Weeks 11 and 12: Small Animal Orthopedic Surgery!

These past two weeks I had the opportunity to be on the orthopedic surgery service. They say there are generally two types of people in veterinary medicine; those who love surgery and those who don’t. As someone who identifies more with the medicine side things, I was excited to jump outside my comfort zone and get some experience with something new.

The orthopedic surgery service has a unique schedule. Monday and Wednesday are their receiving days, meaning that they take cases and recheck appointments, and then Tuesday, Thursday, and Friday are the surgery days. On Monday and Wednesday, we also have “topic rounds” where we can dictate what topic we discuss and dive into certain orthopedic conditions, along with their treatment, and management.

The first week of the rotation had a common theme, TPLO. Almost every student on the rotation had a patient go to surgery for a TPLO so by the end of the rotation, we all felt comfortable explaining the procedure and understanding the recovery process. In short, the tibial plateau leveling osteotomy (TPLO) is a procedure that is used to treat dogs with a torn cranial cruciate ligament. The CCL ligament is similar to an ACL in humans. Instead of repairing the ligament, the TPLO surgery helps reshape the top of the tibia with the intent of stabilizing the knee joint.

Initially, this concept can be hard to understand. In a healthy dog, the knee joint has a slanted tibia; this causes the thigh bone (femur) to slide down when weight is applied, but the cranial cruciate ligaments help to prevent this sliding. When the ligament is ruptured, sliding can occur which is painful and ultimately means that the dog’s knee is unstable. The surgery involves making a calculated semicircular cut at the top of the tibia, rotating the bone to achieve a more level angle, and securing it in this new position with a plate and screws. When performed correctly, the surgery effectively eliminates joint instability.

The recovery process for this procedure involves strict confinement and rest for roughly the first 8 weeks. Throughout the healing process, the duration of small walks is slowly increased until around 12 weeks post-op. During this time, it is crucial to keep the patient in an area with limited space along with carefully monitor their caloric intake since they will not be as active and any excessive weight can be detrimental for the joints.

During the first week, I also had the privilege of working with an incredibly sweet fracture program patient. The fracture program provides surgical care for homeless cats and dogs from animal shelters and rescue groups so that they can be put up for adoption. Our lovely patient, Grandpa Smur, was a young male domestic shorthair with a chronic femur fracture. It was reported that this fracture had occurred earlier in the month and there was no other history provided. After performing some radiographs, we saw that the distal femur was displaced proximally, caudally, and laterally indicating that it was not in a position that would heal on its own. We took Grandpa Smur to surgery, and his fracture was corrected with the use of an intramedullary pin, bone plate, and screws. This was a fascinating procedure to witness, and I also had the opportunity to help with his neuter since he was still intact. Grandpa Smur recovered well from surgery and the following day he was able to be sent home with a foster. He is still currently up for adoption so if you are looking for a sweet kitty with a little personality, let me know!

Grandpa Smur ♡

In addition to learning about, and watching awesome surgeries, I also had the chance to witness the collaboration between the orthopedic surgery team and the neurology team. Wednesday afternoon I had a patient that had presented for bilateral epicondylitis which is similar to “tennis elbow” in people. This poor kitty seemed to be walking on her toes and had a slightly abnormal gait. After performing an orthopedic exam, the team wanted to send her to the neurology team for a quick consult to make sure that they weren’t missing something neurologic before sedating her for her afternoon CT scan. Luckily for our little friend, no neurologic abnormalities were found, so she was able to proceed with a CT scan for surgical planning.

Later that afternoon, we reversed roles, and the neurology team sent over a patient for an abnormal gait and tremors. After performing an orthopedic exam, we were unable to localize a specific problem area and tentatively ruled out an orthopedic cause. After further research and gathering some additional history on the patient, we came across a condition called myotonia congenita. This is an inherited muscle disorder caused by a genetic defect in muscle cell chloride channels which ultimately prevents muscles from relaxing normally. We ran this idea by the neurology team and then came across the idea that this may be pseudomyotonia since the dog has not had this condition its whole life. This pup also had a history of being on a steroid called Budesonide which may have potentially attributed to the development of this condition. While this wasn’t specifically an orthopedic case, it was an interesting learning opportunity and a way to demonstrate collaboration across specialties.

The second week of every rotation is always smoother than the first. The flow of events makes more sense, and any procedural kinks are usually worked out. On Monday of the second week, I had an awesome patient with an OCD lesion of right ankle. Osteochondrosis dissecans is a developmental condition where diseases cartilage separates from the underlying bone, creating a painful flap in the joint. This disease typically affects rapidly growing, large-breed dogs which fit my patient’s signalment perfectly.

Since the ankle joint is responsible for holding a lot of weight, after the OCD lesion was removed, an external skeletal fixator was placed to help distribute the weight and protect the surgical site so that it could heal appropriately. This apparatus was screwed into the bone above and below the ankle joint so that it could prevent the joint from collapsing. This patient stayed with us for almost a week so that we could monitor the apparatus and healing process before sending him on his way. During this time, I had the opportunity to learn how to clean and care for an external skeletal fixator which is a nice skill to have! I know it may seem intense to have something sticking out of the dog’s leg, but it is tolerated fairly well and with dedicated owners, most dogs recover well!

The last surgery of the rotation was an ulnar ostectomy. This procedure was done to help correct and angular limb deformity in a young puppy. Angular limb deformities occur when a bone is growing faster than the other, especially when these bones are closely related, such as with the ulna or radius. This can be due to trauma of the growth plate and can set the dog up for a life of orthopedic issues. In the case of our patient, the ulna was growing too much and to correct this, a chunk of the ulna (usually a few mms) is removed and then left to heal on its own. There is a high likelihood that this dog will need to have an additional surgery in the future depending on how the ulna grows back, but for the time being, this procedure will help prevent the angular limb deformity from worsening.

As with every rotation thus far, I have been blown away by the kindness and support shown by the faculty and technical staff. Everyone is incredibly motivated to enhance our learning experience while pushing us to think clinically. The technicians are always willing to provide a hand and were incredibly patient as we learned how to navigate the service. Dr. Kapatkin and I immediately bonded over our passion for keeping dogs lean, and my interest in clinical nutrition was helpful in recommending diet trials and weight loss for most of our patients. Dr. Filliquist and I had a chance to dive into the myotonia case and share resources. I also had a blast getting to know the anesthesia faculty members better and learning from them while they were preparing our surgical patients.

Another highlight of the second week was Jayce – an awesome undergraduate student from the Virginia Tech! She was participating in the Summer Enrichment Program and shadowed the orthopedic surgery service for a week. I loved having her with all of us and she did a great job staying engaged and learned a lot. She presented a case at the end of the week and used the dog with the OCD lesion and external skeletal fixator! I love mentoring students and their passion is always a fresh reminder of where I used to be and the privilege it is to be living a life I dreamed of years ago!

All that being said, this proved the point that even if a rotation is not specifically aligned with what you think you will be doing post-graduation, there are still a plethora of key learning points that you can acquire. This journey is what you make of it, so don’t waste the opportunities and brilliant people that are there to help you reach your goals!

Quote of the week: “I pushed the drugs and God did the chest compressions.” – Dr. Machado