Thank you so much. Good evening, everybody. Here it's in, it's in the afternoon.
It's 3 o'clock in the afternoon. The topic of the webinar, as you know, will be clinical management of septic arthritis in cattle. This, presentation will be very, practical, a lot of pictures and videos, not so many, theory, and I'll be glad to answer a question at the end of the webinars.
We'll review very quickly, in about two slides, aetiology, then we'll spend quite a few, time on the diagnosis. We'll discuss how to do joint lavage, aprotomy, arthrodesis, and of course, we'll discuss also the medical treatment and medical management, of septic arthritis in cattle. We classify the cytic arthritis in three categories in cathode, and it, it is based on the aetiology.
So we have the primary, secondary, and tertiary, cyvic arthritis. The primary is a direct trauma to the joint, like a simple laceration. To the pastor, for example, or to the heart.
Secondary, it's an infection that is close to a joint. The best example for that, we'll see a picture in the next, slide. It will be a sole abscess and then the abscess goes into the coffin joint or the P2, P3 joint.
In tertiary, this will happen in cats, most frequently, and it is from a systemic infection. So I removed infection, the bacteria goes into the bloodstream and then the, will finish in the, in, in, in the, in the, the joints. 33 pictures showing you the different type of of septic arthritis in cattle.
So you have a primary, and you see the laceration here at the pastor area and the laceration goes right into the joint. Here, the secondary, it was, it's a P2, P2 infection, secondary to a severe. So abscess that ended up into the joint.
And finally, the picture that you see, just below tertiary, it's an umbilical vein infection or afalo phlebitis. So here you have the liver, right there, and then you have the umbilical vein that is quite big, and most likely full of pus. Diagnostic of cytic arthritis is quite easy, especially in cattle, because as you know, we don't see those cases very acutely.
The, the owner, tried something before calling you, unfortunately, so the joint will be swollen, it will be warm, it will be painful to the touch, so it has all the hallmarks of inflammation. But it's not so obvious in proximal joints like the hip, and the shoulder, for example. This is a very painful, disease, so the animal will be nonweight bearing.
In your differential of non-weightbearing lameness, you need to include septic arthritis, of course, and then fracture, ligament injuries, tile synovitis, and sole abscesses. Always do a complete physical exam when you have a septic arthritis, especially if you don't see any obvious wound or laceration, over the, the affected joint. If it's a calf, you need to auscultate the lungs very carefully and also the umbilicus to be sure that there is no infection there.
If it's a cow, and you have multiple joints that are infected. Be sure to auscultate the heart very well to be sure you don't have a murmur, that can be caused by an endocarditis. So this is an example of a calf that was presented with a quite acute septic arthritis.
So you see that he is laying, of course, he is weight-bearing and he's even running on that leg. And, but the carpus is quite swollen. So the problem with those cases is sometimes because the animal is still able to walk, the owner, will try to treat him, with some, you know, pain, killer like, any type of NSAIDs, and antibiotics, antibiotics without very specific knowledge of, of what's going on.
And the more you wait. The worse it is for the prognosis. So, you know, a calf with an enlarged joint, equal septic arthritis until proven otherwise.
It it's another, it's a, it's another calf that is, quite clean, and she has, it's a heifer, she has an infection of the left tarsus. The tarsus is swollen, and she is extremely painful. So in that case, she was presented a bit more chronically.
Here it's a beef animal. The reason why I'm showing that is depending on the, the type of animal, they will not show the same kindled sign of lameness. Like this one is a bit excited, so she is lame.
If you notice, she had a, I'm gonna start the video again. If you notice, she had a swollen, left front foot, and she is laying on that leg, and more specifically, it's swollen just on the lateral aspect of the foot, and she had an infection of P2, P3. Another beef animal, since they are in a feedlot with many others, they are not seen as often as a dairy, animal.
In that specific case, you can see the laceration that is, medial and just above the fatlock. What is particular about that case is that he has also tinosynovitis. Notice the severe swelling at the back of the fatlock here.
So in that very specific case, we have two synovial sacs that we have to treat. We have the fatlock that is infected. And also the, the tin she has a tinovi, he has a tenosynovitis.
It's a, it's a very complicated case and depending on the value animal that of the animal, maybe this animal will be cold or euthanized. I'm showing that picture because this animal was presented, for septic arthritis, of course, bilateral carpi were infected, but it's been a while and notice the infection of the carpus. When you see a case like this, you know that if you want to treat it, it's going to take a long time to become normal.
This animal has contraction of the capsule, probably also tendon contraction. So even though you can, control the infection with any type of medication and surgical treatment. Physical therapy will be necessary to regain that range of motion.
So that's something you need to consider when you start a treatment, on an animal like this, and the, the owner needs to be aware that he will probably have to do some work, with this animal to, so he can come back to normal. The most The most commonly joints infected are the carpus, the stifle, and the Tarsus. This is a study that we published recently with Dr.
Catherine Constand, and we looked at specifically 60 calves ranging from 0 to 6 months old. One thing that is particular, if you look at the carpus and the stifold, you see that the neonatal group, meaning that until, the, until about 3 months. The corpus is more frequently affected compared to the older calves, up to 6 months, it's the stifle that is more frequently infected.
But carpus stifle torso are the most commonly infected joint in calves, and I would say also in adult. I mentioned that in calves, specifically, you need to do a complete physical exam. What you see on this video is somebody palpating the, I will start the video again because I was talking.
So let's start the video again. So I, the, the person is palpating the cranial aspect of the umbilicus and that's the umbilical vein. The umbilical vein is infected and there's pus coming out of the umbilicus.
And here at the ultrasound, you see the infected umbilical vein going close to the liver. So we know that this animal has of phlebitis. Therefore, there is bacteria in the bloodstream that ended up in the joint.
Knowing that, it will help you to determine which type of antibiotics eventually you will, use to treat acetic arthritis of this animal. Compared to this one, another young calf that was presented with, multiple septic joint, and, he also, she also had lung, abnormal lung sounds that were compatible with pneumonia. In that very specific case, this animal had mycoplasma pneumonia.
So when you have an animal with a respiratory disease or ortitis also, and this animal has a swollen joint, you need at least in Canada, and I think you do this, you do have the same problem in the UK, you need to think about mycoplasma. So you don't want to treat this animal with a beta lactta because it will never work, so. Here, the protocol is that if an animal has, if you are suspecting a pneumonia on an animal with septic arthritis, we will give an antibiotics that would be good for mycoplasma.
This is an adult cow, obviously, and, she was presented because, she had a very swollen left hind limb. I'm showing you this, picture because when the limb is swollen like this, it's difficult to evaluate the joint, . Because everything is swollen, so it's you cannot feel the pouch of the joint.
And, and the other thing also that is complicated is when you have cellulitis like this, you kind of, you are afraid of going through the swelling under the skin into the joint because you don't want to contaminate the joint with a subcutaneous infection. So those cases are a challenge for your diagnosis, but Usually what we do with those cases, we will use ultrasound. To see if the joint is swollen, and then we'll take a decision if we should tap it or not.
In that case, that's what we did. We did the ultrasound and we found that the joint was infected just by looking at the synovial fluid. It's supposed to be clear, .
Mildly yellow. This one is cloudy, and dark yellow. So we know that even though it's not submitted to cytology, that this animal has septic arthritis.
Another interesting thing also that you can do if you have a laceration over close to a joint, but you don't know if there is a communication with the joint. It's a very simple technique. You, prepare the joint sterilely, surgically, and then you inject fluid into the joint and you see, you look for fluid.
Coming out of the laceration, as you will see like right here. So we know in that specific case that there is a communicate a communication between the joint and the laceration. I will show you some videos of animals that have, that have, joint infection, but, of the opera limb.
It it is difficult to palpate and especially if you don't see those type of cases very often, they are very frustrating, and often they are treated symptomatically with painkiller. But without knowing that it could be aseptic arthritis. So this is a, a, a young Ayrshire, that is suffering from septic arthritis of the elbow.
So we, based on her behaviour, we know that it's a severe condition, could be a fracture, could be septic arthritis, so abscess, but now that you look at the animal, you can see that the elbow is swollen, . And compared to. The other one.
I'm gonna stop the video right here. And I want, I want to show you something and there's a misconception about shoulder lameness, and this is a very good example here. So you can appreciate the asymmetry between the two elbows.
This one is very swollen. However, in those animals that had chronic disease or chronic lameness, there's an atrophy around the shoulder. So those animals are referred to us very frequently.
For a shoulder problem. This is shoulder problems in cattle are quite rare. The shoulder is more obvious just because there is atrophy surrounding the shoulder.
So just be careful when you see something like this. Be sure it's not simply atrophy, that is causing the elbow to be, the, the shoulder to be more permanent. Man manipulating those animals, it's not easy.
As you can see, I'm doing some, the student is doing some flexion of the limb and extension trying to localise where is the pain. So there is no doubt that the pain is coming from the elbow just by palpating it. This is an animal with a septic arthritis of, the hip.
It is really painful. And the animal is almost non-weightbearing, and just by looking at the limb, you see absolutely no swelling. So when you see a severe lame mist like this and you see no swelling at all, you need to suspect something going on, at the hip, it, but With some basic manipulation by abduction and and direct pressure on the trochanter, sometimes you can precise where is the pain, but it's, it's not easy.
It's a difficult disease to diagnose. The diagnostic tools to, confirm your diagnosis cytology is, a very easy one to do. Bacteriology, culture, or PCR specifically for microplasma, Ray, ultrasound.
Of course, CBC and chemistry profile, especially if it's a young calf and you want to know if the, the level of globulins are, enough, and ery or nasal swab, PCR for mycoplasma bovis. The most common problem, joint problem in catal is septic arthritis, but there are other conditions that I'm going to describe here. But by far, if you have a swollen joint, you need to think first septic arthritis.
It could be a traumatic arthritis. The way to make your differential is to take, a synovial fluid, and if there's blood, well, it's traumatic arthritis. Ligament injury, they are rare, possible, but rare.
The most common one would be an adult, a 5 year old, typically, and it's gonna be a cranial cruciate ligament rupture. Articular fracture, extremely rare and cattle, best way to diagnose those with X-rays. Osteoarthritis, it's a very slow progressive disease that will affect specifically the heart and the stifle.
So with the history of the disease, you will know that it's not something acute tachycytic arthritis, but it's been going on for a few days, a few weeks. And finally, osteochondrosis that will affect young animal, fast growing animals, more specifically the hawk and the stifle, and those animals, those animals will not be so lame compared to a cytic arthritis. Actually, they will have a swollen joint, soft to the touch, and the animal can walk quite normally.
Cytology, is it always necessary? And I don't know how expensive it is in the UK, but here, for a cytology is around $40. And as I mentioned earlier, the most common joint disease in cattle is septic arthritis.
Just by looking at the fluid, you have a pretty good idea if it's septic or not. This is a good example. So on your right, the fluid is septic, on your left, it's non-septic.
And just by looking at it, you don't have the cell count just looking at it, but you have, you know, especially in the field, that it's a septic arthritis, I need to treat it accordingly. I think it's pretty obvious in that case that it is a septic arthritis of the heart. The fluid is opaque, white, no need to send it to cytology to confirm the diagnosis, especially if you are in the foetal situation and you need to take action right now.
You don't wait for the results. Here, this is a normal synovial fluid viscosity. So you see with my finger, I'm taking just a small drop and it's like, like mozzarella cheese, for so it's, it's very slimy and what we say is that this, this fluid, the viscosity should be as much as 7 to 10 centimetres.
So that's a normal viscosity for synovial fluid. This is what you want. Here on your, left, you have an abnormal viscosity, and this is from an animal with osteochondrosis.
It's clear, not so obvious on the video, but the viscosity is quite poor. On your right, this is a skin of your food from a septic joint. It's opaque, almost white, and there is no viscosity to it.
So you see with those simple tricks, you can appreciate the, the, the quality of the seal fluid and, and take action, rapidly instead of waiting for results. However, if you are not sure, because there's always animals that, don't read the book and you are in the grey zone, we did publish a study a few years ago looking at, we tried to find a difference between non-infectious arthritis and infectious arthritis. So the numbers in red, it's the average of all the animals with infectious arthritis.
So it's 63,000 for nucle cell, proteins 56, neutrophils, 94%, and monocyte 5%. The cutoff of those values were nucleated cells 25,000, neutrophils greater than 80%, and total proteins greater than 45%. So if you have those value, the animal has septic arthritis.
In 2002, 1 of my colleagues, presented a study that was not published, but, we looked at 172 cases of septic arthritis, and we looked at the, what type of bacteria is affecting those animals, here in our, hospital. As mentioned earlier, carpal and stifle joint were mostly affected. We had a percentage of 60%.
A positive culture, which is quite good. In the literature, usually it's around 50% and 60%. So 60% is very good.
And in 47% of those animals, we found one bacteria and in 13% more than one bacteria. Back then, back then in 2002, Tupperella pyogenes was the number one bacteria in young animals and specifically in adult. Streptococcide, only 14%.
And then if you look down, mycoplasma, 4%. It was back in 2002. Now, There's a change in our population, and this is a study that we published in 2018 and that's only on calves, I have to be very specific, none in adult cattle, only on calves.
However, there's, there's a switch in the, in the, an obvious switch in the common bacteria that we found is we have a percentage of isolation of 59%, which is quite good. The most common bacteria were streptococci, in calves. Mycoplasma came 2nd, and 3rd, Gram-positive rods, cherella.
Now, if you look at radiographic study of cytic arthritis and calves, it's not doing radiographs in field situation is not always easy. You need specific equipment that is expensive, but it's a good way to make a final diagnosis. And also to evaluate what's going on with the, the joint.
What we are looking for is the joint space. If there's a septic arthritis, there's an increased joint space. There is also an irregularity of articular surfaces.
And I will see, so, I will show you some examples of subchondral bone lysis. And finally, Soft tissue swelling, that is what's interesting with the paper we we published. The soft tissue swelling is more important, in cases where the animals that is infected with chorella paogenes.
Here we have a radiograph of a stifle. It's a, it's a cranial caudal view. Lateral side is on your left, medial side on your right.
Here, circle with a red circle in the middle, you see, a subchondral bone lysis on the proximal aspect of the tibia with a little bit of sclerosis. This is a very typical lesion of septic arthritis of the the stifle. This is a corpus, of a young calf, and, in that specific radiograph, we can see the increased joint space that you can see in the radiocarpal joint.
Same thing in the middle carpal joint and the carpal metacarpal joints. So in that very specific case, the three joints were communicating together and we'll discuss that a little bit later. There's also a little bit of gas here at the distal aspect of the carpus.
Those are more obvious. On your, left, you have a, septic arthritis of the Petla. You can actually see air or gas in the joint.
So when you have this amount of gas in the joint, we are suspecting either Terella paogenes, or it could be also an arrow like Fusobacterium microfen, but torella is certainly more frequent. On your, right, this is a, it's a dorsal plantary view of a foot. So, looking at the bottom of the X-ray, you can compare the 2 P2P3 joints.
The joint space here is quite enlarged and there's subchondrial bone lysis. There's a little bit of bony proliferation, so we have a septic, a chronic septic arthritis of the distal interphalangeal joint. And those two cases are very severe, but they do happen and, and it's a shame because those animals are suffering and there's nothing we can do when it's that severe.
Well, there's some stuff we can do, but it's, it's usually it's a salvage procedure. So on your left, you have a severe chronic septic arthritis of the carpus and the animal is in the process of ankylosing. Is joint.
On your right, you have a severe distention of the fetlock with gas and liquid inside the joint, and the pressure is so high that the joint is basically, almost ex stated, because of this large amount of fluid and gas. Ultrasound is an interesting tool. However, if you are not used with ultrasound, it's something that, it's, you will be very limited with what you can do with ultrasound.
Doctor Kopfler, from Vienna did a bunch of study and publication on that topic. And, and it's a very, actually, it's a tool that is, when you get good at it, it's better to evaluate this type of infection than the X-rays, but you need a lot of practise. But one thing that is very easy to do, and, we use it very often because of that is to, we want to determine, the synovial fluid ecogenicity.
So if it's homogeneous hypoechoic, it means that the synovial fluid, doesn't have so much cells and fibrine, so we will lavage the joint with the 2 and 2 lava simple technique. However, if it's hyperechoic, then we will have to perform an aronomy, because there's too many fibrins. So it helps us to decide.
Which treatment we will use to for on this animal. The other thing also that, where we use the ultrasound, and the other reason why we use the ultrasound is to diagnose, especially in field situation when, when you get used to the, the instrument, acute septic arthritis of the shoulder, the hip, and other joints, difficult to evaluate. Doing x-rays, on the shoulder, and the hip.
Even in the hospital, it's not easy to do. So if you can diagnose it with an ultrasound, that's way better for the animal and it's faster. So it's interesting, the ultrasound is interesting in, in those very specific, infection.
Very quickly because, it's, it's a difficult topic to discuss. Here, we have a septic arthritis of a tarsus. You see on your right, there's no obvious lesion of the tarsus, but there is some severe swelling at the dorsal aspect of the Tarsus.
So the, the arrow is pointing, On the ultrasound, so this portion here corresponds to this portion over there. So here it's distal, it's proximal, sorry, here it's distal. And what you have to notice is this fluid here that is ecogenic, is hyperechoic, meaning that there's some cells and fibrin and with a case like this, we will probably go ahead and do an acronomy instead of doing articular lavage.
The treatment plan, depends on many things. The duration of clinical signs. If, if it's an acute septic arthritis, then you will probably go with antibiotics, anti-inflammatories, and, lavage only.
However, if it's been going on for 3 weeks, there's a pretty good chance that there's gonna be fibrine into the joint and the lavage will not be very helpful. So, knowing the duration of the sign will help you to take the, to decide the appropriate treatment. Severity of the lesion.
How many joints are involved. We'll see that a little bit later, but at this point, I need to tell you that if there's, if there are more than 2 joints involved in the process in, in the, in the, in the infection, then it's a poor prognosis. So we rarely, rarely treat animals with more than 2, joints infected.
We will discourage, the owner to put any money, on those animals. So we'll treat 1 for sure, 2. But more than 2, the animal needs to work a lot of money and the owner needs to be aware that the chance of survival, are extremely low.
The radiographs also will help you to decide if the animals should be treated or not. As, if you remember the last few radiographs, those animals, the prognosis, is not very good because of the severity of the lesions. Cost of treatment, and that's, that's a problem, because you cannot treat septic arthritis.
Like a pneumonia with just a couple of injections. Any type of musculoskeletal infection, needs at least a couple of weeks of antibiotics. So if the owner doesn't want to go that far, you need to have a discussion with him, or her, I should say, that, maybe he needs to put the animal down if he doesn't want to put the money and the effort to treat, cystic arthritis.
And need to to think about the prognosis, what is the goal of this animal? Is it a breeding animal that you want to keep for very long or it's just, it's a, it's a, it's a beef and you want the animal to weigh 1000 pounds and then go to the slaughter? The, the older I get, the less antibiotics I have in my pharmacy and it's, it's, it's, it's When you, when you are like me and you treat basically individual, and you are doing individual medicine, it's a problem.
I will, I cannot discuss the type of, I, I can answer a question at the end if you want advice, but it's difficult for me to tell you which antibiotics to use because there's so many variation nowadays between countries. That, it's, it's, I, I don't want to, you know, give you, specific, rules for antibiotics. I will give you principles and then at the end, I will be happy to answer a specific question.
But as you know, it's very limited in food animal. I think right now in Quebec, I have like 5 antibiotics I can use, on food animal. More specifically, I don't know in the UK, but here in North America, I have to say that every time you are treating an animal for septic arthritis.
It's extra label, for many reasons, the, the, the route can be different than what it's labelled for, the withdraw the, the duration, duration 2 to 3 weeks. I don't think anybody, any companies are labelling, put things on the label that you can treat an animal for 2 to 3 weeks, and it's, it, it will affect the withdrawal time. So it's .
It's a very difficult topic to discuss, because of all those limitations that we have nowadays. And I respect that, but for cytic arthritis, it's, it's difficult, frustrating in a way. So if you ask me what is the best route to give antibiotics to treat septic arthritis, of course, it's gonna be IV, but I, I'm fully aware that it's not always possible.
There's some alternative administration around. One of them is the IV on the tourniquet. You can give only one dose when you treat, an animal and you want to achieve high concentration only one, only once when you're gonna flush the joint.
Or you can actually, eventually put a catheter in it and give local antibiotics regularly for a week, and depending on the catheter and depending on the animal, up to 10 days. That the The goal of that is to achieve high local concentration of antibiotics. Since you're gonna use the 3rd of the systemic dose, You're going to decrease the cost also.
but the problem is extremely difficult to keep a catheter and you cannot inject. Every day just with the, finding a vein, rapidly, you will have a thrombosis of the vein and swelling, and it will be difficult to find a vein again. So if you want to repeat.
The dosage, you repeat the injection, you need to install, some type of, of catither and it's limited to the distal limb because it's not possible to do an, an efficient tourniquet, for example, above the stifle. So it's limited to, you know, fetlock, carpus, and torso, torsos infection. This is the type of catheter that we are using, when we do, continuous, not continuous, but, A daily injection of antibiotics on their tourniquets.
So it's the company Arrow, the, they use, it's a, it's a human catheter that they are using to measure the central venous pressure. And that's the type of catheter that we use also for juler administration of antibiotics. And you can keep this catheter for up to 21 days.
So it's it's, and actually the owner in with our Chanel are used with this type of catheter and even the practitioners are using it to give IV antibiotics. So this is a practical example, septic arthritis of the carpus, two different cases, but just to show you how we do it. So on your left, we have a tourniquet just above the elbow.
You see the vein very well here, and then we're gonna insert this long-term catheter and polyurethane. And we're gonna have a tourniquet just above the, the elbow and I'm gonna inject the antibiotics and we're gonna leave the tourniquet for 5 to 10 minutes. Another route is the intra-articular antibiotics.
It's very easy to use. Usually we do it at the end of a joint lava. It will achieve high concentration of antibodies for 24 hours and a little bit like, the, IV administration on the tourniquet, we use about a third of the systemic dose.
You need to be careful with the type of antibiotics you are using when you are injecting into the joint because some of those antibiotics are really irritating. So usually we stick with the soluble antibiotics like here we use ampicillin and we use a third generation of cephalosporin, to put into the joint. You can use lecomycin also and stomycin.
Depending on the animals, you need to be realistic. And, even though I'm telling you that you need to give like 3 times a day ampicilian on the rodeo ball, it will not happen. So you do your best, considering, what you can do in, in, in, in the field, but you need to play with those principles as long as the owner is aware of, of the potential outcome and you don't always have the control of what you can do on those animals.
The articulo lavage. Articulavage is, is quite essential, when you treat, when you want to treat efficiently aseptic arthritis. The goal of the articulavage is, of course, is to get rid of the microorganism, but moreover, it is to get rid of all the inflammatory cells and the byproducts of inflammation like the cytokines.
So, and we think that in some cases, the reason why we don't have, we don't isolate microorganism is because they are just gone. The, the inflammatory cells did their job, they killed everything, but then because they are there and creating inflammation, it's a vicious circle and the animal is in pain, and that's why the article of bios is so important to get rid of all those byproducts. Joint lavage is a painful procedure.
So those animals needs to be restrained, sedated, and you need to give some type of analgesia and anaesthesia. You need to surgically prepare the site also hair removal and scrubbing because you don't want to enter, foreign bacterias into, into the joint. So usually when we get prepared for John savage, we do the joint tap at the same time that then we will submit the sample for analysis, either cytology and or bacteriology.
When we do joint labagege, we use large size needle. We're gonna use 14 gauge needle, even though if it's a cat, we can, you can start with the 18 gauge to do your joint tap to collect your sample, but rapidly we switch to. Bigger size needle because the lava will be more, more efficient.
Otherwise, if you are using small needles like 18 gauge, it will always be plugged with some small, you know, flakes of fibrine and it will be, it will be inefficient. So we use 14 gauge needle in, in cattle, in adult cattle, we will use cannula, basically, 5 millimetres cannula, to increase, the, the efficiency of the. Abdullaba.
The type of fluids that you're gonna use, it's not important. It needs to be sterile, and isotonic and isoosmotic so like saline or LRS, they are just fine and you don't need to add anything to those fluids. Volume is more important than the type of fluids that you're going to use.
So when you do your join lava, you insert one needle and then you distend the, the, the joint. This is painful for the animal. And when the, when the joint is well extended, then you insert a second needle, and then you flush it until the fibrine, until there's no fibrine and the fluid is clear.
Of course, it depends on the joint. If it's the coffin joint, 100 millilitres could be enough. If it's a stifle or a hawk on an adult animal, then 2 litres sometimes is not enough.
All those animals need to receive, non-steroidal anti-inflammatory drugs before the procedure. It is a painful procedure, as I mentioned. And then they will have also to receive, anti-inflammatories for a few days after the.
Procedure. Then it depends, of course, on the economy, and the size of the animal, but since it's, you want to control the inflammation and the pain, we always continue the NSAID at least for a week, after the procedure. Regional aesthesia, we always try to do some kind of block to decrease the pain when you are doing this procedure.
One that is very easy to do is the intra-articular injection of the back pain, but it takes at least 10 to 20 minutes to, to be efficient. Then you can use epidural, brachial block, a nerve block, and IV on the tourniquet. And in some cases, especially here in the hospital, it's possible to do it, we can do it in under general anaesthesia.
Here, you need to know a little bit the anatomy before inserting your needles. You need to remember that in carpus, there's 3 joints and the, the radiocarpal joint communicates. With the middle carpal in only 13% of the time.
So if you want to flush the carpus and the three joints are swollen, you might want to think of flushing the radiocarpal joint by itself and the other, together. Stifle, same thing, the left femoral tibial joint will communicate with the femoral patellar joint, excuse, excuse me, not the left, the lateral femotibial joint communicate with. The femo patellar joint in 40% of the time.
So, again, the lateral femotebular joint should be considered and independent from the rest of the other joint sac. Tarsus, everything is communicating together, fatlock is the same. Here, this is an example of a septic arthritis of the stifle, .
And we use a spinal needle to do the tap, but at one point we will switch with 14 gauge needle. We're gonna use 214 gauge needles to do the through and through lava. As you can see, the fluid is really opaque, and then we're using 14 gauge needle and we're gonna flush it until it becomes clear.
When you have a complex joint like the tarsus or the carpus, you can insert multiple needles. Otherwise, the cul de sac at the back of this joint, this particular joint, is usually it's full of fibrines. So you need to put some needle there, to flush it, as well.
So then you can play with the ingress and egress, so you change where, the fluid is coming out and going in, to be sure that all the joint is flushed. Here we have a radiocarpal joint infection and we are doing what we call a tidal lavage. So to dislodge the fibrine and at the same time to evaluate if you are doing a good job, we're gonna use a, a 10 cc syringe and we're gonna aspirate fluid and push it back in just to create some turbulence and dislodge the fibrin.
Here, it's septic arthritis of the elbow. Even if it's a small calf, we are using 4 gauge needle. Here it's a shoulder.
And finally here, I'm showing you a tidal lavage. It's a cuff and joint infection. We are using 14 gauge needle and as you see with the 10 CC I'm gonna aspirate a little bit of fluid and push it back in.
This is painful for the animals, so it needs to be well sedated. And then I'm going to let it go until I don't have any more fibrine in my syringe. Then it means that the joint is clear.
And those procedures can be done in field situation. This is from one of my friends in Italy, Tomikili Beetin, and, he's performing joint lavage regularly, in his herd. He has 5000 heads.
So it is possible to do it in future situation. Is it easy? The answer is no, but, it's possible to do it.
So in that case, it was a septic arthritis of the heart. Joint lavash could be repeated, once a day for 2 days, and if fibrin is present after the second lavage, usually you can do a third lavash. But, otherwise, if it's, if there is too much fibrine, then you need to think of the, of doing a rootomy.
The joint cabbage is cancelled if there's clinical improvement and some Sometimes even after the first lava, the animal will improve. So if it improves significantly after the first lavash, you don't have to do a second lavash, especially in the field, in the field, it's not always easy to get on the farm, so just one lavash is better than no lava. I'm gonna, we are a little bit late, so I'm gonna go fast on that.
And this is an example of a fluid from an animal that we treated with joint lavage and antibiotics, of course. And you see that slowly the viscosity is coming back after 2 to 3 days of joint lavage. This is, and it comes back really rapidly if it's relatively an acute septic arthritis.
So it's a good sign that we are doing a good job, and we can stop the joint lava. Aroscopy can be done, and I think I'm gonna, I'm gonna stop discussing about arthroscopy because it's something that is limited to a referral centre. But even if it's a fancy piece of equipment, it's difficult to do in cattle because cattle, they have a lot of fibrine in their cytic arthritis.
So it's, it's, you need to be very patient, to get rid of all the fibrin. It's a lot easier to do in other species than in cattle. So sometimes what you do is you start with an arthroscopy and you end up doing a natroomy because you don't see nothing, just fibrine, and it's impossible to debride it.
So this is an, I started with an naroscopy of the hip and I finished with a narotomy of the hip. Why we are doing arotomy because it's a failure of the medical treatment, antibiotics and lavage. There is a large amount of fibrine plugging up the needle.
So when, you know, after 5 minutes of trying to do a joint lavage and my needles are, are always plugging with fibrine. I have no hesitation of removing the needles and doing incision. Otherwise, it takes forever and the fibring that you get out from the needle is just the tip of the iceberg.
So it's, it's, it's better to do a, an astronomy. For the, the astronomy technique, it's, it's, it's the same principle as lavage. The only difference is you're gonna do incision instead of inserting needles.
You can do, it's better to do a local block of the incision site. You need at least 2 incisions per joint. You're gonna distend.
The joint with fluid as well, so you can flush it with fluids. Usually, we use sterile saline with a big syringe and we're gonna push the fluid inside, the joint and you need to debride the joint, so you need some type of forcep to remove the fibrine from the joint. So here, the joint is repaired surgically.
We start with one incision, it's in the carpus and Then with a hemostat, we're going to explore the joint and see where is the fibrine and locate another area, if possible, far from the second incision. To do a, far from the first incision, to do a second incision, and, and, and flush the joint. So here, this carpus was, all the joints of the compartment of this carpus was infected, so we had to do 6 incisions to treat this animal.
This is a, a, a satisfying case of it's a cytic arthritis of the tarsus, and then we are using MacGill forceps to get rid of all the fibrine inside the joint, exploring all the different cul-de-sac of the tarsus. This one is even better, hopefully for you, gentlemen and, and ladies, you had dinner because this is what we got out. Of the joints, so a lot of fibrine, a lot of cheese out of this hack, and I think you can appreciate that it's not possible, to get rid of this fibrine just with needles.
Atroomy was necessary. Post-op care matronomy, it's a bit more complicated than, with, with a joint lava, and the reason for that is because you need to cover those incision. If it's, if you are doing apttrotomies, the distal limb, you can put a bandage on, but if it's a proximal limb, and then we, we use some stent, by doing this, we don't shoot.
It here because you want to go back in the field you can structure it if you want, but here what we do is we put some umbilical, umbilical cord, on each side of the incision and, and then we're going to put a roll of gauze over the incision to protect it. So then we just need to remove them, remove it, and, and flush it the day after. And there are incisions that are healing, a few days.
Usually it takes about 5 days to close, to be watertight. It depends on the cases, but usually 5 days, it's closed, so you can remove the bandage after 55 days. And this is an example of an animal that underwent atrotomy of the scile and a few days after and he's doing very well, but I have to say that it's not always like this.
We have a failure. The success rate to treat septic arthritis, remember that it's around 60%, 60. 60%, yeah, being of all the different studies, but remember it's 60% and, in those two cases on your left, this is a fatlock full of fibrine.
We try to treat it, but we cannot get rid of all the fibrin inside the joint. And the other one on your right is a stifle, secondary, I remember that case very well. It was secondary to your umbilical vein infection, and we were unable to treat this animal and we had to put him down.
Time is running out, atrodisis very rapidly. We do it last resort, of course, because it will affect the biomechanic of the gate, especially if it's those are the high range motion, joints like the carpus and the tarsus, doing an aphrodesis of the P2P3, P1, P2 joint or the fetlock, it's possible to do it and actually it's quite. Easy to do and the prognosis is good, but when you start to do a carpus rodesis, it's more complicated and should be done in a referral centre.
And tarsus, we don't do it. We don't do tarsus arthrodesis because it's incompatible with, a cattle, the way their biomechanic work. Fascinated ankylos of P2P3 is probably the most common artradisus or ankylosis that we are doing in veteran medicine, I should say.
So here's, we are doing a vacillated ankylosis of P2P3 secondary to ASO, abscess, and here we see the joint closer. We can do it also in field situation. Maybe some of you have done, have done this technique in, in the field.
This is just a few pictures of the carpal arousaltrudius just to show you that it's not an easy procedure to do in the field. The incision is transversed and basically what we have to do, we have to remove rows of, carpal bones. It should be done under general anaesthesia because it's a painful procedure, and then, the animal will have to stay on a, in a cast for a long time, and this is a picture from, one of my colleagues and friends, Mean Gupil, and, he's a private practitioner, but he has a small animal clinic, and I decided to, took his chance and he did that, in, in the field, and, we suc he was able to successfully, successfully treat this little gaff that had chronic septic arthritis of the carpuss.
And finally, the prognosis. The prognosis, as I mentioned, you need to remember that it's around 60%, but it depends on a few factors. No concomitant diseases.
So if it's a septic arthritis without apolebitis or long abscesses, of course, the chance of success, the chances of success are higher. If there is also absence of bony changes on the X-rays, it's a better prognosis, absence of fibrine after a tidal lavaage, bearing weight after 72 hours, and no soft tissue swelling. One interesting finding, that we got from, this retrospective study is, here, when you look at the synovial fluid, we have something extremely significant.
So when you look at the result of the, the The white cells and neutrophils. The animal with a positive outcome as they had a really high neutrophil counts compared to the one with the negative account, and it was a significant 0.001.
So that's something that now we have a tendency to use to establish a prognosis. Poor prognosis would be related to more than 2 joints, infected, as I mentioned, very fibrinous. A penis, penis is fibrin recovering the, the articular surface, flexial deformities because it's a chronic case of septic arthritis, perarticular infection, and joint collapse, when looking at the X-rays.
This is an example of a calf with, I think pretty much all these joints were swollen and infected. It was secondary to a mycoplasma infection. So you can see in that picture that the stipo on that side was swollen, same thing for the heart, carpus.
Elbow also and I know that in that case, the the shoulder were infected on both sides. I think the only joint that were not inflamed or swollen were P2, P3. So this poor little guy was, euthanized.
In conclusion, when you are facing a cystic arthritis, Instead of jumping and doing a joint lavage or treating the animal, please do a complete physical examination before establishing your treatment. Joint I should be part of the treatment, especially if it's an acute case. Otherwise, you can always use annatronomy.
And antibiotics locally and 2 or 3 times a week, systemically, if possible. I know it's not always possible in the field, but if you want to increase your chance of sis rate, you need to increase the duration of of antibiotics, in those cases. Ironomy is thick pus orfi plugging the needle.
You can do a prodesis of everything out of the joint in the foot, and the carpus, and, and please, it's the painful disease. Those animals need to receive some, NSAID also to decrease inflammation that is, a part of the, of the process. So at this point, I will be happy to any question, and thank you for your attention and hopefully you have learned something, tonight.
Thank you so much. Andre, can you hear me? Yes I can hear you.
Yes, excellent. I, I just, I feel sympathy for the animals with the amount of pain they must be going through with those X-rays that you showed. Yeah, and, and the thing now with the, the welfare issues, I think as veterinarians, we have a, a role, at treating those animals as rapidly as possible or, to euthanize them, but, As you mentioned, it is a really painful, a really painful process, a pathology, and we need to take a decision rapidly and we don't want to leave those animals in a corner of the barn hoping that they're going to get better.
Yeah, that would be fair. Right, Andre, we have no questions coming through. I think everybody like me has sat fascinated and hung on every word you've said.
So thank you so much for your time and we look forward to having you back on the webinar.