This document discusses the anatomy, biomechanics, pathogenesis, diagnosis and treatment of cranial cruciate ligament disease in dogs. It provides details on the cruciate ligaments and menisci, how injury typically occurs from trauma or degeneration, common clinical signs, and traditional surgical techniques for repair or reconstruction. Current trends focus on techniques that better restore normal joint kinematics, such as intra-articular reconstruction and use of isometric graft placement. Meniscal injury often accompanies cruciate ligament rupture and removal can accelerate osteoarthritis.
Management of ruptured cruciate ligament in dogsKamil Malik
it deals with the management of the ruptured cruciate ligaments in canines , i have gathered the information right from the predisposing factors , mechanism of injury , various diagnostic tests , and at last the treatment with old as well as latest techniques , all the pics that i have collected are from net , and few from books by pete muir and nunamaker ,
For vets especially importance of physical examination in any animal diagnosis can be well understand. No short cuts! to any treatment as we always say.
A comprehensive presentation about lameness in equine Covering almost all musculoskeletal and metabolic neurological diseases rendering a horse lame. Lameness examination i also explained.
Management of ruptured cruciate ligament in dogsKamil Malik
it deals with the management of the ruptured cruciate ligaments in canines , i have gathered the information right from the predisposing factors , mechanism of injury , various diagnostic tests , and at last the treatment with old as well as latest techniques , all the pics that i have collected are from net , and few from books by pete muir and nunamaker ,
For vets especially importance of physical examination in any animal diagnosis can be well understand. No short cuts! to any treatment as we always say.
A comprehensive presentation about lameness in equine Covering almost all musculoskeletal and metabolic neurological diseases rendering a horse lame. Lameness examination i also explained.
Preoperative planning in veterinary orthopaedics Ravi Raidurg
Aim : Introduce the concept of “ Preoperative planning in Veterinary Orthopaedics”
Learning Objectives
At the end of this session you should be able to:
Describe Fracture healing (Primary vs Secondary bone healing)
Describe Fracture Classification
Describe AO Fracture Classification of Long bones (eg AO 32 A3 ???)
Derive a Fracture Patient Assessment Score (FPAS) and describe factors (mechanical, biological and clinical) which support the score.
List Preoperative planning in MIO (Minimally Invasive Osteosynthesis)
The Importance of Good Handling Skills for Dairy CowsDAIReXNET
Dr. Proudfoot presented this information for DAIReXNET on November 5, 2015. To see the full recorded webinar, please visit http://www.extension.org/pages/15830/archived-dairy-cattle-webinars
Dan McFarland, an Agricultural Engineering Extension Educator for Penn State University, presented this material for DAIReXNET on January 14, 2015.
Find more information at http://www.extension.org/pages/15830/archived-dairy-cattle-webinars
Preoperative planning in veterinary orthopaedics Ravi Raidurg
Aim : Introduce the concept of “ Preoperative planning in Veterinary Orthopaedics”
Learning Objectives
At the end of this session you should be able to:
Describe Fracture healing (Primary vs Secondary bone healing)
Describe Fracture Classification
Describe AO Fracture Classification of Long bones (eg AO 32 A3 ???)
Derive a Fracture Patient Assessment Score (FPAS) and describe factors (mechanical, biological and clinical) which support the score.
List Preoperative planning in MIO (Minimally Invasive Osteosynthesis)
The Importance of Good Handling Skills for Dairy CowsDAIReXNET
Dr. Proudfoot presented this information for DAIReXNET on November 5, 2015. To see the full recorded webinar, please visit http://www.extension.org/pages/15830/archived-dairy-cattle-webinars
Dan McFarland, an Agricultural Engineering Extension Educator for Penn State University, presented this material for DAIReXNET on January 14, 2015.
Find more information at http://www.extension.org/pages/15830/archived-dairy-cattle-webinars
A presentation by Dr Dave Collins of SASH Vets Sydney
on Canine Biliary Disease - Gallbladder mucocoeles, Cholangitis and Extrahepatic bile duct obstruction.
SASH : Intravenous Lipid Emulsion - Applications in Toxicology by Dr Nicole ...SASH Vets
A presentation by Dr Nicole Spurlock
Emergency and Critical Care Medicine Vet at SASH veterinary hospital in Sydney Australia on Intravenous Lipid Emulsion and its Applications in Toxicology
DARTHROPLASTY – Practical Training – Wet Labs - Part 2Rafael Lourenço
DARTHROPLASTY – Practical Training – Wet Labs
11-12th November 2016 – Warsaw and Legionowo, Poland.
Legwet Veterinary Clinic, Centro de Cirurgia Veterinária de Loures and KK-Art held a practical training on 11-12th of November 2016, in Warsaw and Legionowo – Poland. It was attended by veterinary doctors from several countries.
You can see the slideshow presentation by Dr. Rafael Lourenço
Part 2
A comparative study on the clinical and functional outcome of limb salvage su...NAAR Journal
The aim of this study was to analyze the survival, recurrence, complications as well as the quality of life (QOL) in tibial osteosarcoma (OSA) patients managed by limb salvage surgery (LSS), either by a prosthesis, resection or graft or by amputation. 106 tibial osteosarcoma patients were enrolled where 39 had custom-designed endoprosthetic arthroplasty (LSS1), 36 underwent resection and bone graft (LSS2) while only 31 underwent amputation. A Comparison was done based on post-operative survival rates, postoperative recurrence, and complications. The impact of the patient’s QOL was also evaluated.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
SASH : 101 ways to fix a cruciate by Dr Stephen M. Fearnside
1. “101 ways to fix a
Cruciate”
Stephen M Fearnside
Veterinary Surgical Specialist
Small Animal Specialist Hospital
sfearnside@sashvets.com
2.
3. Design: Multicentre
prospective comparative
study
“in the absence of a
cohort of willing oxen as
a control group” ……..
Chose to compare
intelligence test scores
and dominant hand grip
strength in ortho
surgeons (x36) and
anaesthetists (x40)
3 UK District General
Hospitals
VS
4.
5. Introduction
• Incidence of CrCL disease in the USA in
dogs exceeds that in humans (Helliker,
Wall St Journal 2006)
• Estimated repair costs in USA (2003)
are $1.23 billion annually
• Recent studies demonstrate that no
single technique returns patients to
normal function consistently
6. Summary
Anatomical considerations
Biomechanical analysis
Review of Pathogenesis
Review of traditional techniques
What about the poor old meniscus?
Current trends and issues
7. Anatomy
Diarthrodial joint
2 distinct articulations
1. Femoral-tibial
2. Femoropatella
Joint Capsule:3 distinct
interconnecting
cavities. Reinforced by
fibrous retinaculum,
local ligaments and
tendons
9. Ligamentous support
Primary support via femorotibial ligaments:
1. Cruciate ligaments
2. Medial and lateral collateral
ligaments.
10. Cruciate Ligaments
Blood supply – from
synovial tissue sheath,
fat pad, caudal joint
soft tissue.
Intra-articular but
extrasynovial
Primary stabilisers
against cranial/caudal
tibial translation, axial
rotation (twisting on
each other),
hyperextension and
excess valgus/varus in
flexion.
Cruciate ligaments’
blood supply
11. Cranial Cruciate Lig
Origin = caudomedial
aspect of lateral femoral
condyle
Insertion = cranial
intercondyloid area of tibia
2 functional componants
1. Craniomedial band
2. Caudolateral band
Ligament spirals laterally
approx 900
collagen bundles grouped
into fascicles –
tightening/relaxing through
motion.
Craniomedial
Band
Caudolateral
Band
12. Stifle Joint Motion
Flexion and extension in sagittal plane
Slight cranio-caudal movement – not uniplanar
motion
Secondary restraints to cr-ca motion = joint
capsule, menisci, collat ligs, articular surface
shape, muscle forces
“Screw-home” mechanism
13. Stifle Joint Motion
Cranial Tibial Thrust
Result of ground
reaction forces +
extensor muscle forces
= compressive forces
through tibia shear
force generated
Countered by CrCL
(passive restraint) and
hamstrings/biceps m
(active restraints)
14. Pathogenesis
“rupture of the cranial cruciate
ligament is seen for the most
part in active jumpers, and
especially in those individuals
having the defect in
conformation where stifle and
tarsus are carried in over-
extension. The absence of
normal flexion angle of these
joints in the standing position
appears to be a predisposing
cause”
Erwin Schroeder, 1939
16. Pathogenesis
Degeneration
Age related changes in ligament (Vasseur et al, 1985).
Stress/strain energy of ligament decreases with age
Age related changes significantly greater for dogs>15kg
Histological changes
Tissue changes identified during progressive rupture (Muir et al
2002, Vasseur et al 1985)
Loss of ligament fibroblasts
Transformation of fibroblasts to ovoid or spheroid phenotype
Disruption of normal type I collagen – loss of crimp, disruption of
fascicles
Contribution of blood supply
Bilateral disease – 37% within average 17months (Doverspike
et al, 1993)
Young large breed dogs - <4ys, Rottweilers over
represented. Postulated cause = inadequate exercise when
young?? (Bennett et al, 1988)
18. Pathogenesis
Conformation
Contributing factors = internal rotation,
hyperextension, tibial plateau slope
Young large breed dogs -Read & Robins (1982)
Small breed dogs – Macias et al 2002, Selmi &
Padhilla 2001
Medial patella luxation
Congenital narrowing of the intercondylar notch
19. Pathogenesis
Immune mediated joint disease
Plasmacytic lymphocytic synovitis (Galloway &
Lester, 1995).
Anticollagen antibodies in serum and synovium
(Nierbauet et al 1987, DeRooster et al, 2000)
The chicken or the egg???
Osteoarthritis
OA a primary lesion?? (Hulse & Aron, 1994).
Role of genetics and conformation.
21. Epidemiology
Breed: large breed dogs predisposed
Rottie, Newfowndland, SBTerrier (Whitehair & Vasseur,
1993)
N.Mastiff, Retriever, Labrador, SBTerrier (Duval et al,
1999)
Breed variation in physical properties – Rottie ligament
requires ½ load per unit body mass that the GH ligament
requires to rupture (Wingfield et al, 2000)
Comparison of TPA between clinically normal GH and
Labradors with and without cruciate lig disease (Wilke et
al 2002).
Body Size: <22kg lower prevalence (Whitehair et al 1993)
<15kg tend – degenerative changes occur later in life
(Vasseur et al, 1985)
Obesity = increase load.
22. Epidemiology
Sex: Whitehair & Vasseur, (1993) reported higher
prevalence in neutered and female dogs
Duval et al (1999) increased risk in desexed dogs
but no male/female difference.
23. Clinical Signs and Diagnosis
Gait assessment: reducing external limb load, limb carried in
greater flexion (Vilensky et al 1994, Korvick et al 1994)
Joint effusion
Cranial draw and tibial compression (mimics loading to elicit
cranial tibial thrust)
What % of patients have drawer????? (Carobbi &
Ness 2009)
Radiography – Degenerative joint disease
effusion,
Compression stress radiography (de Rooster & Van
Bree 1999)
Joint fluid analysis: WCC<5000/mm3
, mononuclear cells
predominate.
25. Treatment
Conservative management
Cats – mean follow-up 20.5 months all cats (n=18) clinically
normal. Mean time to normal function 4.8wks (Scavelli &
Schrader 1987)
Small dogs <15kg :
90% success rate if <20kg (Pond & Campbell 1972).
86% clinically normal or improved after mean f/up 36.6mths
(Vasseur, 1984).
73% (8/11) free of lameness after mean 5.5mths (Strande
1967)
Dogs >15kg: 81% of dogs had persistent or worsening
lameness after mean f/up 10.2mths (Vasseur, 1984)
26. Surgical Management
Methods of conventional repair:
1. Primary repair – only for avulsion
injuries.
2. Intra-articular or intra-capsular repair
3. Extra-articular or extra-capsular repair.
28. Graft issues
Arnoczky et al 1982:
• Patella tendon graft revascularisation by 20 weeks –
vulnerable during the first 20weeks
• Initial necrosis revascularisation remodelling
• Revascularisation from: fat pad, posterior synovial
tissues
• 12mths = vascular and histological characteristics of
normal ligament
Biomechnical studies:
• Material properties decline significantly after
implantation
• Ultimate stiffness and load <35% of original ligament
29. Extra-articular reconstruction
Quicker, easier (except fibula head
transposition)
Changes the ‘instant centre of
motion” of the stifle which results in
compressive forces at the tibio-
femoral contact points (Arnocsky et
al 1977)
Designed to rotate tibia externally
allowing the MCL to act
synergistically with the laterally
placed suture to inhibit draw. Stifle
therefore becomes “hinge joint”
altering stifle kinematics (Patterson
et al 1991)
Ultimate joint stability due to
periarticular fibrosis.
30. Isometry
“For a suture that spans a joint to provide
support without limiting range of motion, its
attachment points on either side of the joint
must remain the same distance from each other
from full extension to full flexion”
Roe et al, VCOT 2008
31. Isometry: Roe et al VCOT 2008
Most isometric = Tibia site:1,2,5 if
femoral anchor site 4 used
32. Materials
Braided non-absorbable suture
material – draining sinus tracts
reported in 21% cases.
Monofilament nylon leader
line
Orthofibres
Sterilisation
Knotting vs crimping –
Crimping shown to result in less
elongation (knots tend to slip)
but also reduces strength
(Sicard et al 2002).
Crimping superior in all
biomechanical assessment
parameters (Anderson et al,
1998)
34. Materials – transcondylar systems
Tightrope CCL
Securos
systems:
• XGen CCR
• Bone anchors
and orthofibre
35. Results
Postoperative results: 85-90% improve. Complete
soundness = Less than 50% (Moore & Read, 1996).
Studies evaluating factors that influence prognosis
found that surgery type had little influence (Fallon &
Thomlinson 1986, Moore & Read 1995)
Studies report that DJD progresses despite
satisfactory clinical results (Vasseur & Berry 1992)
Biomechanically intra-articular techniques more
consistent with normal state using “instant centre of
motion” model (Arnoczky et al 1977) – the future??.
36. Meniscal Injury
Incidence varies – low
frequency for partial ruptures
(25% reported by Scavelli et all
1990) up to 80% in some
reports with complete tearing of
CrCL
Vascular supply – outer 10-
25%
Mechanism of damage –
crushing injury during cranial
subluxation of tibia
Lesion classification – 7
types (Bennett & May, 1991)
37.
38. The Meniscus
Human studies suggest that degree of
degenerative change directly proportional to
amount of meniscus removed (Cox et al
1975).
Meniscal release – controversial. Simple
transection has been shown to result in loss
of load bearing capacity – loss of ability to
resist circumferential strain.
39. Management of meniscal
injury
Healing potential –
peripheral tears, radial
tears
Experimental techniques –
vascular access channels,
exogenous fibrin clots,
allograft, prosthesis.
Porcine small intestinal
submucosa implants –
Welch et al (2002), Cook et
al (1999).
40. Tibial Plateau Leveling Osteotomy
The Slocum approach:
1. Slocum B, Devine T. Cranial tibial thrust: a primary force
in the canine stifle. JAVMA, 183:456, 1983
2. Slocum B, Devine T. Tibial plateau leveling osteotomy for
eliminating cranial tibial thrust in cranial cruciate ligament
repair. JAVMA, 184:564, 1984.
Procedure does not attempt to restore
function, but rather provide stability during
weight bearing by reducing cranial tibial
thrust
Note – does not eliminate passive drawer!!
41. Determining the
tibial plateau angle (TPA)
True lateral of stifle (femoral
and tibial condyles
superimposed).
Tibia parallel to table top
Slope of medial tibial plateau
determined
Tibial functional axis
determined
TPA defined as angle between
slope of the medial tibial
condyle and the perpendicular
to tibial long (functional) axis.
Tibial long
axis
Medial tibial
plateau
Perpendicular
to long tibial
axis
TPA
42. Procedures
Slocum Technique –
patented
Meniscal release –
recommended to allow
caudal pole of medial
meniscus to remain in
caudal compartment of
joint during cranial
translation of tibia.
Medial arthrotomy –
routine or limited
caudomedial approaches.
67. Postoperative rehabilitation – the
forgotten science?
Marsolais et al 2002: Prospective clinical trial with 51
dogs.
Limb function evaluated before and after surgery using
force plate analysis
Dogs assigned into rehabilitation or exercise restriction
groups.
Rehab programme – leash walking, massage, passive
ROM, swimming.
Significant increase in limb usage in rehab gp
compared with exercise restricted gp at 6mths.
68. “My Opinion – for what it is worth ”
Cruciate surgery in the dog = strong
opinion based on weak data.
A good extracap = a good TPL
surgery……BUT
TTA provides a more consistently good
outcome in large breed dogs
Small breeds????
Going forward with extracap – focus on
isometry.
69. Inspect the joint - Resect damaged
ligament and meniscus – controversial!
Adhere to strict aseptic principles.
Antibiotic use
Don’t over-tighten extracap sutures –
achieve stability
Rehabilitation is important!
70. The unanswered questions
There are many!!!
Preventative strategies remain in their infancy
If TPL restore mechanical stability then why does DJD
progress?
Why do only 60% of dogs with confirmed CrCL disease
have drawer
Why are we seeing so many cases of CrCL disease
What role does genetics play – shown to play a role in
Newfies (Wilkie et al, 2006)
72. Stifle Joint Replacement
We have the
technology!!!
Long recovery times
Complicated and
challenging surgery
Case selection!
73.
74. Tables
Table 1 Participants’ demographics, intelligence, and grip strength
Characteristic Orthopaedic surgeons (n=36) Anaesthetists (n=40)
Mean (SD) age (years) 42.2 (8.82) 42.5 (8.63)
Grade—consultant:specialist registrar 20:16 21:19
Handedness—right:left 36:0 38:2
Mean (SD) intelligence 105.19 (10.85) 98.38 (14.45)
Mean (SD) grip strength (kg) 47.25 (6.95) 43.83 (7.57)
75. Study Conclusions
The stereotypical image of male orthopaedic
surgeons as strong but stupid is unjustified in
comparison with their male anaesthetist counterparts.
The comedic repertoire of the average anaesthetist
needs to be revised in the light of these data.
76. The author’s recommendations:
“we would recommend caution in making
fun of orthopaedic surgeons, as unwary
anaesthetists may find themselves on the
receiving end of a sharp and quick witted
retort from their intellectually sharper
friends or may be greeted with a crushing
handshake at their next encounter”.
78. PICO – Negative pressure for wound
therapy
Single use negative pressure
wound therapy system
Provides -80mm Hg negative
pressure to wound bed
7 day use, 2 dressing per pack
Dressing consists of:
Silicone adhesive contact
layer
Airlock layer that
distributes –ve pressure
evenly
Absorbent layer
High MVTR that allows
excess fluid to transpire
79. Advantages of NPWT:
Promotion of closed moist
wound environment
Reduction of tissue oedema
Enhances wound contraction
Mechanical stimulation of
wound bed
Stimulation of angiogenesis
and alteration of blood flow at
wound edge
Aids in GT formation
Physical splinting of wound
and aids graft adherence.
Screw Home mechanism = cranial gliding and external rotation of the tibia relative to the femur as the joint is extended.
Magnitude of force determined by magnitude of ground reaction force and slope of plateau.
Human studies: increase in posterior angle inclination increases degree of anterior translation – 6mm increase for every 100 increase in slope angle.
Balance of muscle forces – humans 220 plateau slope. &lt;220 (relative extension) = increase CrCL ligament strain. Impact for conformation in dogs???
Increase tibial plateau angle suggested to predispose to CrCL rupture (Read & Robins, 1982, Morris & Lipowitz, 2001)