Treatment of Radius Curvus in a Young Dog with Association of Radial Physeal Stapling, Ulnar Ostectomy and Transarticular Dynamic External Fixator Techniques

Background: Radius curvus is a clinical manifestation of the premature closure of the distal ulnar physis and the most common physeal disease in dogs, representing 63% of all physeal injuries. There are few reports indicating the technique of stapling for treatment of radius curvus in squeletically immature dogs. The aim of this study is to report a case of radius curvus in a young dog successfully treated with a combination of 3 surgical tecniques: 1- Stapling the medial and cranial portions of the distal radial physis; 2- Oblique osteotomy of the proximal ulna and ostectomy of the distal ulna, and 3- Dynamic external skeletal fixation in the elbow joint.Case: A 5-month-old female dog was referred to the University Veterinary Hospital with a history of left thoracic limb deformity for 2 weeks. There was a history of possible traumatic event on the front limb, in addition to providing nutritional supplements daily. In the radiographic evaluation the changes were identified in the left thoracic limb: shortening of the ulna, procurvatum and medial angulation of the distal radius, increased joint space and articular incongruity of the elbow joint. The dog was subjected to surgical treatment by the combination of three main surgical techniques. For the stapling of the distal radial physis the surgical approach on the cranial-medial surface of the distal radius was made. Two surgical staples were positioned in the distal radial physis. Thereafter a caudal approach was made to the distal region of the ulnar diaphysis for the distal ostectomy of the ulna. A bone segment of 1 cm in length of the distal ulnar diaphysis was removed. Another caudal approach was made to the proximal region of the ulnar diaphysis and a proximal oblique osteotomy of the ulna was performed. For the dynamic external skeletal fixation in the elbow joint two Steinmann pins were inserted. The first pin was proximal to the supracondilar foramen of the humerus and the second pin was caudal to the trochlear notch of the ulna, both parallel to the joint surface. To create a dynamic system, the pin tips were connected with elastic rubber bands on the medial and lateral sides of the elbow joint. Clinical and radiographic revaluation were made at 15, 30 and 60 days after surgery. Total correction of the limb deviation was achieved at 60 days postoperative. Two years after the surgical procedure, the owner was contacted and reported that the dog was very well and with no change in the operated limb.Discussion: The most common cause of premature closure of the distal ulnar physis is trauma. Due to the proper conical shape of the distal ulnar physis, there is more predisposition to the compression of the germinative cells in traumatic events, leading to radius curvus disease. Another cause of the radius curvus is the nutritional disbalances. In the reported case the patient had both predisponent factors, although unilateral limb involvement suggested trauma with primary causative agent. The treatment included the interruption of the supplementation of the diet associated with surgical techniques. The stapling of the distal radial physis is usually indicated for mild angular valgus deviation. In the current case the technique was applied with success regardless of the higher grade of radial deviation. Generally, the ulnar ostectomy is preferred to the osteotomy, since it reduces the rate of ulnar osteosynthesis, ensuring that the restrictive effect of the ulna upon the radial growth does not restart. In the reported case the ulnar ostectomy was associated with ulnar osteotomy to achieve a more effective result. Furthermore, the proximal ulnar osteotomy is usually indicated when elbow subluxation is present. In the current case the joint congruence was improved with the use of the dynamic external skeletal fixator

Juvenile pubic symphysiodesis associated with pectineus myectomy for treatment of hip dysplasia in dog

Background: Hip dysplasia (HD) is the most common non-traumatic orthopedic disease in large breed dogs. Treatment is chosen according to the severity of the condition, the age of the dog and the involvement of osteoarthritis (OA). For puppies up to 20-weeks-old, surgical treatment by the juvenile pubic symphysiodesis (JPS) technique can be performed. This procedure promotes the ventrolateral rotation of the acetabulum over the femoral head, which improves hip joint congruence and stability. The objective of this study is to report the case of a young dog with HD treated with JPS and pectineus myectomy. Clinical and radiographic outcomes were assessed for up to one year after surgery.Case: A 17-week-old Saint Bernard puppy was attended at the University Veterinary Hospital showing abnormal weight bearing and lameness in pelvic limbs, without history of previous trauma. On orthopedic examination, there was a marked hypotrophy of the pelvic limb muscles, severe pain and laxity in the hip joints, and positive feature in the Ortolani test. The hip joint subluxation angle (SA) and reduction angle (RA) were measured. A radiographic study was carried out to evaluate the hip joints and measure the Norberg angle (NA), distraction index (DI), acetabular angle (AA) and dorsal acetabular rim angle (DARA). The 20-week-old dog underwent surgical treatment by JPS technique. A ventral surgical approach to the pubis was performed and the pubic symphysis was cauterized with electrocautery. Partial pectineus myectomy technique was also performed. Drug therapy and restriction of physical activities were indicated in the early postoperative. The dog was evaluated by clinical and radiographic examinations at 4 months and 1 year after the surgical procedure. In the reassessment after 4 months of surgical treatment, the patient showed improvement in clinical signs, with mild lameness and absence of painful sensitivity in the movement of the hip joints. Radiographically, hip joint incongruity was observed, but with progressive improvement in the values of the measured variables. In the clinical examination 1 year after the procedure, the dog showed satisfactory weight bearing with slight lameness in pelvic limbs in the running gait. There was improvement in the thigh muscles and no painful signs were observed in the hip joints, but a positive result was detected in the Ortolani test. In the radiographic examination, bilateral articular incongruity was still observed, however, there was a mild improvement in the coverage of the acetabulum over the femoral head. The measured angles and indices showed favorable results regarding the recovery of hip joint stability and proper development.Discussion: Studies evaluating the JPS technique for the treatment of HD have shown to be a relatively simple and effective procedure, which allows altering the acetabular coverage, reducing the development of HD and the progression of OA. The need for an early diagnosis of this condition is essential, so that the JPS technique can be used in young dogs and offer effective results. In the present report, in the late postoperative period, the dog showed improvement in clinical signs, with favorable weight bearing and ambulation in pelvic limbs, recovery of limb muscles, absence of pain in the hip joints and decrease in RA and SA. Radiographically, the reduction in joint subluxation, improvement in acetabular coverage over femoral heads, increase in NA and AA, reduction in DI and DARA are evidence of the favorable outcome of ventrolateral rotation of the acetabulum after surgical treatment. The surgical technique used was effective, which enabled the dog to recover the functional use of the pelvic limbs and improve the quality of life.Keywords: hip dysplasia, juvenile pubic symphysiodesis, hip joint, osteoarthritis, dog.Título: Sinfisiodese púbica juvenil associada à miectomia do pectíneopara tratamento de displasia coxofemoral em cãoDescritores: displasia coxofemoral, sinfisiodese púbica juvenil, coxofemoral, osteoartrite

Clinical comparison between two stabilization methods in distal tibial angular deviation corrected by the CORA method

Background: Angular deformity is characterized by the deviation of part of the bone that can occur in three different planes, frontal, sagittal and transverse. Trauma on physeal plates is the most common cause of angular deviations of the limbs in dogs. Currently the CORA (Center of Rotation of Angulation) methodology is the best way to evaluate and surgically correct these deformities. The objective of this study is to describe the surgical procedures performed to treat the uniapical valgus deviation affecting both tibial bones in a dog, comparing the outcomes of hybrid external skeletal fixator used in the right pelvic limb in relation to the locking plate used in the left pelvic limb.Case: A 10-month old Border Collie dog was attended at the University Veterinary Hospital with history of lameness and deviation of both pelvic limbs. In the orthopedic examination, it was possible to identify bilateral valgus deviation in the region of the tibio-tarsal joints and moderate lameness, with absence of pain or joint crepitation. Radiographic examination showed that the deformity was only uniapical in the frontal plane, affecting both tibial bones of the dog. Signs of osteoarthrosis were not observed and the preoperative examinations were within the normal limits for the species. The deformities were corrected in two surgical times starting with the procedure in the right tibia, which appeared to be clinically worse. Due to the fact that it was a bilateral affection and there was not a healthy pelvic limb to obtain the normal angles values of this dog, for planning according to the CORA methodology, the values of the tibial mechanical angles for dogs of similar size were taken from the literature. For surgical correction of the right tibia, a closed wedge osteotomy was performed following the second rule of Paley, with bone stabilization using type IB hybrid external skeletal fixator (ESF). The radiographic follow-up was done every 30 days postoperatively, however at 60 days the dog presented with severe lameness and the ESF had to be removed due to the breaking of one of the wires that composed the ring of the hybrid system. The limb continued to be treated by external bandages and total bone healing occurred at 210 days after surgery. Only after the complete recovery of the right limb, the left pelvic limb was operated and was also corrected by closed wedge osteotomy from the second Paley's rule. However, the bone stabilization was achieved with the use of a T-shaped locking plate. Radiographic follow-up was performed every 30 days postoperatively and at 60 days the osteotomy gap was already consolidated and the dog showed good weight bearing in the pelvic limbs without signs of lameness or pain.Discussion: Currently, it is indicated that bone deformities in small animals should be corrected using the CORA methodology. The hybrid ESF is one of the most commonly used fixation systems for bone stabilization after corrective osteotomies due to great versatility, however, the reported complication rates are relatively high. The locking plates with special shapes, such as the "T" plate used in this study, provide the stable fixation of osteotomies with limited bone stock, as they allow the introduction of larger number of screws per area. Thus, this latter type of implant becomes advantageous for the correction of bone deformities close to the joints. It is concluded that CORA methodology is really effective in the planning of corrective surgeries of angular deviations in dogs. In this case report, the resulting tibial angles after the surgical corrections were within the normal range for healthy dogs of similar size. However, the use of locking plate provided better results with early bone healing and fewer complications than the type IB hybrid ESF

Juvenile pubic symphysiodesis associated with pectineus myectomy for treatment of hip dysplasia in dog

Background: Hip dysplasia (HD) is the most common non-traumatic orthopedic disease in large breed dogs. Treatment is chosen according to the severity of the condition, the age of the dog and the involvement of osteoarthritis (OA). For puppies up to 20-weeks-old, surgical treatment by the juvenile pubic symphysiodesis (JPS) technique can be performed. This procedure promotes the ventrolateral rotation of the acetabulum over the femoral head, which improves hip joint congruence and stability. The objective of this study is to report the case of a young dog with HD treated with JPS and pectineus myectomy. Clinical and radiographic outcomes were assessed for up to one year after surgery.Case: A 17-week-old Saint Bernard puppy was attended at the University Veterinary Hospital showing abnormal weight bearing and lameness in pelvic limbs, without history of previous trauma. On orthopedic examination, there was a marked hypotrophy of the pelvic limb muscles, severe pain and laxity in the hip joints, and positive feature in the Ortolani test. The hip joint subluxation angle (SA) and reduction angle (RA) were measured. A radiographic study was carried out to evaluate the hip joints and measure the Norberg angle (NA), distraction index (DI), acetabular angle (AA) and dorsal acetabular rim angle (DARA). The 20-week-old dog underwent surgical treatment by JPS technique. A ventral surgical approach to the pubis was performed and the pubic symphysis was cauterized with electrocautery. Partial pectineus myectomy technique was also performed. Drug therapy and restriction of physical activities were indicated in the early postoperative. The dog was evaluated by clinical and radiographic examinations at 4 months and 1 year after the surgical procedure. In the reassessment after 4 months of surgical treatment, the patient showed improvement in clinical signs, with mild lameness and absence of painful sensitivity in the movement of the hip joints. Radiographically, hip joint incongruity was observed, but with progressive improvement in the values of the measured variables. In the clinical examination 1 year after the procedure, the dog showed satisfactory weight bearing with slight lameness in pelvic limbs in the running gait. There was improvement in the thigh muscles and no painful signs were observed in the hip joints, but a positive result was detected in the Ortolani test. In the radiographic examination, bilateral articular incongruity was still observed, however, there was a mild improvement in the coverage of the acetabulum over the femoral head. The measured angles and indices showed favorable results regarding the recovery of hip joint stability and proper development.Discussion: Studies evaluating the JPS technique for the treatment of HD have shown to be a relatively simple and effective procedure, which allows altering the acetabular coverage, reducing the development of HD and the progression of OA. The need for an early diagnosis of this condition is essential, so that the JPS technique can be used in young dogs and offer effective results. In the present report, in the late postoperative period, the dog showed improvement in clinical signs, with favorable weight bearing and ambulation in pelvic limbs, recovery of limb muscles, absence of pain in the hip joints and decrease in RA and SA. Radiographically, the reduction in joint subluxation, improvement in acetabular coverage over femoral heads, increase in NA and AA, reduction in DI and DARA are evidence of the favorable outcome of ventrolateral rotation of the acetabulum after surgical treatment. The surgical technique used was effective, which enabled the dog to recover the functional use of the pelvic limbs and improve the quality of life.Keywords: hip dysplasia, juvenile pubic symphysiodesis, hip joint, osteoarthritis, dog.Título: Sinfisiodese púbica juvenil associada à miectomia do pectíneopara tratamento de displasia coxofemoral em cãoDescritores: displasia coxofemoral, sinfisiodese púbica juvenil, coxofemoral, osteoartrite

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference -1·69 [-9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5-8] vs 6 [5-8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52-23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75-0·86]; p<0·0001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status