LEAVE THE ORTHOPAEDICS TEXTBOOK on the shelf when planning surgery to repair a limb fracture, Stuart Carmichael told one of the clinical streams at VetsSouth 2017 at Exeter in February. The professor of small animal surgery at the University of Surrey said that a common mistake made by inexperienced surgeons as to base their repair methods on the similarities between the fracture seen on the patient’s radiograph and that in a published case. An x-ray will only give part of the information needed to determine how to proceed with the surgery. The simple technique proposed for stabilising a good clean fracture may prove much more challenging if the limb involved is attached, for example, to an obese and elderly St Bernard, he said. The surgeon must take account of a wide range of different factors in planning the surgery, both mechanical (such as nature of the fracture and surrounding bone) and biological (e.g. the patient’s age, breed and overall status). But he or she must also take into account their own knowledge, experiences and access to all essential equipment and the characteristics of the owner (e.g. their financial resources and ability to provide appropriate postoperative care). “One of my pet hates is when a first opinion practice sends me a case for further surgery and they say to me: ‘The owners didn’t listen to what we told them to do’. I am sorry, but that should have been part of the initial assessment and it is your problem.” He reminded his audience that the most expensive orthopaedics procedures are those carried out when trying to put right surgery that has already gone wrong. “The client will expect you to meet the costs and so it is vital that you get it right first time.”
Systematic assessment approach
Prof. Carmichael described a systematic approach to assessing a canine patient that should help guide decision-making. Known as FPAS (fracture patient’s assessment score), the method is one that many first opinion clinicians may have heard of, but few understand it well enough to apply in their own practice, he said. FPAS is a valuable aid to managing such cases, irrespective of whether vets decide to carry out the surgery themselves or refer it on. The first opinion practitioner needs to be able to outline the treatment options if the owner takes on the major commitment of seeking a referral, he pointed out. The system involves assigning a score of 1 to 10 for a number of different mechanical, biological and clinical factors. The first of these would determine how strong the repair method would need to be and the second would affect the duration that the fixation method would need to be in place. The clinical factors (such as the likely levels of owner compliance or the consequences of the surgery failing to achieve its objectives) will modify the decisions proposed through the weighting of all the different mechanical and biological factors, he said. The scores in each of the three categories should be combined to give an overall score, which would shape the type of fixation method used. A poor score of less than five out of 10 would indicate a need for more complex surgery in order to achieve a stable result, while a score of seven or higher would mean the surgeon could choose the simplest option and still expect a good outcome. “The true art of successful fracture management is applying the simplest method that will give a high chance of a good outcome and avoiding overcomplication,” he said. In the post-operative period, the quality of bone healing should be assessed on x-ray using the four As: alignment, apposition, apparatus and activity. This will show whether the treatment is working effectively and whether further intervention is needed, for example to tighten a screw that could eventually work loose. During questions, Prof. Carmichael said that while surgeons may worry about the likelihood of post-operative problems in patients belonging to the giant breeds, those from the toy breeds could be equally challenging. “We often underestimate the complexity of surgery in these patients. They may be difficult because of the size and shape of the bones and the unwillingness of implants to stay in place. The technologies needed are more expensive and harder to use when constructed to fit smaller bones,” he said. In future, however, such patients may receive better treatment as a result of the huge popularity of toy breed dogs in Japan. This has stimulated a lot of high-quality research in recent years into developing surgical technologies and procedures to improve the outcomes in orthopaedic surgery, he said.