Plantar Pastern Subluxation - A Case Study

Check out this interesting case study that Bianca Ruspi from Cornell University was a part of!

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Shunt Case Report

Kristin Reichert, University of Wisconsin 

1. Signalment: Xxxx (not revealing name for patient confidentiality), 4-month-old intact female Golden Retriever

2. Presenting complaint: Intrahepatic Portosystemic Shunt 

3. History: Back in July, Xxxx reportedly presented to the emergency service with unspecified neurological signs. She underwent investigations that revealed elevated total bilirubin and ammonia, and she was transferred to the internal medicine service with a suspicion for a congenital hepatic portosystemic shunt. Upon abdominal ultrasound, internal medicine suspected that Xxxx had an intrahepatic shunt and recommended a soft tissue surgical consult. This would likely be for computed tomography with contrast to confirm the location of the shunt, followed by surgical management. To help mitigate her neurological signs from the accumulation of ammonia within her system and ultimate crossing of the blood brain barrier, Xxxx was prescribed levetiracetam, lactulose, and metronidazole. She was reported to have improved significantly with regards to her clinical signs as a consequence of these medications.

4. Physical examination findings: Xxxx presented BAR. Eyes and ears were noted to be unremarkable. Oral examination identified multiple fractured deciduous teeth. Mucous membranes were moist and pink with a capillary refill time of under 2 seconds. Heart rate and rhythm were normal with no murmur auscultated. Lung fields in all four quadrant were normal. Abdominal palpation was soft and comfortable. Peripheral lymph nodes palpated within normal limits. Integument had no abnormalities. Temperature remained within normal limits throughout hospitalization. Her presenting weight was 11.3kg.

5. Differential diagnoses: Upon presenting to the soft tissue service, the top differential was intrahepatic portosystemic shunt, due to the previous diagnostics that had been performed. However, upon initial presentation, differential list included ingestion of toxins, an episode of hypoglycemia causing seizures (potentially secondary to other disease processes), intracranial congenital defects causing seizures, idiopathic seizure activity, peripheral vestibular disease (including secondary to otitis media or otitis interna), neoplasia of the central or peripheral nervous system, infectious disease processes (including bacterial, viral, fungal) and a vascular event in the central nervous system.

6. Diagnostic tests/procedures and associated results: Whilst with the soft tissue service; a pre-operative complete blood count and serum biochemistry were performed in conjunction with an abdominal computed tomography scan with contrast, to confirm the location of the shunt and to appropriately prepare for our intraoperative approach.

7. Working diagnosis: Total bilirubin had returned to the normal range, which was slightly anomalous, however her ammonia had increased since her previous bloodwork, which remained consistent with the shunt persisting. The CT scan confirmed the presence of an intrahepatic shunt and provided visualization for surgical approach. This was determined most appropriate between the left medial and quadrate lobes of the liver.

8. Treatments administered/procedures performed: A 9mm Amyloid ring and key was placed around the shunt once surgically accessed and freed from surrounding connective tissue to the liver. A concurrent liver biopsy was performed and is pending histopathology. Intraoperatively, a temporary total ligation was performed to determine the necessity of the amyloid ring. It was determined that the portal pressures were too high with total ligation. This was determined by assessing the increase in motility of the intestines and force of vessel pulsation with the ligation in place.

9. Outcome/progress (if applicable): The amyloid ring is slow-closing and will progressively close over the next month or so. Xxxx will be monitored closely during this time, as there are concerns over portal hypertension or formation of acquired shunts. While generally positive in the long-term, if these complications do not occur over the next few months, there is always a concern that acquired shunts may form over time. In the meantime, Xxxx will remain on levetiracetam for two weeks, and lactulose and metronidazole for two months following the procedure, in hopes of helping her transition back to life as a puppy and decrease the accumulation of ammonia within her system.

Rehabilitation Following a Femoral Head Ostectomy and Total Hip Replacement on a Bengal Cat

Blair Hooser, Purdue University

Introduction
The patient was a 1 year old, male, neutered, Bengal cat. Within 1 year the patient sustained a capital physeal fracture of the right and left hip. This resulted in a femoral head ostectomy (FHO) of the right hip and a later total hip replacement (THR) of the left hip (1) (2) both performed at the Purdue University Veterinary Teaching Hospital (PUVTH). Physical rehabilitation exercises performed following both procedures at PUVTH included: assisted standing and weight shifting, warm pack, massage, stretching, passive range of motion, controlled walking, cavaletti rails, dancing, and the underwater treadmill. These exercises were also prescribed for the owners to continue at home. The patient was given Onsior and buprenorphine for pain management. Following completion of post-op physical rehabilitation, the patient had almost normal range of motion in both hips with some bilateral atrophy of the hip musculature.

FHO

Clinical Findings/Assessment
The patient presented to the PUVTH with a history of limping in the right pelvic limb. Radiographs had been taken at an emergency clinic and revealed a possible right femoral head fracture just prior to referral (Figure 1). Upon physical examination, a right hindlimb lameness and pain upon manipulation of the right hip were observed. The remainder of the physical exam was within normal limits. Blood was drawn for a complete blood count (CBC)/chemistry panel and no significant abnormalities were seen. Figure 1 Additional radiographs were obtained which confirmed the diagnosis of a capital physeal fracture of the right femoral head.

Treatments/Modalities
An FHO was performed at PUVTH. No surgical complications were encountered and the patient was discharged the following day on Onsior at home for pain relief. Postoperative radiographs were taken (Figure 2). The patient returned 2 weeks post-surgery for the beginning of physical rehabilitation. At this time, the incision had healed and the patient no longer required medications for pain. Gait analysis was normal and the Colorado State Pain Scale Assessment was 0/4. Assessment of the right hip showed decreased range of motion. Goniometry of the right hip in extension was 100 degrees and the limb girth of the right hind limb was 19.5cm at the mid-femur region. While walking and standing there was mild to moderate weight shifting off of the right pelvic limb, but the patient still used that limb with each step. The rehabilitation plan for the patient included improving functional walking, improving hip extension, and strengthening the muscles of the right pelvic limb. Pain management was also a major consideration for rehabilitation, since pain affects how the animal wants to use an affected limb, and thus would be counterintuitive to rehabilitation (3). Injuries to the musculoskeletal system can affect an animal’s proprioception and specific exercises are needed to help regain it (4). While at the PUVTH, several exercises were carried out with the patient. Assisted standing and weight shifting were performed on the Dino-disc to help with Figure 2 proprioception, muscle strength, and balance. The patient’s thoracic limbs were placed on the Dino-disc to add an element of instability and his back end was gently pushed from side to side and forward to back to encourage weight shifting from one leg to another. Warm packing and massage was done to increase blood flow and loosen the muscles (5). Passive range of motion and stretching of the pelvic limbs was performed to work on increasing flexibility, increasing synovial fluid flow, and decreasing muscle contracture. To work on strengthening, the patient did controlled walking for 10 minutes on flat, as well as uneven surfaces. This encourages the patient to use their leg as a whole unit; performing both extension and flexion. An element of unevenness can be added, such as a wobble board or short incline to add more proprioception to the exercise and encourage the patient to put more weight on the affected leg. To also promote coordination and increased flexion, the patient went over 10 caveletti rails (Figure 3). The owners were given instructions to continue exercises at home. Warm packing of the affected limb and massage were recommended for 10 minutes once per day. They were also instructed to perform 10-15 repetitions of passive range of motion (PROM) for each joint of the affected limb, 3 times a day, including stretching the right hip in extension for 10-15 seconds 10 times per session, for 3 sessions per day. To promote muscle strength and maintain movement, controlled walking was prescribed. The speed for controlled walking should be slow to encourage the use and placement of the right pelvic limb. To work on coordination as well as strength, in place of one of the daily walks, walking the patient through an obstacle course was recommended. To encourage coordination as well as joint motion, the owners were encouraged Figure 3 to make caveletti rails at home. Lastly, dancing 30 seconds 1-2 times per day was recommended to improve strength, coordination, and hip extension. A follow-up rehabilitation appointment was made approximately one month later. At that time, the patient’s flexion and extension of the right hip were normal and he had mild weight shifting lameness when standing, although he was ambulating very well. These exercises were performed the same as the previous visit: warm packing and massage, passive range of motion, controlled walking (decreased to 5 minutes), assisted standing and weight-shifting (on a Physioball). An underwater treadmill session was added to this visit (Figure 4). Underwater treadmills provide a vast number of advantages to rehabilitation (6). It was recommended to the owners that they continue all of the exercises previously mentioned, with the addition of assisted standing and weight-shifting. At this point, no further rehabilitation appointments were deemed to be necessary provided the owners continued the at-home exercises.

Outcomes/Results
With the rehabilitation exercises, the patient recovered almost normal range of motion in the right pelvic limb with only a mild decrease at maximal extension.

THR

Clinical Findings/Assessment
Eight months following the right FHO surgery, the owners reported that the patient tried to make a jump, missed his landing, and fell. The patient was referred to PUVTH for assessment of a suspected left capital physeal fracture. A CBC, chemistry and urinalysis revealed no significant findings. Orthopedic evaluation revealed crepitus on left hip palpation. Additional hip radiographs were obtained (Figure 5) confirming a capital physeal fracture of the left femoral head.

Treatments/Modalities
Surgical options of a FHO vs. THR were proposed to the owners. The owners elected to have a THR performed. The implant was placed without complications and postoperative radiographs were taken (Figure 6). The patient was later discharged on buprenorphine. The patient returned in approximately a month and a half post-op surgical repair for physical rehabilitation. On assessment, the patient had normal range of motion in his knees and tarsi. There was a slight reduction in hip extension bilaterally. His pain was a 0/4 on the Colorado State Pain Scale Assessment. In-house exercises performed included: warm packing and massage of the left hip and femur, assisted standing and weight-shifting, cavaletti rails at the lowest setting, and the underwater treadmill. Cold packing was also added to help reduce inflammation and pain at the end of the session. The exercises to be continued at home were controlled walking for 10 minutes a day and assisted standing and weight-shifting. They were also instructed to apply cold packing after each exercise session to reduce inflammation and pain.

Outcomes/Results
Figure 6 Approximately 9 weeks following left THR, the patient showed no signs of pain. Radiographs revealed a healing left THR. He was fully weight-bearing on all four limbs. There was some bilateral muscle atrophy in the pelvic limbs. Both pelvic limbs could be extended without difficulty and there was good range of motion. It was determined that the patient did not need to return for a follow-up appointment unless any there were any concerns.

Summary
While rehabilitation with dogs is a growing field, rehabilitation in cats is still relatively uncommon. Part of this may be the perceived difficulty of working with cats, however, if done properly, successful rehabilitation is still possible (7). This patient not only had successful rehabilitation, but also demonstrated that feline rehabilitation is possible. The overall goal of rehabilitation for both hips in this patient was to improve gait and stride, improve hip extension bilaterally, increase muscle mass and hip proprioception. Without the support of the implant, FHO’s require more postoperative rehabilitation than THR’s for the patient to regain as much function as possible (8). The patient would have to rely more heavily upon the muscles to hold the joint together, muscles that would have recently undergone atrophy from disuse (9). This is why he worked more heavily upon correct gait and range of motion with the FHO, with the idea that muscle mass would follow with increased exercise. However, with THR’s there is a concern with implant failure (10). Thus, rehabilitation was started later after surgery and cage rest was more strictly adhered to. Successful physical rehabilitation of this patient was accomplished with a combination of manual and modality therapies at home and also in hospital.

References
1. Johnson AL, Dunning D. Chapter 17 - Femoral Head and Neck Ostectomy with Joint Capsule Interpolation. In: Johnson AL, Dunning DBT-A of OSP of the D and C, editors. Saint Louis: W.B. Saunders; 2005. p. 46–7. Available from: http://www.sciencedirect.com/science/article/pii/B978072169381150020X
2. Schiller TD. BioMedtrix Total Hip Replacement Systems: An Overview. Vet Clin North Am - Small Anim Pract [Internet]. 2017;47(4):899–916. Available from: http://dx.doi.org/10.1016/j.cvsm.2017.03.005
3. Ortel S. Physical Rehabilitation and the Veterinary Technician [Internet]. Pain Management for Veterinary Technicians and Nurses. 2017. (Wiley Online Books). Available from: https://doi.org/10.1002/9781119421436.ch16
4. Millis DL, Levine D. Exercises for Proprioception and Balance [Internet]. Second Edition. Canine Rehabilitation and Physical Therapy: Second Edition. Elsevier Inc.; 2013. 484-494 p. Available from: http://dx.doi.org/10.1016/B978-1-4377-0309-2.00028-4
5. Formenton MR, Pereira MAA, Fantoni DT. Small Animal Massage Therapy: A Brief Review and Relevant Observations. Top Companion Anim Med [Internet]. 2017;32(4):139–45. Available from: http://dx.doi.org/10.1053/j.tcam.2017.10.001
6. Jurek C, McCauley L. Underwater treadmill therapy in veterinary practice. Vet Med [Internet]. 2009;104(4):182–90. Available from: https://liverpool.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?direct=tru e&db=a9h&AN=37469261&site=eds-live&scope=site
7. Drum MG, Bockstahler B, Levine D, Marcellin-Little DJ. Feline Rehabilitation. Vet Clin North Am - Small Anim Pract [Internet]. 2015;45(1):185–201. Available from: http://dx.doi.org/10.1016/j.cvsm.2014.09.010
8. Witte PG, Scott HW, Tonzing MA. Preliminary results of five feline total hip replacements. J Small Anim Pract. 2010;51(7):397–402.
9. Millis DL, Ciuperca IA. Evidence for Canine Rehabilitation and Physical Therapy. Vet Clin North Am - Small Anim Pract. 2015;45(1):1–27.
10. Davidson JR, Kerwin SC, Millis DL. Rehabilitation for the Orthopedic Patient. Vet Clin Small Anim Pract [Internet]. 2005 Nov 1 [cited 2018 Sep 28];35(6):1357–88. Available from: https://www.vetsmall.theclinics.com/article/S0195-5616(05)00109- 9/abstract#.W623x5tEv4E.mendeley

Case Study: "Bunny" Trubey

Check out this cool case submitted by Jessica Trubey from Lincoln Memorial University!

Case:
1 year old Nubian doe. Presenting for chronic lameness.

History:
Patient appeared acutely lame back in February 2018. Owner suspected trauma as the patient was housed with 4 other goats at the time and was the bottom of the pecking order. After a brief physical exam, owner elected to hold off on treatment to see if the injury would heal on its own. In May, patient received a physical exam by two veterinarians with unremarkable exam findings, aside from obvious limping on the left hind limb, mainly appearing to be in the hip or stifle joint. Physical exam showed no hoof abnormalities, no muscle wasting, no decreased range of motion of any joints, no pain elicited upon manipulation or palpation, and no heat or swelling of any parts of extremities. Veterinarian prescribed Meloxicam 15 mg – 1.5 tablets PO SID to see if pain control effected lameness. After a month of Meloxicam administration, no improvement was noted, so owner pursued a physical exam with another veterinarian in June. This vet suspected possible luxation of hip joint, so radiographs of hips and stifles were recommended along with discontinuation of the Meloxicam. Radiographs revealed no bone or joint changes or abnormalities per veterinarian at the time. Veterinarian recommended therapeutic laser treatments of twice a week for 3 weeks at the acute inflammation setting over the hip and stifle of affected leg. Following laser treatments, no improvement was noted. September no changes in lameness are present, for better or worse. Not currently on any medications. Vaccines received CDT April 2018. Dewormer: injectable doramectin in June 2018. No other medical history aside from a bout of mild diarrhea in June. Prior to May kept at pasture; since then has been fed hay predominately with some grain supplementation.

Lat Stifle 6/13/18Rt Stifle and Hock 6/13/18

Pelvis 6/13/18Pelvis 2 6/13/18

Spine 6/13/18

Spine 2 6/13/18

Case Report: Periocular Conjunctivitis in a group of Laboratory Swine (Sus scrofa)

Submitted by Curtis Rheingold from Tufts University Cummings School of Veterinary Medicine

History & Clinical Presentation
Eight, adult, female, Yorkshire pigs (Sus scrofa) arrived to the University Laboratory Animal Resources at The Ohio State University for use in an Institutional Animal Care and Use Committee (IACUC) approved dermatologic wound-healing research study. Initial visual assessments performed by veterinary technical staff revealed bilateral periocular conjunctivitis. Closer examination performed by facility veterinarian revealed chemosis (OU), mucopurulent discharge (OU), scleral injections (OU), and blepharospasm (Fig 1). No other significant findings were reported upon completion of physical exam. All animals were quarantined into a separate room and started on empirical therapy which involved daily eye flushing using ophthalmic solution eyewash (Medi-First, Medique Products, Fort Myers, FL) BID (OU) and topical neomycin-polymyxin B sufates and bacitracin zinc ophthalmic suspension (Bausch+Lomb, Rochester, NY) TID (OU). A more in depth ophthalmic exam was also scheduled to be performed at each subject’s next experimental anesthetic event. After 72hr of treatment, all subjects were reevaluated. Reexamination revealed no significant improvement of ocular clinical signs. Clinical staff reported difficultly administrating topical ophthalmic medications in subjects.

Within 7-14 days all subjects were anesthetized for study-related events. At this time a more thorough ophthalmic examination was performed. All previously reported clinical signs (i.e., conjunctivitis, chemosis, and mucopurulent discharge) were still present. Both affected eyes were rinsed with ophthalmic eye wash, had conjunctival scrapes performed for cytology interpretation and swabbed with sterile curettes for bacterial culturing and sensitivity testing (aerobic and mycoplasma spp. specific). All samples were submitted to The Ohio State University Clinical Pathology Laboratories, Veterinary Medical Center (Columbus, OH) and Antech Diagnostics (Oak Brook, IL).

Fluorescein staining was also performed using ophthalmic strips (Bio Glo, Fluorescein Sodium 1 mg strips U.S.P., Hub Pharmaceuticals, Rancho Cucamonga, CA)  and revealed no signs of superficial corneal ulceration. At this time, empirical treatment was discontinued, and all subjects were started on a combination of enrofloxacin (Baytril® 100, 100 mg/mL, Bayer, Shawnee Mission, Kansas) and dexamethasone-SP (DexaJect SP, 4 mg/mL, Henry Schein®, Dublin, OH) solution (1:1 ratio) administered subconjunctivally in the bulbar and palpebral regions, while still under general anesthesia (Fig 2). This was performed using a 1 mL syringe with 27 gauge needle attached. Total volume of each injectable solution was 0.15 mL respectively. Additionally, 2-3 drops of topical ophthalmic neomycin-polymyxin B sulfates and dexamethasone suspension (Bausch+Lomb, Rochester, NY) were applied. This therapy regimen was continued until return of all diagnostic testing.

Analysis and findings
Twenty percent of the animals were selected to undergo diagnostic testing in order to capture the overall herd health.

              Cytological findings

Two slides prepared from conjunctival scrapes revealed occasional to modest numbers of intact nucleated cells with minimal hemodilution on a pale eosinophilic background with copious amount of magenta staining, granular material, presumed lubrication or eye ointment. There were occasional anucleate and nucleated squamous epithelial cells that often have a mixed bacterial population consisting of small rods and cocci. Additionally, occasional to modest numbers of variably degenerate neutrophils were present. No overtly neoplastic cells were seen.

Impression

Mild to moderate neutrophilic inflammation with mixed bacterial infection that consistent of small rods and cocci (Fig 3).

Antibiotic sensitivity testing of cultured aerobic bacteria revealed that all species were susceptible to both gentamicin and tobramycin.

Morphologic diagnosis

Mycoplasmic conjunctivitis with associated ocular and conjunctival sequelae.

Post-diagnostic testing: treatment and results
Upon diagnostic findings and results, the current medical therapy was discontinued and subjects were started on gentamicin sulfate (40 mg/mL, APP Pharmaceuticals, Schaumburg, IL) /dexamethasone solution (DexaJect SP, 4 mg/mL, Henry Schein®, Dublin, OH) was injected into the bulbar and palpebral conjunctiva of both eyes in a similar 1:1 ratio as previously described. Two to three drops of topical 0.3% tobramycin ophthalmic solution (Akorn Inc, Lake Forest, IL) was also applied to the globe.

Upon examination 24 hours after treatment, all pigs’ eyes showed significant improvement with reduction in gross clinical signs (Fig 4). Weekly treatment of gentamicin/dexamethasone and tobramycin continued during research-related anesthesia until each pig’s euthanasia endpoint. At euthanasia, final aerobic and mycoplasma cultures from each pig were sent for further diagnostic testing. Culture results from the last pig showed no remaining Mycoplasma spp., approximately two months after initiating treatment.

Discussion:
The conjunctiva of domestic animals is rarely sterile, and the microbial species found in pig conjunctiva are similar to other domestic species. In a study of a commercial swine operation, bacteria were found in 98% of healthy pigs tested (1). The most common bacteria included alpha-Streptococcus spp (89% of pigs), Staphylococcus epidermidis (39%), and Staphylococcus spp (39%). Chlamydia spp. were also identified in 28% of pigs (2). Mycoplasma species were not identified in any of these healthy pigs.

Mycoplasmosis has been implicated in spontaneous conjunctivitis and keratoconjunctivis in swine (3, 4), as well as in other domestic animals such as cats and dogs (5). In our group of pigs, Mycoplasma spp. was the only pathogen identified with reports of causing clinical disease. The recommended treatment in companion animals is tetracycline (5,6). Intramuscular oxytetracycline is typically used in production swine with a 28-day withdrawal period. Our group was limited on treatment options due to the risk of interfering with the approved IACUC study protocol, with systemic antibiotics and tetracyclines not available. Additionally, while we would have normally used diclofenac or a similar non-steroidal anti-inflammatory drug (NSAID) to alleviate inflammation and discomfort associated with the conjunctivis, all NSAIDs were contraindicated by the research protocol as well.

Diseases in research animals present a unique challenge for laboratory animal veterinarians since all diagnostic procedures and medical treatments must be carefully considered as to not interfere with the research protocol. The present case illustrates how coordination between research and veterinary staff can result in improved welfare for research animals. After initial treatment with empirical therapy did not affect any clinical signs, we were able to collaborate with the research group to evaluate and treat the pigs under general anesthesia. Topical ophthalmic administration is not consistently feasible in an awake, active pig.  Since the research protocol involved weekly anesthetic episodes, allowing the veterinary staff to examine and treat the animals while they were still under general anesthesia eliminated the need for additional sedation. With tetracyclines contraindicated by the research group, we elected to treat the susceptible aerobic bacteria with antibiotics recommended by sensitivity testing.

Treating non-research related diseases is vital from both an ethical and a data quality perspective. Preventing and relieving pain and disease is a vital mission for all health-related staff, veterinarians and technical staff alike. The Guide for Care and Use of Laboratory Animals, which sets standards and guidance for NIH-funded animal research, states that, “Pain is a stressor, and if not relieved, can lead to unacceptable levels of stress and distress in animals”. Even though certain treatments may not be possible in the context of a certain study, it is up to the laboratory animal veterinarian to devise a treatment plan that is both usable and effective. Treatment of diseases in research animals also ensures that data collected is free of any confounding factors. A sick or injured animal is drastically different from a healthy animal on many dimensions, including behavior, immune responses, and even gene expression. These differences can affect the reliability or reproducibility of study results and hinder collaboration between research labs.

In summary, a group of laboratory swine presented with periocular conjunctivitis and several other ocular clinical signs. Through collaboration with the research group, diagnostic testing and ophthalamic treatment were successfully conducted without any additional anesthesia or sedation. The present case demonstrates how coordination between veterinary and technical staff can lead to better outcomes for laboratory animals’ health and therefore augment the research process.

References

1. Davidson HJ, Rogers DP, Yeary TJ, Stone GG, Schoneweis DA, Chengappa MM. 1994. Conjunctival microbial flora of clinically normal pigs. Am J Vet Res 55(7): 949-951.
2. Zimmerman JJ, Karriker LA, Ramirez A, Schwartz KJ, Stevenson GW, editors. 2012. Diseases of Swine. Ames (IA): Wiley-Blackwell.
3. Rogers DG, Frey ML, Hogg A. 1991. Conjunctivitis associated with a Mycoplasma-like organism in swine. J Am Vet Med 198(3): 450-452.
4. Friis NF. 1976. A serologic variant of Mycoplasma hyorhinis recovered from the conjunctiva of swine. Acta Vet Scand 17(3): 343-353.
5. Maggs D, Miller P, Ofri R. 2017. Slatter’s Fundamentals of Veterinary Ophthamology, 6^th edition. St. Louis (MO): Saunders.
6. Schaer M. 2009. Clinical Medicine of the Cat and Dog, Second Edition. Boca Raton (FL): CRC Press.