xSURGICAL PRINCIPLES

LECTURE 1 – PREVENTING SURGICAL INFECTIONS

Asepsis: free of pathogenic microorganisms

Sterile: complete absence of all microorganisms

- Inanimate objects, living things cannot be sterile

Surgically clean: kill all of the accessible microorganisms on the surface (usually skin)

Contaminated: a surface or structure where microorganisms are present

- Floors, walls, air

Surgical Site Infection: infection (pus) from a surgical incision within 30 days of surgery
- 1 year if you insert a permanent implant
- Superficial vs deep infections
- Why care?
o Most common hospital acquired infection
o Prevents morbidity and mortality
o Prevents spending money on treating the infection

Microorganisms
- Sources: environment, equipment, patient, surgical team, surgical site
- Transient bacteria: bacteria there for the short term
- Resident bacteria: bacteria normally living on an animal
- Surgeons have more resistant bacterial flora compared to the average person

Environmental Factors
- Hospital design
- Cleanliness
- OR design and cleaning protocol
- Traffic: the more people going through the OR the higher the chance of infection
- Use of antibiotics (kills 95% of bacteria)

Prophylactic Antibiotics
- Lots of prophylactic antibiotics used in surgery – used to lower the infection rates
- Use antibiotics when:
o significant risk of infection
o the disease in the patient (GIT surgery – lots of contamination)
o long surgeries >90 minutes
o Infection is catastrophic (in brain, spinal cord, etc)
- Which antibiotics
o Cephazolin – IV cephalosporin for staph & G- enterobacteria
o Want high levels in the tissues they are “playing in” when they cut in the skin
o Repeat every 90 minutes, stop antibiotics when the last stitch is closed
o Increased infection and more resistant bacteria if used more than 24 hours
Equipment (Instruments, Drapes, etc)
- Steam sterilization – autoclave, most common
- Gas (ethylene oxide) – used less now, bad for environment
- Plasma (H2O2) sterilization – growing in popularity, very expensive
- Ionizing radiation
- Cold chemical

Autoclave
- Each unit is individual, get to know the protocol
- Tools need to be cleaned before being wrapped – if blood is on tool after autoclave it is NOT sterile
- How do we know it worked?
o Look at instruments, are they dirty?
o Autoclave tape turns black = pack got to high enough temperature on the outside
o Indicator strips in middle of pack = turns color at high enough temperature on the inside
o Biologic Indicators: GOLD STANDARD, hot enough for long enough to kill everything and they
change colour

Cold Chemical Sterilization

- Glutaraldehyde
o For equipment sensitive to heat and can be submerged in water
o Very toxic – respiratory/dermal irritant, carcinogenic - MUST RINSE WELL / USE PPE

Patient Preparation
- Hair removal to remove gross contaminants (feces, etc)
- Use #40 blade on clippers
- Do it as close to surgery as possible – otherwise there is time for their skin to get colonized with the
resistant bacteria found in the hospital
- Avoid clipping b/w the toes and paws in small animals

Skin Preparation
- Remove dirt
- Eliminate transient bacterial flora
- Reduce resident microbial count
- Inhibit rapid rebound growth microbes
- Follow manufacturers recommendations
- We cannot remove the ~20% of bacteria in the hair follicles

What to use?
- Chlorhexadine
o Potent killer of bacteria
o Binds to skin and keeps working during surgery
o Very few skin reactions
o CONTACT TIME CRITICAL – needs to be on the skin for 3 minutes
o Want clean sponges after the prep, do 3 preps
o Alcohol + chlorhexidine the new best
- Benadine
o Cheaper, good initial kill rates, better for spores if left on for 20 minutes
Skin Prep Techniques
- Sterile prep – use sterile gloves to prevent transfer of bacteria from tech to patient
- Dominant hand to prep and other hand to pick up the gauze
- **Circular pattern from incision site to the periphery
- Do not go back to incision site with same sponge
- Don’t scrub too hard (skin abrasions)

Draping the Patient

- Why? Barrier to prevent spread of microbes from patients skin into incision
- 2 layers
o 1st layer = 4 ground drape, typically made out of cloth
 Cloth needs a tight weave & are waterproof
 Hole needs to be small enough that bacteria cant get through
 Thread count needs a minimum of 270
 Cloth is only an effective barrier while dry – increases pore size and bacteria get through
 Use towel clamps to hold drapes – need to go into skin to be effective
 Do not reuse towel clamps once they penetrate skin
o Final Drape – single complete layer that closes everything off, slit goes over the incision
- Once you place a drape you should never move it, drags bacteria around

Surgeon Preparation
- Scrubs (greens) for surgery only & only worn in the hospital
- Surgical caps to cover all hair
- Mask – use new one for each surgery
- Shoe cover/booties – does not decrease infection rates in big ORs

Hand Scrubs
- Need our skin as clean as possible, surgeons have more resistant bugs
- Surgical scrub w/ soap and brush OR ethyl alcohol based rub solutions
- Short, clean nails
- No rings/nail polish

Surgical Gowns
- Waterproof impermeable barrier (for 75-100 washings)
o Cuffs not impermeable – cover w/ gloves
o Wet = contaminated
o Use new one for each surgery
- Paper vs treated cloth – no difference as long as they are waterproofed

Surgical Gloves
- Not an absolute barrier (1.5% have holes when open)
o This is why we spend a lot of time scrubbing
- 30% incidence of glove perforation at end of surgery
o More common in non-dominant hand & during orthopedic surgery
- Change if you notice holes
What is sterile?
- Anything below surgery table surface is contaminated
- Arms/gloves, instruments are sterile
- From about the shoulders down the waist is sterile
- Back is contaminated

Surgical Techniques Factors

- Strict asepsis (OR protocol)
- Tissue trauma – minimize by knowing anatomy and gentle technique
- Amount of hemorrhage
- Dead space
- Surgical time – infection rate doubles each hour of surgery

Surgical wound classification (overall 5.1%)

- Clean 2.5%
- Clean contaminated 4.5%
- Contaminated 7.3%
- Infected 18.1%

Patient Factors
- Disease status
- Distant infection
- Duration of hospitalization ( nosocomial infections)
- Total anesthesia time (risk  by 30% each hour of anesthesia)
- Anesthetic drugs
- Hypotension
- Peri-operative hypothermia

LECTURE 2 – WOUND CLASSIFICATION

Anatomic Location
- Head/body/limbs – head/body wounds heal good, legs don’t and tend to have complications
- Severity of wound

Mechanisms of Trauma

Laceration
- Direct anatomic disruption
- Little collateral injury

Avulsion/Degloving
- Direct tissue loss
- Collateral damage

Punctures
- Extent of the injury is undetermined
- NEVER pull out before taking a radiograph
- Porcupine quills – can migrate around the body, view with ultrasound to get out
 Bite Wounds
- Predisposed to infection (especially cat bite wounds)
- Predisposed to foreign body

Blunt Trauma
- Massive soft tissue injury
- Severe skeletal damage – depending on where the trauma occurs

Thermal Burns
- Usually from fire
- Smoke inhalation – can result in edema in the airway, could take a year for animals to succumb (die)
from smoke inhalation
- Results in protein loss and increased chance of sepsis
- Different degrees depending on how many layers of skin are affected
- If you go all the way through the skin, only glandular tissue is left – need to look at other ways to
manage the wound (skin grafts, etc)

Radiation Injury
- Common in oncology patients
- Tissue trauma below the skin you are radiating

Chemical Burns
- Direct and collateral tissue injury
- Serum scald
- Chemical burns from chronic diarrhea
- Iatrogenic injury from application of copper tox - makes things green colour, in non-diluted
form is caustic enough to eat away live tissue

Gun Shot Injuries

- Low velocity (22-calibre)  tumbling phenomenon when bullet goes from one tissue density to
another, where you find the bullet in the body it does not follow the expected trajectory
- High velocity (high-power rifles)  shockwave collateral injury that creates a “vacuum” causing huge
amounts of collateral injury, usually fatal in a dog/cat body cavity injury
- Significant contamination – seeds bacteria, hair, dirt into cavities.

Hit by Car
- High energy injury
- Frequent collateral injury
- Evaluate the major body systems (X-ray, ultrasound)
o Chest – pneumo/hemothorax
o Abdomen – bladder and kidneys intact

International Harvester
- Massive & multiple injuries
- When animal get into accident with a combine/corn picker

Vascular Injuries
- Cast Complication - too tight, compromises blood flow to the skin (can cause skin sloughing)
Septic Injury
- Clostridial myositis – more common in horses
- Usually after intramuscular injection of flunixin (banamine)
- Save 50% of horses if you make superficial muscle fascia incisions – allow draining
- Not really seen in ruminants – as they are vaccinated for clostridia organisms
- Dogs/cats not very sensitive for clostridia

Infection Risk
- Site Considerations
o Clean wound = surgical incision into clean aseptic tissue
o Clean contaminated = wounds that we or animal makes into hollow viscus (trachea, bladder)
o Contaminated = procedures of wounds that get into GI structures
o Dirty = wounds that are contaminated from the outside or inside with fecal material
- Contributing Factors
o Aseptic technique = gloves
o Tissue handling = as little manipulation as possible, use appropriate tool (thumb forceps), etc.
Cut out contaminated tissue
o Suture material = any time you put suture into contaminated wound you  likelihood of wound
staying infected
 Braided suture material = holds bacteria better
 Use monofilament suture material
o Electrocautery = hemorrhage control, target the end of the cut vessel not just a gob of tissue
 Don’t want blood/serum exudating into wound
o Patient immune status
 Often overlooked
 In small animals lots of animals on immunosuppressive drugs -  risk of infection
 Chronic glucocorticoids -  risk of infection, slower healing
 Large animals – take animal off feed for anesthesia
 For 24 h in horse has negative effect on immune status

Clean Surgery
- Clean wound
- Elective surgery performed under aseptic technique
- No viscus violated, no drain
- Infection Rate: 2.5% in dog/cats
- Prophylactic antibiotics
o Cannot really justify use when infection rate is so low… (antibiotic resistance)
o Inexperienced surgeons – use cephazolin
o Target the likely pathogen in the species
 Dog  staph, coliforms – want a broad spectrum, high power antibiotic
 Cow  Trueperella pyogenes, coliforms – sensitive to almost anything
 Horse  strep zooepidemicus, coliforms

Clean-Contaminated Surgery
- Hollow viscus surgery
- Minimal contamination of the wound from the outside
- Drain – turns any procedure into a clean-contaminated surgery, infection rate ~ 4.5%
- Prophylactic antibiotics – YES, target most likely pathogens
Contaminated Surgery
- GIT surgery
- Contamination of tissues
- Fresh and open wound less then 4 hours old
- Infection rate = 5.8%
- Antibiotics are therapeutic – best guess at first, wound culture and susceptibility testing to determine
long term antibiotic

Dirty Surgery
- Old wounds > 4 years old – significant contamination from outside
- GIT rupture
- Infection rate 18.1%
- Antibiotics are essential

Triad of Considerations
1. Surgeon Factors (most important)
o Aseptic – surgical technique
o Patient management techniques
2. Patient Factors
o Age – not a big consideration if animal is healthy
o Immune status
o Metabolic status
3. Surgery Site Factors
o Degree of contamination (clean  dirty)
o Justification for using antibiotics

LECTURE 3 – WOUND HEALING

First Intention Healing: primary wound healing, primary closure

- Sutured incision, tissue apposition

Second Intention Healing: open wound healing

- Granulation tissue, contraction, epithelialization

Wound Healing Sequence of Events

1. Wounding
2. Vascular Phase
 Endothelial injury, hemorrhage, vasoconstriction, cellular adhesion, coagulation
3. Inflammatory Phase: 7-14 days, wound swelling, contraction
 Localized protective response elicited by injury or tissue destruction which serves to destroy,
dilute or wall off both the injurious agent and injured tissue, prepares wound for repair process
 Vascular events: cell adhesion, vasodilation
 Increased vascular permeability  inflammatory exudate (cells, fluid, mediators)
 Cells: mast cells, granulocytes, platelets, macrophages
 Vasoactive substances: histamine, serotonin, kinins, prostaglandins, chemotactic agents – all
work to increase vascular permeability and mitosis
 Localization: vasodilation, leakage, lymphatic blockage
  Signs of Inflammation: redness, heat, swelling, pain, loss of function
 Epithelialization: fibrin-fibronectin seal, epithelial migration, epithelial proliferation
4. Cellular Phase: 30-35 days, fibroplasia, further wound contraction
 Fibroblast infiltration: fibrin-fibronectin scaffold, fibrinolysis
 Ground substance secretion, capillary ingrowth
 Granulation tissue: capillary loop, fibroblast, macrophages
 Proliferation: 2-4 weeks, collagen increases, gains strength
5. Maturation phase
 Crosslinking: aldehyde bonds
 Collagen remodelling (Type 3  Type 1)
 Cellularity decreases
 Gains strength

Factors Affecting Wound Healing

- Local Wound Factors
o Surgeon:
 Tissue handling
 Procedure duration
 Suture material
 Suture tension
 Hematoma
 Seroma
o Wound environment
 Infection
 Foreign body
 Microenvironment: oxygen tension, temperature, pH, use of topical medications
- Systemic Factors
o Patient: age, nutrition, deficiencies, corticosteroids, NSAIDs, immunosuppression

LECTURE 4 – EARLY WOUND MANAGEMENT

Signalment and History

- Duration and mechanism of injury
- Estimate blood loss – because we will likely sedate/anesthetize the patient
- Previous treatments & outcomes

In large animal medicine, we hear a lot about wounds over the telephone:
- Make remote recommendations
o Restrict movement
 Kimsey splint – 500$, takes up a lot of room in truck
 PVC splint – need a lot of pipe, takes up a lot of room in truck
 Pressure bandage and cast material
o Garden hose lavage
 Flushes wound out
 cleans up wound faster than it takes you to get there
o Control hemorrhage
 Pressure bandage – want to put the wrap on almost fully stretched, large animals
 Apply pressure with your hand – small animals
 o Suspected fracture
 You must attend the patient, make the diagnosis, manage the limb (stabilize limb)
 Want to prevent a closed fracture from becoming an open fracture

Patient Assessment
- Full systemic assessment – don’t want to miss anything
o Cardiovascular status – pulse, MM colour, CRT
 Pale, prolonged CRT = blood loss
  pulse = pain
o Respiratory status – RR
  RR = short, rapid breaths
o Body condition
  BCS = decreased prognosis, delayed healing
- Wound assessment
o Golden period < 8 hours = when wound is contaminated but not infected
 Primary closure
o Visual examination (look at wound closely)
 Location, extent of injury, age of wound, condition of wound
o Digital examination
 Sedate patient (local anesthesia)
 Sterile lube in wound – catches hair/debris that goes into wound while clipping, when
you lavage it hair/debris flushes out
 Clip/Prep before touching
 Explore the wound – look for involved structures
 Joint evaluation – look for joint involvement arthrocentesis
 Do protein and cell count on it
 Do differential on it – want to see low protein and low cell count, predominantly
mononuclear cells
 If 90% neutrophils the joint is likely compromised = joint sepsis
 Fluid injection
 Indicated if you do arthrocentesis and don’t get any joint fluid
 Inject sterile saline or LRS – see if fluid leaks out
o Diagnostic imaging (x-rays, ultrasound, CT, MRI)
 Assess bone

Client communication
- Wound, severity, treatment plan, prognosis
- Show them pictures of similar wounds, show them how it might turn out if you manage it a particular
way
- Make sure client understands the financial implications

Wound Debridement
- Not every wound needs it, but every wound benefits from debridement
- Goals
o Remove contamination
o Remove devitalized tissue
o Eliminate infection
- 3 Methods of Debridement
 o Sharp dissection – don’t do much collateral damage
o Curettage – scrapes the affected bone out
o Irrigation – flush with sterile fluid or water

Wound Lavage (a debridement tool)

- Goals
o Remove debris
o Reduce bacterial numbers
- Mechanics of Lavage
o Ideal pressure – 7 PSI (10 ml syringe with 19-gauge needle on it)
o Avoid low and high pressures
 Low = doesn’t get debris
 High = pushes debris into wound
- Lavage Instruments
o Garden hose
o Syringe
o Pulsavac
- Lavage Solutions
o Ideal solution: non-irritating & bactericidal
o Saline – fairly acidic, causes low-grade inflammatory reaction, not anti-bacterial
o Lactated Ringer’s – better then saline, not anti-bacterial
o Povidone Iodine
 Need > 1% (1:10 dilution) to be bactericidal
 Non-irritating
 At > 0.5% it is histotoxic (kills cells, inhibits neutrophil migration)
 Not good from a healing standpoint
o Chlorhexidine
 Need 0.05% (1:40 dilution) to be bactericidal
 Non-irritating
 Histotoxic at 0.02%
 Makes wounds heal faster
 Incredibly irritating in synovial structures
 Not good for lavage of bladder @ 0.05%  severe hemorrhagic cystitis
o Chlorhexidine in TrisEDTA
 0.0005% chlorhexidine is bactericidal
 TrisEDTA = cell wall detergent, allows you to lower the chlorhexidine dose 100 fold
 Non-irritating to tissues or synovial structures
 Good for peri-anal fistulas, occasionally joint infections
 Efficacy not evaluated
o Antibiotic containing solutions
 0.25% neomycin, 0.1% gentocin
 Most of antibiotic ends up on the floor when you are doing a lavage
 Little evidence of efficacy
 Might be effective to leave it in the joint (regional perfusion scenario)

Role of Antibiotics
- Prophylaxis – before contamination
- Therapeutic – once the injury has occurred (trauma)
LECTURE 5 – WOUND CLOSURE

Types of Wound Closure  primary, delayed primary, secondary

Primary Wound Closure

- Surgical incisions OR fresh wounds
- Advantages: optimal function, best cosmetics, shortest healing time
- Wound selection is really important
o Anatomic location
 Head = well vascularized, not much movement, handle being repaired very nicely
 Body = somewhere in the middle
 Limbs = nearly deficient regional blood supply, more likely to get tissue loss the farther
away from the heart
o Wounds not suited to closure: tension, tissue, motion
- Closure technique
o Anatomic reconstruction – put tissues back into normal position
o Tension free coaptation – sutures gently hold skin in apposition
o Non-surgical wounds – avoid braided suture,  chances of infection

Delayed Primary Closure (Underutilized)

- Resolve infection
- Achieve debridement
- Before granulation tissue (3-5 days)
- Success is dependent on: Resolution of infection & Tension managed closure
- Steps: Day 1 – debride, Day 2 – cleanse, Day 3 – repair

Secondary Closure
- After granulation tissue
- Advantages: allows resolution of infection, host debridement (allows animal to “self-debride”)
- Disadvantages: tissue less manipulative (due to fibrosis)
- Will need tension relief techniques to get the wound closed

Reasons for Failure Price of Failure

- Tension - Client’ money
- Devitalized tissue - Veterinarians time
- Infection - Tissue loss
- Extension of infection
Managing Tension
1. Tension relieving sutures
- Near-Far-Far-Near suture pattern
o No eversion/inversion, opposes tissue nicely
- Vertical Mattress
o Along with simple interrupted
- Stented vertical mattress
o Red rubber stoppers on vertical mattress stitches
- BAD: horizontal mattress – compromises the vascular supply, area within the sutures will slough
and end up with a big scar
2. Tissue undermining: Dissect tissue subcutaneously usually with scissors
 3. Tension relieving incisions: Heal very quickly, contract, epithelialize, undetectable once hair grows
back
4. Plasty procedures
5. Pre-suturing
- Large mattress sutures overtop of mass and pull skin over mass, leave it there for 4-8 hours and
skin stress relaxes, then when you do mass resection you can close tissues without tens ion
- Good for sarcoids in horses

Alternatives to Closure (when you can’t close a wound)

- Second intention healing
- Skin grafts and flaps

LECTURE 6 – SECOND INTENTION HEALING

Key Components
1. Granulation
o Exuberant granulation tissue is a problem in the horse
o Prevention & good wound management  debridement, sterile dressing, pressure bandages
2. Contraction
o Myofibroblasts – actin, fibronectin
o Contraction theories – picture frame theory, pull theory
o Limitations: contact inhibition, opposing tension, myofibroblasts disappear
o Rates of Contraction: body 1 mm/day vs. limbs 0.2 mm/day
 Why is it slower than the body? Inelasticity of skin, vascular insufficiency, fewer
myofibroblasts, cytokines
3. Epithelialization
o Rates of Epithelialization: body 0.2 mm/day vs. limbs 0.09 mm/day

Bandage Philosophy Consequences of Treatment

- Pressure early - Bandages
o Minimize limb swelling - Wound medications
o Reduces wound size
- After inflammatory phase Indications of Immobilization
o May need mechanical protection - Wounds in high motion areas (heal, hocks,
o Slow healing – increase temp, lower elbows)
oxygen

MANAGEMENT OF EXUBERANT GRANULATION TISSUE

Critical Observation
- Need to watch how granulation tissue is behaving in the horse
- If you are not the reason for granulation tissue, you need to look for what is causing it!

Sharp Debridement
- Use scalpel to cut back damaged tissue (start distally, work proximally)
- Repeat as needed
- Costly/cumbersome for client
- Use a pressure bandage to control blood loss (1 st 4-5 hours then replace with a bandage with less
tension)
Topical Medications
- Control granulation tissue, owner friendly
- Impede healing (contraction and epithelialization) – takes a lot longer compared to sharp debridement

- Corticosteroids
o Inhibit granulation tissue, slows epithelialization
o Use judiciously – don’t want the granulation to atrophy
o Eg. Panalog, Green Wound Cream, 0.1% dexamethazone ointment
- White Wound Lotion
o Lead acetate, zinc sulfate  metabolic toxins – kills fibroblasts
o Slows epithelialization
o Bandage over ointment – if animal licks off there is potential for lead poisoning
- Copper sulfate
o Astringent/caustic – very cheap, kills fibroblasts
o 10% concentration – mix with corn starch
- Furacin
o Stimulates granulation, inhibits epithelialization
o Harbors pseudomonas
o NOT acceptable for wound management
- Preparation H
o Yeast extract
o Stimulates granulation, slows contraction and epithelialization
- Amnion
o Wound dressing  Inhibits granulation tissue, promotes epithelialization
o Speeds up healing – only one with evidence that proves its beneficial
o Not commercially available, need relationship with broodmare farm
- Honey
o Unpasteurized
o Osmotic – helps suck the juices of life out of bacteria
o Peroxidase may be present in honey as well
- Collagen Preparations
o No negative effects, no benefits, expensive
- Biosyst
o Porcine small intestine submucosa (collagen, proteoglycans, cytokines)
 Beneficial effects if you put on top of granulation tissue
o Promoted – scaffold, healing modifier, fill in hole with cornea
- Split-Thickness Skin Grafts
o Inhibit granulation, promotes wound contraction
o Zenographs (pig skin)
o Allografts – harvest from similar species
o Autografts – harvest from patient at hand
- Effect of Medication Preparation
o Gentamicin cream (oil based) vs. Solution (water based)
 Oil based ointment negative affected wound
- Red, Purple, Green
o Don’t put on wounds, pisses the wound off get more problems with granulation tissue
LECTURE 7 – SUTURE MATERIALS

Historically
- Horse hair
- Tendons

Ideal Suture Properties

1. Maintain tensile strength
o If intended to be absorbable – predictable decay curve for loss of strength. Inverse relationship
to how fast the wound heals
o If non absorbable – should maintain tensile strength
2. Non-capillary
3. Good handling – pull through tissue without it dragging, keep it from knotting/kinking
4. Secure knots
5. Minimal reactivity – shouldn’t contribute to inflammation
6. Dependable absorption or inert
7. Should not favour bacterial growth

Classification of Suture Materials

Absorbable Non-absorbable
- Collagen - Silk
- Surgical gut - Cotton
- Polyglycolic Acid - Nylon
- Polyglactin 910 - Polypropylene
- Polydioxanone - Polymerized Caprolactam
- Polyglyconate - Polyester
- Poliglecaprone 25 - Stainless steel
- Glycomer 631

ABSORBABLE SUTURE

Surgical Gut (Surgigut)

- Natural Multifilament – made from SI of cattle and sheep, favours bacterial growth, capillary action,
good handling
- Formaldehyde treatment – makes it very reactive, changes collagen conformation, more resistant to
phagocytic absorption (but still susceptible) – more absorption with more inflammation!
- Ionizing radiation to sterilize
- Not autoclavable – breaks down collagen
- Loses 50% of tensile strength after 14 days

Polyglycolic Acid (Dexon II)

- Synthetic Multifilament – capillary action will wick fluid into wound, favours bacterial growth, saws
through tissues, is reactive
- Secure knots – need long tails
- Tensile strength is not great (20% @ 14 days)
Polyglactin 910 (Coated Vicryl)
- Synthetic Multifilament – place for bacteria to hide
- Maintain tensile strength – 50% @ 14 days, good for holding fascia
- Coating to help smoothen it
- Need 4 throws to have secure knots, long tails
- Absorption is 40-90 days – good for SQ closures or infected wounds

Polydioxanone (PDS II)

- Less likely to kink / tie knots in itself
- Monofilament – not capillary, doesn’t favour bacterial growth
- Synthetic
- Great strength retention characteristics, 75% of strength left at 14 days – ideal for closing fascial
tissues and suturing tendons
- Good handling – a bit slippery
- Knots are secure – need 4 throws
- Not absorbed until ~ 180 days – physically there much longer

Polyglyconate (Maxon)
- Green Synthetic Monofilament – not capillary, doesn’t favour bacterial growth, minimal reactivity
- Similar tensile strength and absorption characteristics as PDS II
- Hard to get tight secure knots, good for buried patterns
- Teal coloured

Poliglecaprone 25 (Monocryl)
- Monofilament – not capillary, doesn’t favour bacterial growth
- Synthetic
- 30% of strength left at 14 days
- knots are very secure
- Absorbed by 60-90 days – good for SQ closures

Glycomer 631 (Biosyn)

- Monofilament – non-capillary, doesn’t favour bacterial growth
- Synthetic
- 50% of strength left at 21 days – slightly better than Monocryl
- Absorbed by 90-110 days – good for uterine closures in pigs/cows/sheeps (anything you intend to get
pregnant again in same season)

NON-ABSORBABLE SUTURE – maintains 75% of strength out to 6-9 months

Silk
- Multifilament – capillary action, favours bacterial growth
- Natural
- Ligature standard – knots are very secure
- Pretty reactive – itchy during healing process
- Good tensile strength – 50% remains after 1 year
Cotton
- Multifilament – capillary, favours bacteria, reactive
- Natural
- Often seen as umbilical tape – good for uterine prolapse
- Terrible material

Nylon (Dermalon)
- Black Synthetic Monofilament – not capillary, black dye makes it antibacterial
- Maintains strength
- Has a bit of memory – stays in shape of the pack
- Knots secure with 4 throws
- Inert

Polypropylene (Novafil, Prolene)

- Blue Synthetic Monofilament – non-capillary, doesn’t promote bacterial growth, minimal reactivity
- Very slippery, has a bit of stretch in it
- Secure knots in 4 throws

Polymerized Caprolactam (Vetafil, Supramid)

- Coated Synthetic Multifilament – favours bacterial growth, capillary action
- Related to nylon – very strong, handles well
- Secure knot in 4 throws
- Reactive - DO NOT BURY

Polyester (Ethibond)
- Synthetic Multifilament – capillary, promotes bacterial growth, reactive
- Stronger then nylon
- Saws through tissue
- Secure knot in 6 throws – bacteria can hide in these large knots, may form suture abscesses

Stainless steel
- Incredibly strong
- Handling is difficult, don’t want to kink it
- Secure knots in 2 throws with fine material
- Non-reactive, inert, doesn’t favour bacteria

SELECTION OF SUTURE MATERIALS

- Ideally suture strength mirrors strength of tissue
- Decay curve mirrors the rate of the wound healing

Suture Material
- Skin – monofilament non-absorbable
- SQ – synthetic absorbable (PDS II, Monocryl)
- Fascia – monofilament absorbable or non-absorbable
- Tendon – monofilament absorbable (PDS, Maxon) or Nylon

Suture Needles
- Swaged on needles – less traumatic, easier
- Eyed needle – more traumatic, difficult
Needle Shapes (depth of wound determines type of circle – deeper wounds need more curved needles)
- Half circle
- 3/8 circle
- ½ curved
- Straight

Needle Points
- Taper – ideal for loose areaolar tissues, small intestine, bladder
- Cutting – ideal for skin closures, cuts where the suture is going to lie
- Reverse cutting – ideal for skin closures
- Taper cut – getting through tendons and heavy fascia
- Trocar Point

Tissue
- Skin – cutting
- Bowel/SQ – Taper
- Fascia/Tendon – taper or modified cutting
- The deeper the wound, the more curved the needle

LECTURE 8 – DEAD SPACE AND DRAINAGE

What is dead space? Abnormal space or potential space within a wound that contains fluid or gas

Causes of dead space

- Extensive dissection
- Injury resulting in tissue loss
- Removal of large masses
- Reconstruction with flaps and grafts

Fluid Accumulation Within a Wound = Reduces healing, favors infection if bugs are present
o Antibody opsonic activity lost
o Disrupts phagocyte-bacteria interaction
o Substrate for bacterial growth
o Compromises blood supply
o Interferes with graft acceptance

Avoid Creating Dead Space If Possible

- Meticulous, minimalist technique
- Avoid undermining when you make incisions
- Mayo dissection (actually done with metzenbalm scissors)
- Don’t remove tissue unless there’s a good reason for it to go

Dealing with Dead Space

1. Tacking/Walking Sutures
2. Pressure Bandages
3. Drainage
Tacking (walking) sutures
- take lots of little bites to close up a moderate amount of dead space, may prevent SQ from sliding over
muscles

Pressure bandages
- Pushes skin down onto what lies underneath

Drainage
- Passive Drains: fluid is let out, some by capillary action, most by gravity (path of least resistance),
depends on pressure differences, efficacy dependent on surface area
o Penrose Drains
 Doesn’t exit through primary incision or wound, exits out around the drain, drain just
keeps wound open
 Gravitationally dependent
 Aseptic post-op care – needs to be covered and bandaged
- Active Drains (Closed Suction Drains)
o Tubing within wound attaches to a suction apparatus
o More efficient than passive suction, not gravity dependent
o Most Common: Jackson-Pratt drain attached to grenade suction device
- Physiologic Drainage
o Omentalization: take omentum and suture it into the area.
 Great for abscesses in abdominal organs

Treatment as an Open Wound

- Right answer when significant contamination present
- Exception: brain and heart

Vacuum Assisted Closure (VAC)

- Vacuum applied to wound through open cell foam covered by occlusive layer
- Encourages granulation tissue formation, eases wound care

When to use drainage? If fluid will remain or be produced post-op and it is a problem
- If massive contamination present and can’t be resolved surgically
- DO NOT use drainage for post op seromas and hematomas

When to remove drain

- 1-7 days after surgery OR when it stops working (clogs/kinks)
- Dependent on fluid quality and quantity
o Decreased amount (1/4 of original over 24 h)
o Serosanguinous
o if fluid <0.2 ml/kg/hr

Removing Drains
- Remove sutures and pull
- Ensure entire drain is removed (mark end of tube that is in wound)
- Usually no sedation needed
- Cover wound for 24-48 hours
LECTURE 9 – TENSION RELIEF AND PLASTIES

What is tension?
- Pulls on wound and counteracts closure
- Increases complications: dehiscence, tissue death (causes capillaries to collapse), delays healing

Excessive tension
- Prevents wound closure
- Compromises blood flow
- Tourniquet effect on distal limb
- Restricts movement excessive scarring or strictures

What affects tension?

- Species and breed – horses have little extra skin, Sharpay dogs have lots
- Location on body – trunk, neck, flank have lots of extra skin, legs have little extra skin
- Orientation of wound

Lines of Tension
- Wounds usually close best if closed parallel to the lines of tension
o Also consider movement of nearby appendages
- Pinch test to check skin tension in all directions

Planning Surgery
- Is there enough skin to close?
- How much of surrounding tissue is healthy and can be used?
- Use towel clamps to manipulate tissues to find a closing pattern that works

Managing Tension
- Undermining
o Undermine in direction of skin advancement (perpendicular to lines of tension)
o Undermine deep to the cutaneous muscle layer (preserves skins blood supply)
o Beyond a certain point, undermining further won’t help
- Walking sutures
o Obliterate dead space & distributes tensile forces throughout wound
o Facilitates progressive advancement of undermined skin into wound defect
- Skin stretching
o Skin is viscoelastic
o Tissue expanders: balloon implanted beneath skin next to where you need skin to go, it is
gradually inflated with saline over several weeks, balloon removed when skin is moved
o Presuturing: large mattress or lambert sutures, fold up skin on either side of defect (3-5 cm) for
24-72 hours.
o Adjustable sutures: button, splint shot, advances edge together
o Adherent skin pads applied 10 cm on either side of wound, elastic cables connect pads and held
in place under tension with Velcro, leave for 48-72 hours, increase tension 3x a day
- Releasing incisions
o Make secondary incisions around the primary incisions so you can close the primary incision
o Avoid leaving narrow strip of skin b/w two incisions (will die)
- Plasties
 o Useful when wounds are adjacent to structures that will not tolerate tension (anus, prepuce,
eyelids)
o V-Y plasty
 More tension from side to side, less tension in perpendicular
direction
o Y-U plasty
 Useful for pyloric constrictions
 Used to make something wider from side to side
o Z plasty
 Decrease tension in one direction at the expense of increased tension in another
direction
 Treats contracture
 Central limb is along the line of tension and arms are the
length of the central limb.

LECTURE 10 – SKIN FLAPS

Flaps and Grafts

- Used for closing skin defects in situations where the wound wouldn’t heal completely or by contracture
and epithelialization
- Used to close big surgical wounds without producing undue tension

Flaps
- Maintain connection to donor site at one end (at least)
- Depend on blood supply coming from donor area to survive
- The need to maintain blood supply from donor site limits length and positioning of flap

Subdermal Plexus Flaps

- Nourished by random blood supply via subdermal plexus (keep cutaneous
trunci with skin)
- Should not be more than twice as long as they are wide
- Base should be wider than the tip

- Rotation Flap: arc is 3x the length of the defect, must undermine the
flap

- Single Pedicle Advancement Flap: should be perpendicular to the line

of tension.

- Transposition Flap: flap rotates to cover defect then close donor flap

- Skin Fold Flap: redundant tissue in inguinal/axillary region, transposed to

adjacent thoracic/abdominal wall and proximal limbs

- Phalangeal Fillet: move pad from digital pad for metacarpal pad
Axial Pattern Flaps
- Cutaneous artery goes with the flap, bigger artery and higher blood pressure (can make a longer flap)
- Are generally transposition flaps – can be transposed up to 180 degrees
- Robust closure for high motion/pressure areas (trunk/proximal limb)
- Follow anatomical landmarks (angiosomes) or use transillumination technique (shine light
through skin) to find the cutaneous artery
- Useful for reconstruction of large wounds of head, neck and proximal extremities
o Not good for anything below the elbow

- Lateral Genicular Flap: used to cover lateral or cranial side of distal leg, can cut as high as the grea ter
trochanter with the base starting at the level of the patella

- Caudal Superficial Epigastric Flap:

o External pudendal artery exits inguinal ring and branches into CGE
then extends cranially along mammary chain
o Angiosome includes mammary glands 3, 4, 5
o Can extend to include gland 2
o Good for closure of medial thigh wounds

- Thoracodorsal Flap
o Close defect on proximal aspect of forelimb or cranio-ventral thorax defects
o 2x the width of the distance from the scapular spine to caudal border of scapula

- Superficial Brachial Flap

o Flap starts at crook of the elbow & is as wide as the greater tubercle

Island Flaps
- Subset of axial pattern flaps
- Cut the base of skin but not through the artery

Grafts
- Term usually reserved for tissue removed entirely from the donor site and placed into
the recipient site
- May be either vascularized or not (more common in vet med)
LECTURE 11 – SKIN GRAFTS

Skin Grafts
- Pieces of skin that are completely detached from the donor site
- Vascular grafts require microsurgery to connect their main vessels to supply vessels in the recipient site
- Avascular grafts depend on ingrowth of blood vessels from the wound for survival

Flaps Grafts
- Robust, require little after care - More delicate, need protection and lots of
- Good cosmetic appearance aftercare
- Donor bed may be large - Cosmetic appearance depends on graft
- Not easily used on sites at or distal to the thickness and donor site
carpus/tarsus - Donor site smaller than flaps
- Especially useful for covering wounds of
distal extremities

Partial Thickness Grafts

- Can get big chunks of skin b/c you don’t need to close donor bed (skin grows back)
- Donor site quite painful
- Do this when there is not much intact skin left
- Requires special instrument for harvest
- Results in poor hair growth at both recipient and donor site
- More common in large animals and people

Full Thickness
- Prettier
- Easier to harvest and less painful
- Similar survival as partial thickness
- More common in small animals
- Takes all of the dermis, cuts off SQ, preserves base of hair follicles so hair can grow back

Types of Skin Grafts

- Sheet, pie crust, mesh
- All general full thickness

Pinch and Punch Grafts

- Advantages
o Minimal donor site morbidity – just lots of little holes
o Done under local
o Motion at recipient site not a big deal as each graft moves independently
o Commonly used in horses
- Disadvantages
o Not very cosmetic, poor hair growth
o Majority of coverage is only epithelial – more prone to trauma than full-thickness skin

Footpad Free Grafts

- Type of punch grafts
- Place around periphery of wound
- Epithelial component will slough and regenerate
Incorporation of Skin Grafts
- Graft adherence is initially dependent on suturing and bandaging
- Fibrin attachment comes first (then fibrinolysis 2-3 days later)
- Later, blood vessel ingrowth and collagen attachment
- Graft must be in close contact with wound bed to allow nutrition/oxygenation of cells and later
ingrowth of blood vessels/collagen (cannot let fluid accumulate b/w these layers)

Nutrition of Skin Grafts

- Plasmatic imbibition: osmotic/capillary movement of wound fluid and proteins
- Inosculation: open end of vessels in wound bed and graft kiss and allow fluid exchange
- Vessel ingrowth: capillary buds from wound bed invade graft

Wound Beds
- Good Recipients
o Healthy granulation tissue
o Fresh wounds
- Bad Recipients
o Infected/contaminated tissue
o Desiccated, dead bone
o Very irregular surfaces

Selection of Appropriate Donor Sites

- Can adequate skin be harvested and close the donor defect?
- Consider hair characteristics and post op functional/cosmetic concerns

Full Thickness Mesh Grafting

- Trace template of the wound then use template to mark the donor site
- Or can use a towel and press on it then use blood stain as the template

Graft Harvest
- Excise graft from donor site leaving as much SQ tissue as possible
- Mark graft so you know which way hair goes
- Suture donor site

Graft Preparation
- Remove all SQ tissue until you see cobblestone appearance of hair follicles
- Pin graft to sterile foam or cardboard and make multiple holes with scalpel
o Allows fluid out and expands graft

Preparation of Recipient Site

- Gentle surgical prep if wound isn’t fresh
- Excise excessive granulation tissue and epithelialized edges
- Pressure wrap to control hemorrhage if necessary

Graft Inset
- Establish correct orientation
- Stabilize graft edge to wound edge – staples or simple interrupted or continuous sutures
- Tacking sutures within body of graft to hold the middle down
- Do not stretch – tension = bad, rather it didn’t fit perfectly than have it stretched
Postoperative Considerations
- Stabilize the graft – bandages, negative pressure wound therapy (VAC), splints, external skeletal
fixation in high motion areas
- Bandaging:
o First layer non-stick and porous so fluid escapes – petrolatum impregnated gauze
o Next layer: absorbent
o Splint if needed
o Avoid changing bandage for first 5 days post op – may disrupt blood vessel ingrowth

Series of Events
- Day 1: blanched graft
- Day 2-4: early revascularization
Day 5-7: improved vascular perfusion
- Day 8-10: approaches normal appearance

LECTURE 12 – FRACTURE BIOMECHANICS & CLASSIFICATION

Forces Acting on Fractures

- Bending: results in angulation
- Torsion: results in rotation
- Compression: results in shear (oblique fractures) or collapse (comminuted fractures) or is beneficial for
transverse fractures
Tension: results in distraction

Avulsion: fracture caused by tensile force

- Common when quadriceps pulls free the tibial tuberosity

Most fractures are acted on by a combination of forces that must be neutralized for the fracture to heal.

Controlling Forces
- Casts/Splints: good for bending, fair for torsion, do nothing for compression/tension
- IM pins: good for bending only
- Wires: control tension and produce compression, do nothing for other forces
- Interlocking nails: good against all forces
- External skeleton fixators: good against all forces as long as a good configuration is chosen
- Bone plates: good against all forces
- ** can combine types of fixation to improve control over the forces

Fracture Classification
- Degree of soft tissue disruption
o Closed: swelling, deformed, no open wound
o Open: open wound, bone may be exposed, worry about infection as it slows healing
 If a bullet is in the wound it’s an open fracture
- Degree of cortical disruption
o Greenstick: cortex disrupted on one side, bent on other side, heal easily just got to hold them
together
o Fissure: a tiny hairline fracture, can go on to become something worse
 o Saucer Fracture: bit of cortex breaks off the bone. Common when kicked by horse or bite
wounds in small animals, or when surgeon sends screw in and it emerges
o Complete Fracture: complete break through both cortices, bone in two separate pieces, most
common fracture dealt with
o Depression Fracture: happens in flat bones
- Geometry of Fracture Lines
o Transverse
 Prone to bending and
torsion forces
 Compression is good
and promotes healing
o Oblique
 Prone to shearing from compression (bad for blood vessels) and torsion
 Can only use wires/screws on long oblique fractures (2x the width of the bone)
o Spiral
 Common in tibia & humerus due to natural spiral component of
bone
o Comminuted
 Multiple pieces of bone
 Butterfly, segmental or multiple
 In butterfly/segmental middle piece may have less blood supply
 No occlusion at all with a multiple comminuted fracture
- Location Within the Bone
o Proximal, distal or middle 1/3 of bone
o Fractures in middle of bone are called midshaft
o Proximal/distal fractures are harder to fix compared to midshaft fractures
and may interfere with joint function
o Articular, physeal, metaphyseal, diaphyseal, condylar/supracondylar, trochanteric
- Displacement
o Named after distal fragments location relative to the proximal fragment
 Eg. Caudo-lateral = the distal fragment is caudal and lateral to the proximal fragment
o If fragments are angled relative to each other describe where apex of the angle points in that
plane
- Cause
o Traumatic: HBC, shot
o Pathologic: bone is weaker secondary to pathologic processes and breaks under normal forces
 Eg. Neoplasm, Bone Cysts, etc.
o Fatigue
o Iatrogenic

Factors Influencing Fracture Type

- Energy applied
o Bone is viscoelastic
o The more rapid the loading the more likely bone is to break (Laffy Taffy Example)
- Type/direction of force applied
- Which bone is injured
- Age of animal
LECTURE 13 – EXTERNAL COAPTATION

External coaptation = limb splinting External fixation = bone splinting

EC is good at neutralizing bending forces (good) and is fair at neutralizing torsion (but cast needs to fit very
well). Good for a well aligned transverse fracture, not great for oblique fractures

Advantages of EC
- Minimal disruption of blood supply
- Minimal interference with physeal growth
- Nonsurgical placement = cheaper, may need
GA to get EC on, weekly rechecks/changes
add up, avoid potential for surgical
complications (infection)
Limitations of EC
- Poor control of tensile and compressive
forces (oblique fractures)
- Less rigid stabilization than with internal
fixation
- Alignment and reduction is
difficult/impossible to attain closed
- Inappropriate for some bones (femur,
humerus, pelvis)

Complications of EC
- Joint immobilization can lead to stiffening, muscle atrophy or contracture osteoarthritis
o Especially true in young animals or birds
- Rub sores and dermatitis = splint too loose
- Constrictive coaptation can lead to congestion or necrosis of extremities = splint too tight

Indications for EC
- Transverse fractures where compression will be your friend – should line up well (>50% overlap)
- NOT in tiny breed dogs or Italian grey hounds with distal radial fractures
o Poor blood supply to this area, should send for surgery b/c prone to non-union
- Fractures stabilized by an adjacent intact bone (fibula, ulna, metacarpals/tarsals)
- Fractures in young animals with intact periosteal sleeve (greenstick or fissure fractures)
- Some joint injuries while they heal (collateral ligament tears, luxations that feel stable after reduction)
- Temporary support until definitive repair can be done
- To augment or support surgical repairs
- For immobilization/protection of concurrent soft tissue injuries

Principles of Application
- Immobilize the joint above and below the fracture
o Exception: if you are immobilizing a joint, ONLY need to immobilize the 1 joint
- Include toes in coaptation no matter what to prevent venous congestion (small animals only)
o Middle 2 toes should be peaking out
- EC should conform closely to the limb and be applied firmly enough to prevent motion of padding
against
- Coapt limbs in normal walking position – bones need forces to heal
- Coapt limbs in neutral position or with a slight varus tendency
Forms of EC:

Casts
- Circumferentially placing rigid material around the limb
- Minimal padding, most rigid form of EC
- Common in large animals – need lots of strength in horses/cows
- Uses: definitive stabilization of some fractures, joint immobilization, support after arthrodesis

Splints
- Padding and compressive layers encircle limb, but rigid material is not around the whole limb (only on
one side)
- Easier to check and change
- Most commonly used in small animals
- Uses: definitive repair of relatively stable fractures, fracture repair in young animals, support of
operative repairs/reduced luxation, temporary stabilization
- Schroeder-Thomas splints should only be used for fractures at or distal to the elbow joint, should
NEVER be used to repair femoral fractures (holds stifle in rigid extension, quadriceps contract and leg
gets trapped forever with stifle extended = cannot walk on it, fix is limb amputation)
- Palmar splint – used for carpal and metacarpal injuries
- Spica splint – good for elbow injuries, goes up and wraps around the thorax.

Braces (Orthotics)
- Like splints, minimal padding
- Designed to be worn part time
- May allow motion in one plane but not another
- Best ones are custom designed to the dog
- Not much science supports their use

Bandages
- Provide minimal support
- Can cover wounds, may help control swelling
- NOT for fracture immobilization

Slings
- Non-rigid supports that alter limb position or weight bearing Ehmer Sling
- Padding generally minimal
- Ehmer Sling: produces flexion and internal rotation of hip - keeps hind limb non-weight bearing, used
mostly after hip luxation reduction, can produce wicked pressure sores if not carefully monitored.
- Hindlimb Non-weight Bearing Sling
- Sciatic Sling – used to discourage knuckling in limbs with incomplete sciatic
palsy
- Velpeau Sling – forelimb non-weight bearing sling, used after reduction of
medial shoulder luxation, scapular fractures and for misc. shoulder repairs.
Valpeau Sling
LECTURE 14 – INTERNAL FIXATION OF FRACTURES I

Indications for Surgical Fracture Repair

- Things that external coaptation doesn’t work well for
- Open fractures
- Fractures of humerus, femur and some pelvic fractures
- Articular fractures
- Oblique or comminuted fractures
- Avulsion fractures

Intramedullary Pins (IM Pins)

- Fix the fracture by running a pin down the middle of the bone (at neutral axis of bending)
- Advantages:
o Cheap – each stainless-steel pin costs $7
o Readily available equipment – can literally use a drill from a hardware store
o Good axial alignment of fragments
o Can be placed minimally invasive
o Very good at controlling bending
o Minimal disruption of blood supply to bone (will disrupt endosteal blood supply to bone)
o Hardware easy to remove – under sedation or a short anesthetic
- Forces Controlled: bending ONLY
o The more you fill the medullary canal the more it resists bending
o Usually combined with other fixation devices
 Cerclage: wiring the bone together circumferentially – helps control torsion and
compression, crap against bending
 Bone Plate: controls compression and torsion
 External skeleton fixation – run pin out of the top of the animal, connect it to the
connecting bar that holds the other pins. Prevents the pin from backing out and
prevents animal from pulling fixator off.
- Limitations
o Only controls bending
o IM pins must be in a stable fracture – if unstable the pin will migrate and back out
 Need to reduce the fracture (put it back together in anatomically correct positions)
o Pin migration or bad placement can damage adjacent joints or soft tissues
o Inappropriate for repair of bones (radius, phalanges) which lack non-articular tubercles near the
end of the bone to admit placement of a pin = no good place to start or end the pin
 NEVER pin the radius!!!
- Placing IM Pins
o Normograde Pin Placement: reduce the fracture, start the pin at one end of the bone and run
to the other end of the bone. Nice and straightforward. Works well for easily reduced fractures,
good for bones where distal ends are easily accessible (calcaneous, olecranon, greater tubercle)
 If you don’t have a perfect reduction distally the pin may “slip” out of the bone
o Retrograde Pin Placement: can insert pin at fracture sit, push it way up then run it down into
the distal fragment
 Very common for femoral fracture repair
 A bit difficult due to the sciatic nerve – extend hip & adduct the limb
- IM pinning rules
o Pin with diameter about 60% of the medullary canal at its narrowest point
 Bigger pins controls forces better, not so big that it affects blood supply.
 o Spear the pin into the cortex at the distal end (do not penetrate)
- Types of IM Pins
o Threaded Pins: threads cut into pins, pin is fat in one part and skinny at another part, pin will be
prone to breaking at the pin-thread interface, doesn’t improve grip
o Interlocking Nails: big IM pin with holes drilled in it, can send screws or bolts through holding it
in place to bone cortices.
 Advantages: control ALL forces acting on a fracture, pin migration not a problem,
usually do not require removal, anatomic reconstruction of the fracture is not
necessary.
 Disadvantages: only work where you can place IM pins (femur, humerus, tibia),
inappropriate for fractures with very short proximal or distal fragments
o Cross Pins: pins do not run up IM canal, they enter one cortex and exit another cortex.
 Advantages: use limited to metaphyseal and physeal fractures where the adjacent joint
will bend instead of the repair
 Disadvantages: short pins, do not control bending well

Cerclage Wiring (Circumferential Wiring)

- Used to augment other repairs (bone plates, IM pins)
- Generally, never used by itself
- Advantages:
o Controls torsion, compression or tension forces
o Great for spiral fractures or fractures with a LONG oblique component to it
- Disadvantages: does not control bending
- Rules:
o Always place at least 2 cerclage wires.
 One wire acts as a fulcrum and concentrates forces at fracture site
o Must be placed perpendicular to the bone and must be tight
 If loose = interfere with blood supply and slips
o Must reconstruct the cylinder of the bone – no gaps, no mushing
 Must get all of the pieces together

Interfragmentary Wiring
- Generally used to augment another form of repair
- Hole must be drilled for placement

Tension Band Fixation

- For repair of fractures acted upon by tensile force
o Tibial tuberosity, olecranon of ulna
LECTURE 15 – EXTERNAL SKELETAL FIXATION (ESF)
- Controls ALL forces

Definitions
- Transfixation pins go into the bone and connect to a connecting bar outside of the body
- Smooth tip pins = don’t hold very well
- Negative profile pin = threads cut into the pin, point of weakness at pin-thread interface
- Positive profile pin = threads on outside of the pin, most commonly used
- Half pin – goes from connecting bar, through skin, through both sides of the bone, but not out the
other side. Threaded at the tips
- Full pin – goes from connecting bar, through skin, through both sides of bone, out the other side of the
skin and to a connecting bar. Centrally threaded

Connecting Bars

- Rods and Clamps: Kirschner-Ehmer apparatus, Securos and S-K systems, steel and carbon fiber rods
o Advantages
 Uniformly strong – each type has been tested
 Bone is stabilized once you have the framework built
 Construct is adjustable if you don’t like the positioning of something
o Disadvantages
 Pins have to be placed in a straight line
 Limited angling of pins possible
 Pins must be of a smaller size (to fit into clamps)

- Acrylic: methymethacrylate, thermoplastic, acrylic putty

o Connecting bar made of something that hardens later (after placement)
o Advantages
 Lots of options for fitting the apparatus for the patients situation
 Pins can vary in size, can be bent and angled
 Many freeform configurations possible
 Cheap
o Disadvantages
 Fracture is not stable until all pins in place and the apparatus is hardened
 Not adjustable once connecting bar has set

Type Ia ESF
- Just pins coming from one side, attaching to a single connecting bar
- Most commonly used ESF, simplest and easiest to do, pins/connecting bars are
strongest for this type of thing
- Minimum of 3 pins per proximal and distal fragment

Type II ESF
- Same as above, but add a connecting bar to the other side
- Not common for radius/ulna fractures anymore – got to go through a lot of muscle
Type Ib ESF
- Second most common type of apparatus
- Is two type 1a EST at 90 degrees to one another
- Common on radius/humeral fractures

Type III ESF

- Type II plus Type Ia at 90 degree angles
- Almost never used anymore – “too strong” – bone doesn’t feel a need to heal

IM Pin – ESF Tie-In

- IM pin goes down into bone and exits out of the animal and gets incorporated into an external fixator
- Can reduce # of transfixation pins to 1-2 per proximal/distal fragment
- Can fix most fractures with this method, very good technique to know
- Advantages:
o Good axial alignment of bone
o Good bending control with fewer transfixation pins
o IM pin can’t migrate
o Stronger than pin combined with fixator but not tied in
- Disadvantages:
o Can only use in bones appropriate for IM pinning

Circular ESF
- Use very thin pins (quite flexible – called wires)
- Attached to a circular apparatus, 2-3 connecting bars
- Strings are not strong without tension, promotes bone jiggling
- Slight amount of up/down jiggle promotes bone formation

Bone Lengthening
- If you pull bone apart slowly you can promote new bone formation across the gap

Circular-Hybrid ESF
- Good for short proximal or distal fragments
- Circular part around the short distal fragment, the rest held together with a type Ia ESF

Transfixation Cast
- Problem with shortening/compression of the fracture in the hoof
- Run pins through upper fragment and incorporate them into the cas t
- Cast and pins control torsion adequately
- Used especially in horses, cattle and people, also bunnies

Rules of Engagement

Transfixation Pins
- Even half pins must fully penetrate both cortices of the bone
- Minimum of 3 pins per major fragment
o Place one pin in each fragment close to the joint
o Place one pin in each fragment close to the fracture (no closer than 0.5 cm from the edge)
o Space other pins in between
- Fewer pins acceptable if ESF is tied in to IM pins (then minimum of 1 pin per major fragment)
 - Pins should not exceed 25% of the diameter of the bone at that point
o Risk of iatrogenic fracturing >30%
- Angle smooth pins relative to each other, threaded pins do not need to be angled

Connecting Bar Rules

- The closer the bar to the bone the stronger the fixator (more bending control)… BUT
o Clamps and rods to close to the skin causes nasty rub sores
o Solution: place clamps/bars a finger’s width away from the skin

ESF Postoperative Care

- Pins are placed through stab incisions
- Patient on antibiotics for first 5 days (the time where we worry about infection)
o It takes ~5 days for granulation tissue to form in pin tracks (resists infection)
- Until that time, pad soft tissues b/w pins
- After just pad the external fixator (protects animal and furniture) & lets air get to it

ESF Advantages
- Minimal disruption of blood supply to the bone
- Hardware is removed with only sedation when fracture is healed
- Hardware removal can be staged to gradually transfer weight-bearing forces back to the bone
- Anatomic reconstruction of bone is not necessary
- Good for fractures with relatively short proximal or distal fragments
- Joints can be spanned if necessary
- Relatively inexpensive

ESF Disadvantages
- Not great for femur/humerus/ilium repair – goes through large muscle mass, may restrict the motions
- Some owner vigilance required
- Hardware does need to be removed eventually

What is ESF good for?

- Open fractures
- Degloving injuries
- Highly comminuted fractures
- Fractures with short proximal/distal fragments
- Stabilization of corrective osteotomies

Pin Track Drainage

- Loose pins
- Pins going through lots of muscle
- Antibiotic therapy may work short term
- Remove or replace offending pins
LECTURE 16 – PLATES AND SCREWS

Non-locking plating: force transferred from bone to plate via friction at each screw site
- Plate needs to be contoured to the bone, especially where there are screws.

Locking plating: screws and plate work as a unit, like an external skeletal fixator
- Head of screw has threads in it which engage with threads in the hole in the plate
- Each screw becomes “continuous” with the plate
- Gap b/w the plate and the bone is OK, does not have to be perfectly contoured to the
bone

Forces Controlled by Bone Plates and Screws

- ALL of them as long as you follow the rules and choose a big enough plate
- Screws alone control torsion and compression but to some degree are ineffective against bending
(because the screw can break at the threads)

Advantages of Bone Plating

- Anatomic reconstruction of fracture not always necessary
- Minimal irritation of overlying muscle
- Little intervention required by owner
- Fragments can be compressed

Limitations of Bone Plating

- Most expensive way to fix a bone
- Considerable exposure required (unless minimally invasive technique chosen)
- Very disruptive to blood supply
- Even plates can break with cycling
- Plate removal requires a second operation (typically not removed)
- Not appropriated for fractures with very short proximal or distal fragments
o Holes predrilled in the plate, cannot choose where you put the screws, may only be able to get
one screw into short proximal/distal fractures

IM Pin-Plate Combination
- Most resistant to cycling forces than plating alone
- Pin on neutral axis of bending of bone
- Pin at least 30% diameter of bone at its thinnest point
- Minimal screws per major fragment: 1-2

Screw Size Matters

- Screws are classified according to external diameter
o External diameter: diameter of screw including threads
 Accounts for screws ability to fight being pulled out
o Internal diameter: diameter of screws not including threads
 Accounts for screws strengths
- Plates are sized according to the size of screws they accommodate

Screw 2.7 mm across in external diameter = a two-seven screw

A plate that takes 2.7 mm screws = a two-seven plate
Method of Screw Application
- Neutral: positional screws – no compression added across fracture line by screw
o Pull fracture fragments together, hold them together with cerclage wire or clamp then send the
screw across.
- Compression: lag screws – squeeze fractures together
o Use screw to squeeze two fracture fragments together. Does not rely on a clamp/cerclage wire
o Drill a small hole the size of external diameter on the near side. The screw doesn’t engage with
the near cortex, then starts engaging threads on the far cortex. As it advances through the
screw head engages with the near cortex and pushes the near cortex against the far cortex
pulling the pieces together.

Counting Cortices
- In order for a nonlocking plate to be stable there must be a minimum of 6 cortices engaged in the
proximal and distal fragments. Generally, means 3 screws per each cortex, but not always
- Minimum for locking plate = One bicortical and one monocortical screw per fragment

Plate Nomenclature
- Named by screw diameter that fits the holes in the plates
- Also named by the shape and purpose of the plate

Methods of Applying Bone Plates

- Neutralization Plate: fragments held in reduction and alignment (but not compressed)
o Used when the main fracture fragments can be reconstructed but when compression would
produce shearing (oblique fractures)

- Compression Plating: transverse fractures and osteotomies

o Use non-locking screws
o As screw slides into the curved hole it pushes the bone plate to
the side (depends on where you put the screw)

- Buttress plate: gap b/w fragments, so plate must bear all of the force until the fracture heals
o Need a nice thick plate that’s very strong

- Tension band plating: counters tensile forces

The Same plate can be used for all methods of application.

Where to Put the Plate?

- Put the plate on the tension side (harder to pull apart steel then to
bend it)
LECTURE 17 – BONE HEALING AND FRACTURE MANAGEMENT

Strain = a change in length, some cells handle strain better than others
- More pieces = lower strain
- Bigger gap = lower strain

The type of bone healing you get depends upon the size of gap b/w fragments, the strain, and the amount of
motion at the fracture site. Small blood vessels can move about 1 mm without dying.

Types of Bone Healing

Secondary Healing (Indirect) = callus formation OR endochondral ossification

- Healing via a sequence of tissue types which progressively make stiffer matrix
- Occurs in fractures which have some movement and or more than a 1 mm gap
- This is essentially the way we healed before surgeons came along

Mechanism:
- Fracture
- Hematoma followed by fibrin clot
- Fibrous tissue formation: cytokines released, fibroblasts move in and lay down collagen (fibrocartilage)
- As it gets stiffer chondrocytes can survive, move in and start laying down cartilage matrix
- Cartilage mineralization and blood vessel ingrowth (& chondrocytes start dying off)
- Osteoblasts move in and lay down bone
o Woven bone first, extends beyond the cortices
- Remodelling: osteoblasts lay down bone more along lines of stress, osteoclasts take away bone that
isn’t working for the animal

Wolff’s Law: bone remodels in response to stress  it is laid down where it is needed and resorbed where it is
not needed (Takes bone away where it is stretched, lays down new bone where there is compression)
- Wolffs law is good for angular defects, not good for torsion defects or lengthening of the bone

Growth Factors Influencing Bone Healing

- BMP 2 and 7 responsible for stimulating bone growth
- Insulin-like growth factor
- Transforming growth factor 
- PDGT, Fibroblast growth factors, VEGF

Primary Healing = if fracture allows and rigid stabilization of the fracture

- Formation of bone without intermediate tissue coming first
- Requires close apposition of fragments, blood supply and rigid stabilization
- Contact healing
o Requires direct contact b/w bone fragments
o Multicellular bone forming units (cutting cones) form spot welds
o Then remodelling of laminar bone occurs
- Gap Healing
o Gap of 1 mm or less b/w fragments and fracture is rigidly stabilized
o Hematoma  CT/blood vessels  osteoblast lay down lamellar bone in gap  cutting cones go
across new bone
Osteoblasts: make bone, must work on surfaces
Osteoclasts: eat bone, multiple nuclei, ruffled border, throw acid at bone and make a hole (resorption bay)
Cutting cone:
- Osteoclasts first – make a hole
- Osteoblasts behind – close the hole with woven bone

Blood Supply to Bone

- Nutrient artery  medullary canal and endosteum
- Metaphyseal blood vessels
- Periosteal blood vessels
- Extraosseous blood supply of healing bone comes from muscle
attachments – so try to minimally disrupt them when fixing a
fracture.
o This is why when you have a highly comminuted
fracture it is better to leave the tiny pieces in there

Some forms of fracture repair disrupt blood supply more than others
- External fixator: little stab incisions, not very disruptive to blood supply or muscle attachments
- IM Pins: not too bad, some may disrupt endosteal blood supply
- Cerclage Wire: If tight not disruptive, if hoola-hooping will scrape off the blood supply
- Bone plate: leaves blood supply on 3 surfaces of the bone

Anatomic vs Biologic Repair

Anatomic Repair
- Perfect alignment and apposition of fragments is the goal - primary healing
- Some early weight bearing may be possible through reconstructed one, sparing the apparatus and
helps the fracture to heal
- Usually requires generous exposure and direct manipulation of fragments
o Disrupts blood supply/early healing response to some extent
- Indications:
o Only for fractures that can be reconstructed
o Very slow healing fractures
o To avoid callus formation

Biologic Repair
- No big attempt to reconstruct the fractured bone
- Want joints to be aligned, good length and function. Don’t care what it looks like in the diaphysis
- Minimal disruption of blood supply
- Either closed or open approach to fracture reduction. Pull limb to length, align limb to correct angular
and rotational deformities - hold it in place with pins/nails, etc.
- Bone generally heals faster.. BUT until healing has occurred the hardware bears all the forces of weight
bearing
- Indications:
o Fractures with good blood supply that are expected to heal rapidly
o Appropriate for fractures you can’t reconstruct
o Not a good choice in situations where callus is bad (joints)
LECTURE 18 – COMPLICATIONS OF FRACTURE REPAIR

Technical Errors: if the repair method chosen is insufficient to neutralize forces acting on the fracture, the
repair will fail

Soft tissues also contribute to fracture repair fails

- Muscle atrophy
- Joint stiffness
- Tissue fibrosis
- Poor function or pain

Quadriceps Contracture
- Most common, most devastating
- Tends to follow delayed femoral fracture union
- Common after Schroeder-Thomas splinting of femoral fractures
- Common in young dogs (and cats)
- Use solid fracture repair and aggressive rehab to increase stifle flexion, best to avoid it all together.

Malunion
- Fracture healing with abnormal alignment, may or may not be a clinical problem.
- Malalignment may be angular, axial (shortened), torsional or a combination
- Up to 20% loss of femoral length is well tolerated in dogs/cats
- Up to 15 degrees self-correction of angular malalignment may happen over time
- Rotational malalignments and shortening do not self-correct

Correction of Malunions: Osteotomy

- Closing Wedge Osteotomy: find where the biggest curvature and take out a wedge, should turn into a
transverse fracture that you can repair easily. Downside is making the bone shorter, nice bone to bone
contact, heals fairly quickly

- Open Wedge Osteotomy: good for young patients, length of bone remains the same

- Combination Wedge Osteotomy: take half of a closing wedge and jam it in on the other side.
Disadvantage is that you have a tiny avascular piece of bone that is hard to get hardware into.

- Oblique Osteotomy: incision made the same, jam point tip into medullary canal of distal fragment.
Spanned with bone plate or external fixator.

- Dome osteotomy: saw makes semi-circular cut, then slide two pieces relative to each other. Not good
for torsional correction, get great bone on bone contact.

- Step Osteotomy: carve a flat Z into the bone, take a wedge out. Disadvantage is that there is not great
contact on either side but you can get a screw through it.

- Distraction Osteogenesis: cut the bone and use motors that we control to fix angular corrections over
time and to make a bone longer as need be.
Delayed Union and Nonunion Causes
o Excessive motion of fracture fragments
o Infection – prevents blood supply from forming
o Excessive gap b/w fragments
o Devitalized bone – attachments ripped off, no good blood supply
o Poor blood supply to fragments

Delayed Union: fracture that has not healed within the usual time (usually 3-5 months)

Nonunion: no healing well beyond the expected maximal time (6 months)

- Vascular hypertrophic nonunion: results from instability of the fracture site. Callus is present, fracture
edges are indistinct
o Treatment: rigid stabilization
- Avascular (Atrophic) nonunion: results from poor blood supply or excessive gap. Minimal to no callus
evident, sharp edges to bone ends which may be sclerotic, osteopenia may be marked, looks like bone
is withering away
o Treatment:
 Encourage ingrowth of new blood vessels
 Remove offending hardware, resect fibrous tissue and sclerotic bone ends from
fracture site, drill longitudinal holes (osteostixis) into medullary canal to
encourage blood vessel ingrowth
 Rigid stabilization, under compression if possible
 Stimulate bone growth: Cancellous bone graft, provide growth factors, mesenchymal
stem cells, bone transport

Bone Grafting = Transplanting of bone to stimulate healing or replace bony deficits

o Autografts: come from same animal, most common
o Allografts: come from different animal of the same species
o Xenografts: come from other species, least common

- Cortical bone grafts: used to replace big bone defects and provide physical support

- Cancellous bone grafts: very commonly used, take from metaphysis of nearby bone, provides little to
no physical support but stimulates healing
o Osteogenesis: transfers mesenchymal precursor cells in graft and differentiate into active
osteoblasts that make bone. Only 10% survive.
o Osteoconduction: scaffold for osteoblasts to lay down new bone on
o Osteoinduction: growth factors within graft recruit cells to turn into osteoblasts

- Collection of Cancellous Bone Grafts

o Make small hole in donor bone with pin/drill, use curette to scoop it out, store cancellous bone
in a bloody sponge in the dark until implantation
o Location of collection: proximal humerus, proximal tibial, femoral condyle, ilium (cats), sternum
(horses/birds)
o Where to use: delayed unions and nonunions, long bone fractures in adult animals, places
where there are bone deficits, osteomyelitis, arthrodesis

- Bone Graft Substitutes: injection of bone marrow into fracture/delayed union site, calcium phos phate
cements, bioglass, coral, BMP proteins / growth factors
LECTURE 19 – FRACTURE HEALING ASSESSMENT

What influences fracture healing?

- Nature of fracture
- Location of fracture
- Bone that is fractured
- Degree of soft tissue disruption
- Strain/motion at the fracture site
o Little tension promotes healing, too much tension is bad
o Axial bounce is good, up to a point
o Shear/torsion is bad
o Too little strain is bad
- Type of healing affects speed at which strength returns
- Limb use - use it or lose it
- Species
- Age – magic healing puppy juice!

Guidelines for Uncomplicated Fracture Healing Expectations

- 2-5 months of age: 2-4 weeks
- 6-12 months of age: 4-8 weeks
- Adult: 6-10 weeks
- Geezer: 12-16 weeks

Radiographic Union
- Primary (direct) healing: fracture line disappears
- Secondary (indirect) healing: bridging callus on at least 3 out of 4 cortices

Radiographic vs Clinical Union

- First resorption of dead bone occurs
- In adults, it takes about 6 weeks for callus to mineralize
- Feel for fracture getting sticky

Assessment of Repair and Healing – Three A’s

- Alignment and reduction
- Apparatus
- Activity

LECTURE 20 – HEMOSTASIS

All bleeding stops at some point. Surgery causes bleeding, we need to manage it, do not wait.

Why we want hemostasis?

- Critical to success of surgery
o Bleeding  anemia  shock  death
o Ideal culture media  more chance of infection
o Blood causes inflammation  delays healing
- Surgeon concerns
o Blood blocks view of surgery, want a clear dry field & want to be as efficient as possible
Minimizing hemorrhage minimizes infection/inflammation

Patient Problems
- Ideally coagulation is normal before surgery
- Good physical exam to see if there are coagulopathies
o Eg. Severe liver disease = produces coagulation factors
o Emergency procedures = GDV  uses up coagulation factors  DIC
o Septic animals more prone to bleeding
- Advanced testing if concerned: platelet count, PT/PTT, FDPs

Primary hemorrhage
- Cut vessels and it actively bleeds
- Careful surgical planning
o Minimized vessels that you cut during procedure (know your anatomy)
o Treat vessels before you cut them: clamp and ligate
o Gentle tissue handling

Secondary hemorrhage (delayed bleeding)

- Starts after surgery
- Didn’t adequately deal with problem during surgery
o Ligature - slips off vessel and it bleeds
o Infection – erodes through vessels
o Necrosis of vessels/tissues – usually due to trauma (clamps, etc)
o Hypotension during surgery  normotensive when awake

Minimizing Hemorrhage
- #1 rule = hemorrhage must be controlled, not blind or can do more damage
o Eg. Pull out ovarian pedicle, cut it and the vessel retract back into abdomen. Don’t grab clamps
and go in blind (might crush intestines, etc)
- Patients can lose <10% of blood acutely, if on fluids can lose a little more
o ~15-20% = likely need help (blood transfusion/support)

1. Pressure (finger/surgical sponge)

- Slows blood flow and lets clot flow
o Might be all you need for small vessels
o Larger vessels need a little more time – apply pressure, find exactly where bleeding is
happening then clamp it with a hemostat
- Dab not wipe (wipes clot away), moisten & slowly remove (adheres to clot)

2. Clamp (hemostat)
- Crushing vessel stimulates coagulation within the vessel – makes clot form in lumen of vessel
o Sacrifices the vessel
o Anything bigger then 1mm (artery) or 2mm (vein) then clamping/crushing likely is not enough.

3. Ligature (gold standard)

- Tie the end of vessel off with suture material, pulled tight until end of vessel is squished (sacrifices
vessel). Must be very tight (flashing – opening hemostat, tightening ligature, then reclose hemostat)
- Suture material is typically absorbable (unless working on great vessels like aorta or vena cava)
- Secure knots
 o If you think it’s not secure enough, do a double ligation
- Artery and vein tied separately = the gold standard.
- Single Ligature – rope wrapped around tube, tie as tight as you can, tie 4 square knots
o Can do 2 of these, put ½ - 1 cm b/w ligatures if doing a double ligation
- Transfixation – go through lumen of vessel or tissue around the vessel with your suture then tie it
tight, it cannot slip off. Caveat – making hole in vessel so bleeding may occur. Can put simple
circumferential below that to hold off bleeding.

STANDARD IN GENERAL PRACTICE: pressure, clamps, ligatures

BIGGER SURGERIS IN GENERAL PRACTICE: electrocautery & radiofrequency units

4. Vascular Clips
- Metal clips compressed on end of small vessel
- Fast, not as secure as a ligature (can slip), expensive
- Caution with MRI/CT

5. Topical Hemostatic Agents – help things clot

- Bone wax: cannot grab vessels in the trabeculae of bone, stuff the wax ito the bone and it plugs vessels
(pressure builds up which lets a clot form inside the bone). Not absorbable, acts as a foreign body
(don’t want to use a ton of it, use a small amount for vessels you cant see)
- Gelfoam: gelatin sponge, forms gel when wet, most commonly used for small low-level bleeding liver
and spleen. Put on with pressure and it makes a matrix for clot to form on. 4-5 weeks for it to absorb,
serves as a nidus for infection (do not use for intestine)
- Topical hemostatic agents: TONS, quick clot (powder), Avitene (bovine collagen), foreign material,
increased intestine.

6. Electocautery
- Pass electrical current through tissues, burns/destroys tissues and ends of vessels
- Works very well on small vessels <2 mm, if bigger then that isolate vessel & ligate
- Monopolar Cautery: current from hand piece  tissue  patient  ground plate (externally). Use to
coagulate bleeding vessels or cutting through tissues (prevents capillary bleeding)
o Direct: touch tip to vessel  burn
 If bleeding at same time, blood disperses electrical current and you get more burning
 Want a biggest possible ground plate and LOTS of contact
 Watch flammable liquids, paper drapes, other metal contacts (ECG leads)
 Minimal duration, minimal tissue
o Indirect: clamp vessel, touch clamp with tip, transfers through hemostat to vessel. More
accurate and controlled but must isolate vessel to get a clamp on it.
- Bipolar Cautery: 2 tips, current travels from one tip through tissue to the other tip (doesn’t go through
ground plate)
o Coagulation of what is in between
 Smaller bites = less damage to surrounding tissues
o Need small gap b/w tips of 1 mm
o Fast, accurate coagulation of isolated smaller vessels

7. Radiofrequency Units
- Similar to electrocautery, except uses radiofrequencies NOT electrical currents
- Good for both coagulation and making small tissue incisions
- Very affordable for general practice
8. Vessel Sealing Device (Ligasure = Electrothermal device)
- Vessel sealing device
- Bipolar with automatic feedback control
- Uses electric currents, not as much burning – melts collagen to seal the vessel permanently
- Coagulates +/- cuts b/w tips
- Seals the vessel with very low risk of problems

LECTURE 21 – BANDAGING

Indications
- Support suture lines
- Early wound management
- Management of granulation tissue
- Owner convenience

Function
- Pressure Bandages
o Rid of dead space, reduce limb edema, control hemorrhage and granulation tissue
- Support
o Mechanical – can protect lacerated tendons
o Circulatory support – supports venous/lymph supply
o Immobilization – if stiff
- Wound Environment
o Decrease pH, increase temperature  promotes granulation tissue
o Topical medications – holds in location you need
- Aesthetics
o Can be functional and eye catching

Ideal Bandage Material

- Inexpensive
- Conformable
- Inert
- Gas permeable
- Easily sterilized
- Capable of desired function (wicking fluid away from wound)
- Free of particulate matter
- Aesthetically pleasing

Basic Bandaging
- Primary (contact) layer = dressing
o Sterile, conduct exudate away from wound, maintain wound contact
o Adherent vs non-adherent, occlusive vs non-occlusive
- Secondary (intermediate) layer = padding/absorption layer (capillary action)
o Pressure distribution
o Support
o Material: cotton products
- Tertiary (outer) layer = occlusive or partially occlusive (protects internal components of bandage)
o Pressure application
 < 30 minutes w/o elastics – don’t use flanel
  50% stretch for elastics
o Protection from elements

Adherent Dressings
- Uses an open weave gauze
- Dry to Dry
o Open weave, put dressing on dry  aggressive debridement
o Removes exudate, dead tissue and superficial layer of granulation tissue
o Hurts to rip dressing off – heavily sedate animal for this
- Wet to Dry
o Put the bandage on wet  less aggressive debridement
o Reduces exudate viscosity, enhanced capillary action, topical antibiotics
- Wet to Wet
o Minimal debridement, enhanced capillary action, minimal adherence
o Good for high fluid producing wounds

Non-Adherent Dressings
- Gentle on tissue – good for covering skin grafts
- Materials: Telfa, Petrolatum (vasoline) Impregnated, Polyethylene Glycol
- Occlusive – almost never used, prevents good wound healing
- Semi-occlusive – oxygen can get to wound, exudate can get away from wound
- Non-occlusive

Difficult to Bandage Areas

 Tie-Over-Bandage (Stent Bandages)
 Vacuum Bandage
 Shave body part that will be unbandaged
 Steri-drape placed over wound, hook suction up to drain, sucks the bandage down
 Good for abdominal bandages, back wounds, etc, skin grafts

LECTURE 22 – TRAUMA OF MAJOR SURGERY

Response to Major Injury

- Local Phenomenon: wound healing
- Systemic Phenomenon: whole animal

Systemic Response to Injury

- Increased cardiac output
- Increased minute ventilation
- Febrile
- Increased metabolic rate – 1½ to 3 times the normal rate
o Just feeding the patient wont ensure the patient stays in a positive energy balance

In the face of increased energy demand there is:

- Accelerated lipolysis and proteolysis
- Easier to get glc out of protein compared to fat, muscles disappear first, fat goes second
- Amino acids are decent source of glucose and acute phase protein made in liver
- Ultimately need glucose for wound healing and to maintain vital organs (brain, kidneys, etc).
Pain Factor
- An active player – causes increased metabolic rate
- Pre-emptive analgesia – more effective than giving drug after wounding has happened, minimizes the
systemic response, giving small amounts earlier is better than giving large amounts later on.

Energy/Nitrogen Balance
- Nutritional Intake
o Important, may limit degree of catabolism, does not prevent catabolism
o Want to get animals back on feed asap after surgery
- Active players
o Endocrine system
o Nervous system
o Tissue factor

Fluid Compartments
- Expansion of the ECF which changes the volume of distribution of drugs that you give to the patient
- Aminoglycosides are widely distributed through ECF, if ECF is increased 20% and we don’t increase AG
dose by 20% then antibody level is not as high as it should be for the bug we are targeting.

Complex of Changes
- Volume Loss: circulating volume goes down, pituitary releases ADH and kidney releases aldosterone,
adrenal gland produces catecholamine to expand the blood volume.
- Under perfusion: in low flow states, there is compensatory flow distribution (body pumps blood to
brain and shunts it away from organs/skin). Ischemia leads to tissue deterioration. Beware of
reperfusion injury (ROS made when tissues reperfused).
- Starvation: trying to get glucose from krebs cycle, its made from pyruvate, fat is utilized to make A-Coa
with by product of ketones for energy, produces a decrease in metabolic rate
- Tissue Damage: hypercatabolic response, ACTH, IL, TNF, Interferon.
- Infection: endotoxin activates TNF and COX pathways which cause vasodilation/constriction
- Endocrine: afferent nerve signal trigger ACTH which activates adrenal gland to produce cortisol and
catecholamines.
o Catecholamines: decrease insulin, increase glucagon, and fat mobilization to increase glucose.
o Cortisol: increase amino acid breakdown to produce glucose

Metabolic Rate
Endocrine weight loss (in face of being fed) and immune suppression
Nutritional state

Controlling Factors
- Control hemostasis to control volume loss which improves underperfusion
- Do good quality surgery, don’t leave deleterious tissue in body for animal to look after

Pain Management
- Pre-emptive: before surgery
- Systemic analgesia: NSAIDs, Opioids
- Local anesthesia: epidurals, intraarticular analgesia (opioids)
LECTURE 23 – ADHESIONS

Adhesion: type of scar tissue formed b/w organs and tissue after abdominal surgery
- Forms as a result of tissue injury
- Dog/Cat adhesions are rarely a problem after abdominal surgery – due to their active fibrinolytic
system.
- Adhesions are the most common cause of recurrent abdominal pain in horses after SI surgery
- 2nd most common cause for repeat celiotomy in horses after abdominal surgery
- Most common reason for death after surgery in horses with SI lesions

Risk Factors in Horses

- Small intestinal lesions
- Prolonged post-op ileus
- Repeated exploratory celiotomy
- Age (higher incidence in <30 day old foals)
- Peritonitis and abdominal abscesses

Inflammation and Ischemia Predispose to Adhesion Formation

- Inflammation
o Peritoneal trauma
o Infection
o Bacterial contamination
o Foreign material
- Ischemia Tissue plasminogen activator
o Strangulating lesion is the key regulator of
o Vascular compromise fibrinolysis
o Intestinal distention
o Tight sutures
- Increased fibrin deposition, decreased fibrinolysis

Adhesions become a clinical problem

- Fibrinous adhesions  restrictive fibrous adhesion
o After inadequate fibrinolysis
- Permanent fibrous adhesions – form 7-14 days after surgery
- Compress or distort intestine
- Narrow intestinal lumen
- Impede normal passage ingesta

Fibrinous adhesions
- Rarely cause clinical problems
- Ungergo fibrinolysis in ~48-72 hours

Omental Adhesions – develop primarily to increase vascular supply, in non-equine spp, rarely a clinical
problem, most benign adhesion, may entrap the SI.

Fibrous adhesions
- From inadequate fibrinolysis
- Result from ingrowth of fibroblasts and endothelium
- Cause clinical signs
Classification of Adhesions
- Mostly involve the small intestine
- Occasionally cause problems in other GIT locations
- Clinical signs cab be divided based on severity.

Focal Fibrous Adhesion

- Intestine to mesentery, intestine to incision, intestine to peritoneum
o Do NOT cause distortion or kinking of intestine
o May predispose to obstruction or stricture of the SI
- Intestine to Intestine
o Cause distortion of mesentery or intestine  sharp convolutions  impede flow ingesta 
cause obstruction
o May predispose to intestinal volvulus
- Adhesive fibrous bands – b/w intestinal loops or intestine and mesentery  incarcerate SI

Massive Fibrous Adhesions

- Most severe form, adhesions b/w multiple loops of SI

Prevention of Adhesions
- Goals:
o Minimize peritoneal/serosal inflammation
o Maintain or enhance fibrinolysis
o Mechanically separate adhesiogenic surfaces
o Stimulate intestinal motility
- Prevention should begin at surgery and continues 3-4 days post-op
- Meticulous aseptic surgical technique is most important step in preventing adhesions

Intra Op Considerations
- Halsteds Principles
o Gentle handling of tissues
o Meticulous hemostasis
o Remove damaged tissue
o Minimize exposure suture
o Minimize surgical time
- Starch powder gloves – promote peritoneal inflammation, rinse gloves with sterile saline
- Keep bowl moist – avoid drying of serosa, continuous lavage, warm sterile isotonic fluid, prevents
desiccation

Perianastomotic Adhesion Formation

- Mucosal exposure, leakage at anastomosis, suture exposure (use inverting suture pattern)

Abdominal Lavage
- Sterile isotonic solutions (saline, LRS)
- Removal blood, fibrin and inflammatory mediators
- Decreases adhesions formation
- Good for contaminated procedures OR end of surgery
Protective Tissue Coating Solutions
- Mechanical lubricating barrier – serosal & peritoneal surfaces
- Application viscous solution – serosal surfaces, before manipulation
- 1% sodium carboxymethylcellulose = high MW solution = belly jelly
- Decreases incidence of adhesions, does not affect healing

Resorbable Barrier Materials

- Seprafilm – forms protective barrier against adhesion formation

Omentectomy
- Controversial
- Omental adhesion  cause abdominal pain (tension of mesentery, intestinal
obstruction/strangulation)

Post Op Abdominal Lavage

- Hydroflotation
o Separates intestinal and serosal surfaces, reduces inflammatory mediators and peritoneal fibrin
- Abdominal drain
o Placed at surgery or standing.

Pharmacological Interventions
- Broad spectrum antibiotics – sodium penicillin, gentamicin
- NSAIDs – flunixin
- DMSO
- Heparin – anticoagulant via anti-thrombin III
o Minimizes fibrin, enhances fibrinolysis (Decreased PCV in horses)

Prevent Post-Op Ileus

- Stimulate intestinal motility
- Prokinetic agents – lidocaine CRI, erythromycin, metoclopramide, bethanchole

OVERALL: Treatment of adhesions is unrewarding, expensive w/ poor prognosis for survival

Less Severe Adhesions

- Recurrent colic
- Managed medically – flunixin
- Low residue diets – pelleted rations, grazing

Severe Restrictive Adhesions

- Intestinal obstruction
- Strangulating lesion
- Repeat celiotomy – poor prognosis
- Euthanasia

Surgical Treatment of Adhesions

- Removed devitalized intestine – establish functional passage of ingesta
- Adhesiolysis – breakdown of adhesion
o Can be done laparoscopically – for focal intestinal adhesions
 Minimally invasive, standing, R-flank approach, dorsal recumbency