PAULClinical Experience
! 1!
KYON Symposium 2013 Innovations in Veterinary Orthopedics and Trauma
Boston, USA - April 12 - 14
Friday, April 12th 19:00 Welcome Reception Saturday, April 13th 07:00 Registration 07:50 Welcome and meeting organization Session 1 – STIFLE 08:00 Ultra-CL – Arthroscopic Application: Michael Bauer 08:10 Ultra-CL – Research: Juan Pu 08:20 LESS – Research & Clinical Application: Otto Lanz 08:30 TTA-2 – Introduction: Slobodan Tepic 08:40 TTA-2 – Clinical Experience: Joop Hopmans 08:50 TTA-2 – Research: Krista Adamovich 09:00 TT-Crown – Research & Clinical Experience: Zoran Lonĉar 09:10 TT-Crown – Clinical Experience: Simone Niederhäuser 09:20 TT-Crown – Clinical Experience: Hugh Davis 09:30 DISCUSSION moderator: Andy Torrington participants: STIFLE session speakers 10:00 Coffee break & BREAKOUT SESSION 1 Session topics and facilitators are listed below. Session 2 – LANDSCAPES: BUSINESS 11:30 A Family Practice: Randy Acker 11:45 A Distinctive Business Model: Denny Aron 12:00 A Specialty Clinic: John Stephan 12:15 Franchise Operations: Dave Gersholowitz 12:30 DISCUSSION moderator: Preston Stubbs participants: LANDSCAPES: BUSINESS session speakers 13:00 LUNCH Session 3 – LANDSCAPES: SURGICAL INFECTION 14:00 Microbiology and Minimizing Clinical Risk: Scott Weese 14:30 THR – Clinical Experience: Aldo Vezzoni 14:45 Internal Fixation – Clinical Experience: Ayami Nojiri 15:00 DISCUSSION: moderator: Ursula Krotscheck participants: LANDSCAPES: SURGICAL INFECTION session speakers 15:30 Coffee Break
Aldo Vezzoni, DVM, Dipl. ECVS, Cremona, Italy
Wednesday, April 24, 13
Medial compartment syndrome of the elbow
• End result of FCP and OCD of
the Elbow
• Due to joint incongruity
• Short radius or short ulna
• Cartilage loss and bone
eburneation
• Progressive OA
• Friction, heating, pain
Wednesday, April 24, 13
• Ingo Pfeil pilot study developed with Slobodan Tepic
PAUL
‣ Similar effect as for genu varus in man‣Medial open wedge
osteotomy‣Causing shift of weight
bearing from medial to lateral
Wednesday, April 24, 13
• Ingo Pfeil pilot study developed with Slobodan Tepic
PAUL
LM
‣ Similar effect as for genu varus in man‣Medial open wedge
osteotomy‣Causing shift of weight
bearing from medial to lateral
Wednesday, April 24, 13
• Dogs of any age (1 year to 9 years)
• Severe OA developed from FCP-OCD
• Medial Compartment Syndrome
• Unresponsive to conservative or arthroscopic treatment
• Offering palliative treatment with expected variable
improvement or no improvement, age and OA dependent,
but no worsening
• 7-12 month PrDUO
• < 7 months, DiDUO
Case Selection
Wednesday, April 24, 13
Golden, M, 4 yrs. Labrador, M, 5 yrs.
Case Selection
• Mature dogs
Rottweiler, F, 7 yrs.
Wednesday, April 24, 13
Case Selection
Blade, Labrador, M, 5 yrs., 35 kg
• Planning:
‣ arthroscopy to confirm medial compartment erosion and
cartilage integrity in the lateral compartment
Wednesday, April 24, 13
• Exclusion:
‣ end-stage OA
‣medial & lateral
joint collapse
‣ > 10 years of age
Case Selection
Labrador, F, 8 yrs, 38 kg
Wednesday, April 24, 13
• Exclusion:
‣ severe elbow incongruity by
short ulna and UAP
‣ radial head degeneration
‣ lateral compartment affected
Case Selection
GSD, M, 3 yrs., 36 kg
Wednesday, April 24, 13
• Exclusion:
‣FCP without medial compartment erosion
Case Selection
Rottweiler, M, 8 mo.
Wednesday, April 24, 13
• Planning:
‣ radiographic study and measurements
‣mechanical elbow medial angle
‣ normal: 81.5 ± 2.5
‣ < 80° ⇒ 3 mm step plate
‣ > 80° ⇒ 2 mm step plate (first choice in more chronic cases)
Case Selection
76°
Wednesday, April 24, 13
• Visual Planning:
‣ video clips
‣ still frame from front
‣measure forelimb adduction
‣ degrees of correction related to
amount of internal limb
adduction, & limb size
Tobia, Golden Retriever, M, 1.5 yrs.
6°
Planning
Wednesday, April 24, 13
Outcome
• Post-op radiographs
• M-L
• Cr-Cd
‣FUs at 2 and 6 months
‣ then yearly
Wednesday, April 24, 13
• Breeds
Clinical cases
Labrador
Golden
Rottweiler
GSD
Am. Staffordshire
Bernese
0 4 8 12 16 20
18
5
5
Total: 32 elbows
2
1
1
Wednesday, April 24, 13
• Age
1-2 yrs
3-5 yrs
6-8 yrs
9 > yrs
0 2 4 6 8 10 12 14 16 18 20
53%
18%
18%
1%
Clinical cases
Total: 32 elbowsWednesday, April 24, 13
• Plate size
2 mm
3 mm
4 mm
0 4 8 12 16 20
53%
43%
3%
Clinical cases
Total: 32 elbowsWednesday, April 24, 13
• Arthroscopy
Previous
Contemporary
No
0 4 8 12 16 20
13%
62%
25%
Clinical cases
Total: 32 elbowsWednesday, April 24, 13
• Gap
Bone graft
Collagen sponge
No
0 2 4 7 9 11 13 16 18 20
6%
56%
38%
Clinical cases
Total: 32 elbowsWednesday, April 24, 13
• FU
1-2 months
6 months
1 > year
0 20 40
97%
64%
52%
Clinical cases
Total: 32 elbowsWednesday, April 24, 13
‣Clinical and rad assessment
‣ Independent owner interview (April 2013)
• Outcome
Clinical cases
• Great improvement, no NSAID
• Improvement, less NSAID
• Same as before
• WorsenedTotal: 32 elbows
Wednesday, April 24, 13
• Outcome (physical evaluation, X-Ray and owner’s satisfaction)
Great improvement
Improvement
Same as before
Worsened
0 4 8 12 16 20
56%
22%
19%
3%
Clinical cases
Total: 32 elbows
78%
Wednesday, April 24, 13
• Outcome
Great improvement
Improvement
Same as before
Worsened
0 4 8 12 16 20
1-2 years17 dogs
3-5 years6 dogs
6-8 years6 dogs
53%
30%
16%
66% 50% 66%
Clinical cases
17%
Total: 32 elbows
9 > years3 dogs
17%17%
34%
17%17%
Wednesday, April 24, 13
• Outcome
Great improvement
Improvement
Same as before
Worsened
0 3 6 9
1-2 years
53%
30%
Clinical cases
17%
83%
Tot.: 17 elbowsWednesday, April 24, 13
• Outcome
Great improvement
Improvement
Same as before
Worsened
0 0.8 1.6 2.4 3.2 4
3-5 years
66%
Clinical cases
17%
17% 83%
Tot.: 6 elbowsWednesday, April 24, 13
• Outcome
Great improvement
Improvement
Same as before
Worsened
0 1 2 3
6-8 years
50%
17%
Clinical cases
17%
17%
Tot.: 6 elbows
67%
Wednesday, April 24, 13
• Outcome
Great improvement
Improvement
Same as before
Worsened
0 1 2
66%
Clinical cases
34%
Tot.: 3 elbows
9 < years
Wednesday, April 24, 13
• Minor Complications: 9 (28%) broken screws, delayed union, seroma
• Major Complications requiring surgical revision: 4 (12.5%)
• Major Complications with new implants: 2 (6%) implant removal
Brocken plate
Broken screws
Implant removal
Delayed union
Seroma
0 1 2 3 4 5
6%
3%
Clinical cases
(Prototype plate)
6%
(over 6 mo.)
Total: 32 elbows
15%
9%
Wednesday, April 24, 13
Rottweiler, F, 7 yrs., FU 6 mo.
• Complications:
‣Plate breakage
‣Prototype plate
only
Clinical cases
Wednesday, April 24, 13
American Staffordshire, M, 4 yrs., 20 kgFU 9 mo., implant removal, too big plate
Clinical cases
Wednesday, April 24, 13
Labrador, M, 1 yr., FU 5 mo.
• Complications:
‣ screw breakage
‣ young, active dog
‣ conservative
Clinical cases
Wednesday, April 24, 13
Tobia, Golden Retriever, M, 1.5 yrs., 36 kg3° chronic left lameness, FCP 5 mo. before
Clinical cases
6°
Wednesday, April 24, 13
Tobia, Golden Retriever, M, 1.5 yrs., 36 kg3° chronic left lameness
Clinical cases
Wednesday, April 24, 13
12°(+ 6°)
Tobia, Golden Retriever, M, 1.5 yrs., 36 kg1 month p.o. PAUL 3 mm, limb abduction
3 mm step
Clinical cases
Wednesday, April 24, 13
Tobia, Golden Retriever, M, 1.5 yrs., 36 kg1 month p.o., limb abduction
Clinical cases
Wednesday, April 24, 13
Tobia, Golden Retriever, M, 1.5 yrs., 36 kg1 month p.o., limb abduction
Clinical cases
Wednesday, April 24, 13
slow motion
pre-op
pre-op
1 mo. post-op
Tobia, Golden Retriever, M, 1.5 yrs., 36 kg1 month p.o., limb abduction
Clinical cases
Wednesday, April 24, 13
pre-op
Giobbe, Labrador, M, 9.5 yrs., 30 kgFU right PAUL U3, 2 yearsFU left PAUL U2, 2.5 months
Clinical cases
R L
Wednesday, April 24, 13
pre-op
Giobbe, Labrador, M, 9.5 yrs., 30 kgFU right PAUL U3, 2 yearsFU left PAUL U2, 2.5 months, client satisfaction!
Clinical cases
Wednesday, April 24, 13