Equine Orthopaedic Surgery and Perioperative Care

Question 1

what elective surgery can be done?

Answer 1

– Arthroscopy/tenoscopy
- osteochondritis dissecans lesions
- Tendon sheath disease
– Angular limb deformities
(foals)
– Soft tissue surgery
- Neurectomy / fasciotomy
- Desmotomy e.g. palmar annular ligament

Question 2

what emergency surgery might be done?

Answer 2

• Arthroscopy/tenoscopy
• Synovial sepsis
• Intra-articular fracture repair
• Fracture repair
• +/- sequestrum removal

Question 3

what would an arthroscopy/tenoscopy be done for?

Answer 3

intra-articular fracture repair, osteochondritis dissecans, synovial sepsis

Question 4

what is synovial sepsis?

Answer 4

– Bacterial infection leading to septic arthritis

Question 5

what is Osteochondritis dissecans (OCD)?

Answer 5

–Development defects in cartilage and bone

Question 6

why is sequestrum removal indicated?

Answer 6

Trauma resulting in damage to the periosteum can result in death of the bone in
this region and necrotic bone separates (sequesters)
and becomes a “foreign body” so the sequestrum is often infected

Question 7

what are angular limb deformities?

Answer 7

bendy legs - lateral or medial bend

Question 8

who often gets angular limb deformitites?

Answer 8

foals

Question 9

what are the different factors for angular limb deformity?

Answer 9

nutrition, incomplete ossification, tendon/ligament laxity

Question 10

what sugical techniques can fix angular limb deformities/

Answer 10

– Growth arresting techniques e.g. transphyseal screw, plating
– Growth accelerating techniques e.g. periosteal transection

Question 11

what are the considerations for fracture repair?

Answer 11

• average weight of a horse is 500kg so lots of stress on fracture
• athletes need repair to be strong
• recovery from GA, flight animal
• lack of soft tissue on distallimb so potential for contamination

Question 12

what are the considerations for the emergency patient?

Answer 12

• Clinical examination
  – When in doubt, treat like a fracture…
  – Is the patient stable?
• Sedation?
  – a2 agonist e.g. detomidine and butorphanol
• IV catheter
• Wound care
  – Clippers, swabs, chlorhexidine, warm water, sterile isotonic fluids, needles/syringes

Question 13

what pre-op considerations are there for the emergency patient?

Answer 13

– Medications e.g. antimicrobial drugs, tetanus
antitoxin, analgesia
- Have these been given prior to referral?
- Is limb support required? - Do we suspect a
fracture?

Question 14

what are the goals for fracture stabilisation?

Answer 14

– Stabilize fracture
– Reduce discomfort and distress
– Minimize further trauma to bone ends, soft tissues and vasculature
– Prevent further contamination

Question 15

what is the nurses role during surgery?

Answer 15

• Scrub nurse – run table/anticipate next step during procedure
• Orchestrate – run the room
  – This starts pre-operatively

Question 16

how do you prep theatre for surgery??

Answer 16

• Clippers
• Antibacterial preparations
• Fluids
• Medication
• Urinary catheter
• Shoe removal?
• Anaesthetic machine, circuit etc

Question 17

howdo you repare the patient for surgery?

Answer 17

• Patient is primary source of
  pathogens
• Cover feet and tail
• Clip hair Preferably outside operating theatre
• At least 10-15 cm away from
  intended surgical site
• 1st Clean skin
• 2nd Disinfect skin

Question 18

how can you prepare the skin for surgery?

Answer 18

• Chlorhexidine
  – Residual activity (binds to protein in skin)
  – Low toxicity (but can be toxic for fibroblasts)
• Iodine compounds
  – Stains, radiopaque, smells.
  – Only free iodine is bactericidal
• Povidone iodine:
  – No free iodine unless diluted or combined with detergent
  – Low toxicity (individual sensitivity reported) – Inactivated in presence of organic debris
• Synergistic effect with alcohol

Question 19

what are the uses for alcohol as a skin prep?

Answer 19

• Only effective against bacteria
• Inactivated by organic debris
• No residual activity
• Commonly used as rinse after surgical scrub

Question 20

what specific requirements are there for preparing the theatre?

Answer 20

• ropes/support stands, cushioning/padding for positioning
• instruments required?
• imaging equipment required?
• post-op bandaging/casting materials

Question 21

what surgeon considerations are there for positioning of the patient?

Answer 21

– Comfort
– How accessible is the surgical site?
– Is there more than one surgical site?

Question 22

what positioning considerations are there for the horse?

Answer 22

– Comfort
– Myopathy/neuropathy risk

Question 23

what types of recovery can you do for horses?

Answer 23

• Unassisted
• Rope recovery
• Sling recovery
• Pool recovery

Question 24

what are the risks with pool recovery?

Answer 24

infection/ pulmonary oedema

Question 25

what post-op care should you provide?

Answer 25

• Analgesia
• Antimicrobials?
• Normal parameters:
  – TPR within normal limits
• Reasonable faecal output / consistency
  – Impactions common!
• Reasonable appetite
• IV catheter required / removed?
• Bandage care - strike through, slipping, comfort
• Monitoring

Question 26

what post-op care should you provde for synovial sepsis?

Answer 26

• Antimicrobials
  (– Systemic
  – Intrasynovial
  – Intravenous regional perfusion)
• Repeated synoviocentesis?
  (– WBC, TP, SAA
  – Is a second lavage required?)
• Wound management

Question 27

what are the complications associated with orthopaedic surgery?

Answer 27

• Post-operative infections
• Incision breakdown
• Unacceptable pain post-operatively
• Bandage sores
• Cast sores
• Supporting limb laminitis
  – Frog support opposite limb

Question 28

why might bandage complications arise?

Answer 28

– Horse sweating / hot
– Horse moving around a lot
– Poor application
– Incorrect tension

Question 29

how can you monitor casts?

Answer 29

• Twice daily
• Sudden or gradual changes in comfort
• Fever
• Discharge or staining
• Wear on sole
• Cast breakage
• Heat
• Flies sitting one spot (in summer)
• smell

Question 30

what are the complications associated with fracture fixation?

Answer 30

• post-op infection
• breakage of implants/implant failure
• further fracture of limb

Question 31

what equipment do you need for fracture fixation?

Answer 31

• drill
• plates and screws
• bone reduction forceps
• general kit and drapes
• fracture kit (4.5mm set and screws, 5.5mm set and screws)
• plate benders

Question 32

what equipment do you need for arthroscopy?

Answer 32

• camera
• synovial resector
• trochars
• cannula
• fluid line
• screen
• scope
• light cable
• fluid pump
• arthroscopy tower

Question 33

what is a tenoscopy?

Answer 33

Arthroscope to look in tendon sheaths instead of joints

Question 34

why might a patient develop arthritis after arthroscope?

Answer 34

if chip fragments are left inside the joint

Question 35

what is rope recovery?

Answer 35

rope on head collar and tail, guiding the horse up when they are ready, would leave in ET tube or NO tube