Perineal Urethrostomy Surgery for Cats

Unfortunately, urinary obstruction (blockage) is a common and potentially serious problem in male cats. Sometimes the blockage can be caused by stones or a cancerous growth, but the most common cause by far is “feline lower urinary tract disease” (FLUTD) that can cause obstruction without a large stone or growth. The causes of this problem are complex, but the result is an inability for urine to exit the body via the urethra, which is the anatomic tube that connects the urinary bladder with the outside world.

An inability to urinate causes urine to build up in the bladder, causing potential bladder damage and, more importantly, causing an unhealthy buildup of several substances in the blood such as Potassium and creatinine. The best treatment is different for every patient and situation. A combination of IV fluids, urinary catheterization, and medications is often the first line of treatment to combat the harmful effects of the changes in the blood, relieve the blockage and help prevent early re-obstruction. Changes in diet and drinking habits can also help decrease the chance of a recurrence.

Sometimes, despite these efforts, the problem recurs. This can be shortly after the first episode or can be years later, and for some cats it can happen multiple times. In cases where it is determined that the risk or recurrence is high, or where re-obstruction happens despite multiple treatments, a surgical procedure called a perineal urethrostomy can be considered to alleviate the symptoms.

The concept behind the surgery is fairly simple, and the procedure has been utilized for some time. The cat urethra is quite narrow, and becomes even narrower as it goes towards the tip. Because most cats with FLUTD develop an obstructing plug-like substance, increasing the size of the urethral opening can help allow passage of the potentially-obstructing material before it forms a blockage. This is accomplished by opening up the urethra and using the larger part, farther in from the tip, as the new opening.

The procedure is done under general anesthesia, often combined with a local anesthetic delivered via “sacrococcygeal nerve block”, a special epidural injection. As with all anesthetic procedures at VSH, our staff (including a board-certified veterinary anesthesiologist) is meticulous about selecting anesthetic medications and monitoring patients during procedures to minimize the chance of complications.

Patient positioned for perineal urethrostomy. There is a “purse-string” suture in the anus to prevent contamination with feces.

Patient positioned for perineal urethrostomy. There is a “purse-string” suture in the anus to prevent contamination with feces.

The patient is draped for sterile surgery.

The patient is draped for sterile surgery.

The surgery is delicate and demands a high level of skill and experience as well as special equipment to be done in a consistently successful fashion. The skin around the penis is incised and dissection occurs to safely access the larger portion of the urethra. One of the key steps is making sure the dissection is done “deep” enough to make the opening as large as is safely possible. Once the right amount of dissection is determined, the urethra is cut lengthwise along the top to open up the lining of the urethra. This is meticulously sutured to the surrounding skin to promote predictable healing of the new opening. The lining of the tip of the urethra is maintained and used as a “drain board” to stay in contact with the urine as it exits the body. This is preferable to allowing the urine to contact the skin, which would cause irritation.

TPLO Cruciate Repair

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Cranial Cruciate Ligament Injury

Cranial cruciate ligament rupture (CCLR) is the most common orthopedic injury in dogs. In people, the same ligament is called the anterior cruciate ligament. In both species the ligament may stretch or tear, leading to pain and osteoarthritis. CCLR can make the menisci vulnerable to tearing, which is quite painful. The menisci are two small cushions of fibrocartilage that sit between the bones of the knee.

The signs of CCLR vary, but they include an acute onset of lameness followed by mild improvement but continued lameness. Other dogs experience a moderately progressive lameness particularly associated with exercise or lameness when the dog gets up after resting.

Diagnosis

CCLR is first diagnosed by palpation (examination and manipulation by hand). X-rays are routinely taken in dogs with CCLR, but this disease cannot be diagnosed on x-rays because the ligament does not appear on radiographs.

Treatment

Surgery is recommended for most dogs with CCLR. In very small dogs it is possible for the knee to improve in stability without surgery as the body lays down scar tissue, but in most dogs adequate stabilization of the knee will usually not be achieved, and the pain and lameness will continue.

More traditional surgical treatments of CCLR involve replacing of the ligament with either a natural or synthetic material. In these procedures, natural fibrous tissue, nylon suture, or wire is used to stabilize the knee. These procedures have been used for more than half a century, and the results are good in many cases. The main concern with these procedures is that the stabilizing material can stretch or break, after which the knee is stabilized by scar tissue. This may lead to a decrease in the range of motion of the joint. We recommend extracapsular suture surgery for smaller dogs (less than 35 pounds) or when medical or financial limitations prohibit performance of a Tibial Plateau Leveling Osteotomy (TPLO).

Tibial Plateau Leveling Osteotomy

The most widely used technique in treatment of CCLR by board certified surgeons is the TPLO. In this technique, the lower bone of the joint (tibia) is cut and rotated to eliminate the abnormal motion of the knee during normal activity. The advantage of this procedure is that it does not rely on materials that can stretch or break to stabilize the knee. We recommend TPLO in most of our medium and large patients and particularly in more active dogs.

How the TPLO Works

Studied have demonstrated that if the lower bone of the knee (the tibia) is steeply sloped at the level of the joint, the upper bone of the knee (the femur) is always sliding down the tibia. This constant sliding places strain on the cruciate ligament, possibly causing it to fail. The TPLO procedure corrects the tibial plateau angle to eliminate the sliding and the instability of the knee and the accompanying pain and slowing the progression of osteoarthritis.

Cruciate Surgery at Peak

Cruciate surgery at Peak Veterinary Referral Center is performed by a highly experienced and caring team who prioritize your pet’s welfare. Dr Schulz has been performing cruciate surgery including TPLO for over 15 years. He served as chief of surgery at the University of California and has published over 60 manuscripts in canine orthopedics. He is an author of several books including Small Animal Surgery, Small Animal Arthroscopy, and the Pet Lovers Guide to Joint Problems and Osteoarthritis.

At Peak we feel it is important to educate owners and help them make the best decision for their pet and their family. In many cases surgery may be performed the same day as your initial appointment.

Keratoconjunctivitis Sicca – Dry Eye

Learn about Dry Eye from Emily Moeller, DVM, DACVO
What is dry eye? 
The surface of the eye is covered with tears that are produced by glands located around the eye.  Tears provide oxygen, sugar, proteins, and healing factors to the surface of the eye.  Dry eye is a disease of low tear production.
What causes dry eye? 
The most common cause of dry eye is inflammation within the tear glands.  The cause of the inflammation is usually unknown.  Inflammation in the tear gland interferes with tear production, and if unchecked, can cause complete and irreversible loss of gland function.
Why does dry eye matter? 
The cornea (the clear dome on the surface of the eye) relies on tears for nutrition and protection.  When tear production is low, the cornea does not receive the nutrients that it needs to survive.  The cornea will respond by developing inflammation and scar tissue to protect itself.  In the short term this can be uncomfortable, however in the long term it can lead to vision loss as scar tissue and inflammation accumulate on the cornea.
How will I know if my dog has dry eye? 
Common signs of dry eye include redness, mucoid ocular discharge, squinting, and rubbing.  Many dogs with dry eye will develop recurrent conjunctival infections due to bacterial overgrowth in the ocular discharge.  Dry eye can be diagnosed with a simple test performed by your veterinarian called a Schirmer tear test.
How is dry eye treated? 
Most dogs with dry eye show significant improvement with use of tear stimulating medications called ‘lacrimostimulants’.  Artificial tear drops can be useful, however it is important to remember that artificial tears alone will only mask the symptoms of dry eye and do not treat the underlying inflammatory process.  The two most commonly prescribed lacrimostimulants are cyclosporine and tacrolimus.  These can be provided by your veterinarian as an ophthalmic ointment or drop.  They work by reducing inflammation in the tear gland and stimulating your dog’s own tear production.  There is an excellent chance that your dog’s dry eye will improve with medications; however medications are usually required for life.

Patella Luxation

What is patella luxation?

Patella luxation (PL) is a common cause of hind limb lameness in dogs and also on rare occasion in cats.  In this condition the patella, or kneecap, is displaced from its normal resting place within a groove in the femur (thigh bone), and is instead located toward the inside of the leg (the medial surface) or outside of the leg (lateral surface).  While this condition can occasionally be due to traumatic injury, most affected animals are born with skeletal abnormalities that predispose them to the development of this condition.  Thus, this disease is typically diagnosed in the young adult to adult age dog.  The degree of lameness seen is variable depending on the severity of luxation and of the underlying skeletal abnormalities.

Figure 1A: Radiograph demonstrating the patella positioned centrally within the trochlear groove

Figure 1A: Radiograph demonstrating the patella positioned centrally within the trochlear groove

Figure 1B: Radiograph demonstrating the patella positioned outside of its normal position within the trochlear groove

Figure 1B: Radiograph demonstrating the patella positioned outside of its normal position within the trochlear groove

How is patella luxation diagnosed?

Typically the diagnosis of patella luxation is based on a thorough orthopedic evaluation.  The limping seen in early stages is often intermittent with the animal picking up the affected limb and walking on three legs when the patella is luxated, and returning the limb to the ground when the patella returns to the groove.  The severity of patella luxation is determined by assessment of how easily the patella is luxated from the groove while the hind limb is extended, or how challenging it is to return the luxated patella to its normal position within the groove.  Radiographs (x-rays) can be taken to help confirm the abnormal position of the patella and to help rule out other causes of hind limb lameness (Figure 1A and 1B).

Figure 2: CT reconstruction of a dog with abnormal angulation and rotation of the tibia and femur, contributing to MPL

Figure 2: CT reconstruction of a dog with abnormal angulation and rotation of the tibia and femur, contributing to MPL

In cases of advanced patella luxation, computed tomography (CT) evaluation with 3-D reconstruction is helpful in evaluating the limb for skeletal abnormalities that may be contributing to luxation (Figure 2).  This reconstruction also aids in the surgical planning process.

Can other orthopedic diseases contribute to patella luxation?

Patella alta, a condition where the patella sits too high within the trochlear groove, can be seen in association with patella luxation.  The uppermost portion of the trochlear groove is shallower, allowing the patella to luxate more easily during normal rotation of the limb. Patella alta can be diagnosed on x-rays with the limb in a semi-flexed position.  Correction of patella alta consists of a distal tibial tuberosity transposition, a surgical procedure during which the patella is moved downward.

How do you treat patella luxation?

In early cases of patella luxation where luxation of the patella is infrequent or minimal lameness is seen, conservative management with rest and anti-inflammatory medications may be advised.  In more advanced cases of MPL where the patella is difficult to return to its normal position or significant lameness is observed, surgical intervention is likely to be recommended.  The board certified surgeons at Veterinary Specialty Hospital are trained in several surgical techniques for repair of MPL in dogs including: (1) Trochleoplasty, (2) Tibial Tuberosity Transposition, and (3) Distal Femoral Osteotomy.  A combination of surgical techniques is often performed to achieve pain-free function of the operated limb.

Figure 3: Trochlear block recession

Figure 3: Trochlear block recession

Trochleoplasty

The goal of trochleoplasty is to widen and deepen the groove in which the patella normally rests.  By creating a deeper groove which accommodates approximately 50% of the surface area of the patella, it is more challenging for the patella to luxate to the inside of the leg (Figure 3).  During this technique the cartilage of the femur is preserved, and very little osteoarthritis is noted long term.

Figure 4: Tibial Tuberosity Transposition

Figure 4: Tibial Tuberosity Transposition

Tibial Tuberosity Transposition

The patella is connected to the tibia along its tuberosity by a very strong ligament.  The patella can be redirected to track within the groove by moving this ligament’s attachment on the tibial tuberosity toward the outside of the limb. This is accomplished by creating a controlled cut to the bone to allow the tuberosity to be placed in its new position.  The tuberosity is then stabilized in the new position with wires or pins (Figure 4).  When correcting for patella alta, the tibial tuberosity is shifted downward (distally) to direct the patella to a deeper portion of the trochlear groove.

Figure 5: Radiographs performed immediately postoperatively of a DFO. Note the area where bone has been removed to allow the femur to be straightened (blue arrow)

Figure 5: Radiographs performed immediately postoperatively of a DFO. Note the area where bone has been removed to allow the femur to be straightened (blue arrow)

Distal Femoral Osteotomy

In large breed dogs diagnosed with patella luxation, abnormal bone conformation can contribute significantly to patella luxation.  These abnormalities lead to a bow legged stance causing increased tension on the patella to be drawn medially.  The presence of these abnormalities is determined by evaluating radiographs, or a CT scan, to look for inappropriate angulation of the femur near the knee.  To correct the angulation, a cut in the bone (osteotomy) is created to allow the limb to be straightened (Figure 5).  A bone plate and screws are used to stabilize the osteotomy until healing is complete.

In general, the prognosis for return to pain-free function following surgery is good, with more advanced luxations having more difficulty in recovery.  Following an initial 2-3 week period of extreme exercise restriction, a gradual increase in controlled activity is permitted; total recovery time following surgery is generally between 8-12 weeks.  Your surgeon will review specific recommendations regarding postoperative rehabilitation during the initial consultation and follow-up visits.  Postoperative physical rehabilitation, in some cases, can maximize the positive outcome and shorten the rehabilitation period.  Fortunately, the majority of dogs do not require additional physical therapy beyond leash controlled activity at home.  Potential complications exist for any orthopedic surgery and include infection, implant failure, and incision complications.  An experienced surgeon and appropriate postoperative care significantly decrease the risk and negative effects of these complications.

Management of Canine Arthritis (Osteoarthritis)

What is arthritis?

Osteoarthritis is an irreversible condition in our canine patients.  However, with appropriate medical therapy, most pets can live long, happy, pain-free lives. There are numerous conditions that can lead to the development of osteoarthritis including: hip dysplasia, cranial cruciate ligament injuries, osteochondrosis dissecans, and elbow dysplasia (fragmented medial coronoid processes, ununited anconeal processes, and elbow incongruity). There are numerous ways to help limit the effects of osteoarthritis on your pet’s life.

 

How can I manage the impact of arthritis in my pet without surgery?

Weight Loss:

Excess weight places undue stress on the joints and can accelerate the progression of arthritis.  Even if your pet is not overweight, decreasing his weight will decrease the stress on his joints. The primary components of a weight loss plan include a decrease in caloric intake and an increase in quality exercise.

-Decreasing caloric intake can be accomplished by decreasing the total volume of food consumed or by switching your pet to a lower calorie diet.  Prescription diets (such as Hill’s r/d or w/d or Purina OM) can be used until a desired weight is achieved.

-Increasing activity level also helps with weight loss by increasing the number of calories burned.

-In order to establish a successful weight loss program, it is imperative that you remain in close communication with your primary veterinarian and schedule weekly to bimonthly weight checks.  Once a routine is established, the veterinarian can fine-tune your pet’s weight loss program to a safe and acceptable rate.

-Ideally your pet would be limited only to his prescribed weight loss diet but we understand that some pets enjoy food treats in addition to the regular food.  Please avoid all over the counter pet treats as these are usually high in fat, salt, and calories.  Instead consider feeding such things as frozen green beans or carrots in small amounts. You can also use dog food as treats, remembering to decrease the amount fed at mealtime as well. Avoid onions, garlic, nuts, grapes, and raisins as these are toxic to pets.

-In addition to appropriate caloric restriction and exercise, an oral diet medication (Slentrol® (Pfizer)) can be prescribed to help control hunger and further accelerate weight loss.  This medication is available only by prescription and is not right for every dog, so please discuss the use of this medication with your primary veterinarian.

Exercise:

-Promoting exercise in your arthritic pet is very important for weight loss and helps lubricate the joints. We recommend low impact exercises, such as controlled leash walks or swimming. Walks on softer surfaces, such as grass, will decrease the impact on his or her joints, as well. We recommend starting slowly with any activity and gradually working your pet up to additional activity. This may mean starting with 5 minute walks, three times per day, and gradually increasing by 5-10 minutes each week until you reach 30 minutes, three times daily.

-If your pet has lost significant muscle mass, physical therapy with a pool or underwater treadmill may be beneficial to improve muscle mass prior to attempting walks on your own. If you are interested in water therapy with a pool or treadmill we can provide you with the names of local rehabilitation facilities that specialize in aquatherapy.

-If at any time your pet experiences increased lameness or pain following activity, please stop all exercise for 24 hours. If the lameness continues, please see your veterinarian or any of the veterinary surgeons at VSH for a physical examination. If the lameness resolves you may resume activity at a lesser amount and gradually work back up to longer walks.

Nutraceuticals:

Nutraceuticals, herbal/natural products and complimentary /alternative medications are products that are intended to aid in disease management, but they are not regulated by the Food and Drug Administration (FDA). Rigid quality control standards are not required for these products, and as a result substantial variability can occur in both the potency and the purity of these products.  Few well-controlled clinical studies have been performed in animals documenting the use of these products; however, some products have been shown to have beneficial effects in humans and animals. When choosing a product labeled for human-use for your pet, always consult with your veterinarian. The United States Pharmacopoeia (USP) is a standard-setting authority that certifies nutraceutical products and requires testing to ensure the purity, potency, and quality of finished products. Look for their stamp of quality on products you buy.

Glucosamine/Chondroitin sulfate: These compounds are naturally occurring within the joints. They are part of the structure of normal cartilage and are thought to help with cartilage repair. Glucosamine/chondroitin supplementation has been shown to improve comfort/pain control in humans. No similar studies have been performed in canine or feline patients. Several products have been shown to contain appropriate levels of available glucosamine and chondroitin including Cosequin®, Dasuquin™ (by Nutramax) and Seraquin® (by Boehringer Ingelheim). These are available only through veterinarians. The ideal starting dose would be 1500 mg per day of the glucosamine portion.  This dose can be divided and given twice a day.

Omega 3 fatty acids: These are a family of unsaturated fatty acids that cannot be made by the body and are required in the diet. These include ALA, EPA, and DHA. These products are especially concentrated in certain foods like cold water fish, such as salmon, herring, mackerel, anchovies, or sardines. They are thought to help block enzymes that can degrade cartilage and reduce the creation of substances that cause inflammation. The ratio of omega 3 to omega 6 fatty acids may be more important than the actual amount of omega 3 fatty acids consumed; this is controversial and the specific ratio and dose has not been determined for our pets, but is assumed to be similar to humans.  Fish oil products are especially sensitive to the effects of heat, light and oxygen exposure. Be sure to store the products exactly as is recommended. One product that has been shown to contain the labeled amount of EPA and DHA that is recommended is Omega-3 Pet™ by Nordic Naturals® but there are many products available. Currently we recommend Nordic Naturals® which can be purchased at your local health food store.  When using Nordic Naturals® use the label dosage appropriate for your pet’s weight.  Fish oils can be started at 1000-1200 mg per day.  Many other products are available and you can consult with your veterinarian for additional options.

Adequan® (by Lutipold): This is a polysulfated glycosaminoglycan (PSGAG). PSGAGs are similar to the main component of joint fluid and cartilage. They are thought to help decrease inflammation in the joint and protect healthy cartilage. Adequan® is a prescription, water-based product to be injected into the muscle that can be given on a tapering regimen. It can be started weekly or twice a week for a month and tapered slowly over time. These can be given by your primary veterinarian, as injections to give at home, or by a surgeon at Veterinary Specialty Hospital.

Hyaluronic acid (HA): This is a naturally occurring substance found within joints. It is made by cartilage cells and helps support the composition of joint fluid and decrease inflammation within the joint. This product is rarely used in companion animals and is usually injected directly into the joints. There are several products containing HA that are available as food supplements, however the effectiveness of orally administered HA is unknown. There is substantial variability between products and an HA supplement should be chosen only when other products have not been effective.

Diets:

Several commercially prepared prescription diets are available that contain high levels of omega-3 fatty acids and glucosamine/chondroitin. They are additionally formulated to help decrease inflammation. These diets include Hill’s Science Diet J/D, Purina JM, Iams® Veterinary Formulas Joint Health, and Royal Canin Mobility Support JS. The amount of omega-3 fatty acids contained in Hill’s Science Diet J/D eliminates the need for fatty acid supplementation. These products do not contain therapeutic levels of glucosamine/chondroitin and you should continue to supplement your pet while on these diets.

Unfortunately these diets are only formulated for dogs. Additionally, if your pet is on a hypoallergenic diet or has food allergies, these diets are not recommended as most contain chicken, rice, and wheat products. These diets are not considered weight loss formulas and care should be taken to ensure that your pet does not gain weight while on these diets.

Please contact your veterinarian or their office to purchase these prescription diets.

Non-steroidal anti-inflammatory drugs (NSAIDs):

This is a class of prescription medications that act to decrease inflammation by blocking the mediators of inflammation at a point along the pathway. By blocking these inflammatory mediators, there is also a decrease in pain. This group of drugs includes Rimadyl® (carprofen), Deramaxx® (deracoxib), Metacam® (meloxicam), Previcox® (firocoxib), Zubrin® (tepoxalin)and Etogesic® (etodolac). These medications act similarly to several human medications including aspirin, ibuprofen (Motrin/Advil), Aleve, and Celebrex.

NSAIDs should never be given without the supervision of your veterinarian. These products can cause serious, life-threatening side effects, even in small doses.

NSAIDs are often used intermittently to control pain secondary to osteoarthritis, but can be used on a long-term basis. It is important to monitor your pet’s kidney and liver function at least every 6 months if he or she is administered NSAIDs long term. This monitoring is important for continued treatment.

The most common complication of NSAID use is stomach/intestinal upset. If any vomiting, diarrhea, or a decrease in appetite occur while giving an NSAID, please stop their use immediately and contact your veterinarian, or a veterinarian at VSH immediately.

Alternative Therapies:

-Acupuncture: Some previous clients have mentioned the benefits gained from acupuncture therapy.  Although we do not perform this procedure here at VSH there are many local veterinarians who have training in this procedure.

Stem cell therapy: Stem cell therapy has recently received a large amount of attention in the press. It was initially used in horses to help stimulate the repair of tendons and ligaments. Its use in companion animals has been more recent and as of yet there has been little scientific data to prove its efficacy. As there is significant expense associated with the procedure and little clinical data to support its use, we do not currently recommend the use of stem cell therapy.  We will continue to monitor the objective research in the field of stem cell therapy and consider forms of appropriate treatment when they become available.

Liver Lobectomy for Liver Masses

What is a liver lobectomy?

Liver lobectomy refers to removal of a liver lobe.  In dogs and cats, the liver is made up of six separate lobes.  Beginning from the left side of the abdomen, these include the left lateral lobe, left medial lobe, quadrate lobe, right medial lobe, right lateral lobe, and caudate lobe.  Surgical removal of large liver tumors often requires concurrent removal of a substantial amount of normal liver tissue.  Thankfully the healthy liver tissue has a strong regenerative capacity and removal of 65% – 70% of the total liver volume can be performed without significant consequence.  Liver regeneration begins within hours after liver lobectomy and may last up to 6 – 10 weeks.

Shaved abdomen of a dog with a very large liver mass, prior to undergoing surgery.

Shaved abdomen of a dog with a very large liver mass, prior to undergoing surgery.

Why is a liver lobectomy performed?

The most common reason to perform a liver lobectomy is to remove a mass that has been diagnosed within the liver.  Masses found within the liver may be benign, malignant, or may represent metastasis (spread) from a tumor located elsewhere.

Solitary liver mass occupying an entire live lobe in a dog.

Solitary liver mass occupying an entire live lobe in a dog.

What are the most common types of liver masses in dogs and cats?

The most common type of liver mass in the dog is termed a massive hepatocellular carcinoma. These masses have a relatively low metastatic rate (chance of spreading elsewhere in the body, between 4% – 35%) and are most often found on the left side of the liver.  Surgery is the treatment of choice for this tumor and generally carries a favorable prognosis. In one study, dogs that underwent successful surgery for removal of a massive hepatocellular carcinoma ultimately lived longer than four years following surgery.  Chemotherapy and radiation therapy are not considered to be highly effective for treatment of massive hepatocellular carcinoma.

Large, nodular liver mass immediately following surgical removal.

Large, nodular liver mass immediately following surgical removal.

Approximately 30% of canine hepatocellular tumors are benign adenomas. They are most often diagnosed incidentally but can grow to be quite large.  These masses can be difficult to differentiate from massive hepatocellular carcinomas without evaluation of the tissue microscopically.  When associated with symptoms from their growth within the abdomen, surgical removal of these benign masses is considered to be the treatment of choice.

In cats, bile duct tumors are the most commonly diagnosed liver masses.  Benign masses (bile duct adenomas or biliary cyst adenomas) are seen twice as frequently as malignant tumors (bile duct carcinomas). The prognosis for bile duct adenomas after surgical removal is thought to be very good.  Sadly, the prognosis for malignant biliary tumors in cats is quite poor.  Metastases are frequently (~65%) seen and a mortality rate of 100% in the perioperative period has been reported.

A multitude of other tumors types can be seen in dogs and cats, including hemangiosarcoma, leiomyosarcoma, osteosarcoma, fibrosarcoma, mesenchymoma, chondrosarcoma, rhabdomyosarcoma, mast cell tumors, histiocytic sarcoma, and lymphoma.  Prognosis and preferred treatment method varies greatly with tumor type.

Intraoperative picture of a liver mass effacing (taking over) the normal liver architecture

Intraoperative picture of a liver mass effacing (taking over) the normal liver architecture

The liver is a common site for metastasis of cancer from other bodily organs.  Lymphoma is the most common tumor seen to spread to the liver, followed by carcinomas.  The prognosis for metastatic liver masses is generally very poor.

What are some signs that my pet may have a liver tumor?

Liver tumors are more commonly seen in older pets.  Clinical signs can be vague, but may include vomiting, lethargy, anorexia, or weight loss.  In more severe cases, your veterinarian may be able to feel the mass is in the abdomen, there may be free fluid within the abdomen causing a distended appearance, or your pet may be jaundiced (have a yellow-tinged appearance to the skin, eyes, or gums).

Jaundice (icterus) in a cat. Note the yellow tinge to the inner ear and above the eye.

Jaundice (icterus) in a cat. Note the yellow tinge to the inner ear and above the eye.

How is a liver tumor diagnosed?

Often the first abnormality noticed is elevations of liver enzymes (ALKP, ALT, GGT, AST) on routine screening bloodwork.  This finding often prompts evaluation with further imaging, including abdominal radiographs (x-rays) or ultrasound.  On abdominal radiographs, a liver mass is often seen as a mass in the front of the abdomen which displaces the surrounding organs.

Abdominal ultrasound can be very helpful, and may allow determination of which liver lobe or lobes are affected, the approximate size of the mass lesion, and proximity of the mass to other important vital structures, including the gall bladder and the vena cava (large vein in the abdomen that lies close to the liver).

Diagnosis of tumor type can be challenging without surgical intervention.  Ultrasound-guided aspirates (using a needle to try to obtain cells from a tumor) can be performed but yield an accurate diagnosis in only 14% – 50% of dogs and in 33% of cats when compared to evaluation of tissue (biopsy or histopathology). Some tumor types, such as lymphoma, are generally readily identified by fine needle aspirate and respond well to chemotherapy; surgery is not recommended with lymphoma.

Thoracic radiographs (chest x-rays) and complete blood work should be performed in any pet diagnosed with a liver mass. A CT scan may be recommended to better evaluate the resectability of (ability to safely remove) a liver mass from its size and location, as well as to evaluate for the presence of metastatic disease.

CT scan: The larger arrow indicates a mass in the right medial liver lobe. The smaller arrow is denoting the location of the caudal vena cava.

CT scan: The larger arrow indicates a mass in the right medial liver lobe. The smaller arrow is denoting the location of the caudal vena cava.

CT Scan: Arrow indicates large right sided liver mass.

CT Scan: Arrow indicates large right sided liver mass.

How do you treat tumors of the liver?

For most types of liver masses, surgical removal of the affected liver lobe(s) is the recommended treatment; this is referred to as a liver lobectomy.  A standard surgical approach to the abdomen is performed through a midline incision.  The blood supply to the affected liver lobe may be sealed using staples or suture material.

Some liver masses cannot be removed in their entirety without high risk of bleeding (hemorrhage) at surgery or compromise to other organ systems.  In these situations the surgeon will either attempt to remove as much of the liver mass as can be done safely or will instead elect to collect a biopsy of the liver (histopathology) to determine if further treatment is necessary.

SurgiTie loop

SurgiTie loop

Surgical stapler with cartridges.

Surgical stapler with cartridges.

After removal, the abnormal tissue is submitted for tissue evaluation.

What can I expect after surgery?

Generally your pet will remain in hospital monitored closely in the ICU for between 36 – 48 hours following liver lobectomy.  The red blood cell volume is monitored following surgery to ensure that no postoperative hemorrhage occurs.  Injectable pain medications are administered until the morning of anticipated discharge from the hospital to make certain your pet is comfortable.

Hematocrit tube for evaluating the red blood cell concentration post liver lobectomy.

Hematocrit tube for evaluating the red blood cell concentration post liver lobectomy.

Incision one week following abdominal surgery and liver biopsy.

Incision one week following abdominal surgery and liver biopsy.

Following discharge from the hospital, exercise restriction is recommended for 10-14 days.  During that period of time no running, jumping, or rough-housing activity should be allowed.  A recheck examination with your surgeon is recommended two weeks following discharge from the hospital to ensure the abdominal incision is healed prior to return to full activity.  Biopsy results are generally available 5 – 7 days following submission of the sample.  The surgeon will contact you with further information and recommendations when the results are received.

Total Hip Replacement

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Osteoarthritis is one of the most common diseases of dogs, affecting up to 25% of all dogs during their lifetime. The hip and knee are the most common locations but have dramatically different causes and treatments.

The majority of osteoarthritis of the hip is due to hip dyspla­sia. This disease is a result of genetics which leads to poor hip conformation and laxity and subluxation (loose joints) while the dog is young. As the dog ages the joints actually tighten up but the resulting poor fit of the joint (incongruence) leads to grinding of cartilage and inflammation of the joint. Many adult dogs with severe hip dysplasia and osteoarthritis have no normal cartilage remaining in their hip joint.

The common signs of osteoarthritis of the hips in dogs are limping and exercise intolerance. Exercise intolerance is actually the most common while fewer dogs actually limp with hip dysplasia.

There are two broad categories of management of hip dys­plasia and osteoarthritis in dogs. They are medical and surgical. It is important to remember that even when surgical management is elected, medical management may be necessary still. This is particularly true when one hip receives surgical therapy but the opposite side remains diseased.

Medical management

Medical management of hip dysplasia includes 5 treatment principles:

  • management of body weight
  • nutritional supplementation
  • moderation of exercise
  • physical therapy
  • medications

Surgery

Surgery for hip dysplasia is indicated when medical man­agement no longer maintains quality of life and function. It may also be indicated when medical management causes complications. The decision to pursue surgical treatment should be made by the owner in consultation with the veterinarian but the owner must decide on quality of life.
There are two surgical options for the mature dog with hip osteoarthritis. They are femoral head and neck ostectomy (FHO) and total hip replacement (THR).

FHO

FHO is an excellent option in small dogs (and cats). In this surgery the ball of the ball and socket joint is removed. The hip then works by having the leg supported by the gluteal muscles. (This procedure was developed for treatment of hip infection in people.) Because of their small body weight small dogs and cats tolerate this procedure very well. In larger dogs the outcome is not always as good but it may be necessary for financial or medical (infection) reasons. Ultimately the outcome of this procedure is unpredictable but is probably improved by combining the procedure with professional physical therapy.

THR

Total hip replacement has been performed in thousands of dogs in the US and the world. The outcome is generally excellent in 85% to 90% of dogs; however when complications occur they can be frustrating and expensive. Traditionally THR was always performed as late in life as possible because of concern for the implants wearing out. The development of cementless implants (left) allows THR in patients as young as 8 months of age.

For additional information about Total Hip Replacement download PDF

Hip Dysplasia

What is Hip Dysplasia?

Hip Dysplasia is a common, inherited, developmental condition that involves increased laxity of the hip joint. It is one of the most common orthopedic abnormalities in young, giant and large breeds, but all breeds can be afflicted. Although the exact cause of hip dysplasia has not been determined, many factors have been implicated. Genetics, rapid growth, excessive nutrition and diminished muscle mass have been associated with increased severity of hip dysplasia. Affected dogs are born with normal hips (Figure 1), but develop a lack of conformity between the femur and acetabular cup which invariably leads to the development of arthritis.

Figure 1: X-ray of Normal Hips

Figure 1: X-ray of Normal Hips

Diagnosis

Dogs with hip dysplasia may present with signs of hip pain, commonly indicated by a reluctance to jump into the car, pain when rising, or inactivity and reluctance to play as puppies. Signs are common between 6 and 18 months when there is excessive laxity (Figure 2) and again in dogs over 3 years of age when arthritis becomes more severe (Figure 3).

Figure 2: X-ray of Hip Dysplasia in Young Dog.

Figure 2: X-ray of Hip Dysplasia in Young Dog.

Figure 2: X-ray of  Hip Dysplasia in Young Dog. There is increased laxity of the joint causing a separation of the femoral head (ball) from the acetabulum (socket) and there is already some arthritis forming along an area called the femoral neck.

Figure 3: X-ray of Hip Dysplasia in Mature Dog. There is severe change to the bones making up the hip joint.

Diagnosis is based on physical examination findings of laxity (a positive Ortolani test) or pain in the hips, and is confirmed with x-rays. We recommend screening examinations be performed by your regular veterinarian at four months of age in any large  breed dog.  Standard “hip extended”  (OFA: Orthopedic Foundation of America)views combined with distraction views (PENN Hip) give the most information.

Figure 3: X-ray ofHip Dysplasia in Mature Dog. There is severe change to the bones making up the hip joint.

Figure 3: X-ray ofHip Dysplasia in Mature Dog. There is severe change to the bones making up the hip joint.

What are PENN Hip Radiographs?

PENN Hip has a strong scientific foundation  as being the most effective hip screening tool for dogs.  PENN hip is typically used on immature dogs to help determine their candidacy for breeding or help determine their risk of developing arthritis.  The PENN Hip technique is performed on heavily sedated or anesthetized dogs and uses a padded distraction device placed between the back legs while the x-ray is taken.  Evaluation of these images will generate a distraction index (DI) that will help give an objective assesment of the degree of hip laxity present and help predict the likelyhood that your pet will develop arthritis in the future.  Dogs with a distraction index of less than 0.3 are very unlikely to develop arthritis, while those with a DI greater than 0.7 are highly likely to develop arthritis.  PENN hip can be performed as young as 16 weeks of age.  It has been shown that breeding dogs with tight hips (low DI) to dogs with tight hips can decrease the incidence of hip dysplasia.

Figure 4: PENN hip radiographs demonstrating how DI is determined

Figure 4: PENN hip radiographs demonstrating how DI is determined

Treatment

Many treatment options are available for hip dysplasia. Treatment is based on severity of signs, age at presentation, your expectations of performance, and financial considerations.

Medical Management

The most conservative method of treatment of hip dysplasia involves medical management consisting of weight loss, controlled activity, physical therapy and anti-inflammatory drugs or nutraceuticals (e.g. glucosamine, omega 3 supplemenation, see our link on osteoarthritis).  Many new non-steroidal anti-inflammatory drugs are available for dogs. Ask your family veterinarian which are best suited for your pet’s needs. Medical management does not reverse arthritis, but provides control of pain.  Weight loss can be as effective as medications at decreasing pain and improving quality of life.

Symphysiodesis

Symphysiodesis is a technique for preventative management of the progression of juvenile canine hip dysplasia. It involves closing the growth plate on the “floor” of the pelvis, increasing femoral head coverage as patients grow. This technique can be performed relatively rapidly, is not highly invasive, and entails no surgical implants. Ideal candidates have hip laxity with no radiographic signs of arthritis and are between 15 and 20 weeks of age.  Complications with the procedure are rare but include infection and incision complications.  Most patients can be discharged the day of surgery and recovery is complete by 2 weeks after the procedure.

Triple Pelvic Osteotomy (TPO):

Dogs that have hip laxity but not significant arthritis are candidates for Triple Pelvic Osteotomy (TPO). Because arthritis can progress fairly quickly, dogs that are candidates for TPO are typically between 6 and 12 months old. TPO improves femoral head coverage (Figure 4) through a procedure that involves making three cuts in the bones of the pelvis, then rotating and plating a section of the pelvis. The goal of this surgery is to decrease pain and the progression of arthritis. Long term evaluation of dogs after TPO has shown excellent results.  Complications include infection, anesthetic risk, incision complications and implant complications. Complications after surgery are uncommon with the new locking, titanium plate system that we utilize.

Figure 5: X-ray of TPO with Securos locking plate

Figure 5: X-ray of TPO with Securos locking plate

Femoral Head and Neck Ostecotmy (FHO)

FHO is a salvage procedure to address hip dysplasia. This surgery involves removing the bone of the femoral head (Figure 5) and aims to eliminate the source of pain. Small dogs and cats may be better candidates for this procedure than large and giant breed dogs which may have prolonged recoveries and variable outcomes. Gait abnormalities may persist after FHO and post operative physical therapy is critical to the success of the procedure.

Total Hip Replacement (THR)

THR involves implantation of a prosthetic hip in a similar fashion as is done in humans (Figure 6) and has been well – established in veterinary medicine since the 1970s. Both “cemented” and “cementless” options are available for dogs and your surgeon will discuss which would be best for your pet. The availability of many different implant sizes makes this the best option for most dogs with severe signs of hip problems. Ideal candidates are over six months of age with no overt systemic illness. Although hip dysplasia is often a bilateral disease, THR is performed on only one hip at a time, with the most painful hip treated first. Often, only one hip needs to be replaced to achieve acceptable function. If pain persists, a second THR may be performed at least two months after the first.  As with any surgery, complications exist with THR and include infection, dislocation, implant failure and femur fractures. These complications combined occur in less than 10% of patients and improvements in implant design and technique have led to the low complication rate. Full recovery from THR takes approximately eight weeks with most dogs able to walk on the affected leg the day after surgery. The success rate of THR is excellent with 90-95% of dogs able to have normal use of the affected limb after surgery.

Figure 6: Cementless hip replacement

Figure 6: Cementless hip replacement

Figure 7 Hybrid (cemented femur, cementless acetabulum)

Figure 7 Hybrid (cemented femur, cementless acetabulum)

Why choose the Veterinary Specialty Hospital for your pet’s total hip replacement?

Experience is critical to the success of total hip replacement.  The surgeons at the Veterinary Specialty Hospital have over 50 years of combined experience in hip replacement and we are one of the most experienced teams in the country.  Our surgeons are invited lecturers internationally on hip replacement techniques and have taught surgeons around the world how to perform the surgery.  We are also one of the only private practices in the country to employ a board certified anesthesiologist to help assure your patient will not only do well under anesthesia, but will be comfortable in the post- surgical period.

The Skinny on Raw Food Diets

Sarah Cocker, DVM
Residency Trained in Internal Medicine
Raw meat-based diets (RMBD), is an emerging trend with pet owners. Raw meat-based diets are those that contain uncooked or undercooked food animal species that are fed to dogs and cats. These diets can be found commercially or prepared at home and some are stored frozen or freeze-dried. People in favor of RMBDs view them as natural and closer to what a wild dog or cat would eat.
Most of the claimed nutritional benefits of RMBDs are simply opinions with no proven scientific research, but sound plausible to well-intended pet owners. There is very little research showing that RMBDs provides any health benefits over cooked commercial pet food diets. There is some evidence showing improvement in intestinal microbiome (good bacteria) in dogs and improved digestibility in dogs and cats fed raw diets.  However, the clinical effects of these differences are unclear and require further study.
In contrast, there are several reports of vitamin and mineral imbalances in RMBDs causing illness in dogs and cats fed those diets. These include excessive or deficient amounts of vitamin A, E and D, calcium, phosphorous, iodine, copper and zinc. Many of these diets can be high in fat, which puts some pets at risk for pancreatitis, gastrointestinal issues and obesity. The largest concerns associated with RMBDs are contamination with pathogens such as Salmonella, E. Coli, Campylobacter spp. Clostridium spp., Listeria spp., Echinococcus spp., and Toxoplasma spp. These pathogens can cause illness in dogs and cats and several have zoonotic potential meaning that they can be transmitted to humans from infected pets.  This becomes a huge concern for children, immunocompromised adults, and pets that come in contact with infected pets and can have life threatening consequences.
Most veterinarians are not in favor of raw food diets and owners need to be educated about the risks of these diets before feeding them to their pets. If an owner elects to feed a RMBD then it is best to purchase one that adheres to AAFCO nutritional guidelines or if home preparing these diets, a veterinary nutritionist should be contacted to ensure the diet is nutritionally balanced. It is also important to be very careful with the storage, handling, and preparation of these diets to decrease risk of contamination.

Fractures

If you are reading this, it is likely you received the devastating news that your family friend is suffering from some unfortunate trauma.  We know this can be an incredibly stressful and traumatic time for both you and your pet. How will things turn out? Will he/she be OK? There are many factors that will affect the answer to this question. The severity and nature of the injury is certainly one of them. Equally important is the skill, experience, and tools of the team treating him/her. The success of your pet’s fracture treatment has much to do with type and severity of the injury, but also with the experience and equipment of the team treating them.  Rest assured that you are in good hands.

No two fracture cases are exactly the same, but it is unlikely that the team of surgeons at the Veterinary Specialty Hospital has not seen many fractures similar to the one you are facing.  After an accident, it is important to ensure your pet is stable and not experiencing major internal injury and a discussion with your surgeon will determine the need for testing like blood work, x-rays of the chest or an ultrasound of the abdomen to look for additional trauma.  Once it is time to focus on fracture repair, we will take a lot of different factors into consideration when determining the best repair technique for your pet.

A variety of treatment options exist for repair of fractures, depending on the type and location of fracture, the age and activity of the patient, the presence of other injuries and your ability to manage your pet in the post-surgical period.  There are often many routes to healing for each case, and the goal is to pick the intervention that will result most consistently in the fastest healing with the least amount of complications in the short and long term.

3 month old Great Dane puppy with a tibial fracture. This is a cranial-caudal or “front-to-back” view showing the fracture at the lower (distal) portion of the tibia (shin bone). Note that the small fibula bone that runs parallel to the tibia is not fractured. In a young patient, this fracture can heal successfully with an appropriately-placed and maintained splint or cast.

3 month old Great Dane puppy with a tibial fracture. This is a cranial-caudal or “front-to-back” view showing the fracture at the lower (distal) portion of the tibia (shin bone). Note that the small fibula bone that runs parallel to the tibia is not fractured. In a young patient, this fracture can heal successfully with an appropriately-placed and maintained splint or cast.

This is approximately 3 weeks from the injury. The bone is healed enough to allow removal of the splint. The bone will continue to heal and “remodel” to a more normal appearance.

This is approximately 3 weeks from the injury. The bone is healed enough to allow removal of the splint. The bone will continue to heal and “remodel” to a more normal appearance.

Splints and Casts

Also known as external coaptation, this form of treatment is typically used for fractures that are closed (not poking through the skin), below the elbow or knee, not significantly displaced, and usually not more than two pieces.  A variety of fractures can be managed successfully with splints, but it is important to remember animals have a hard time telling us when there is a problem with their splint.  It is also very hard to convince our animal patients to use crutches and stay off of their splinted limb while it heals.  Bandages that get wet, slip, are too loose or too tight, can all cause devastating complications.  When factoring in the decreased initial cost of doing a splint owners should be aware of the typical weekly bandage changes, possibly with sedation, and the need for follow up x-rays.

Bone Plates (xray of bone plate radius, femur, humerus, plate rod, picture of lockings)

Fractured tibia in a cat.

Fractured tibia in a cat.

Radiograph immediately after surgery showing a “plate-rod” repair, restoring the alignment of the bone and providing stability to allow bone healing without the need of a cast or splint.

Radiograph immediately after surgery showing a “plate-rod” repair, restoring the alignment of the bone and providing stability to allow bone healing without the need of a cast or splint.

One of the most common methods of fracture repair is the application of a metal bone plate and screws to bridge the fracture.  This is an extremely versatile method of repair and can be used in everything from the smallest puppies and kittens to the largest giant breed dogs. The benefit of plates and screws is that they allow early use of the operated area, particularly the joints around the injury, and often avoid bandages with their associated complications.  Early limb use helps prevent muscles from atrophying, keeps the joints healthy, and helps to stimulate bone healing.  It is important to realize that patients will often feel back to normal within a couple of weeks from surgery, but it will take the bone 6-12 weeks to heal.  During that period, controlled activity is extremely important to prevent breakage of the implants.  Complications after fracture repair include bending or breakage of the plate and screws, infection, swelling and incision complications. We generally leave bone plates on for the rest of the patient’s life even though they are no longer needed once the bone has healed.  Patients that develop an infection may need the bone plate to be removed after the bone is healed to resolve the infection.  The Veterinary Specialty Hospital has an enormous inventory of the latest technology implants, and our surgeons are actively involved in the research and development of new orthopedic systems.  Our surgeons have lectured nationally and internationally on different types of plate fixation.

Fracture of the upper portion of the tibia in a Chihuahua. This injury would have a guarded prognosis with a cast or splint.

Fracture of the upper portion of the tibia in a Chihuahua. This injury would have a guarded prognosis with a cast or splint.

Radiograph immediately after surgery. The bone has been returned to its normal position with a specially-designed titanium locking plate that acts as an internal fixator on the bone.

Radiograph immediately after surgery. The bone has been returned to its normal position with a specially-designed titanium locking plate that acts as an internal fixator on the bone.

One of the most common methods of fracture repair is the application of a metal bone plate and screws to bridge the fracture.  This is an extremely versatile method of repair and can be used in everything from the smallest puppies and kittens to the largest giant breed dogs. The benefit of plates and screws is that they allow early use of the operated area, particularly the joints around the injury, and often avoid bandages with their associated complications.  Early limb use helps prevent muscles from atrophying, keeps the joints healthy, and helps to stimulate bone healing.  It is important to realize that patients will often feel back to normal within a couple of weeks from surgery, but it will take the bone 6-12 weeks to heal.  During that period, controlled activity is extremely important to prevent breakage of the implants.  Complications after fracture repair include bending or breakage of the plate and screws, infection, swelling and incision complications. We generally leave bone plates on for the rest of the patient’s life even though they are no longer needed once the bone has healed.  Patients that develop an infection may need the bone plate to be removed after the bone is healed to resolve the infection.  The Veterinary Specialty Hospital has an enormous inventory of the latest technology implants, and our surgeons are actively involved in the research and development of new orthopedic systems.  Our surgeons have lectured nationally and internationally on different types of plate fixation.

External fixators

External fixators are a common method of fracture repair.  Metal pins are placed through the skin and into the bone.  The pins on either side of the fracture are connected to a variety of different connecting bars made up of acrylic, carbon fiber, stainless steel or titanium.  External fixators are an extremely versatile method of repair and can be used on everything from fractures in the mouth to fractures of the spine.  External fixators can often be placed with a minimally invasive technique without having to open the fracture site and disrupt the initial healing that has already started from the moment of the injury.  We often do this type of repair for very young patients with fractures of the tibia or for open (bone poking through the skin) fractures, because plates placed in open fractures may be at higher risk of harboring infection.  We will often use fluoroscopy (moving x-ray) to assist us in placing external fixators to minimize the need for surgical exposure.  An additional benefit of external fixators is that they can be easily removed once the bone has healed without the need for an additional surgery.  The drawback is that there is more follow-up (weekly) and there is an apparatus attached to the patient.  Often patients will need to wear an e-collar until the apparatus is removed.  Complications are similar to plates such as infection, implant failure, and failure to heal of the fracture.

External fixator in a young patient

External fixator in a young patient

Ring fixator for fractures close to joints or limb deformity

Ring fixator for fractures close to joints or limb deformity

There are times when an internal implant like a plate, pin, screws, or combination of those, can be placed non-invasively as described above. In the right situation, this can provide many advantages of both non-invasive surgery (smaller incisions, less trauma, precise implant placement using fluoroscopy) and avoid the issues with an external apparatus. Minimally-invasive internal fracture repair can be used for fractures of the long bones (like tibia), certain elbow fractures, and separation of the pelvis from the spine (sacroiliac fracture/luxation). This is another example of VSH’s cutting-edge approach to fracture repair.