Thanks, Rich. Welcome everyone. Good evening.
. One of my favourite subjects. It's good to be back talking about managing complicated claw lesions. I have, lots of material tonight, lots of photographs.
I really hope you enjoy them. So, here's the plan of, the webinar. I'm gonna do a quick review of the common lesion types of, claw of.
Foot lesions on cattle, just so we're all talking from the same page. I will look at mixed lesions, which are otherwise known as complicated claw horn lesions, which is the focus of the webinar today. And the basic principles of treatment of those complicated claw horn lesions.
Then common indications for surgery, and these are the two big ones are distal interphalangeal joint infections. So I have some photographs to illustrate those and also necrotic toes, which is a a subject that is, a specialist area of my own. We will review digital computation and look at the preferred method, and finally look at dorsal wall resection and be bribing for the treatment of necrotic toes.
So that's the plan, as you see, lots of materials, so let's make a start. This though is my first poll question and as Rich says it's really just to help me find out a little bit about you. So, er the question, Rich, do you want to read it out?
Yeah, of course, I've just launched it, so it should pop up on your screen now. And the question is, how often are you personally involved. In bovine foot surgery.
Is that on a weekly basis, a monthly basis, once in a while, or never? As I say, no wrong right or wrong answer. It's just to give Owen an indication of what sort of experience, that we, we're dealing with, with yourselves listening tonight.
So if you could all partake, I can see there's a number of you still haven't popped er your vote in yet. So that's either weekly, monthly, once in a while, or never. Just 5 more seconds for the last few of you stragglers to answer.
OK, I'll end it there. So let's have a look. So, no one is doing it on a weekly basis at the moment.
13% of people are doing it on a monthly basis, 38% once in a while, and 50% have never done this before. OK, thanks, Rich. And in a way that doesn't surprise me.
I don't know whether I'm talking to practitioners mainly or people in academia or a bit of both, or, or, or even non-vets. So, as a vet when I first qualified, over 25 years ago. It was very easy to get involved in, in lame cows, because there was, plenty of opportunity.
There were less foot trimmers around and, and vets tend to do more lameness work. And now it's harder to get involved, which is a real shame because it's an interesting area, but it also means that we tend to get a little bit disenfranchised as a, as a profession, when it comes to lameness. And in fact, the feet that we do get to see are the very difficult ones to deal with.
So perhaps that'll be useful for many of you. So looking at the lesion types, first of all, we're gonna look at the infectious lesions, otherwise known as skin lesions. There are 3 main infections causing lameness.
This is digital dermatitis, by far the most common, two different physical manifestations. This is a more acute active lesion. This is a more chronic, lesion here, but they're both digital dermatitis caused by treponin bacteria.
Another example of digital dermatitis where the lesion has been cleaned up, showing it very clearly. And this is its common area where you'll see it on the heel of the, of the, of the feet, very painful. Same again.
This one hasn't quite been cleaned up as well, but you can see, the raised area and, that redness there, which, would cause quite, a degree of lameness. And again, there, and I've shown this foot because it has different types of lesions going on here or different conditions. We have a little bit of, heel horn erosion here, these cracks in the back of the heel, and we have a little bit of soul bruising on this pad claw here.
This is a more unusual manifestation of digital dermatitis because it's in a slightly unusual place. It's on the front of the feet and it's a very, granulomatous or varicose cauliflower-like proliferative lesion, but it's just another example of digital dermatitis. And more digital dermatitis.
I show lots of pictures because it could look different on different cows. So again, a little bit more of a proliferative, lesion here that hasn't been cleaned up, but that's, it's classic location. And again, it's a mixed infection here because we have this second type of, infection of, or, or, infectious cause of lameness, and that's heel horn erosion caused by bacteria.
Of the bacteroides, species. So that's a different type of lesion there. This is the 3rd infection foul of the foot.
I'm sorry, it's not a very clear picture. I haven't got a very clear photograph of a picture of foul in the foot. But this is caused by a fusiformis necropher, and it's between the toes, you'll get an acute sudden onset lameness.
You'll get bilateral swelling of the coronary bands of both claws. And, if you look at the foot pair, the, separate the, the digits, and you'll see a very smelly open wound between the feet, and that is foul of the foot, otherwise known in America as footrot. And here is a more complicated infectious lesion.
It is an indigital growth, which quite often occurs due to chronic foul of the foot or untreated foul of the foot, and it has a secondary infection of digital dermatitis on it. In actual fact, it's probably the digital dermatitis that's superimposed on this inter digital growth, which would cause the lameness in this particular cow. So those are infectious diseases.
Let's look at Claw horn lesions, so, otherwise known as the non-infectious conditions. And again, there are 3 main ones. The first one is soul bruising.
Some people still term this as laminitis, that's the incorrect terminology. So please use the term sole haemorrhage or soul bruising, for this type of lesion. Don't confuse it with normal pigment of the foot, so this fork shows blood or serum, which is the yellow and red staining of the sole horn here.
But this is normal horn pigmentation towards the toe. This is another example of soul bruising, just showing it in a different location. So the classic location that we tend to see in our UK, particularly housed cows, housed on concrete is, soul bruising towards the hill area here.
But on grazing herds, where you get thin soles towards the toe, then you can get sole bruising, . At the, at the toe here. So that's just to show different areas of bruising.
And here is a thought, again, I'm sorry, it's a bit blurred, but this has got a soul bruising all the way over it. If you touch the sole of this foot, it would be very thin, thin sole. It would, intent to thumb, thumb pressure very easily.
And this is again, not laminitis. It is soul bruising, bruising caused by contusion of the corum, which is the tissue, the soft tissue which produces the sole horn. And in this case, it was a young bull that was put on concrete for the first time and with a bunch of heifers, serving them like mad, ended up with very thin feet, very thin soles, and soul bruising just from that pure, physical bruising of the concrete floor.
And all 4 ft were lifted up and had this bruising throughout the soul in all areas. OK, so that's soul bruising. The second, Clawhorn lesion to consider is white line disease.
And white line disease, it's very difficult to get a classic picture of like white line disease because it can look very different in lots of different cases. But here is a white line disease where there's white line separation and it's become impacted with dirt and grit. Little bit of underrun soul here, you can see that this is part of the dirt and grit, this underrun some of this soul here, which could be trimmed away quite easily.
Here's another example of white line disease. So again, we got a little bit of underrun soul here, but what can happen very often in white line disease is that there is pus that builds up and under pressure that has to go somewhere. It either causes underrunning of the soul or, or and it will track along the laminate under the wall and follow the arrow, burst out at the coronary band here, or It'll burst out after the shot of the photograph, but the bulbs of the heel here.
So those are all different manifestations of the same thing, white Lyme disease. Here's a white line disease that has started here. It's under on the wall, burst out the coronary band, and this has been correctly trimmed, exposing all the corum for that to heal, and the ipsilateral claw has been blocked to take the weight off the lesion.
And this is the 3rd Claw horn lesion, our example of, and it's a soul ulcer. This is on the front foot, but it's the classic area where you'll get a sole ulcer. And if you like, think of this as a severe bruise, that's, that's gone into the next stage where, the, weak bruised horn has been removed, and that leaves a horn deficit underneath with protruding corum.
Into that horn deficit, which is in fact the soul ulcer. So the soul ulcer, it's very important to realise soul ulcer is developed from within and and work the way out to the surface rather than being from soul penetration from a stone, for example. So there we are, quick run through of lesions.
What I really want to do though is get onto the complicated lesions which are when you have a clawhorn lesion, such as a a white line disease or a soul ulcer, that then becomes secondarily infected. So these are infected claw horn lesions. So if we look at an example here, it's a nice picture to show a sort of fairly straightforward, if you like, simple example of what I'm talking about.
This is a white line lesion. It has underrun the wall, burst out of the coronary band, been trimmed away. But can you see that there's a digital dermatitis lesion here, which is very obvious and in all probability, the exposed corum here underneath the white line lesion will also be infected with digital dermatitis.
Names. And it is this that stops these lesions healing. So some people know these lesions as non-healing Claw horn lesions.
Perhaps it's better to turn them as difficult to treat Claw horn lesions or infected Claw horn lesions. So there's an example of a white line the disease which has become secondary infected with digital dermatitis. And here is a more severe example of something similar.
This will start as a white line disease. The corum soft tissue has been exposed because of that initial white line injury and then digital dermatitis bacteria has secondarily infected that soft tissue. And you can see that there's a very cauliflower-like growth of a chronic digital dermatitis infection, and this has got no chance of healing whatsoever, without radical resection or probably a digit amputation.
I think it would be my treatment of choice for, for, for that case. Something similar, but in this case, it probably started as a soul ulcer, it's a classic soul ulcer site. And the, dal dermatitis treponemes have again infected the exposed corium.
You can see that this looks like a dal dermatitis lesion even. It has that kind of slightly speckled kind of appearance to it. And because of that infection, the soul ulcer has then caused underrunning of the soul, and all of this soul tissue has been removed.
And this is new sole horn is forming underneath what will have been in effect become a false soul. What people know know is a false soul when you can remove, one layer of soul tissue, to expose a new, layer of, of, sole horn underneath. So this is a, a, an example of a complicated, claw horn lesion in this case, soul ulcer, which without treatment of this digital dermatitis infection would not heal.
And a similar sort of thing. But again, this probably started as a white line lesion here in this region instead of a soul ulcer. And it's important to remove all of this underrun soul tissue.
You can see it's all been removed here, in the actual area as well. . Being very careful to try and avoid damage to the healthy tissue and avoid bleeding, but you can see the area of exposed corum.
Which has become secondarily effective with digital dermatitis. And until that is exposed to the air and treated with appropriate topical antibiotics, then this lesion will not heal. So this will heal.
Now it's been treated in this way, or it's not had the antibiotic applied yet, but I would fully expect that lesion to heal. But this cow probably been chronically lame for a little while with a non-healing claw horn lesion. So, I said I would mention what the basic principles of treatment were of these complicated or infected claw horn lesions.
And it can be summarised by these four points. So whatever it looks like, whether it be a white line disease that's complicated or a soul ulcer that's become complicated. It's important to remove the weight off the lesion.
Remembering that the primary lesion would have been a claw horn lesion, which is due to bruising and contusion, or aspects thereof. It's important to remove weight off that lesion. And in, in effect, for the vast majority of cases, that would require putting a block on the other claw, so that the affected claw is raised off the ground when the cow walks.
And that will take pressure off the lesion in the initial lesion to allow healing to occur and new horn to be produced. So use blocks liberally. It's beyond the scope of this webinar to talk about blocking and blocking techniques and blocking types, but it's, it's almost a webinar in in its own right.
I, I, I sometimes worry that farmers and vets are are lacking confidence, perhaps in the area of blocking and therefore don't use blocks often enough or, or have poor success rates them being applied properly. So I'll put off by blocking. But blocking is a really important technique to, to master for treating claw horn lesions.
So, The #2 point is to remove all unattached horn to the point of film attachment. Have a think about what that actually means, . The underrunning could be the wall, or it could be the sole horn, or it could be a combination of both.
And there was a school of thought . Probably back when I first qualified 20 odd years ago, that, certainly for white line lesions where the infection underruns the wall towards the coronary band, there was a school of thought for leaving a bridge of horn to stabilise the wall either side of the lesion rather than removing all of the, all of that wall horn. Now, it's thought that it is preferable to remove all unattached horn, and for example, not leaving a bridge of horn there on the wall.
. Because of this secondary infection with digital dermatitis trepodines, which is so common now. So in other words, it is better to expose all of the corum to to oxygen, to air and, and to allow good exposure for topical antibiotic treatment, than to leave any, overlying horn, which isn't detached. So, How much do you remove?
Well, remove it to the point of firm attachment, and that's a very careful, job required. I'm gonna just go back a slide here and you can see what I mean. So, so how much of this soul needs to be removed?
Well, it gets removed, removed, removed, removed until the point of firm attachment. Here, when you can not lift the sole horn from, from the pocket. And it's the same here.
Point of firm attachment, and you can see that the part of the sole in the axial region has been removed even until the point of firm attachment. And this will be a Just nicking the, quick here, nicking, nicking the corium. There's a bit of blood.
So we've gone just slightly beyond the point of film attachment in that little region there. So that's the, that's the sort of area you need to be going to. You need to be going to the point of where it's about to bleed.
But here we are, point number 3, avoid bleeding. The reason to avoid bleeding is that, two reasons. One, you're then, affecting healthy tissue, which is, is perhaps prohibitive for healing.
But the other practical aspect about trying to avoid bleeding is that as soon as you get blood, you, destroy your, your, field of view. It makes it very difficult to see what you're doing. So, I always, always carry when I'm doing any, any footwork, I carry a lot of cotton wool.
I use cotton wool. I'm always dabbing cotton wool on so I can see. my way, and, and that really helps sort of get to that point of firm attachment.
And, even when you do get a little bit of blood. So here, for example, a little bit of blood, I'll be dab dab, dabbing away at that. I'd be dabbing this all the time.
So I can just see, do I need to remove any more of this wall or have I gone far enough? So, It's hard to do point number 2 and point number 3 at the same time, but that's the principle that you're trying to follow. And then finally, there's good evidence now for using non-steroidal anti-inflammatories early on with these claw horn lesions.
And that's, the idea is particularly with soul ulcers, is it reduces the Inflammation and the damaging effect that the inflammation can have, that could be permanent, for example, are, changing the, the, the, the nature of the soft tissue to, to make it more fibrous or, or new bony growth on the pedal bone. Which can then make that cow prone to getting Clawhorn lesions time and time again. So I used NSAIDs early on, which is for that anti-inflammatory effect as well as the painkiller effect, which is also important.
OK. Sometimes you will have a complicated clawhole lesion where it is just beyond treatment. And this is an example of a white line lesion.
Which has got digital dermatitis, secondary infected, and it's a severe chronic lesion. And this is, that you can see what the treatment was. It was a digit digit amputation in this case, but let's continue to look at the same foot.
That's from the underside. And then opening it out, you can see the extent of that secondary digital dermatitis infection on the corum here to try and pare that back and remove all, loose horns to the point of film attachment to have a hope of treating that digital dermatitis infection. I would contest it is impossible and therefore, digital amputation or killing the cow would be the treatment for cases like this.
So there we are, same foot again, just showing the extent of that lesion. And almost the horn capsule has been shelled off here. And people with the experience of cod in sheep, contagious Avi dermatitis, have I got that right?
I'm not a sheep man. Will recognise this as being similar to this kind of shelling lesions that you get with, cod, foot infections in sheep, which again, is caused by, or thought to be caused by the same digital dermatitis trepoines or very similar trepoines. So, don't often see this kind of degree of shelling of the, claw horn, thankfully in cattle, but this is a, a very nasty, severe example.
OK, moving on. That's complicated Claw horn lesions or or or er hard to treat Claw horn lesions where. The primary lesion, whether it be a white Lyme disease or soul ulcer, has had secondary infection with digital dermatitis treponemes on the soft tissue, which is, impeding healing.
Now, I want to look at distal interphalangeal joint infection, or sometimes colloquially known as clubfoot. Here's an example of the sort of cow I'm talking about. There are sadly, too many cows that I see in my travels with this condition.
This cow will be chronically lame. It should be a mobility score 3 if you're familiar with the AHDB mobility score system. She will have had this lameness for a degree of time.
She's losing weight, she's arched backed. She will be in pain. I hate to see these.
I guess most people do, but they are disappointingly common. This is the foot that we're looking at, club foot back left. This is the same cow, and this is the same foot looked at from a different angle from the back.
You can see actually. That it's a unilateral swelling on the outer claw that back left foot, and it's swelling around the chondral band and you might appreciate that there's a slight . Hyperextension of that digit.
Let's look at a similar foot from a different cow, this time back right foot, but you can see it's unilateral. It's severe swelling around the conary band and the bulb of the heel, and you can see that there is again a hyperextension of that digit relative to the unaffected digit. This, by far and away, when I was a newly qualified vet 25 years ago, was the most common reason for doing a digit amputation and actually here's some glimmer of hope.
I think that we saw more of these cows with club feet 20 odd years ago than we do now. Farms, farmers have become better. I think at spotting these, soul ulcers and intervening before they become a dysphalangeal joint infection.
And I think farms, harbour these cows less than they used to. In other words, they're called, when, when they become like this. Here is another example.
So it's less severe, but this photograph shows probably two things a little bit better than the previous photograph. So the first thing it shows here is again, it's unilateral swelling at the coronary band of the bulb of the heel. And can you see that the toe is cocked up or, or hyperextended compared with this one here?
And that's because there will be disruption, if not full rupture of the superficial. Sorry, the deep flexor tendon that we'll insert on the, back of the pedal bone here. Don't worry, I'm going to show you some cross section photographs, which will illustrate that in a minute.
But there's a flexor tendon here, and that gets disrupted. And so, that you end up with a cocked up toe. But the other thing I wanted to show you with this photograph is that in the middle, these distal inyal joint infections are nearly always from infected soul ulcers.
So, we've got a soul ulcer here and you'll see a little bead of white pus there. And this for me is diagnostic for when there is distal phalangeal joint infection. If I see a little bit of white pus here, then I go in with a digit amputation, and I don't wait.
I don't hang around. I don't wait for it to get worse. I don't try and put the cow on 5 weeks of antibiotics and all that palaver, and, and make her suffer even longer before making my decision or persuading the farmer to call the cow.
I either persuade the farmers that the cow needs culling or she needs a digit amputation, because the, The success rate for treating these cows with digit amputation, if it's done early, is very good. But if it's waited until the cows become very chronic and the infections start to spread up the back of the leg, then the success rate falls dramatically. So, how do you diagnose when it needs a a digit amputation?
I would forcibly er flex, extend the toe, sorry, I beg your pardon, extend the toe, so push the toe further upwards. Sorry, I've got that wrong way round, I beg your pardon. I would forcibly.
Flex the toe. Sorry, push the toe down. I'm trying to get my flexing and extending the right way around.
Whilst simultaneously putting pressure with the fist of my hand, my other hand on the ball with the heel here. And that compresses the joint space and that will squeeze, if, if there is a joint infection, that will squeeze a bit of puss out of the sinus, here. Let's have a look at another one.
So same sort of thing. So also sir. Flexing the toe, get it the right way this time.
Whilst applying pressure at the bulb of the hill here, and you'll see pus being squeezed out of the sinus here. And that to me is an indication that there is almost certainly distal interphalangeal joint infection and needing an amputation. Now it's normally from a soul ulcer, and here is a dissected thought.
So we can see a few things on here. This is the sinus. This is a intranasal vaccine infuser.
Just put into the sole also sinus here, and you can see the tract, and it's extending to this joint space here. This is the distal interphalangeal joint. You get swelling around the coronary band because when you get, infection here, the, the fluid has nowhere to go.
So it tends to push out the tissue here and you get swelling at the coronary band here and also at the bulb of the heel. The toe becomes cocked up because this is the deep. Flex attendant And, this ruptures, you can see how it's rupturing here.
Normally, it inserts on the back of the pedal bone. It's ruptured. Sometimes it's a partial rupture, sometimes it's a full rupture, and therefore, the toe becomes extended.
It cocks up, in other words, because of, of this disruption here. So when we're squeezing, when we are a, when we are flexing the, Digit, whilst applying pressure here. Basically that puts pressure on the joint space and so if there's any pus, it will be coming out of this fistula here.
That's the, the, the way to diagnose these. Occasionally, you'll see something similar for, from a very deep and nasty white line lesion. Again, it's a bit of a blurred photograph, but this would be a, distin fungeal joint infection, where the primary lesion would have been a white line lesion.
And again, if we did the same thing, if we, flexed the toe, pressure on the ball with the heel, if that was infected into the joint space, you'd see a be the white pus coming out of a, a tract sinus there. So What I would do, without a doubt with those cases, is a digit amputation. There are some digit preserving techniques which can be used.
I haven't included them in this webinar. I will, point you to resources where to go to or resource where you go to to read about those if you want to know more about those. But, I want to just focus on digit amputation, because I think it's more important to talk about that, which is a common and successful technique, if it's done correctly, then talk about all the whys and wherefores of different digit preserving surgical techniques.
There are 3 basic. Primary methods that you could employ for doing a digit amputation. They're described in this diagram here.
Either method number one, you could er. Cheese wire, embryotomy wire through the distal part of P1. This is proximal phalanx otherwise known as P1.
So cheese to the distal part of P1, it's quite a high up amputation technique. Or let's move to number 2. You could cheese wire through, somewhere through the second phalanx or P2, which is this bone here.
I'm outlining it with the arrow. CP to that. And that is achieved by putting the cheese wire between the toes and cutting very obliquely through to try and achieve .
a cut through the middle of P2. Or thirdly, you could disarticulate or ex-articulation, by dissection through the proximal interphalangeal joint. In the words, this P1, P2 joint.
So this is, that would be by dissecting here, that would expose, the shiny, end of the bone, the, the, cartilage of the, of the end of P1, which would need, that would be scraping away in order for granulation tissue to then. cover that bone surface and for, for healing to occur. But basically, it's a, a dissection technique through this joint space here.
So we're now moving on, Rich to my second poll question, which is simply this. If you do digit amputation, which method do you usually use? So I've just launched the, poll question.
So your options are, is it distal P1, proximal P2, Xarticulation of P1 and P2. Another method entirely, not sure, e.g., simply wire across where you can.
Or number option 6, not applicable, never done one. So just to repeat that, which method do you use for digit amputation? Is it distal P1, proximal P2, Xarticulation of P1, P2, another method entirely, not sure, e.g., simply wire across where you can, or not applicable, never done one.
OK. One more just answering. 5 more seconds.
And we'll end it there. OK, so we have 11% have said A. 35% have said B.
6% C. No one has said D, 6% E and 47% F. So the majority of people have said they've never done one, but after that, the majority of people are saying proximal P2.
OK, thank you, Rich. And again, actually that's pretty much confirms what I would have thought, given that we had I think 50% of people were not doing . Much foot foot surgery from poll question number one, then perhaps it's not surprising that, about half of the respondents said they've never done one.
No one said this another method. In, certain, well, I think, I think actually, in, in some European countries, there is a, there is a bit of a fashion for doing or it has been described as doing a disarticulation of P2P3, but that's not something I've ever done. I know at least Liverpool vet school, maybe some of the vet schools teach the ex-articulation P1, P2 dissection method.
The majority of vets in practise that I know do this proximal. P2, in other words. Yeah, just in the middle of P2.
This though, distal P1 is the method that I would extol and I would, really encourage everyone to use. There is a better success rate with this method, and I'll explain why. So this is a method I'm gonna talk about, this is a method that you should use.
This articulation, by the way, is would be equally as good. I just think it's a bit more fiddly and it's harder to keep a clean surgical site, in my opinion, and you have the problem of having to remove this, . Cartilage at the end of the bone in any case, which again makes it more fiddly.
So, so for all those reasons, I would favour just doing the cheese wire P1. But it's a high up technique, and the reason is this, is if you go through P2, you will disrupt the blood supply for P2. That means you will end up with a necrotic bone fragment remaining.
In other words, the proximal part of P2, the bit of P2 that you leave behind will become necrotic. No doubt. It will become necrotic.
And that means it'll eventually slough away. What happens when it sloughs away, that leaves the exposed cartilage at the end of P1. What happens then?
Well, it may or may not eventually granulate over, by which time the cow is fed up, the farmers fed up. Probably you've given up as a bad job. The cow's been cold.
And this is the reason why digit amputation, in my opinion, has a bad rap. This is why you'll sometimes come across farm. Was, oh, I don't want to have a digit amputation.
Last one did, never did. Last one the vet did, I had to call it anyway. Well, that's rubbish.
When I do digit amputations doing distal P1, I would expect, well, I always quote around about a 75% success rate, however you measure success, but I would be disappointed, unless it was a very, very chronic lesion that had been going on for a long time, with a lot of infection going up the flexor tendons, I would be disappointed if it wasn't a success. And I think The higher success rate with with the method that I use is, is because you haven't got this necrotic bone fragment and then delays healing and . I, I would expect my digit amputations to be healed within about 6 weeks, for uncomplicated cases and the cow to go on and live a healthy life within the herd and be called perhaps for an entirely unrelated reason later on in her life.
So the way you do it is you, it's very simple, choose wire still, but you need to make a incision, a vertical incision between the digits dorsally, right, and ventrally . About 2.5 centimetres or 1 inch, depending on whether the inches or centimetre person.
And then thread your embryotomy wire, and then it's about level with the accessory digit and then use a slightly oblique angle to cut into the P1. Once you've, once you've sort of, once that wire is bitten into the bone, you can then start repositioning your wire to come more at a 90 degree angle across rather than more oblique. So this wire is, is shown here at quite an oblique angle.
That was the initial angle that it would need. Sorry. That would be the initial angle that it would need to, to sort of make its first bite into, into that P1 bone.
And then as soon as you sort of made a few bites into the bone, you can then sort of re-angle the cheese wire and take it more across. You do end up with an L-shaped. Imagine you've got an L shaped wound because you got up between the toes and then across here.
So a bit, an awkward wound to bandage without a doubt, that is a disadvantage of this method, but the healing will be quicker, and I suggest your success rates will be better if you use this method. So here we are. This is the thought we looked at before.
This is the initial incision, so good 1 inch, about 1 inch, front to back. Then you can thread the cheese. So you see, front, back.
Then you would thread the cheese wire, and then you would, aim to put an oblique, a lique kind of angle of the cheese wire just to get the first bite into the bone and then come straight across. So you'll end up with an L shaped wound. Like this I do you appreciate that L shaped kind of wound?
OK, which does need careful dressing. Again, it's probably without outside the scope of this webinar to talk in depth about the dressing because of time and other areas to consider, but . It, it is, it's the dressing is, is important to get it right.
I think actually, dressing is more important than the the surgical preparations as you might appreciate. I don't shave my digit amputations, I just clean them usually dry wipe and surgical spirit. I always use clean, .
Equipment and a new piece of embryotic way, but, other than that it's not a sterile technique. You just want it needs to be a clean technique. I think you're better to spend a little bit of time and effort doing a good dressing than you are spending a lot of time shaving and clipping the foot, which in any case, if you do a wet shave, you'll end up with water dripping into the wound, which is, probably less than ideal anyway.
But yes, you wanna use a careful dressing. Basically you wanna fill that dead space with a big wad, fist size wad of cotton wool before applying the a, a pressure bandage to prevent the bleeding. At this point, there won't be bleeding if you've got a tourniquet further up for the intravenous regional anaesthesia.
But as soon as that tourniquet is released, you'll get quite a big blood vessel here where the arrow is. You'll get quite a lot of bleeding out of there if you don't have a pressure but a good pressure bandage on. But it's been, it's the reason why you need to take care doing this dressing is if you're not careful that that dressing.
Because it's going around the remaining digit, can form a tourniquet around the remaining digit, which is obviously disastrous because you don't want that cutting into the back of the heel here because you've got, only one digit left to play with. So you don't want to tourniquet off, that remaining digit. This is that same cow, walking back to the field.
OK, she's got a local anaesthetic in, so you'd expect it to be numb, but I would also expect after that local anaesthetic to wear off, she'll be covered with the non-steroidal anti-inflammatory, but I would expect her to be. Just absolutely heaps better than she was before the amputation because those distin phalangeal infections must be incredibly painful. And it's why I hate to see them so much.
And I really do encourage farmers to do digit amputations at the first opportunity because 6 weeks later, This is what I would expect. I would expect the skin to have healed over. I would expect the animal to be sound, and I would expect her to, in an uncomplicated case, to go on and live a happy, productive life.
We did a little in-house study at my old practise back in 2008. It was Sarah Peterson who conducted this, one of the vets at the time. She looked at 110 cases that have been done within the practise.
Using this method, she pair matched them with control cows within the same herds. She found that the, survival rate. Day 100, 89% of cases were still in the hood versus 95% of the paired matched cows and survival rate at 365 days, 54% of cases were still in the herd compared to 62% of the pet cows, which I think is a pretty good result.
This is why I quote a 75% success rate. But of course, some people will be doing it to amputation purely in order to, send the cow away, by transport. So, once they've healed.
So in actual fact, the fact that 54% was still in the herd a year later, it is a very good result, I would say. OK, moving on. The more common reason for doing a digital amputation, certainly my experience at the moment, nowadays would be necrotic toes rather than .
The distal interphalangeal joint infection which is thankfully less common than it used to be. So necrotic toes, this has definitely become more common. I'm gonna show you some pictures and I'm gonna talk about some treatment.
The treatment is either by digit amputation or dorsal wall resection. Dorsal wall resection, choose your cases carefully, it takes longer to do. It's more fiddly, it takes more skill than digit amputation.
The success rate is high with good case selection, and it does preserve the digit. So, here is a cow with a necrotic toe. It's her back left foot.
Anyone who has experience of toe necrosis, you, you'll spot these a million miles away because you end up with a cow. Usually, well, they walk on their heel, you have a cocked up toe like this. There's no swelling around the conary and in the same way as it is with a disline fungeal joint infection, but the cow.
Is chronically lame. Again, they're usually mobility score 3. They're usually very skinny, thin, looking miserable.
This cow's got a hollow room and she's not eating very well. You can see she's got knocked about, bangs on her back here. She's got a bang here.
And that's because she's probably struggling to get up and down in the cubicle with this horrible, painful lesion. Now, it's estimated that between 2 and 4% of adult dairy cows in the UK are suffering from this disease, to crosis at any one time. If there's 1.8 million dairy cows in the UK, that's 50,000 cows today right now that have this condition, and that's awful.
This is the same cow, same foot, just showing it, slightly, blown up. You can see she's walking on the back of the heel here, and the tone roses will be here. This is a different cow, more chronic case.
In this case, it has, it has been so chronic, there is a little bit of swelling around the coronary band, but that's not usual. But the, because cows are walking on the heel, you'll see if they're not trimmed, you'll see that they have, almost like a Turkish slipper appearance to the feet, with these long toes sticking up in the air. This will be the tonyrosis here.
When they're trimmed, this is what they look like. This is what they look like just before trimming. This is another one that's been trimmed, you get the point.
All of these necrosis cases will be unified by the fact that there will be bone necrosis at distal P3. This is painful, . Understandably.
And it's a chronic condition, it doesn't heal, it isn't gonna get better by itself. Often, the reason why there are an estimated 2 to 4% of cows affected by this condition at any one time is not because the new incidence rate is particularly high, it probably isn't. It's that these cows can survive for a long, long time in the herd, .
With these painful conditions without actually progressing much worse. And, and so I think because there's a general ignorance about how to treat them, it's, treatment, involves, surgery. So it's a vet job, not a foot trimmer job.
Foot trimmers have their hands tied a little bit. They can't treat these cows. They, they get presented with them on a, on a recurrent basis.
They probably the good foot trimmers will be saying, you should be showing this to their vet, your vet. Farmers will be saying, my vet is not interesting feet in any case, the vet wouldn't know what to do with these feet. So therefore, the cow just goes back to being lame again and 3 weeks later, the foot trimmer comes again, it's presented with the same cow and you can see the gist, the cycle goes on and on, and these cows survive for ages and ages and ages.
The infection doesn't normally extend to the joint space, so it doesn't progress in that way, like a disin phalangeal joint infection. And because it's quite a long way from the, flexor tendon, there's no chance of it going up the back of the leg. So the, the infection is, is, limited to the distal toe, but because it involves the bone, it's painful and it's chronic.
And it's not gonna get better. Now, how do these things occur? Well, traditionally and probably logically, you might think, well, if it's a toe infection, the infection is coming through the toe.
And that was, historically, the main route, well, that was the root of infection that people considered, was the aetiology behind these toe necrosis. So you can see some examples here of, cows that have got Tulsa, and you can see the infection can quite easily go in these open toe ss. Here we are into, the end of the pedal bone causing To crosis.
And here's an example of just exactly what's happened there. A toe ulcer, infection going in. Tony Crow says, infected Peter bone.
Hey presto. This still is a route of infection. There are some parts of the world where this is called checker plate disease because it is associated with particularly feedlot cattle that have been transported long distances on lorries with metal checker plates, and they get worn toes, just through abrasion on the, on the metal checker plate.
That gives you a toll, sir. They become secondarily infected. Therefore, to necrosis results.
However, In the vast vast majority of dairy cows in the UK that I see with necrotic toes, I don't believe that's the aetiology. I believe the aetiology is something entirely different. So I've spent many years amputating these feet and collecting them and dissecting them.
And I find that a lot of them have some kind of split either on the actual wall or up the dorsal wall there is a lesion which extends to the coronary band. Occasionally, you'll see an actual digital dermatitis active lesion at the carary band, not usually, but occasionally. And that, and this photograph does actually show an active digital dermati lesion in the coronary band here in an unusual place because it's at the front of the foot, not at the heel.
And it would be quite difficult to spot actually before this digit was amputated and when the cow's foot was on its ground, on the ground, because it's is an unusual spot. But I believe that the infection actually for the vast majority of cases we see in the UK in dairy cows is a descending digital dermatitis infection which is going. Under the wall, tracking along the line of least resistance along the lamin towards the toe end here, in a similar way to a white line lesion might track under the wall, but in a reverse direction.
So here we are, this is an infection in the distal, area here of P3, so the pedal bone here, and there is no breach to the sole horn, so this definitely hasn't come from a, a sole. Sorry, a table, sir. Having dissected lots of cases like this, I believe the vast majority have attracted that even if it's not initially obvious, that originates at the coroner bands.
This is the same fortress showing the dissection, and you can see piecing it back together again. Having found the tract and a little bit of coat hanger wire, you can see that it probably started at the carer band here. It's tracked under the wall, caused a deep seated infection of the pedal bone.
That then becomes open to the toe end once that foot becomes trimmed by the first person who picks it up to trim it. And therefore, from that point onwards, everyone assumes that it is an infection that has come from, the toe and ascended towards the pedal bone. But in actual fact, it probably hasn't at all.
It's, it's come from the coronary band tracked under the wall and got into the distal part of the pedal bone. That's important because it means that when you come to treat them, this just shows the laminar here where the line of least least resistance where once a dermatitis infection gets onto the quick, it soon can track down towards the pedal bone. It's important because when it comes to treatment, understanding that gives you this, the key, the, the key to success, and I'm gonna show you some pictures to illustrate what I mean.
Now, this was a rare cow. This was a cow where I found a, a descending infection, starting in the coronary band, starting to track on the wall, but I hadn't yet reached the toe end, or the tip of the pedal bone. I don't think these are commonly seen because, you need to be seeing them at a very early stage, and we don't tend to see, these, these lame cows at an early enough stage.
But this is the initial lesion that was presented to me. This is as it was trimmed out on that first occasion. And you can see how the, how the infection already had started to track under the wall here, heading in that direction towards the pedal bone.
And this would be infected with trapodines. It would be involving digital dermatitis bacteria. I am absolutely convinced.
And whether that was a primary digital dermatitis lesion there or whether it was a damage to the coronary band from trauma, and then secondary digital dermatitis infection, then, then I don't know. This is 2 weeks later and you can start to see a healthy granulation bed tissue here, it's starting to heal and this is 3 weeks after that. So 5 weeks after the initial lesion was presented, and this is new horn.
And that was a big learning experience for me, this particular cow, in particular, because it gave me the confidence that actually, if we compare these lesions away thoroughly and debride and treat the digital dermatitis infection on the exposed chum, we don't need to wait for the Wall to repair by new growth from the coronary band, because in actual fact, you'll get, creatinization, once you've got a healthy cornulation tissue, you'll get caratinization on top of that. And this is new wall horn here, which has filled in the defect. And so that means that for treating cows like this, You do have an option of radical resection as long as you remove all of the underrun tissue and can treat all of the, of the digital dermatitis infected tissue.
So here we are, this is having a go at treating this particular cow and you can see the tract go right up towards the coronary band here. Same cow, this is 2 weeks later, starting to get a healthy granulation tissue, starting to caratinize. This is 3 weeks later again, caratinized.
And again, this is the day of initial treatment, so removing all of the under horn to the point of firm attachment, making sure that any dig dermatitis trepones are treated with topical antibiotics here. This cow wasn't treated with systemic antibiotics at all. And this is, I think it was 6 weeks later, where, it has recreatinis and start to heal.
Again, 6 weeks later. This is the cow. 23 litres a day, milk on the farmers' call list, be chronically lame.
She was bought in cow, so the farmer didn't know how long she'd been lame for. He bought her for next to nothing because she was so lame. He bought her as part of a herd sale.
And this is eight weeks later. She was giving 41 litres a day. She looked a lot better.
She was no longer lame. She was walking squarely on her foot, no, flexed toe. And you can see she has a heat time collar applied there because the farmer had decided not to call her after all because she's actually a very good cow and put her back in calf, so that's a good result.
And a similar case, just a different cow, different foot, front foot, young heifer. You can see the degree of resection is required and you can see the recurinization several weeks later. Once that dorsal wall resection has been thoroughly, paired away, and then the underlying dermatitistrapoin is treated.
It's not easy to do. It takes a long, long time to do that kind of pairing. But it's an option.
It's an option which, is available for some of these, necrotic toe cows. Just moving on to control of torosis. Well, if we go with the theory that digital dermatitistraponemes are the primary lesion, particularly the coronary band tracking under the wall, then control of digital dermatitis, particularly at the front of the of the foot on the coronary band, is, is a critical part of control.
And watch foot bath depth. I have come across farms that have high numbers of necrotic toes when they've changed their foot bathing regime, perhaps or . Automatic foot sprays rather than foot bathing and perhaps that's treating the tis on the back of the heel but not on the, on the front, on the front of the foot.
Early detection and treatment in new cases, in other words, nip it in the bud before it becomes to a point where the pedal bone is infected. And then if you are going to do a dorsal wall resection to treat, then you must remove all the unattached horn and open up all the infected tracts to effectively treat the digital intached trapin, and that will always go to the coronary band. So, If you don't think you have gone to the coronary band, if you, if you, if you're, if you've done a, a resection, you've got a lot of blood and you can't quite see what you're doing, and you've not gone to the, the coronary band, then be careful because I would suspect that you've not taken enough wall away and that, infection will remain, the dermatosis infection will remain and, you'll be still left with a non-healing, Claw horn lesion.
OK, we're coming towards the end because I, I wanted to, I, I've gone very quick. I'm conscious of that. There's bits I've missed out because of wanting to talk about, the bits that we have covered, but I wanted to leave some time for questions, which I've managed to do.
I said though that I would point you in the direction of a further resource if you want to look at, other. Techniques or other, possibilities for, digit surgery, which are digit preserving techniques rather than doing a digit amputation, for example, for distal or joint infection. So the resource that I'm pointing you to is the bovine surgery and name this book.
And I, I, I guess I have a vested interest in this in the sense that I was involved in, writing the, rewriting the, the, the latest edition, the 3rd edition, which was published this time last year. It's a completely revised edition. The lameness chapter is about a quarter of the book, and, that has been totally rewritten from scratch.
And within that, . What I've talked about has been, is, is, is illustrated in more detail and also those alternative digits bearing techniques. So I do recommend this book to you, as something to have on the shelf.
It's a, if you've got a similar, if you've got the 2nd edition or the 1st edition on the practise shelf already, then I do commend this one, at least have a look at it. It is a totally, revised edition. It's a handy little book.
It's the sort of thing you can have in the car. it isn't the be all and end all. If you're looking for a more detailed book on, on surgery in cattle, then there are other books available.
But, for a handy practise, ready to use guide that's, that's, that's not too expensive, then I do recommend this book. So that does, Rich, leave me er just a short amount of time for, for those questions. Thank you very much.
That's brilliant, thank you very much there, Erin. . As Owen says, he's left some time.
It's been perfectly timed by you in there, so, you know, it'd be great to have some questions from you. It'd be great to hear, obviously at the beginning, you know, 50% of you hadn't come across or had to perform anything nice before, but it'd be great to get your thoughts on if you feel more comfortable now being able that you actually feel comfortable tackling some of these, conditions that Owen has, and techniques that Owen has highlighted. So I'll give you a couple of, a minute just to have a think about that and please do post them in the Q&A box.
I will also say, please do at the end of this webinar, there should be a tab open on your browser asking for feedback, so please do take some time just to complete that, cos that helps us develop our programme. As, as I said, I haven't got a veterinary background myself, but I suppose one question I've got Owen is, I know it's been talking about the management of claw lesions, but, you know, a lot of it, you know, does it strikes me, does it come from the environment and, you know, almost prevention is better than cure, and without a doubt, prevention is always better than cure and, and, and I mean this, this, this, webinar has been sort of focused on how to treat some of those difficult conditions once they've, once they've occurred. In, in every instance, you know, everyone, every vet's attention should be in trying to reduce lameness in the first place.
So, does it come from the environment? A lot of it is environmental. Di dermatiti control is, is, is has basic principles of infectious disease control.
It wouldn't be dissimilar to how you would tackle a staph aureus mastitis infection in the herd. The reservoir of infection. Is the infected cows themselves, and you can reduce that reservoir very effectively by treating affected cows, reducing the number of cows with lesions, and that will reduce the reservoir of infection for digital dermatitis.
And digital dermatitis can be treated. It might not be eliminated in a cow in the same way as staphysis is quite difficult to eliminate in a cow, but it can be treated, to reduce the shedding very effectively when, the feet are. And lifted, but it has to be done on an individual cow basis.
No problem. Thank you for that. That's brought me a little bit of time.
We've got a couple of questions coming in. So the first is from Charles. Charles saying, you've not mentioned systemic antibiotics at all.
If systemic antibiotics are indicated, is it a cool case? Systemic antibiotic. Well, I would use systemic antibiotics after a digit amputation.
I wouldn't use systemic antibiotics, necessarily for the, dorsal wall resections. I might if I think that there's a high degree of secondary infection that my topical antibiotics are not gonna be effective for. What frustrates me, Charles, is the, is when there is a tendency to see a cow with a swollen foot and think, oh, it'll be foul, hoping it's foul.
Give it a jab of antibiotics, and, and the foot hasn't been lifted. And, and 9 times out of 10, it isn't foul. It's, it's something entirely different, like a soul ulcer.
And there is no, there's no indication for systemic antibiotics to treat her. Uncomplicated soul ulcer, and when a cell ulcer does become complicated, to the extent that it's a distant phalangeal joint infection, then antibiotics won't work. So we.
Have seen too much use and abuse of systemic antibiotics for the treatment of foot lameness in cattle. Fantastic. Thank you.
Hannah has asked the question. What do you recommend as a routine foot bathing solution? No, I'm not gonna answer that, and the reason I'm not gonna answer that is because I think there's too much focus on what is the magic chemical.
And to answer that question. And give it justice. I would rather talk about how you do your foot bathing and.
One aspect of how you do your footing is the chemical that's being used. So, sorry, Hannah, to disappoint. I'm not going to answer that question because I think it's too simplistic just to think, oh, what, what do I, what do I need to foot bathe my cattle with?
You can foot bathe whatever you want, or use whatever chemical you want, and it won't work if you're not foot bathing, effectively. So foot baths, whatever chemical you're using, become grossly contaminated very often, and that can make dig dermatitis and heal horn erosion worse if you're not careful. I will say what you mustn't use, and that's antibiotics.
I am absolutely firm that there is no place ever for antibiotics in foot baths. There we are, thank you very much for that. I've got a question here from John.
John is actually over the ponder in New Jersey in the states. So he's asking the question, in the UK do you use the drill method much to. Awise the joint in those severely affected cases.
Sometimes we do here to hopefully have a longer, more than that, lactation survival when did your experience with them. Yep, yep, good question. That's discussed me more depth in the in the books that I pointed out.
Yes. Occasionally in the studies I've seen, and one of them does come from it comes from Wisconsin, I think it's from, Nigel Cook and Co. I think, looking at a study comparing digit amputation with the drip with a, with a drill method and radical, resection method.
Then the drill method came out better, but it was comparing it with a, with what I think is a flawed digital sorry, digit amputation technique, which was P2. If you compare it with P1, which I described in this webinar, as in the distal P1 amputation site, then I think you'll find that you'll get a better resolution, a better success rate with that, digit amputation technique. So if I'm right, thinking of the papers that I am aware of that do look at that, that drill technique, is the success rate wouldn't be as high as I would hope to achieve with a, digit amputation through distal P1.
So it is a technique, it is an alternative. If you're faced with the farmer who just will not do a digit amputation because they've had a bad experience with it in the past, and you can't persuade them that otherwise, then, you know, it might be something to consider. But I'm not a big fan of it because I think the healing times are longer and I think the success rate is probably not as good as a good digit amputation technique.
Thank you very much for that. Well, I think that what brings us to time. It leads me to do is to say thank you to yourselves for attending tonight's webinar and peeling yourself away from the Liverpool Barcelona game.
Yes, I know. I'm sure many of you can catch up with that if you're interested afterwards. Thank you to Lewis, for being on hand, to deal with any technical queries you've got.
And also, obviously, finally, thank you to Owen for the brilliant presentation he's delivered today. If there are any elements of it you want to revisit, the recording will be on our website within the next 24 to 48 hours for you to access and review at your leisure. So, thank you very much to everyone.
I hope you can join us, next month. I can't believe it's gonna be June, but er the months are flying by there. So join us in June for our next farm webinar and I wish you all a pleasant evening.
Goodnight.