Ladies and gentlemen and dear colleagues, greetings from Germany. My name is Marian Kossina, and I'm a practitioner working with cattle in the very northern part of Germany. Topic for the next 150 minutes is surgery on the distal limb in cattle.
No visible subtitle is under field condition. To perform surgery with the success, you have to have a deep knowledge of anatomy. This is essential.
Just a short overview. The digit is built with the bones by the bowvines. It is.
They stal phalanx. Called the swell pedal bone, distal sesamoid bone called the swell navicular bone, the middle phalanx, and proximal phalanx. Digital extensor tendon is situated on the dorsal aspect of the digit and ends on the prous extensorus of the pedal bone.
The flexors are situated on the opposite side. Superficial flexor tendon ends on the middle phalanx, and the deep digital flexor tendon has its insertion of the tuberculum flexorium of the pedal bone. All three joints of the digit have a curved shape with a distal convexity.
This is very important to keep in mind if you're performing surgery, we will see it later on. Very close to the distal interphalangeal or pedal joint are two and two synovial structures. First, the small one, you can see it here, is the podorolar bursa between navicular bone and and part of the deep flexor tendon.
Digital flexor tendon sheet is situated on the plantar aspect and surrounding both flexor tendon of the digit. Surgical intervention is necessary in all cases with proliferation of potoderma or skin with the consecutive infection of the deep structures which is manifested as osteomyelitis, arthritis, tendinitis, tendovvaginitis. The hallmark of the clinical presentation in such cases is severe lameness.
Degree 3 to 5 of 5 point scale. The clinical findings we can Get the local . In this table.
Normally phlegment and swelling is present on the beginning in early stages, only about affected clone in a coronary region. Later on, over both claws extending proximately in severe cases to tarsus and carpus. By concurrently tenovaginitis, you can see the typical swelling, proximal and distal.
To do close on the Plantar aspect of the digit. Palpation with the forceps is very painful, the same as extension, flexion, and rotation tests. They are positive first of all by affection of the pedal joint.
We can see horn lesions. There is severe purulent necrotic or the dermatitis, and in severe cases, we can see deep structures. By the lesion of the deep flexor tendon and its partial or total disconnection to the pedal bone, you can see tilting claw, which means that the apex of the affected claw is rotating upwards.
Examination with the probe is a very important part of diagnostic. Through the perforated potoderma, you can reach directly deep structures rough perrose bone, ray tendon, open tendon sheath, and open distal interphalangeal joint. Very important in the diagnostic is the function.
The punction allows find the answer for the question if the pedal joint is affected or not. Here on the picture in the middle you can see pedal joint, normally more or less completely hidden inside of the horn capsula. The punction side of the dorsal recessus on the left picture.
Is approximately one finger above coronary band in the middle of the dorsal aspect of the claw. The punctu side of the Plantar recessus. One picture on the right side is in the middle of the coronary band.
On the abaxial side, approximately one finger proximal of it. Cannula with the white lumen? It's inserted in 45 degree angle with the central direction to reach the joint.
Yeah Short video function from Abuxial aspect. And the pure and synovia Icaro synovia is coming out of the cannula. To perform surgical procedures, you need anaesthesia.
Intravenous regional anaesthesia is widely used, under field condition on the digit in bovines. One of the digital veins should be choose for this purpose. Dorsal digital vein, the punctum site is approximately 3 to 4 fingers approximately to coronet.
The vein is situated centrally between Digits on the dorsal aspect. This is an advantage. The disadvantage of this vein is this vein is neither visible nor palpable.
The alternative is to use one of the digital palmar or plantar veins. The punction site is two fingers there approximately to the new cloth. The advantage of these veins is they are visible and palpable after application of the tourniquet, but only in cases, if no phlegment or just a moderate phlegmo is present.
The disadvantage of these veins is they are very close to tendon sheath, and the colours of these veins vary a lot between the animals. The anaesthetic procedure starts with the surgical preparation of the puncture site. We see shaving, cleaning the alcohol, and disinfection with iodine.
After application of the tourniquet in the middle of the metatarsus or metacarpus. Small needle will be inserted in one of the veins, the blood is coming out, and finally 20 millilitres of anaesthetics will be applied into the vein. Complete anaesthesia is accomplished within a few minutes, maybe 12 minutes, but at the latest after 3 to 5 minutes.
The first surgery I would like to show you is the digit amputation. Digit amputation is indicated by a section of many structures, single or in various combinations. From the bones, the pedal bone could be affected, the navicular bone could be affected.
Middle phalanx, of course, the affection of the pedal joint is no problem. The affection of the and parts of all the tendons is no problem to perform surgery with success and A fraction of other labsa and tendon sheet is now a problem as well. Normally, most common indication are perforating claw lesions, such as sole ulcers, perforating white line abscesses, and toe tip necrosis with a huge extent.
Perforating in the digital necrosis and perforating injuries on the coronet. Digit amputation I perform and recommend is very easy and it's an open amputation proximal to coronate performed as an exacticulation at the level of the proximal interphalangeal joint. To perform this surgery, you need very simple equipment scalpel, faucets, and sharp, spoon, or curt.
This procedure starts with a circular incision of the soft tissue completely down to the bone, one finger proximal to coronet. After that, you search for the articular space on this picture you can see open. Articular space.
On found you have just to follow articular space to make exacticulation, but remember, The joint has a curved shape. With the distal convexity which means on the dorsal and plantar aspect, it's higher than in the middle. It follows ex articulation on the left side you can see wide open proximal interdigital.
Joined Interphalangeal joint, sorry, and here completed exepticulation. Now steps are excision of the necrotic tissue, curettage of the cartilage, and cleaning of the wound. The pressure bandage will be applied, and now we will see all the steps in real-time videos starting with the amputation.
We start with the circular incision. Through the soft tissue, be careful in interdigital space not to perforate the fat interdigital cushion and to bring the infection. To the healthy opposite side.
Now, you are searching for the articular space. You can use digital digital palpation for it. It's necessary to mobilise the joint.
It means to cut all of the soft tissue. To the bone To be able to find the Particular space. In some cases it's difficult because of excessive proliferation of fibrotic tissue and sometimes even with calcification.
So you have to To successive accession. Of this change this you to be able to reach the joint space. Now again, help with the digital digital palpation.
And finally, We reached the time. Space Now you follow him. Remember?
Dial convexity and now we can see widely open proximal interpharyngeal joint. And Exceptticulation. Will be completed.
It follows removal of overlying skin. Shortly to the level of the remaining bone. Around the whole amputation wound.
Very important is to do it on the planter aspect. Because you have to be sure that the amputation won't has enough space and distance is enough to the ground to be completely taken out of the pressure by the walking. Now a section of the.
Necrotic tissues, small abscesses, small necrosis should be removed completely. And now finally look. From plantar aspect, you can see there is enough space between the ground and the amputation wound to be sure.
It comes to no pressure by the walking. You can see this patient has wooden block applied it's because of previous Treatment of glow lesion, but normally by this type of amputation is wouldn't block, not necessary. Now, the second step is curettage of the cartilage.
Cartilage is a type of tissue, bloody trophic tissue, which nutrition is completely ensured from diffusion from synovial fluid if . Left intact after exoticulation, it comes to its necrosis and coverage with the granulation tissue is delayed. So, that's the reason why you have to remove.
Now the video. Removal with a sharp spoon is Yeah, very easy. You can do it with a scalpel as well, but with a sharp spoon or with the cure.
It's, as I told already easier. The next video shows applying a pressure bandage. The first liar medica.
Earliest substances then tampona and then Soft bedding. There are. Many different materials you can use for the.
Applying a bandage. I prefer cotton, . During the amputation, bleeding is stopped because of application of the tourniquet, after surgery, this job must be done, from a bandage, so that's the reason you have to bring a lot of pressure to stop the bleeding, post-surgical.
And just to avoid the pressure necrosis on the soft tissue, you have to put more layer of the cotton. So now the petting. Nair is Finished, completed.
The second layer is application of the elastic bandage. With these layer, you can actually bring a lot of pressure on the surgical wound and so. Stop the post-surgical bleeding in the next hours and days.
Because you have to apply this layer with a lot of pressure, . In opposite to the layer with With the padding layer with the cotton and two clothes, . You have to let free just to avoid pressure necrosis under the clothes on the skin, which can lead in some cases if noticed, if does noticed early with the complication, such tenovaginitis.
Tendonitis. So, Yeah. Layer with elastic bandage is more or less completed now.
And the next layer is application of the isolation tape. With the application of the isolation tape and next layer you can Bring additional pressure on the Surgical wound? You can reach more stability.
Of the band-aid, it's . Yeah, necessary by the patients with a huge flag bone because each movement is painful, painful, so, stability is important, but The reason why we do it in the first line is protection against moisture, humidity, and to keep it dry inside. Now to the healing process, the first bandage change will be performed in 7 days.
On the left side, you can see that correctly applied bandage stays in position during the period between surgery and first, bandage change and can fulfil completely its function. On the right side, picture, after removal of bandage, the first time, that the healing is, undisturbed is a reduction of the phlegm. You can see on this digit, the phlegone is, disappeared more or less completely.
This is the same patient as from the videos, and you can see, she lost the wooden block, but even despite of this, there, there is enough space between soul and Amputation wound, so even by applying of a bandage, there is no pressure by working on the wound. Here, the amputation wound, we can see centrally is the bone completely covered with the fibrine with the blood clot and on the peripheral side, you can see beginning. Granulation.
7 days later, it means 14 days after amputation. On this picture, immediately after removal of the bandage, you can see the former fibrine and blood clots. Over the bone is become to be necrotic and there is a purulent smelling discharge in the wound.
This is completely normal situation. Don't worry. After cleaning the wound, you can see in the middle naked bone.
This is complete normal. The bone is smooth, the bone is not rough. The bone is not painful and very important as the bone has very good contact to surrounding granulation tissue.
On the edge of the granulation you can see already starting epitalization. 7 days later, it means 21 days after surgery, you can see retraction of the wound if you compare it with this picture. The bone is not visible anymore, but if you make an examination with the probe, you can reach it still.
It doesn't matter. It's completely normal. It's normal that the bone is reachable for the probe for the couple of weeks, 567, maybe 9 weeks after amputation.
The most important thing is it's not painful, it's smooth, it's not rough, and has a very good connection to the surrounding granulation tissue. In such cases, the last bandage, from our side as a veterinarian is applied and after 2 to 3 weeks, should be removed from the owner. The most common complication by the perforating low lesions from the beginning or during the healing process after amputation, for example, is septic tennovaginitis.
You can see a typical picture, the swelling on the plantar aspect proximal and distal to the dew close. In such cases, surgical debridement, lava, and drainage is necessary. For this reason, the simplest way how to do it is a minimal invasive 10 of vaginotomy with tendonectomy, for this purpose, long forceps, will be inserted into the tendon sheet by a distal opening, to the very proximal end, approximately 8 to 10 centimetres, proximal to the do close.
And the small incision just over the tip of the forceps, to open the tendon sheath will be performed. You can see it now on the video insertion of the forceps, a small incision over the tip to open the tendon sheath. Now it tendon she open and in .
Second step, the instrument is placed under the deep digital flexor tendon to be able to pull it out of the tendon sheet and to Extraction. Now the short video, you see the instrument under the deep flexor tendon. In this case, it was really, really problematic because of fibroblastic adhesions between tendon sheet and deep flexor tendons.
So, but finally, it was successful. You can see pathologically changed and this is all part of the Deep digital flexor tendon and a lot of ecstasy. Fibrine adhesions on the surface of the.
The digital flexor. Now all the necrotic parts and fibrin should be removed out of the. Tendon sheet and luggage and drainage is necessary.
To drain the tendency to have more options, maybe in the beginning by really high exudation rates, by a lot of pus and fibrine deposits, it's better to start with a multi-instrated tubes, which has advantage you can. Make next days, 23 days, so long as necessary. The leverage of the tendon sheet later on.
If the exudation it's reduced, you can use the simple drainage, for example, using this band normally used for closure of the vulva, or you can use, glow, yeah, normally used for the rectal palpation. Alternative technique is complete tenovaginotomy in the whole length for this purpose, long surgical incision starting on the proximal end of the tendon sheet on following on the axial aspect of the dew close to the middle of the heel bulb, will be performed. And now on the second picture, you can see already open tandem sheet in the whole length.
You can have a look at the Superficial flexor tendon. And deep flexor tendon. The big advantage or huge advantage of this technique is you make everything under visible control so you can control all the structures situated in the tendon sheet.
You can do complete exploration, . If necessary, you can do surgical incision through the superficial flexor tendon. After that, you can remove.
Deep flexor tendon and of course, if necessary, you can remove superficial flexor tendon as well. This operation is of course indicated as well by single, affection of the, tendon sheet or tendinitis or complicated, tendnovaginitis, if, another structures are not affected, so it, Shouldn't be done with amputation simultaneously, of course. Here we have a patient, after amputation, after complete tennovaginatomy and tendonectomy, you can see the wound after leage cleaned and after application of the simple drain.
The bound will be closed, with a simple sutures. The patient Two days after surgery, first, one toilet, and, first, drainage change in 7 days after surgery, the drainage, could be removed and the sutures as well. And on the right side, you can see.
Completely healed digit and Yeah, and the patient is healed. The next surgical procedure is the resection of the distal interphalangeal or pedal joint. There are many different methods you have to do that.
I would like to show you a resection of the pedal joint with the plantar or palmar approach. Indication for this procedure is septic arthritis of the pedal joint with the affection of the structures of the plantar or palmar aspect which involve tuberculum flexorium of the pedal bone distal part of the deep digital flexor tendon. For the labsa.
Navicular bone and distal part of the middle phalanx, and of course tendon sheath could be affected as well. What's the goal of this operation? It is preservation of the affected claw despite the damage of the joint and surrounding structures.
We want to achieve ankylosis in the medium term, within 7 to 12 months. The indication for the palmar or plantar approach are, first of all, complicated soul ulcers. Deep heel injuries and septic hematogeneous arthritis of the pedal joint as well.
The instruments compared to digit amputation, you need more instruments scalpel, forceps, wound spreader, double edged knife, and first of all, drill with a drill bit. How to do this operation, before you start the operation, heal and sole horn should be cut as thin as possible and then start the operation with the saggittal incision approximately 5 centimetres approximate the coronet down to the middle of the claw lesion. It means in this case, to solve ulcer.
In the second step, excision of the insertion of the deep flexor tendon is performed. On the right side, you can see the situation in the surgical field after resection of the distal part of the deep. Digital flexor tendon.
Using bone spreader is advantage because you have very good overview to during whole operation about Surgical field. The next step is excision of the navicular bone. You can see here in this picture.
This is a metal phalanx. The pedal bone in here, in the middle is a navicular bone. The most of cases with the perforation, so ulcers is, this bone affected and should be removed completely after that should be removed all necrotic tissue, surrounding, fistula tract, but, be careful.
And try to work preserving heel pet because this is very important for post-surgical healing. You have removed already a distal part of the flexor tendon, which means that that the extensor of the claw has no counterpart, and the claw tends to tilt, means to rotate apex to the dorsally. To avoid it and to, reach, good healing and ankylosis in correct position preservation of the heal but is necessary.
Now the situation, this pictures in operation field in surgical field after the removement of navicular bone, you can see middle phalanx and Pedal, bone, and the plantar aspect of the pedal joint. Now, the second steps are drilling of the canal through the pedal joint. You can see it here.
And milling of the tuberculum flexorium of the pedal bone, you can see it here on these pictures. These two steps will be performed using these instruments. It's a drill bit with two functions with a drilling function to the front and with a milling function to the side.
The canal will be drilled from plantar aspect of the joint to the dorsal aspect of the joint, and the, drill should reach on the dorsal capsula approximately one finger distally from coronary band. The finally, wooden block, will be attached on the healthy partner claw and the bandage will, will be applied with the fixation of the operated claw. In the flexion, and this is a second very important part to avoid the tilting of the cloth.
So the first part, please preserve the heel pit, make resection only in noted extent. And fixate the operated glove for the next weeks post-surgical 4 or 5 weeks in the flexion to minimise the risk of tilting glow. Now, the healing process, we can see on the left side, freshly operated low after pedal joint resection.
Here the picture, the same patient 5 days after surgery, the operation wound is fulfilled with. Blood clot and with a fibrine, the bone is completely covered. The patient is, still, the lameness, is still severe.
It's normal. After 12 days after surgery, here you can see in the Middle of the operation wound naked bone, but it's no problem. It's normal, but the bone shouldn't be painful, shouldn't be rough.
It should be smooth with a very good connection to this. Surrounding . Granulation tissue as you can see it here on the picture and we can see already optical part of the soul is soft cogificated.
At that time, lameness should improve markedly. On the day 20, it means 3 weeks after surgery, the bone is completely covered with a stable, fine-grained granulation tissue, and 1 month after surgery there is only a very small part, not cognificated. The patient in this, stadium of the healing process doesn't need any bandage.
It's important to, keep the, wooden block on the cloth, on the partner cloth maybe for the next 4 to 6 weeks more. Now the comparation advantages and its advantages of the boat operation, amputation versus pedal joint resection. Amputation is accompanied with the loss of affected glow.
Of course, that's the purpose of the operation. And the pedal joint resection, the main goal of this operation is the preservation of affected glow. Surgery and aftercare, mm.
In the course of amputation, it takes a short time, and you need simple equipment. In the case of pedal joint resection, it's a time costing procedure, and you need more equipment. By the patient undergoing pedal joint resection, application of the wooden block is very important.
After amputation, wooden block, is not really necessary. And after amputation, you need to, yeah, maybe more 3 bandage changes, changes. After pedal joint resection, you need 45, maybe 6 bandage changes.
So a 4 is huge. After amputation, that's very important for the animal, rapid improvement of the lameness is a normal case. So, improvement, .
You can notice within the 1st 2-3 days within the first week post-surgical. By the federal joint resection, longer post-surgical lameness is normal. On average, there is no noticeable improvement of the lameness during the first post-surgical week.
The improvement comes in the second post-surgical week. Important difference between two surgical approaches is, what happens if the partner grow in the future is affected. After amputation is a serious problem because it's the only clue on the digit.
So after affection treatment is problematic, it's accompanied with the loss of animal in a lot of cases. After pedal jointrec section, there are two close on the digits, so a section of the part low is no problem and the treatment is easier than after amputated patients. The last operation I would like to show you is resection of the apex of the pedal bone, called as well as the toe tip resection.
This operation is indicated by affection only of the apex of the pedal bone. Any other structure should be affected by affection more than 1/3 of the pedal bone, . Is to expect the deformation of the horn capsula.
So, if there is infection more than 30-40% of the pedal bone amputation, it's a better option. What's the indications traumatic fractures of the horn capsula, including tip of the pedal bone. Then complications after, conservative treatment of the soul ulcers, including so-called non-healing lesions, which are, lesion, apical ulcers, with, infection of the potoderma with treponema species.
And very often lesions and infections due to a thin soul. Doesn't matter if after food over trimming or caused by excessive abrasion on rough flooring. The second one, we can see on the farms with a very new concrete floor or with a very old mastic asphalt.
There are many different methods, you can choose, you can do total prosection using so wire, normally used for phototomy. You can use a special drill bit, faster drill bit. Mm, but I prefer to use angle grinder.
It's a very simple. The whole procedure is very simple. You have just removed affected apex of the pedal bone till the bone, whitish and well vascularized appear.
You can see it here. What is important, important is to minimise overheating because it leads to thermic necrosis. And this is accompanied with the sequester building.
Sequester building is the most common complication. After toe tip resection. So what can you do?
You can do aluminium disc, you can work in a short interrupted sequences. Mm, you can, do cooling with the cold water, but, water and electricity. On the same place at the same time, it could be really difficult.
And dangerous, so it follows rounding off the sharp edges of the horn capsule. And finally, application of the wooden block and application of the bandage. Now we can see one case in healing process here on this picture, you can see.
Fresh resected toe tip, whitish bone, ice, bleeding. And here from a solar aspect, you can see the completely soul, has a loose horn. It was removed 10 days after a resection, .
Solar area with the former superficial for the dermatitis is already cogificated but the wound after toe tip resection is covered only the bone is covered only with the fibrine and peripheral beginning. Granulation tissue. And one month after the surgery, the horn capsula is still not closed.
The apex of the pedal bone is covered with fine grained granulation tissue. You can see a very small amount of purulent exudate, but, the capsula is still open. It's completely normal.
You, we expect after depending from the extent of the wound, we expect the complete closure of the horn capsula approximately 2 to 3 months after the the resection. In the cases with the very fresh affection of the bone and circumscribed, you don't have to make resection of the whole tip of the toe. You can make a local resection of the pedal bone.
Here you can see the patient. On the left side after conservative treatment, freshly treated apical soul ulcer, and on the right side, the same animal, 7 days after surgical treatment and the soul is more or less cogificated, but the Place area of the former ulcer is in a granulation in the detail you can see in the central position necrosis, necrotic potoderma after removal, you can see brownish. Bone, very painful.
So it's ostitis. This part of the bone should be resected using drill and milling head. There are many different types of milling head.
And now, short video of the resection, because, the affection is very fresh and only superficial, mm, you have just to take a small part of the bone away. It's, it takes, mm. Normally 30 seconds, maybe 1 minute, and the operation is completed.
Important, the bone should appear whiter. Well, vascularized, we can see it here on this picture. Mm nice bleeding and white.
Healthy bone. The same patient, one week after resection of the pedal bone, the complete bone is covered with a thin layer of granulation tissue, and 5 weeks after surgery, there is a stable congenification of the soul. Now, only a few words to the aftercare, after surgery.
Of course, systemic medical treatment is necessary, antibiotics, optimal, . 5 to 7 days till the first band the change and then you can decide if it's necessary to prolong it or not. Non-steroidal anti-inflammatory drugs, of course, surgery is, painful first of all, post-surgical on first days, so you have to give, give 3 to 5 days, painkiller.
We as a veterinarian make control of the Operated patients by the bandage change. The first one is 5 to 7 days after surgery, and then depending on the local findings, every 7 to 14 days, what is really very important is, housing of the patients after surgery. They should be kept in a dry and clean environment.
Even not slippery floor, slatted floor is no problem, even not after digit amputation. But the problem is tha stall, for example, because severe lame animals have some difficulties to lie down, to stand up, so the thai stall is, of course, handicapped straw bedded boxes and muddy pasture is critical for the healing as well because operated clothes sing, . In the ground and, comes, to the contact, with the ground.
So, there is some mechanical irritation, so. If it's possible, not straw bedded boxes and if pasture with no muddy areas. If it's possible, you have to keep, the waste of food, water, and milking as short as possible.
What is very important for the owner. He should make daily control of the animals, first of all, degree of the lameness and general condition by worseninglea, very quick reaction is necessary to minimise the complication. And now the last slide, there are many numbers.
You don't have to check all the numbers. This is a healing rate of the surgical procedure performed during the year 2018. You can see 26 amputation.
Most frequently performed, radical surgical procedure, comparing to pedal joint resection very seldom with only 4 cases. Which is clear, yes, you cannot treat successful all the patients. It's not possible.
There are losses on two of these patients, . Had to be authorised and 4 of these patients went to the slaughtery during the healing, but there are positive information as well. Depending on the surgery, approximately 50 to 70% of the patient undergo complete undisturbed healing process and by the rest of the patient, they are small complication.
They delayed healing by one patient, . After pedal joint resection amputation of the affected globe was necessary. And that's it.
Everything for today, for this session, I would like to thank you for your attention. We see us, by the next webinar. I hope we see us in the next year, hopefully, face to face.
And I wish you take care, stay healthy, and God bless you.
