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The clinical path of a patient with lameness starts with a thorough orthopaedic examination, which thanks to the use of the latest diagnostic tools will guide us in making a diagnosis and prescribing the most appropriate medical-surgical treatments for all types of orthopaedic disorders.
Hip dysplasia is a hereditary disorder caused by abnormal development of the hip joint and can be seen in all breeds of cats and dogs. In most cases, it is bilateral and its clinical impact can vary in different subjects depending on multiple environmental and nutritional factors, as well as on the subject’s lifestyle. The consequences of this disorder cause an early alteration in the morphology of the hip leading to rapid cartilage damage and subsequent development of ostoarthritis that can become invalidating. Hip dysplasia is a disorder that has been widely studied and innovations in diagnosis and therapy are constantly emerging. Currently, it is possible to identify affected patients at an early age (4-6 months) using clinical-radiographic studies and to treat the disorder with remodelling surgery (Juvenile Pubic Symphysiodesis and DPO) that is able to avoid or slow down the natural evolution of osteoarthritis . In young subjects and adults, in the presence of serious osteoarthritis and lameness, the most effective treatment currently available is THR – Total Hip Replacement. Since this disorder is hereditary, subjects affected by this pathology should be excluded from breeding. For this reason, radiological examinations are carried out to select breeders.
Elbow dysplasia (ED) is a hereditary disorder characterised by growth disturbances in the elbow joint and can be seen in numerous dog breeds leading to the development of osteoarthritis already from a young age. The pathological complex of ED includes Ununited Anconeal Process (UAP), Fragmented medial Coronoid Process of the ulna (FCP), Osteochondritis Dissecans of the humeral trochlea (OCD) and Elbow Incongruity (EI). The etiopathogenesis of the disorder is still not completely understood. However, it appears to be caused by an abnormal distribution of loads across the joint. Early clinical signs such as pain and lameness often appear from approximately 4 months of age and evolve with a worsening of the clinical picture due to joint inflammation and degeneration (osteoarthritis) throughout the life of the patient occasionally leading to seriously invalidating conditions. Clinical diagnosis is through radiology and it is possible to identify the disorder already from early clinical manifestations. In most cases, surgery is recommended and should be carried out as early on as possible to avoid or slow down the development of osteoarthritis. Multiple and different surgical treatments are possible and vary from case to case: arthroscopic removal of the fragmented coronoid process, distal ulnar osteotomy (DUO), bi-oblique ulnar osteotomy, screw fixation of the ununited anconeal process and elbow prosthesis. Ulnar osteotomies carried out on young subjects allow to redistribute abnormal intra-articular loads in the elbow affected by dysplasia with the objective of balancing homogeneously loads and thus limiting joint degeneration and development of osteoarthritis. Since ED is a hereditary disorder, affected subjects might be excluded from breeding and this is why official radiological studies are carried out to select breeders.
Cranial cruciate ligament rupture is a surgical disorder that represents one of the major causes of hind limb lameness. This disorder affects dogs of all sizes and can also be seen in cats. In dogs, the cranial cruciate ligament is one of the main ligaments that allows stabilisation of the stifle and is responsible for maintaining the articulation between the femur and the tibia. Due to its function, this structure can be subjected to complete or partial rupture following both degenerative causes that lead to progressive wear or traumatic events that causes a complete acute rupture. The instability of the knee that originates from cranial cruciate ligament rupture triggers lameness, pain and an inflammatory process that if neglected, can become chronic leading to the early onset of osteoarthritis with subsequent deterioration of the quality of life of the affected subject and worsening of lameness. The treatment of choice for the resolution of this condition is surgery; there are several surgical procedures (Extracapsular surgery, TPLO, TTA, CBLO, CWO), each of which with specific characteristics and indications. The orthopaedic surgeon decides which surgical procedure to adopt depending on the individual characteristics of the subject to be treated.
Patellar luxation is one of the most frequently diagnosed orthopaedic disorders in both small and large breed dogs and can lead to degenerative joint disease, pain and lameness. It occurs when the patella dislocates or moves out of its physiological position in the femoral trochlear groove; it can be medial (MPL) or lateral (LPL), of congenital or more rarely of traumatic origin. The disease is classified into 4 grades of severity and is sometimes associated with severe musculoskeletal deformities. Surgical options include trochleoplasty, tibial tuberosity transposition and corrective osteotomies of the femur and tibia; however, it is not possible to establish beforehand which is the best surgical option, as each individual patient requires specific treatment with one or more associated techniques. Selection of the best therapeutic option is possible exclusively after thorough orthopaedic examination and radiological study of the pelvic limb.
Osteochondritis dissecans (OCD) is the evolution of Osteochondrosis (OC), which is defined as impaired endochondral ossification (lack of ossification) in animals with rapid growth rate. Impaired ossification leads to thickened and weakened cartilage, which then detaches with the formation of a cartilage flap (fragment). 
The ethiopathogenesis of this disease includes hereditary, nutritional and growth factors.
OCD can involve various joints and those most affected are the shoulder (humeral head), elbow (humeral trochlea), stifle (medial and lateral condyles), and hock (astragalus). OCD of the shoulder mainly affects large or giant breed dogs with rapid growth rate and is more frequent in males and subjects often present bilateral lesions. Border Collies and English Setters are also frequently affected. The disease causes lameness in one or both front limbs and typically appears between 5 and 8 months of age. Surgical treatment of choice consists in the arthroscopic removal of the dissected cartilage flap and guarantees complete functional recovery in nearly all treated subjects. When left untreated or treated without following correct methods and timing, the disease evolves into osteoarthritis with progressive functional limitation of the affected joint.
Agility dogs, utility dogs, hunting dogs, field trials dogs, search and rescue dogs, obedience dogs: our dogs are increasingly involved in athletic/recreational activities. The athletic dog must reach skeletal and muscular perfection; this is why it becomes essential to take athletic dogs to regular orthopaedic examinations before and during athletic activity. Small or serious injuries can not only reduce athletic performance but also cause the dog to suffer. It is the utmost duty of the owner to recognise even the slightest of problem and take their dogs to the most suitable check-ups in order to guarantee optimal psychophysical wellness that is fundamental for reaching important goals.
Most geriatric patients that have not undergone preventive and early orthopaedic examinations have a high probability in adult age of deterioration of their quality of life due to the presence of one or more joints affected by osteoarthritis. Osteoarthritis is the chronic-degenerative inflammation of all joint structures, which leads to a progressive reduction of function; in this situation, the patient tends to become more and more sedentary progressively increasing joint disuse. Today, Veterinary Medicine offers multimodal management of the patients with osteosrthritis consisting in the use of special anti-inflammatory drugs associated with body weight management and physical activity. Moreover, today, increasing interest towards modern technologies in the field of Regenerative Medicine, has opened the way to new curative options for the arthritic patient thanks to the use of intra-articular infiltrations with platelet-rich plasma (PRP) or stem cells.X-ray Examination
Modern digital radiology is an irreplaceable tool in the hands of the orthopaedist and allows the diagnosis of most orthopaedic disorders in dogs and cats. ORTOVET carries out radiological studies for the official screening and certification of Hip Dysplasia and Elbow dysplasia, early clinical-radiological screening for the diagnosis in puppies of impaired developmental orthopaedic disorders (i.e. hip dysplasia, elbow dysplasia, Osteochondritis dissecans of the shoulder, knee and hock) and radiological studies to evaluate skeletal deformities.
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Hip Dysplasia (HD) and Elbow Dysplasia (ED) are hereditary diseases and thus can be passed down to offspring. In order to limit the diffusion of these diseases, affected subjects should not be used for breeding. Italian law allows to carry out official radiological studies in order to classify subjects as exempt or affected (which are then classified depending on severity) and this classification is then included in the pedigree of the subject itself. Hip Dysplasia can be classified into HD A-B-C-D-E, whilst Elbow Dysplasia into ED 0-1-2-3 and individual breed clubs recommend which subjects should or should not be used for breeding. Official radiological studies for HD and ED must be carried out by qualified vets on subjects between 12 and 18 months of age depending on the breed and involve several radiographic views; the images are then sent to one of the two x-ray evaluation centres that operate at a national level (FSA or Celemasche) to be analysed and classified. ORTOVET is authorised to perform x-rays for both FSA and Celemasche; the client at his/her own discretion can choose one of the two different evaluation centers.The minimum age for undergoing radiographic diagnosis for hip dysplasia is 12 months for all breeds with the following exceptions:
a) 15 months for Bernese Mountain dogs, Greater Swiss Mountain dogs, Briards and Rottweilers;
b) 18 months for Bullmastiffs, Pyrean Mountain dogs, St. Barnard dogs, Dogue de Bordeaux dogs, Great Danes, Leonbergers, Maremma-Abruzzese Sheepdogs, Mastiffs, Neapolitan Mastiffs, Newfoundlands, Continental Landseers, Giant Schnauzers, Irish Wolfhounds, Standard Poodles, Russian Wolfhounds, Caucasian Shepherd dogs, Sarplaninac shepherd dogs and Slovensky Cuvac dogs
The minimum age for radiographic diagnosis for elbow dysplasia is 12 months for all breeds.
The frequency of skeletal disorders due to impaired development (Hip Dysplasia and Elbow Dysplasia, OCD of the humeral head, Patellar Dislocation and others) is significant in most dog breeds. These disorders all lead to the development of osteoarthritis and significant limitations in the quality of life of the affected subjects if not treated correctly. When diagnosed early on, it is possible to carry out surgical interventions that are able to halt or limit disease development and this is why radiological screening is now common practice (preventive medicine) in order to make an early diagnosis (before the appearance of lameness) of these disorders. The first x-rays are carried out under sedation from 4/5 months of age (however, the best age varies depending on breed) and in multiple views; a complete study of the hip is performed (standard VD view, VD view with distraction to evaluate joint laxity calculation of the Distraction Index, VD frog-leg view. DAR view and clinical measurement of reduction and subluxation angles). The screening includes the radiographic examination of the shoulder, elbow and in relation to specific risk factors associated with breed, of the stifle and tarsus. Data collection allows identify subjects at high risk of developing dysplasia and osteoarthritis and thus, adopt the medical and surgical treatments available today to halt disease or limit its severity. It is fundamental to discuss with one’s vet the possibility of subjecting the dog to this clinical-radiological screening, as late diagnosis (at one year of age as is erroneously recommended) leaves little space for resolution treatment.
In dogs, skeletal deformities are relatively common pathological disorders and generally require surgery to reconstruct normal bone anatomy. The most common forms of skeletal deformities involve the forearm (radius-ulna) and can cause even serious abnormalities in front leg, whilst femur and tibia deformities are often associated with patellar luxation. Surgery is complex and requires detailed pre-operative planning that consists in a complete radiographic assesment of the limb with multiple views and accurate measurements of the deformity.When radiographic examination is not sufficient, in certain cases, patients may be subjected to Computed Axial Tomography (CT).
Surgeries
Each patient must be guaranteed top-quality surgery.
Modern day surgery plays a key role in most orthopaedic disorders. A surgical approach can be of preventive or corrective value for impaired skeletal development, of therapeutic value in traumatised patients and of replacement value in prosthetic surgery.
ORTOVET applies innovative surgical protocols using high-tech materials, which are minimally invasive and respect the biological principles of healing.
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Juvenile Pubic Symphysiodesis is a minimally invasive surgical procedure for the treatment of mild and early forms of Hip Dysplasia carried out on young patients (3-4 months of age) making the most of the growth potential of the hip bones to induce greater ventral and extra-rotations of the acetabulum. This growth of the acetabulum is induced through the devitalisation of the pubic symphysis cartilage by reducing or halting the growth of the pubis encouraging continuous growth of the ileum and ischium. Unlike double pelvic osteotomy (DPO), which is a surgical procedure that involves the acute correction of the position of the acetabulum, Juvenile Pubic Symphysiodesis is a procedure that makes use of the growth potential of the dog leading to a gradual remodelling of the position of the acetabulum. For this reason, this type of preventive surgery is more effective when carried out early on. Despite Juvenile Pubic Symphysiodesis being a relatively simple procedure to perform, patient selection is extremely complex and this surgery should be carried out exclusively on patients diagnosed early with low grades of hip dysplasia.
Early diagnosis of hip dysplasia in growing dogs made between 4 and 6 months of age allows a series of preventive-remodelling surgical procedures to be considered in order to limit the osteoarthritis due to the disorder. Following a correct selection of the patient through early clinical-radiological specialist orthopaedic examination, it is possible to carry out double pelvic osteotomy (DPO). This procedure consists in performing an ostectomy of a small segment of the pubis and osteotomy of the ileum allowing the rotation of the acetabulum to improve coverage of the femoral head and in this way limit articular incongruity determined by articular laxity, which is always present in hip dysplasia. Once the acetabulum has been extra-rotated to the necessary degree, iliac osteotomy is stabilised and fixed with a special locking implant to guarantee healing of the bone maintaining the position of the acetabulum. This procedure can be performed bilaterally during the same surgical session.
The hip joint is formed by an articulation between the pelvic acetabulum and the head of the femur and allows a wide range of flexion-extension, rotation, adduction and abduction movements. Total hip replacement allows the replacement of the entire joint and today, represents the treatment of choice available for severe and symptomatic forms of hip dysplasia and chronic or non-reducible hip luxations. Surgery consists in the ablation of the pathologic hip and its replacement with a prosthesis. The prosthesis is formed by a femoral component called ‘stem’ that is inserted inside the femur to support the prosthetic neck and head, whereas, the acetabular component is called ‘cup’: after having appropriately prepared the surgical site, it is positioned to replace the acetabulum which will host the prosthetic head. Depending on the different types of implants available on the market, the stem can be fixed inside the femur (KYON Prosthesis, Swiss Model), or can be locked with a “press fit” mechanism (BIOMEDTRIX Prosthesis, American Model), whilst cups are mainly applied and fixed with a press fit mechanism. The surgical procedure requires the presence of a specialized team equipped with dedicated instruments.
Tibial Plateau Levelling Osteotomy, TPLO is currently one of the most modern and efficient surgical techniques for the treatment of cranial (or anterior) cruciate ligament rupture in dogs. This technique allows complete functional recovery with the possibility of returning to athletic activity. It is also possible to treat both large size dogs and toy breeds with a low risk of complications also thanks to the use of modern angular stable plates (Locking implants) both in surgical steel and in titanium alloy. The surgery does not consist in the replacement of the ruptured ligament but in the osteotomy of the tibia that modifies the biomechanics of the stifle guaranteeing joint stability also in the absence of the cranial cruciate ligament.
Tibial Tuberosity Advancement surgical technique was developed at the Veterinary School of Zurich in collaboration with the genius of Slobodan Tepic. TTA, which is based on the same biomechanical principles previously developed by Doctor Barclay Slocum for TPLO, has the objective of contrasting cranial tibial thrust, preventing the tibia from slipping forward during cranial cruciate ligament rupture. This is achieved by advancing the tibial tuberosity together with the tibial insertion of the patellar tendon. Tibial tuberosity is held in the new position by the use of dedicated implants.
Numerous new biomechanical techniques that have been designed and developed to improve and strengthen the principles of TTA have become available over the last years. Thanks to 3D technology, TTA Rapid allows the use of titanium porous cages to encourage rapid healing of the osteotomy of the patient conferring stability to the stifle affected by cranial cruciate ligament rupture.
Arthroscopy has become the technique of choice for the diagnosis and treatment of many joint diseases in dogs. This minimally invasive and highly accurate technique allows the patient to achieve complete and rapid recovery thanks to low morbidity and a drastic reduction of healing times. The complete visualisation and magnification of the joint structures allow the orthopaedic surgeon to study and treat in a targeted way the cause of lameness of the affected subjects. Shoulder, elbow and stifle Osteochondritis dissecans (OCD), treatment of the fragmented medial coronoid process of the ulna (FCP), meniscal treatments, diagnosis of partial cranial cruciate ligament rupture are only few of the ever increasing orthopaedic disorders that require arthroscopic treatment.Full-limb amputation is unfortunately a necessity for a series of pathologies that do not allow in dogs and cats other more conservative solutions.
Fortunately, the amputation of a single limb is a procedure well tolerated by the patient and generally provides an adequate functional outcome. Sometimes, clinical situations in which the limbs involved in pathologies and requiring amputation are more than one may occur; in these cases, amputation cannot in any way represent a real solution able to guarantee an adequate quality of life for our patients.
For these reasons, in addition to the negative perception of the owner toward amputation, limb sparing techniques are becoming increasingly popular, allowing selective amputations with the anatomical preservation of part of the affected limb.
External prosthetic limbs (esoprosthesis) applied after partial amputation are common in human medicine and are currently available for animals. Esoprostheses rely on prosthesis-skin interface to transmit the forces from the ground to the affected limb which may lead to frequent complications, including skin irritation, infections and skin necrosis; also periodic changes or adjustments are required, they can be difficult to manage and sometimes poorly tolerated by the patient.
The limitations associated with the esoprosthesis have been overcome with the use of endoprostheses called ITAP, initially developed for the amputated fingers in human medicine.
The ITAP is inserted into the bone of the limb subject to amputation. These prostheses are patient-specific custom made pure titanium implants, built with EBM technology in order to guarantee the best possible biocompatibility and osseointegration.
Each prosthesis consists of three sub-units: the first one is implanted into the bone and intended for bone ingrowth, the second one serves for the attachment of the skin and the third one, external, serves as a support for the prosthetic foot.
Primary stabilization of the prosthesis can be achieved with press fit or screws.
The external support (foot) must be functional and may have different shapes in relation to the affected skeletal segment, the patient’s attitude and body weight.
The anconeal process, normally, fuses with the ulna around 20 weeks of age. When this does not take place within this age, there is an Ununited Anconeal Process of the ulna, which is a disorder that falls within Elbow Dysplasia (ED). Once diagnosis of UAP has been made, it is possible to promote the fusion of the anconeal process within six and a half months of age through surgery by fixing it to the ulna with a screw. Fixation is accompanied by ulnar osteotomy that brings the proximal end of the ulna nearer to the anconeal process. The aim of this surgical technique is to promote a complete and correct development and limit elbow incongruity and osteoarthritis progression in adult subjects.
Angular deformities of the limbs have long been recognised as a cause of lameness and debilitation in cats and dogs. For this reason, a method of stabilisation and correction called CORA commonly used in human medicine has been adapted to veterinary orthopaedics. This method is based on a series of standard geometrical principles and accurate indications on angular deformities that are necessary to calculate and reproduce intraoperatively precise corrective osteotomies independently of the bone segment involved and the type of osteosynthesis’ implant.
Arthrodesis is a surgical technique commonly used as a salvage procedure in situations in which it is not possible to re-establish correct joint function. The objective of this procedure is to eliminate pain through the removal of cartilage planes with subsequent immobilization of the joint using special fixation implants and autologous or heterologous bone grafts that promote the formation of the bone callous and the healing of the patient. The joints that most frequently require arthrodesis are the carpus and tarsus. However, in certain clinical conditions, it may become necessary to carry out arthrodesis also on the shoulder, elbow and stifle.
The fracture of a skeletal segment always represents a highly traumatic event for both the patient and the owner. Most fractures in dogs and cats require surgical treatment that must be carried out in the first days after trauma. Dogs and cats need robust and comfortable surgical solutions respecting as much as possible the physiology of the healing process of the fracture itself. Locking plates in veterinary orthopaedics represent cutting-edge implants that are used in the treatment of fractures of all skeletal segments. Locking plates are secured to the bone with special screws that allow to achieve a stable fixation of the fracture site promoting healing through biological repair processes. Ortovet uses a wide range of locking implants that are currently on the market in order to guarantee the best possible care to all its patients of all species, breeds, sizes and ages. In certain types of fractures (i.e. exposed fractures), other osteosynthesis systems are used such as Linear External Fixation and Ilizarov External Fixation.
Most orthopaedic conditions in cats are of traumatic nature and since cats are small animals, often patients are polytraumatised.
Advances in the devices currently available mean that nearly all fractures in cats are treatable both with internal and external fixation techniques.
As well as modern locking plates, Ortovet uses an innovative type of synthesis: the Targon Vet ® interlocking nail, which is an osteosynthesis system used for the internal fixation of fractures. It is indicated for the treatment of fractures of long bones in cats and small dogs and is applied inside the fractured bone leading to stable fixation that makes it mechanically comparable to the latest stabilising systems. The use of this technology, which originates from human medicine, allows us to treat complex fractures that cannot be reconstructed with minimally invasive approaches and promotes functional recovery and biological healing of the fracture.
Ilizarov external fixation was invented in the 1950s by the Soviet human orthopaedic surgeon Gavriil Ilizarov. The system, which originally was used to correct skeletal deformities of human long bones, was later used in traumatology. In Veterinary Orthopaedics, circular external skeletal fixation with the Ilizarov apparatus allows to correct skeletal deformities of long bones in a dynamic and gradual way and in specific cases can also used to treat bone fractures. The apparatus is made up of a series of external rings that completely surround the skeletal segment to be treated and give support through different types of wires and half pins that reaches the two ends of the fracture. The rings are then assembled together with rods that are usually threaded and that complete the apparatus and transfer the loads from one fracture end to the other until the bone is completely healed. The advantages of this type of reduction is that it is minimally invasive; however, since it is an external fixation apparatus, it requires continuous management and care after its application until complete healing and removal.Useful Documents
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