the SOP™ implant and bone
cement in three dogs with dorsal acetabular rim deficiency:
early outcomes
N. Fitzpatrick, DUniv, MVB, CSAO, CVR, M. Bielecki, Mag.med.vet, C. Nikolaou, DVM,
M. Hamilton, BVM&S, CertSAS, DipECVS
INTRODUCTION
Hip dysplasia is the most common indication for total hip replacement (THR) in canine patients. Chroni-
cally affected dogs frequently demonstrate a diminished dorsal acetabular rim (DAR) as this is abraded by
dorsal subluxation of the femur. Obtaining osseous support for the acetabular component during THR is a
major challenge in such cases. Bulk and particulate grafting have been described in human medicine with
both cementless and cemented prosthesis. In humans, placement of large grafts not supported with bone ce-
ment is associated with a high incidence of graft failure. We describe the use of the string-of-pearls (SOP™)
locking implant as a means of reinforcement of a dorsal bone cement mantle without graft in four cases with
dorsal acetabular rim deficiency undergoing THR.

Medical records of three dogs receiving a Biomedtrix CFX™ cemented THR with dorsal acetabular rim
augmentation (DARA) using a SOP™plate and polymethylmethacrylate bone cement were evaluated retro-
spectively. DARA was achieved by anchorage of a pre-contoured 2.7 mm SOP™ plate dorsal to the acetab-
ulum with bicortical screws followed by application of cement in liquid phase to facilitate filling of the pre-
prepared acetabulum and complete coverage of the plate. A trial acetabular component facilitated marking
of angle of inclination and the polyethylene cup was manually inserted assisted by the version guide to de-
fine angle of closure and retroversion. Excess cement was removed and the remainder was appropriately
moulded around the SOP™ plate/screw construct. Great care was taken to avoid placement of the plate or
cement too far caudally, which could result in encroachment of the sciatic nerve. Angle of inclination (AI),
version (AV) and lateral opening (ALO) of the acetabular cup were measured using digital imaging pro-
cessing software on orthogonal radiographs postoperatively. Any implant associated complications were
recorded. Follow-up clinical examination was performed after two weeks, six weeks and 12 weeks.
RESULTS
Mean (SD) values for AI, AV and ALO were 23o (11.3o) (range 10o to 310), 23o (24.2) (range 8o to 51o)
and 43.3o (10.1o) (range 380 to 55o) respectively. Case 1 had already undergone a previous THR (CFX™)
procedure, with dorsal augmentation using cement alone, however the cement mantle fractured after four
months. No further complications were recorded for this case at 6-month follow-up and clinical function is
deemed satisfactory without residual lameness. Two month follow-up is currently available for case 2. Tran-
sient sciatic neuropraxia occurred in which was responsive to physiotherapy and clinical progress is satis-
factory at the time of abstract submission with lameness attributed only to disfunction of the contralateral
limb, also affected by coxofemoral arthrosis. Three month follow-up is available for case 3 and lameness has
resolved with return to full function.
CONCLUSION
POSTERS
DARA as performed in these cases facilitated placement of an appropriately sized acetabular component with
complete dorsal coverage and appropriate seating of the implant for all cases. Obtaining correct cup positioning
is technically challenging and requires assidious application of osseous landmarks and positioning aids. Radi-
ographic orientation angles for cup positioning were within reported tolerance ranges in all cases. The develop-
ment of sciatic neuropraxia in case 2 was thought to be due to excessive traction on the nerve during the pro-
cedure, however thermal injury could not be ruled out. Further studies are required in a larger number of cas-
es for firm conclusions to be drawn. Based on the clinical and radiographic outcomes of this small case series,
this methodology of DARA may be a viable alternative to previously reported augmentation techniques.
REFERENCES
Pooya H, Schultz K Wisner E. et al.(2003): Sort-term evaluation of dorsal acetabular augmentation in 10 canine total hip
replacements. Vet Surg 32:142-152.
M. Boghossian WVOC 2010, Bologna (Italy), 15th - 18th September • 644
Use of meynard clamps external skeletal fixator with

intramedullary tie-in pin for the treatment of femoral
fractures in dogs and cats. A four case report
M. Boghossian, DVM, MSc, V. Boghossian, DVM
Clínica Veterinária Penedo, Itatiaia - Rio de Janeiro, Brazil
INTRODUCTION
Femur fractures commonly occur in cats and dogs and usually after substantial trauma as a result of vehic-
ular accidents. Most femur fractures are closed because of the heavy overlying muscle, unless it is a pene-
trating injury such as a gunshot wound (Beale, 2001). An intramedullary pin external skeletal fixator “tie-
in” configuration can be used in tibial, femoral and humeral fractures. In vitro testing of the configuration
using cadaver bones, more resistance to bending was gained by the tie-in arrangement than was possible
with one not tied-in, in the same work on clinical cases, no migration of the IM pin has been observed in
24 dogs and 17 cats (Aron et al. 1991). Although the meynard clamps are slightly bigger and weights more
than other clamps, some may find it easier to use because of its simple design. The design allows the appli-
cation of additional clamps to an existing frame between installed clamps without disassembling the con-
struct (Gilley et al. 2001). The purpose of the present study is to report the outcomes of the intramedular
(IM) pin external skeletal fixator “tie-in” with meynard clamps for the treatment of femoral fractures in two
dogs and two cats.

Two dogs and two cats that had been admitted to the ‘Clínica Veterinária Penedo’ with closed fractures of
femur were enrolled in this study. The fractures were due to motor vehicle accidents (n=1) and unknown
cause (n=3). Patients were aged four months to two years and weighed 3,5 to 9,0 Kg. All the animals were
admitted with unilateral femoral fractures. Besides a femur fracture, one dog (case #2) had contralateral tib-
ial fracture, diaphragmatic hernia and sacroiliac fracture-luxation and other dog (case #4) had contralateral
second metarcarpian fracture.
After premedication with acepromazine (0,1 mg/Kg IM) and tramadol (1,0 mg/Kg IM), general anaesthesia
was induced in dogs with propofol (5 mg/Kg IV) and in cats with tiletamina (2,5 mg/kg IM) and zolazepan
(2,5 mg/Kg IM) in the same syringe, both maintained with isoflurane. In addition, epidural anaesthesia was
performed with 2% lidocaine between L7-S1 in dogs and S3-C1 in cats (1 ml per 4,5 kg). All patients were
prepared for aseptic surgery. Following the traditional approach to the bones (Piermattei et al. 2004), the
fractures were reduced and stabilized using an IM pin inserted in a retrograde fashion left protruding from
the skin proximally. Small separate incisions were made in the lateral femoral skin area through which the
external skeletal fixator (ESF) pins were inserted into the bone by slow speed drill placement. In three of the
four cases one ESF pin proximal and one distal were used and in one case two ESF pin proximal and one
distal were used. The ESF pins and IM pin were fixed with meynard clamps in a tie in fashion.
Cephalexin (30 mg/Kg, PO, q12h) was administered on the day of the surgery and for 7 days postopera-
tively. Meloxican (0,1 mg/kg, PO, q24 h) was administered on the day of surgery and for 5 days postoper-
atively.
Postoperative evaluation included, pin/skin interface, visual gait examination and time of bone healing. Ra-
diographic examinations were taken immediately after the surgical procedure and along the bone healing
period. The ESF with IM pin tie in was removed once the bone had healed. The limb functional results
POSTERS
were classified as ‘excellent’ (normal function of the limb); ‘good’, (functional use of the limb but partial
weight-bearing after exercise); ‘fair’ (full weight-bearing when standing, light to moderate lameness when
walking slowly, but no weight-bearing running);‘poor’ (non-use).
RESULTS
Case #1 was a cat, male, crossbreed, two years old and 3.8 kg. It was a left distal third of the diaphysis frac-
ture, presence of one small bone fragment and closed. Without other injuries. Five days after surgery the
limb function was good. The time of bone healing was 48 days, with excellent limb function. The compli-
cation was minor IM pin tract drainage. Case #2 was a dog, female, crossbreed, 7 months old with 5,6 kg.
It was a right oblique of the middle third diaphysis fracture and closed. Other injuries were left tibial frac-
ture, diaphragmatic hernia and right sacroiliac luxation/fracture. Ten days after surgery the limb function
645 • WVOC 2010, Bologna (Italy), 15th - 18th September M. Boghossian
was fair. The time of bone healing was 43 days, with good limb function. The complication was minor IM
pin tract drainage. Case #3 was a cat, male, crossbreed, one year old with 3,6 kg. It was a left middle third
diaphysis fracture, multifragmental and closed. Twenty days after surgery the limb function was excellent.
The time of bone healing was 55 days, with excellent limb function. The complication was ESF distal pin
tract drainage. Case # 4 was a dog, male, crossbreed, four months old with 9 kg. It was a left middle third
diaphysis fracture, multifragmental and closed. The time of bone healing was 21 days, with excellent limb
function. The complication was ESF distal pin tract drainage
The main complication in all 4 cases was pin tract drainage, the problem was prominent in the protruding
IM pin where there are three gluteal muscle layer. The time of bone healing was between 21 to 55 days with
average term of 41,75 days and the age of the animals ranged between four months to 2 years. The quick
bone healing was probably due to the fact that animals were less than 2 years old in this group.
CONCLUSION
It’s simple to build an ESF with IM tie in pin frame with meynard clamps. The device is more easily re-
moved than other tecniques like plate and interlocking nail. A good resistance to bending and axial rota-
tional force can be obtained with this frame. Recovery time was short and limb function after surgery was
good to excellent. The disadvantage was pin tract drainage mainly in IM pin.
REFERENCES
Aron DN, Foutz TL, Keller WG, Brown. (1991). Experimental and clinical experience with an IM pin external skeletal
fixator tie-in configuration. Vet. Comp. Orthop Traumatol; 4: 86-94.
Beale B. (2004). Orthopedic Clinical Techniques Femur Fracture Repair. Clin Tech Small Anim Pract. 19:134-150.
Gilley RS, Bourgeault CA, Wallace LJ, Bechtold JE. (2001). A comparative mechanical study of 3 external fixator clamps.
Vet. Surg. Jul-Aug;30(4):341-50.
Piermattei DL, Johnson KA. (2004). An Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. 4th
ed. PA: W.B. Saunders Company; 400.
POSTERS
P.J. Burns WVOC 2010, Bologna (Italy), 15th - 18th September • 646
Evaluation of pharmacokinetic-pharmacodynamic
(PK-PD) relationships for BioRelease meloxicam
formulations in horses
Patrick J. Burns1, PhD & Richard M. Gilley1, Chris Morrow2 DVM, Mark G. Papich3 DVM, MS
1
BioRelease Technologies LLC, Lexington, Kentucky and Birmingham, AL
2
Mobile Veterinary Practice, Amarillo, Tx
3
College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27606, USA
INTRODUCTION
Non-steroidal anti-inflammatory drugs (NSAIDs) are a heterogeneous group
of agents to treat symptoms of acute pain and chronic inflammatory and de-
generative joint diseases, such as osteoarthritis (OA) as well as for their an-
tipyretic, antithrombotic, and antiendotoxic properties. The molecular target
for NSAIDs is cyclo-oxygenase (COX). It is now well known that there are two
COX isoforms, COX-1 & COX-2, and that the extent of NSAID-associated
relative inhibition of COX-1 & COX-2 activities varies among the drugs.
Commonly administered NSAIDs in horses are flunixin, phenylbutazone, and
ketoprofen, which are relatively non-selective and inhibit both COX-1 and
COX-2 to various degrees. Because COX-1-derived prostaglandins play a role
in protecting the gastrointestinal mucosa, NSAIDs that inhibit COX-1 have
been associated with adverse events in horses such as gastric and intestinal ul-
cers, gastrointestinal bleeding, and renal injury.1 This has led to development of newer NSAIDs such as
meloxicam and firocoxib which are more selective for the inhibition of the COX-2 isoenzyme. Meloxicam
is traditional NSAID of the oxicam class with Cox 2 selectivity on the order of 5 to 12 times (depending on
blood levels) that of flunixin or phenylbutazone in the horse.2 Based on their observations Beretta et al2 sug-
gested that meloxicam seems the best of the tested traditional NSAIDs for use in horses. Meloxicam has
most commonly been used for the alleviation of inflammation and relief of pain in both acute and chronic
musculo-skeletal disorders or for the relief of pain associated with equine colic. Meloxicam is available for
oral administration or IV daily administration and can be administered once daily for periods up to 14 days.
At present, The European Agency for the Evaluation of Medicinal Products has approved meloxicam for
oral and IV use in horses at a dose of 0.6 mg/kg every 24 hours. However, the clearance of meloxicam in
horses is faster than in other animals.3 With a half-life of approximately 5.5 hrs (2.7 to 8.5 hrs)3, most of the
drug will be eliminated during a 24 hour interval. A drug formulation that will deliver meloxicam via a con-
trolled-release formulation at a more continuous, but lower rate may maintain the drug concentrations at a
more constant level throughout the dosing interval. This can be accomplished by applying recent advances
in biodegradable controlled release drug delivery systems to allow single administration products to replace
multiple daily treatment protocols. Such formulations reduce labor and the associated handling stress to the
animals and veterinarians and offer an important means of maintaining effective compliance rates on farms
with wide varieties of management systems.
The present study was designed to test this principle of controlled-release delivery of meloxicam using this
technology. The BioRelease Delivery System used for this study is a proprietary low viscosity non-aqueous
liquid system that uses an easily injectable biocompatible suspension. Our objective was to use a BioRelease
Delivery System to prepare several controlled-release formulations of meloxicam and use pharmacokinetic
POSTERS
principles to compare the plasma concentrations produced. Our hypothesis was that a slow, but controlled
release of meloxicam would produce sustained plasma concentrations that would be potentially effective for
treating pain and inflammatory conditions in horses – lameness in particular. The results of this study will
then be used to aid in selection of one for use in clinical studies to support a potential approval.
EXPERIMENTAL METHODS
In the present study, 12 research horses of various light breeds weighing 466+18.4 kg were randomly as-
signed to one of 3 treatment groups (n=4 horses per group), 2 mL (1500 mg) of 3 BioRelease meloxicam
formulations Blue (slow release), Green (medium release) and Red (fast release). Formulations were pre-
pared to give a final concentration of 750 mg/mL, and designed to deliver meloxicam for approximately 72
hrs after I.M. injection using an 18 gauge needle.
647 • WVOC 2010, Bologna (Italy), 15th - 18th September P.J. Burns
Beginning prior to injection (day 0) serial blood sample collections were be initiated. Blood samples were
collected -1hr prior to drug administration, and at 1, 3, 6, 12, 24, 36, 48, and 72 hrs post injection. A sec-
ond injection was given at 72hrs and continued sampling followed at 73, 75, 84, 96, 108, 120 and 144 hrs
from the initial dose. Plasma samples were harvested and stored at -20ºC until assay for meloxicam by
HPLC. Based on previous PK-PD analysis3 that reported a median effective meloxicam concentration of
0.130 ug/mL for stride length and 0.195 ug/mL for lameness scores, the aforementioned values were used
for comparison purposes in the present study.
Injection site assessments were made and recorded at each blood collection. Scores were based on a subjec-
tive scale of 0-3 (0 = none, 1 = slight – diameter of swelling 12.5 mm, 2 = moderate - diameter of swelling
12.5 mm to 25 mm, 3 = significant – diameter of swelling about 25 mm or larger), sensitivity to touch
(yes/no) and temperature elevation at injection site (yes/no). Lastly, general well being scores (Normal or Ab-
normal – with description) were recorded at each blood collection.
Drug Analysis
Equine plasma samples were analyzed by high pressure liquid chromatography (HPLC) with a method
developed and validated in the laboratory at NCSU. Reference standards for meloxicam were purchased
from Sigma Chemical (St. Louis, Missouri, USA). Meloxicam reference standard was weighed and dis-
solved in 100% HPLC grade distilled water to a concentration of 1 mg/mL. From this stock solution, fur-
ther dilutions were made in HPLC grade distilled water to make up fortifying solutions for plasma in or-
der to prepare quality control samples, calibration curve samples, and for development of these methods.
The stock solution was kept at 4°C in a tightly sealed dark vial. The fortifying solutions made from the
stock solution was added to blank (control) plasma, to make up 7 calibration standards, including zero
(range 0.0 µg/mL to 10 µg/mL). All calibration curves were linear with a R2 value of 0.99 or higher and
the intra-assay precision was < 15%. Limit of quantification for this study was 0.01 µg/mL, which was de-
termined from the lowest point on a linear calibration curve. The laboratory used guidelines published
by the United States Pharmacopeia.
Pharmacokinetic Analysis
Each horse was analyzed separately using pharmacokinetic techniques. All horses within each of the three
treatment groups were then grouped and averaged (standard two-stage analysis). Visual analysis of the plas-
ma drug concentrations indicated that a non-compartment model was the best approach for this data. Analy-
sis of curves and pharmacokinetic modeling was then performed using a commercial pharmacokinetic pro-
gram (WinNonlin, Version 5.2, Pharsight Corporation, Mountain View, CA).
EXPERIMENTAL RESULTS
The plasma concentrations are presented in Figure 1. Pharmacokinetic values for each formulation are pre-
sented below. Also shown on Figure 1 are the values predicted by Toutain & Cester3 for effective meloxicam
concentrations in horses, who reported a median effective meloxicam concentration of 0.130 ug/mL for
stride length and 0.195 ug/mL for lameness scores. Examination of the injection site data indicated that all
examination scores for all animals at all time points were 0 or none, therefore statistical examination of the
data were considered not necessary. Similarly, general well being scores were also recorded as normal at all
time points and statistically not examined.
PK PRAMETERS (After 2nd Dose X+SD)
Terminal rate: (1/hr) RED=0.010+0.003;BLUE=0.015+0.006;GREEN=0.019+0.006

POSTERS
Half life: (hr) RED=79.04+27.25;BLUE=61.3+43.5;GREEN=40.11+14.79
Tmax (hr) RED=77.25+1.5;BLUE80.25+4.5;GREEN=79.5+3.00
Cmax (ug/mL) RED=0.714+0.392;BLUE=0.346+0.113;GREEN=0.775+0.411
AUC (hr*ug/mL RED=49.97+18.64;BLUE=22.36+4.52;GREEN=45.44+18.48
MRT (hr) RED=107.50+33.89;BLUE=91.41+62.33;GREEN=59.84+21.7

P.J. Burns WVOC 2010, Bologna (Italy), 15th - 18th September • 648
Figure 1 - Meloxicam mean concentrations (+/- Std.

Dev) in four horses per group. Each horse was adminis-
tered 3.75 mg/kg IM, twice at 0 and 72 hours. Overlaid
on the graph is the predicted median effective concentration
for improvement in stride length (dashed black line 0.13
µg/mL), and improvement in lameness score (dashed pink
line 0.195 µg/mL) as reported by Toutain & Cester3.
Groups are represented by the rate of release: Blue (slow
release), Green (medium release) and Red (fast release).
CONCLUSIONS
Results from the present study suggest that potential therapeutic advantages of meloxicam may be able to
be enhanced by applying recent advances in biodegradable controlled release drug delivery allowing single
administration products to replace multiple daily treatment protocols.
REFERENCES
1. MacAllister CG, Morgan SJ, Borne AT, et al. Comparison of adverse effects of phenylbutazone, flunixin meglu-
mine, and ketoprofen in horses. 1993 J Am Vet Med Assoc; 202:71-77.
2. Beretta C, Garavaglia G, Cavalli M. 2005. COX-1 and COX-2 inhibition in horse blood by phenylbutazone, flu-
nixin, carprofen and meloxicam: an in vitro analysis. Pharmacol Res 52:302-306.
3. Toutain PL, Cester CC. 2004. Pharmacokinetic-pharmacodynamic relationships and dose response to meloxicam
in horses with induced arthritis in the right carpal joint. Am J Vet Res. Nov; 65(11):1533-41.
POSTERS
649 • WVOC 2010, Bologna (Italy), 15th - 18th September M. Bush
Evaluation of the tibial tuberosity advancement procedure

using inverse dynamics gait analysis in thirteen dogs
Mark Bush1, Pamela Sibley2, Mark Owen3, Martin Owen1, Robert Colborne2
1
Department of Clinical Veterinary Medicine, University of Bristol, UK;
2
Department of Anatomy, University of Bristol, UK;
3
Mark Owen Referrals, Bristol, UK
INTRODUCTION
Tibial tuberosity advancement (TTA) is advocated for the management of cranial cruciate ligament failure
(CCLF) in dogs. The purpose of this study was to evaluate outcome 12 months following TTA in dogs af-
fected unilaterally by CCLF.
Thirteen dogs underwent inverse dynamics gait analysis (IDA). Six dogs had CCLF on their right side (RC-
CLF) and seven on their left side (LCCLF). Stifle joint moment and power, and total support moment
(TSM) were calculated for both affected and unaffected limbs.

All surgeries were performed by the same surgeon. The technique used was as described in the literature1.
For kinematics and inverse dynamics, for each dog, flat, circular retroflective adhesive markers measuring
0.8cm diameter were placed on the skin overlying the centres of rotation of the metatarsophalangeal (MTP),
tarsal and stifle joints, the mid-point of the greater trochanter of the femur and the cranial aspect of the ilial
wing, on both pelvic limbs. The dogs trotted on the force plate runway at their own self-selected pace. Kine-
matic and force data were collected at a sample rate of 200 Hz for a period of three seconds per trial using a
four-camera Qualisys system and Kistler force platform. Six trials were collected for each pelvic limb for each
dog. The kinematic and force data were imported into a custom programme to obtain an inverse solution for
the net joint moments. Joint angles were measured on the plantar (caudal) aspect of the limb. Net joint mo-
ments on the plantar (caudal) aspect of the limb were attributed negative values. Net joint power was calcu-
lated as the product of the net joint moment and the angular velocity of the joint, such that decreasing plan-
tar joint angle with a concurrent net negative moment for that joint produced a positive power. The total sup-
port moment was the sum of all the joint moments contributing to extension of the limb against gravity. Peak
vertical joint reaction force at the MTP joint was also calculated. For the purposes of biomechanical evalua-
tion, the cases were divided into left (LCCLF) and right cranial cruciate ligament failure (RCCLF).
RESULTS
• In both groups, mean sti-
fle joint moment changed
from flexor to extensor
about midstance on the
right side, and about 10%
earlier in stance on the
left pelvic limb.
• Peak flexor moment was
significantly larger (P<.05)
for the right stifle com-
pared to the left stifle in
POSTERS
LCCLF dogs, but was sim-

ilar in both stifles in RC-
CLF dogs.
• Peak stifle extensor mo-
ment was significantly
larger (P<.05) for the left
stifle versus the right stifle
in RCCLF dogs, and was
also larger (P>.05) for the
left stifle versus the right
stifle in LCCLF dogs.
M. Bush WVOC 2010, Bologna (Italy), 15th - 18th September • 650
• The mean age of the unilaterally affected dogs at the time of

surgery was 5.6 (range 2.2-10) years.
• The mean weight was 35.9 (range 22-74) kg.
• The mean time between suspected CCLF and surgery was
2.5 (range 1-6) months.
• The mean time elapsed between surgery and IDA evaluation
was 13.8 (range 11-20) months.
TSM was larger on the right (P>.05) in RCCLF dogs and sig-
nificantly larger on the right (P<.05) in LCCLF dogs.
Both LCCLF and RCCLF cases exhibited symmetrical hind

limb GRF, with less than 5% difference between limbs. The
forces in the left limb were lower than the right limb for LCCLF
cases and the right limb forces were lower than the left limb for
RCCLF cases.
Stifle power in early stance was larger on the left (P>.05) in RC-
CLF dogs and significantly larger (P<.05) on the right in LC-
CLF dogs.
DISCUSSION
Objective gait analysis is commonly performed using force plate data. There are significant advantages in
objective assessment of limb use over subjective methods; subjective measures of outcome are inherently
weakened by the potential for observer bias and the limitation of owners and veterinarians to accurately de-
termine the degree of lameness2. Peak vertical force (PVF), derived from the ground reaction force meas-
ured by the force plate, is a parameter commonly used to assess limb use3. Its magnitude has been shown
to decrease in animals with lameness, however its sensitivity in assessing improved force acceptance in joint
disease has been questioned3. Reduction of positive stifle power in early stance is a consequence of a re-
duction in stifle joint angular velocity and/or reduction of the net flexor stifle moment, indicating smaller
concentric contraction of the stifle flexors. Stifle power was significantly smaller in operated limbs for LC-
CLF dogs, and was likewise smaller, but not significantly so in the operated limbs for RCCLF dogs. The
moment curves indicate that the left and right stifle joints behave differently, regardless of operated side; the
left stifle begins to generate an extensor moment earlier in stance, and this may partly explain the power dis-
crepancy. A deficit of the inverse dynamics approach is the inability to determine the degree of co-activation
of the quadriceps and hamstrings muscle groups4. Therefore, reduction in stifle power may be a result of re-
duced concentric flexor muscle contraction, or increased antagonist stifle extensor muscle activity during
flexion.
POSTERS
CONCLUSIONS
• Dogs demonstrated near symmetrical vertical GRFs.
• Using inverse dynamics gait analysis, irrespective of the side of CCLF, Total Support Moment is larger
on the right side and the stifle extensor moment is larger on the left stifle in late stance
• CCLF affected limbs demonstrated a reduction in amplitude of concentric contraction of the stifle flex-
ors in the early stance phase.
• The reduction in stifle joint power in the CCFL affected limbs suggests inverse dynamics analysis may
provide valuable insight for the investigation of outcome following limb surgery; however, the impact of
normal mechanical limb dominance needs to be further clarified before more definitive conclusions can
be reached.
651 • WVOC 2010, Bologna (Italy), 15th - 18th September M. Bush
REFERENCE
1. Lafaver S, Millar NA, Preston Stubbs W et al. Tibial Tuberosity Advancement for Stabilization of the Canine Cra-
nial Cruciate Ligament-Deficient Stifle Joint: Surgical Technique, Early Results, and Complications in 101 Dogs.
Vet Surg 2007; 36: 572-586.
2. Waxman AS, Robinson DA, Evans RB. Relationship Between Objective and Subjective Assessment of Limb Func-
tion in Normal Dogs with an Experimentally Induced Lameness. Vet Surg 2008; 37: 241-246.
3. Budsberg SC, Chambers JN, Lue SL, et al: Prospective evaluation of ground reaction forces in dogs undergoing
unilateral total hip replacement. Am J Vet Res 1996; 57:1781-1785.
4. Bockstallher BB, Gesky R, Mueller M. Correlation of Surface Electromyography of the Vastus Lateralis Muscle in
Dogs at a Walk with Joint Kinematics and Ground Reaction Forces Vet Surg 2009;38:754-761.
POSTERS
E. de Bakker WVOC 2010, Bologna (Italy), 15th - 18th September • 652
Flexor enthesopathy in dogs: diagnostic findings

E. de Bakker, Y. Baeumlin, I. Gielen, Y. Samoy, H. Seghers, D. van Vynckt,
S. Diels, S. Vermeire, H. van Bree, B. Van Ryssen
Department of Veterinary Medical Imaging and Small Animal Orthopaedics, Faculty of Veterinary Medicine,
Ghent University, Belgium
INTRODUCTION
Front leg lameness in dogs is often localized in the el-
bow joint.
Elbow dysplasia is the most important disorder. Pathol-
ogy of the flexor muscles and their attachment to the
medial epicondyle (‘flexor enthesopathy’) is less
known1-4. However, it should be included in the dif-
ferential diagnosis of elbow problems, although radi-
ographic changes at the medial epicondyle are often Figure 1 - Radiographic images of elbows with lesions near the
considered to be clinically insignificant. The most fre- medial humeral epicondyle. A: Example of an ‘ununited medial
quently described radiographic changes at the medial epicondyle’ (see arrow). B: Example of ‘dystrophic calcification of
epicondyle are1-4: the flexor muscles’ (see arrow). C: Example of ‘flexor enthesopa-
thy with spur formation’ (see circle).
• fragmentation, also called ‘ununited medial epicondyle’
(Fig. 1A)
• dystrophic calcification of the flexor muscles (Fig. 1B)
• enthesopathy with or without spur formation (Fig. 1C)
AIM OF THIS STUDY

To describe the features of flexor enthesopathy with
different diagnostic techniques.
METHODS Figure 2 - Ultrasound images of a normal (A) and an affected el-

For each patient with flexor enthesopathy we used the bow (B). A: longitudinal view of an intact flexor insertion to a nor-
following diagnostic protocol: mal medial epicondyle (see arrows). B: abnormal flexor muscles; bow-
■ Radiography (Fig. 1)
ing (right arrow) and hypoechoic fluid (left arrow). 1: superficial dig-
ital flexor - 2: deep digital flexor - 3: m. flexor carpi ulnaris.
■ Ultrasonography (Fig. 2)
■ Scintigraphy (Fig. 3)
Figure 3 - Scintigraphic
■ CT (Fig. 4) images of an elbow with
■ MRI (Fig. 5) flexor enthesopathy. Left: a
■ Arthroscopy (Fig. 6) planair image with a clear
■ Explorative surgery (Fig. 6) hot spot in the right elbow
(see arrow). Right: a High-
RESULTS Spect image with a hot spot
■ Fourteen medium/large breed dogs with elbow at the medial epicondyle of
lameness, age: 1-7 years (15 joints, n=15) the humerus (see arrow).
■ Five dogs had concurrent medial coronoid process
pathology
■ Results
• Radiography (15 joints) (Fig. 1)
POSTERS
- Mineralized fragment in the soft tissue at the lev-

el of the medial epicondyle (n=4)
- Spur at the distal aspect of the medial epicondyle
(n=10)
- Mild osteoarthrosis (n=9), severe osteoarthrosis Figure 4 - CT images in a Figure 5 - MRI sagittal T2
soft tissue window. Left: a weighted images. Left: normal
(n=5)
normal m. flexor carpi ulnaris view at the level of the m. flexor
• Ultrasonography (14 joints) (Fig. 2) (see arrow). Right: a thick- carpi ulnaris (see arrow). Right:
- Outward bowing of the flexor muscles (n=10) ened m. flexor carpi ulnaris hyperintense signal cranial to the
- Hypoechoic flexor muscles (n=10) located at the medial humeral flexor attachment, associated with
- Thickening of the connective tissues and flexor epicondyle (see arrow). an ill defined flexor muscle delin-
muscles (n=9) eation (see arrow).
653 • WVOC 2010, Bologna (Italy), 15th - 18th September E. de Bakker
• Scintigraphy (5 joints) (Fig. 3)

- Planair scan: ‘hot spot’ located at the elbow
(n=5)
- High-Spect: ‘hot spot’ at the medial epicondyle
(n=5)
• CT (14 joints) (Fig. 4)
- Thickening of the flexor muscles (n=11)
- Uptake of IV iodine contrast in flexor muscles
(n=10)
• MRI (14 joints) (Fig. 5)
- Hyperintense signal around the flexor attach-
ment in T2-weighted and STIR images (n=13)
• Arthroscopy (14 joints) (Fig. 6)
- Thickened and fibrillated flexor attachment
(n=14)
• Explorative surgery (8 joints) (Fig. 6)
- Local fibrosis and thickening of the flexormuscle Figure 6 - Arthroscopy & explorative surgery. A: arthroscopic im-
(n=8) age of a normal flexor attachment (see arrow). B: arthroscopic im-
age of an affected flexor muscle: Thickening and ruptured fibers
(see arrow). C and D: explorative surgery showing a thickened fi-
brotic part of the flexor muscle.
CONCLUSION
‘Flexor enthesopathy’ is a term to indicate pathologic findings at the flexor muscles and their attachment at
the medial epicondyle. All imaging techniques showed specific changes in each affected elbow joint. The
combination of different imaging techniques should be used to diagnose flexor enthesopathy and to deter-
mine the clinical significance of medial epicondylar changes.
REFERENCES
1. Ljunggren et al. (1966). The elbow dysplasias in the dog. Journal of the Veterinary Medical Association; April 15;
148(8):887-91.
2. May C., Bennett D. (1988). Medial epicondylar spur associated with lameness in dogs. Journal of Small Animal
Practice; 29:797-803.
3. Meyer-Lindenberg et al. (2004). Vorkommen und Behandlung von Knochern Metaplasien in den ammedialen
Epikondylus des Humerus entspringenden Beugesehnen bei Hund. Tierärztl Prax; 32:276-85.
4. Piermattei D.L., Flo G.L., DeCamp C.E. (2006). Brinker, Piermattei and Flo’s Handbook of Small Animal Or-
thopaedics and Fracture Repair, 4th edition.
POSTERS
M. El Keiey WVOC 2010, Bologna (Italy), 15th - 18th September • 654
Experimental studies on segmental cortical bone xenografts:

clinical and radiographical assessment
M. El Keiey, PhD, S. GadAllah, PhD, M. Amer, MSc
Faculty of Veterinary Medicine, Dept. of Surgery, Anaesthesiology and Radiology, Cairo University, Giza, Egypt
INTRODUCTION
Bone grafts are extensively used for several orthopaedic applications including treatment of severely com-
minuted fractures, non union, and replacement of bone loss resulting from tumor or infection, and in cases
requiring reconstructive procedures such as fusion or joint replacement (Okumus and Cabnela, 2006).Vari-
ous bone graft substitutes including autograft, allograft, xenografts, polymers, ceramics and some metals
have been employed to promote bone union (Albee, 1996, and Beaman et al., 200). The objective of this ex-
periment was to evaluate the efficacy of autoclaved cortical bone xenografts of goat cadavers in reconstruc-
tion of experimentally induced bone defects in canine model.

The present study was designed into two main stages, Stage I, 50 native breed adult goats were used as
donors for bone grafts. Clean harvesting method was used for collection of bone grafts followed by auto-
clave sterilization (121°C / 30 minutes). The feasibility of the banked bone was assessed through radi-
ographic examination. Also the handling characteristics were estimated for up to 6 months post- retrieval.
The results revealed that the bone bank should be replenished after 3 months. Stage II, included 20 dogs;
these dogs were subjected to an artificial induction of femoral defects (3 cm length). The induced defects
were reconstructed with autoclaved cortical bone engrafts (ACXG) in 16 dogs and fresh cortical autograft
(FCAG) in 4 dogs. The operated dogs were observed for up to 12 months post-operatively (P.O) through
clinical and radiological examinations.
RESULTS
The obtained results showed that the use of autoclaving as a method of sterilization has several advantages
in terms of simplicity, efficiency and economy. The clinical, radiological and evaluations during the course
of 12 months confirmed acceptance of ACXG in similar manner to FCAG in reconstruction of experimen-
tally induced femoral defects.
I. Clinical evaluations: In case of FCAG (control group), all operated dogs were partially weight bearing on
the operated limb by 3-5 days P.O and they showed full weight bearing at the 4th week P.O. The gait was
varied from occasional lameness to full limb function by the end of 12 weeks P.O. No clinical evidence of
infection. The popliteal node was slightly enlarged during the first week post-operatively. There was a mod-
erate degree of seromal reaction in two dogs and severe reaction in another one. These reactions were sub-
sided spontaneously within 1-2 weeks P.O.
In case of ACXG, out of 16 operated dogs, twelve dogs (75%) were partially weight bearing on the operat-
ed limb at one week P.O and they showed full weight bearing at 6 weeks P.O. The signs of lameness were
almost disappeared by 16-24 weeks P.O with full limb function. The popliteal lymph nodes were enlarged
and palpable during the first two weeks P.O and returned back to normal by the end of the first month.
Moderate degree of seromal reaction was observed in all operated dogs 2-3 days P.O which spontaneously
subsided by the end of the first week except in two dogs. The latter’s showed subcutaneous draining sinus-
es one week P.O.
II. Radiographic Evaluations: The results of sequential radiography of FCAG control and ACXG at different
POSTERS
observation periods. At 1 month the rounding off the edges of the host bone with the start of the periosteal re-
activity was observed. At 2 months P.O., was showing rounding off the edges of the graft and initiation of lip-
ing callus at the host graft interfaces starting from the proximal one. At 3 months P.O. the proximal host-graft
interface disappeared and the radiodensity of the graft is less than the host bone. At 6 months P.O., showing
both host-graft interfaces disappeared. At 12 months P.O. the homogenesity in the radiodensity along the bone
was observed. The results of contact radiography of FCAG (control group) and ACXG after harvesting of the
operated femur at one month, 2 months, 6 months and 12 months post-operative times. Slight periosteal and
endosteal bridging callus particularly at the proximal host-graft interface at one month. Cortical union along
with remodeling at the proximal host-graft interface observed at 3 months. Cortical union at the proximal and
distal host-graft interfaces complete incorporation of the graft into the host bone at 6 months. The radioden-
sity of the graft was nearly similar to the radiodensity of the host bone at 12 months.
655 • WVOC 2010, Bologna (Italy), 15th - 18th September M. El Keiey
Complications of xenografting procedure were recorded in 4 dogs. They included implant failure as a re-
sults of broken plate and screws in two cases (one, G I and one, G III) and fracture of xenografts in anoth-
er two dogs (G II).
CONCLUSION
The results of the present study revealed that the incorporation of autoclaved cortical bone engrafts ACXG
of goat cadavers into femoral defect repair in canine model was successful (75%) as determined by the
achievement of full limb function, fracture healing and graft remodeling. These results are promising for the
clinical application of such graft procedures.
REFERENCES
Albee F. H. (1996): Bone graft Surgery. Clinical Orthopedics and Related Research, 324:5-12.
Andersen, JR., Detlie, T and Griffiths, J.J. (1995): The radiology of bone allografts. Radiologic. Clinics of North Amer-
ica, 33: 391-400.
Beaman, F. D.; Bancrofts, LW; Peterson, JJ and Kransdorf, M. F. (2006): Bone graft materials and synthetic substitutes.
Radiol. Clin. North Am. 44(3): 451-461.
Bob, P.; and Peter, J.F (2001): Physiological aspects of xenotransplantation. Transplantation Rev., 15 (4): 200-209.
Burchardet, H. (1987): Biology of bone transplantation. Orthop. Clin. North. Am., 18 (2): 187-196.
Dehaghani, SN; Baizaei, FE. (2001): Using xenografting bovine bone pin for fracture repair in dogs. 27th world Small
Animal. Vet. Asso, Congress Proceeding. Vancouver, British Columbia Canada.
Donald, L P and Gretchen, L.F (1997): Bone grafting: In Small Animal orthopaedics and fracture repair, (3rd edition).
W.B. Saunders Co., Philadelphia, Pennsylvania PP 147-149.
Draenert, GE., and Delius, M. (2007): The mechanically stable steam sterilization of bone grafts. Biomaterials, 28 (8):
1531-1538.
Gadallah, SM (1998): Studies on entire segment cortical bone allografts in dogs. PhD. Thesis Surg. Fac. Vet. Med. Cairo
University. Giza.
Hofmann, C.; Schadel-Hopfner, M.; Berns, T.; Sitter, H.; and Gotzen, L. (2003): Influence of processing and sterilization
on the mechanical properties of pins made from bovine cortical bone. Unfallchirurg, 106 (6): 478-482.
Johnson, Al; Shokry, MM and Stein, LE (1985): Preliminary study of Eo sterilization of full thickness cortical allograft
used in segmental femoral fracture repair. Am. F. Vet. Res. 46 (5): 1050 -1056.
Kumar, P.; Shrestha, D.; and Bajracharya, S. (2006): Replacement of an extruded segment of radius after autoclaving and
sterilizing with gentamycin, J. Hand Surg., 31-8 (6): 616-618.
Okumus, DA., and Cabnela, ME. (2006): Impaction bone grafting for revision hip arthroplasty. Biology and clinical ap-
plication. J. Am.Acad. Orthop. Surg., 14: (11): 620-628.
Rovillain, JL; Navarre, T., Noseda, O., and Garron, E; (2006): Traumatic femoral bone defect reconstruction with an au-
toclaved autologous femoral segment: A 10 years follow-up. Acta. Orthop. Belg. 72 (2): 229-233.
Schena, C.J.: Mihen, RW, and Hoefle, WD (1985): Segmental freeze – dried fresh cortical allografts in the canine femurs.
II: A sequential histological comparison over a one year time interval. Am. Anim. Hosp. Assco. 21: 193-204.
Schmidt-Ochtering and Alef. (1995): Neue Aspekte der Veterin. Anasthesie, und Intensivtherapie, Blackwell Wissenschafts-
Verlag. Berlin.
Sinibaldi K R. (1989): Evaluation of cortical allografts in 25 dogs. JAVMA, 194 (11: 1570-1577)
Yun-Yu. Hu; Wei Lieu; Yu – Pu lu; (2000): Recombined xenograft of cancellous bone graft and bone morphogenic pro-
tein (BMP). The Iowa orthopaedic Journal, Vol, 11: 54-58.
POSTERS
H.R. Fattahian WVOC 2010, Bologna (Italy), 15th - 18th September • 656
A retrospective comparison study of success rate

of arthroplasty of coxofemoral joint in dog
H.R. Fattahian1, M. Nasrollahzadeh Masouleh2, H. Molookpour3,
F. Kabir2, N. Vazir4, A. Hoseinzadeh5
1
Dept of Surgery, Faculty of Specialized Veterinary Sciences, Science and Research Branch, Islamic Azad University, Tehran-Iran
2
Dept of Radiology, Faculty of Specialized Veterinary Sciences, Science and Research Branch, Islamic Azad University, Tehran-Iran
3
Dr. Hooman’s Small Animal Private Clinic, Tehran-Iran
4
Dept of Anatomy, Faculty of Veterinary Medicine, University of Tehran, Tehran-Iran
5
Paradise Small Animal Private Clinic, Tehran-Iran
INTRODUCTION
Hip joint insufficiency (loss of function as a joint to transfer force) follows some causes as traumatic, devel-
opmental and acquired conditions. Clinical signs depend on severance of joint disease and degenerative
changes. Aim of this retrospective study was to determine key factor in prognosis and comparison success
rate of hip arthroplasty in referral toy and large breed dogs for 4 years.

One hundred and four dogs with toy and large breed dogs have been referred to small animal clinic with
lameness, pain and loss of function on hindlimb. Radiograph survey was done and revealed various changes
in hip joint. Conservative and surgical treatments were carried out and followed up till two years.
RESULTS
All dogs tolerated head and neck osteotomy of femur. In congenital cases, weight was not as a determinant
factor and correlation between degenerative joint disease (DJD) and prognosis was significant statistically in
dogs less than 10 kg (p=0.024) and more than 10 kg (p<0.001). The correlation between DJD and prog-
nosis was not significant statistically in dogs 1 to 5 years and weighing less than 10 kg (p<0.05) and more
than 10 kg (p<0.05). In senile dogs (older than 5 years), weight was not as a key role and correlation be-
tween DJD and prognosis was significant statistically in dogs less than 10 kg (p=0.004) and more than 0 kg
(p=0.019).
CONCLUSION
In this study has been showed that weight and etiology were not as important and effective factors in prog-
nosis but age is as a key role in prognosis in dogs.
REFERENCES
1. Fossum, TW; Hedlund, CS; Hulse, DA; Johnson, AL; Schulz, KS; Seim, HB; Willard, MD; Bahr, A and Carroll,
GL (2007). Medial and lateral patellar luxation. In: Fossum, TW; (Eds.), Small animal surgery, (3rd. Edn.), Mos-
by, St. Louis, USA, PP: 1233-1246.
2. Mann F.A., Tangner C.H., Wagner-Mann C., Read W.K., Hulse D.A., Puglisi T.A., Hobbson H.P. (2008). A com-
parison of standard femoral head and neck excision and femoral haed and neck excision using a biceps femoris
muscle flap in the dog. Veterinary surgery 16(3), 223-230.
3. Rawson E.A., Arosohn M.G., Burk R.L. (2005). Simultaneous bilateral femoral head and neck ostetomy for the
treatment of canine hip dysplasia. Journal of the American Animal Hospital Association 41: 166-170.
POSTERS
657 • WVOC 2010, Bologna (Italy), 15th - 18th September E.P. Freitas
Development and optimization by finite element modeling

of a bone plate used for treatment of mandibular fractures
in dogs
E.P. Freitas1, S.C. Rahal1, M.A. Gioso2, L.C. Vulcano1, A.C. Shimano3,
J.V.L. Silva4, P.Y. Noritomi4, A.O.E. Warrak5
1
Department of Veterinary Surgery and Anesthesiology - São Paulo State University (Unesp) - Botucatu - SP - Brazil
2
Department of Veterinary Surgery - University of São Paulo (USP) - Sao Paulo - SP - Brazil
3
Medical School, Department of Biomechanics - São Paulo University (USP) - Ribeirão Preto - SP - Brazil
4
Product Development Division, Renato Archer Research Center (CTI) - Campinas - SP - Brazil
5
Department of Clinical Sciences - Faculty of Veterinary Medicine - University of Montreal - Canada
INTRODUCTION
Mandibular fractures account for 3 to 6% of all the fractures observed in dogs with the most common lo-
cation being the mandibular body1. Various techniques can be utilized to treat mandibular fractures includ-
ing conservative management and surgical procedures2,3. However, the main goal is the reestablishment of
a physiological occlusion and masticatory function4.
The present study aimed to develop a plate for treating oblique fractures of the mandibular body in dogs
and to validate the project by using finite element modeling (FEM) and biomechanical evaluations.

The 20 pure titanium plates and 120 Ti 6Al 4V locked self-tapping cortical screws were developed to avoid
damaging tooth roots. A computerized tomography (CT) examination was performed on the head of a 35
kg adult male dog cadaver. The 3D virtual model of the mandible based in CT data was rapidly prototyped
in nylon. The 20 mandible prototypes with oblique fractures (10 favorable and 10 unfavorable fractures)
were submitted to osteosynthesis using the plate and screws previously developed and they were used as
samples for the mechanical evaluations. The analyzed parameters were structural rigidity and maximum de-
flection. For the FEM, CTscan data, reconstructed in a 3D STL model was used to reproduce the osteosyn-
thesis conditions adopted in the mechanical testing previously reported.
RESULTS
The statistical analysis showed the

stabilization of the favorable frac- Figure 1 - Mandible prototype with favor-
tures has a higher mechanical re- able fracture stabilized by the plate and locked
sistance than the unfavorable frac- monocortical screws.
tures in the deflection test.
POSTERS
Figure 2 - von Mises stress concentration. Figure 3 - von Mises stress analysis. By re- Figure 4 - von Mises stress distribution. The
Observe the von Mises stress in the center of the moving both upper screws, stress increased in G3 configuration displayed higher von Mises
plate. the lowest screw in the cranial segment of the stress concentration, mainly around the lower
fracture. screw of the caudal region of the plate.
E.P. Freitas WVOC 2010, Bologna (Italy), 15th - 18th September • 658
CONCLUSION
In conclusion, the double-arch geometry plate fixed with locked monocortical screws seems to provide suf-
ficient resistance to stabilize oblique fractures of the mandibular body, without compromising the dental or
neurovascular structures.
ACKNOWLEDGMENTS
CNPq (National Council for Scientific and Technological Development) and, Mr. Guy Beauchamp from the
Faculty of Veterinary Medicine of the University of Montreal for the statistical analysis.
REFERENCES
1. Smith MM, Kern DA. (1995). Skull trauma and mandibular fractures. Vet Clin North Am, Small Anim Clin 25,
1127-1174.
2. Verstraete FJM. (2003). Maxillofacial fractures. In: Slatter D. Textbook of small animal surgery. Philadelphia: Saun-
ders, 2190-2207.
3. Johnson AL. (2007). Management of specific fractures. In: Fossum TW. Small animal surgery. 3ed. St. Louis: Mos-
by, 1015-1142.
4. Rudy RL, Boudrieau RJ. (1992). Maxillofacial and mandibular fractures. Semin Vet Med Surg (Small Anim) 7, 3-20.
POSTERS
659 • WVOC 2010, Bologna (Italy), 15th - 18th September M. Gangl
A preliminary study evaluating the effect of the Pessoa

training aid on abdominal and back muscles
S. Pierron, M. Rosengarten, F. Bouldouyre, M. Gangl
Equine center, Veterinary Campus of Lyon, Vet Agro Sup, 1, av Bourgelat, F-69280 Marcy L’Etoile, France
INTRODUCTION
Reputed benefits of training aids and demanded posture (foreward-down- PESSOA

ward position of head and neck with good hindlimb impulsion): better de- training aid
velopment of abdominal and back muscles.
Objectives
- To propose a reliable and repeatable in the mobilization of the spinal column using sonography
- To compare the development of these muscles between 2 groups of horses, trained respectively with and
without the Pessoa training aid

a. Measuring method (1) b. Training of horses
MT ML With the aid of tape, 7 equi- 6 horses: for each site,
distant markers are placed in measures before and after
the length between the greater the training period
tubercule of the humerus and
A1 the tuber coxae, markers 4,5 Training: 3 lunging-sessions
A3 and 6 are then used to define weekly, 20 min at a trot,
A2 the measuring points. during 3 months
Rectus abdominis muscle,

at 3 si (A1,A2,A3)
→
Multifidus With Pessoa training aid

muscle, in the
(n= 3 horses)
POSTERS
thoracic (MT)
and lumbar
(ML) area
Psoas muscles: (P) transrectal

approach, measured adjacent
to the external iliac artery at Without trainig aid
the level of the ilium (n= 3 horses)
M. Gangl WVOC 2010, Bologna (Italy), 15th - 18th September • 660
RESULTS
a. Measuring method b. Evaluation of muscular development with training
Comparison of measurements of the Ex. measurements before (grey) and after (black) 3 months of one
rectus abdominis muscle (A1,A2,A3) horse trained with Pessoa training aid
and the mulitfidus muscle (MT,ML)
taken by 3 different operators on the
same horse
→ No significznt difference among

the operators (Student test):
method considered as valid
Ex. measurements before (grey) and after (black) 3 months of one

horse trained without training aid
→ No significant difference before-after training, nor depending

on the use or not of the Pessoa training aid
DISCUSSION
Choice of muscles measured guided by technical difficulties to
have complete access to larger muscular masses
Low number of horses, biased due to management conditions
(housed in group in a large pasture: no contrôl of their activity du-
raing day)
Different results if training were to include canter (more vertebral
flexion) or longer and more intensive training periods?
CONCLUSION
Sonography measurement: non invasive, reliable, low cost
Evaluation of effect of the Pessoa training aid: in the present study
no effect, but longer and/or more intensive training needed, use of other evaluation methods: kinematic eval-
uation of the quality of locomotion, muscle biopsies?
REFERENCE
1. MAC GOWAN C., STUBBS N., HODGES P., JEFFCOTT L.: Back pain in horses, epaxial musculature. Rural
POSTERS
Industries Research and Development Corporation, 2007.

661 • WVOC 2010, Bologna (Italy), 15th - 18th September L. Gardel
A regenerative medicine approach for the treatment

of large gap on bone fracture in the cat using mesenchymal
stem cells: a case report
L. Gardel, PhD student1,2, T. Rada, PhD1, M. Gomes, PhD1, R. Reis, PhD1, L. Serra, PhD3,
C. Frias, Technician2, M. Afonso, Student2
1
3B’s Research Group, Dept. Polymer Eng, Univ. Minho, Headquarters of the European Institute of Excellence on Tissue
Engineering and Regenerative Medicine, Guimarães, Portugal
2
3Department of Clinic Veterinary ICBAS-University of Porto, Porto, Portugal
3
Departament of Ortophysiatric, General Hospital Santo António, Porto, Portugal
INTRODUCTION
Regenerative veterinary medicine therapies can make use of cell transplantation, materials science and bio-
engineering to develop biological substitutes that will restore and maintain normal function in diseased and
injured tissue. One possible therapy consists in isolating the stem cells from patient tissue, such bone mar-
row/adipose tissue and administering the cells back to the patient, with or without in vitro expansion and/or
differentiation. This therapy would be of great use in orthopaedics patients, firstly because of the need of
rapid recovery of the affected limb and secondly due to the difficulty of the owners to keep their pets at cage
rest for a long time. This work reports a clinical case in which it was used cat bone marrow stem cells (CBM-
SC) to repair a large gap fracture in the same animal, injecting these cells directly in the tibial fracture site,
after their in vitro expansion and differentiation into osteoblasts.

The surgery was performed through of the closed reduction and external skeletal fixation, and at the same
time, 1 ml of bone marrow (BM) was harvested from femoral medullar cavity. To isolate the CBMSC, 10
ml of osteogenic medium was added to the BM and centrifuged (1200 rpm/5 min). The pellet was resus-
pended and seeded in two culture flask with osteogenic medium. After reaching confluence (2 weeks), the
cells were trypsinized and it was prepared a cells suspension containing 9x106 cells in 0, 6 ml of the PBS to
be injected using a sterile 1 ml syringe. An in vitro control of the cells was kept, consisting of cells were cul-
tured in osteogenic medium for 0, 7 and 21 days. Osteogenic differentiation of the CBMSC was character-
ized by ALP assay and Alizarin red staining. The levels of ALP were also measured in the animal, using
serum obtained from 0.5 ml samples of cephalic vein blood harvested after 0, 7 and 21 days. Sequential X-
rays were performed in day 0, 7, 21, as well as 1 and 6 months after application.
RESULTS
The results show that, in the application day, the CBMSC (previously cultured in osteogenic medium) exhibit
high levels of ALP, demonstrating a high osteogenic potential; the decrease in ALP synthesis in day 7 and day
21 confirm the evolution of the cells towards mineralization. This calcification could be visualized by alizarin red
staining in day 21. The implanted CBMSC caused an increase activity of serum ALP after 7 and 21 days of
cells application demonstrating the high osteogenic potential in the fracture site. These results are in good agree-
ment with the excellent regeneration and bone healing characteristics of the fracture site, observe in the se-
quential X-rays. In fact the formation of bone callus is readily identified in X-ray images of the long time.
CONCLUSION
The postoperative of orthopaedic patient requires reduction of movement of the limb, affected until the clin-
POSTERS
ic union, which is very difficult to achieve for most patients. For example, in this case, a lateral displacement
in the axial focus of fracture was observed. This collapse was caused by the complete use of the limb, asso-
ciated with the inability of owners to keep the patient in cage rest, proving further evidence of the need to
perform the autologous stem cell therapy. This case report shows that a regenerative medicine approach
based on the use of autologous mesenchymal stem cells should be considered as a successful adjuvant ther-
apy for a quick, safe and effective method for accelerating the rate of fracture healing1, in treatment of long-
bone fracture in the orthopaedic surgery of small animals.
REFERENCES
1. Kim JS, Shin WY, Yang HK et al: A multi-center, randomized, clinical study to compare the effect and safety of au-
tologous cultured osteoblast (OssronTM) injection to treat fractures. BMC Musculoskeletal Disorders, 10:20, 2009.
E. Herrero WVOC 2010, Bologna (Italy), 15th - 18th September • 662
Tomographic findings in lesions of the medial coronoid

process in the canine species. Retrospective study in 34 joints
E. Herrero1, J.I. Redondo2, A. Hernández2, C. Soler1, J. Soriano2, 3, V. Bisbal1, C.I. Serra2
1
Centro de Investigación Príncipe Felipe, Valencia, Spain
2
Universidad CEU Cardenal Herrera, Animal Medicine and Surgery Department, Valencia, Spain
3
Hospital Veterinario Massamagrell, Valencia, Spain
INTRODUCTION
Damage to the medial coronoid process of the ulna is one of the most common causes of appearance of el-
bow dysplasia. Diagnosis of this condition should be based on a good clinical history, orthopedic examina-
tion and results of the complementary tests. There are several diagnosis tests for the image used in this
pathology. In recent years, there has been an increased use of computerized axial tomography. However,
there are not many publications describing the tomographic abnormalities that we found associated to this
pathology. Therefore, the objective of this work is to do a detailed description of tomographic alterations
that can be seen in joints affected by lesions of the medial coronoid process in dogs. At the same time, a sec-
ondary objective is to evaluate the coexistence or not of joint incongruity in the elbow.

It has been performed a retrospective study of patients diagnosed and treated for a medial coronoid lesion,
which had undergone a CT scan, in the Hospital of the Univerisity CEU-Cardenal Herrera, between May 2005
and November 2009. All the selected animals had clinical symptoms compatible with a lesion of the medial
coronoid process in, at least, one of the extremities; and they were subject of a tomographic study of both
elbows. In all such cases, the disease was confirmed during the surgery.
A third-generation scanner was used for performing the CT study. For that purpose, the animals were sub-
jected general anesthesia, for subsequent positioning in lateral recumbency, with the shoulder in extension
and the elbow flexed 90 degrees. Thus, transversal sections were obtained. From those sections, multipla-
nar reconstructions were made to obtain the dorsal and sagittal reformatted views.
The presence of tomographic signs associated with the medial coronoid process lesion, was made based on
previous studies of Samoy et al. (2006) and Groth et al. (2009). Tomographic signs were grouped into 5 cate-
gories, depending on the anatomic region affected and the nature of the injury: 1. medial coronoid lesions,
2. lesions in other areas of the ulna, 3. humeral lesions, 4. presence of periarticular osteophytes, and 5. el-
bow incongruity. With the obtained data, a descriptive statistical analysis was performed. The frequency (N)
and the percentage (%) of the variables were stated.
RESULTS
Seventeen animals were included in the study. 100% of the cases showed bilateral involvement, obtaining a
total of 34 joints studied. The lesions that were most frequently identified were: fragmentation of the medi-
al coronoid process (76.50%), subchondral bone sclerosis in the medial coronoid process (94.10%), anom-
alous medial coronoid process (100%), subchondral bone sclerosis in the trochlear notch of the ulna
(80.64%), irregularity in the anconeus cortical (79.40%) and subchondral bone sclerosis in the medial
humeral condyle (76.50%). The presence of periarticular osteophytes was a finding of high incidence
(97.10%), being the dorsal area of anconeus the most common (90.90%). Among those elbows in which the
coronoid process fragment was visualized, 65.37% of these fragments were displaced. And this displacement
was cranial or craniolateral in 80% of the cases. Meanwhile, 45.16% of joints were noted an elbow incon-
POSTERS
gruity, by a short radius or by a decrease in the diameter of the trochlear notch.
CONCLUSION
Tomographic examination of a joint with medial coronoid lesion allows the evaluation of multiple alterations
in the same one. At the same time, we can affirm that the tomographic pictures are a good tool to the ther-
apeutic planning, gaining higher importance in those cases in which we decided a surgical treatment.
REFERENCES
Samoy Y., Van Ryssen B., Gielen I., Walschot N., Van Bree H. (2006). Review of the literature: elbow incongruity in the
dog. Vet Comp Orthop Traumatol 19, 1-8.
Groth AM., Benigni L., Moores AP. Lamb CR. (2009). Spectrum of computed tomographic findings in 58 canine elbows
with fragmentation of the medial coronoid process. J Small Anim Pract 50, 15-22.
663 • WVOC 2010, Bologna (Italy), 15th - 18th September K. Kafshdouzan
Biomechanical study of radial fracture in diabetic rats

augmented with autogenous bone graft
K. Kafshdouzan, DVM, PhD Student1, H.R. Moslemi, DVM, PhD2
1
Dept of Microbiology, Faculty of Veterinary Medicine, Tehran University., Tehran, Iran
2
Dept of Surgery and Radiology, Faculty of Veterinary Medicine, Islamic Azad University, Garmsar Branch, Garmsar, Iran
INTRODUCTION
In certain systemic conditions, such as diabetes mellitus, the fracture healing process is significantly im-
paired. The association between diabetes and impaired osseous healing has been documented in both clini-
cal and experimental settings. The replacement of osseous tissue with autogenous bone grafts to fill defects
has been shown to highly desirable. Because autografts are collected from the same patient, they provide
early revascularization and osteoinduction. This study was undertaken to determine the effectiveness of au-
tografts on radial fracture healing in diabetic rats through biomechanical method.

Fifteen white male Sprague Dawley rats were randomly divided into three equal groups including: 1-diabetic
rats treated with bone graft, 2- diabetic rats non-treated with bone graft and 3-non diabetic non treated group
(negative control). Diabetes was induced in 10 rats by the alloxan (165 mg/kg) intraperitonealy. After 2
weeks, all the rats were generally anesthetized with combination of ketamine hydrochloride and xylazine hy-
drochloride and transverse osteotomy was performed in the mid-shaft of the right radius under aseptic con-
dition. In group 1, the osteotomy gap was filled by the bone graft, harvested from the iliac crest of the same
rat. Group 2 that used as diabetic bone graft control, not received bone graft and group 3 was used as a neg-
ative control. After 5 weeks, all rats were euthanased with overdose of thiopental sodium and radial bones
are collected for biomechanical examination.
RESULTS
Biomechanical results demonstrated, increased structural strength in autograft treated groups compared with
diabetic non-treated group (group 2). Our findings revealed a significant reduction in biomechanical pa-
rameters of diabetic bones of rats without autograft compared with diabetic rats treated with autogenous
bone graft. In these factors, between groups 1 and 3 there was not statistically significant.
CONCLUSION
It was concluded that application of autogenous bone grafts have the positive effects on the fracture healing
process of diabetic rats.
REFERENCES
1. Alexander JW. Use of combination of cortical bone allografts and cancellous bone allografts to replace massive bone
loss in fresh fracture and selected nonunions. J Am Anim Hosp Assoc 1983; 19(5): 671-678.
2. Bauer TW, Muschler GF. Bone graft materials-an overview of the basic science. Clin Orthop 2000; 371:10-27.
3. Beam HA, Parsons JR, Lin SS. The effects of blood glucose control upon fracture healing in the BB wistar rat with
diabetes mellitus. J Orthop Res 2002; 20: 1210-1216.
4. Bisla RS, Singh K, Singh J, Chawla SK. Clinical and radiographical studies on evaluation of entire segment corti-
cal bone grafts in goats. Indian J Anim Sci 1991; 61(7): 699-701.
5. Funk JR, Hale JE, Carmines D, Gooch HL, Hurwits SR. Biomechanical evaluation of early fracture healing in nor-
POSTERS
mal and diabetic rats. J Orthop Res 2000; 18: 126-132.

P. Laganga WVOC 2010, Bologna (Italy), 15th - 18th September • 664
Megavoltage radiotherapy for painful degenerative joint

disease - preliminary results
P. Laganga, DVM1, S. Cancedda, DVM1, V.F. Leone, DVM1,
M. Vignoli, DVM, SRV, Dipl. ECVDI1,2, F. Rossi, DVM, SRV, Dipl. ECVDI1,2,
R. Terragni, DVM1,2, C. Rohrer Bley, DVM, Dipl. ACVR (Radiation Oncology)1,3
1
Centro Oncologico Veterinario, Sasso Marconi (Bo), Italy
2
Clinica Veterinaria dell’Orologio, Sasso Marconi (Bo), Italy
3
Section of Radiation Oncology, Vetsuisse Faculty, University of Zürich, Zürich, Switzerland
INTRODUCTION
Irradiation of benign disease including degenerative joint disease has a longstanding tradition in radiation
therapy. In human medicine, one fourth of irradiations for benign disease include patients with treatment-
refractory pain in the region of small and large joints. The applied low dose radiotherapy leads to a satis-
factory anti-inflammatory efficiency followed by reduction of pain in a majority of patients.
We have recently started with a protocol for irradiation of painful joint diseases in dogs and the present da-
ta show preliminary results from regular follow-up regarding pain status in these patients.

Dogs with orthopedically and radiologically confirmed degenerative joint disease of one or more joints and
treatment-refactory chronic pain were included into the study. Classification of clinical overall lameness was
performed by the same veterinarian according to fixed criteria. All dogs were treated with megavoltage ir-
radiation. Regular follow up was performed by either re-check of the patients or telephonic interview of the
owners according to a questionnaire. Pain status before and after ionizing radiation, necessity of additional
pain medication as well as duration of eventual changes are collected.
RESULTS
Ten dogs of several large breeds (Retrievers n=4, German sheperds n=3, others n=3) were included up to
April 2010. At the time of presentation the dogs had a mean age of 9.5 years (range 4-15 years) and a mean
weight of 29.7 kg (range 20-37 kg). Six cases initially presented with severe lameness, in 3 cases lameness
was considered moderate, and one case presented with mild lameness. The median applied dose of radia-
tion was 6 Gy (3-6 Gy) with a median fraction size of 2 Gy (1.5-2 Gy). In four patients 1-2 joints were treat-
ed and in six cases 3-5 joints were irradiated in simultaneous treatments. In all cases, the dose was applied
within a week (either on three consecutive or on alternate days). The median follow-up period up to April
2010 is 3.9 months.
In all of the cases improvement after radiation therapy was reported. Seven dogs are still alive and six dogs
are still in the improved status after radiation therapy. Three of the dogs died or were euthanized due to un-
related disease. At the time of statistical evaluation, median time of clinical improvement was 135 days (95%
CI: 61; 209 days). All patient owners feel that ionizing radiation reduced the chronic pain status in their an-
imals to a relevant degree and all owners were happy with their decision to have treated the chronic degen-
erative problems of their animals with radiation therapy.
CONCLUSION
These preliminary results underline, that ionizing radiation therapy is a simple and safe method to provide
relief from treatment-refractory chronic pain due to degenerative joint disease. Due to the low applied total
dose, there are neither acute nor chronic side effects to be expected. Radiobiologically, this treatment can be
POSTERS
safely repeated after the re-occurrence of increased pain.

Owner satisfaction of outcome is high and it is to be expected that a large part of these owners are moti-
vated to re-treat their animals in case of worsening of clinical problems.
REFERENCES
Hartung K.: “Fundamentals of radiotherapy in animal joint diseases”, Acta Radiol Suppl. 1972;319:137-40.
Hartung K.: “X-ray therapy of inflammatory diseases in the dog”, Tierarztl Prax. 1980;8(3):363-6.
Ruppert R, Seegenschmiedt MH, Sauer R.: “Radiotherapy of osteoarthritis. Indication, technique and clinical results”, Or-
thopade. 2004 Jan;33(1):56-62.
665 • WVOC 2010, Bologna (Italy), 15th - 18th September V. Ledecký
Screening program of canine hip dysplasia in some breeds

of dogs in Slovakia and its analysis
V. Ledecký, L. Skurková, A. Ševčík, M. Hluchý
Small animal clinic, UVLF in Košice, Košice, Slovakia - ledecky@uvm.sk
ABSTRACT
This study is designed to determine the prevalence of canine hip dysplasia in five dog breeds in Slovakia
and to compare data about prevalence on the beginning of the screening (1977) until 2009. Our results sug-
gest that prevalence of CHD is slowly decreasing, but strict screening is necessary for monitoring of the fur-
ther development.
INTRODUCTION
Canine hip dysplasia (CHD) is known for more than 70 years (Schnelle, 1937).
Schnelle (1954) proposed the first classifying system in 1954; currently there are many different systems in
use. First attempts to control HD were undertaken by the Swedish Kennel Club in 1958. The Scientific
Committee of the Federation Cynologique Internationale (FCI) held their first workshop in 1974 to deal
with the problem of HD (Novak, 2007). All the systems have been based mainly on phenotypic selection of
breeding animals and have obtained varying results (Leppänen et al., 2000). In Slovakia, the first control pro-
gram started for German Shepherd Dogs in 1977 (Ledecky et al., 1997). At the beginning, program includ-
ed only working dogs (police, army) of German Shepherd Dog. Today, there are over 20 different breeds of
dogs attending the canine hip dysplasia screening program in Slovakia, but there is lack of information about
efficacy of these programs.
Objectives
• Determine prevalence of CHD in population of five predisposed dog breeds.
• Compare prevalence of CHD at the beginning of the screening program and today.
Hypotheses
• Prevalence of CHD in population of dogs will be similar to the data in other countries.
• Prevalence will be decreased in comparison to the beginning of the screening.
MATERIALS AND
METHODS Table 1 - Period of CHD screening in Slovakia for four different dog breeds
Radiographs made for the purpose
Dog breed Period of CHD screening
of canine hip dysplasia screening
were retrospectively analyzed to German Shepherd Dog (GSD) 1977 - 2010
determine prevalence of CHD
Bavarian and Hanover Hound (BHH) 1995 - 2010
from 1977 to 2009 and effective-
ness of current screening program. Bernese Mountain Dog (BMD) 1999 - 2010
Radiographs were evaluated ac-
Rhodesian Ridgeback (RR) 2001 - 2010
cording FCI system. Analysis was
done for population of five predis-
posed dog breeds (Tab. 1).
POSTERS
Table 2 - Number of evaluated dogs (N) and distribution (percentages)

RESULTS into the groups (without CHD – grade A, with mild, moderate and severe
Total number of evaluated dogs and CHD – grades C, D, E) during CHD screening period
prevalence of CHD in population
Total No. Grades
• There were evaluated 10,640 Breed (evaluated) Grade A C, D, E
dogs of 5 dog breeds during the
screening period: 9,133 German German Shepherd Dog 9133 68.38% 12.94%
Shepherd Dog (85.84%), 872 Bernese Mountain Dog 418 75.54% 14.4%
Bavarian and Hanover Hound
(8.20%), 418 Bernese Mountain Bavarian and Hanover Hound 872 69.84% 11.81%
Dog (3.93%) and 217 Rhodesian Rhodesian Ridgeback 217 85.71% 5.53%
Ridgeback (2.03%) (Tab 2).
V. Ledecký WVOC 2010, Bologna (Italy), 15th - 18th September • 666
Comparison of CHD prevalence at the beginning of the screening and today

• Prevalence of CHD of GSD (n = 9,133) during observation period decreased while prevalence of degree
A increased from 38.9% (1977-1980) to 83.4% (2009). Prevalence of canine hip dysplasia (grades C, D,
E) was on the beginning of the screening period 33.1%, but at the end (2004-2009) decreased to ap-
proximately 7.5%.
• Prevalence of CHD of RR has been monitored since 2001. Altogether 217 dogs have been examined.
On the beginning of the screening period were almost 76.5% of RR without CHD. In last years about
87-100% of the population was scored grade A. Prevalence of grade D in the population of RR was de-
tected only rarely. Grade E have not been yet detected in Slovakia.
• In the period 1999-2009 were examined 361 Bernese Mountain dogs. Results during period 2004-2006
and 2008 indicated no tendency for long-term improvement. On the beginning of the screening peri-
od was occurrence of grade A 65.8% (1999) and in the period 2005-2009 it varied from 65.5% to
84.6%. In last years was typical also increased prevalence of grades D and E (2006-17.2%, 2007-12.5%,
2008-12.5%).
• On the beginning of the screening period (1995) was occurrence of CHD “free” Bavarian and Hanover
Hound 61.7%, after 15 years it increased to 71.4%. During this period was noted worsening of the re-
sults in 2001-2002. Prevalence of moderate and severe HD has been presented in the population since
2001 (from 2.2 to 11.0%).
Also slight increase of the mild CHD was noted.
Figure 1 - Prevalence of CHD on the beginning of the screening Figure 2 - Prevalence of CHD in year 2009.
period (GSD:1977-1980, BHH: 1995, BMD:1999, RR:
2001).
CONCLUSION
• Prevalence of CHD of five predisposed dog breeds determined in our study were comparable with the
results from previous studies. Generally, our results were lower with respect to the prevalence of CHD
that in other studies (Corley, 1992; Leppännen et al., 2000; Genevois et al., 2008).
• During the periods of CHD screening programs for different dog breeds we noticed decreased preva-
lence of CHD in the population of German Shepherd Dog and Rhodesian Ridgeback. Very strict se-
lection in the population of RR (only dogs with grade A are allowed for breeding) and long-term se-
POSTERS
lection in the population of GSD (with respect to other dog breeds screening lasts from 1977) are the
most probable reasons for this decrease. Another reason is that some dogs of GSD underwent radio-
logic examination of hip joints in young age and because of bad results did not attend the official
screening program. Otherwise, in the population of BHH increased percentage of dogs without CHD
(grade A) but grades D or E are also presented in the population. We did not find any significant long
term improvement of the CHD status in population of BMD, so it is important to monitor tendency
for further CHD development in this population. Clubs of breeders of these predisposed breeds
(BHH and BMD) should consider carefully tightening of conditions for breeding (with respect to
CHD grade).
667 • WVOC 2010, Bologna (Italy), 15th - 18th September V. Ledecký
ACKNOWLEDGEMENTS
Study was made with support of the Scientific sponsorship agency of the
Ministry of Education of the Slovak Republic and Slovak Academy of Sci-
ences (project VEGA 1/0246/10).
REFERENCES
Corley, E. A. (1992). The role of the Orthopedic Foundation for Animals in the control of canine hip dysplasia. Vet Clin
North Am Small Anim Pract 22, 579-593.
Genevois, J.-P., Remy, D., Viguier, E., Carozzo, C., Collard, F., Cachon, T., Maitre, P., Fau, D. (2008). Prevalence of hip
dysplasia according to official radiographic screening, among 31 breeds of dogs in France. Vet Comp Orthop Trau-
matol 21, 21-24.
Ledecky V., Šev ík A., Capík I., Trbolová A. (1997). Analysis of hip joint dysplasia development in dogs. Vet Med –
Czech 42, 1-4.
Leppänen M., Mäki K., Juga J., Saloniemi H. (2000). Factors affecting hip dysplasia in German shepherd dogs in Finland:
efficacy of the current improvement programme. Journal of Small Animal Practice 41, 19-23.
Novak D. (2007). The FECAVA symposium 2007 Canine Hip Dysplasia – where do we stand now with diagnosis, treat-
ment, scoring and genetics? EJCAP 17, 125.
Schnelle G. B. (1937). Congenital subluxation of the coxofemoral joint in a dog. University of PA Bull 65: 15.
Schnelle G. B. (1954). Congenital dyslasia of the hip (canine) and sequalea. VMA. Proceedings of the Annual meeting.
Seattle, WA, 253-258.
POSTERS
H.R. Moslemi WVOC 2010, Bologna (Italy), 15th - 18th September • 668
Comparison of the effects of hydroxyapatite and cartilage

graft on radial fracture healing in rabbits
H.R. Moslemi, DVM, PhD1, H. Mohyeddin, DVM, PhD1, M. Sajjadipour, DVM1,
M. Ahmadi, Undergraduate student2
1
Dept of Surgery and Radiology, Faculty of Veterinary Medicine, Islamic Azad University- Garmsar branch, Garmsar, Iran
2
Member of Young Researchers Club, Faculty of Veterinary Medicine, Islamic Azad University-Garmsar Branch,
Garmsar, Iran
INTRODUCTION
Hydroxyapatite (HA), as bone substitute materials has the advantages of abundant supply and absence of
immunogenecity. Cartilage grafts have been commonly used in plastic and reconstructive surgery applica-
tions for many different goals, such as auricular reconstruction and rhinoplasty. The use of autogenous car-
tilage is ideal for many reasons. This study was conducted to evaluate the effects of hydroxyapatite and au-
togenous cartilage graft on the radial fracture healing in rabbits was assessed by radiographic and histolog-
ical methods.

Eighteen healthy New Zealand White rabbits were randomly divided into three equal groups. All rabbits
were generally anesthetized and transverse osteotomy was performed in the mid-shaft of the right radius un-
der aseptic condition. In groups 1 and 2, the osteotomy gap was filled with the HA and auricular cartilage
separately. Group 3 not received any treatment, and was used as a negative control. Radiographs were tak-
en in lateral view at days of 0, 15 and 35. All rabbits were euthanized 5 weeks after operation and the radi-
al bones harvested and prepared for histological test. In radiography, callus formation, gap and cross reac-
tion between radius and ulna were evaluated. In histology, healing rate and tissue inflammation were eval-
uated.
RESULTS
Radiographic signs of bone healing in negative control were lower than from treated groups. In histological
finding, healing process in treated groups was higher than from negative control significantly. This finding
showed the same healing in two treated groups.
CONCLUSION
It was concluded that application of hydroxyapatite and autogenous auricular cartilage have the same effects
on the radial fracture healing process in rabbits but HA is preferred because of easy in using and does not
need an additional incision.
REFERENCES
Alexander JW. (1983). Use of combination of cortical bone allografts and cancellous bone allografts to replace massive
bone loss in fresh fracture and selected nonunions. J Am Anim Hosp Assoc 19(5), 671-678.
Brien EW, Terek RM, Lane JM. (1994). Allograft reconstruction after proximal tibial resection for bone tumors. An analy-
sis of function and outcome comparing allograft and prosthetic reconstruction. Clin Orthop 303, 116-127.
Caria PHF, Kawachi EY, Bertran CA, Camilli JA. (2007). Biological assessment of porous-implant hydroxyapatite com-
bined with periosteal grafting in maxillary defects. J Oral Maxillofac Surg 65, 847-854.
Fujishiro T, Nishikawa T, Niikura T, Takikawa S, Nishiyama T, Mizuno K, Yoshiya S, Kurosaka M. (2005). Impaction
POSTERS
bone grafting with hydroxyapatite. Acta Orthop. 76(4), 550-554.

Zhao DM, Liu ZH, Wu SO, Li AM, Zhao JJ, Wang P, Sun KN. (2006). Biocompatibility of carbon nanotubes/hydrox-
yapatite composite with tibia of rabbit. Chinese J Biomed Eng. 25(3), 342-345.
669 • WVOC 2010, Bologna (Italy), 15th - 18th September A. Necas
Implant failures of 3.5 LCP vs. 4.5 LCP used for flexible
bridging osteosynthesis of segmental femoral diaphyseal
defects in a miniature pig
A. Necas1, P. Proks2, L. Urbanova1, R. Srnec1, L. Stehlik2, M. Crha1, P. Rauser1
1
Department of Surgery and Orthopaedics, Small Animal Clinic, Faculty of Veterinary Medicine, University of Veterinary
and Pharmaceutical Sciences, Brno, Czech Republic
2
Department of Diagnostic Imaging, Small Animal Clinic, Faculty of Veterinary Medicine, University of Veterinary
and Pharmaceutical Sciences, Brno, Czech Republic
INTRODUCTION
Bone tissue is able to regenerate; however, the natural bone healing process might be in some cases insuffi-
cient. These include critically sized bone defects in the form of comminuted fractures, and ostectomies after
excision of bone tumors.
Experimental removal of a larger bone segment imitates clinical conditions in comminuted fractures or in
ostectomy during bone tumor removal. The aim of this experimental study was to radiographically assess
the types of failure of flexible bridging osteosynthesis with two different size of LCP (Locking Compression
Plate) implants, a six-hole 3.5 mm titanium LCP (Synthes®) versus a five-hole 4.5 mm titanium LCP (Syn-
thes®), for fixation of segmental ostectomy of femoral diaphysis in miniature pigs, and to determine the ab-
solute and relative numbers of implant failures (Necas et al., submitted). Other aim of this pilot study was
to verify in vivo whether for fixation of the above mentioned segmental bone defect the less robust six-hole
3.5 mm LCP with four 3.5 mm screw inserted into the plate holes or the more robust 4.5 mm LCP with
four 4.5 mm screws is more suitable.

Using a miniature pig model (n = 49), an iatrogenic segmental bone defect (ostectomy) was created in the
centre of the diaphysis of the left femur using an oscillating saw in the whole cross section of the bone at the
height of 15 mm of the bone column of femoral diaphysis. Then, while maintaining the principles of flexi-
ble bridging osteosynthesis the main femoral fragments of the miniature pigs were stabilized using one of
the two dimensionally relevant (with regard to the dimensions and size of the bone of the animals used) sys-
tems of LCP, either a six-hole 3,5 mm titanium LCP (Synthes®) (n = 9) and four bicortical 3.5 mm titani-
um locking screws (leaving two central plate holes empty at the level of the segmental bone defect) or a five-
hole 4,5 mm titanium LCP (Synthes®) (n = 40) and four bicortical 4.5 mm titanium locking screws (leaving
one plate hole empty at the level of the segmental bone defect). In all the cases stabilized with 3.5 mm LCP
(n = 9), the ostectomy defect was left without filling. In cases stabilized with 4.5 mm LCP (n = 40), the de-
fect was left without filling in four (n = 4) cases. In seven animals the segmental bone defect was filled with
autogenous cancellous bone graft harvested from tuberculum majus humeri. In twenty nine animals the seg-
mental bone defect was filled with scaffold hydroxyapatite (HAP) and 0.5% collagen scaffold (n = 5), HAP
and 2% collagen scaffold (n = 7), HAP and 2% collagen scaffold seeded with mesenchymal stem cells (n =
4), multilayer HAP and 2% collagen scaffold (n = 4), Chronos (Synthes®) (n = 4), Chronos (Synthes®) sead-
ed with mesenchymal stem cells (n = 5).
Radiographic examination of the healing of the segmental bone defect was done immediately after the sur-
gical procedure, and 2, 4, 8, 12 and 16 weeks after ostectomy. Mediolateral (ML) and craniocaudal (CrCd)
views were made.
POSTERS
After 16 weeks post op experimental animals were lege artis euthanized. The experiment was performed
in accordance with the regulations for animal experiments (Project Nr. 7/2009). Complications of fracture
healing in the form of implant fixation failure were assessed radiographically. Observations were done on
digital radiographs (CR Capsula XL/Fuji) in the program JiveX (Visus-tt). We evaluated the number of
failures of fixation of the segmental ostectomy of the femur by flexible bridging osteosynthesis using both
3.5 and 4.5 mm LCP, the collapse of fracture line, the number and positions of broken screws inserted
through the plate holes or the bending and loosening of the screws, and the difference in the occurrence
of implant failure for the 3.5 mm LCP and for the 4.5 mm LCP. For statistical analysis, Wilcoxon test for
unpaired data was used. Null hypothesis presumed that there would be no significant difference in the fre-
quency of implant failures between the group of pigs treated with the six-hole 3.5 mm LCP and the five-
hole 4.5 mm LCP.
A. Necas WVOC 2010, Bologna (Italy), 15th - 18th September • 670
RESULTS
Titanium locking screws were broken in the group of pigs treated with the 3.5 mm LCP in 66.7% of cases
(6/9). In four cases, a broken screw in position 2 in the proximal femoral fragment was noted 2 weeks after
surgery; in two cases 4 weeks after surgery. In four cases the breaking of the screw in position 2 was ac-
companied by loosening of screw in position 3 of the proximal bone segment, and by collapse of the seg-
mental ostectomy defect. In the group of pigs with femoral ostectomy stabilized with a 4.5 mm LCP the
screws were broken in 15% of cases (6/40). In three cases the broken screw was noted during radiography
4 weeks after surgery; in three cases 12 weeks after surgery. In neither case was the breaking of the 4.5 mm
screw accompanied by loosening of another screw or a collapse of the ostectomy defect. In the group of pigs
with segmental ostectomy stabilized with the 3.5 mm LCP, a significant difference was noted (p < 0.01) in
the number of failures of screws compared to the group of animals treated with the 4.5 mm LCP. In the
group treated with 3.5 mm LCP, no case of LCP breaking was found. In the group of pigs treated with the
4.5 mm LCP the breaking of LCP was noted in 7.5% of cases (3/40). In all cases the LCP was broken at the
level of the empty central plate hole at the place of the segmental bone defect. In one case a broken LCP
was found during radiography fourth week post op (HAP and 2% collagen scaffold). In two cases a broken
LCP was found in week 16 after surgery (HAP and 2% collagen scaffold, Chronos seeded with MSCs). In
all three cases, symptoms of bone healing in the form of bone callus formation were not found at the time
of finding the implant failure in the form of broken LCP. No significant difference was found (p > 0.05) be-
tween the failure of 3.5 mm LCP and the 4.5 mm LCP. Regarding the total number of implant failures (LCP
breaking, screw failure), a significantly higher number of implant failures was found in the group of pigs
treated with the 3.5 mm LCP (p < 0.05) than in the pigs treated with the 4.5 mm LCP.
CONCLUSION
Based on the results of our study, the five-hole 4.5 mm titanium LCP may be recommended as appropriate
plate for flexible bridging osteosynthesis stabilizing segmental femoral defects in miniature pigs. Five-hole ti-
tanium 4.5 mm LCP compared to the six-hole 3.5 mm LCP appears to be a more suitable implant for per-
forming flexible bridging osteosynthesis of a critically sized segmental defect of femoral diaphysis in a minia-
ture pig model.
ACKNOWLEDGEMENT
This work was supported by the Ministry of Education, Youth and Sports of the Czech Republic (Research
Project NPV II 2B06130).
REFERENCES
Necas A., Proks P., Urbanova L., Srnec R., Stehlik L., Crha M., Rauser P., Planka L, Amler E., Vojtova L., Jancar J. Ra-
diographic Assessment of Implant Failures of Titanium 3.5 LCP vs. 4.5 LCP Used for Flexible Bridging Os-
teosynthesis of Large Segmental femoral Diaphyseal Defects in a Miniature Pig Model. Physiological Research, sub-
mitted.
POSTERS
671 • WVOC 2010, Bologna (Italy), 15th - 18th September C. Nikolaou
String-of-pearls (SOP™) locking plate and cerclage wire

stabilisation of periprosthetic femoral fractures following
total hip replacement in 5 dogs
N. Fitzpatrick, DUniv, CSAO, CVR, MVB, C. Nikolaou, DVM, R. Yeadon, BVM&S, CertSAS,
M. Hamilton, BVM&S, CertSAS, DipECVS
INTRODUCTION
Periprosthetic femoral fracture is an uncommon but potentially catastrophic complication following total hip
replacement (THR). Subsequent stabilisation of these fractures can be challenging, due to limited or poor
quality bone stock, particularly if explantation is to be avoided. Locking plate technology may optimise im-
plant purchase in available bone and is commonly used in human periprosthetic femoral fracture manage-
ment. We report the use of the locking string-of pearls (SOP™) plate for the management of periprosthetic
fractures following THR in five dogs.

Inclusion criteria required the presence of complete clinical and radiographic follow-up and the presence of
femoral fracture following THR with SOP plates +/- cerclage wires employed as the sole means of fracture
fixation. Data regarding fracture configuration, time since THR, history of trauma and body weight was ob-
tained from the medical records. Details of implant type used in revision surgeries were also recorded. Man-
ufacturer’s guidelines were followed during plate application. Radiographs were obtained immediately post-
operatively and at 2, 6 and 12 weeks postoperatively. Clinical examination was performed at the same time
intervals, with additional examinations at discretion of the surgeon. Orthogonal radiographs were assessed
for evidence of bony healing and complication associated with the plate, screws or femoral component.
RESULTS
In cases 1-3, fractures occurred intra-operatively during placement of the femoral component during ce-
mentless THR. In each of these cases, non-displaced long oblique or spiral femoral diaphyseal fractures oc-
curred during final stem insertion. In case 4, a displaced long oblique femoral diaphyseal fracture occurred
three weeks after cementless THA, propagating proximally and distally from the tip of the femoral compo-
nent. This case necessitated explantation of the femoral component and revision by means of a Biomedtrix
(Boonton, NJ, USA) cemented CFX™ THR at time of fracture stabilisation. In case 5, a transverse femoral
diaphyseal fracture occurred two weeks after cemented THR at the level of the distal extent of the cement
mantle. All SOP™ plates were applied laterally. Reconstruction of the bony column was achieved in 4/5 cas-
es, with the plate acting as buttress support in case 5. In 4/5 dogs monocortical plate screws were used in the
proximal segment because of limited bone stock due to the presence of the femoral component. Plate frac-
ture occurred adjacent to the original fracture line in case 5 four weeks following initial fracture stabilisation.
This was successfully revised by application of biplanar SOP plates cranially and laterally. In case 2 com-
plete bone union was noted at six week radiographic follow-up, but the dog was euthanased due to quadri-
ceps muscle contracture and ongoing severe osteoarthritis of the contralateral coxofemoral joint. Bone heal-
ing had occurred in the remaining four cases by 14 weeks postoperatively, as evident by bridging osseous
callus present on orthogonal radiographs. No complications associated with the femoral stem were seen. At
12 week follow-up, no pain or crepitus was noted on pressure over the fracture site.
POSTERS
CONCLUSION
SOP™ plate and cerclage wire application achieved uncomplicated fracture healing and return to function
in 3/5 cases with peri-prosthetic femoral fractures following THR. SOP™ locking plate technology optimised
implant purchase in limited bone stock, including application of monocortical screws where necessary, avoid-
ing THR explantation in all cases. For very large patients or those where reconstruction of the bony column
can not be achieved, application of biplanar implants may be considered.
REFERENCES
P.J. Haaland, L. Sjostrom, M. Devor, A. Haug (2009). Appendicular fracture repair in dogs using the locking compres-
sion plate system: 47 cases. Vet Comp Orthop Traumatol 22: 309-315.
M. Okumura WVOC 2010, Bologna (Italy), 15th - 18th September • 672
Mechanism of anti-inflammatory effect of polysulfated

glycosaminoglycan in cultured equine synoviocytes
and chondrocytes
Masahiro Okumura, DVM, PhD, Dip JCVS, Yasuharu Sumie, DVM,
Kenji Hosoya, DVM, MS, DipACVRO, Satoshi Takagi, DVM, PhD
Laboratory of Veterinary Surgery, Department of Veterinary Clinical Sciences
Graduate School of Veterinary Medicine, Hokkaido University, Sapporo 060-0818, Japan
INTRODUCTION
Osteoarthritis is one of the most common performance-limiting diseases of race and competition horses. Re-
cently, glycosaminoglycans, including glucosamine and chondroitin sulfate, and hyaluronic acid have been
used to improve osteoarthrosis; however, their mechanisms of action are not known in detail.
THE PURPOSE of THE PRESENT STUDY was to investigate the underlying mechanisms of the clinical
effect of polysulfated glycosaminoglycan (PSGAG), using cultured equine synoviocytes and chondrocytes.

CULTURED EQUINE SYNOVIOCYTES & CHONDROCYTES
were stimulated by 10 ng/ml interleukin (IL)-1β or 10 ng/ml tumor necrosis
factor (TNF)-α with or without pretreatment with 10 or 100 mg/ml PSGAG
for 24 hours. Subsequently, phosphorylation of two mitogen-activated pro-
tein kinases (MAPKs) (JNK and p38) and the expression of matrix metal-
loproteinase (MMP)-3 were analyzed by Western blotting, and nuclear translocation of nuclear factor
(NF)-κB was evaluated by the immunofluorescence technique.
RESULTS
1. Detection of NF-κB and its nuclear translocation
Cells (2.5×104/well) were cultured on fibronection coated chamber slides.
↓
PSGAG was supplemented in medium with the final concentration (0, 10 and 100 mg/ml),
and then incubated for 24 hours.
↓
IL-1β or TNF-α 10 ng/ml was added into media and incubated another 24 hours.
↓
After removal of media, cells were fixed on the slides and blocked with bovine
serum albumin.
↓
Anti-NF-κB antibody (1st antibody) was mounted on fixed cells and inoculated
for 60 minutes.
↓
After washed out the 1st antibody solution, FITC conjugated antibody (2nd antibody)
was mounted on the cells and inoculated for 60 minutes.
↓
NF-κB was visualized and then observed.
PSGAG could prevent nuclear translocation
of NF-κB induced by TNF-α or IL-1β.
POSTERS
Rate of nuclear
translocation of
NF-κB induced
by IL-1β or TNF-α
was significantly
reduced by
supplementation
of PSGAG.
673 • WVOC 2010, Bologna (Italy), 15th - 18th September M. Okumura
2. Phosphorylation of JNK and p38 and production of MMP-3
Cells (5.0×105) were cultured into each well of 6-well

↓
PSGAG was supplemented in media at concentrations of 0, 10 or
100 mg/ml and incubated for 24 hours.
↓
IL-1β or TNF-α 10 ng/ml was added in media
After 15-minutes incubation, After 24-hours incubation,

cells were harvested and sub- MMP-3 in media
mitted for immunoblotting to was detected.
detect phosphorylation of
JNK and p38.
In both synoviocytes and chondrocytes, both IL-1β and TNF-α induced the phosphorylation of JNK and p38 and
production of MMP-3, all of which were reduced with PSGAG pretreatment compared to the controls.
• MAPKs could be activated by various extracellular stimuli.

JNK and p38, which were members of MAPKs, were switched
on by ultraviolet irradiation, cellular stress and inflammation. Set-
ting in motion of these signals may induce nuclear translocation
of NK-κB and later produce related products. (Ref. 5)
• These final products after nuclear translocation of NK-κB in-
clude MMPs, NOS-2, COX-2 and inflammatory cytokines such
as IL-1β or TNF-α, which could deteriorate arthritis. (Ref. 6)
• While main enzymes to distruct joint structure would be MMPs-
1, 2, 3, 7, 8, 9 and 13, MMP-3 is believed to break framework of
articular cartilage. (Ref. 7)
• Glycosaminoglycans were phagocyted into cells and could reach
nucleus where they play important rolls. (Ref. 8)
These results suggest that PSGAG has a series of anti-inflammatory effects, which inhibit the activation of certain
MAPKs, nuclear translocation of NF-κB, and, subsequently, the production of MMP-3 in equine synoviocytes and
chondrocytes in an inflammatory environment. PSGAG could therefore have chondroprtective effects on arthrosis/
arthritis in horses by inhibition of these intracellular signalings as one of possibilities.
REFERENCES
1. Jeffcott, L. B., Rossdale, P. D., Freestone, J., Frank, C. J. and Towers-Clark, P. F. 1982. An assessment of wastage
in Thoroughbred racing from conception to 4 years of age. Equine. Vet. J., 14: 185-198.
2. Rossdale, P. D., Hopes, R., Digby, N. J. and Offord, K. 1985. Epidemilological study of wastage among racehors-
POSTERS
es, 1982 and 1983. Vet. Rec., 116: 66-69.

3. Bird, J. L., Wells, T., Platt, D. and Bayliss, M. T. 1997. IL-1 b induces the degradation of equine articular cartilage
by a mechanism that is not mediated by nitric oxide. Biochem. Biophys. Res. Commun., 238: 81-85.
4. Pelletier, J. P. 1999. Pathophysiological targets in OA therapy. Osteoarthritis Cartilage, 7: 353-354.
5. Chang, L. and Karin, M. 2001. Mammalian Map kinase signalling cascades. Nature, 410: 37-40.
6. Iovu, M., Dumais, G. du and Souich, P. 2008. Anti-inflammatory activity of chondroitin sulfate. Osteoarthritis Car-
tilage, 16 (Suppl 3): S14-S18.
7. Kolset, S. O., Prydz, K. and Pejler, G. 2004. Intracellular proteoglycans. Biochem. J., 379: 217-227.
S. Park WVOC 2010, Bologna (Italy), 15th - 18th September • 674
Application of bilateral retinaculum overlap in 83 cases

of medial patellar luxation in small breed dogs
K. Cho, MSc, DVM, J. Park, BSc, DVM, S. Park, BSc, DVM, S. Choi, PhD, DVM, G. Kim, PhD, DVM
Department of Veterinary Surgery, College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk, South Korea
INTRODUCTION
Canine patellar luxation is one of the most common orthopedic disorder in small breeds. Deepening of the
trochlear groove by trochleoplasty is necessary in cases where the trochlear groove is shallow or flat. However,
it is not possible to maintain the integrity of the patellofemoral articulation and the hind limb extension mecha-
nism by using only one of techniques. Therefore, in cases with stifle joint abnormalities, a combination of two
or more techniques is needed to achieve anatomic realignment and to improve limb function. We hypothesize
that a joint capsule with medial and lateral femoropatellar ligaments can interfere in the appropriate depression
of the flat patella in the groove. This will result in reluxation, even in cases of sufficient depth after trochleoplasty.
The objectives of this study were to evaluate the effects and outcomes of the bilateral retinaculum overlap (BRO)
with trochleoplasty for preventing the patellar reluxation in canine patients.

Eighty-three patellae of 45 dogs with naturally occurring patellar luxations ranging from grade I to III were
used in our study. All dogs were undergoing correction of patellar luxation with the BRO and trochleoplasty.
In the BRO procedure, the medial and lateral margins of the patella were incised in a parallel fashion. The
patella was retracted to medial direction and trochleoplasty was performed with either trochlear block re-
cession or trochlear wedge recession. These incisions were extended proximally and distally, and the final
incisional length was about 3 times than that of the patella. The incised tissues were both sutured directly
above the patella. Each grade of patient was divided into 3 groups by the follow-up point. The evaluations
of lameness were performed after 3 months (83 cases), 2 years (47 cases) and 4 years (20 cases) postopera-
tively. Evaluations of lameness were quantified using the lameness scoring system which is modified from
the lameness grades of Roy et al. (1992). Lameness score was from 1 (no lameness) to 5 (non-weight-bear-
ing lameness). The overall follow-up rate was approximately 74%.
RESULTS
Surgical correction of patellar luxation via the BRO procedure was successful in majority of cases. All sub-
jects were categorized into 3 groups according to the point of time when the follow-up was conducted. The
selected time points were 3 months (short-term), 2 years (middle-term) and 4 years (long-term). On the post-
operative evaluations of lameness, the patients with grade III patellar luxation showed a score of 1.35 to
1.66, whether no lameness was detected in patients of grade I luxation. The average scores of the patients
with grade II luxation were from 1.03 to 1.35. The patella could be rotated or twisted due to the over-deep-
ening trochleoplasty, overdeveloped vastus medialis muscle and/or tibial deformity. To prevent this rotation
of patella, trochleoplasty should be performed with the appropriate depth. When this problem occurred, it
could be minimized by additional suturing between retinacular fasia and parapatellar fibrocartilage and by
transposing tibial tuberosity, or both. Patella luxation cases with reluxation in the stifle movement were cor-
rected with BRO, trochleoplasty and other methods. In an extended position, to better resist patellar luxa-
tion, it is required to increase patellar depth, patellar articular contact with the recessed proximal trochlea
and recess more percentage of trochlear surface area (Johnson et al., 2001), therefore the trochlear block re-
cession was more suitable than the trochlear wedge recession for this BRO technique.
CONCLUSION
POSTERS
The BRO technique with trochleoplasty is a simple surgical method that effectively releases the tightening of ex-
tracapsular tissues and depressing of the patella into the groove, thus it provides a satisfactory treatment for ca-
nine patellar luxation. Furthermore, a joint capsule bearing medial and lateral femoropatellar ligaments may in-
terfere with the depression of the patella into the groove which could be removed by incisions of both medial
and lateral margins of the patella. However, the efficacy of BRO remains to be determined by histological and
synovial fluid examinations for the progressing of orthopedic problems such as degenerative osteoarthritis.
REFERENCES
Roy R.G., Wallace L.J., Johnston G.R. et al. (1992) A retrospective evaluation of stifle osteoarthritis in dogs with bilater-
al medial patellar luxation and unilateral surgical repair. Veterinary Surgery 21, 475-479.
Johnson A.L., Probst C.W., Decamp C.E. et al. (2001) Comparison of trochlear block recession and trochlear wedge re-
cession for canine patellar luxation using a cadaver model. Veterinary Surgery 30, 140-150.
675 • WVOC 2010, Bologna (Italy), 15th - 18th September M. Pepe
Development of first phalanx osseous cyst-like lesion after

fracture repair: two cases
F. Beccati1, M. Pepe1, R. Gialletti1, M. Puccetti2, C. Tamantini1, S. Nannarone1
1
Dipartimento di Patologia, Diagnostica e Clinica Veterinaria, Sezione di Chirurgia e Radiodiagnostica,
Facoltà di Medicina Veterinaria, Università degli Studi di Perugia, Italy
2
Libero Professionista, Perugia, Italy
INTRODUCTION
Subchondral osseous cyst-like lesions (SCLs) in horses are well documented. SCLs at locations other than
the medial femoral condyle have a relatively low incidence. Their aetiopathogenesis is not completely un-
derstood, although developmental factors, sepsis, trauma, and ischemia have been proposed as possible
causes.
CASES DETAILS
Case 1 was a 5-days-old, Warmblood colt foal referred for transverse first phalanx fracture of the left fore-
limb. Case 2 was a 3-months-old Warmblood filly foal referred for complete diaphyseal third metacarpal
bone fracture of the right forelimb. Both fractures were treated by internal fixation under general anaesthe-
sia. Post operatively, foal 1 received amikacina sulphate (25 mg/kg bwt, i.v., s.i.d.) and cefquinome sulphate
(1 mg/kg bwt i.v. b.i.d.) for seven days, whereas foal 2 received the same treatment for fourteen days. In both
cases pain management was provided by administration of phenylbutazone (2.2 mg/kg, bwt, i.v., s.i.d.). Re-
spectively 28 days (foal 1) and 20 days (foal 2) after fracture repair, a diagnosis of implant infection was made
in both patients based on clinical and diagnostic findings. Implants were removed 67 days (foal 1) and 73
days (foal 2) after fracture repair and the infection was resolved in both cases. Forty days after fracture re-
pair foal 2 showed severe lameness (grade 4/5) of the left hind limb, whereas foal 1 showed severe lameness
(grade 4/5) of the right hind limb 20 days after implant removal. In both foal physical examination revealed
soft-tissue swelling of the pastern, severe local pain and a positive flexion test of the distal limb. Lameness
was abolished by plantar digital anaesthesia in both foals. Four standard radiographic views of the affected
proximal interphalangeal joint were taken for each patient (dorsoplantar, lateromedial, dorso 45°lateral-plan-
taromedial oblique and dorso 45°medial-plantarolateral oblique). A circular, irregular, focal area of sub-
chondral lucency surrounded by mild sclerosis was observed in the distal medial end of the proximal pha-
lanx on the dorsoplantar and D45°MPLO views in both foals. On the lateromedial view, marginal osteo-
phytes and periarticular new bone growth were detected in the proximal end of the middle phalanx and were
associated with irregular linear subchondral radiolucency in the dorsal aspect of the distal end of the PI. For
foal 1, radiographic follow-up was obtained 3 months after diagnosis of the SCL. On dorsoplantar view, the
SCL was surrounded by severe sclerosis and showed a strongly irregular outline. On lateromedial view, mar-
ginal osteophytes and proliferative bone growth were detected. The dorsal aspect of the distal end of PI was
sclerotic. For foal 2, radiographic follow-up was obtained at 2 and 4 months after diagnosis of the SCL. On
dorsoplantar view, the first follow-up examination showed a sclerotic appearance of the proximal aspect of
the SCL and 2 small irregular circular radiolucencies were detected close to the joint surface.
On the lateromedial view, the subchondral plate and the dorsal cortical rim of the dorsal aspect of the dis-
tal end of PI were sclerotic and had increased in thickness. Radiographic examination showed the presence
of severe remodelling of the distal condyle of PI and flattening of the dorsal aspect of the distal articular sur-
face of PI. At 4 months, the second follow-up examination showed the SCL was completely filled with scle-
rotic bone. On the lateromedial view, the radiolucency had disappeared, whereas the flattening of the artic-
POSTERS
ular surface of PI was still evident. An increase of the cortical rim of the dorsal aspect of the middle phalanx
associated with bone remodelling was still evident.
DISCUSSION
Several of the clinical features found in these two cases suggest that aetiology other than osteochondrosis
may be responsible for the development of the subchondral bone cyst. Given the young age of the foals
(mean age 1 month), failure of endochondral ossification could potentially explain the development of the
SCLs, but the radiographic findings (irregular focal area of bone loss) and the acute and severe onset of
lameness in both foals make this unlikely. The severe and sudden onset of lameness and the history of im-
plant infection could suggest a septic aetiology in the development of SCLs. The continued severe lameness
following fracture repair and the consequent overloading of the other limbs may also suggest a traumatic
M. Pepe WVOC 2010, Bologna (Italy), 15th - 18th September • 676
mechanism in the development of SCLs. In these young horses, the development of SCLs in locations oth-
er than the fractured limb could be considered as a complication of fracture repair and/or implant infection.
Weight-bearing induced laminitis is the most common and devastating complication of fracture repair in
adult horses. In foals, continued severe lameness following fracture repair frequently results in angular limb
deformity and occasionally in contracture deformity. In cases of implant infection and severe lameness, de-
velopment of SCLs could be also potentially considered a severe complication in foals.
REFERENCES
1. Montgomery L.J. and Juzwiak J.S. (2010) Subchondral cyst-like lesion in the talus of four horses. Equine Veterinary
Education 21, 629-637.
2. Garcìa-Lopez J.M., Kirker-Head C.A. (2004) Occult subchondral osseous cyst-like lesions of the equine tarsocrur-
al joint. Veterinary Surgery 33, 557-564.
3. Baxter G.M.: Subchondral Cystic Lesions in Horses, in McIlwraith C.W. and Trotter G.W. (eds): Joint Disease in
the Horse. Philadelphia, WB Saunders Company, 1996, pp 384-396
4. Nixon A.J.: Laminitis and Contracture Deformity, in Nixon A.J. (ed): Equine Fracture Repair. Philadelphia, WB
Saunders Company, 1996, pp 367-370.
5. Trotter G.W., McIlwraith C.W., Norrdin R.W. and Turner A.S. (1982) Degenerative joint disease with osteochon-
drosis of the proximal interphalangeal joint in young horses. Journal of the American Veterinary Medical Associa-
tion 180, 1312-1318.
POSTERS
677 • WVOC 2010, Bologna (Italy), 15th - 18th September O.C.M. Pereira-Júnior
In vitro evaluation of three different biomaterials as

scaffolds for canine mesenchymal stem cells
O.C.M. Pereira-Júnior, S.C. Rahal, J.F. Lima-Neto, F.C. Landim-Alvarenga
Department of Veterinary Surgery and Anesthesiology - School of Veterinary Medicine and Animal Science,
UNESP Univ Estadual Paulista - Botucatu/SP - Brazil
INTRODUCTION
• Biomaterials have been used as scaffolds in reconstructive surgeries with excellent results while avoiding
the use of bone grafts. However, it is recognized that some biomaterials lack either osteogenic or os-
teoinductive properties.
• The association of biomaterials and cells with osteogenic potential such as the mesenchymal stem cells
(MSC) may be a viable and promising alternative in the treatment of bone defects as observed in animal
models.
OBJECTIVE
• The aim of this study was to investigate three different types of biomaterial (BioOsteo, Bonefill and Hidrox-
iapatita) utilized as scaffolds for canine MSCs.

• BioOsteo (Biomecanica Ltda-Brazil), in granule presentation (800 µm in diameter) with pores of 1 to 2 µm,
is a polyurethane containing castor oil (soft segment), associated with calcium carbonate (34.5% concen-
trated).
• Bonefill (Bionnovation Biomedical - Brazil) is a granular biomaterial (0.6-1.5 mm in diameter) composed
of inorganic matrix obtained from bovine bone.
• Hidroxiapatita (Bionnovation Biomedical - Brazil) in granules of approximately 0.6 mm in diameter is a
sintered ceramic mineral produced by precipitation of calcium phosphate.
• Canine bone-marrow derived MSCs (CD34-, CD44+) at a density of 2x106 cells/flask were seeded onto
the biomaterials granules, placed in a 75 cm2 cell culture flask.
• The cell morphology was evacuate at days 2, 4 and 7 of cell culture. Scanning electron microscopy (SEM)
was used to evaluate the cell attachment and growth on the surfaces of the biomaterials at day 7.
• At day 7, the adherent cells in the culture flask were stained with Alizarin Red solution. Furthermore, ad-
herent cells were also marked with Sp7/Osterix antibody for osteogenic differentiation.
RESULTS
In vitro cell response with biomaterial at day 7 of cell
culture
• BioOsteo: the cells reached 80-90% confluence
(Figure 1a)
• Bonefill: the cells showed about 90% confluence
(Figure 1b)
• Hidroxiapatita: the cells reached 80% confluence
(Figure 1c)
Figure 1 - Phase microscopy at 7 days of cell culture. Cell mor-
Cell differentiation markers phology and spreading in the presence of the BioOsteo(a), Bone-
POSTERS
• Alizarin Red staining revealed no calcium deposi- fill(b), and Hidroxiapatita (c) granules (*). Observe the high cel-
tion in the cell monolayer for the BioOsteo and lular confluence with the three biomaterials.
Bonefill (Figure 2a and b). Hidroxiapatita showed
little deposition of extracellular calcium (Figure 2c).
• Anti-Sp7/Osterix antibody was positive only in relation to cells cultivated in the presence of Hidroxiap-
atita granules (Figure 2d).
SEM
• BioOsteo: cells with fibroblastoid morphology were aggregated at the surface of all granules (Figure 3a).
Approximately 90% of the granules had spherical hydroxyapatite-like structures adhering to their surface,
surrounding the cells (Figure 3b).
O.C.M. Pereira-Júnior WVOC 2010, Bologna (Italy), 15th - 18th September • 678
Figure 2 - Comparison at 7 days of cell culture of the Alizarin

Red solution staining among the cells cultured in the presence of
BioOsteo (a), Bonefill (b), and Hidroxiapatita (c) granules. Ob-
serve calcium deposition stained only when the Hidroxiapatita Figure 3 - SEM of the cells (arrows) attached to BioOsteo (a,b),
was added to the cell culture. The osteogenic differentiation of the Bonefill (c) and Hidroxiapatita (d) granules. Observe calcified ma-
cells with the Hidroxiapatita granules was confirmed by the anti- trix deposition (*) around the cells over the surface of the BioOsteo
Sp7/Osterix antibody (d). granule.
• Bonefill: marked cell aggregation covering almost the entire granular surface. The cells had fibroblastoid
morphology (Figure 3c).
• Hidroxiapatita: few cells with smaller diameter were aggregated on the granular surface (Figure 3d).
CONCLUSION
All tested biomaterials were able to support MSC adhesion and proliferation, and may be used as scaffolds
for MSCs in bone tissue engineering.
POSTERS
679 • WVOC 2010, Bologna (Italy), 15th - 18th September S. Pinna
PEMF therapy in the treatment of canine osteoarthritis:

preliminary results
S. Pinna, DVM, PhD, A.M. Tribuiani, DVM, E. Pizzuti, DVM, A. Venturini, DVM
Clinical Veterinary Department, Alma Mater Studiorum, University of Bologna, Ozzano Emilia (Bologna), Italy
INTRODUCTION
The purpose of this study is to evaluate the analgesic and anti-inflammatory effects of the pulsed electro-
magnetic field (PEMF) in the treatment of osteoarthritis (OA) in dogs.
The effectiveness of the PEMF therapy has been demonstrated by several experimental and clinical studies.
In fact, while it is widely used in humane field1, up to now, as far as dogs are concerned, only a few physi-
cal therapy reports have been published2,3.
PEMF employs low frequency non-ionized athermic pulsed electromagnetic fields. It is assumed that, due
to its interaction with the membrane channels, PEMF alters the transport of ions, like calcium, and causes
a consequent modification of the membrane potential. This induces the fall of transduction signals which
stimulate the synthesis of growing factors, important for bone and cartilage formation1,4. PEMF chon-
droprotective action is both direct, by means of homeostasis and articular metabolism modulation, and in-
direct due to its anti-inflammatory properties.
Some trials demonstrated that PEMF increases chondrocytes proliferation and extracellular matrix compo-
nents synthesis, while reducing OA progression5,6.
Its anti-inflammatory properties are mediated by an agonist activity on adenosin receptors as well as by an
inhibition of prostaglandines synthesis7.
PEMF analgesic effect could either be the result of a direct effect on the brain waves, or a consequence of
its capacity to affect the endogenous and exogenous opioids system8.
Furthermore, PEMF increases blood circulation and tissues oxygenation, and reduces pain, edema and
hematoma1.

For this study, only dogs that had had lameness for at least four weeks were chosen. It was also required a
radiographic evidence of OA in one or more joints. Other factors of exclusion were: systemic diseases, in-
fectious arthritis, pregnancy, and treatments with anti-inflammatory drugs in the last two weeks. Owners
were informed about the clinical survey as well as the physical and therapeutic characteristics of PEMF.
They were asked to sign an informed consent, stating their obligation to bring their dogs to the veterinary
hospital at least 3 times per week, for a total of 20 sessions. Besides, owners were asked not to give any an-
ti-inflammatory drugs, nor to change their dogs dietary and environmental habits, and to report any health
problems which might occur during the study period.
For this purpose, 20 dogs of different breed -10 male and 10 female- were enrolled. The mean body
weight±SD was 24.68±13.74 kg (range, 5.5 to 50 kg), the mean±SD age was 7.3±4.3 years (range, 9 mounths
to 17 years). The OA joints were 27 (11 elbows, 8 knees, 5 hips, 2 shoulders and 1 carpus).
Lameness, pain on manipulation and palpation, and range of motion were evaluated at the beginning of the
therapy (T0), at the tenth session (T10), at the end (T20), and re-evaluated after 4 and 12 months.
Radiographic exams at T0 and T20 were taken, to score the OA signs. At the same time questionnaires were
submitted to the owners for the assessment of chronic pain and its impact on their dogs health-related qual-
ity of life on the basis of behavioral changes9 and the PEMF therapy level of satisfaction.
Follow-up included clinical and radiographic examinations and questionnaires 4 and 12 months after treat-
POSTERS
ment. Scoring was based on a scale of 0 (normal) to 4 (severe) for each variable, except for pain recorded
as yes/no, and range of motion recorded as increased/decreased compared with contralateral joint.
Dogs were lain on a pulsated magnetic field mat with cyclic frequency (3-22-250-500-750-1000 Hz) and 0.75
microT intensity for 10 minutes, and then a small pad was applied on the affected joint for 8 minutes.
RESULTS
The percentage of dogs with lame that improved by at least one grade was 85% at T10 and 90% at T20 (18
dogs out of 20) (significantly P<0.05). There was pain on manipulation on 77.8% (21 joints out of 27) at T0,
it was so on 14.3% (3 joints out of 21) at T10 and on 9.5% at T20. The range of motion scores were im-
proved on 18.5% (5 joints out of 27) at T20. The radiographic signs of OA were scored in all dogs (mean
3±1.04) at T0, but were not significantly (P>0.05) improved at T20 (2.96±1.09).
S. Pinna WVOC 2010, Bologna (Italy), 15th - 18th September • 680
At 4 months all 18 dogs had maintained the benefits recorded at T20. At 12 months 11 dogs were exam-
ined, two of them (18.2%) showed lameness and pain. No significantly x-ray changes (P>0.05) were record-
ed. The owners reported improvement (vitality, appetite, lameness) in 45% of dogs at the 5th session. At T0
the owners questionnaire score was 1.07, at T10 it was decreased to 0.80, and at T20 it was significantly
(P<0.05) improved to score 0.59. The owners’ satisfaction was scored 0.43 (0=high satisfaction, 4=unsatis-
faction). No adverse effects were recorded during the treatment.
CONCLUSION
The majority of the dogs improved with PEMF treatment with respect to their baseline lameness and pain
values, and this was already obvious at half therapy. The benefits were maintained for medium-long time
without using anti-inflammatory drugs.
We suppose that a mechanical block from osteophytes, recorded on x-ray films, could be the reason of the
lack of improvement of the range of motion.
It must be noted that immunohistochemistry trials on Guinea Pigs showed that PEMF treatment preserves
the morphology of articular cartilage and retards the development of osteoarthritic lesions5,6. In contrast with
what expected in the present study, the radiograph signs of OA were not decreased probably because 20 ses-
sions were not sufficient to observe any x-rays changes of bone and cartilage.
The results of questionnaires indicated that the decrease of pain impacted positively on the dogs health-re-
lated quality of life, and on their owners’ high grade of satisfaction.
Double-blind, randomized, controlled studies of comparison between NSAID and PEMF efficacy could be
a topic for further research.
In conclusion, PEMF is a non-invasive remedy, lacking in adverse effect, easy to employ, and useful for con-
trolling pain and inflammation associated with osteoarthritis.
REFERENCES
1. Markov MS (2007). Pulsed electromagnetic therapy history, state of the art and future. Environmentalist DOI 10.
1007/s10669-007-9128-2. [http://www.curatronic.com/pdf/PEMFenvironmentalist.pdf].
2. Canapp DA (2007). Select Modalities. Clin Tech Small Anim Pract, 22,160-165.
3. Marcellin-Little DJ (2004). Benefits of physical therapy for osteoarthritic patients. Proceeding 12th ESVOT Con-
gress, Munich, 10th-12th September, pp 100-103.
4. Trock DH (2000). Electromagnetic fields and magnets. Investigational treatment for musculoskeletal disorders.
Rheum Dis Clin North Am 26,51-62.
5. Ciombor DM, Aaron RK, Wang S. Simon BB (2003). Modification of osteoarthritis by pulsed electromagnetic field-
a morfological study. Osteoarthr Cartil 11,455-462.
6. Fini M, Torricelli P., Giavaresi G, et al (2008). Effect of pulsed electromagnetic field stimulation on knee cartilage, sub-
chondral and epyphiseal trabecular bone of aged dunken Hartley guinea pigs. Biomed Pharmacother 62,709-715.
7. Varani K, De Mattei M, Vincenzi F, et al (2008). Characterization of adenosine receptors in bovine chondrocytes
and fibroblast-like synoviocytes exposed to low frequency low energy pulsed electromagnetic fields. Osteoarthr Car-
til 16,292-304.
8. Thomas AW, Graham K, Prato FS, et al (2007) A randomized, double-blind, placebo-controlled clinical trial using
a low-frequency magnetic field in the treatment of musculoskeletal chronic pain. Pain Res Manag 12,249-258.
9. Wiseman-Orr ML, Scott EM, Reid J, et al (2006). Validation of a structured questionnaire as an instrument to meas-
ure chronic pain in dogs on the basis of effects on health-related quality of life. Am J Vet Res 67,1826-1836.
POSTERS
681 • WVOC 2010, Bologna (Italy), 15th - 18th September L. Pratola
Conversion total hip replacement after failed femoral head

and neck excision in one dog and two cats
N. Fitzpatrick, DUniv, CSAO, CVR, MVB, L. Pratola, BSc, BVMS, MRCVS,
N. Christos, DVM, M. Hamilton, BVM&S, CertSAS, DipECVS
INTRODUCTION
Despite the increasing availability of total hip replacement (THR), femoral head and neck excision (FHNE)
remains the most popular surgical technique to ameliorate hip pain due to chronic osteoarthritis in dogs and
cats. Reported success rates for FHNE range between 60 to 83%. Common complications include ongoing
lameness, limb shortening, patellar luxation, sciatic neuropraxia and poor range of motion of the pseudoarthro-
sis. Reports of total hip replacement (THR) after failed FHNE in the veterinary literature are limited, howev-
er favourable short-term clinical outcomes have been reported. We report THR following unsuccessful FHNE
in one dog and two cats.

A standard craniolateral surgical approach was employed. For two cats, one dog, THR included cemented
CFXTM (Biomedtrix, LLC, NJ) acetabular and femoral components. For one dog, Biomedtrix non-cemented
BFXTM (Biomedtrix, LLC, NJ) acetabular and cemented CFXTM femoral components were used.
RESULTS
Conversion THR was performed four months post-FHNE in one case and five months post-FHNE in two
cases. One cat required two revision surgical procedures following recurrence of lameness three months fol-
lowing the previous operations. On each occasion, loosening at the cement-bone interface was noted on or-
thogonal radiographs. Both revision surgeries were performed with the CFX™ system. At the second revi-
sion, multiple holes were burred into the ilium and ischium to increase the macrointerlock of the bone ce-
ment to available bone stock. Follow up radiography at 6 and 12 weeks after the last surgical procedure re-
vealed satisfactory cement-bone stability through interlock albeit that there were still subtle radiolucency be-
tween the thin cortical bone and the cement interface. At two-year follow up, this patient remains clinically
sound and leads an outdoor lifestyle. In the other two cases, follow up radiography revealed no implant re-
lated complications and satisfactory limb function was evident with no pain or lameness noted at nine and
two month follow-up respectively.
CONCLUSION
Revision of failed FHNE by THR resulted in significantly improved limb function for all three cases. Aseptic
loosening was the only complication encountered in one case requiring two revision surgeries and was attrib-
uted to dense sclerotic endosteal surface with paucity of interface integration capability for the cement mantle
on very thin cortical bone, subsequently requiring creation of perforation apertures to provide cement anchors.
The major technical challenge for all cases was femoral canal preparation in the presence of deformed proxi-
mal femoral geometry and sclerosis subsequent to remodelling after previous FHNE. The femoral stems cur-
rently available are straight, which in one feline case did not fit the distorted femoral canal, requiring implan-
tation of the stem further caudo-laterally in the trochanteric region to allow adequate stem purchase. Under-
sized femoral stems may be used to overcome such anatomical restrictions in the clinical setting, but can result
POSTERS
in paucity of neck length and subsequent dislocation. Custom-designed modular stems have proven useful in
human medicine and may increase the popularity of salvage of failed FHNE by THR in animal patients.
REFERENCES
Gofton N, Sumner-Smith G (1982): Total Hip Prosthesis for Revision of Unsuccessful Excision Arthroplasty. Vet Surg;
134-139.
Liska W, Doyle N, Schwartz Z. (2010): Successful revision of a femoral head ostectomy (complicated by postoperative
sciatic neurapraxia) to a total hip replacement in a cat. Vet Comp Orthop Traumatol; 23:119-123.
S.C. Rahal WVOC 2010, Bologna (Italy), 15th - 18th September • 682
Kinematic analysis in healthy poodles

C.C. Otoni1, S.C. Rahal1, N.S.M.L. Miqueleto1, F.S. Agostinho1, M.R. Verdugo1,
C.R. Padovani2, J.H. Cavini1
1
Department of Veterinary Surgery and Anesthesiology, School of Veterinary Medicine and Animal Science -
Univ Estadual Paulista (UNESP), Botucatu, São Paulo, Brasil
2
Department of Biostatistics, Institute of Biosciences - Univ Estadual Paulista (UNESP), Botucatu, São Paulo, Brasil
INTRODUCTION
There are several reasons to perform gait analysis, but it is especially useful to distinguish between normal
and abnormal locomotor patterns; to detect and determine disease severity; to select the treatment strategy; and
to predict a prognosis1,2,3. Kinematics is an objective measurement that may be used to quantify velocities,
positions, accelerations, and joint angles1,2. The three-dimensional kinematic system gives more information
than the two-dimensional2. Determination of motion patterns through kinematic studies have been per-
formed more frequently in middle to large size dog breeds4,5. Therefore, the aim of this study was to evalu-
ate kinematic patterns of forelimbs and hind limbs in clinically normal miniature poodle dogs.

Nine clinically healthy poodles were used; 4 males and 5 females, weighing 4.8-7.3 kg (mean 5.47), and aged
from 2 to 6 years. Before beginning the kinematic analysis, the dogs were trained to trot on the built canine
treadmill. Each dog was tagged with 11 reflective spherical markers placed by the same investigator using dou-
ble-sided adhesive tape. Kinematic data were collected by use of a 3-camera system (0.3 Megapixel) with a
recording frequency of 120-Hz (Vicon MX3+) strategically placed in one side along the treadmill.
The kinematic study was performed with markers placed first on the right side of the dog, and after on the
left side. For each analysis, the treadmill was repositioned and the system calibrated. Velocity of the tread-
mill was maintained between 1.4 and 1.6 m/s. A minimum of 5 valid trials were obtained from the right and
left sides of each dog. In each trial, five completed
strides were analyzed, yielding a single mean value for
each side of each dog. Specialized computer software
was used to collect and process kinematic data. Data
were analyzed by use of a motion-analysis program (Vi-
con Motus 9).
Flexion and extension joint angles (maximum, mini-
mum, displacement), angular velocity (maximum, min-
imum, displacement), and angular acceleration (maxi-
mum, minimum, displacement) were determined for
the shoulder, elbow, carpal, hip, stifle, and tarsal joints.
Statistical analysis using Student's t-Test for dependent sam-
ples was performed to compare values from the right
side to the left side of both forelimbs and hind limbs.
Differences were considered significant at p<0.05.
RESULTS
Some of the distal reflective markers the forelimbs (sty-
loid ulnar process and/or distal lateral aspect of the fifth
metacarpal bone) and/or hind limbs (styloid ulnar
POSTERS
process and/or distal lateral aspect of the fifth

metacarpal bone) were temporarily invisible or even
completely lost during the trials. For this, some recon-
struction parameters, especially acceleration factor,
were readjusted to guarantee the three-dimensional tra-
jectories of these markers, minimizing the interruptions
and fragmentation of the coordinates (gaps). The final
trajectories were filtered to reduce noises and improve
the precision of the results.
No significant differences were observed between the
right and left limbs in all variables (Tables 1, 2 and 3).
683 • WVOC 2010, Bologna (Italy), 15th - 18th September S.C. Rahal
CONCLUSION
In conclusion, the kinematic patterns of forelimbs and hind limbs in clinically normal miniature poodle dogs
trotting on a treadmill at a constant velocity may be obtained. However, more studies are necessary to im-
prove the capture of the distal markers.
ACKNOWLEDGEMENTS
This study was supported by The State of São Paulo Research Foundation (FAPESP), and The National
Council for Scientific and Technological Development (CNPq).
REFERENCES
1. McLaughlin RM. Kinetic and kinematic gait analysis in dogs. Vet Clin North Am Small Anim Pract 2001; 31:193-
201.
2. Whittle MW. Gait Analysis: an Introduction. 4th ed. Elsevier, Edinburgh; 2007:255p.
3. Gillette RL, Angle CA. Recent developments in canine locomotor analysis: A review. Vet J 2008; 178:165-176.
4. Marghitu DB, Kincaid SA, Rumph PF. Nonlinear dynamics stability measurements of locomotion in healthy grey-
hounds. Am J Vet Res 1996; 57:1529-1535.
5. Owen MR, Richards J, Clements DN, et al. Kinematics of the elbow and stifle joints in grey hounds during tread-
mill trotting - an investigation of familiarization. Vet Comp Orthop Traumatol 2004;17:141-145.
POSTERS
G.L. Rovesti WVOC 2010, Bologna (Italy), 15th - 18th September • 684
Clinical evaluation of joint distraction for stifle

and shoulder arthroscopic procedures
G.L. Rovesti, Dr Med Vet, Dipl. ECVS
Clinica veterinaria M. E. Miller, Cavriago, Italy
INTRODUCTION
Arthroscopic procedures have been greatly developed in the past few years, following the same path already
present in human surgery. Compared with human surgeons, one of the major problems the veterinary
arthroscopist has to front is the reduced size of the veterinary patient’s joints. Though joint exploration can
usually be achieved, the joint room available becomes critical when arthroscopic procedures are to be per-
formed. Due to the need to introduce into the joint the instruments required to perform the procedure, when
the room available is reduced the risk is not only not to be able to perform the scheduled procedure, but al-
so to damage the intraarticular structures, namely the joint cartilage. This could result in an iatrogenic dam-
age, even worse than the presenting problem. The aim of the study was to clinically evaluate the use of a
joint distractor to increase the joint room available when specific intraarticular procedures were required.

Dogs to be operated on for cranial cruciate ligament (CCL) deficient stifle or shoulder diseases were considered as
potential candidates for inclusion in the study. They were prospectively subjected to arthroscopy examination be-
fore a further surgical procedure was performed. When the arthroscopy procedure alone was considered satisfac-
tory, no distraction was applied to the joint. When an arthroscopic procedure was required that was considered dif-
ficult to manage, either for problems in visualizing the intraarticular structures or in performing the scheduled ma-
neuver, a distraction device was applied. In the stifle, the distraction stirrups were applied in the distal metaphyseal
area of the femur and the proximal metaphyseal area of the tibia by means of K wires. In the shoulder, they were
applied to the supraglenoid area of the scapula and to the area of the major tubercle of the humerus. Once ten-
sioned the K wires, the stirrups were connected to the distractor, and distraction was applied. A specific amount of
distraction was not measured, being the room available to perform the scheduled procedure the reference param-
eter. The distractor was removed when the arthroscopic procedure was considered completed.
RESULTS
The distractor was used in 26 stifle and in 8 shoulder procedures. In the stifle, the reasons for distraction were
due to the need of performing meniscal procedures in 18 cases (69%), for exploring the caudal compartment in
7 cases (27%), and for curetting a cartilage lesion in 1 case (4%). All those cases when then operated on for cor-
rection of CCL deficient-stifle presenting problem. In the shoulder, the reasons for distraction were for curetting
an OCD lesion properly in 6 cases (75%), for curetting an ununited caudal glenoid ossification center (UC-
GOC) in 1 case (12.5%), and for vaporization of medial chronic scar tissue on the medial compartment in 1
case. In all the shoulder cases no further surgical procedure was performed. The time for distractor application
to the patient was in average 12 minutes. The amount of widening of the joint achieved was measured with an
intraarticular probe, and ranged from 2 to 4 mm (mean 3 ± SD 0,7). No problem was experienced during the
procedure as for distraction loosening. Time of distraction application was linked to the nature of the scheduled
procedure, and was in average 25 minutes. The average for the stifle was 26, and for the shoulder 19 minutes.
The follow-up was scheduled as usual for the specific procedure, and was in average 13 months. The mean FU
time for stifles was significantly longer (15 months) than that for shoulders (6 months). No specific complica-
tions linked to the use of the distractor could be observed in the PO period. Though many of the patients ex-
perienced some kind of problems, these were always considered compatible with the presenting problem, and
of the same entity and amount as in other patients, not subjected to distraction.
POSTERS
CONCLUSION
Intraoperative joint distraction for arthroscopic procedures is a technical option that can be considered when
the reduced room available in veterinary patients’ joints may hinder specific procedures, or can induce an
iatrogenic damage to intraarticular structures. Though this was just a pilot study, based on a reduced num-
ber of patients, a morbidity linked to the procedure itself was not observed so far.
REFERENCES
1. Gemmill T.J., Farrell M. (2009). Evaluation of a joint distractor to facilitate arthroscopy of the canine stifle. Vet Surg
38, 588-594.
2. Böttcher P., Winkels P., Oechtering G. (2009). A novel pin distraction device for arthroscopic assessment of medial
meniscus in dogs. Vet Surg 38, 595-600.
685 • WVOC 2010, Bologna (Italy), 15th - 18th September Y. Samoy
Arthroscopic findings in 32 joints affected by severe elbow

incongruity
Y. Samoy, D. van Vynckt, H. Seghers, K. Vermote, E. de Bakker, I. Gielen,
H. van Bree, B. Van Ryssen
Department of Veterinary Medical Imaging and Small Animal Orthopaedics, Faculty of Veterinary Medicine,
Ghent University, Belgium
INTRODUCTION
Elbow incongruity is most frequently described as the absence of a parallel joint space, resulting in a step
between the radius and the ulna1. It is part of the elbow dysplasia complex2 2and is believed to play a role
in the development of a fragmented medial coronoid process (FCP). While the arthroscopic measurement
of radio-ulnar incongruity has been evaluated in an in vitro study and proved to be a reliable technique for
this purpose3, the typical arthroscopic findings in clinical cases of severe incongruity have not been de-
scribed.
AIM
To describe the typical arthroscopic findings in elbow joints with severe incongruity by comparing them to
normal joints and joints affected with FCP without an obvious incongruity.

In a retrospective study data of three groups of dogs were analyzed. Arthroscopy of the examined joints was
performed under general anesthesia via a medial approach with a 2.4-mm, 25° oblique arthroscope (Richard
Wolf GmbH Knittlingen, Germany)4. Different regions of the elbow joint were inspected.
Group 1: This group was used as a reference for normal findings and consisted of 10 joints of 5 healthy
purpose bred dogs, with a meanage of 42 months (11-96 months).
Group 2: This group was used as a reference for congruent joints affected by FCP5,6 and consisted out of
32 joints of 21 lame dogs with a mean age of 15 months (7-23 m). Twelve dogs were Labrador
Retrievers, 3 were Rottweilers, and 3 were Bernese Mountain Dogs. The others were a Fox Ter-
rier, a Boxer and a Staffordshire Terrier.
Group 3: This group was the target group and consisted out of 32 severely incongruent joints of 19 lame
dogs with a mean age of 11 months (5-24 m). Seventeen dogs were Bernese Mountain Dogs; the
other 2 were Labrador Retrievers. There were 14 male and 5 female dogs.
RESULTS Comparison between normal elbow joints (above), con-

gruent elbow joints with FCP (middle) and severely in-
congruent elbow joints with FCP (below). Drawings be-
low indicate the localization of the arthroscopic images.
Colum A shows the appearance of the trochlear notch.
The black arrow indicates an irregular notch with ab-
normal tissue. Colum B shows the condition of the medi-
al coronoid process and the medial radio-ulnar transition.
On the upper image, no abnormalities are visible. A fis-
POSTERS
sure line is present on the middle image (short arrows)

with a smooth radio-ulnar transition. The lower image
shows a step (horizontal transparent arrow), irregular
delineation of the radio-ulnar transition (vertical grey ar-
row) and a large displaced fragment (see star).
Colum C demonstrates the irregular tissue of the radial
head in severely incongruent elbow joints (asterisk),
which is absent in the other joints. Colum D shows the
lateral view of the radio-ulnar transition. While the up-
per and middle images show a smooth transition, the
lower (incongruent) joint has an irregular transition.
MHC = medial humeral condyle, LHC = lateral
humeral condyle, R = radial head, MCP = medial coro-
noid process, LCP = lateral coronoid process.
Y. Samoy WVOC 2010, Bologna (Italy), 15th - 18th September • 686
CONCLUSION
Arthroscopy allowed the detection of several features as a sign or as a consequence of severe elbow incon-
gruity or the accompanying inflammation. These findings were not seen in normal joints and exceptionally
in congruent joints with FCP. These changes not only help in diagnosing elbow incongruity, but may also
be used to determine parameters that enable a reliable grading of incongruity in clinically dysplastic joints.
REFERENCES
POSTERS
1. Samoy Y, Van Ryssen B, Gielen I, et al: Review of the literature: elbow incongruity in the dog. Vet Comp Orthop
Traumatol 19:1-8, 2006.
2. Blond L, Dupuis J, Beauregard G, et al: Sensitivity and specificity of radiographic detection of canine elbow in-
congruence in an in vitro model. Vet Radiol Ultrasound 46:210-216, 2005.
3. Wagner K, Griffon DJ, Thomas MW, et al: Radiographic, computed tomographic, and arthroscopic evaluation of
experimental radio-ulnar incongruence in the dog. Vet Surg 36:691-698, 2007.
4. Van Ryssen B, van Bree H: Arthroscopic findings in 100 dogs with elbow lameness. Vet Rec 140:360-362, 1997.
5. De Rycke LM, Gielen IM, Van BH, et al: Computed tomography of the elbow joint in clinically normal dogs. Am
J Vet Res 63:1400-1407, 2002.
6. Wind AP: Elbow incongruity and developmental elbow diseases in the dog: Part I. J Am Anim Hosp Assoc 22:712-
724, 1986.
687 • WVOC 2010, Bologna (Italy), 15th - 18th September H. Seghers
Lameness after arthroscopic treatment of FCP:

diagnostic findings in 35 joints
H. Seghers, E. de Bakker, D. van Vynckt, Y. Samoy, S. Diels, I. Gielen,
J. Saunders, H. van Bree, B. Van Ryssen
Department of Medical Imaging and Small Animal Orthopaedics, Facultyof Veterinary Medicine, Ghent University, Belgium
CLINICAL CASE
Figure 2
Figure 1 - Radiographic (A), CT (B) and arthroscopic images

(C) of a Labrador Retriever with FCP at 7 months of age (left)
and 6 years later (right). A1. sclerosis, A2. severe degree of
arthrosis. B1: discrete fissure, B2: calcification (left arrow) and an
osteofyte (right arrow). C1: fissure, C2. calcification, visible as a
large bony fragment (black arrow) and extensive erosions of the
medial compartment (white arrow).
Figure 2 - Arthroscopic view of a joint with a new fragment of
the medial coronoid process (A), a calcification with the aspect of
a bony fragment (B), loose fibrocartilagenous tissue (C) and an
Figure 1 erosion of the medial compartment (D).
INTRODUCTION
A fragmented coronoid process (FCP) is the most important cause of frontlimb lameness in large breed dogs.
The arthroscopic removal of a fragment or the affected part of the coronoid process is a frequently performer
procedure. Although the general prognosis is good, some dogs relapse or do not improve1,2,4,5. In those cas-
es, the progression of arthrosis is commonly recognized but radiography provides insufficient information
about the pathologic changes within the joit3. CT and arthroscopic findings may contribute to a better un-
POSTERS
derstanding of the problem and to the treatment decision.

AIM
To describe the clinical, radiographic, CT and arthroscopic findings in dogs that were presented for lame-
ness following a previous arthroscopic treatment of FCP.
• Retrospective study;
• Dogs: 29 client owned large breed dogs, treated arthroscopically for FCP and presented for renewed el-
bow lameness (35 affected joints);
• The average time between treatment and the second presentation: 2.5 years (3 months-6 years);
• Description of the radiographic arthrosis, CT and arthroscopic findings.
H. Seghers WVOC 2010, Bologna (Italy), 15th - 18th September • 688
RESULTS
First presentation Second presentation
Average age
2.5 years (7 months - 8.5 years) 5 years (9 months - 11 years)
Radiography (35 joints) (chart 1, Fig. 1)
Chart 1 - Degree of arthrosis according to IEWG at the first

and second presentation. By the time of the second presentation,
arthrosis had increate in all but one joint.
CT (Fig. 1) 18 joints
30 joints • fragment: 3
• fragment: 12 • calcification: 6
• fissure: 14 • filling of the defect: 4
• osteofyt: 4 • no indicative lesions: 5
Arthroscopy (35 joints) (Fig. 1 and 2)
Primary lesions MCP
• fissure: 14 • calcification: 15
• non-displaced fragment: 5 • calcification + new fragment: 1
• displaced fragment: 10 • loose fibrocartilagenous tissue: 15
• chondromalacia: 5 • medial compartment erosion: 4
• medial compartment erosion: 1
• concurrent OCD-lesion: 7
Secondary cartilage lesions
• sound cartilage: 19 • sound cartilage: 2
• minor erosions: 14 • minor erosions: 12
• extensive erosions: 2 • extensive erosions: 21
CONCLUSION
In dogs that are presented with lameness after a previous arthroscopic treatment of FCP, a bony fragment
can be diagnosed in more than half of the cases. This fragment should not be confused with an original FCP
and it does not mean that the first treatment was performer incorrectly. Since a new fragment of the medi-
al coronoid process was only seen once, we can assume that a correct treatment rarely leads to ‘refragmen-
tation’. In a large number of joints (43%), loose fibrocartilaginous tissue developed at the defect site of the
original lesion. Progression of radiographic arthrosis was seen in 97% and progression of cartilage erosions
was seen arthroscopically in 94%. The benefit of removing the bony fragment or loose cartilaginous tissue
can be questioned, considering the bad condition of most joints. The results of anarthroscopic revision are
investigated in an ongoing study at Ghent University.
REFERENCES
POSTERS
1. Bubenik L.J., Johnson S.A., Smith M.M., Howard R.D., Broadstone R.V. (2000). Evaluation of lameness associat-
ed with arthroscopy and arthrotomy of the normal canine cubital joint. Veterinary Surgery 31, 23-31.
2. Evans R.B., Gordon-Evans W.J., Conzemius M.G. (2008). Comparison of three methods for the management of
fragmented medial coronoid process in the dog –a systematic review and meta-analysis. Veterinary and Compara-
tive Orthopaedics and Traumatology 21, 106-109.
3. Fitzpatrick N., Smith T.J., Evans R.B., Yeadon R. (2009). Radiographic and arthroscopic findings in the elbow joints
of 263 dogs with medial coronoid disease. Veterinary Surgery 38, 213-223.
4. Meyer-Lindenberg A., Langhann A., Fehr M., Nolte I. (2003). Arthrotomy versus arthroscopy in the treatment of
the fragmented medial coronoid process of the ulna (fcp) in 421 dogs. Veterinary and Comparative Orthopaedics
and Traumatology 16, 204-210.
5. van Breeand, Van Ryssen, 1998. Diagnostic and surgical arthroscopy in osteochondrosis lesions. Veterinary clinics
of north America: Small Animal Practice 28, 161-189.
689 • WVOC 2010, Bologna (Italy), 15th - 18th September A. Sotoudeh
A new biodegradable nanofiber scaffold for cartilage

tissue engineering
A. Sotoudeh1, G.R. Abedi2, P. Mortazavi3, M.R. Aflatoonian4, A.A Jahanshahi5,
M. Aashrafzadeh5, SH. Halilabadi6
1
Faculty of veterinary science, Islamic Azad University, kahnooj Branch, kerman, Iran
2
Department of surgery, Faculty of specialized veterinary sciences, Islamic Azad University, Science & research Branch, Tehran, Iran
3
Department of pathology, Faculty of specialized veterinary sciences, Islamic Azad University, Science & research Branch, Tehran, Iran
4
A member of dermatology and Leishmaniasis research center, Infection diseases and tropical medicine research center and HSR,
Kerman University of Medical Sciences, Kerman, Iran
5
Ph.D. student, Islamic Azad University, Science & research Branch, Tehran, Iran
6
Bachelor student, Islamic Azad University, Chalous Branch, Chalous, Iran
INTRODUCTION
Articular cartilage has a limited capacity for self-repair; untreated injuries of cartilage may lead to os-
teoarthritis (Temeno et al. 2007). At present, the electrospinning technique has been used as an efficient pro-
cessing method to manufacture nanoscale fibrous structures for tissue engineering scaffolds (Zhang et al.
2007, Buttafocoa et al. 2006). Tissue engineering involves the use of synthetic scaffolds, fabricated from bio-
compatible materials, to carry, support and guide cells towards tissue regeneration (Papkov et al. 2007). The
object of the present study was to investigate whether Collagen-PVA (poly vinyl alcohol) hybrid nanofiber
scaffold implants could initiate regeneration and repair of osteochondral defects in rabbits.

Nanofibrous scaffolds were fabricated by electrospinning
(stem cell technology research center, Iran). Briefly, the
polymer solutions were placed separately in a vertically
fixed glass syringe and a 12 kV electric field was applied
at a distance of 20 cm between an aluminum foil sheet
covering a copper plate and the needle tip. An electrospun
Collagen-PVA mat was formed homogeneously on the
aluminum foil. The both sides of the scaffold were steril-
ized by ultraviolet irradiation. The morphology of the
scaffolds was examined by scanning electron microscopy
(SEM). 10 mature female New Zealand White rabbits (20
knees) had a defect penetrating into the subchondral con-
structed on both knees, right knees filled with Collagen-
PVA nanofiber scaffold (group I), and left knees left with-
out treatment for defects were used as control (group II)
(Figure 1). Postoperatively, rabbits were left uncasted and Figure 1 - Photographs of rabbit knee articular cartilage de-
allowed free cage movement. Specimens were harvested at fects immediately after creation (A) and after treatment with the
scaffolds (B).
12 weeks after implantation, examined histologically for
morphologic features, and stained immunohistochemical-
ly for type II collagen.
RESULTS
POSTERS
A homogeneous, fibrous mat was produced from

Collagen-PVA by the electrospinning process,
resulting in a three dimensional nanofibrous
structure with polygonal, interconnected pores,
and composed of uniform, randomly oriented
nanofibers with diameters ranging from 500 to
900nm. Visual inspection revealed a smooth sur-
face topography for the majority of the joints im-
planted with Collagen-PVA scaffolds. These sur-
faces were absent of inflammation, degenerative Figure 2 - The images are of the defects at 12 weeks without treatment
changes (fibrillation, fissures or osteophytes), intra (C) and with Collagen-PVA scaffold treatment (D).
A. Sotoudeh WVOC 2010, Bologna (Italy), 15th - 18th September • 690
articular adhesions, meniscal damage, and liga-

ment damage. The repair tissue presented with a
lighter pinkish-white coloration than the surround-
ing host tissue, with the majority of defects having
better than a 90% fill of the defect site. But the sur-
face and integration of the newly formed cartilage
plug with host cartilage was not very well. The
center of the grafted area was slightly rough sur-
face remained. The control group showed fibrous
tissue at the site of the defect, the repaired tissue
when no graft was applied revealed signs of disin-
tegration and surface irregularities, with no carti-
lage formation and little reconstruction of sub-
chondral bone layer (Figure 2).
Histology observation showed the group I had bet-
ter chondrocyte morphology, continuous subchon-
dral bone, and much thicker newly formed carti-
lage compared with control group 12 weeks post- Figure 3 - Histological and Immunohistochemical of group I (F, H) and
operatively. There was a significant difference in group II (E, G).
histological grading score between these two
groups. A positive immunohistochemical staining of Collagen II was observed in group I, but not in control
group (Figure 3). Detailed results of microscopic evaluations are summarized in Table 1.
Table 1 - Group I is significantly different from group II, P < 0.05
Reconstruction Binding to
Total (18) of subchondral articular Cartilage Surface Metachromasia Cell Characteristic
layer (4) cartilage (2) thickness (2) characteristics (3) of matrix (3) morphology (4) (maximum score)
MEAN ± SD MEAN ± SD MEAN ± SD MEAN ± SD MEAN ± SD MEAN ± SD MEAN ± SD GROUP
*8.6 ± 2.7 1.7 ± 0.32 1.1 ± 0.48 1.1 ± 0.5 1.5 ± 0.5 1.7 ± 0.4 1.5 ± 0.5 GROUP 1
3.1 ± 2.3 0.5 ± 0.3 0.2 ± 0.1 0.5 ± 0.3 0.5 ± 0.2 0.5 ± 0.8 0.9 ± 0.6 GROUP 2
CONCLUSION
The results of the present study show that the Collagen-PVA nanofiber scaffold provides a favorable envi-
ronment for formation of hyaline-appearing repair tissues sustained over 12 weeks. The implants are well
tolerated by surrounding tissues, and reabsorb with no ill effects upon the remodeling host. It also renders
these devices excellent vehicles for chondrocyte or stem cell transplantation.
REFERENCES
Buttafocoa L., Kolkmana NG., Engbers-Buijtenhuijsa P., Poota AA., Dijkstraa PJ., Vermesa I., Feijen J. 2006: Electro-
spinning of collagen and elastin for tissue engineering applications. Biomaterials 27: 724-734.
Papkov MS., Agashi K, Olaye A, Shakesheff K, Domb AJ. 2007: Polymer carriers for drug delivery in tissue engineering.
Advanced Drug Delivery Reviews. 59: 187-206.
Temeno JS., Mikos AG. 2000: Review: tissue engineering for regeneration of articular cartilage. Biomaterials. 21: 431-
POSTERS
440.
Zhang1 YZ, Su1 B, Venugopal J ,Ramakrishna S, Lim CT. 2007: Biomimetic and bioactive nanofi brous scaffolds from
electrospun composite nanofibers. International Journal of Nanomedicine. 2 (4): 623-638.
691 • WVOC 2010, Bologna (Italy), 15th - 18th September V. Trilla Muntanyola
Use of the biplanar external fixator in the treatment of the

distal radial and ulnar fractures in small dogs and cats
Victor Trilla Muntanyola
Hospital Veterinari del Maresme, Cami de la Geganta, 113, 08302 Mataro (Barcelona), SPAIN
info@hospitalveterinarimaresme.com
INTRODUCTION
Fractures of the distal one-third of the radius and ulna are the third most common fracture in dogs. The in-
cidence of these fractures is particularly high in small and miniature breeds of dogs (Muir, 1997). Small and
miniature breeds of dogs are particularly prone to nonunion of fractures of the distal radius and ulna. The
intraosseous vascular anatomy of the radius show a great variety in function of body weight. Small-breed
dogs, appear to have a decreased vascular density at the distal diaphyseal-metaphyseal junction compared
with large-breed dogs. The reduced vascularity corresponded to the region associated with a poor progno-
sis for fracture healing in small-breed dogs. This regional association suggests that a decreased vascular sup-
ply in the distal radius may contribute to a higher frequency of delayed union and nonunion in smaller dogs
(Welch et al., 1997). Open reduction and fracture stabilization using a bone plate, and open or closed re-
duction and fracture stabilization using an external fixator have been advocated for adequate repair of dis-
tal radius and ulna fractures. Larsen et al. (1999) reported that fifty-four percent of distal radius and ulna
fractures in small-breed dogs treated with plate fixation developed complications (18% of them were cata-
strophic complications) while a forty percent of complications (13,6% catastrophic) were reported using a tu-
bular external fixatior (Haas et al., 2003). Some authors have pointed out that external fixators such as the
Kirschner and Meynard system, are not ideal for use in small animals because of the disparity in size be-
tween clamps and bones, which restricts the proximity of pin placement in small bone fragments (Haas et
al., 2003). Moreover, the use of Bilateral frames are compromised due to the small diameter of pins. That
is, following the upholding recommendations to use pins with a diameter of approximately 20% of bone di-
ameter, pins size of 0.6-0.8 mm of diameter. The use of the frontal plane, however, allows a larger pin size.
The purposes of this study were to evaluate the efficacy of biplanar external fixation for repair of the distal
radius in small and miniature-breed dogs and cats and to document the type and rate of complications as-
sociated with this fracture repair technique in those animals.
METHODS
Medical records of 27 animals (23 toy breed dogs and 4 cats) with distal radius and ulna fractures present-
ing to the Hospital Veterinari del Maresme (Mataró, Barcelona)/ 1999- 2006, body weight < 6 kg (range 1.3-
5.8 kg). Average age 2.9 years (range 0.5- 11 years). Two patients sustained bilateral fractures. Therefore, 29
fractures were included in the study.
Standard surgical preparation and operative procedure were used in all patients. All fractures were stabilized
using only a biplanar external fixation (Meynard system: clamps 1X2, 1.5X2; smooth pins 1 and 1.5 mm
in diameter; connecting bars 2.0 mm in diameter). Post operative radiographs were taken at 30, 45 and 60
post operative days if necessary. The external fixation was removed under sedation after clinical union of
the fracture was evident on radiographs.
RESULTS
Toy poodle constituted thirteen (56.5%) of the 23 dogs in this study. Other breeds represented were Mixed
breed (n=4), the York-Shire Terrier (n=2), Chihuahua (n=2), Miniatuire Pinscher and pomeranian (n=1).
POSTERS
Three (75%) of the 4 cats are domestic short hair and one Siamese. The mean body weight was 3.7 kg (range
1.3-5.8 kg). The mean age at fracture were 2.9 years (range six month to eleven years). There was no
predilection for right versus left limb. The fracture type, according to the system described by Unger were
as follows: 12 (41.4%) transverse, 14 (48,3%) short oblique, 2 (6.9%) complex. One atrophic non-union was
also present (dog seen for revision surgery).
The morphometric analysis of the radiographs showed that the total longitude of the radius were 8.45 ±
1.52 cm and the distal fragment of the bone were 1.81± 0.83.The diameter of the radius measured from the
frontal plane was 5.8 ± 1.52 mm while in the lateral plane was 4.1± 0.90 mm.
Three cases in this series (10.3%) showed evident signs of clinical healing at 30-35 postoperative days. At 45
postoperative days fracture healing were evident in seventeen cases (58,7%); six cases (20.7%) were healing
at 60 postoperative days.
V. Trilla Muntanyola WVOC 2010, Bologna (Italy), 15th - 18th September • 692
That is, fracture healing was considered adequate in 26 of 29 cases (89.7%). No complication were observed
in 17 cases.
Overall complications occurred in 41, 3% (12/29) of the fractures. Catastrophic complications occurred in
10.3% (3/29), and minor complications occurred in 31% (9/29) of fractures. Catastrophic complications in-
cluded one non-union and two refractures (one of them had atrophic non-union). Minor complications in-
cluded bone resorption (7 cases) and synostosis between radius and ulna (2 cases). In order to repair cata-
strophic complications a new bilateral frame and a cancellous bone graft was applied.
CONCLUSION
In this retrospective study, 89.7% of cases fracture healing was considered adequate and the time from sur-
gery to fixator removal ranged from 30-35 to 60 days. The results of this study support biplanar external
fixator for treatment of distal radius and ulna fractures in small-breed dogs and cats as an alternative to
other methods of fracture fixation and a preferable fixation method. It combines the advantages of stable
fracture fixation with minimal invasion of the traumatised area. The results of this study also showed that
the vast majority of the fractures in the distal radius and ulnar had a short oblique or transverse fracture
pattern.
REFERENCES
Haas B, Reichler IM, Montavon PM: Use of the tubular external fixator in the treatment of the distal radial and ulnar
fractures in small dogs and cats. Vet Comp Orthop Traumatol 2003;3:132-137.
Larsen LJ, Roush JK, McLaughlin RM: Bone plate fixation of distal radius and ulna fractures in small- and miniature-
breed dogs. J Am Anim Hosp Assoc, 1999, 35(3):243-250.
Muir P: Distal antebrachial fractures in toy-breeds dogs. Compend Contin Educ Pract Vet 1997;19; 137-145.
Welch JA, Boudrieau RJ, DeJardin LM, Spodnick GJ: The intraosseous blood supply of the canine radius: implications
for healing of distal fractures in small dogs. Vet Surg, 1997: 26(1):57-61.
POSTERS
693 • WVOC 2010, Bologna (Italy), 15th - 18th September S. Ulusan
Experimental study with the use of Noltrex®

in osteoarthritis induced on the knee of rabbits
C. Adabag1, H. Bilgili2, A. Adabag1, O. Ozdemir2, S. Ulusan2, D. Mutluay2
1
Ministry of Health, Ankara Research and Training Hospital, 2nd Orthopaedics Clinic, 06110 Diskapi, Ankara, Turkey,
2
Department of Orthopaedics and Traumatology, Faculty of Vet. Med., Ankara University, 06110 Diskapi, Ankara, Turkey
INTRODUCTION
Noltrex® is an hydrogenated biopolymer containing silver ions (HBISA) that is used for the treatment of os-
teoarthritis (OA). Noltrex® has a long-lasting effect, is not absorbed by any route, does not migrate from the
point of implantation, does not result in infections, does not necessitate reapplications, is not allergic and re-
sults in regaining of joint function; that is why it can be used for the treatment of osteoarthritis. With this study,
we analyzed the effects of an endoprosthesis named Noltrex® (non-absorbable) which is a synthetic gel and is
composed of three-dimensional polyacrylamide based polymer containing silver ions together with apyrogenic
water in the treatment of experimentally induced secondary traumatic OA in the knee joints of the rabbits.

This study was carried on 20 Angora breed 12-month old male rabbits weighing 2250-3750 grams (Ankara
University, Faculty of Veterinary Medicine Ethical Committee Approval 2004/44). The subjects that proved
to be healthy after performing general clinical and orthopedics examinations, that had stability tests for both
knee joints and bilateral radiograms were recruited in the study. Knees of the subjects were exposed under
general anesthesia, anterior cruciate ligaments were dissected and partial menisectomy was performed. Both
knee joints of all the subjects were examined for stability on day 30. In these examinations, anterior drawer
test, tibial compression test, genu valgum and varum stress tests were carried out; crepitation and pain in the
flexion and extension of the knee was checked. Bilateral radiograms of both knee joints were obtained from
all subjects. These radiograms were evaluated for the osteoarthritis of the knee joint according to Bilgili and
Orhun Scale 2002. On postoperative day 30, two randomly chosen rabbits were sacrificed and their both
knee joints were excised. For the identification of experimental traumatic osteoarthritis, macroscopical and
histological examinations were carried out on these samples. Of the remaining 18 subjects, 3 died within this
period and were excluded from the study. 15 rabbits were separated into two groups: First group had 10 and
the second group had 5 subjects. 10 rabbits in the first group had injections of 1 ml. Noltrex® to both knee
joints; 5 rabbits in the second group only had 1 ml. Noltrex® injection to their right knee and physiological
saline to their left knee. 4 cases were selected on postoperative days 30 and 60 to be sacrificed and remaining
7 cases were sacrificed on day 90. All the knee joints were examined clinically and histopathologically.
RESULTS
None of the rabbits could use their extremities, they all had pain, they had all developed instability on post-
operative day 30 and all had crepitations. Following the application of Noltrex® the subjects did not feel pain,
started using their extremities again and the sounds of crepitation disappeared. There was not any difference
between the body temperatures of the subjects. For the measurement of the silver ions contained in Noltrex®,
the sera of rabbit bloods were sent to Refik Saydam Hygiene Center Laboratories (Ref.No:1434,25.9.2003) to
be measured by ICP-MS method and were found to contain lower amounts than the lower threshold for sil-
ver which is 0.050 µg/l. In postoperative first, second and third months, the sections obtained from synovial
tissue of the non-degenerative knees treated with Noltrex® had findings of normal synovitis. Noltrex® applied
degenerative knees had foreign body granulation tissue together with synovitis. At the end of postoperative 3
months, there was no change in the thickness of the cartilage tissue of the femoral condyle and the condrocytes
were found to be normal. The knees with synovitis had 5-6 cell layers with vascular proliferation of the stro-
POSTERS
ma and mild degree of mononuclear infiltration that was rich from lymphocytes.
CONCLUSION
Noltrex® has a polyacrylamide structure and when the following characteristics such as: being biologically in-
ert and non-toxic, resulting in minimum tissue reaction, preventing fibrosis, having antibacterial features and
inducing minimum level of foreign body granulation tissue, ease of use are all taken into consideration we can
conclude that; in the experimentally induced traumatic osteoarthritis of the rabbit knee joint, it eliminates the
pain in the joint, increases the range of motion of the joint and results in easier use of the involved extremity.
REFERENCES
Bilgili, H., Orhun, S. (2002). The research of the changes on joint tissues radiological and histopathologically on an ex-
perimental osteoarthritis performed on rabbit stifle joint. Turk J Vet Surg 8, 8-12.
H. van der Zee WVOC 2010, Bologna (Italy), 15th - 18th September • 694
The cranial sartorius muscle

Hans van der Zee
Valley Farm Animal Hospital, Pretoria, South Africa, hans@valleyfarmvet.co.za
Peculiar strap like strand, or prominent muscle and significant contributor to Medial Patellar Lux-
ation in the dog?
According to Hermanson and Evans the M. sartorius is a long, flat muscle that extends in two peculiar, strap
like strands, on the cranial contour of the thigh from the region of the tuber coxae to the medial surface of
the stifle joint - Miller’s anatomy of the dog - 3rd edition1
Left Leg draped before During surgery MRI Scan of mid-femoral Ultrasound scans
surgery Surgical exposure reveals area Ultrasound examinations
A taut band is often felt on the broad, thick muscle, the The MRI scan above at the mid-femoral region
the cranio-medial aspect of belly of the cranial part of demonstrates how the reveal that the diameter
the mid-femoral area while the sartorius muscle, quadriceps group lies within of the cranial part of the
the patient is taking weight attaching on the medial its fascial envelope. The sartorius is often of
on the affected leg. aspect of the patellar cranial band of the sartorius similar diameter to the
This band is the cranial tendon. (Maltese 14 months lies in a separate fascial width of the vastus
part of the sartorius. Grade 2 MPL) sheath, but it joins the lateralis. (Chihuahua 10
It can also be visualized quadriceps tendon on the months Grade 2 MPL)
as demonstrated by this medial aspect just before
picture. (Photo above of inserting on the patella.
Chihuahua, 10 months (Pug 9 months Grade
Grade 2 MPL) 3 MPL)
Although some theories, many secondary conformational abnormalities and many treatments for MPL have
been described, there is still no clear evidence of the primary cause. References2 - 56
According to the author, the cranial part of the sartorius creates an unbalanced force on the patella.
POSTERS
BEFORE SURGERY
AFTER SURGERY
After surgical reimplantation

of the cranial part of the
sartorius muscle.
695 • WVOC 2010, Bologna (Italy), 15th - 18th September H. van der Zee
REFERENCES
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POSTERS
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POSTERS
697 • WVOC 2010, Bologna (Italy), 15th - 18th September D. van Vynckt
Effect of intra-articular anesthesia as a diagnostic aid and

its effect on different lesions of the medial coronoid process
D. van Vynckt, Y. Samoy, K. Vermote, E. de Bakker, H. Seghers, H. van Bree,
F. Verschooten, B. Van Ryssen
Department of Medical Imaging and Small Animal Orthopedics, Faculty of Veterinary Medicine, Ghent University, Belgium
INTRODUCTION
Lameness in dogs is commonly associated with joint
pain, therefore intra-articular anesthesia (IA) can be
helpful to confirm the intra-articular localization of the
problem1. Elbow pathology, especially fragmented coro-
noid process (FCP), does not always show clear clinical
or radiographic lesions2. The value of IA for the diag-
nosis of FCP was determined by comparing the effect
with the arthroscopic findings.
AIM
The purpose of this study was to evaluate the use of IA in
Figure 1 - Examples of minimal radiographic changes in frag-
the elbow in order to point out the elbow as the source of
mented coronoid process cases. Left: young dog: coronoid process
pain and to compare the effect in different forms of FCP. seems normal, open growth plates (arrow), no arthrosis. Right:
adult dog (6y) mild sclerosis (right arrow), unsharp delineation
METHODS of medial coronoid process (left arrow), no arthrosis.
Fifty dogs with front leg lameness with suspicion of FCP
were included in this study. All dogs had inconclusive
findings on clinical and radiographic examination. Figure 2 - Dog in
Diagnosis of FCP was confirmed with arthroscopy. IA lateral position. The
needle is inserted me-
was performed under sedation with acp-methadone or
dial to the lateral epi-
with domitor with antisedan afterwards. Two ml of condylar ridge, proxi-
mepivacaine was injected in the elbow joint. Lameness mal to the olcecranon.
was evaluated 2-15 minutes after injection. After aspiration of
synovial fluid the lo-
RESULTS cal anesthetic is inject-
ed into the elbow.
Positive False
IA negative IA Total
Chondromalacia(1) 7 1 8
Fissure(2) 16 2 18
Non displaced fragment(3) 18 18
Displaced fragment(4) 3 1 4
Erosions(5) 2 2
Total 46 4 50
Effect of intra-articular anesthesia on different forms of medial
coronoid lesions. Positive IA indicates the elimination of lameness.
POSTERS
False negative IA indicates that lameness grade was not influenced,

Figure 3 - Mepivacaine (Scandicaine 2%) has a fast onset of
but lesions were found during arthroscopy.
action, short duration and low toxicity.
1. Chondromalacia 2. Fissure 3. Non displaced fragment 4. Displaced fragment 5. Erosion

D. van Vynckt WVOC 2010, Bologna (Italy), 15th - 18th September • 698
CONCLUSION
Selective intra-articular anesthetic injection provides a direct method to confirm the elbow joint as the local-
ization of pain. All forms of FCP respond well, but results need to be assessed with care: in 8% a false neg-
ative result was noted. Discrete lesions such as chondromalacia and fissures as well as more clear lesions did
sometimes not respond to the IA. In case of a positive result, lameness can be attributed to the elbow. When
a negative result is obtained, other diagnostic methods such as scintigraphy should be applied to localize the
problem3.
REFERENCES
1. van Vynckt D, Verschooten F, Polis I, Van Ryssen B. A review of the human and veterinary literature on local anes-
thetics and their intra-articular use: relevant information for lameness diagnosis in the dog. Vet Comp Orthop Trau-
matol 2010; 23.
2. Punke, JP, Hulse DA, Kerwin SC, Peycke LE, Budsberg SC. Arthroscopic documentation of elbow cartilage pathol-
ogy in dogs with clinical lameness without changes on standard radiographic projections. Vet Surg 2009; 38: 209-
12.
3. Schwarz T, Johnson VS, Voute L, Sullivan M. Bone scintigraphy in the investigation of occult lameness in the dog.
J Small Anim Pract 2004; 45: 232-7.
POSTERS
699 • WVOC 2010, Bologna (Italy), 15th - 18th September E. Viguier
Sensitivity and specificity to determine lameness in dogs

with a pressure walkway system
S. Gibert1, T. Lequang3, P. Maitre1, L. Poujol1, T. Cachon1,2, C. Carozzo1,2,
D. Fau1,2, Jp. Genevois1, E. Viguier1,2
1
CHEVAC, VetAgro Sup, Campus Vétérinaire de Lyon
2
UPSP 193 08, RTI2B, VetAgro Sup, Campus Vétérinaire, Université de Lyon 1, F-69280 Marcy l’Etoile, France
3
Université vétérinaire de Hoshimine ville, Viet Nam
INTRODUCTION
Pressure walkway systems have been used in research for several years for gait analysis in dogs to charac-
terize normal gait and assess lameness.
The aim of this study was to statistically assess the performance for detection of a lame limb and to provide
clinicians a quantitative tool of gait analsis suitable for routine use.
MATERIALS AND METHOD

A 4.3 m pressure walkway system was used to calculate spatiotemporal and pressure parameters in 115 lame
adult dogs suffering from one or several limbs 32 from a forelimb lameness (shoulder 10, elbow 15, ex-
tremities 7), and 74 from a hindlimb lameness (hip 36, knee 35, extremities 3) and 9 from the both.
Sensitivity and specificity were first calculated without taking care of the disease. Sensitivity measures the pro-
portion of actual positives which are correctly identified [Sen = TP / (TP + FN) TP = true positive, FN = false
negative]. Specificity measures the proportion of negatives which are correctly identified [Spe = TN / (FP +
TN) TN = true negative, FP = false positive]. Because of many different cases of lameness and based on the
orthopaedic exam they were classified according the localisation of the lameness: 6 cases of unilateral elbow
dysplasia (ED), 16 cases of unilateral Cranial Cruciate Ligament rupture (CCLr) and 35 cases of unilateral or
bilateral hip dysplasia (HD). Orthopaedic conditions were confirmed by esplorative surgery or X ray.
RESULTS
For all orthopaedic pathologies
diagnosed, sensitivity and speci-
ficity were respectively 84.6
and 91.1%. (100-97.8 for ED;
93.7-95.7 for CCLr; 89.8-90.8
for HD).
The pressure walkway presented
a high sensitivity and specificity
for the diagnosis of a lame limb.
In fact for specific orthopaedic
conditions, it seemed even more
reliable than clinical findings
(Table 1) (Fig. 1).
Particularly for elbow dyspla-
sia, gait analysis sensibility and
Figure 1 - Test on the pres- Figure 2 - VD RX of Figure 3 - FCP of a dog
specificity were higher than sure walkway Gaitrite. HD of a dog with a clini- with a clinical lameness.
those of arthroscopy (94-
POSTERS
cal lameness.
81.9%), CT (85-45.8%) and
radiography (99.3%-42.4%) for diagnosing of Radio-Ulnar
incongruency (Table 2) (Fig. 3). Table 1 - Results of the different studies
For diagnosis of CCL rupture, sensitivity of cranio-caudal Sensitivity Specificity
thrust (CCT) without (64%) or with anaesthesia (88%) are
lower (Table 3). General Study 84.6 91.1
For hip dysplasia, gait analysis sensibility and specificity Elbow dysplasia 100 97.8
with this device was close and sometimes higher than
those of Ortolani test (72-90%) and X-Ray (Penn Hip with Rupture CCL 93.7 95.7
Distraction index (81-93%), (Norbert Olson angle 92-79%) Hip Dysplasia 89.8 90.8
(Table 4) (Fig. 2).
E. Viguier WVOC 2010, Bologna (Italy), 15th - 18th September • 700
Table 2 - Results concerning ED Table 3 - Results concerning CCLr

Sensitivity Specificity Sensitivity
Gait analysis 100 97.8 Gait analysis 93.7
Arthroscopy 94 81.9 CCT without anesthesia 64
CT 85 45.8 CTT with anesthesia 88
Radiography 99.3 42.4
CONCLUSION AND DISCUSSION Table 4 - Results concerning HD

Because of the high specificity and sensitivity, and thanks
to its portability, a pressure walkway system provide quick Sensitivity Specificity
results through a non invasive procedure without anaes- Gait analysis 89.8 90.8
thesia. Such a device could be used in veterinary clinics to
help diagnosis of orthopaedic diseases, particularly for hip Ortolani test 72 90
and elbow congenital diseases.
Penn Hip 81 93
AKNOWLEDGEMENTS Olson angle 92 79
Biometrics franceand CIR System Inc.USA, Voxscan.
REFERENCES
T. Le Quang and al: Is a pressure walkway system able to highlight a lameness in dog, J.A.V.A. 8(10):1936-1944, 2009.
P. Maitre, T. Le Quang, D. Fau, Jp. Genevois, E. Viguier. Hip dysplasia in dogs: correlation between clinical lameness
score, radiographic findings and walkway gait analysis, CMBBE, vol11, S 1: 153-154, 2008.
T. Le Quang, P. Maitre, T. Roger, E. Viguier. The gaitrite® system for evaluation of the spatial and temporal parameters
of normal dogs at a walk, CMBBE, vol 10, S 1: 109-110, 2007.
P. Maitre, F. Arnault, M. Verset, T. Roger, E. Viguier. Chronic Cranial Cruciate Ligament Rupture in dog: four legs as-
sessment with a walkway; CMBBE, vol 10, S1: 111-112, 2007.
POSTERS
701 • WVOC 2010, Bologna (Italy), 15th - 18th September C. Yardimci
Treatment of long bone fractures with unilateral

semicircular external skeletal fixation system:
clinical study in 57 dogs
Cenk Yardimci, Ahmet Özak, H. Özlem Nisbet
Department of Surgery Faculty of Veterinary Medicine Ondokuz Mayis University, 55139, Kurupelit, Samsun, Turkey
SUMMARY
In present study, treatment results of long bone fractures of dogs with unilateral semicircular external skele-
tal fixation system (SESFS) was aimed to present. Material of the study was consisted of 57 dogs in various
breed, age and sex in which long bone fracture was diagnosed. Of the cases, fracture fixation was performed
in 24 femur (two bilateral case), 16 tibia, 13 humerus, and 6 radius-ulna. The principal connecting elements
of SESFS used in this study are the 6-holed 45° (180 mm Ø, 1/8 ring arch, 7x18x85 mm) or 5-holed 40°
(180 mm Ø, 1/9 ring arch, 7x18x80mm) carbon-fibre arches. The other components of the system composed
of 6 mm Ø threaded rods (80, 100, 120, 150 mm length), half pin fixation bolts for 3 and 4 mm Ø half pins,
6 mm Ø hex nuts, and 3 and 4 mm Ø negative profile end-threaded half pins. In the study, 3, 4 or 5 arched
configurations -depending on the fracture type, and body weight of the patient- were used by open, limited
open or closed fashion. The 40° and 45° carbon-fibre arches were used in dogs weighting < 10 kg and ≥ 10
kg respectively. The most common complication encountered was mild pin tract discharge and periosteal re-
action. Good to excellent result were achieved in all cases except one non-union case. As a result it was con-
cluded that unilateral semicircular external skeletal fixation found to be practical and efficient in the treat-
ment of the long bone fractures of dogs. This is the preliminary report about the treatment of long bone
fractures in dogs with SESFS in which early postoperative and long term results seem to be favorable.
KEY WORDS
Carbon-fibre, dog, external skeletal fixation, femur, semicircular.
REFERENCES
1. Whitehair JG, Vasseur PB: Fractures of the femur. Vet Clin North Am Small Anim Pract 22:149-159, 1992.
2. Marcellin-Little DJ: External Skeletal Fixation, in Slatter D (ed): Textbook of Small Animal Surgery (ed 3). Philadel-
phia, PA, Saunders, 2003, pp 1818-1834.
3. Marti JM, Miller A: Delimitation of safe corridors for the insertion of external fixator pins in the dog 1: Hindlimb.
J Small Anim Pract 35:16-23, 1994.
4. Lewis DD, Cross AR, Carmichael S, et al: Recent advances in external fixation. J Small Anim Pract 42:103-112,
2001.
POSTERS
C. Yardimci WVOC 2010, Bologna (Italy), 15th - 18th September • 702
Treatment of unusual congenital flexural and torsional

limb deformities with circular external skeletal fixation
system in two calves
Cenk Yardimci, Ahmet Özak, H. Özlem Nisbet
Department of Surgery Faculty of Veterinary Medicine Ondokuz Mayis University, 55139, Kurupelit, Samsun, Turkey
SUMMARY
The purpose of this article is to report two uncommon congenital limb deformity and their management by
using circular external skeletal fixation (ESF) system. Two different newborn calves were referred to the Vet-
erinary Teaching Hospital of the Ondokuz Mayis University for the evaluation of unilateral congenital hind
limb deformities. On clinical examination of the cases, there were severe flexural and torsional deformities
observed below the hock joint due to the contracture of both deep and superficial flexor tendons. The de-
gree of the flexion-torsion deformities were 130°-40° and 90°-180° respectively. Both cases were completely
healthy except the described deformity. In the preoperative planning procedure, the plane and range of mo-
tion of the joint was carefully examined. In the first case, frame configuration was formed from two alu-
minium full rings on the proximal fragment and two aluminium full rings on the distal fragment which were
connected with 4 hinges, with a 160 mm internal diameter. Following transection of the flexor tendons, pe-
riarticular disruption was performed from the medial and lateral aspect of the joint. Then re-establishment
of the distal limb and hock arthrodesis was performed. On postoperative 47th day frame was removed. In
the second case, frame configuration was formed from two carbon fiber full rings on the proximal fragment
and two carbon fiber full rings on the distal fragment, with a 150 mm internal diameter. Firstly, transection
of the flexor tendons performed and then in order to correct the angulation of the proximal metatarsals, a
transverse osteotomy was performed from the proximal metaphysis of the third and fourth metatarsal. Fol-
lowing osteotomy, preoperatively prepared frame was fixed to the limb according to far-near-near-far prin-
ciple. Because knuckling of the phalangeal joints could not be corrected at the end of the 34th day following
removal of the frame, artrodesis of the fetlock and pastern joints were performed by 3 full rings 100 mm in
diameter. Twenty days after the second surgery frame was totally removed and the calf was discharge. Ac-
cording to clinical examinations and telephone interviews on 15th and 24th weeks after discharge, functional
use with slight lameness in the first case and full functional use in the second case was achieved. None of
the previously reported cases had radiographic signs similar to those of the calves in our report, and the de-
formities were not as severe as those reported here. To our knowledge, this is the first report of the descrip-
tion and treatment of two unilateral congenital flexural and torsional deformity with circular external skele-
tal fixation system.
KEY WORDS
Calf, congenital anomaly, external fixation, flexural torsional deformity.
REFERENCES
1. Leipod HW. Congenital defects of the musculoskeletal system. In: Lameness in Cattle. 3rd ed. Greenough PR,
Weaver AD (eds). Philadelphia: WB Saunders Company, 1997; 79-86.
2. Mulon P-Y. Correction of a severe torsional malunion of the metacarpus in a calf by transverse osteotomy, trans-
fixation pinning and casting. Vet Comp Orthop Traumatol, 2010; 1:62-65.
3. Bilgili H, Kurum B, Captug O. Use of circular external skeletal fixator to treat comminuted metacarpal and tibial
POSTERS
fractures in six calves. Vet Rec, 2008; 163: 683-688.

4. Leipold HW, Hiraga T, Dennis SM. Congenital defects of the bovine musculoskeletal system and joints. Vet Clin
North Food Anim Pract, 1993; 9: 93-104.
5. Aksoy O, Kilic E, Ozturk S, et al. Congenital anomalies encountered in calves, lambs, and kids: 1996-2005 (262
cases). Kafkas Univ Vet Fak Deg, 2006;12:147-154.
07) SCIVAC congress_07) SCIVAC/SIOVET congress 02/09/10 12.33 Pagina 703
ABSTRACTS
of
SCIVAC CONGRESS
SCIVAC CONGRESS
Elbow dysplasia - what are the new surgical options

and are they successful?
INTRODUCTION
Canine elbow dysplasia is a commonly reported thoracic limb disorder. Elbow dysplasia is characterized by an
abnormal development of the elbow joint coupled with characteristic pathological changes of the medial com-
partment. Pathologic changes are associated with the coronoid process and humeral condyle. Pathology of the
medial coronoid is typified by subchondral bone microfracture and fragmentation as well as cartilage erosion
secondary to incongruence as seen. Many hypotheses have been formulated about the etiopathogenesis of the
pathologic changes including radioulnar incongruence. The histologic and ultrastructural appearance of FCP
is consistent with mechanical failure and subsequent unsuccessful fibrous repair. Fragmented medial coronoid
process (FCP) is the most common manifestation of elbow dysplasia. Osteoarthritis is also typically found in
most patients with FCP and the amount of cartilage damage can vary greatly. The prevailing belief is that ra-
dioulnar incongruence is secondary to improper growth of the radius and ulna during maturation. The result
is malalignment of the articular surfaces where the medial coronoid is subject to high mechanical loads and mi-
crofracture or fragmentation. Another theory suggests fragmentation and microfracture of the medial coronoid
may be secondary to mechanical overload associated with contraction of the biceps brachii/brachialis muscle
complex. Arthroscopy confirms fragmentation of the medial coronoid adjacent to the radial head without the
presence of visible cartilage erosion in some dogs, supporting this hypothesis. Acute trauma to the medial coro-
noid process can also cause fracture of the MCP. Surgical treatment is believed to provide superior results to
conservative management by most surgeons. The outcome following surgery appears to be improved in the
past decade, partly due to new and improved surgical techniques. Surgical techniques that have improved the
treatment of elbow arthroscopy include arthroscopy, abrasion arthroplasty, microfracture, subtotal coro-
noidectomy, biceps tendon release and sliding humeral osteotomy (SHO).
ARTHROSCOPY
Arthroscopy has revolutionized the surgical
treatment of FCP for two main reasons- im-
proved assessment of the condition and de-
creased morbidity associated with the treat-
ment. The arthroscope provides an en-
hanced view of the anconeal process,
trochlear notch, lateral coronoid process, ra-
dial head, ulnar incisure, humeral condyle
and medial coronoid process due to its mag-
nification and ability to view anatomical
structures from an optimal perspective.
Arthroscopy gives the surgeon the ability to Fragments of the medial coronoid process develop near the radial head. Fragments
better evaluate the number and position of may be non-displaced (A) or displaced (B).
fragments within the joint. The surgeon
can also assess congruity by evaluating car-
tilage wear patterns and noting the relative
positions of the radial head, medial coronoid process, ulnar incisure, trochlear notch and anconeal process.
Treatment of the condition can also be done with arthroscopic observation. This allows the surgeon to be
more precise and less invasive. Fragment removal, abrasion arthroplasty, microfracture, subtotal coronoidec-
tomy and biceps tendon release can be performed with arthroscopic assistance. Arthroscopic evaluation has
very low morbidity which allows treatment of multiple joints at the same time.
FRAGMENT REMOVAL
SCIVAC CONGRESS
Removal of fragments and necrotic bone of the medial coronoid process is recommended. Arthroscopic or
arthroscopic-assisted removal is recommended because of its low morbidity and increased precision. Removal
of the fragment from the medial coronoid process can occasionally be accomplished by simply grasping the
loose fragment with a grasping forcep while the medial joint space is opened as valgus pressure is applied by
the surgical assistant. This is typically not possible without causing iatrogenic damage to the cartilage of the
medial coronoid process, radial head and medial coronoid process. Several practical tips can facilitate removal
of the fragment. Sometimes the fragment is visible, but is clearly not dislodged. Occasionally the fissure line as-
sociated with the fragment is not initially visible. Use the probe to gently probe and rub the region of the me-
dial coronoid process. This maneuver will usually reveal the margins of the fragment. A small curette, probe
or banana knife is used to try to elevate the fragment to facilitate its removal. Fragment removal can be more
effectively performed after removal a small portion of bone and cartilage from the medial coronoid process just
cranial to the fragment. Chondomalacia and microfractures of the subchondral bone are typically found in this
region. A curette, hand burr or power shaver can be used to remove these damaged tissues, creating more space
and improved access to remove the main fragment. The fragment may have to be removed in multiple pieces,
either due to the fragility of the fragment or due to the sheer size of it. Fragments having necrotic bone and
microfractures will often break into smaller fragments when grasped to remove them. In this case the fragment
is removed by passing the grasper multiple times until all the fragments are removed. Alternatively, a power
shaver can be used to remove small multiple fragments. If the fragment is large and comprised of dense bone,
it may be too large to grasp and remove in one piece. The fragment can be broken into smaller pieces using a
small osteotome or power burr. Multiple fragments are often found. Inspect the region cranial to the radial head
carefully using a probe. Many patients have multiple loose fragments and they usually are found cranial to the
main fragment adjacent to the radial head. Some fragments may have a soft tissue attachment which prevents
simple withdrawal of the fragment form the joint. Large soft tissue attachments should be severed from the
fragment using a banana knife, aggressive shaver blade or small forceps. Small soft tissue attachments can of-
ten be broken down by simply twisting the fragment 360-720° while it is grasped.
OSTEOARTHRITIS
The severity of osteoarthritis is best evaluated using an arthroscope. The arthroscope can be inserted into
the joint using ypical arthroscopic portals or through an arthrotomy incision to improve the surgeon’s view.
Osteoarthritis can be treated arthroscopically using hand instruments or a motorized shaver. The goal of the
treatment is debridement of necrotic cartilage, removal of sclerotic bone, neovacularization, and recruitment
of pluripotential mesenchymal cells. Cartilage debridement is accom-
plished using a hand burr, hand curette or motorized shaver. The ex-
posed subchondral bone can be treated using abrasion arthroplasty
or micropick technique.
Abrasion arthroplasty
To perform abrasion arthroplasty, insert a hand burr or preferentially
a power shaver burr through an instrument portal or arthrotomy. Ei-
ther method will produce significant bone debris that can clog the
egress portal and impede visualization, therefore it is important to
monitor and maintain the flow of fluid through the joint during this
procedure. Spin the burr to remove subchondral bone over the area of
the lesion. Check for resulting bleeding frequently by stopping inflow
of fluid and ensuring adequate outflow to decrease the pressure in the
joint. When bleeding is observed diffusely from the lesion bed, lavage A motorized shaver is used for abrasion arthro-
the joint to remove the remaining bone debris and close routinely. plasy to remove necrotic cartilage and bone.
A hand curette can also be used for surface abrasion if the subchon-
dral bone is not too sclerotic. Similar principles should be used as de-
scribed above. The curette is also useful to contour the edge of the
cartilage defect; an effort should be made to leave the edges of the ar-
ticular cartilage perpendicular to the subchondral bone.
Microfracture
To perform microfracture, insert an appropriately angled micropick
into the joint and press the tip against the subchondral bone surface.
Have an assistant tap the pick handle once or twice. The pick should
be held securely to avoid gouging the surface and adjacent healthy
cartilage. Apply the micropick diffusely across the diseased area and
SCIVAC CONGRESS
check for resulting bleeding frequently by stopping inflow of fluid

and ensuring adequate outflow. When bleeding is observed diffusely
from the lesion bed, lavage the joint to remove the remaining bone Microfracture is used to treat the exposed sub-
debris and close routinely. chondral bone after removal of necrotic cartilage.
SUBTOTAL CORONOIDECTOMY
Subtotal coronoidectomy was introduced by Fitzpatrick as a
means of treating FCP by removing the majority of the medial
coronoid process (MCP).
The rationale of removing a large portion of the MCP is the dis-
covery of microfactures within all regions of the subchondral
bone of the MCP in affected dogs.
Fitzpatrick found positive results in dogs treated with this
method if they met the proper criteria. Subtotal coronoidectomy
can be performed via a standard medial arthrotomy, arthro-
scopic–assisted arthrotomy or arthroscopically.
BICEPS TENDON RELEASE

The biceps/brachialis muscles constitute a large muscular
complex. The anatomic origin and insertion of the biceps and
brachialis muscles are such that the muscular complex exerts
considerable force on the medial compartment of the elbow.
The force exerted by the biceps is continuous since it is a pen- The ulnar component of the biceps tendon can be re-
nate muscle with central tendon. More importantly, because leased from its insertion near the MCP. This is thought
the insertion of the biceps/brachialis complex is at the ulnar to release load in the medial compartment and conflict
tuberosity, a large polar (rotational) moment is exerted at the between the radial head and medial coronoid process.
cranial segment of the medial coronoid. The magnitude of the
polar moment is a product of the moment arm (distance from
the ulnar tuberosity to the tip of the coronoid) multiplied by
the force created by the biceps/brachialis muscular complex.
The polar moment rotates and compresses the craniolateral
segment of the medial coronoid against the radial head. The
compressive force is medial to lateral transverse to the long
axis of the coronoid. A compressive force generates internal
shear stress at an oblique angle to the applied compressive
force. In this situation, maximal internal shear stress would be
oblique to the long axis of the coronoid. Under the right cir-
cumstances, the polar moment and resultant compressive
force produced by the biceps/brachialis complex may produce
sufficient internal shear stress to exceed the material strength
of the cancellous bone in the craniolateral segment of the me-
dial coronoid. The ulnar insertion of the biceps tendon can be released
The result would be microfracture/fragmentation adjacent to arthroscopically in an attempt to decrease loads placed
the radial head at an oblique angle to the long axis of the me- across the medial compartment of the elbow.
dial coronoid. Interestingly, microfracture/fragmentation of
the coronoid seen clinically is in the craniolateral segment of
the medial coronoid adjacent to the radial head. This location corresponds to the plane of maximal shear
stress generated by the compressive force exerted by the polar moment produced by contracture of the bi-
ceps/brachialis complex.
Hulse first reported the use of biceps tendon release as an adjunctive treatment for dogs affected by FCP.
Fitzpatrick also reported on the clinical use of this procedure and found encouraging results. The tech-
nique is used to lessen the conflict between the radial head and MCP. This conflict is theorized to be a cause
of microfracture of the subchondral bone of the MCP and cartilage erosion of the radial head and MCP.
Following removal of fragments, the tension placed on the MCP can potentially be decreased by cutting the
ulnar component of the tendon and transferring it to a more lateral location. This tendon can actually be re-
leased at the elbow or shoulder. At the present time, it is unknown where the optimal release site is. Side ef-
fects and complications appear to be very low. Dogs typically use the leg with little lameness following bi-
ceps tendon release.
SCIVAC CONGRESS
SLIDING HUMERAL OSTEOTOMY

Schulz et al. introduced a humeral osteotomy technique designed to shift the weightbearing loads from the me-
dial to the lateral compartment of the elbow. Fitzpatrick reported on its clinical use in a series of clinical patients
and found improvement in lameness in dogs having cartilage erosion of the medial compartment fo the elbow
and fragmentation of the MCP. A

medial approach to the humerus is
made and a mid-humeral trans-
verse osteotomy is performed. The
distal humeral segment is transposed
or slid to a more medial location, thus
shifting load towards the lateral com-
partment during ambulation. A spe-
cially designed SHO plate and lock-
ing screws made by New Genera-
tion Products are used to stabilize
the bone. The plate has a step in the
middle of the plate to accommodate a
repeatable amount of medial sliding.
The plate comes in several sizes with
varying steps. Early outcome results
are encouraging. Most dogs show im-
provement in lameness following Sliding humeral osteotomy is a reasonable
SHO even though the technique has surgical option for dogs having cartilage
been initially proposed for dogs hav- erosion in the medial compartment of the
ing severe degenerative changes asso- elbow. The distal aspect of the humerus is
ciated with elbow dysplasia. translocated to a more medial position,
shifteing weightbearing loads to the later-
References are available al compartment of the elbow.
upon request.
SCIVAC CONGRESS
Partial tears of the cranial cruciate ligament -

is it really that controversial?
Gulf Coast Veterinary Specialists, Houston, TX
WHAT IS A PARTIAL TEAR?

Partial tears of the cranial cruciate ligament (CrCL) are commonly di-
agnosed in dogs. Partial tears may involve the craniomedial band, cau-
dolateral band or both. Partial tears may or may not be associated with
gross instability. Many patients with early partial tears of the CrCL do
not have demonstrable cranial drawer or cranial tibial thrust. These pa-
tients are commonly referred to as stable partial tears. Other dogs have
variable amounts of instability in flexion. These patients are commonly
referred to as unstable partial tears. Some dogs with partial tears have
grossly intact fibers that have stretched (plastic deformation) and are
nonfunctional. Instability found with this type of partial tear is similar
to that seen with a complete tear; cranial drawer and cranial tibial thrust
are evident. It is important to realize that osteoarthritis and meniscal
damage can occur with any type of partial tear. Early diagnosis and A partial tear of the insertion of the craniome-
prompt treatment of partial CrCL tears gives the patient the best op- dial band of the CrCL (a) can be accurately di-
portunity of avoiding these painful and debilitating sequelae. The CrCL agnosed and treated arthroscopically.
should be examined under magnification using an arthroscope or mag-
nifying loops. Many partial tears can not be adequately seen with the
naked eye. In addition, early treatment may help prevent the progressive of a partial tear to a complete tear. Most
partial tears of the CrCL are thought to progress to a complete tear over time if left untreated.
TREATMENT OF PARTIAL TEARS OF THE CrCL

Several options can be considered for treatment of partial tears of the CrCL in dogs. Factors to consider when
choosing a method of treatment include severity of the tear, amount of instability, condition of the meniscus,
patient size and expected activity level of the patient. Options to consider include a procedure that neutralizes
cranial tibial thrust (TPLO, TTA, TTO), extracapsular prosthetic ligament repair, intracapsular ligament re-
pair, and physical rehabilitation exercise. Surgical debridement of the ligament is also a factor to be considered.
Some surgeons debride only the torn fibers, some debride the entire ligament and others debride none of the
torn fibers. Studies are currently in progress to evaluate the need and outcome following ligament debridement
or preservation in patients with partial CrCL tears. Arthroscopy can be combined with any of the above sta-
bilization techniques in an effort to reduce patient morbidity and increase accuracy of treatment. At the pres-
ent time, no method of treatment has been shown to be superior for treatment of partial CrCL tears in dogs.
EXPECTED OUTCOME
Tibial Plateau Leveling Osteotomy (TPLO) is frequently performed to treat the cruciate-deficient stifle and
is recommended by many surgeons to treat dogs having partial CrCL tears in an effort to preserve the lig-
ament as a result of reduced strain on the ligament. Second-look arthroscopy at long term follow-up sup-
ports the ability of TPLO to protect the CrCL. Following TPLO, cranial tibial thrust is eliminated during
weight bearing, thus reducing the work that the CrCL has to perform. TPLO can be performed as initially
described by Slocum, but a minimally-invasive technique is now available which reduces patient morbidity
and is much less invasive. Minimally-invasive TPLO requires arthroscopic-assistance and a small medial in-
cision over the proximal aspect of the tibia. Following surgery, patients are recommended to start a con-
trolled, progressive rehabilitation program that focuses on increasing muscle strength and joint motion. Out-
come following TPLO in dogs having a stable partial tear has been excellent. Most patients are expected to
return to near-normal function. Patients are permitted to return to running after adequate healing of the os-
teotomy, typically at 8 weeks following surgery. Rehabilitation continues for another 8 weeks at which time
SCIVAC CONGRESS
most patients are close to reaching their level of maximum performance. Patients treated in this manner are
expected to have no restrictions and to perform well in athletic or working roles.
Extracapsular prosthetic ligament repair techniques can also have an acceptable outcome in dogs with par-
tial CrCL tears. This technique can be performed in a minimally-invasive manner or by a traditional arthro-
tomy. The prosthetic ligament will provide immediate static stability to the stifle and will allow fibrous tis-
sue to form over time to provide a biologic tissue to provide long term support. It is unknown whether place-
ment of an extracapsular lateral prosthetic ligament will prevent continued deterioration of a partial CrCL
tear to a complete tear. A potential problem with this technique is the continued presence of cranial tibial
thrust in the patient and the potential for cyclic failure of the prosthetic ligament. Materials used for extra-
capsular prosthetic CrCL repair have been found to stretch or break in the early postoperative period, lead-
ing to recurrent stifle instability. Recent studies support the placement of lateral extracapsular prosthetic lig-
aments in an isometric position (known as the F2-T3 sites). Isometric positioning reduces strain on the pros-
thetic ligament during normal range of motion of the stifle and is thought to decrease the risk of implant fail-
ure. In addition, isometric positioning of the ligament allows more normal range of motion and proper ro-
tation of the stifle during flexion. Suture anchors and bone tunnels are typically used to anchor the pros-
thetic ligament at the isometric positions. The material chosen for the ligament prosthesis should be strong
and resistant to elongation. A braided polyblend polyethylene material known as FiberWire and FiberTape
(Arthrex Vet Systems, Naples, FL) meets these criteria and is successfully used routinely for extracapsular
prosthetic CrCL repair in dogs. Following surgery, patients are recommended to start a controlled, pro-
gressive rehabilitation program that focuses on increasing muscle strength and joint motion. Patients are per-
mitted to return to running at 16 weeks in most dogs. Rehabilitation continues for another 8 weeks at which
time most patients are close to reaching their level of maximum performance. Patients treated in this man-
ner are expected to have no restrictions and to perform well in athletic or working roles. Osteoarthritis may
be slightly more severe in this group of patients compared to TPLO patients.
Arthroscopy is an invaluable tool for evaluation of the stifle in dog’s having a presumptive tear of the Cr-
CL. Many early partial tears of the ligament are not visible to the naked eye and can only be identified with
magnification. It would be easy to miss this diagnosis and leave the patient untreated, leaving the patient
with an increased risk of developing osteoarthritis and meniscal damage. Arthroscopic assisted surgery im-
The torn fibers of the CrCL can be debrided carefully with a shaver or radiofrequency probe. Complete debridement of fibers is not needed.
Debridement of fibers should be performed if easily accessible or if needed to view the menisci.
SCIVAC CONGRESS
Debridement of torn fibers at the origin of the CrCL (a) was performed prior to TPLO. The remaining fibers (b) appear to have good in-
tegrity and no obvious cranial drawer could be palpated. This would be considered a “stable” partial CrCL tear.
proves accuracy of treatment of torn CrCL fibers and meniscal tears. Iatrogenic cartilage damage during
meniscectomy is reduced. Arthroscopy can be performed using traditional portals or it can be performed
through a standard or mini-arthrotomy. Use of an arthroscope through an arthrotomy incision dramatical-
ly decreases the difficulty of the procedure. The use of the scope allows the surgeon to make a much small-
er arthrotomy, reducing patient morbidity while at the same time improving visualization of joint structures.
The arthrotomy incision acts as the egress, scope and the instrument portals. Extravasation of subcutaneous
tissues with arthroscopic fluids is avoided. The learning curve for arthroscopy is dramatically reduced. The
need for many instruments and equipment typically used for arthroscopy is eliminated.
Surgical debridement of the torn CrCL is a factor to be considered. Surgical debridement of fibers is gen-
erally performed in complete tears of the CrCL, primarily to improve visualization of the menisci. The re-
moval of torn fibers to prevent osteoarthritis or pain is unfounded. It is known that intact fibers of the Cr-
CL may be at various stages of degeneration at the time of partial CrCL tear. Some surgeons believe the en-
tire CrCL ligament should be removed if a partial tear has occurred due to the possibility of fiber degener-
ation and the compromised ligament acting as a potential source of postoperative pain. Other surgeons have
achieved a good outcome with preservation of the intact functional fibers and believe that the added stabil-
ity of the remaining ligament is beneficial for the patient. At the present time, it is recommended that torn
fibers and non-functional stretched fibers of the CrCL be debrided. It is critical that debridement of the torn
fibers be performed meticulously to avoid iatrogenic damage to articular cartilage, the remaining fibers of
the CrCL, the fibers of the caudal cruciate ligament and the cranial ligaments if the medial and lateral menis-
ci. Intact, functional fibers are recommended in patients treated by TPLO to be preserved in hopes of pro-
viding adjunctive stability and reducing the chance of future osteoarthritis and meniscal tears. Complete lig-
ament debridement may be best in patients treated with an extracapsular technique due to anticipated
stretching of the prothetic ligament and retrun of cranial tibial translation. This amount of instability will
likely lead to additional tearing of the CrCL and increase the chance of pain and lameness.
Debridement of the entire CrCL (a) was performed prior to TPLO in this patient due to laxity present in the remaining fibers. This patient
had approximately 7 mm of cranial drawer with the stifle in flexion and 4 mm in extension. SCIVAC CONGRESS
This dog had a “stable”partial tear of the CrCL and was treated by arthroscopic debridement of the torn fibers (a) and TPLO. Note the syn-
ovitis at the insertion of the CrCL (b). The ligament appears to have good integrity (c) and the inflammation has subsided at the time of plate
removal 14 months later.
How to succeed in repairing medial patellar luxation

in small dogs and cats
Patella luxation is a problem in all breeds and sizes of dogs, but the condition is most common in small breed
dogs. Commonly affected breeds include the Yorkshire terrier, maltese, toy poodle, miniature poodle,
pomeranian, pekingese and chihuahua. Medial patellar luxation predominates in both small and large breeds,
although past literature suggests lateral luxation is much more common in large breeds. Patellar luxation oc-
curs less frequently in cats and medial luxation is most common. Patellar luxation is generally graded from
1-4 based on increasing severity. Grade 1 patellar luxations are generally not repaired, but surgical repair is
recommended for grades 2-4, depending on the age and clinical presentation of the patient. Treatment of me-
dial patella luxation may be conservative (small breeds only) or surgical. The decision as to which method is
applicable for a patient is dependent upon the clinical history, physical findings and the age of the patient. An
older patient in which patella luxation is noted as an incidental finding on physical examination and in which
the client reports nonclinical lameness does not warrant surgical intervention. Rather, the client should be in-
formed as to the clinical signs associated with patella luxation. Surgery is advised in the young adult patient
even though no clinical problem is apparent since intermittent luxation may prematurely wear the articular
cartilage of the patella. Surgery is indicated in any aged patient exhibiting lameness and is strongly advised
in a patient with active growth plates since skeletal deformity may worsen rapidly. However surgical tech-
niques used in actively growing animals should be those that will not adversely affect skeletal growth. Surgi-
cal options include trochleoplasty, trochlear wedge recession, trochlear block recession, tibial tuberosity trans-
position, tibial tuberosity transposition, rectus femoris transposition, retinacular imbrication, derotational su-
ture, retinacular releasing incision and corrective osteotomy in cases of femoral or tibial deformity. In severe
cases that do not respond to the above treatments, patellectomy and stifle arthrodesis are a possibility; these
techniques are fortunately rarely needed (these techniques will not be presented).
CLINICAL FINDINGS
Pet owners typically report a skipping lameness in affected pets. Typically the pet uses the affected leg nor-
mally between skipping episodes. Some owners do not recognize any lameness or gait abnormality in af-
fected patients. Patellar luxation frequently occurs bilaterally, but may one stifle may be more severely af-
fected than the other. Owners often report a slow progression in severity of clinical lameness. The lameness
may appear to resolve in some patients over time, but this may be due to the progression of patellar luxa-
tion from grade 2 to grade 3. The skipping gait may disappear because the patella is no longer displacing
into and out of the trochlear groove. It the patella remains in a luxated position, the patient may not exhib-
it obvious lameness, but may have a bowlegged gait. Lameness that acutely worsens in patients with patel-
lar luxation may be associated with a concomitant tear of the cranial cruciate ligament. Cranial cruciate lig-
ament injury occurs in approximately 25% of patients with patellar luxation.
Patellar luxation is generally graded from 1-4 based on increasing severity. Grade 1 luxation is not associ-
ated with clinical lameness. The patella can be displaced out of the trochlear groove by applying digital pres-
sure, but spontaneous luxation does not occur. Grade 2 luxation typically presents with an intermittent non-
weightbearing lameness, the typical “skipping-gait”. Digital displacement of the patella is possible during ex-
amination, but the patella moves back into the trochlear groove when pressure is released or when the stifle
is extended. Grade 3 luxation may present with intermittent non-weightbearing lameness or persistent
weightbearing lameness. Many of these patients do not have an obvious lameness, but rather display a bow-
legged posture when walking. The patella is typically luxated at the time of examination, but can be replaced
into the trochlear groove with digital pressure. The patella usually quickly luxates again once pressure is re-
leased or the stifle is moved through a range of motion. Grade 4 luxation presents as a persistent weight-
bearing lameness or bowlegged gait. The patella is fixed in a luxated position and can not be reduced with
digital pressure, even in the anesthetized patient.
SCIVAC CONGRESS
RADIOGRAPHIC FINDINGS
Patients having medial patellar luxation should be evaluated with appropriately positioned orthogonal sur-
vey radiographic views of the stifle. Orthogonal views of the entire femur and tibia should also be evaluat-
ed if limb deformity is present in small breed dogs and in all medium and large breed dogs with patellar lux-
ation. The patient should be assessed for patella position, distension of the
joint capsule, presence of tibial translation, tibial tuberosity position, axial
alignment of the femur and tibia, torsional alignment of the femur and tib-
ia, and osteoarthritis. CT imaging is recommended, if available; to more ac-
curately assess hind limb alignment.
Radiographic changes vary from no obvious change to severe limb defor-
mity and marked patellar displacement depending on the grade of luxation,
age at onset of patellar luxation and duration of the condition. Minimal ra-
diographic changes are seen in adult patients with uncomplicated grade 1 or
2 medial patellar luxation. Some patients have no abnormal radiographic
changes. Radiographic changes that may be seen include patellar displace-
ment, tibial tuberosity displacement, and rarely mild osteoarthritis and mild
joint effusion. Grade 3 and grade 4 patellar luxations are more likely to have
radiographic patellar displacement, tibial tuberosity displacement, joint effu-
sion and osteoarthritis. These patients are also more commonly affected
with axial or torsional abnormalities of the femur or tibia. Patients with se-
vere medial patellar luxation and abnormal limb alignment usually have dis-
tal femoral varus, proximal tibial valgus, internal femoral torsion or internal
tibial torsion. Radiographic assessment of the depth of the trochlear groove
is usually best evaluated by palpation or gross observation, but severely
shallow trochlear grooves can be seen radiographically.
Radiographic changes are most severe in puppies where the onset of patel-
lar luxation occurs at an early age when the physis is undergoing rapid
growth. Medial luxation of the patella in these dogs causes compression on
one side of the distal femoral and proximal tibial physes and compression on
the opposite side. As a consequence, the medial aspect of the femoral physis This grade 4 MPL patient has varus
has retarded growth and the lateral aspect has accelerated growth resulting deformity of the distal femur and val-
in distal femoral varus. The lateral aspect of the tibial physis has retarded gus deformity of the proximal tibia.
growth and the medial aspect has accelerated growth resulting in proximal Slight internal rotation of the bones is
tibial valgus. Torsional deformity of the femur and tibia can also occur si- also present.
multaneously. Correction of the deformity is usually based on comparison
of the degree of angulation and torsion found on radiographic examination
of the affected patient in comparison to normal reference values. The sur-
geon should be cautious when interpreting the measured angle of axial de-
formity as torsional deformity can artificially raise or lower the actual
amount of axial malalignment. A CT scan is likely to give the most accurate
measurement of axial and torsional deformity.
Patients with medial patellar luxation should also be evaluated for the po-
tential for concomitant cranial cruciate injury. Typical radiographic changes
include joint distension and cranial tibial displacement. Osteoarthritic
changes are more likely with cranial cruciate ligament injury. If cranial cru-
ciate ligament injury is suspected, measurement of the slope of the tibial
plateau may be helpful when deciding on a surgical plan.
Complications associated with medial patellar luxation (MPL) repair can be
categorized as intraoperative or postoperative. Complications are fairly com-
mon, but fortunately many are easy to resolve or prevent. Most complica-
tions can be avoided by better preoperative planning, meticulous surgical Tears of the cranial cruciate ligament
technique and appropriate postoperative care. is seen in approximately 25% of dogs
with MPL.
DECISION-MAKING FOR PATELLAR LUXATION REPAIR
Many surgical options are available when considering repair of the luxating patella. It is important to con-
sider the underlying problems associated with the particular luxation when choosing a surgical plan. Factors
to consider include, depth of the trochlear groove, alignment of the quadriceps mechanism (quadriceps,
patella, patellar tendon), and the presence of excessive laxity or tension of the joint capsule and retinacular
SCIVAC CONGRESS
tissues medially and laterally. The surgical options chosen should alleviate the underlying factor contribut-
ing to the luxation. For example, if a dog has good alignment of the quadriceps mechanism, but a shallow
trochlear groove- the surgical plan should include a technique to deepen the femoral trochlea, but not a tib-
ial tuberosity transposition.
METHODS TO DEEPEN THE TROCHLEA

Three methods are commonly used to deepen a shallow
trochlear groove. These methods are described below. A head-
to-head comparison as not been performed to document supe-
rior efficacy of one technique compared to the others. Usually
trochleoplasty is reserved for toy-breed dogs and cats.
Trochlear wedge recession and trochlear block recession are
preferred for small, medium and large breed dogs, but also can
be performed effectively in toy-breed dos and cats with a slight
increase in technical difficulty.
Trochleoplasty - Trochleoplasty is a traditional technique that

involves removal of articular cartilage and subchondral bone A shallow trochlear groove should be deepened using a
from the trochlear sulcus, thereby deepening the sulcus. Fi- trochlear wedge or trochlear block recession.
brocartilage repair is generally seen. This technique is consid-
ered less desirable to cartilage-sparing techniques described
below, although it is sometimes used in toy breeds very suc-
cessfully. Trochleoplasty is technically easy to perform. A
deepened groove can be quickly formed using appropriate
sized rongeurs. Attention should be paid to ensuring adequate
depth of the groove proximally.
Trochlear Wedge Recession - Trochlear wedge recession pro-

vides a means of adequately deepening the trochlear sulcus,
while preserving most of the articular cartilage. This tech-
nique is described elsewhere, but basically involves removal of
a v-shaped wedge of bone and cartilage from the trochlear sul-
cus, removal of underlying bone, followed by replacement of Saw-blade cut for trochlear block recession.
the original wedge in a recessed position. This is an excellent
technique, but technically more demanding than trochleoplas-
ty. The technique is performed using a fine-tooth hand saw-
blade. Care should be taken when beginning the saw cut, not
to excoriate the adjacent cartilage due to slippage. The cut is
initiated perpendicular to the cartilage surface adjacent to the
peak of the trochlear ridge. Once the saw blade has engaged
the subchondral bone, the blade is gradually redirected in the
proper direction, parallel to the v-shaped trochlear groove. A
cut is made from the lateral and medial ridge, meeting deep to
the central sulcus of the groove. The wedge is removed and
carefully stored to avoid accidental discard. The groove is fur-
ther deepened by removing a block of bone from one side of
the groove by making a parallel cut with the handsaw. A mod-
ification of this technique is to broaden and deepen the proxi- Osteotome cut begins above the intercondylar notch.
mal aspect of the new, deepened groove by performing a par-
tial trochleoplasty in the proximal aspect of the groove only, as
described above using rongeurs. A portion of bone can also be
removed from the underside of the trochlear wedge to further
deepen the groove. The wedge is replaced and the adequate
depth of the groove is documented. Fixation of the wedge is
usually not needed due to pressure applied from the patella ly-
ing above and the congruency between the groove and wedge
geometry.
Trochlear Block Recession - Trochlear block recession is sim-

SCIVAC CONGRESS
ilar to trochlear wedge recession except that a block-shaped

wedge is removed from the trochlear sulcus rather than a v-
shaped wedge. This technique allows a deeper sulcus proxi-
mally, which may provide better biomechanical stability of the Osteotome is used to elevate the trochlear block.
patella when the stifle is in an extended position. This is an ex-

cellent technique, but technically more demanding than
trochleoplasty. The technique is performed using a fine-tooth
hand saw-blade, a small osteotome and mallet. Care should be
taken when beginning the saw cut, not to excoriate the adja-
cent cartilage due to slippage. The cut is initiated perpendicu-
lar to the cartilage surface adjacent to the peak of the trochlear
ridge. Once the saw blade has engaged the subchondral bone,
the blade is gradually redirected in the proper direction, per-
pendicular to the long axis of the bone. A cut is made from the
lateral and medial ridge and each cut is carried to an adequate
depth deep to the central sulcus of the groove. The block of
cartilage and bone is removed gently using an osteotome and Bone is removed below the block deepening the groove
mallet. The osteotome is positioned just proximal to the inter- after replacing the block
condylar notch beginning at the depth of the trochlear cuts.
The osteotome is directed towards the proximal extent to the
trochlear groove. Gentle raps with the mallet will advance the osteotome, dislodging the trochlear block.
The trochlear block is removed and carefully stored to avoid accidental discard. The groove is further deep-
ened by removing a complimentary block of bone from the deep portion of the groove by making a paral-
lel cut with the osteotome or by deepening with a rongeur. A portion of bone can also be removed from the
underside of the trochlear block to further deepen the groove. The block is replaced and the adequate depth
of the groove is documented. Fixation of the block is not needed due to pressure applied from the patella ly-
ing above and the congruency between the groove and block geometry.
ALIGNMENT OF THE QUADRICEPS MECHANISM

Tibial Tuberosity Transposition - Tibial tuberosity transpo-
sition is an excellent method of improving alignment of the
patellar mechanism in patients having an abaxially displaced
tibial tuberosity. If the tuberosity is displaced medially, luxa-
tion occurs medially; therefore, the tuberosity must be trans-
posed laterally and secured. Lateral luxations require medial
tibial tuberosity transposition. An osteotomy is performed as
previously described; the tuberosity is transposed then se-
cured with a single or multiple k-wires. An attempt is made
when performing the osteotomy to leave the distal cortical
bone intact to act as a tension band against the pull of the
quadriceps mechanism. If the tuberosity is freed completely, it
is prudent to secure the transposed bone with either a pin and
tension band or a lag screw. The tuberosity should be trans-
posed to a position that restores axial alignment to the quadri-
ceps mechanism. The tibial tuberosity is moved laterally an appropriate dis-
Rectus Femoris Transposition - This is a technique described tance to align the patellar mechanism such that the patel-
by Dr. Barclay Slocum for use in bow-legged dogs having me- la lies in the trochlear groove during flexion and extension.
dial patellar luxation. This technique is done in combination
with a medial releasing incision. A trochlear deepening tech-
nique should also be performed as needed. The rectus femoris is transected from its pelvic origin with a
small piece of attached bone, then laterally transposed by tunneling under the vastus lateralis and reattach-
ing it to the cervical tubercle or third trochanter of the proximal femur with wire or heavy suture. This re-
aligns the quadriceps mechanism, restoring a straight-line pull.
Corrective Osteotomy of the Femur - Varus deformity of the distal femur is a contributing factor to me-
dial patellar luxation particularly in large breed dogs. Accurate radiographic assessment of the distal femur
is needed to measure angulation. If the distal femur has a varus deviation of greater than 10° a varus cor-
rective osteotomy may be needed. A closing wedge osteotomy using a bone plate is commonly used for this
SCIVAC CONGRESS
procedure.
Corrective Osteotomy of the Tibia - Valgus deformity of the proximal tibia may require corrective os-
teotomy using a closing wedge osteotomy. This typically is only needed in dogs having severe medial patel-
lar luxation when they were puppies. Unequal pressure on the growth plate leads to incongruent growth
and angulation of the proximal tibia.
RETINACULAR IMBRICATION
Lateral imbrication is usually performed with correction of a medial patellar luxation as a means of creating
lateral restraint. The stretching of the lateral joint capsule and retinaculum occurs chronically with long-
standing patellar luxation. Occasionally a traumatic luxation may result in rupture of these tissues; imbrica-
tion is also a good technique for repair in this case. Imbrication is usually performed using heavy, ab-
sorbable, monofilament suture placed in a vest-over-pants- or horizontal mattress pattern. Care must be tak-
en not to tighten the retinaculum excessively (especially if a retinacular releasing incision has been per-
formed on the opposite side), because it is possible to create an iatrogenic luxation in the opposite direction.
An alternative method of supplying lateral restraint is placement of a lateral derotational suture from the lat-
eral fabella to a bone tunnel in the tibial tuberosity.
RETINACULAR RELEASING INCISION

A medial releasing incision is performed if fibrous hyperplasia has occurred medially following prolonged
or severe medial patellar luxation. An incision is made through the retinacular tissues in a medial parap-
atellar location. The incision should extend proximally beside the medial edge of the quadriceps tendon.
Placement of the incision in this location will release the insertion of the sartorius muscle, decreasing pull on
the patella. The incision occasionally has to be carried deeper to include the joint capsule if marked joint
capsular fibrosis has occurred creating excessive medial restraint. The incision is left open and not sutured.
Arthroscopic medial releasing incisions can be performed. This technique is quick, easy to perform and has
low morbidity. Long-term follow-up is presently unavailable. In addition, the clinical indications with this
technique are presently unknown.
SCIVAC CONGRESS
Arthroscopic-assisted arthrotomy… ride the wave

of the future
Arthroscopy has revolutionized the treatment of joint disease in man and animals. Arthroscopic-assisted sur-
gical techniques reduce postoperative pain, the length of hospital stay and shorten the time required for re-
turn to function. At the present time, arthroscopy in animals is used primarily by veterinary surgeons hav-
ing advanced training, usually working out of specialty practices or in a university hospital. General practi-
tioners who routinely perform joint surgery have been slow to adopt arthroscopy due to the learning curve
involved. Consideration should be given to implementing arthroscopy at the time of arthrotomy to enhance
surgical view, improve surgical treatment and assist in arthroscopic training. The arthroscopic procedure is
simplified when using arthroscopy at the time of arthrotomy. Arthroscopic exploration can be attempted pri-
or to or during routine arthrotomy as previously described.1 May conditions affecting the joints are best
viewed arthroscopically including, OCD of the shoulder and elbow, ligamentous and tendinous injuries of
the shoulder, fragmented medial coronoid process, cranial cruciate ligament tears and meniscal tears.
BENEFITS OF ARTHROSCOPY AT THE TIME OF ARTHROTOMY

Arthroscopy is easier to perform when used at the time of arthrotomy. The arthrotomy incisions functions
as the arthroscope, instrument and egress portal. Extravasation of fluids into the subcutaneous tissues is un-
likely due to the ease of fluid egress from the arthrotomy incision. The arthroscope can be quickly and eas-
ily moved in and out of the joint as needed. The surgeon’s orientation of the scope and anatomic target is
improved. The scope can be positioned in the desired location by gross observation, while the anatomic
structure of interest can be assessed more completely using the magnification and enhanced viewing field
provided by the arthroscope. Over time, the surgeon will improve their arthroscopic skills to the point where
arthrotomy may no longer be needed. Other important advantages of arthroscopy compared to arthrotomy
include decreased pain, earlier return to function, improved visualization and more precise and accurate
treatment. Other potential advantages include reduced scarring of the skin, decreased periarticular fibrosis
and improved long term function. Smaller arthrotomy incisions can be made when arthroscopy is used at
the same time, thus capturing some of the benefits gained form the use of arthroscopy.
Postoperative Pain
Pain following surgery of the stifle can be substantial. Disruption of tissues leads to pain. Pain is generated
locally by cellular mechanisms and activation of pain receptors. The perception of pain is dependent on
transmission of impulses through the peripheral and central neural pathways. The source of pain may in-
clude skin, subcutaneous tissues, muscle, ligaments, tendons, synovial membrane, and subchondral bone.
Inflammatory mediators within the synovial fluid also cause pain. Surgical pain can be decreased by appro-
priate preemptive analgesia, adjunctive NSAID therapy, reducing the number and extent of tissues invaded,
and by meticulous handling of tissues. Arthroscopic-assisted surgery is minimally-invasive, sparing soft tis-
sues around the joint, thereby reducing painful stimuli.
Return to Function
Early return to function is desirable to reduce muscle atrophy and preserve joint motion following surgery.
Limb disuse quickly leads to muscle atrophy. The loss of muscle mass results in increased force on the joint,
which may predispose to osteoarthritis and additional injury to ligamentous structures. Pain, tissue swelling,
activity restriction and bandaging contribute to postoperative loss of joint range of motion. Early range of
motion exercise is advantageous due to the tendency for joints to become stiff following surgery. Arthro-
scopic-assisted techniques also help to preserve joint range of motion due to its effect on decreasing postop-
erative pain and swelling.
Visualization of Joint Structures

SCIVAC CONGRESS
Arthroscopic evaluation is superior to open surgical evaluation for 3 reasons:

1. magnification of joint structures
2. greater access to joint structures
3. assessment of joint structures in a fluid medium
The biceps tendon cannot be seen through a caudolateral arthroto- Tears (b) of the biceps tendon (a) are easily viewed during
my, but is easily seen if the arthroscope is employed. arthroscopy of the shoulder.
Osteochondral fragments (b) near the biceps tendon (a) can be seen Fragments of the medial coronoid process are best seen arthroscop-
with the arthroscope, but not with a routine arthrotomy. ically.
SCIVAC CONGRESS
Multiple fragments of the medial coronoid process can be easily Partial tears of the cranial cruciate ligament not visible to the
missed with arthrotomy. naked eye can be seen easily with the arthroscope.
Visualization of the menisci can be difficult using an arthrotomy. Arthroscopic assessment of the menisci improves visualization of
small meniscal tears due to magnification. This tear would likely
not be visible to the naked eye.
A bucket-handle tear is more precisely removed arthroscopically Large bucket-handle tears can be removed through small stab in-
using a grasper and a cutting forcep. cisions as the surgeon becomes more proficient with arthroscopy, re-
sulting in decreased morbidity.
SCIVAC CONGRESS
Meniscal tears can be difficult to see during routine arthrotomy. A probe is used to assess the meniscus during arthroscopy, helping
the surgeon to identify tears that can not be seen with the naked
eye during arthrotomy.
Magnification of intraarticular structures allows for more accurate identification of pathological change. Ear-
ly osteoarthritic changes to articular cartilage, not visible to the naked eye, are clearly seen arthroscopically.
Fine and course fibrillation, superficial erosions and neovascularization of the cartilage are readily evaluated
and documented. Small radial and axial tears of the menisci often become evident only after magnification.
SHOULDER
Arthroscopic assessment of the shoulder is greatly enhanced during arthrotomy due to the ability to evalu-
ate the entire joint through a typical caudolateral approach. The medial, lateral and cranial compartments
can not be evaluated with a caudolateral arthrotomy, therefore osteochondral fragments or tears of the lig-
amentous or tendinous structures in these regions may be missed. OCD of the shoulder is the most com-
mon indication for arthrotomy or arthroscopy of the shoulder. This condition often leads to fragmentation
of the cartilage flap. Loose fragments frequently float into the medial or cranial aspect of the joint. Fragments
may move into the bicipital tendon sheath causing inflammation and irritation. Arthroscopy gives the sur-
geon the ability to identify and remove these potentially painful fragments that might otherwise be left be-
hind when performing a routine arthrotomy.
ELBOW
Arthroscopic evaluation of the elbow at the time of arthrotomy is particularly useful to better evaluate the
patient with elbow dysplasia. Fragmentation of the medial coronoid process can be assessed arthroscopical-
ly or by arthrotomy. When assessed using an arthrotomy, most surgeons use a minimally-invasive approach
in order to preserve the medial collateral ligament of the elbow. The field of view is quite small when eval-
uating the joint by this manner. Attempts at improving the view by applying a valgus force to the elbow may
result in iatrogenic tearing of the ligament. In addition, the medial coronoid process is often times has mul-
tiple fragments. Arthrotomy may allow removal of the main fragment, but smaller fragments and those lo-
cated cranial to the medial collateral ligament may be missed. Arthroscopy gives better views of the region
and allows more complete removal of the fragments. The subchondral bed can also be more accurately treat-
ed with curettage or abrasion arthroplasty when viewed with the arthroscope. Lastly, The extent of cartilage
damage of the medial humeral condyle, medial coronoid process and trochlear notch can be assessed accu-
rately arthroscopically, which assists the surgeon’s ability to develop a long term plan for management of
the condition and to give the pet’s owner a more accurate prognosis.
STIFLE
Arthroscopic evaluation of the stifle allows more thorough evaluation of the cranial cruciate ligament and
menisci. The cranial cruciate ligament can be assessed for partial or complete tears. Complete tears of the
ligament are easy to see by arthrotomy or arthroscopy. Partial tears, on the other hand, are often not visible
by the naked eye. Arthroscopic examination of the cranial cruciate ligament gives the surgeon the ability to
identify and document partial tears of the ligament prior to the progression of osteoarthritis (OA) and com-
plete tearing of the ligament. Surgical intervention in the early stages of cruciate disease may help reduce the
severity of future OA and preserve the integrity of the remaining fibers of the ligament. Meniscal views are
also improved due to the ability to position the scope directly adjacent to meniscus in both the cranial and
caudal joint compartment. Partial meniscectomy can be performed more accurately when assessed arthro-
scopically. Meniscectomy performed with the naked eye often leads to iatrogenic cartilage damage or inad-
equate removal of damaged meniscal tissue. Arthroscopic-assisted meniscectomy through an arthrotomy in-
cision gives a magnified view of the meniscus, which helps prevent inadvertent damage to the cartilage dur-
ing instrumentation and allows the surgeon to assess the meniscus repeatedly to ensure complete removal
of damaged portions of the meniscus.
REFERENCES
1. Small Animal Arthroscopy. In: Beale BS, Hulse DA, Schulz KS, Whitney WO. Small Animal Arthroscopy. Philadel-
phia, WB Saunders, 2003.
SCIVAC CONGRESS
Medial patellar luxation in large dogs…

what is the difference?
Gulf Coast Veterinary Specialists, Houston, TX
Patella luxation occurs most frequently in small breed dogs, but the prevalence is increasing in large breed
dogs. In the past, large breed dogs were described as being predominately affected by lateral patellar lux-
ation. Lateral luxation certainly occurs more commonly in large breed dogs compared to small breed dogs,
but medial luxation is most in large breed dogs as well. Medial patellar luxation in large breed dogs can
share many characteristics with small breed dogs. Large breed dogs tend to be overrepresented with distal
femoral varus deformity as a cause for medial patellar luxation. This lecture will focus on evaluation and
treatment of distal femoral femoral varus and proximal tibial valgus deformities in MPL patients.
FUNCTIONAL ANATOMY
Quadriceps mechanism
The patella is essentially a sesamoid bone within the quadriceps mechanism. The quadriceps mechanism
is composed of the quadriceps muscle, the patella and the patellar tendon. The quadriceps muscle has 4
muscle bellies. The rectus femoris muscle originates from the ventral aspect of the ilium just cranial to the
acetabulum. The vastus lateralis, intermedius and medialis originate from the proximal femur. All of these
muscle bellies form a common tendon containing the patella that inserts on the tibial tuberosity. The patel-
la glides in the trochlear groove of the distal femoral condyle. The quadriceps mechanism functions simi-
lar to a simple pulley. Contraction and relaxation of the muscle leads to flexion and extension of the sti-
fle joint. Proper function requires adequate alignment of the quadriceps mechanism, the femur and tibia.
The rectus femoris plays an important role in the tendency for the patella to remain in the trochlear groove.
The patella will tend to remain within the trochlear groove if a line drawn from the origin of the rectus
femoris to its insertion on the tibial tuberosity passes through the trochlear groove. The peri-articular soft
tissues such as the joint capsule and femoro-patellar ligaments add secondary support to the femoro-patellar
articulation.
Femur and tibia

It is imperative that the femur and tibia have adequate alignment in the frontal and sagittal planes for prop-
er patella stability. Alignment of the frontal plane is most important when considering patellar luxation. Ex-
cessive varus or valgus deviation of the diaphysis of either bone may influence patellar position. Excessive
internal or external torsion of either bone can also influence patellar position. In addition, the angle of in-
clination and anteversion of the femoral head can also play a role in the dynamics of the quadriceps mech-
anism. Common anatomic abnormalites that may contribute to medial patellar luxation include coxa vara,
genu varum, distal femoral varus, external torsion of the distal femur, a shallow trochlear sulcus, proximal
tibial varus or valgus, internal tibial torsion, and medial displacement of the tibial tubercle.
RADIOGRAPHIC FINDINGS
Patients having medial patellar luxation should be evaluated with appropriately positioned orthogonal survey
radiographic views of the stifle. Orthogonal views of the entire femur and tibia should also be evaluated if
limb deformity is present in small breed dogs and in all medium and large breed dogs with patellar luxa-
tion. The patient should be assessed for patella position, distension of the joint capsule, presence of tibial
translation, tibial tuberosity position, axial alignment of the femur and tibia, torsional alignment of the fe-
mur and tibia, and osteoarthritis. CT imaging is recommended, if available; to more accurately assess hind
limb alignment.
Radiographic changes vary from no obvious change to severe limb deformity and marked patellar dis-
placement depending on the grade of luxation, age at onset of patellar luxation and duration of the condi-
tion. Minimal radiographic changes are seen in adult patients with uncomplicated grade 1 or 2 medial patel-
lar luxation. Some patients have no abnormal radiographic changes. Radiographic changes that may be seen
SCIVAC CONGRESS
include patellar displacement, tibial tuberosity displacement, and rarely mild osteoarthritis and mild joint ef-
fusion. Grade 3 and grade 4 patellar luxations are more likely to have radiographic patellar displacement,
tibial tuberosity displacement, joint effusion and osteoarthritis. These patients are also more commonly af-
fected with axial or torsional abnormalities of the femur or tibia. Patients with severe medial patellar luxa-
tion and abnormal limb alignment usually have distal femoral varus, proxi-
mal tibial valgus, internal femoral torsion or internal tibial torsion. Radi-
ographic assessment of the depth of the trochlear groove is usually best eval-
uated by palpation or gross observation, but severely shallow trochlear
grooves can be seen radiographically.
Radiographic changes are most severe in puppies where the onset of patel-
lar luxation occurs at an early age when the physis is undergoing rapid
growth. Medial luxation of the patella in these dogs causes compression on
one side of the distal femoral and proximal tibial physes and compression on
the opposite side. As a consequence, the medial aspect of the femoral physis
has retarded growth and the lateral aspect has accelerated growth resulting
in distal femoral varus. The lateral aspect of the tibial physis has retard-
ed growth and the medial aspect has accelerated growth resulting in prox-
imal tibial valgus. Torsional deformity of the femur and tibia can also oc-
cur simultaneously.
Correction of the deformity is usually based on comparison of the degree of
angulation and torsion found on radiographic examination of the affect-
ed patient in comparison to normal reference values. The surgeon should be
cautious when interpreting the measured angle of axial deformity as tor-
sional deformity can artificially raise or lower the actual amount of axial
malalignment. A CT scan is likely to give the most accurate measurement
of axial and torsional deformity.
Patients with medial patellar luxation should also be evaluated for the po-
tential for concomitant cranial cruciate injury. Typical radiographic changes
include joint distension and cranial tibial displacement. Osteoarthritic
changes are more likely with cranial cruciate ligament injury. If cranial cru- This grade 4 MPL patient has varus
ciate ligament injury is suspected, measurement of the slope of the tibial deformity of the distal femur and val-
plateau may be helpful when deciding on a surgical plan. gus deformity of the proximal tibia.
Complications associated with medial patellar luxation (MPL) repair can be Slight internal rotation of the bones is
categorized as intraoperative or postoperative. Complications are fairly com- also present.
mon, but fortunately many are easy to resolve or prevent. Most complica-
tions can be avoided by better preoperative planning, meticulous surgical
technique and appropriate postoperative care.
DECISION-MAKING FOR PATELLAR LUXATION REPAIR

Many surgical options are available when considering repair of the luxating
patella. It is important to consider the underlying problems associated with
the particular luxation when choosing a surgical plan. Factors to consider in-
clude, depth of the trochlear groove, alignment of the quadriceps mechanism
(quadriceps, patella, patellar tendon), and the presence of excessive laxity or
tension of the joint capsule and retinacular tissues medially and laterally.
The surgical options chosen should alleviate the underlying factor con-
tributing to the luxation. For example, if a dog has good alignment of the
quadriceps mechanism, but a shallow trochlear groove- the surgical plan
should include a technique to deepen the femoral trochlea, but not a tibial
tuberosity transposition.
Tears of the cranial cruciate ligament
ALIGNMENT OF THE QUADRICEPS MECHANISM is seen in 25% of dogs with MPL.
Tibial Tuberosity Transposition - Tibial tuberosity transposition is an ex- Partial tears are particular common in
cellent method of improving alignment of the patellar mechanism in patients large breed dogs with long standing
having an abaxially displaced tibial tuberosity. If the tuberosity is displaced MPL.
medially, luxation occurs medially; therefore, the tuberosity must be trans-
posed laterally and secured. Lateral luxations require medial tibial tuberosity transposition. An osteotomy
is performed as previously described; the tuberosity is transposed then secured with a single or multiple k-
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wires. An attempt is made when performing the osteotomy to leave the distal cortical bone intact to act as
a tension band against the pull of the quadriceps mechanism. If the tuberosity is freed completely, it is pru-
dent to secure the transposed bone with either a pin and tension band or a lag screw. The tuberosity should
be transposed to a position that restores axial alignment to the quadriceps mechanism.
Rectus Femoris Transposition - This is a technique described by Dr. Barclay Slocum for use in bow-legged
dogs having medial patellar luxation. This technique is done in combination with a medial releasing inci-
sion. A trochlear deepening technique should also be performed as needed. The rectus femoris is transect-
ed from its pelvic origin with a small piece of attached bone, then laterally transposed by tunneling un-
der the vastus lateralis and reattaching it to the cervical tubercle or third trochanter of the proximal femur
with wire or heavy suture. This realigns the quadriceps mechanism, restoring a straight-line pull.
Corrective Osteotomy of the Femur - Varus deformity of the distal femur is a contributing factor to me-
dial patellar luxation particularly in large breed dogs. Accurate radiographic assessment of the distal femur
is needed to measure angulation. If the distal femur has a varus deviation of greater than 10° a varus cor-
rective osteotomy may be needed. A lateral closing wedge or medial opening wedge osteotomy using a bone
plate is commonly used for this procedure.
Corrective Osteotomy of the Tibia - Valgus deformity of the proximal tibia may require corrective os-
teotomy using a medial closing wedge or lateral opening wedge osteotomy. This typically is only needed in
dogs having severe medial patellar luxation when they were puppies. Unequal pressure on the growth plate
leads to incongruent growth and angulation of the proximal tibia.
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Orthopedic infections… What is new?

Orthopedic infections have always been a risk following surgery, but recent trends would suggest higher
risks and morbidity in dogs afflicted with infection following orthopedic surgery. Many factors contribute to
the prevalence of infection in orthopedic patients. These factors can be categorized as patient factors, surgi-
cal factors, bacterial factors and environmental factors. This lecture discusses current thoughts on the influ-
ence of each of these factors on orthopedic infections that are bacterial in nature. The prevention and treat-
ment of orthopedic infections will be emphasized.
PATIENT FACTORS
Some patients may be at greater risk of developing orthopedic infections. Dogs having the following are
more likely to develop infections postoperatively:
1. Recurrent pyoderma
2. Conditions causing immunodeficiency
3. Severe dental disease or chronic infections
4. Amount of soft tissue trauma
5. Bone condition
6. Patient compliance
Dogs having a history of recurrent pyoderma are at a higher risk of developing orthopedic infections post-
operatively. Pyoderma screens should be considered prior to clipping and prior to surgery. Overt infections
should be treated and eliminated prior to performing orthopedic procedures. Prophylactic antibiotics are
warranted in these patients. Any disorder or medication that compromises the immune system predisposed
the patient to infection. Examples include endocrine disorders (diabetes mellitus, hypothyroidism, Cushing’s
disease) and drug therapy (corticosteroids, cytotoxic drugs). The effect of such preexisting conditions should
be minimized prior to surgery if possible. Consideration should be given to improving the dental status of
patients or resolving infections at distant sites (e.g. cystitis, otitis) prior to performing elective orthopedic con-
ditions. If orthopedic surgery is mandatory in the face of a potential nidus for infection, prophylactic an-
tibiotics are warranted. In addition, ancillary procedures to treat the distant nidus of infection (teeth clean-
ing, surgical debridement) should be avoided at the time of orthopedic surgery and delayed to a future date.
Another important patient factor affecting the chance of developing infection is the amount of soft tissue and
bone trauma present. Extensive trauma to soft tissues disrupts host immune defense increasing susceptibili-
ty to infection. Devitalized soft tissues and compromised blood supply to these tissues increase risk of in-
fection due inability for immune defense mechanisms to eliminate bacterial insult. Interestingly, severely
comminuted fractures do not increase chance of infection unless the fragments become avascular. The most
common cause of compromised blood supply to fracture fragments is surgical manipulation. Lastly, patients
must not traumatize the surgical site postoperatively. Dogs have a tendency to chew or lick orthopedic
wounds during the first week after surgery. Access to wounds should be prevented with bandages or restrain
devices such as Elizabethan collars.
SURGICAL FACTORS
1. Surgical prep and drape
2. Aseptic technique
3. Surgical approach
4. Antibiotic prophylaxis
5. Surgical technique
6. Implant choice
7. Closure technique
SCIVAC CONGRESS
Surgical factors play a major role in the development of orthopedic infections. Strict aseptic technique is
mandatory. Gone are the days of a quick rinse of the hands and gloveless surgery. The surgeon should ad-
here to proper protocol when scrubbing, gowning and gloving prior to surgery. The patient should be
clipped atraumatically with clippers just before surgery is to be performed. Clipping several days in ad-
vance my irritate the skin and increase the chance of pyoderma. Shaving with a razor after the clip is not
recommended. Injury to the epidermis increases the chance of infection. Benefit may be obtained by
bathing the affected limb with chlorhexidine shampoo daily for 2-3 days prior to surgery. Mupiricin oint-
ment can be applied to the nasal mucosa for 2-3 days prior to surgery to reduce the chance of nosocomial
infection associated with methicillin-resistant Staphylococcus spp. The surgical area should be prepped us-
ing proper protocol with effective antiseptics and proper technique. The surgical site should be isolated by
4 surgical towels and towel clamps. An impervious drape should be placed over the towels exposing only
the area to be incised. A second incisional drape can be applied to add further protection against infection.
Incisional drapes (e.g. Ioban drape - 3M products) are available with antiseptics that provide residual an-
timicrobial activity during surgery. The chance of postoperative infection decreases if the incisional drape
remains adhered to the edge of the skin. Steps that can be taken to improve adherence include spray ad-
hesive, thorough drying of proper scrub agent and suturing the subcutaneous tissues to a stockinette at the
incision edges.
Choice of surgical approach is extremely important and can make the difference between normal healing
and complicated healing due to infection. The surgical approach should be as minimally-invasive as possi-
ble to prevent unnecessary damage to blood supply, adjacent soft tissues and bone fragments. Good deci-
sion-making and proper planning is essential before beginning surgery to stabilize a fracture. Fractures
should be assessed as to whether they are reducible or non-reducible. Reducible fractures (typically 2-3 to-
tal fragments) can be reduced without disruption of the soft tissues attached to the fragments. The fracture
fragments are anatomically reduced being careful to preserve the attached soft tissues. The fracture is then
stabilized with a suitable implant. Non-reducible fractures (typically greater than 3 total fragments) cannot
be reduced anatomically without damaging the soft tissue attachments and blood supply to the bone frag-
ments. Reducible fractures can be approached using traditional approaches with an expectation of normal
healing. Non-reducible fractures are best approached using minimally-invasive approaches that preserve
blood supply to the fragments, accelerate bone healing and decrease the chance of implant failure. The tech-
nique of relative fracture reduction is used with non-reducible fractures. Traction is placed on the leg in or-
der to bring it to length. Spatial alignment of the joint above and below is restored, such that the range of
motion of these joints move in the same plane of direction. The fracture is stabilized using a bridging tech-
nique without stabilizing the intermediary fragments.
The implants used should be appropriate for the amount and type of force that will be applied during the
convalescence period. Fractures that are inadequately stabilized have excessive motion at the fracture site.
This leads to implant loosening, disruption of neovascularization and fibrous tissue repair rather than os-
seous repair. Loose implants and vascular compromise are associated with a greater chance of infection.
Surgical closure should be performed in a manner that reduces risk factors for infection. The incisional
edges should be handles meticulously to avoid traumatizing the tissue and damaging blood supply. Dead
space should be minimized. Drains should only be used if absolutely necessary and if so should be of the
closed suction type and they should be maintained with proper aseptic technique. Wounds can be closed
with a variety of suture materials, but monofilament suture is less likely to result in infection. New suture
materials are available (e.g. PDS Plus, Monocryl Plus) that have bacteriocidal activity and these appear to
lessen the chance of infection.
Prophylactic antibiotics are generally recommended in patients that have depressed immunity, damaged soft
tissues, poor blood supply, chronic infection at a distant site, surgical procedures exceeding 90 minutes or
are having implants placed for certain fractures or joint replacement. Prophylactic antibiotics should be ad-
ministered at the proper dose and tissue levels of the antibiotic should be at therapeutic levels throughout
the duration of surgery. Prophylactic antibiotics have questionable merit in patients having uncomplicated
orthopedic surgery with no risk factors for infection. Flushing the wound or join with antibiotics have little
merit. Antibiotics can be delivered to the tissues at a higher concentration using a vehicle that allows an-
tibiotic elution over a period of time. Vehicles that can be used include ingress drains, antibiotic-impregnat-
ed methylmethacrylate and various antibiotic impregnated polymers.
BACTERIAL FACTORS
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1. Type of bacterial organism

2. Tendency to produce biofilm
2. Antibiotic susceptibility
3. Ability to reduce bacterial numbers
Bacterial resistance is developing to most of our common antibiotics. Methicillin-resistant strains of Staphy-
lococcus spp. have become particularly common. Infections associated with this organism are considered
nosocomial in many cases and affected patients may carry the organism as part of their normal flora (eg.
Nasal mucosa or epidermis) or have increased susceptibility. Prophylactic antibiotics should be used judi-
ciously to prevent infection without increasing the opportunity to develop resistant strains. Infected wounds
should be cultured and a sensitivity panel should be run to assess for appropriate antibiotic choice. Con-
taminated wounds should be aggressively lavaged, preferable with high pressure irrigation. Implants should
not touch the skin. Minimize exposure of implants to air and other tissues until time for implant placement.
Lavage the tissues prior to application of implants to reduce the chance of bacterial colonization. Certain
bacteria have genetic coding that give them the capability to produce bacterial slime or biofilm. Biofilm is a
mucopoylsaccharide film secreted by bacteria that attached to the surface of foreign bodies, including suture
material and metallic implants. Biofilm reduces the ability of the host immune system to eliminate bacterial
contamination. Implant removal is recommended in patients having an implant-related infection. The im-
plant should be removed and cultured after healing is complete.
ENVIRONMENTAL FACTORS
1. Nosocomial bacterial population
2. Aseptic technique
3. Wound protection
4. Postoperative antibiotics
5. Fracture stability
6. Owner and patient compliance
A dirty environment is not conducive to successful surgery. The prep area, surgery theatre, recovery area
and hospitalization area should be clean as possible. Each area should be cleaned between patients. Bedding
should be changed frequently. Bandages that become soiled should be changed immediately. Bacterial sur-
veillance of the environment should be performed 1-6 months depending on the incidence of infection in the
hospital. The need for postoperative antibiotics should be considered carefully. Excessive antibiotic use pro-
motes bacterial infection and may even increase the chance of infection form bacterial or other organisms
such as yeast due to elimination of normal flora of the skin and mucosal membranes. Loss of these less vir-
ulent bacterial forms reduces the competition for other more resistant bacterial strains, increasing the chance
for infection. Fracture stability must be maintained for proper healing. Loss of stability leads to loosening of
implants and an increase in infection rate. Owners must be appropriately advised on proper postoperative
care and expectations. Patients must be managed appropriately to ensure good patient compliance.
SCIVAC CONGRESS
Why did this fracture case go wrong?

Comminuted fractures can be especially challenging due to the complexity of the fracture fragments and
concomitant soft tissue injury. Careful consideration should be given to decision-making prior to onset of
fracture repair. Factors that should be considered include mechanical, biological and postoperative compli-
ance. Complex fractures that are treated with a mechanically sound repair often leave the surgeon ponder-
ing what could have possibly gone wrong when a “perfect” repair fails. Often times, the answer lies in the
neglect of the biological or postoperative compliance factors. Neurologic function should always be assessed
because complex fractures are often associated with high-energy trauma that also can injure the brachial
plexus or peripheral nerves of the forelimb. This lecture will focus on presentation of clinical cases involv-
ing complex fractures of the forelimb and hindlimb, with an emphasis on the decision-making process. A va-
riety of fracture repair techniques will be discussed including interlocking nails, plate-rod construct and lin-
ear external fixators. Minimally-invasive surgical approaches reduce pain and minimize trauma to the soft
tissues. Biological factors important for fracture healing are preserved, enhancing the body’s ability for in-
direct bone healing. The technique can be used with all fracture types, but is particularly useful for stabi-
lization of comminuted fractures. This type of bone healing is also referred to as secondary bone healing,
spontaneous bone healing and callus healing. Stabilization of fractures using the principles of biologic frac-
ture management is performed with the same type of implant systems used with traditional fracture repair,
including externally and internally applied devices.
FRACTURE MANAGEMENT
Comminuted fractures of the extremities can be challenging. It is always a race between a fracture healing
and an implant failing. Steps can be taken to tip the scale in the direction of early fracture healing. These
steps include:
1. minimally invasive surgical approach
2. preservation of soft tissue attachments to bone fragments
3. use of cancellous bone grafts
4. rigid method of fracture stabilization
5. early return to function
It is always important to obtain an accurate history prior to stabilizing fractures. A complete physical exam
and appropriate diagnostic tests should performed. Pathologic fractures are more likely to be seen in the geri-
atric dog and cat and should be identified preoperatively to ensure proper client education and communi-
cation.
INDIRECT BONE HEALING

Biological fracture management utilizes indirect fracture reduction to preserve the soft tissue envelope at the
expense of anatomic reduction. Indirect bone healing occurs as a result. Indirect bone healing consists of
three elements: 1. the formation of granulation tissue at the fracture site 2. fracture gap widening due to re-
sorption of bone ends 3. new bone formation involving formation of a bone callus. Less disruption of the
vascular supply to bone fragments is achieved through minimal handling of the fragments, promoting ear-
ly callus formation.2,3,6,7 Indirect bone healing is first associated with the formation of fibrous connective tis-
sue and cartilage callus between the fragments.4 Indirect bone healing occurs due to instability at the frac-
ture site and is partially regulated by fragment gap strain.4 Interfragmentary strain is a ratio of change in the
gap width to the total width prior to physiological loading.1,5 A study of the “interfragmentary strain hy-
pothesis” using ovine osteotomy models demonstrated that the initial stages of indirect bone healing occur
earlier and more extensively between gaps with lower shear strain.1 Management of a non-reducible dia-
physeal fracture with an implant system that does not utilize anatomical reconstruction and creation of sub-
sequent small fracture gaps avoids high interfragmentary strain, favoring bone healing.
IMPLANT SYSTEMS
SCIVAC CONGRESS
External and internal implant systems can be used to achieve bone healing using biological fracture man-
agement. Examples of external devices when used in an appropriate manner include casts, splints, linear ex-
ternal fixators and circular fixators. Internal devices commonly used for this application include the plate-
rod system, interlocking nail and bone plates. Other implant systems can also be used for biologic fracture
management as long as the soft tissue envelope is preserved at the fracture site. Whatever implant system is
used, its application must be possible with minimal or no handling of the comminuted fracture fragments.
External Fixator
External fixators provide rigid stabilization and can be used with minimally-invasive technique. Many frac-
tures of the radius and tibia can be reduced closed and stabilized with an external fixator. The main disad-
vantage is the potential for complications with premature pin loosening and the added care needed in the
postoperative period. The use of external fixators for fracture repair is not optimal if the patient or owner
is likely to have poor compliance in the postoperative period. External fixators frames can be applied in one
of 3 configurations- linear, circular or as a hybrid of linear and circular.
Plate-rod construct
The plate rod system has been found to be an ideal implant system for biological fracture management.
Management of a non-reducible diaphyseal fracture with a combination of an IM Steinmann pin and bone
plate can be applied without anatomical reconstruction and thus, avoids the development of small fracture
gaps with high interfragmentary strain. The addition of the IM pin to the plate also significantly increases
the construct stiffness and estimated number of cycles to fatigue failure when compared to a plate only con-
struct. An IM pin serves to replace any transcortical defect in the bone column and acts in concert with the
eccentrically positioned plate to resist bending.2 Mathematical analysis of the plate-rod construct in the ca-
nine femur demonstrated that the pin and plate act most like a dual-beam structure, assuming slight motion
of the pin in the canal.2 Addition of an IM pin to a bone plate has been shown by Hulse et al. to decrease
strain on the plate two-fold and subsequently increase the fatigue life of the plate-rod construct ten-fold com-
pared to that of the plate alone.1 In the canine femur, plate strain is reduced by approximately 19%, 44%,
and 61% with the addition of an IM pin occupying 30%, 40% and 50% of the marrow cavity, respectively.3
Stiffness of plate-rod repairs may be as much as 40% and 78% greater when the pin occupies 40% and 50%
of the marrow cavity, respectively.2
Locking Plates
Locking plates have become very popular for minimally-invasive fracture repair. Many locking plate sys-
tems are available including the Synthes, FIXIN, SOP and ALPS. Locking plates have the ability to lock
the screw into the hole of the plate. The mechanism for locking varies amongst manufactures. The Italian
design FIXIN locking plate system has a conical locking mechanism while the Synthes system has a thread-
ed locking mechanism. The FIXIN plate hole is tapered to
match the conical nature of the head of the screw. This type
of fitting is similar to the Morse taper of the head and neck
fitting of the Total Hip Replacement implant. The stability
of this design is extremely secure. The Synthes locking plate
has threaded holes in the hole of the plate. Corresponding
threads in the head of the screw engage the threads of the
hole, locking the screw to the plate. The ability to lock the
screw to the plate increases pull-out strength of the screw
and construct stability. Traditional plates do not have
threaded holes. Screws placed in ordinary plates apply pres-
sure to the plate, pressing it onto the bone surface. The fric-
tion between the plate and the bone provides the stability to
the bone-implant construct. In contrast, the locking plate
achieves stability through the concept of a fixed-angle con-
struct. The locking plate is not pressed firmly against the
bone as the screws are tightened. The locking screws and
plate function more like an external fixator. Locking plates The FIXIN locking plate us- A Synthes locking plate
are essential “internal fixators”. The plate functions as a con- es a conical head to lock into and locking screws were
necting bar and the screw functions as a threaded fixator a matching conical hole in the used to revise the frac-
pin. The tapered or threaded head of the locking screw en- plate creating fixed-angle stature. The fracture healed
gages the hole of the plate, similar to the clamp of an exter- bilization. quickly without compli-
SCIVAC CONGRESS
nal fixator. The Synthes locking plate also has combi-holes cation. Locking screws
which allow use of traditional or locking screws when de- have increased pull-out
sired. Traditional screws should be place prior to locking strength compared to tra-
screw when using locking plates. ditional screws.
Locking plates are ideal for minimally-invasive fracture repair for several reasons. Blood supply to the bone
is preserved because the plate is not pressed tightly against the bone. The plate does not require perfect
anatomic contouring because the displacement of the plate will not occur as the screw is tightened into the
hole of the plate. Accurate contouring is difficult with a minimally-invasive approach due to the minimal ex-
posure to the shaft of the bone. Lastly, locking screws give fixed angle support to the non-reduced fracture,
increasing stability and less chance of collapse and instability at the fracture gap.
Interlocking nail
The Deuland interlocking nail system presently available in the U.S. (Innova-
tive Animal Products, Inc., Rochester, MN) is a modified Steinmann pin mod-
ified by drilling one or two holes proximally and distally in the pin, which al-
lows the placement of transverse bolts or screws through the bone and nail.
The nail, bolts and screws can be applied in closed or open fashion due to the
incorporation of a specific guide system that attaches to the nail. The equip-
ment needed to place the nail includes a hand chuck, extension device, aiming
device, drill sleeve, drill guide, tap guide, drill bit, tap, depth gauge, and screw-
driver. Cost of the system is reasonable and each nail is approximately half the
cost of a comparative bone plate. The nails are available in diameters of 4.0,
4.7, 6, 8 and 10 mm and varying lengths and hole configurations. The 4.0 and
4.7 mm nails use 2.0 mm screws or bolts. The 6 mm nail is available in two
models and will accommodate either 2.7 or 3.5 mm screws or bolts. The 8 mm
nail is also available in two models and will accommodate either 3.5 or 4.5 mm
screws or bolts. The 10 mm nail uses 4.5mm screws or bolts. The solid cross
locking bolts have a larger diameter compared to a similar diameter screw,
thus are less likely to break. Bolts also provide superior mechanical behavior Interlocking nails provide axial,
compared to screws. bending and rotational stability
The interlocking nail is placed along the mechanical axis of the bone. The in- due to the ability of the screw to
terlocking nail neutralizes bending, rotational and axial compressive forces due lock the IM pin to the bone.
to incorporation of transfixation bolts or screws which pass through the pin and
lock into the bone. This is in contrast to a single intramedullary Steinmann pin
which is only effective in neutralization of bending forces. The interlocking nail has a similar bending
strength compared to bone plates, but is slightly weaker in neutralization of torsional forces. The screws al-
so prevent pin migration, a common complication seen with Steinmann pins.
When using an interlocking nail, the largest diameter nail should be selected that can be accommodated
by the medullary cavity at the fracture site. In most large dogs, an 8 mm nail and either 3.5 or 4.5 mm
screws or bolts can be used in the femur and humerus. In medium-sized dogs, the 6 mm nail and either
2.7 or 3.5 mm screws or bolts are typically used. In small dogs and cats, the 4.7 mm nail and 2.0 mm
screws are typically used. The tibia of medium and large - sized dogs will usually accommodate a 6 mm
nail, but some large dogs will accept an 8 mm nail. Small dogs and some cats will accept a 4.0 mm nail for
repair of tibial fractures.
Dejardin et. al. have developed a novel interlocking nail that provides an angle stable locking mechanism.
The advantage of angle stable locking is the elimination of torsional and bending slack, resulting in reduced
interfragmentary motion. This interlocking nail system provided comparable mechanical performance to a
plate system. Dejardin’s nail is currently unavailable, but release of the nail is expected in the near future.
SURGICAL APPROACH
Closed reduction and stabilization is the optimal method of treatment when possible. Unfortunately, this
method is rarely possible in the senior patient due to the severity of fractures seen, long time until bony
union, and the tendency for patients to develop bandage sores. Open surgical approaches can be either tra-
ditional or minimally invasive. The minimally invasive approach has also been described as an “open but
don’t touch” approach. The acronym, OBDT, is used to describe this technique. The advantages to using
an OBDT technique is preservation of vascular supply to the fracture site and thus quicker healing, short-
er intraoperative time, less postoperative pain and early return to function. Methods of stabilization that
work well with an OBDT approach include the interlocking nail, plate-rod hybrid and external fixation. The
SCIVAC CONGRESS
key feature of a minimally-invasive approach is the preservation of the soft tissue envelope at the fracture
site. Small comminuted fragments will become quickly incorporated into the bony callus if left with a vas-
cular pedicle. Anatomic reduction of small fragments is difficult if vascular supply to the fragment is to re-
main uncompromised.
A combination of an intramedullary pin and bone plate (plate-rod con-

struct) provides excellent stability of comminuted diaphyseal fractures.
Traction is placed on the limb to bring it to adequate length. The IM
pin is then placed to align the fragments and give bending stability. The
bone plate and screws are placed to provide rotational and axial stabil-
ity as well as additional bending strength.
Pre-op Post-op 7 week 15 week

Comminuted fractures can be managed biologically using an interlocking nail, shortening surgical time and speeding bony union.
BONE GRAFTS
Numerous sites for harvest of cancellous bone graft have been described in the dog, but the most practical
are the greater tubercle of the humerus, wing of the ilium and the medial, proximal tibia. The humerus pro-
vides the greatest amount of cancellous bone, but the ilium and tibia provide sufficient amounts for most ap-
SCIVAC CONGRESS
plications. All of these sites are readily accessible, have easily recognizable landmarks, have little soft tissue
covering, and provide relatively large amounts of cancellous bone. The greater trochanter can also be used if
other sites are not available; however, the yield of cancellous bone is markedly less. Occasionally multiple
sites are required to harvest sufficient quantities of bone to fill large bone defects or during arthrodesis.
Minimal instrumentation is required for harvest of cancellous bone graft. Basic surgical instruments are used
to approach the site selected for harvest. A hole is drilled through the near cortex using either a drill bit,
trephine or trocar-pointed pin. A curette is used to scoop the graft out of the metaphyseal cancellous bone.
The cancellous bone should be scooped out in large clumps if possible. Use a curette that can be comfort-
ably manipulated in the medullary cavity; I prefer to use a relatively large curette as this speeds harvest and
reduces trauma to the graft. Closure is performed routinely in 2-3 layers. Recently, a technique was de-
scribed using an acetabular reamer to harvest large amounts of corticocancellous bone graft from the later-
al surface of the wing of the ilium.
The graft collected should be handled gently. It is desirable to collect the graft immediately prior to usage.
This increases the osteogenic properties of the graft. As graft is harvested, it should be placed on a blood-
soaked gauze until transfer to the recipient site. Extreme care should be taken to store the graft properly; do
not accidentally discard the graft due to misidentification of the gauze as being used. The graft should be
atraumatically packed into the recipient site. Lavage of the site should be avoided after the graft is placed.
REFERENCES
1. Cheal EJ, Mansmann KA, Digioia III AM, Hayes WC, Perren SM. Role of interfragmentary strain in fracture heal-
ing: ovine model of a healing osteotomy. J Orthop Res 1991; 9: 131-142.
2. Hulse D, Hyman W, Nori M, Slater M. Reduction in plate strain by addition of an intramedullary pin. Vet Surg
1997; 26: 451-459.
3. Hulse D, Ferry K, Fawcett A, Gentry D, Hyman W, Geller S, Slater M. Effect of intramedullary pin size on reduc-
ing bone plate strain. Vet Comp Orthop Traumatol 2000; 13:185-90.
4. Johnson AL, Egger EL Eurell JC, Losonsky JM. Biomechanics and biology of fracture healing with external skele-
tal fixation. Compend Contin Educ Prac Vet 1998; 20 (4): 487-502.
5. Johnson AL, Seitz SE, Smith CW, Johnson JM, Schaeffer DJ. Closed reduction and type-II external fixation of com-
minuted fractures of the radius and tibia in dogs: 23 cases (1990-1994). JAVMA 1996; 209 (8): 1445-1448.
6. Palmer, RH. Biological Osteosynthesis. Veterinary Clinics of North America: Small Animal Practice 1999; 29 (5):
1171-1185.
7. Palmer, RH. Fracture-patient assessment score (FPAS): a new decision-making tool for orthopedists and teachers.
6th Annual American College of Veterinary Surgeons Symposium, San Francisco, 1996: 155-157.
SCIVAC CONGRESS
S. Langley-Hobbs WVOC 2010, Bologna (Italy), 15th - 18th September • 732
Feline hind limb lameness -

what if it’s not a fracture or an abscess?
Sorrel Langley-Hobbs M.A., B.Vet.Med., DSAS(O), DECVS, MRCVS
The Queens Veterinary School Hospital, University of Cambridge
Osteosarcoma
The incidence of bone tumours in cats is reported to be 3.1 per 100,000 cases. The most common bone tu-
mour is osteosarcoma (OSA), accounting for approximately 70% of all primary tumours (Bitteto et al 1987).
Older cats are usually affected (mean age 10 years) and the tumour appears to have a predilection for the
metaphysis of the long bones of the hind limb and the pelvis. OSA of the appendicular skeleton of the cat
behaves in a much less aggressive fashion than its canine counterpart. The metastatic rate is relatively low,
1 in 19 cases in one study (Quigley & Leedale 1983); and because wide margins can be achieved by ampu-
tation the prognosis for long survival times is good. OSA of the axial skeleton carries a less favourable prog-
nosis because the site of the tumour often precludes complete surgical removal. Radiographic features of fe-
line OSA are variable, lesions of the long bones are predominantly metaphyseal and lytic.
THE HIP
Hip dysplasia
Hip dysplasia in cats may be detected as an incidental finding when the pelvis or abdomen is radiographed
for other reasons. The lower incidence, or detection rate, is related to the smaller size and varied genetic
background of cats. In addition different clinical signs are exhibited. Pure-bred cats may be predisposed. In
one study the incidence was reported to be 6.6% (Keller et al 1999). Radiographic signs in cats included
more acetabular remodelling with minimal femoral neck changes. A study performed at the University of
Pennsylvania confirmed that cats have high hip joint laxity and there is a relationship between DJD and lax-
ity in the hip joint of cats (Langenbach et al 1998).
Slipped capital femoral epiphysis (metaphyseal osteopathy)

This condition is seen mainly in young male neutered cats, aged 2 years or less. Affected cats present with
unilateral hind limb lameness often of insidious onset. Radiographs show a slipped femoral epiphysis, there
may be ‘apple coring’ of the femoral neck (Queen et al 1998). This is a hypervascular response associated
with attempts to repair the fracture. Biopsies of the affected femoral neck showed evidence of fracture heal-
ing. In some cases the fracture has healed but a malunion is present. One review of 26 adult cats with spon-
taneous femoral capital physeal fractures suggested that they were most likely to be heavier, neutered males
with delayed physeal closure (McNicholas et al 2002). Treatment is femoral head and neck excision. The
other femoral head may slip or fracture at a later date.
Hip luxation (dislocation)

The hip is the most commonly dislocated joint in the cat. The luxation usually occurs in a dorsocranial di-
rection, mainly due to the pull of the gluteal muscles. Lameness may vary from non-weight bearing to mild
with some external rotation of the foot. Manipulation, palpation and comparison of leg length can aid in di-
agnosis, however fractures in this area can have similar clinical findings. Definitive diagnosis is by radiog-
raphy – lateral and ventro-dorsal extended. It is best to radiograph the hip joint prior to attempting closed
reduction, if fracture fragments are present or the cat has hip dysplasia / DJD or another traumatic injury
then closed reduction is unlikely to be successful.
Treatment options include closed reduction, conservative, transarticular pin, ilio-femoral suture and femoral
head and neck excision amongst others. The transarticular pin is a useful method of hip stabilisation in the
cat, and the commonest technique we employ (Sissener et al 2009). 1.6mm K wires are used, and left in tem-
porarily for 2-4 weeks, the duration is mainly dependant on the presence of other injuries. The prognosis is
good for maintenance of reduction, except in bilateral cases where reluxation of one hip is likely. Conser-
vative treatment is an option in cats where cost is an implication, however stiffness is likely.
SCIVAC CONGRESS
Myositis ossificans
A generalised form affects skeletal muscle and connective tissue. Young cats with this disease present with
weakness, stiffness, decreased limb movement and muscle pain. Calcified masses can be palpated in muscles.
Radiographs reveal extensive soft tissue mineralisation. There is no effective treatment for the generalised form
733 • WVOC 2010, Bologna (Italy), 15th - 18th September S. Langley-Hobbs
and prognosis is poor (Norris et al 1980). The localised form has a better prognosis and at CUVS we have
seen three cats with progressive myositis ossificans affecting the semitendinosus / biceps femoris musculature.
THE STIFLE
Cranial cruciate ligament disease
Cats do suffer cranial cruciate ligament disease (Harasen 2005). There are two main forms, traumatic and
degenerative. In the traumatic form there is usually damage to other structures such as the collateral liga-
ments and menisci (stifle derangement). Cats with degenerative cranial cruciate ligament ruptures (or the oc-
casional isolated traumatic rupture) will have hind-limb lameness, stifle joint swelling and the cranial draw-
er test will be positive. Radiographs of affected stifles will show compression of the infra patella fat pad as-
sociated with a joint effusion. Dystrophic mineralisation can be seen especially in older animals (Reinke &
Mughannam 1994, Whiting & Pool 1985). In Reinke & Mughannams (1994) paper they report on six spayed
female cats, five of which had a cruciate rupture. The lameness resolved after cruciate surgery and calcifi-
cation resection. Mineralisation may also be present in the normal stifle.
Treatment of cranial cruciate ligament rupture in cats is either conservative or surgical. In one study where
18 cats were treated conservatively they took an average of five weeks to regain normal gait (Schrader &
Scavelli 1987). Surgery may have the advantage of offering a quicker return to function. Generally extra-
capsular stabilisation techniques are suitable and the prognosis is good. Tibial plateau levelling procedures
have been performed in some cats. It is important to check affected cats carefully for concurrent disease. In
one paper three cats with cranial cruciate ligament rupture were all operated with an extracapsular tech-
nique, all died within 2 weeks of surgery with cardiomyopathy. The author advised ECG and thoracic ra-
diographs prior to surgery or that the cats be treated conservatively (Janssens et al 1991). The author has
also seen two cats with cranial cruciate ligament rupture that had concurrent hepatopathy.
The deranged stifle

Disruption of the stifle after trauma in the cat is not uncommon. Often both cruciate ligaments are disrupt-
ed, together with one, or both, collaterals, and meniscal detachment. The joint is highly unstable and con-
servative treatment is not appropriate, it is therefore important to differentiate these more severe injuries
from an isolated cranial cruciate ligament injury. The options for management are either to individually re-
pair the affected collateral, reattach the meniscus, and the cranial (and caudal cruciate) ligament or to effec-
tively reduce the dislocation and place a transarticular pin. In seven cats where a transarticular pin was used
for deranged stifles the results were excellent in 4, fair in 2, and poor in one (Welches & Scavelli 1990). Com-
plications included pin loosening & bending. These were possibly as a result of inadequate external coapta-
tion. Bruce (1999) reported on the use of TESF after reconstruction of individual ligaments in four cats.
There were serious complications with fractures occurring through ESF pin-holes when cats were not con-
fined indoors, otherwise the method was successful in terms of stabilising the stifle.
Patella luxation
Patella luxation is not common in cats, when it occurs it is generally medial and can be uni or bilateral. Both
traumatic and developmental (congenital) forms are seen. The condition has been reported in the Devon
and Cornish Rex, Persian and Abyssinians as well as domestic short-haired breeds (Engvall 1990). Houlton
and Meynard (1989) report on 8 cats with patella luxation, six of which had bilateral disease. Conservative
treatment was unsuccessful but there was a ninety percent improvement with surgery. One patella fracture
occurred 6 months post operatively.
Patella fracture
These are usually stress fractures in cats. They are generally seen in young cats between one and two years
of age and in over half the cases they are bilateral with a median interfracture gap of 3 months. The frac-
tures rarely heal and pin and tension band wire fixation should not be used as it results in further fractur-
ing of the brittle bone. Circumferential wiring, tension band wiring (without a pin) or conservative treatment
can all be used but which is the best treatment has not been fully determined. Chronic non-union fractures
can be seen in older cats.
THE HOCK
SCIVAC CONGRESS
Scottish Fold Osteochondrodysplasia

The Scottish fold breed of cat derived from a DSH crossed with a Scottish farm cat with folded ears. The
folded ears are a sign of defective collagen / cartilage. Some cats have associated osseous deformity with
ankylosis of the hindlimb, joints and tail. In one case report the cat had bilateral hind-limb lameness, asso-
ciated with tarsal exostoses. Lameness resolved following staged bilateral ostectomies and pantarsal
arthrodeses. (Mathews et al 1995).
Collateral ligament injuries

Traumatic hock injuries are common and usually associated with fractures (Roch et al 2009). Most com-
monly there is fracture of the lateral malleolus (fibula) alone or with a concurrent fracture of the medial
malleolus, most rare is bilateral ligament rupture without fracture. When avulsion fractures are present these
should be staibilised with pin and tension band wire and external coaptation or transarticualr external skele-
tal fixation. Occasionally cats will present with hind limb lameness associated with closed collateral ligament
injury, sometimes just the short collateral ligament may be ruptured. Repair is necessary with closed injuries
– primary repair is often difficult and use of a prosthetic ligament is recommended, Anchorage of prosthet-
ics is challenging in the cat given the small size.
Periosteal proliferative polyarthritis

PPP is a form of Immune-based arthritis reported by Pedersen (1980). It generally affects male cats and has
a guarded prognosis for recovery. It mainly affects hocks and carpi. Radiographically there are erosive
changes in the joints and enthesopathies. Possible viral association but unconfirmed.
REFERENCES
Bitetto WV, Patnaik AK, Schrader SC Mooney SC. Osteosarcoma in cats: 22 cases (1974-1984) J Am Vet Med Assoc
1987;190:91-93.
Bruce W.J. Stifle joint luxation in the cat: treatment using transarticular external skeletal fixation. J Small Anim Pract
1999;40(10):482-8.
Engvall E. Patella luxation in abyssinian cats. Fel Pract 1990;18(4):20-22.
Harasen GL Feline cranial cruciate rupture: 17 cases and a review of the literature. VCOT 2005 18(4) 254-7.
Houlton J.E.F & Meynink S.E. Medial patella luxation in the cat. J Small Anim Pract 1989;30:349-353.
Janssens L.A.A., et al. Anterior cruciate rupture associated with cardiomyopathy in three cats. Vet Comp Orth Traum
1991;4:35-37.
Keller GG, Reed AL, Lattimer JC, Corley EA Hip Dysplasia: a feline population study. Vet Radiol Ultrasound. 1999;
40:460-4.
Langenbach A, et alSmith G. Relationship between degenerative joint disease and hip joint laxity by use of distraction in-
dex and Norberg angle measurement in a group of catsJAVMA. 1998 Nov 15;213(10):1439-43. Erratum in: J Am
Vet Med Assoc 1999 Mar 1;214(5):659.
Mathews KG, et al. Resolution of lameness associated with Scottish fold osteodystrophy following bilateral ostectomies
and pantarsal arthrodeses: a case report. J Am Anim Hosp Assoc. 1995 Jul-Aug;31(4):280-8.
McNicholas WT Jr, Wilkens BE, et al. Spontaneous femoral capital physeal fractures in adult cats: 26 cases (1996-2001).
J Am Vet Med Assoc. 2002 Dec 15;221(12):1731-6.
Norris AM, Pallett L, and Wilcock B. Generalised myositis ossificans in a cat. Journal of the Am Anim Hosp Assoc
1980;16:659-663.
Pederson NC, Pool RR. Feline chronic progressive polyarthritis. Am J Vet Res 1980;41: 522-535.
Queen J, Bennett D, et al. Femoral neck metaphyseal osteopathy in the cat. Vet Rec. 1998 Feb 14;142(7):159-62.
Quigley PJ, Leedale AH. Tumours involving bone in the domestic cat: a review of 58 cases. Vet Path. 1983;20:670-686.
Reinke J.D. Mughannam A. Meniscal calcification and ossification in six cats and two dogs. JAAHA 1994;30:145-152.
Roch SP, St√∂rk CK, Gemmill TJ, Downes C, Pink J, McKee WM. Treatment of fractures of the tibial and/or fibular
malleoli in 30 cats. Vet Rec. 2009 Aug 8;165(6):165-70.
Scavelli, T.D. & Schrader, S.C. Nonsurgical management of rupture of the cranial cruciate ligament in 18 cats. JAAHA
1987;23:337-340.
Sissener TR, Whitelock R, Langley-Hobbs SJ Long term results of transarticular pinning for surgical stabilisation of cox-
ofemoral luxation in 20 cats. JSAP 2009, 50, 112-7.
Whiting P.G. & Pool R.R. Intrameniscal calcification and ossification in the stifle joint in three domestic cats. JAAHA
1985;21:579-583.
Welches, C.D. & Scavelli T.D. Transarticular pinning to repair luxation of the stifle joint in dogs and cats: a retrospective
study in 10 cases. JAAHA 1990;26: 2077.
SCIVAC CONGRESS
Feline forelimb lameness -

what if it’s not a fracture or an abscess?
Osteoarthritis
Cats commonly suffer from osteoarthritis however the clinical signs tend not to be as pronounced as in dogs
(Lascelles 2010). Cats tend to sleep more, exercise less, resent handling and have difficulty jumping up or
down. Osteoarthritis seems to be more common in the forelimb as compared to the hind limb with some
studies showing over representation in the shoulder and elbow in the older cat.
Treatment - It is difficult to modify a cats’ exercise, but it is useful to encourage some movement at regular
intervals during the day. Weight loss is to be encouraged. The use of NSAIDs is restricted because of po-
tential for toxicity and the lack of licensed drugs available. Meloxicam, robenacoxib, ketoprofen & carpro-
fen are all licensed for use in the cat but meloxicam is the only one for long-term (28d) use.
Infective arthritis
Bacterial - The commonest source of infective arthritis in a cat is from a bite, often by another cat. General-
ly only a single joint is affected, that is hot, swollen and painful, careful examination may reveal a puncture
wound. The most useful investigation is to perform arthrocentesis and synovial fluid analysis. Staphs, streps
and Pasteurella are some of the commonest isolates.
Septic polyarthritis is also occasionally recognised in kittens from an infected umbilicus; joint abscessation
and severe joint destruction can occur in which case euthanasia is recommended (Bennett 2000). Arthritis
associated with bacterial L-forms - Cats with pyogenic subcutaneous abscesses and arthritis associated with a
probable bacterial L-form, a cell wall deficient bacteria) were described by Carro et al (1989). The organism
is difficult to culture, resistant to most antibiotics except tetracycline and can cause severe joint destruction.
Mycoplasmal arthritis - Polyarthritis associated with mycoplasmal infection has been reported in old debilitat-
ed cats. Organisms can be cultured on special media or seen with stains such as Giemsa. Gunn Moore et al
(1996) reported one cat that presented with unilateral elbow arthritis associated with tuberculosis, diagnosed
by biopsy.
Calicivirus arthritis - A fleeting stiffness, soreness and lameness with high fever has been reported in young kit-
tens (Pedersen 1983). The prognosis is good as the disease is usually self-limiting. Corticosteroids can be giv-
en in protracted cases (Dawson et al 1992)
Lyme Disease Borrelia burgdorferi - Cats can become infected and seroconvert but there is disagreement as to
whether they suffer clinical disease (Bennett 2000).
Immune-based arthritis
Several different types have been reported to affect cats. They usually cause chronic active synovitis in a bi-
laterally symmetrical fashion. Clinical signs - generalised stiffness, reluctance to jump and exercise. Systemic
signs such as pyrexia, malaise, inappetance can also be present. Immune based arthritis is distinguished from
other types of arthritis by synovial fluid analysis. There are two main categories – erosive and non-erosive.
Erosive inflammatory arthritis
Rheumatoid arthritis - A chronic progressive and destructive arthritis
Periosteal proliferative polyarthritis (Pedersen 1980) - generally affects male cats. Mainly affects hocks and
carpi with erosive changes in joints and entheseopathies. Possible viral association but unconfirmed.
Non erosive inflammatory arthritis
Systemic lupus erythematosus - Polyarthritis may be seen as one feature of a multisystemic disease.
Idiopathic Polyarthritis - Any cases of polyarthritis that do not satisfy the criteria for the joint diseases list-
ed above are be categorised as idiopathic polyarthritis.
Treatment for most of the immune based arthritides is usually with steroids, often prednisolone.
THE SHOULDER
SCIVAC CONGRESS
Anatomy
The feline shoulder joint has some anatomical differences from the canine. The metacromion is located on
the distal scapular spine and extends caudally, the coracoid process forms a prominent extension from the
rim of the glenoid craniomedially and a clavicle is present
Scapular avulsion
There are two case reports of scapular avulsion in cats in
the literature (Leighton 1977, Schneck 1975). Avulsion of
the scapula is a rare injury. Diagnosis is based on palpa-
tion and observation of the dorsal displacement of the
scapula. Fracture of the body of the scapula may coexist.
Repair can be achieved by reattaching the bone to the
serratus ventralis muscle with non-absorbable sutures se-
cured through small holes in the scapula. If the soft tis-
sue repair is tenuous a wire can be placed carefully
around an adjacent rib. The cat needs cage rest and / or
bandaging for several weeks post operatively.
Shoulder dislocation
Shoulder dislocation is very rare in the cat and there is very limited information available in the literature.
Reduction is often easily achieved with closed manipulation. A velpeau like sling is recommended for me-
dial luxations and a spica splint, with the shoulder held in slight abduction, for lateral luxations. If reduc-
tion is unstable then collateral ligament replacement alone or combined with a temporary transarticular pin
or wire mattress suture can be used (voss et al 2009).
Accessory centres of ossification

Accessory centres of ossification are often seen on the caudal and medial aspect of the glenoid in the cat.
These are presumed to be incidental findings and not fracture fragments or joint mice. They are generally
recognised when the cats are being radiographed for other reasons and not for lameness (often seen on tho-
racic radiography).
Osteochondritis dissecans of the shoulder joint in the cat

There are two reports in the literature of cats presenting with OCD like shoulder lesions (Butcher and
Beasley 1986, Peterson 1984). One cat was a nine-month Burmese with sudden onset shoulder lameness, a
one centimetre lesion of discoloured articular cartilage was removed from the caudal aspect of the humeral
head at surgery. The other case was a one-year old male neutered cat and a flap of cartilage was removed
from the humeral head after which time the lameness resolved.
THE ELBOW
Anatomy
In the cat there is a supracondylar foramen that contains the median nerve and brachial artery; the supra-
trochlear foramen is not completely penetrated in the cat. Interrelationship of the ligaments to the proximal
radius & ulna are of particular interest in the cat (Kramers 1992). The elbow joint surface extends cranially
over the edge of the radial head to form a triangular facet similar in size to the large hook-shaped medial
coronoid process of the ulna. These two structures are intimately suspended in a ‘radial oblique’ (annular*)
ligament and an ulnar oblique (anterior medial collateral ligament*) ligament. This suspensory apparatus is
reinforced by an anterior coronoid (ant. oblique*) ligament. Extension, supination and pronation are limit-
ed by the inter-locking mechanism of the cranial facet of the proximal radius with the large medial coronoid
process of the ulna within this suspensory apparatus. This function seems ideally adapted for the agile jump-
ing catching and climbing in cats. Attempts should be made to preserve full antebrachial function in feline
trauma patients.
Synovial cysts
Three cats with cystic extensions of the elbow joint capsule were described by Stead and others (1995), one
cat was reported in a case series by Prymak and Goldschmidt (1991) and another in a ‘Whats your diag-
nosis’ by White et al (2004). In only one cat was surgical excision successful (Prymak & Goldschmidt 1991)
in the other three cats the condition was only temporarily alleviated by surgical excision or drainage, and it
was associated with osteoarthritis. Average age of the cats was 14 years. Diagnosis was assisted by synovio-
centesis, ultrasonography & arthrography. The cause of the cysts is unknown but in man it has been theo-
SCIVAC CONGRESS
rised that they are related to herniations of joint capsule, inflammation and osteoarthritis.
* Nomenclature of analogous structures in the dog.

Elbow dislocation
In a survey of feline orthopaedic injuries the elbow joint accounted for approximately 15% of all luxations
seen (Schrader 1994). Lateral dislocation is the commonest but caudal dislocation is seen with a much high-
er frequency in cats than in dogs. Small fractures of the radial head and anconeal process may be present
but these rarely interfere with reduction and fixation.
Closed reduction is usually possible. Following reduction external reduction should be applied with the
limb held in the position that affords the most stability.
With lateral dislocation full extension usually affords the most stability, extension can be maintained with
an over the shoulder spica splint. With caudal dislocation moderate flexion is usually best. External coap-
tation should be maintained for 14 to 21 days, however if the reduction is unstable open reduction and in-
ternal fixation are indicated. Soft tissue reconstruction may not be adequate and temporary transfixation
with a Kirschner wire or TESF may be indicated. It is particularly important to repair the humeroulnar
collateral ligament in cats (Voss).
Cranial luxation of the radial head in cats

Denny and Butterworth (1999) report that cranial luxation of the radial head associated with rupture of the
annular ligament is occasionally seen in cats. Open reduction is performed and the radial head fixed to the
ulna with a lagged bone screw. Normal function seems to be regained without requiring the screw to be re-
moved.
Osteochondromas
At CUVS several cats have been seen with ‘osteochondromas’ affecting one or both elbow joints. Hubler
and others (1986) report on one cat with similar lesions and one cat with lesions resembling synovial os-
teochondromatosis. Interestingly 4 of the 6 affected cats were Burmese. The prognosis for appendicular os-
teochondromas seems to be better than that for axial osteochondromas where affected animals are often
FeLV positive and euthanasia is usually performed.
Hypervitaminosis A
Chronic hypervitaminosis A can result in the formation of exostoses at the site of tendon, ligament and joint
capsule attachments. The cervical spine is most commonly affected but the forelimbs and particularly the el-
bow joints can also be involved. Affected animals may present with lameness as one of the clinical signs.
THE CARPUS
Hyperextension injury
Carpal hyperextension injury in cats is uncommon. Occasionally young cats / kittens are presented with bi-
lateral hyperextension – this condition may be temporary and it is worth trying conservative treatment ini-
tially. A cat with a true traumatic hyperextension injury was treated by pan carpal arthrodesis (Simpson &
Goldsmid 1994).
An anatomical study of the carpus determined that 1.5mm screws should be used in the third metacarpal
bone and 2 mm screws in the distal radius. It may be preferable to fuse the joint at a slightly hyperextend-
ed angle as compared to dogs.
Luxation of the radial carpal bone in a cat

A case of radial carpal bone luxation in the cat and its management has been described (Pitcher 1996). Open
reduction was performed in combination with repair of rupture of the short radial collateral ligament and
joint capsule. The carpus was supported for one month following surgery by application of transarticular
external fixation.
Four months after treatment the cat was sound, despite evidence of degenerative joint disease. The mecha-
nism of luxation appears to be analogous in the cat to that seen in the dog.
Carpal luxation
Only two cases of carpal luxation and treatment have been published (Voss et al 2004, Shales & Langley-
Hobbs 2005), despite its common occurrence after high-rise injury. In the one case the luxation was palmar
and associated with medial collateral ligament rupture, treatment was achieved by medial collateral ligament
SCIVAC CONGRESS
repair. In the other case luxation was dorsal with radio-ulnar subluxation due to rupture of the radio-ulnar
ligament. It was treated by closed reduction, primary repair of ligamentous structures and TESF for 5
weeks. Compared to dogs pancarpal arthrodesis is not always required as the palmar fibrocartilage and lig-
aments seem to be damaged less frequently.
REFERENCES
Denny H.R., and Butterworth S.J., A guide to canine and feline orthopaedic surgery. 4th edition. Blackwell Science. 1999.
Bennett D.B. Arthritis and Miscellaneous Joint Conditions. In: Feline Orthopaedics and Traumatology. BVOA meeting
11th-12th November 2000;102-104.
Butcher R., Beasley K, Osteochondritis dissecans in a cat? Vet Rec 1986 118 23 646.
Carro T, Pedersen NC, Beaman BL, Munn R. (1989) Subcutaneous abscesses and arthritis caused by a probable bacter-
ial L form in cats. J Am Vet Med Assoc 194 1538-8.
Dawson S. et al Investigations of vaccine reactions and breakdowns following feline calcicivirus vaccination. Vet Rec
1992;132: 346-350.
Farrell M, Thomson DG, Carmichael S. Surgical management of traumatic elbow luxation in two cats using circumfer-
ential suture prostheses. Vet Comp Orthop Traumatol. 2009;22(1):66-9.
Farrell M, Draffan D, Gemmill T, Mellor D, Carmichael S. In vitro validation of a technique for assessment of canine and
feline elbow joint collateral ligament integrity and description of a new method for collateral ligament prosthetic re-
placement. Vet Surg. 2007 Aug;36(6):548-56.
Gunn-Moore D.A., et al Feline tuberculosis. Vet Rec 1996 138 53-58.
Kramers P.C., The feline elbow: special features of bones and ligaments. ECVS 1992 Scientific abstracts.
Lascelles D Feline Degenerative Joint Disease Veterinary Surgery 39 2-13, 2010.
Montavon PM, Voss K, Langley-Hobbs SJ. In Feline Orthopaedic surgery and musculoskeletal disease. Saunders Elsevi-
er 2009.
Paterson M.E. et al Acromegaly in 14 cats. J Vet Int Med 1990;4: 192-201.
Pederson NC, Pool RR. Feline chronic progressive polyarthritis. Am J Vet Res 1980;41: 522-535.
Pederson N.C. et al. A transient febrile limping syndrome of kittens caused by two different strains of feline calicivirus.
Fel Pract 1983;13(10): 26-35.
Peterson C.J., Osteochondritis dissecans of the humeral head of a cat. New Zealand Veterinary Journal 11984 32 7 115-
116.
Pitcher GD. Luxation of the radial carpal bone in a cat. J Small Anim Pract. 1996 Jun;37(6):292-5.
Prymak C. and Goldschmidt M.H. (1991) Synovial cysts in five dogs and one cat. JAAHA 27 151-154.
Schrader S.C., Orthopaedic surgery Ch 49. In The cat diseases and clinical management. Second edn. Ed R.Sherding
Churchill Livingstone, New York p1651.
Shales CJ, Langley-Hobbs SJ. Dorso-medial antebrachiocarpal luxation with radio-ulna luxation in a domestic shorthair.
JFMS 2006(8) 197-202.
Simpson D, Goldsmid S 1994 Pancarpal arthrodesis in a cat: a case report and anatomical study VCOT 7 45-50.
Stead A.C. et al., Synovial cysts in cats. JSAP 36 450-454.
Voss K, Geyer H, Montavon PM Antebrachiocarpal luxation in a cat. VCOT 2003 (4) 266-270.
White JD, Martin P, Hudson D, Clark A, Malik R. What is your diagnosis? Synovial cyst in a cat. J Feline Med Surg.
2004 Oct;6(5):339-44.
SCIVAC CONGRESS
Conservative management and external coaptation

of fractures
This presentation and accompanying notes aim to cover the principles of both conservative management
and external coaptation of fractures and when such methods of fracture management are indicated or con-
traindicated.
CATEGORIES OF METHODS OF FRACTURE FIXATION

1. Conservative Management
2. External Coaptation
3. External Skeletal Fixation with or without open fracture reduction & repair
4. Internal Fixation – using pins, bone plates, interlocking nails etc
THE PRINCIPLES OF FRACTURE FIXATION

The main objective when dealing with a fracture is to try and return the patient to normal function as soon
as possible. Circumstances must be created which allow bone healing to be optimal.
Non-surgical management has the potential advantages of:

• reducing anaesthetic time,
• avoiding the need for an open surgical approach,
• cheaper materials
• more economic overall.
Non surgical management has the potential disadvantages of:

• fracture disease
• providing insufficient instability resulting in a delayed union or non union
• cast sores – morbidity
• insufficient fracture reduction resulting in a malunion
Non-surgical management includes:

• conservative (cage rest etc) and
• external coaptation (coapt = to approximate)
The aim with conservative treatment is that the surrounding soft tissues (muscle, periosteum and adjacent
bones) will provide enough stability to keep the bones in reasonable alignment whilst healing occurs. Frac-
tures suitable for conservative treatment include stable undisplaced fractures, greenstick fractures and se-
lected fractures of the pelvis, scapula or vertebrae where strong muscular forces act to immobilise the frac-
ture fragments. If the anatomical displacement is acceptable then this is a reasonable option in some of these
cases. Management usually involves a period of restricted activity with confinement to a cage or room. Re-
striction time varies according to the severity of the fracture and age of the patient. It is usually 4 – 6 weeks
for most fractures. Prevention of weight bearing may be useful for scapula fractures by using a carpal flex-
ion bandage or velpeau sling.
The aim of external coaptation is that compressive forces are transmitted to the bones by means of the in-
terposed soft tissues. Pressure must be evenly distributed throughout the cast or splint to avoid circulatory
stasis. For successful external coaptation the joint above and below the fracture should be immbilised. This
principle extends usually to all the joints distal the fracture (to prevent foot swelling). So for tibial fracture
the cast is extended from the foot to proimal to the stifle, for antebrachial fractures the cast extends from the
foot to proximal to the elbow.
Fractures suitable for external coaptation include fractures distal to the elbow or shoulder, stable fractures
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with at least 50% overlap of fracture fragments on orthogonal radiographs. Fractures of just the radius with
an intact ulna or similarly fractures of the tibia with an intact fibula can also be suitable for external coap-
tation. When 2 or fewer metacarpal or metatarsal bones are fractured cast fixation can be considered. Con-
sideration should also be taken of the:
• Age - Immature animals (< 6 months) are often suitable candidates given their rapid healing times.
• Breed of dog – it may be easier to keep a cast on a long legged dog than a brachiocephalic breed. Toy breeds
are renowned to develop non-union fractures of the radius and ulna if these are treated with external
coaptation.
• Function of the dog – conservative treatment may be suitable for certain fractures in pet dogs however for
racing or working dogs internal fixation may be advisable – e.g. caudal acetabular fractures.
CAST APPLICATION
Casts tend to be preferable to splints for anything that needs to stay on for more than a week. The ‘Cam-
bridge way’ is to place a double layer of stockinette followed by a layer or two of SofbanÔ(Smith & Nephew)
or a similar water repellant compressible material. Care is taken not to apply too much padding over pres-
sure points such as the point of the hock / os calcaneus, use of a “doughnut” or underpadding pressure
points is preferable. Then I generally use VetcastÔ (Smith & Nephew) with a minimal of 6 layers (3 times
up and down with a 50% overlap) or more in large, active dogs or where there is an acute angle in the cast
(at the hock). Then the cast is bivalved (split in two) and taped immediately back together with strips of zinc
oxide and the whole lot covered in VetrapÔ (Smith & Nephew). The cast extends from the foot to proximal
to the elbow or stifle. The middle two toe-nails and pads should be visible, so the cast can be checked for
slippage, toe swelling etc. If the foot swells the toe -nails will tend to splay outwards.
FRACTURE DISEASE
This occurs during the time necessary for the bone to heal and is a result of immobilisation or decreased
weight bearing of the affected leg.
Typically it includes:
1. joint stiffness,
2. muscle atrophy,
3. osteoporosis,
4. muscle contracture and fibrosis
Fracture disease can be minimised or avoided by aiming for a fast return to weight bearing and avoiding un-
necessary immobilisation by external coaptation (casts / splints / bandages). Fracture disease will occur due
to the period of enforced joint immobilisation whilst the fracture heals. Some fractures suitable for external
coaptation may also be suitable for minimal surgical intervention and ESF. ESF preserves joint mobility,
avoids the need for replacing casts that have been outgrown, been chewed or got wet. ESF will often pro-
vide better immobilisation of fragments, giving more pain reduction and therefore better use of the leg.
Fractures that are not ideally suitable for conservative treatment or external coaptation include
• Articular fractures
• Displaced diaphyseal fractures
• Fractures in older animals
The use of non surgical management of fractures should always be considered for every fracture – in some
cases it will be the optimal fracture management option, however in many cases there are better options that
will return the animal to normal function more quickly.
FURTHER READING
Dyce J. Conservative management of fractures. BSAVA Manual of Small Animal Fracture Repair and Management.
Coughlan & Miller 1998.
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Arthrodesis principles
ARTHRODESIS is the irreversible osseous fusion of a joint undertaken as a salvage procedure to restore
acceptable limb function. The aims of this talk and notes are to review the principles of arthrodesis.
ARTHRODESIS – THE INDICATIONS

Arthrodesis is used to treat joints having severe instability, severe osteoarthritis, or cancer. It is often referred
to as a salvage procedure, but if done correctly; arthrodesis can give a good to excellent functional outcome.
Essentially any diarthrodial joint can be arthrodesed, but the carpus, tarsus, digits and shoulder have the
best outcome. Carpal arthrodesis provides the best functional outcome. Elbow, stifle and hip arthrodesis gen-
erally have a poor to fair functional outcome, but joint pain may be substantially reduced.
ARTHRODESIS – THE BASIC PRINCIPLES

Arthrodesis is much more complicated that repairing a fracture. The surgical goal is similar- bony fusion - but
with arthrodesis, the implant system must counteract extensive bending forces. The implant system is being
placed across a joint that is designed to have motion – a highly negative factor for implant survivability and
bone healing. There are 4 fundamental principles that must be respected to have a successful arthrodesis:
• adequate cartilage debridement,
• proper bone alignment,
• rigid stability and compression
• bone graft augmentation.
Practical tips that can be used to address each principle are described below.
Principle 1: Articular cartilage debridement – The articular cartilage must be removed from the ends of
the bone over the majority of the weightbearing surfaces. Cartilage that is left behind increases the chance
of inadequate bony fusion between the two bones. The cartilage can be removed using a curette, motorized
burr or by performing a juxta-articular osteotomy. A hand curette will adequately remove cartilage when us-
ing a scooping or scraping action. When using a curette, an attempt should be made to invade the sub-
chondral bone plate, ensuring access to a source of mesenchymal stem cells and vascular invasion. If the
bone ends are sclerotic, a motorized burr may be superior to a hand curette. A motorized burr removes ar-
ticular cartilage much more quickly than a hand curette, but generates extraordinary heat. Copious lavage
should be used when using a motorized burr to reduce the risk of thermal necrosis. Necrotic bone cells will
need to be removed and replaced, increasing the time to reach bony union. The burr should be used to re-
move articular cartilage and superficial bone. Some bleeding of bone is desirable, but over-aggressive bone
removal may make alignment of the joint more difficult and reduce stability of the articulation to be
arthrodesed. After removal of articular cartilage the joint should be copiously flushed to remove cartilage de-
bris. Small holes can be drilled in the ends of the bone articulations using a k-wire or small drill bit. This is
often referred to as forage or osteostixis and enhances neovascularization and provides a source for mes-
enchymal stem cells. Another method that can be used to prepare the bone surfaces is a juxta-articular os-
teotomy of the ends of each bone. Copious lavage should be used during the cutting process to avoid ther-
mal necrosis. The line of the osteotomy should be planned carefully to achieve the proper joint angle after
the stabilization. This procedure may also cause shortening and this should be taken into account when de-
termining what angle to fuse the joint at.
Principle 2: Bone alignment – A good functional outcome following arthrodesis requires adequate align-
ment of the limb. Care should be taken to ensure proper axial and rotational alignment. Malalignment leads
to gait abnormalities, reduced willingness to use the limb and abnormal forces placed across adjacent joints,
which may predispose them to osteoarthritis or instability. The arthrodesis should be positioned at a func-
tional angle. A proper functional angle is best chosen by measuring the opposite normal joint using a go-
niometer. This is best performed while the patient is in a standing position. Alternatively, the angle can be
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selected from known joint angles from various surgical text and journal articles.
Principle 3: Stabilization and implant system – Rigid stability is a must. The implant system must be able
to withstand tremendous bending and distractive forces for a prolonged period of time. The most commonly
used implant systems for arthrodesis are bone plates, plate-rod constructs, pin and tension bands, and ex-
ternal fixators. Cross pins or lag screws can be used alone to achieve arthrodesis, but these methods are less
secure and should only be used in very young, small patients. Once the joint is properly aligned one or two
appropriately sized pins can be placed across the ends of the bones to provide temporary stabilization while
the primary implant system is applied. The pins can be removed after applying a bone plate, or if desired
the pins can be left in place if they were initially placed such that they do not interfere with the bone plate
or plate screws. If the pins are left in place, a plate-rod construct has been created. The advantage of leav-
ing the pins in place is the ability for them to absorb some of the load, reducing plate strain and risk of fail-
ure. Compression should be placed across the site of arthrodesis to give improved stability. Greater stabili-
ty reduces the chance of implant cycling and failure and enhances bone healing. Bone plates should ideally
be placed on the tension surface of the bones to reduce the chance of implant failure. Unfortunately this is
not always possible due to poor access due to overlying soft tissues and the lack of a true contiguous ten-
sion surface along the course of the conjoined bones. If a bone plate is applied to the compressive surface of
the bones, the implant should be sized accordingly to handle the additional load. Addition of adjunctive im-
plants such as pins or an external fixator to share loads can help protect the plate and screws. External fix-
ators can also be used effectively as the sole means of stabilization for arthrodesis. They are particularly use-
ful in patients having open wounds over the joints that require arthrodesis. Following bony union, the ex-
ternal fixator is easily removed. In contrast, the use of internal fixation in these patients predisposes them to
infection. If infection occurs, the bone plate, screw and any pins may have to be surgically removed to re-
solve the infection. Arthrodesis techniques have been described in detail in multiple surgical texts and a
through discussion for each joint is beyond the scope of these notes and presentation.
Principle 4: Bone augmentation – Autogenous bone grafts are easy and quick to harvest and speed bony
union of the arthrodesis. Bone grafts can be harvested typically in 10-15 minutes. Autogenous cancellous
bone grafts have osteoconductive, osteoproductive and osteogenic properties. The most productive harvest
sites are the greater tubercle of the humerus and the ilial wing. Other sites that can be used include the prox-
imal tibia, the proximal femur and the sternum, but these sites are not recommended unless the shoulder
and ilium are not available for some reason (usually because of poor presurgical planning!) Bone graft is
harvested from the humerus by drilling a hole with a large pin and harvesting cancellous bone using a
curette. The same technique can be used for the ilial wing; however an alternative technique that provides
a large volume of corticocancellous graft makes use of the acetabular reamer. The reamer is used to harvest
bone form the lateral cortex and medulla of the ilial wing. Following graft harvest from either site, the col-
lected bone is stored in a syringe, stainless steel bowl or on a blood-soaked gauze (do not accidentally dis-
card the gauze!). If possible the graft should be harvested immediately prior to placing it at the site of
arthrodesis to increase viability of osteoblasts, growth factors and the bone scaffold, however it is often more
convenient to harvest the graft at the beginning of surgery particularly in situations when a tourniquet is
used for the limb that is being arthrodesed. Other products available “off the shelf” for use to enhance bone
production, including various synthetic bone substitute compounds, lyophilized and frozen bone products.
REFERENCES AND FURTHER READING

Dyce J Arthrodesis in the dog. In Practice 1996 18, 267-279.
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How to improve meniscal visualization

Antonio Pozzi, DMV, MS, Dipl. ACVS
Meniscal injury in the dog is most commonly associated with ligament injury of the stifle joint. The report-
ed incidence varies from 50 to 90%. Damage to the menisci can be either acute or degenerative and usual-
ly involves the caudal and medial portions of the medial meniscus. The medial meniscus is firmly attached
to the tibia by the medial collateral ligament, the synovium, and the meniscal ligaments. As a result, during
drawer movement and weight bearing the caudal pole may become entrapped between the femoral and the
tibial condyle and therefore may tear due to the shear stress applied on the longitudinal and radial fibers.
MENISCAL EXAMINATION
Exposure
The first step in meniscal examination is adequate exposure to allow evaluation of its gross appearance. Ex-
posure should be optimized using retractors and distraction with or without the aid of distraction devices.
Both valgus and varus stress are required to allow visualization and probing of both menisci. Utilizing a
craniomedial or craniolateral arthrotomy, or arthroscopy from cranial portals, visualization of the medial
meniscus is improved by applying external rotation and valgus stress to the limb; application of varus stress
and internal rotation aids in exposing the lateral meniscus. In stable stifles with a partial CrCL rupture the
caudal pole of the medial meniscus may not be visualized with a cranio-medial arthrotomy, however it can
be well visualized arthroscopically. In case the caudal pole cannot be evaluated, the surgeon can elect to per-
form an arthroscopic examination of the medial meniscus with or without debridement of the CrCL, de-
bride the torn CrCL via a craniomedial or craniolateral arthrotomy, or perform a caudo-medial approach
to the stifle. Similarly a caudal medial arthroscopy port can be used if necessary (for diagnosis and treat-
ment). It should be emphasized that the caudal pole of the medial meniscus is the most common site of in-
jury, thus it should be evaluated carefully for the presence of tears in every case. The flexion angle of the
joint while examining the meniscus is important: visualization is best obtained in approximately 110°-130°
of limb extension, but this angle may vary depending on the morphology of the dog. The position of the
arthroscopy portals is important for diagnostic arthroscopy of meniscal pathology. A common mistake is to
place the arthroscopy portals too far laterally or medially over the femoral condyles, where instrument pas-
sage damages the femoral articular cartilage. The safe area for instrument passage is with the portal just me-
dial and lateral to the patellar tendon with passage into the femoral notch region. The portals should also
be selected based on the dog morphology. Dogs with steeper tibial plateau angle require a more proximal
arthroscopy port, placed in a sub-patellar position. A good rule of thumb is that the arthroscopy portals
should be located approximately where the tibial plateau axis intersects the patellar tendon in the lateral ra-
diographic image. Inspection of the menisci is one of the most difficult arthroscopic procedures performed
in the stifle. Careful attention to the placement of the arthroscopic portals, the arthroscope, the orientation
of the light post, the position and angulation of the limb, and appropriate debridement of the fat pad as nec-
essary are required for optimal visualization of the menisci.
Meniscal evaluation (observation)

First the position of the meniscus is assessed. A portion or the entire caudal horn of the medial meniscus
may be folded cranially, suggesting a displaced bucket handle tear, a flap or a peripheral detachment type of
vertical longitudinal tear. The meniscus may be in its normal position and may look normal. However, care-
ful probing should be performed to rule out incomplete vertical longitudinal tear, or an abaxial tear behind
the femoral condyle. At this stage it is also useful to elicit cranial tibial subluxation to evaluate meniscal sta-
bility. By causing the tibia to subluxate cranially, peripheral detachment and bucket handle tears may dis-
place cranial to the femoral condyle as the tibia translates cranially.
Meniscal evaluation (probing)

After inspection of the axial rim and the femoral surface of the meniscus, probing should be performed to
evaluate regions that cannot be observed. The use of a probe to palpate the meniscus increases the sensi-
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tivity for diagnosing meniscal pathology during both arthrotomy and arthroscopy. Palpation with the probe
should be performed to assess the integrity of both femoral and tibial surfaces as well as the meniscal at-
tachments. Irregularities on the surface and hooking or catching of the probe suggest an incomplete vertical
longitudinal tear. Hooking of the probe at the periphery of the meniscus should be interpreted carefully be-
cause the edge of the caudal pole is only loosely attached to the joint capsule through the coronal ligament.
The probe is also used to evaluate the texture of the meniscus. A normal meniscus is firm and resilient, but
not hard; a soft meniscus is likely degenerative or may have a horizontal cleavage tear. In some cases par-
tial horizontal clefts in the rim may be difficult to diagnose. If a horizontal cleft is suspected based on the
texture of the meniscus, a partial meniscectomy is recommended to allow better probing of the rest of the
tear. Only evaluation of the whole meniscus can indicate the extent of meniscectomy required to resect
pathologic tissue. After diagnosing a bucket handle tear, it is imperative to evaluate the remainder of the
meniscus since multiple tears can be present, and the additional tears can be easily missed. It might be prefer-
able to first perform a partial meniscecomy, then probe the remaining meniscal tissue. A conservative par-
tial meniscectomy followed by probing may facilitate exposure and the remaining meniscus can be more
thoroughly evaluated.
Arthroscopic examination of the meniscus with accurate probing is the best method for diagnosing menis-
cal pathology in dogs. The magnification and illumination provided during arthroscopy allows close evalu-
ation of the menisci. However, a thorough meniscal evaluation is mandatory for arthrotomy as well. A
meniscal tear missed at the time of joint exploration may cause persistent lameness if left untreated. Probing
the meniscus increases the sensitivity of arthrotomy by 2-3 folds.
Initial assessment of the position of the meniscus is critical. A portion or the entire caudal pole of the medi-
al meniscus may be folded cranially, suggesting a displaced bucket handle, a flap or a peripheral detachment
tear. Complex tears may present as a folded caudal pole. In these cases probing is critical to evaluate if the
meniscus can be salvaged with a partial meniscectomy or should be removed. Exposure should be optimized
using retractors, stifle distractor and flexion or extension of the joint. Applying varus or valgus stress is al-
so useful for opening the lateral or medial stifle compartments. In stable stifles with a partial CCL rupture
the caudal pole of the meniscus may not be visualized with a cranio-medial arthrotomy. In these cases the
surgeon should debride the CCL or perform a caudo-medial approach to the stifle. It should be emphasized
that the caudal pole of the medial meniscus is the most common site of injury, thus should be evaluated care-
fully for the presence of tears. After visualization of the axial rim, probing should be performed to assess the
integrity of both femoral and tibial surfaces and the meniscal attachments. Irregularities on the surface and
hooking of the probe suggest an incomplete or non-displaced bucket handle tear. Hooking of the probe at
the periphery of the meniscus may suggest a peripheral detachment, but should be interpreted carefully be-
cause the edge of the caudal pole is only loosely attached to the joint capsule. After diagnosing a bucket han-
dle tear, the rest of the meniscus should be evaluated for multiple tears that can be easily missed. This is an
important step when performing a partial meniscectomy. Late meniscal injuries after TPLO may originate
from meniscal tears that were missed at the first evaluation.
REFERENCES
1. Mahn MM, Cook JL, Cook CR, et al: Arthroscopic verification of ultrasonographic diagnosis of meniscal pathol-
ogy in dogs. Vet Surg 34:318-323, 2005.
2. Samii VF, Dyce J: Computed tomographic arthrography of the normal canine stifle. Vet Radiol Ultrasound 45:402-
406, 2004.
3. Thieman KM, Tomlinson JL, Fox DB, et al: Effect of meniscal release on rate of subsequent meniscal tears and
owner-assessed outcome in dogs with cruciate disease treated with tibial plateau leveling osteotomy. Vet Surg
35:705-710, 2006.
4. Ralphs SC, Whitney WO: Arthroscopic evaluation of menisci in dogs with cranial cruciate ligament injuries: 100
cases (1999-2000). J Am Vet Med Assoc 221:1601-1604, 2002.
5. Pozzi A, Hildreth B, Rajala-Shultz P: Comparison of arthroscopy and arthrotomy for the diagnosis of medial menis-
cal pathology: An ex vivo study. Vet Surg 37(6):23-32, 2008.
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Pearls and pitfalls of tibial osteotomy techniques

TIBIAL PLATEAU LEVELING OSTEOTOMY (TPLO)

A. Methodical planning for accurate position of osteotomy
The TPLO is a radial corrective osteotomy of the proximal tibia. Because of its unique location, TPLO iso-
lates a small metaphyseal fragment caudally, and the tibial tuberosity cranially. The consequences of an os-
teotomy placed too cranially can be an increased risk of tibial tuberosity avulsion fracture, or patellar ten-
don transection. An osteotomy placed too caudally and proximally, although may be geometrically correct
in some cases (centered on tibial eminence), may complicate proximal plate fixation and increase the risk of
mechanical failure of the TPLO (rockback). Accurate pre- and intra-operative planning is necessary to pre-
vent these complications. In most cases the following guidelines can be followed:
1. The tibial tuberosity area isolated by TPLO should have a trapezoidal shape, where the distal aspect of
the tibial tuberosity adjacent to the osteotomy should always be wider than the proximal aspect. A “re-
verse” trapezoid should be avoided;
2. The width of the metaphyseal fragment should correspond to about 2/3 of the total width, while the
width of the tuberosity should be about 1/3 of the total width;
3. The osteotomy should exit the caudal cortex with an angle of about 90 degrees;
4. The proximal fragment should have enough room for placing the plate screws at least 1 screw diameter
from the osteotomy and the joint line;
5. Template the osteotomy before surgery. Choose the appropriate saw radius and placement of the os-
teotomy. The osteotomy should be centered on the intercondylar eminences and isolate a broad-based
tibial crest segment. Measure the distance from the tibial tuberosity to the intersection of the osteotomy
with the tibial profile cranial to the plateau, and archive this for application in surgery.
B. Under or overcorrection of TPA

One of the advantages of TPLO is its ability to modify the TPA with accuracy. However, its precision de-
pends on the accurate placement of the osteotomy and precise rotation of the fragment. A distally centered
osteotomy will cause undercorrection of the TPA caused by tibial axis shift. In addition, mistakes during
placement of the marks may cause under or overcorrection of TPA. Incomplete rotation of the TPLO frag-
ment can be another cause for undercorrection of the TPA. Causes of difficult rotation of the fragment in-
clude poor placement of the TPLO jig (proximal pin) or of the osteotomy (relative to the jig) and tibiofibu-
lar synostosis. For example, in giant breed dogs a relative small diameter radial osteotomy can be difficult
to rotate because of a proximal position. Similarly, a jig pin distally placed may not allow a smooth rotation
of the fragment, because of the distance between center of osteotomy and proximal jig pin. Severe periar-
ticular fibrosis can also cause frustration during rotation of the TPLO fragment. Strategies to prevent un-
der-rotation of the fragment include removing the jig to allow rotation of the fragment, or performing a fibu-
lar osteotomy or a disarticultion between fibula and tibia in cases of synostosis between the tibia and fibu-
la. Overcorrection is less likely, and usually prevented by accurate placement of the rotation marks.
C. Tibial deformity and rotational instability

When developing the original TPLO surgical technique, Slocum emphasized the importance of correcting
femoral and tibial deformities because of the increased risk of complications in case of limb deformity. Al-
though this area needs more research, TPLO seems to function well only if rotational instability at the joint
is minimal. Dogs with varus-valgus deformities (femur, tibia), torsional deformities or medial patellar luxa-
tion may have greater rotational instability than dogs without deformities. The following pearls are impor-
tant to anticipate and prevent complications related to this issue:
1. If required, angular correction to address tibial varus/valgus and torsional deformity is readily achieved
by specific manipulations of the TPLO jig pins. Because of the complexity of the stifle biomechanics,
small changes in relative alignment of the femoro-tibial articular surfaces can cause rotational and trans-
lational instability e.g. pivot shift. At each step of the surgery, limb alignment in both flexion and exten-
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sion should be evaluated. It is important to evaluate alignment in both flexion and extension because
femorotibial alignment can change over a full range of motion.
2. Identify pre-existing medial patellar luxation (MPL). Note that internal rotational instability of the stifle
is associated with CCL rupture and this cannot be neutralized by standard TPLO. An undiagnosed low-
grade MPL associated with CCL rupture can be worsened by TPLO and cause persistent lameness. Dis-
tal femoral varus and internal torsion of the proximal tibia are not uncommon findings in retrievers and
bull terrier types with MPL and CCL rupture. Lateralization of the tibial tuberosity can be achieved by
torsional correction using the jig, but this will produce distraction of the medial osteotomy gap that
should be packed with an autogenous bone graft. It can also be achieved by translation of the metaphy-
seal fragment medially. Consider laterally-based closing wedge ostectomy of the distal femur, to realign
the quadriceps mechanism, if varus exceeds 15o. Lateral imbrication is invariably performed to address
MPL and implies exploratory arthrotomy should be lateral and not medial. Additional procedures e.g.
trochlear sulcoplasty are performed on an as-needed basis. In those cases with patella alta as a predispos-
ing factor for MPL, Slocum-style TPLO may be inferior to cranial closing wedge ostectomy, which will
relocate the patella more distally in the trochlear sulcus.
D. Position of the plate

The advent of locking TPLO plates has improved the technique and the ability to achieve a stable fixation.
However, locking plates are not without risk of failure if placed inappropriately. The ideal placement of the
proximal half of the locking plate should be in the center of the metaphyseal fragment. Plates applied too
close to the osteotomy may be at risk of screw-bone interface failure. A plate too proximal may increase the
risk of intra-articular screws. The newly designed TPLO plates are pre-contoured and the direction of the
holes helps with avoiding placing screws in the joint. However, changes in contouring of the plate, or poor
placement of the locking screws (not in the axis of the screw hole) can cause intra-articular placement of
screws. Maintain the TPLO plate parallel to the tibial long axis. The distal end of the TPLO plate tends to
tilt cranially during placement, resulting in poor seating of the distal screw. Because of the shape of the tib-
ia, the screws should be placed in the caudal half of the metaphysis, where the tibial diameter is greater. Cra-
nially placed screws are shorter and placed in thin cortical bone.
TTA
A. Position of plate
Poor contouring of the plate, or fixation of the plate to the most caudal surface of the diaphysis may cause
plate deformation and malalignment of the tibial tuberosity. Strategies to prevent include:
Strategies to prevent include:
1. Do not oversize the plate;
2. Evaluate the tibial tuberosity and crest conformation. In some cases the orientation of the crest relative
to the tibial diaphysis force the plate in a caudally tilted position before advancement. Tibial tuberosity
advancement causes severe shift of the distal plate holes. To prevent this problem the proximal end of
the plate can be “tilted” caudally, by drilling the proximal holes 1-2 mm more caudal than the distal fork
hole (relative to the cranial margin of the tibial tuberosity)
3. The position of the distal end of the osteotomy contributes to the tilting after advancement; a more prox-
imal osteotomy will cause more displacement/titling of the distal end of the plate.
4. The fork should not be placed too cranial, purchasing more fascia than bone or too caudal (bone is
weaker).
5. Ensure the holes are oriented in parallel direction. Do NOT shift the jig during drilling or fork will not
engage properly.
B. Position of the osteotomy

Although the TTA osteotomy is significantly easier than TPLO, mistakes in positioning the osteotomy can
predispose to complications. Preoperative planning is recommended to plan the proximal extent of the os-
teotomy. These are pearls that the surgeon should consider preoperatively and intraoperatively:
1. The width of the tibial tuberosity fragment should be about 1/3 of the total width of the proximal tibia;
2. Landmarks for the proximal extent of the osteotomy are Gerdy tubercle, region cranial to intermeniscal
ligament;
3. The distal aspect of osteotomy determines the amount of tilting of the plate distally. See above;
4. Straight osteotomy is preferred, but a gentle distal curve may be necessary in some cases.
C. Safe zones and use of marks

It is useful to define the “safe zones” with a cautery mark. The following are marks that can be useful:
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1. Tibial tuberosity for proximal hole for fork;

2. Proximal mark of osteotomy to avoid menisci and fork holes;
3. Distal mark to check safe distance from plate holes;
4. Width of osteotomy (relative to the whole proximal tibia).
CWTO
A. Preoperative planning, size and location of CWTO
Planning is crucial to achieve consistent results with CWTO. Several studies have shown that a more distal
osteotomy requires a bigger wedge to decrease the TPA to about 5 degrees. It has been also suggested that
alignment of the cranial cortices may decrease the tibial axis shift. The following pearls may help achieving
more consistent results:
1. Use a sterilized template (i.e. from radiographic films) or a trigonometric method;
2. Place the osteotomy as proximal as possible.
3. Use temporary or permanent fixation with a cranial cerclage wire;
4. When using a proximal CWTO with cortical alignment, a wedge equal to TPA allow correction of the
TPA to about 5 degrees.
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Managing MPL and CCL rupture in small and large

breed dogs
Medial patellar luxation has been attributed to many factors. Medial displacement of the quadriceps, a shal-
low femoral trochlear groove, and medial displacement of the tibial tuberosity all play a roll in the patho-
genesis of medial patellar luxation. With medial luxation of the patella there are often distal femur or prox-
imal tibial deformities. The origin of this deforming torsional force has not been clearly established. A large
potential for axial and torsional growth exists in the cartilage columns of the growth plates. Growth plates
yield to forces rapidly by either increasing or decreasing their rate of growth, whereas mature bone responds
to changes in forces through bone deposition or resorption. Therefore, remodeling of mature bone is much
slower. This is not present in all dogs with medial patellar luxation.
Chronic rotational instability caused by the MPL can predispose to CCL rupture. Therefore, the combina-
tion of these stifle pathologies is not uncommon, and should be suspected in any clinical case with acute on-
set of lameness, moderate to severe pain and effusion.
Several treatments have been reported for MPL. Additionally a large number of surgical techniques for sta-
bilization of the CCL-deficient stifle are commonly used. Therefore, there are many possible combinations
of techniques for the MPL/CrCL-deficient dog. The treatment of MPL combined with CCL rupture aims
at the same goals of the surgical treatments of the isolated MPL and CCL rupture:
1. To resolve the dog’s clinical signs (lameness, pain);
2. To reestablish a normal patellar tracking and minimize development of osteoarthritis;
3. To reestablish normal joint motion and joint stability (cranio-caudal and external-internal rotation) as
combined MPL and CCL rupture significantly alter joint motion.
The principles of MPL correction apply to all clinical cases of CCL insufficiency and MPL. All dogs should
be thoroughly evaluated with an orthopedic and radiographic exam. Orthogonal views of the femur and tib-
ia are recommended. The cranial-caudal view of the femur is useful to rule out a varus deformity of the fe-
mur. CT scan may provide more information if a deformity is suspected.
The selection of the surgical technique depends on the size of the dog, the presence of femoral or tibial de-
formities and the grade of the MPL. The combination of extra-capsular circumfabellar lateral suture
(LS)/lateral imbrication with trocheoplasty is commonly used in small dogs. This combination is indicated
in small dogs that had a low grade subclinical MPL (grade 1-2) progressing to grade 3 after CCL rupture.
The CCL deficiency causes internal tibial rotation, which exacerbates MPL. Reducing the internal tibial ro-
tation using LS may be sufficient to realign the quadriceps mechanism. Additionally, a trocheoplasty may
improve patello-femoral joint congruity.
The dog should be preoperatively evaluated by palpation of the stifle. If external rotation of the tibial
tuberosity allows reduction of the patella and continuous normal patellar tracking, LS without tibial tuberos-
ity is indicated. In some cases a tibial tuberosity transposition is indicated to realign the quadriceps mecha-
nism. Correction of rotational deformity of the tibia should be done in young animals with remodeling po-
tential. In older animals the entire limb has developed abnormally, with permanent bone and ligaments’ ab-
normalities. Simply rotating the tibia medially or laterally does not correct these problems.
The use of LS as anti-rotational suture is less likely to be successful in large breed dogs. Most large dogs
with MPL have a distal femoral deformity, which may require correction. There are no clear guidelines, but
most surgeons perform correction in case of a distal femoral varus angle >11-13°. My clinical experience is
that large dogs may be at higher risk of recurrence of MPL than small dogs if varus is not corrected. The
femoral correction can be combined with tibial osteotomies such as TPLO, TTA and cranial closing wedge
osteotomy (CTWO). The advantage of TTA is that a moderate tibial tuberosity transposition can be per-
formed without additional procedures. However, successful treatment of CCL rupture and MPL can be
achieved also with CTWO and TPLO.
Femoral corrective osteotomies are rarely indicated in small dogs. Because of the small size of the femur, and
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frequent condrodystrophic conformation, this procedure is complex and may have higher risk of complica-
tions. Small dogs with grade 4 lesions may benefit of femoral osteotomies, while most cases with 10-15°
varus angle can usually cope with the deformity, with no need of corrections.
Pearls and pitfalls of extracapsular techniques

The goal of the treatment of cranial cruciate ligament (CCL) insufficiency is to provide good quality of life
to the patient, while improving limb function. Several surgical techniques have been described including in-
tra-articular stabilization, extra-articular stabilization, and tibial osteotomy techniques. Extra-articular stabi-
lization techniques are predicated on transiently restraining abnormal stifle motion until sufficient joint adap-
tation provides dynamic joint stability. Postoperative complications after CCL repair surgery have a nega-
tive impact on patient’s quality of life and clients’ satisfaction. This lecture will discuss how to prevent some
complications associated with extracapsular techniques.
LATENT MENISCAL TEARS

Accurate joint exploration and meniscal evaluation are crucial steps of the surgical treatment of the CCL de-
ficient stifle. Meniscal injury secondary to CCL insufficiency occurs in 40-70% of cases. Surgeons that rou-
tinely diagnose less than 10-20% of meniscal tears are likely missing some tears. The medial meniscus may
be exposed by arthrotomy through a cranio-lateral, cranio-medial stifle approach or a caudo-medial approach
to the medial compartment of the stifle. The exposure of the medial meniscus is easier through a cranio-me-
dial approach, but some surgeons prefer to use a cranio-lateral arthrotomy during extracapsular techniques.
The caudo-medial approach to the stifle is used when there is a stable joint and the medial caudal pole of the
meniscus is not visualized easily. To expose the meniscus the following steps are recommended:
1. Perform a precise arthrotomy (3-5 mm on the side of the patellar tendon); appropriate length for mini-
arthrotomy or full arthrotomy;
2. Proximal-distal retraction of the fat pad using a Rake or a Volkman retractor;
3. Debridement of the CCL (if not functional);
4. Placement of Gelpi retractor (hooked to medial and lateral aspect of the joint);
5. Placement of Hohman or stifle distractor;
6. Evaluation of meniscus at DIFFERENT FLEXION ANGLES and after applying VALGUS and VARUS
stress;
7. PROBING every region of the meniscus (especially the tibial surface and the caudal pole).
8. EVALUATION OF COLOR, CONSISTENCY, EDGES, SURFACE.
Arthroscopy is considered the first choice for meniscal diagnosis for its high sensitity and specificity if avail-
able. Arthroscopic-assisted arthrotomy can be another excellent method with the advantages of arthroscopy,
through a larger and easier approach.
NON-ISOMETRIC PLACEMENT OF THE TUNNELS

(LATERAL SUTURE, ANCHOR TECHNIQUE, TIGHTROPE)
This is one of the most common technical mistakes. Non-isometric placement of the extra articular pros-
thesis may cause early failure of the suture, decreased range of motion, early laxity. For the tibia it is rec-
ommended to place the tunnel in the cranial aspect of the extensor groove, or immediately behind it, as prox-
imal as possible. A common mistake is to slide the drill bit too distal. It is useful to place an instrument (Mos-
quito) just proximal to the groove in the joint, to precisely position the tunnel. If a more traditional place-
ment is used, the surgeon should drill the tunnel proximal and caudal to the tuberosity. Any location distal
to the tibial tuberosity is too distal. It is also crucial to evaluate the proximal tibial anatomy of each dog on
pre-operative radiographs. For example some dogs can have a very distal tuberosity, which might predispose
to a distal non-isometric tibial tunnel.
EARLY FAILURE OF THE ANCHORAGE OF THE PROSTHETIC SUTURE

This complication is usually caused by poor placement of the prosthetic suture. For example, the circumfa-
bellar suture may fail because the suture was not passed behind the fabella or because multiple attempts us-
ing a cutting needle may have damage the femoro-fabellar ligament. The needle may be deviated from hit-
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ting the femur, or the fabella, and the suture may be placed caudally to the fabella, around the gastrocne-
mius muscle. To avoid this problem it is important to choose the insertion point of the needle based on its
radius of curvature. Most of the time the needle is inserted too close to the fabella. Other strategies include
passing the suture through a tunnel in the fabella. It is useful to perform some cadaver dissection to under-
stand the best direction of the needle. Another cause of failure of the circumfabella suture is poor placement
due to severe fibrosis in case of chronic DJD or in case of fabella fractures or bipartite fabella. In these cas-
es an anchor technique, ot the Tightrope may be indicated.
The femoral anchor or tunnel (Tightrope) is at risk of failure if not placed accurately in bone. The most fre-
quent mistake is to place anchors or tunnels into the femoro-fabellar joint. Exposure of the femoro-fabellar
joint through a 5-10 mm approach allows precise placement.
EXCESSIVE TENSION OF THE PROSTHETIC SUTURE

The belief that a successful extracapsular technique should be “rock-solid” is a misnomer. For example, neu-
tralization of the cranial drawer utilizing non-isometric points can impair range of motion and cause early
failure of the suture. Excessive tension of the suture causes increased lateral compartmental pressure and
may predispose to lateral meniscal injury and early OA. The small dogs are at higher risk of complications
after an excessively tight lateral suture because they are not able to compensate with their total joint reac-
tion force for an unbalanced compartmental pressure. The tension of the suture should be selected based on
neutralization or decrease of the drawer to about 2-3 mm, while preserving normal range of motion. It is al-
so crucial to check tibial rotation when choosing the tension. The tibia should not be externally rotated af-
ter extracapsular suture. The suture tension should allow 5-10 degrees of internal tibial rotation. In general
excessive tension is less concerning in case of large dogs weight-bearing soon after surgery, and in case of
nylon prosthesis for its decreased stiffness over time.
EARLY LAXITY
We already discussed some causes of early laxity. Another frequent cause of instability in the early postop-
erative period is poor compliance and excessive activity. No good solutions for non-compliant owners are
available, but postoperative rehabilitation has improved significantly the outcome and the postoperative
management in my experience. In case of the Tightrope, early laxity may be caused by: 1) soft tissue en-
trapment between the buttons and the bone; 2) poor placement of the tunnels; 3) infection and resorption
at the tunnel exits 4) suture failure. It is crucial to elevate soft tissue and periosteum in the site of the tunnel
exit. The button should be flat against the bone after tying the knot.
PERONEAL NERVE INJURY

This is a rare but severe complication of the circumfabellar suture technique. The most common cause is
excessive dissection caudal to the fabella. It is important to guide the dissection based on the palpation of
the fabella. It is also useful to maintain the joint in flexion to allow the biceps fascia to be retracted more eas-
ily and expose the fabella with less dissection. The dissection should be carried only to allow exposure of
the lateral aspect of the fabella. Anything caudal to it should not be elevated, excised, dissected.
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Introduction to minimally invasive plate osteosynthesis

Recent advancements in fracture healing have focused on minimally invasive fracture stabilization tech-
nique. Invasive open surgical approaches necessary for anatomic fracture reconstruction disrupt the fracture
hematoma as well as the regional extraosseous blood supply. This iatrogenic trauma can retard the rate of
new bone formation and devitalize bone fragments which potentially may have remained viable if the frac-
ture site was not disturbed. An understanding of the benefits of preserving the fracture hematoma and lo-
cal blood supply has led to the development of the principle of biological osteosynthesis as a technique for
fracture management. The principles of biological osteosynthesis were developed to maximize healing po-
tential by balancing biology and mechanics in the treatment of fractured bones. These principles are based
on preserving blood supply by minimizing exposure and disruption of the fracture site.
A new method of bone plating has evolved which allows a plate to be applied through small incisions, made
remote to the fracture site. This technique conforms to the principles of biological osteosynthesis since the
fracture site is not exposed and only minimally disturbed. The technique has been termed minimally inva-
sive percutaneous plate osteosynthesis (MIPO), and has also been referred to as percutaneous plating. Per-
cutaneous plating involves the application of a bone plate, typically in a bridging fashion, without making
an extensive surgical approach to expose the fracture site. The bone segments are reduced using indirect re-
duction techniques. Small plate insertion incisions are made at each end of the fractured bone and an epi-
periosteal tunnel is made connecting those incisions. The plate is inserted through one of the insertion inci-
sions and tunneled along the periosteal surface of the bone, spanning the fracture site. Screws are applied at
the proximal and distal ends of the plate through the insertion incisions or if necessary, through additional
stab incisions. Screws are not placed in the holes located in the central portion of the plate, which is often
positioned over the fracture.
Appropriate case selection is crucial to the success of MIPO. As with any technique, not all fractures are
amenable to percutaneous plate stabilization. Although MIPO is most applicable to comminuted diaphyseal
or metaphyseal fractures which may not be amenable to anatomic reduction, the technique can be utilized
in some simple transverse fractures. Plates are typically applied in a bridging fashion to stabilize comminut-
ed fractures dissipating strain over the comminuted segment. The environment of relative stability provid-
ed by bridge plating results in fracture healing by secondary bone healing.
Although the MIPO technique can be applied to proximal limb fractures, we have found that femoral and
humeral fractures are typically more challenging to reduce using indirect techniques than antebrachial and
crural fractures. Femoral and humeral fractures may be amenable to MIPO after using an intra-medullary
pin, femoral distractor or traction table to achieve reduction and alignment of the fracture. In human pa-
tients MIPO has been demonstrated to be a successful method of fracture osteosynthesis in both humeral
and femoral fractures. MIPO has been utilized commonly to stabilize comminuted tibial fractures in both
humans and dogs. In our experience MIPO is an excellent choice for radial and tibial fractures which can
be indirectly reduced using a temporary external skeletal fixator. MIPO is well suited for stabilizing dia-
physeal long bone fractures as there is usually a sufficient length of bone proximal and distal to the fracture
to allow for adequate plate purchase.
Indirect reduction techniques are generally utilized when performing MIPO fracture stabilization. The frac-
tured limb segment is aligned and original length is restored. The intermediate fracture fragments are left
undisturbed in the soft tissue envelope. Indirect reduction means that fragments are manipulated indirectly
by applying corrective force at a distance from the fracture, by distraction or other means, without exposing
the fracture. In biological terms, indirect reduction techniques confer an enormous advantage by minimiz-
ing the iatrogenic damage incurred during surgery. If correctly applied, it will add minimal iatrogenic dam-
age to tissues already traumatized by the fracture.
The plate is inserted through one of the incisions, slid through the soft tissue tunnel along the surface of the
bone, over the fracture site, until the end of the plate is visualized in the second incision. If available fluo-
roscopy should be used to visualize that the plate is properly contoured and positioned on the bone. If nec-
essary the plate can be removed and re-contoured. Precise contouring and positioning of the plate becomes
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less critical if a locking plate is used. Once the plate is fitted to the bone, screws are placed. Reports of MIPO
in animals have been promising. Our experience of MIPO procedures has been favorable with rapid stabi-
lization of the fracture site by bridging callus, progressing to complete union. In order to validate MIPO for
use in dogs and cats, objective clinical trials and outcome based case series will be necessary.
REFERENCES
1. Baumgaertel F, Buhl M, Rahn BA. Fracture healing in biological plate osteosynthesis. Injury 1998; 29 Suppl 3: C3-6.
2. Field JR, Tornkvist, H. Biological fracture fixation: A perspective. Vet Comp Orthop Traumatol 2001; 14: 169-78.
3. Borrelli J, Jr., Prickett W, Song E, Becker D, Ricci W. Extraosseous blood supply of the tibia and the effects of dif-
ferent plating techniques: A human cadaveric study. J Orthop Trauma 2002; 16: 691-5.
4. Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixa-
tion: Choosing a new balance between stability and biology. J Bone Joint Surg Br 2002; 84: 1093-110.
5. Johnson AL, Smith CW, Schaeffer DJ. Fragment reconstruction and bone plate fixation versus bridging plate fixa-
tion for treating highly comminuted femoral fractures in dogs: 35 cases (1987-1997). J Am Vet Med Assoc 1998;
213: 1157-61.
6. Schmokel HG, Stein S, Radke H, Hurter K, Schawalder P. Treatment of tibial fractures with plates using minimal-
ly invasive percutaneous osteosynthesis in dogs and cats. J Small Anim Pract 2007; 48: 157-60.
7. Pozzi A, Hudson CC, Lewis DD. Minimally invasive plate osteosynthesis: Initial clinical experience in 16 cases.
Veterinary Orthopaedic Society; Big Sky, Montana; March 9-14, 2008.
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The orthopedic examination -

tips and tricks to a successful diagnosis
A good orthopedic examination (OE) is the key for a successful diagnosis and treatment of a dog with a
chronic lameness. Well and systematically performed, the OE should allow us to rule out non-orthopedic
problems as a cause of lameness, to define the source of the lameness, to get a tentative clinical diagnosis
and to decide, which further diagnostic technique will be most useful to obtain a final diagnosis. Imaging
techniques such as radiographs, CT, MRT or arthroscopy should primarily confirm our clinical diagnosis
and not be used as a general searching tool. If we use it as such, there is a risk to detect and to treat abnor-
mal findings, which are of no clinical importance.
A good OE starts with a detailed, careful history. This should include at least onset and duration of the lame-
ness, possible cause of lameness (trauma), any previous orthopedic problems, course of the disease, type
lameness (intermittent, permanent, warm up effect etc), treatments and success of these.
The OE should always go through the same basic steps:
1. Observe the animal while it is moving, standing and sitting.
2. Palpate & manipulate the dog.
3. Perform specific examinations.
A systematic approach helps to avoid missing important pieces of information.
1. OBSERVE THE ANIMAL WHILE IT IS MOVING, STANDING AND SITTING

Analyze the gait and the type of lameness. Determine which leg the dog is limping on, the type and severi-
ty of lameness. This is often different to what the client told you. Have the dog walk, trot and gallop. Re-
peat if necessary on different grounds (lawn, asphalt, gravel). Look for signs of ataxia, toe dragging, gait ab-
normalities. A dog with painful joints will quickly shift from walk to gallop when going faster. Gallop allows
shorter strides and distribution of the weight on two legs at the same time. This is less painful than a trot.
Thus a dog that avoids to gallop but prefers to trot has very not likely an orthopedic, but a (neuro)muscu-
lar problem causing weakness. The trot is an energy saving gait, which is easier for these dogs than to gal-
lop. Remember not all gait abnormalities are caused by pain. Neurological as well as muscular disorders can
cause of very typical gait abnormalities.
Look always how the dog sits down and stands up. This is a great tests to look for stifle problems. A dog
with painful stifle hesitates to flex its knee while sitting down and avoids full flexion. Thus it prefers to move
the foot outward to extend the stifle.
Next, inspect the standing dog. Look at the joint angulations, the loading and position of the feet and toes, look
for asymmetries, abnormal swellings or atrophies. Does the dog takes a specific posture while standing? Dogs
with lumbosacral pain for example often show a typical pelvic tilt with the tail pulled between the legs.
2. PALPATE & MANIPULATE THE DOG

This is best done, while the dog is standing or sitting. Use minimal restraint, try to keep the dog relaxed.
Stand behind the dog and start palpating the back, then the rear legs. Palpate both legs simultaneously. This
is the easiest way to detect subtle differences between the right and left leg.
Look for any abnormalities such as atrophies, swellings, abnormal heat, effusions, scar tissue, muscle spasms
or contractions, and pain etc. Do a deep palpation of the long bones to rule out pain. Check the local lymph
nodes.
Once the dog got used being touched and used to get manipulated, move all the joints through a full range
of motion.
I usually start with the rear legs. Gently lift up one leg and put all joints in full flexion, then gradually ex-
tend the hip. Do each manipulation on both legs, before you proceed to the next joint. Not all dogs show
obvious pain if you hit the sore spot. But most will show some resistance to a painful manipulation. Again,
subtle differences are best identified by comparing the two legs. Not only check for pain, but also degree of
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range of motion (increased or decreased) and abnormal sounds or crepitus.

Partially flex the hip and hyperextend the stifle. Watch for pain response. Work your way down to the tar-
sus and foot. Careful palpate the toes and flexor tendons of the toes. Palpate the sesamoid bones of the
metatarsus.
Check the lumbosacral and caudal lumbar area with the pelvic tilt and -lordosis test.
Have the dog sit down and repeat the exam with the front legs. Do not forget to manipulate the head and
neck. Try to motivate the dog to move his neck itself by offering him goodies. This will reveal subtle prob-
lems a lot better than any forceful manipulations, that most dog resists don’t like to begin with.
Gently lift up the paws and flex the elbow, then hyperextend the shoulder followed by hyperflexion of the
shoulder. Keep the shoulder slightly flexed and hyperextend the elbow only. Flex and extend the carpus.
3. PERFORM SPECIFIC EXAMINATIONS OF EACH JOINT

If a painful joint has been found, then perform specific tests to find the cause of the pain. A classical exam-
ple is the tibia compression test to check for ACL rupture. If the palpations and manipulations did not help
to localize the problem, then all joints should be systematically examined.
Remember: the joint most commonly causing lameness of the rear in dogs is the stifle (most likely assoc with
ACL disease) and the joint most commonly causing lameness in the front limb is the elbow joint (most like-
ly associated with medial coronoid disease). Thus: if a dog is lame on its front it is the elbow - if a dog is
lame on the rear it is the stifle, until proven otherwise.
A dog with sifle pain has a positive sit test. With a partially or fully torn ACL, there is usually a slight swelling
over the medial side of the stifle joint in the area of the medial collateral ligament (medial buttress). In the
very early cases of ACL tears, there is no obvious thickening yet, but the distinct groove between the me-
dial femoral condyle and the tibia plateau is filled in and can’t be palpated. Pressure over this area does cause
a pain response if there is an ACL problem. To check the groove it is best to elevate the tibia and put the
stifle joint in a 90° flexion.
Do a tibial compression test and check the drawer movement. This can be well done in the standing dog.
Always compare to the healthy side to detect subtle differences!
Dogs with elbow pain caused by medial coronoid disease might assume a typical posture while sitting, push-
ing the elbows to the chest while they outward rotate the paws. To check for medial coronoid disease, flex
the elbow 90 degrees and palpate the area cranio-ventrally to the medial epicondyle. Normally, there should
be a distinct indentation and even firm pressure over this area is not painful. With medial coronoid disease
you might feel a slight effusion, some thickening and most of the time pain on firm pressure. If there is no
clear response, repeat the pressure, while you pronate and suppinate the elbow joint in 90° flexion and then
in hyperextension. These are probably the most sensitive tests to discover medial coronoid disease, In fact
the clinical findings are often more sensitive than the radiographs in the early course of the disease.
It can be challenging to rule out shoulder problems as a cause of the lameness. If a dog has a shoulder dis-
ease of clinical importance, there is usually some pain response during manipulation such as hyperextension
and hyperflexion, external and internal rotation as well as abduction. Always palpate the bicipteal tendon.
Check not only for pain, but also for swelling, nodules and irregularities.
If there is no pain on shoulder manipulation and the dog has a normal biceps tendon, it is very unlikely the
dog has a shoulder problem causing lamness.
Front limb lameness diagnosis can be much more challenging then in the rear leg. There are dogs with me-
dial coronoid disease, that have no obvious clinical or radiological abnormalities. Therefore it is important
to examine all the other joints very carefully. If they are normal – it is the elbow, until proven otherwise.
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Complications of tarsal and carpal arthrodesis

The carpus and tarsus are the most commonly arthrodesed joints in small animals. Successful arthrodesis is
achieved with cartilage debridement, autogenous cancellous bone grafting and rigid fixation of the joints. A
variety of fixation techniques have been described using lag screws, plates, pins or external fixation. Primary
goal of all techniques is a solid immobilization until the joint is fused. As for most surgical procedures, com-
plications do occur. Complications are most likely in partial arthrodesis of the carpus and panarthrodesis of
the tarsus. In particular the tarsus seems to be difficult to arthrodese successfully. A high rate of complica-
tions has been observed and is the major reason for poor results. Complications in up to 100% of the cases
have been reported1,3. Implant failures, such as breakage or loosening, lack of joint fusion, osteomyelitis as
well as degenerative joint disease of the intertarsal or metatarsal joints are the most common complications
reported. Careful diagnosis of the underlying causes is important to treat the complications successfully.
The complications of tarsal and carpal arthrodesis can be divided in two general groups: complications as-
sociated with failure of the fixation and complications that result in poor limb function.
FIXATION FAILURE
Fixation failures have either mechanical or biological reasons. Lack of rigid fixation seems to be the most im-
portant mechanical factor leading to fixation failure. Lack of stability causes delayed fusion of the joint(s). This
increases the risk of implant failure due to chronic cycling loads. Inadequate implant strength, inadequate im-
plant placement (i.e. dorsal plating) have been reported to be important factors for lack of stability2.
The implant selected is either too weak or insufficiently anchored to the bone. Insufficient anchorage of an
implant may lead to premature loosening of the fixation such as an ESF or a plate.
Optimal side of implant placement has always been a matter of debate. Plates are most conveniently placed
on the dorsal aspect of the joint surface, which is considered the compression side and therefore not the ide-
al side for plate placement. The tendon apparatus balances compression and tensions in the distal joints. Suc-
cessful arthrodesis using dorsal plates can be achieved, provided the mechanics of the joint function are re-
spected and there are no biological factors leading to a prolonged healing process. A typical reason for fail-
ure of a dorsally applied plate in tarsal panarthrodesis is lack of incorporation of the calcaneus in the fixa-
tion. Fixation of the calcaneus is important to neutralize the forces acting on the joint by the Achilles tendon
apparatus. Screws incorporating the distal tibia and/or the talus together with the calcaneus act as inter-
locking bolts to reduce the weight bearing stress on the plate.
Another important cause of implant failures is poor biology. Biological reasons such as lack of cancellous
bone graft, suboptimal debridement of the joint cartilage or infection and secondary osteomyelitis lead to
delayed healing or no fusion at all. This again increases the cycling load of the implants and thus the risk of
fatigue fractures or implant loosening. Careful analysis of the implant failure will reveal in a majority of cas-
es biological causes as important contributing factors.
Insufficient removal of cartilage is more likely if the debridement was done by hand with a curette. This is
more time consuming, tiresome and less efficient, than debridement with a high-speed burr. Using a high-
speed burr however can cause heat necrosis of the bone, if the bone is not cooled with saline.
Lack of fresh cancellous bone graft is another cause of failure. If there is no (or not enough) cancellous bone
graft used there is no scaffold for bone ingrowth and no promotion for rapid bone healing. Occasionally
there is simply not enough cancellous bone available for harvesting, esp. in older cats. In these cases it is im-
portant to augment the graft with BMP or similar products. The cancellous bone has to be packed in the
recipient site before the implants have been applied; otherwise it is difficult to place the graft well between
the joints spaces to be fused.
Fixation failures result in pain and non-union if left untreated. Revision is needed improving biology and
stability.
POOR LIMB FUNCTION

Poor limb function occurs in spite of a successful arthrodesis. This complication can be challenging to diag-
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nose and frustrating to treat.

Poor limb function might be caused by a fixation that interferes with joint /limb function.
This is typically seen in partial carpal arthrodesis using a dorsally applied plate, which is not placed low
enough on the radio-carpal bone. When the dog is fully extending the joint during weight bearing such a
plate will impinge on the joint capsule and/or the distal rim of the radius. The screws placed in the radio
carpal bone can cause poor limb function if they are too long and exit on the caudal joint surface of the ra-
dio-carpal bone. They interfere with the radial joint on full flexion of the carpus. Removal of the irritating
implant is needed to treat this complication.
Poor limb function can be caused by overload of adjacent joints and subsequent degenerative joint disease
with pain. This is most likely the result of a partial arthrodesis of the radio carpal- or talocrural joint that
overloads the small, tight distal joints. Overload of the calcaneal joints is one predominant causes of poor
limb function after a panarthrodesis of the tarsus. The calcaneus is quite mobile and there is a fair amount
of motion between the calcaneus and the talus as well as between the calcaneus and the quartal tarsal bone.
This motion increases during weight bearing as the Achilles tendon pulls on the calcaneus. The calcaneo-ta-
lar joint however is difficult to access and to fuse surgically. Therefore the only way to incorporate the cal-
caneus firmly in the arthrodesis is by fusing the calcaneo-quartal joint.
Fusion in malposition result in similar problems as a malunion of a fracture. Abnormal wear and tear of the
adjacent joint and toes, resulting in toe dragging, leads to poor limb function. If the angel of fusion is too
extended toe dragging is more likely, if it is to flexed, the gait abnormality is caused by a shortened stance
phase of the foot.
Contraction of the tendons is another complication leading to poor limb function.
The digital flexor tendons are most likely affected. The contraction is probably the result of direct trauma
and prolonged immobilization of the operated leg in a splinted bandage. Full extension of the metacarpal/
metatarsal.phalangeal joints is usually restricted and painful. A severe contraction was seen in a feline pa-
tient that had an arthrodesis of the tarsus due to a sciatic nerve injury. The contractions together with poor
sensation lead to severe ulcerations of the foot.
Contractions of the gastrocnemius muscle have been reported as another cause of poor limb function after
pantarsal arthrodesis. Five of 12 dogs with excellent or good function at a walk were less able to bear weight
on the arthrodesis limb when standing. This appeared to be associated with gastrocnemius tendon pain and
increased tension. One dog that had a gastrocnemius tenotomy was improved within 2 days.
Low-grade osteomyelitis is an other cause of lameness, as it causes chronic inflammation, pain and poor limb
function, which resolves only, once the plate is being removed.
REFERENCES
1. Doverspike M., Vasseur PB.: Clinical Findings and Complications after Talocrural Arthrodesis in Dogs. JAAHA
1991, 27: 553.
2. Gorse MJ, Early TD.; Aron D: Tarsocrural Arthrodesis: Long-Term Functional Results. JAAHA 1991, 27: 231.
3. KlauseSE, Piermattei DL, Schwarz PD: Tarsocrural Arthrodesis: Complications and Recommendtions. V.C.O.T.
1989, 3: 119.
4. McKee WM, May C et al.: Pantarsal arthrodesis with a customized medial or lateral bone plate in 13 dogs. Vet Rec,
2004, 154: 165.
SCIVAC CONGRESS
Fracture planning in cats

“As long as the two ends of a broken cat bone share the same room, they will heal together” is a well-known
saying.
This common misconception is based on the fact that often young inexperienced cats are injured which have
an excellent healing potential, that cats have an excellent ability to protect themselves, as well as to com-
pensate for handicaps and to hide their disabilities. However there is no clinical or experimental evidence
that cat fractures heal indeed better than those of dogs. Distal tibial and proximal ulnar fractures are well
known for their high risk of developing non-unions.
There is also no evidence, that complications are less common in cats than dogs. Complication rates up to
25% have been reported after repair of radius/ulnar fractures. It is therefore wise to take cats as fracture pa-
tients seriously and to provide them the best fracture treatment possible. A sound fracture planning is the
best basis for success and has to take the specific nature of cats into consideration.
Fracture planning not only involves the repair itself, but also the timing of the surgery, the preparation of
the animal, the set up of the operating room and client communication. Risks, potential complications and
prognosis of the proposed procedure as well as the costs must be discussed with the client and ideally, an in-
formed owner consent obtained.
FRACTURE PLANNING - GENERAL CONSIDERATIONS

Good quality orthogonal radiographs of the fractured bone, including the adjacent joints are mandatory. Ra-
diographs of the opposite bone are often helpful for fracture planning and implant pre-contouring.
Fracture planning should not only focus on the repair but also on all potential problems that might happen
during the surgery itself. This avoids prolonged operation time, excessive soft tissue trauma and technical
errors. The surgeon should be ready for the unexpected and always have a plan B and C if the initial plan
is not working.
The optimal fracture plan is not only based on the radiographs to evaluate the fractured bone, but also is
on the assessment of the injured limb and the patient. Assessment of the limb and the patient is important
to predict the healing potential of the fracture and the risk of complications. The healing potential affects di-
rectly the length of time implants must function to support the bone. Longer healing times are expected with
poor biology, because the soft tissue envelope has to heal first.
1. Assessment of the patient

Age, overall general health have an impact how well the fracture will heal and how to repair a fracture. Cats
have high life expectancy and geriatric fractures are not uncommon. The bones of geriatric cats are often
brittle, resulting in challenging comminuted fractures with poor biology and reduced healing potential. Con-
current injuries such as fractures of other limbs force the patient to bear excessive weight on the operated
leg and will stress the repair.
2. Assessment of the injured limb

The type of injury causing the fracture has also a direct impact on the degree of soft tissue trauma and the con-
dition of the soft tissue surrounding the bone. High-energy trauma such road traffic accidents or gun shot in-
juries likely result in severe muscle lacerations and contusions and are often associated with extensive wound-
ing of the skin. Severe open fractures occur more likely with juries of the distal extremity that has less soft tis-
sue protection compared to the upper limb. Time span from injury to admission into the clinic, type of trauma
causing the injury and wound condition will predict how likely a wound or the fracture is already infected.
3. Assessing the fracture

An important step in planning the fracture treatment is to evaluate if the fracture is reducible or not.
Simple two-piece fractures such as transverse, short or long oblique fractures and fractures with 1-2 large
free fragments (butterfly fractures) are classical examples of reducible fractures. Once the bone column is
SCIVAC CONGRESS
anatomically reconstructed it will have some inherited stability and there will be sharing of weight bearing
load with the implant.
Comminuted fractures are non reducible. As the bone column cannot be anatomically reconstructed there
is no load sharing between the bone and the implants. The implants have to carry all loads until callus
is formed and are at risk to fail. A more rigid type of fixation with stronger implants is therefore mandatory.
Based on the collected information a fracture treatment plan is established. The ideal implant is selected, that
provides the required stability for the fracture to heal without untoward effects on the biology and function
of the patient.
The fracture treatment plan includes also the type of reduction to be used.
Reduction either aims at reconstruction of fractured bone fragments to their normal anatomic configuration
or restoring normal limb alignment only. This is also called indirect reduction, because the bone is realigned
without touching the bone fragments.
For anatomical reconstruction of reducible fractures that require interfragmentary stabilization an open re-
duction (OR) techniques is needed. OR is also used for most articular fractures.
OR has several advantages: it allows for better overall orientation (alignment) and also facilitates implant
placement. Cancellous bone graft can be applied to fill bone defects and augment bone healing.
If open reduction is selected to repair a non-reducible comminuted fracture, only enough exposure is made
for realigning the fracture and applying the implants, but the fracture fragments and blood clots are not
touched. This technique is also called “OBDNT” – Open But Do Not Touch.
Closed reduction (CR) is ideal for simple fractures that will be treated conservatively by external coaptation,
external skeletal fixation or IM pinning. It is also used for highly comminuted fractures that are treated by
minimally invasive osteosynthesis (MIO).
CR has the advantage that iatrogenic tissue trauma is minimized and blood supply is maximally preserved with
less post operative pain, faster healing and less risk of infection. It can result in a decreased operative time.
As open or closed reduction can be combined with internal or external fixation, the surgeon has theoreti-
cally 4 treatment options:
1. CREF – Closed reduction and external fixation with a cast, splint or an external skeletal fixator (ESF),
2. CRIF - Closed reduction and internal fixation of the fracture with minimal invasive osteosynthesis using
pins or plates,
3. OREF - Open reduction and external fixation with an ESF,
4. ORIF - Open reduction and internal fixation w/ pins, cerclage, screws and plates.
The optimal technique of repair should have the best chance for uneventful healing and return to full func-
tion, with the least additional trauma to patient and the least risk for complications.
THE CAT FACTOR

While planning the optimal repair, consider the fact that you are treating a cat, which is not just a small dog.
Some of the differences between the two species are:
1. Functional differences
Dogs have legs and paws - cats have arms and hands. They use their front legs for grooming, catching prey,
climbing and self defense. A pronounced pronation and suppination is vital for their limb function and must
be maintained. There are many more such adaptations that have to be taken into account when doing fe-
line orthopedic surgery fracture repair.
2. Anatomical differences
There are specific as well as general anatomical differences between dogs and cats. The distal humerus for
example has a supracondylar foramen through which the median nerve passes. Medial plating of the feline
humerus is therefore not advisable.
Feline long bones are generally straight and uniform w/ a relatively large medullary cavity. This makes them
ideal for IM pinning or IL nailing.
The small sizes of bones and bone fragments makes reconstruction more difficult and rigid fixation often
impossible due to lack of appropriate implants.
In general the flat bones (ileum, mandible) and the cortex of the long bones are thin and the holding pow-
er of implants is reduced.
SECONDARY FACTORS
Once a treatment plan has been selected, it has to be re-evaluated in the light of secondary factors:
SCIVAC CONGRESS
1. The surgeon and facilities

The surgeon must be confident to deal with the type of repair and should be able to handle all intra- and
postoperative complications if they occur.
All the implants and instruments necessary to perform the surgery properly should be available.
2. The cat
Not every planned repair is compatible with the personality of the cat. A cast or an external fixation re-
quiring an intensive post operative management might not be the best decision for a mean, non-compli-
ant cat.
The treatment plan might be influenced whether the cat is an indoor or outdoor cat.
3. The owner
Client compliance, reliability and cooperation may influence the initial treatment plan. The success of a sur-
gical repair depends strongly from the willingness and ability of the owners to attend to their patients post-
operative needs. Client expectations need to be discussed.
Last but not least the owner has to pay for your treatment. Never take any negative assumption on the client
and take a decision for the client. Always give him the best treatment option for a given fracture. If the client
cannot afford it or is not willing to pay, discuss alternative repairs. It is an art to do a good job with limited re-
sources! But costs can never be an excuse for doing a bad or sloppy job.
SCIVAC CONGRESS
Management of cruciate ligament rupture in small breed

dogs and cats
Management of anterior cruciate ligament (ACL) ruptures in small- or toy breed dogs and cats have not re-
ceived as much attention as the same condition in large breed dogs lately. In fact many surgeons feel, that
small breed dogs and cats do well enough with conservative management. There is convincing evidence,
that ACL ruptures should be treated with the same rational as done in large breed dogs.
There are however differences between large breed dogs and the small breeds dogs and cats.
The following presentation will discuss some of these differences of ACL rupture and treatment between
large breed dogs (LgBD) and small breed dogs (SmBD) and cats:
First, early partial or partial tears are not as commonly diagnosed in SmBD and cats. They usually have a
fully torn ligament at the time of clinical presentation. It is unclear however, why partial tears are less com-
monly seen. There are two possible explanations: 1. Partial tears do exist as well, but clinical signs are not
as obvious and as readily recognized in SmBD as in LgBDs - or - 2. ACL rupture in SmBD has a different
etiology and /or course of disease. While in dogs ACL ruptures are considered to be usually the result of a
degenerative disease, in cats they are mostly traumatic in origin.
Due to the synergistic function of the different stifle ligaments concurrent injuries have to be expected. It is
therefore not surprising, that almost 40% of the cats with ACL ruptures have additional stifle ligaments in-
jured. Concurrent injuries to the medial collateral and posterior cruciate ligament are most common. These
result often in highly unstable knees or even stifle joint disruptions. As there is rarely a history of major trau-
ma and concurrent stifle ligament injuries are seldom seen in SmBD, it is most likely, that the ACL is sub-
ject to chronic damage and degeneration in SmBD as in LgBD and the early signs of the disease simply go
unnoticed by the owner.
The average tibial slope in SmBD seems to be steeper and often excessive. This clinical impression is sup-
ported by one paper that reports an average inclination of the tibial slope of 27.4 degrees in SmBD (Petazzoni,
2004). This might put increased stress on the ACL. The average tibial slope in cats is less then in dogs and
has been reported to be 20.5° (+/- 4°) (Schnabel et al. Thesis, Univ of Vienna. 2006).
ACL ruptures associated with chronic medial patellar luxation is another common finding in SmBD. Me-
dial patellar luxation rotates the proximal tibia inward, which results in an impingement of the ACL by the
medial condyle and directly leads to ligament failure.
MANAGEMENT
Surgical management is the preferred treatment also in toy breed dogs and cats with ACL rupture.
It has been reported, that cats do not need surgical repair and recover with conservative treatment as well.
In our experience surgical management is superior to return the cat to normal function compared to con-
servative treatment. Operated cats show faster recovery and seem to have a better overall prognosis. This
observation is supported by the fact, that 42% of the cats with ACL have also an injured meniscus.
The classical repair with a lateral suture and joint capsule imbrication is a quick and simple surgical proce-
dure that results in an acceptable outcome in most dogs and cats. However suture failures resulting in un-
stable stifles do occur. This is becoming increasingly evident, as more and more small breed dogs are com-
peting in sporting activities, such as agility. Isometric suture placement using suture anchors seems to elim-
inate some of the problems with the classical suture techniques, but optimal suture anchor placement is not
easy in the very small patient. Complications do occur and include fracture of the condyle, misplacement of
the anchor into the joint or rupture of the suture.
Similar to large breed dogs, TPLO is a viable alternative to the lateral suture techniques.
The TPLO procedure is technically somewhat more demanding due to the small size of the patients. Menis-
ceal release by a caudo-medial approach - as done in LgBD - is possible, but inspection and removal of dam-
aged portions of the medial meniscus is difficult due to the small field of view. A craniomedial approach to
the joint is a good alternative and allows for full inspection of the stifle joint.
SCIVAC CONGRESS
However mensiceal release or resection is more difficult.

Even the small jig (Slocum Enterprises, USA) and its fixation pins are often too large and bulky for the SmBD.
If smaller fixation pins are used with the jig, they are not rigid enough to provide adequate stability. There-
fore we are no longer using the jig in SmBD.
The smallest saw blades available and most commonly used have a 12 mm radius. Some blades are rather
thick and remove a lot of bone while cutting. There are now thinner cutting blades available, that allow for
a fast and very precise cut.
The amount of rotation required to level the tibial plateau depends the radius of the osteotomy. To level a
35° slope to 5° with a 24 mm radius osteotomy 12.4 mm of rotation is required, With a Ø 12 mm osteoto-
my only 6 mm rotation is necessary. Thus the tibial crest is less exposed and the risk for an avulsion frac-
tures is reduced.
Be aware, that cats have a rather flat tibial crest with a compact proximal tibia. This puts, cats are at risk to
sustain an avulsion fracture of the crest if the TPLO cut is performed to cranially.
The oscillating machines commonly used are rather bulky and make a precise cutting through the delicate
bones of SmBD difficult. Using a pin for rotation and temporary fixation of the proximal segment can be
somewhat clumsy. A pointed reduction forceps can be used instead of the rotation pin. This facilitates in-
sertion of the temporary fixation pin.
For stabilization, Mini-instrumentation and -plates are needed. There are 2.0 mm TPLO plates available but
not all fit well in the very small patients. All provide enough stability for the osteotomy to heal. Be aware,
that long 2.0 mm cortical Mini-screws are needed and make sure you have them ready. There are 2.0 mm
cortical screws up to 34 mm long available (Synthes Vet, Paoli USA).
Plate placement might be difficult in some SmBD due to the conformation of the proximal tibia. They of-
ten have a very prominent tibial crest, a caudally curved proximal tibial shaft and / or a varus deformity of
the proximal tibia.
Even so TPLO in SmBD and cats is more demanding, it can be achieved without major difficulties or in-
tra-operative complications and has shown to be an efficacious technique for the treatment of anterior cru-
ciate ligament rupture.
LITERATURE
Petazzoni, M. TPLO in small breed dogs:18 cases. Abstract 12th ESVOT congress, Munich 2004.
SCIVAC CONGRESS
Distal radial fractures in toy breed dogs

Most fractures seen in toy breed dogs are managed very similar to those seen in regular or large breed dogs.
Obviously the major difference between toy and larger breed dogs is the size of the implants needed to sta-
bilize the fractures. Thanks to the miniaturization of many implants, in particular of the plates and screws,
rigid internal fixation is nowadays feasible even in the smallest patient.
Fractures of the distal radius and ulna are the third most common fracture in dogs, but the incidence of these
fractures is particularly high in toy breed dogs. There seems to be an inherited weakness of the distal radius
in some toy breed dogs, as bilateral fractures or a fracture of the opposite radius to a later date are not un-
common. Usually the fractures are caused by minor trauma. Younger dogs (1-2 yrs) are most commonly af-
fected.
Management of these fractures seems to be associated with a high rate of complications. Miniature breed of
dogs are reported to be particularly prone to non-union. Studies have shown, that when distal radial and ul-
na fractures in small and medium dogs were treated identically, delayed union and non-union complications
occurred primarily in the small-breed dogs.
Inherent biomechanical instability, decreased intra-osseous blood supply and a limited soft tissue envelope
for provision of extra-osseous blood supply for early revascularization and healing while the nutrient artery
redevelops, all these factors most likely contribute to the higher frequency of delayed union and non-unions
in toy breed dogs. Of these factors, the marginal blood supply in the distal radius of small and miniature-
breed dogs seems to be a major cause of delayed union or non-union. It has been shown that in small breed
dogs, there is a decreased vascular density and arborization of the vessels in the distal metaphysis as com-
pared to larger breed dogs. This paucity of vessels results in a zone of reduced vascularity at the distal meta-
physeal region of the radius in small dogs.
Biomechanical instability certainly is another major cause predisposing to non-union after fracture reduc-
tion. There is minimal bone surface contact resulting from the small bone size and the short oblique or trans-
verse nature of many distal radius and ulna fractures. Instability in a small fracture gap associated with sim-
ple fractures is more devastating to fracture healing than the same amount of instability in a comminuted
fracture, where motion between the fragments is better distributed and thus diminshed.
Fixation of distal radius and ulna fractures in toy breed dogs with casts, intramedullary pins, external fixa-
tors and bone plates have been reported.
However eighty-three percent of distal radial fractures treated with cast fixation developed serious complica-
tions such as malalignement and non-union. Therefore casting is not an acceptable technique for fracture
stabilization. Intramedullary pinning is also not recommended because a) it fails to adequately counteract rota-
tional forces, b) the pin is difficult to insert without interfering with the carpal joint and c) the pins that can
be inserted safely are too weak to effectively stabilize the fractures. Therefore it is not surprising, that com-
plication rates are unacceptably high with this technique, being 80% as reported in one study.
Open or closed reduction and external fixation have been advocated for adequate stabilization of distal radius
and ulna fractures. Because several pins have to be inserted within a very short distance, the size of most
–even small - clamps is often too big to bring them as close together as needed. One exception is the Mini-
FESSA® System initially designed by the French army. It allows for inserting within a very short distance
several fixation pins in the bone directly through the FESSA-connecting bar. Alternatively, many surgeons
use a free moldable acrylic (PMMA) to connect the fixation pins.
Reported complications associated with ESF include pin loosening, pin tract infections, mal-alignment and
- rarely - delayed union or nonunion.
Open reduction and internal fixation using Mini plates is the authors preferred technique. Depending how
distal the fracture is, a 5 – 9 hole 2.0 DCP plate is used. Note however, that the 6 mm 2.0 DCP is available
at a thickness of 1.5 and 1.0 mm. The stronger plate is preferred in most instances. The 2.0 DC - plate al-
lows compression of the fracture by 0.6 mm, provided the appropriate load guide is used. If the fracture is
very distal, a Veterinary Mini-T plate might be used. Due to the size and shape of the bone, the plate is best
applied on the dorsal side of the bone.
SCIVAC CONGRESS
Even so there is usually enough room to use the stronger 2.0 mm screw, I prefer to use the 1.5 mm screw
to fix the plate to the bone, if possible. It is the impression, that this screw does less damage to the bone and
screw loosening is not a problem. Using the 1.5 mm screw also diminishes the risk of a fracture through an
open screw hole, once the plate is being removed.
Perfect alignment is important. It seems that catastrophic failures with break down of the fixation due to
plate failure or screw pull out primarily occurs in cases where fracture reduction was inadequate or the frac-
ture malaligned. Mild transient osteopenia can occasionally be seen, but does not seem a clinical problem.
If fracture fixation using Mini-DC plates is properly performed, the risk of delayed or non-unions in toy
breed dogs is not higher than in any other breed of dogs. Other complications occasionally reported are skin
erosions over the distal plate end, thermal conduction, synostosis between radius and ulna and decreased
ROM in the carpal joint.
Due to the distal location of the fracture and the vascularity problems assoc with these fractures, the use of
2.0 LCP might become an interesting alternative. In the very small toy dogs we also used with good success
the compact hand plates. They are used with 1.3 mm screws.
Overall plate fixation provides a successful method of repair of distal radius fractures in toy breed dog re-
sulting in good to excellent outcome in the majority of cases.
REFERENCES
Welch, JA et al.: The intraosseuos blood supply of the canine radius: implications for healing of distal fractures in small
dogs. Vet surg 1997, 26:57-61.
Summer-Smith GA: A comparative investigation into the healing of fractures in miniature poodles and mongrel dogs. J
Sm Anim. Pract. 1974: 15:323-8.
Summer-Smith GA: A histological study of fracture nonunion in small dogs. J SM Anim Pract 1974: 15:571-8.
Campell JR: Healing of radial fractures in miniature dogs. Vet annual 1980; 20 106-12.
Wilson JW: Vascular supply to normal bone and healing fractures. Sem Vet Med and Surg 1991 6:26-38.
Larsen LJ et al: Bone plate fixation of distal radius and ulna in small-and miniature-breed dogs JAAHA 1999, 35: 243-50.
SCIVAC CONGRESS
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Alma Mater Studiorum

Alma Mater Studiorum

3rd World Veterinary Orthopaedic Congress, ESVOT-VOS

Small Animal Program Chairman

Large Animal Program Chairman

Local Organizing Committee Chairman

University of Bologna - Faculty of Veterinary Medicine

Bologna Congress Center

WVOC 2010, Bologna (Italy), 15th - 18th September • 2

Previous E.S.V.O.T. Congresses

Board 2008-2010 of the European Society of Veterinary Orthopaedics and Traumatology

5 • WVOC 2010, Bologna (Italy), 15th - 18th September

Welcome to the WVOC 2010 by the ESVOT President ................................................7

Program Small and Large Animals ....................................................................................8

List of Speakers & addresses .............................................................................................25

List of Exhibitors and Sponsors .......................................................................................39

Abstracts: State of the Art Lecture......................................................................................41

Abstracts: Main Program Small Animals............................................................................47

Abstracts: Main Program Large Animals .........................................................................191

Abstracts: Pre-congress Seminars ......................................................................................257

Abstracts: In-depth Seminars .............................................................................................379

Abstracts: SCIVAC Congress............................................................................................703

7 • WVOC 2010, Bologna (Italy), 15th - 18th September

Welcome to the WVOC 2010 by the ESVOT President

Prof. Olivier M. Lepage

Tuesday, September 14 th, 2010 - 5.00 pm

Pre-congress: Wednesday, September 15 th, 2010 - At the

Min 12 - Max 20 seats Min 8 - Max 16 seats

1:00 pm Lunch break

3:30 pm Coffee break

3:50 pm Group B: Live horse demonstration

6:00 pm End of the Course End of the Course

From 6:00 pm BUSES FROM THE

SMALL ANIMAL EQUINE SCIVAC

OPENING TIME FOR REGISTRATION

e University of Bologna, Faculty of Veterinary Medicine

Min 10 - Max 30 seats Min 8 - Max 18 seats

Practical exercise: Image reporting

End of the Course

UNIVERSITY TO THE CONGRESS CENTER

SIVE IN-DEPTH FREE COMMUNICATION

Pre-Congress: Wednesday, September

Chair: G. Ricardi Chair: J. Innes Chair: M. Petazzoni

1:00 pm Lunch break and exhibition

SMALL ANIMAL EQUINE SCIVAC

15 th, 2010 - At the Congress Center

Chair: J. Houlton Chair: S. Tepic Chair: G. Rovesti Chair: G. Robins

Lunch break and exhibition

Coffee break and exhibition

SIVE IN-DEPTH FREE COMMUNICATION

1:00 pm Lunch break and exhibition

SMALL ANIMAL EQUINE SCIVAC

September 16 th, 2010 - Morning

Chair: H. Hazewinkel Chair: B. Peirone Chair: M. Ness

Coffee break and exhibition

Lunch break and exhibition

SIVE IN-DEPTH FREE COMMUNICATION

Chair: C. Riggs SA COMPLICATIONS THE STIFLE 1

2:00 Subchondral bone necrosis in Chair: T. Turner Chair: R. Vannini

3:55 Managing cruciate disease -

4:30 pm Coffee break and exhibition

STATE OF THE ART LECTURE - ROOM EUROPA

SMALL ANIMAL EQUINE SCIVAC