Noel Fitzpatrick

Predictive variables for complications after TPLO with stifle inspection by arthrotomy in 1000 consecutive dogs.

OBJECTIVE To evaluate risk factors for complications, including meniscal injury and infection, after tibial plateau leveling osteotomy (TPLO) in dogs. STUDY DESIGN Retrospective case series. SAMPLE POPULATION Dogs (n=1000; 1146 stifles) with cranial cruciate ligament (CCL) rupture that had TPLO. METHODS Medical records (January 2004-March 2009) were reviewed for dogs operated sequentially by medial arthrotomy with instrumented meniscal inspection (IMI) and TPLO by a single experienced surgeon. Multiple logistic regression models were used to evaluate independent contribution of risk factors to the recorded complications. RESULTS Overall complication rate was 14.8%, of which 6.6% were major complications. Incidence of primary meniscal injury (PMI) was 33.2%, and subsequent meniscal injury (SMI) 2.8%. Postoperative infection occurred in 6.6% dogs. Bilateral CCL rupture was diagnosed in 14.6% dogs and no statistically significant complication incidence difference was recorded for simultaneous or staged bilateral surgical procedures. Administration of postoperative antibacterial therapy and being a Labrador reduced infection incidence, whereas increased body-weight and being an intact male increased infection risk. Increased body-weight and complete (versus partial) CCL rupture were significant predictors of overall complications. CONCLUSIONS Incidence of SMI recorded in this study is similar to that reported previously involving arthroscopic meniscal inspection at time of TPLO. Infection was the single most important complication and antibiotic therapy was protective. Complication rate did not differ between bilateral simultaneous or staged procedures. CLINICAL RELEVANCE Complication rate after TPLO with arthrotomy and IMI is lower than previously reported, bilateral simultaneous TPLO is reasonable, and incidence of major complications compares favorably with general orthopedic procedures.

Radiographic and Arthroscopic Findings in the Elbow Joints of 263 Dogs with Medial Coronoid Disease

OBJECTIVE To report clinical, radiographic, and arthroscopic findings in dogs with thoracic limb lameness attributed solely to disease of the medial aspect of the coronoid process (MCP). STUDY DESIGN Case series. ANIMALS Dogs (n=263) with MCP disease (MCD; 437 elbows). METHODS Clinical records (January 2000-July 2006) and radiographs were reviewed and pertinent data recorded. Radiographic interpretation included measures of periarticular osteophytosis, gross assessment of MCP integrity, and measurement of ulnar subtrochlear sclerosis (STS). Statistical analysis was performed to evaluate associations between data; confidence interval was set at 95%. RESULTS Labrador Retrievers were 50.2% of all dogs with MCD. Mean age at diagnosis was 32 months and duration of lameness was 14.5 weeks. Thirteen elbows (3%) were considered radiographically normal. Osteophytosis was identified on the anconeal process (70.2%), radial head (37.3%), and lateral epicondyle (56.5%), and STS was identified in 86.7% of elbows. Median osteophytosis score was 1; mean absolute osteophytosis score was 1.7. Arthroscopic findings included: fissuring (18.3%) and fragmentation (64.1%) of the MCP and kissing lesions (49.0%) of elbows. Median-modified Outerbridge score of the MCP was 2 and the humeral condyle, 0. Weak or moderate correlations were found between osteophytosis and modified Outerbridge scores and weak correlation between modified Outerbridge scores of the MCP and medial humeral condyle. CONCLUSIONS Wide ranges in clinical, radiographic, and arthroscopic findings are recognized in dogs with MCD but correlations between such factors are generally weak. Radiographic and arthroscopic findings do not correlate with owner-reported duration of lameness. CLINICAL RELEVANCE Radiographic measures of osteophytosis are poor predictors of severity of arthroscopic pathology for MCD.

Working algorithm for treatment decision making for developmental disease of the medial compartment of the elbow in dogs.

Presentations Veterinary Orthopedic Society, Colorado, USA March 2009 Fitzpatrick N, Evans K, Yeadon R: Synthetic Osteochondral Transplant for Treatment of OCD of the Canine Elbow, Stifle, and Shoulder with Arthroscopic and RI Outcome Measures Fitzpatrick N, Danielski A: Biceps Ulnar Release Procedure for Treatment of Medial Coronoid Disease in 49 elbows Veterinary Orthopedic Society, Colorado, USA March 2010 Fitzpatrick N; Danielski A: Validation of lumbosacral neuroforaminal distraction in dogs using a novel intervertebral spacer and mri mensuration instruments – a cadaveric pilot study Fitzpatrick N; Danielski A: Long-term follow-up of lumbosacral distraction-fusion using combined dorsal and ventral fixation including a novel intervertebral spacer device (23 dogs) Fitzpatrick N, Nikolaou C: True spherical dome osteotomy for acute correction of sagittal and frontal joint axes in dogs with angular and rotational antebrachial deformities (11 limbs) European College of Veterinary Surgeons symposium, Helsinki, Finland, July 2010 Danielski A, Fitzpatrick N: Validation of Lumbosacral Neuroforaminal Distraction in Dogs Using a Novel Intervertebral Spacer and MRI Mensuration Instruments – A Cadaveric Pilot Study World Veterinary Orthopaedic Conference Bologna, Italy, September 2010 Fitzpatrick N: Pantarsal arthrodesis in 10 cats using a novel dorsal plate: technique and complications Fitzpatrick N: Minimally Invasive Plate Osteosynthesis Using Two Perpendicularly Oriented Plates for the Treatment of Tibial Fractures in 23 Cats American College of Veterinary Surgeons Symposium, USA, 2010 Fitzpatrick N, Ash K: Constrained total knee replacement, a novel prosthesis for salvage arthroplasty in the dog and cat Fitzpatrick N, Ash K: Novel modular limb salvage endoprostheses for treatment of primary appendicular tumors in dogs Fitzpatrick N, Yeadon R. Ash K: Synthetic osteochondral transplant for treatment of osteochondritis dissecans of the canine elbow, stifle, and shoulder with arthroscopic and MRI outcome measures Veterinary Orthopedic Society, USA March 2011 Nikolaou C, Fitzpatrick N, Isaza J, Correa Velez S, Wavreille V, Ash K, Ochoa J, ,: The effect of configuration and radiographic positioning on measurements of deformity magnitude in a dog with a complex antebrachial growth deformity: comparison between radiographic and 3D computer modelling measurements Fitzpatrick N, Nikolaou C, Ochoa JJ, Isaza JF, Correa Velez S, Wavreille V, Ash K, Wavrielle, Szanto Z,: True spherical dome osteotomy using a novel blade design in a dog with antebrachial growth deformity Fitzpatrick N, Ash K, Blunn GW: Application of Novel Endoand Exo-Prostheses to the Calcaneus of the Dog and Cat following Distal Limb Amputation. European College of Veterinary Surgeons symposium, Ghent, Belgium, July 2011 Nikolaou C, Fitzpatrick N, Wavreille V, Ash K, Ochoa J, Isaza J, Correa Velez S: The effect of configuration and radiographic positioning on measurements of deformity magnitude in a dog with a complex antebrachial growth deformity: comparison between radiographic and 3D computer modeling measurements Fitzpatrick N, Bielecki M, Yeadon R, Hamilton M:Total Hip Replacement with Dorsal Acetabular Rim Augmentation using the SOPTM Implant and Polymethylmethacrylate Cement in Seven Dogs with Dorsal Acetabular Rim Deficiency Fitzpatrick N, Nikolaou C, Isaza J, Correa Velez S, Wavreille V, Ash K, Szanto Z, Ochoa J: True spherical dome osteotomy using a novel blade design in a dog with antebrachial growth deformity: Planning and Execution of Technique American College of Veterinary Surgeons Symposium, USA, 2011 Abstracts: Fitzpatrick N, Caron A, Wavrille V: Bi-oblique dynamic proximal ulnar osteotomy: surgical technique, computed tomographic assessment of radio-ulnar congruency over 12 weeks and clinical outcome in 87 dogs Fitzpatrick N, Garcia-Nolen TC, Daryani A, Watari S, Hayashi K: Structural analysis of canine medial coronoid disease by micro CT: radial incisure versus tip fragmentation Sajik D, Fitzpatrick N, Nikolaou C: Pantarsal arthrodesis in dogs: a clinical comparison of dorsal vs medial plate techniques without coaptation Fitzpatrick N, Bertran J: Sliding humeral osteotomy: Reduction of major complication rate to zero and clinical outcome equivalence with or without focal coronoid treatment Veterinary Orthopedic Society, Colorado, USA March 2012 Fitzpatrick N, Egan P: Treatment of canine talar osteochondritis dissecans using a synthetic osteochondral substitute Fitzpatrick N, Egan P, Pugliese L: Custom built uniplanar constrained total knee repacement in the canine and feline: clinical applications, design principles, surgical technique and clinical outcome Wucherer KL, Fitzpatrick N, Conzemius MG: A Prospective, Randomized Clinical Trial Evaluating the effect of Proximal Ulnar osteotomy for the Treatment of a Fragmented Medial Coronoid Process in the Dog. Fitzpatrick N, Solano M: Application of a novel osteointegration screw for treatment of incomplete ossificaiton of the humeral condyle in four dogs (six elbows) and humeral unicondylar fracture in addition to a locking plate in four elbows. Sparrow T, Fitzpatrick N: Total shoulder arthroplasty in a canine for treatment of severe glenohumeral arthrosis Fitzpatrick N, Nikolaou C, Ochoa J, Isaza J, Velez SC: Planning and Executing DOME Osteotomy: Implications for CORA Methodology Farrell M, Heller J, Kowaleski M, Sparrow T, Solano M: Fitzpatrick N: Does radiographic arthrosis correlate with cartilage disease in Labrador Retrievers affected by medial compartment disease of the elbow joint? Sparrow T, Fitzpatrick N: Shoulder hemiarthroplasty for treatment of severe osteochondritis dissecans lesion located on the humeral head in a dog BSAVA Congress Birmingham UK April 2012 Caron A, Fitzpatrick N: Cranial cruciate ligament rupture in dogs: lateral fabello-tibial suture failure and revision by tibial plateau levelling osteotomy, 59 cases Fitzpatrick N, Caron A: Bioblique dynamic proximal ulnar osteotomy: computed tomographic assesssment of radio-ulnar incongruency over 12 weeks in 29 elbows Fitzpatrick N, Bertran J: Sliding humeral osteotomy: reduction of major complication rate to zero and clinical outcome equivalence with or without focal coronoid treatment Caley A, Fitzpatrick N, Caron A: Kinematic gait analysis of the thoracic limb of normal dogs and patients with confirmed medial compartment disease using a six degrees of freedom marker set: 13 cases Law A, Fitzpatrick N: Total hip replacement in dogs 6 to 10 months of age – case series of 20 dogs Sajik D, Fitzpatrick N: Canine partial tarsal arthrodesis using a lateral type 1 ESF with a tied-in intramedullary calcaneal pin: 9 cases Fitzpatrick N, Egan P: Treatment of canine talar osteochondritis dissecans using a synthetic osteochondral substitute Sajik D, Fitzpatrick N: Pantarsal arthrodesis of the feline hock using a novel dorsal plate design applied according to the principles of minimally invasive plate osteosynthesis: 11 cases Solano M, Fitzpatrick N: Cervical distraction and stabilization using a novel intervertebral spacer and 3.5mm string-of-pearl (sopTM) plates for dogs affected by disc associated wobbler syndrome (daws) in 16 dogs Diribe O, Fitzpatrick N: Development of rapid Point-of-Care diagnostic tests for the detection of bacteria implicated in surgical site infections and the determination of their antibiotic resistance profile Fitzpatrick N, Bertran J: Long-term clinical outcome after subtotal coronoid ostectomy (SCO): retrospective study in 68 dogs Caron A, Fitzpatrick N: Bioblique dynamic proximal ulnar osteotomy: surgical technique and clinical outcome in 98 elbows De Sousa R, Farrell M, Fitzpatrick N: Simultaneous repair of bilateral medial patellar luxation: Clinical outcome and complications in 21 dogs and 5 cats Fitzpatrick N, Egan P: Use of a prosthetic trochlear groove for the surgical management of patellar luxation in 3 dogs Hamilton M, Belch A, Fitzpatrick N: Three cases of patellar tendon repair using canine fascia allograft Caley A, Fitzpatrick N, Caron A: Kinematic gait analysis of the thoracic limbs of normal dogs using a six degrees of freedom marker set Fitzpatrick N, Kovach K: Pedicle screw-rod construct with multi-directional clamps for stabilisation of vertebral instability in discospondylitis European College of Veterinary Surgeons symposium, Barcelona, Spain, July 2012 Fitzpatrick N, Solano M: Application of a novel osteintegration screw for treatment of incomplete ossification of the humeral condyle in four dogs (six elbows) and humeral unicondylar fracture in addition to a locking plate in four elbows American College of Veterinary Surgeons Symposium, USA, November 2012 Bertran J, Knapik GG, Marras WS, Fitzpatrick N, Allen MJ : Comparison of optical white light scanning and computed tomography for the generation of 3d models of the canine cervical spine Bertran J, Fitzpatrick N, Allen MJ: Non-invasive measure of bone density to predict mechanical properties of the vertebral endplate in the canine cervical spine

Techniques of Application and Initial Clinical Experience with Sliding Humeral Osteotomy for Treatment of Medial Compartment Disease of the Canine Elbow

OBJECTIVE To determine medium-term clinical efficacy of sliding humeral osteotomy (SHO) for treatment of lameness and elbow pain associated with clinically diagnosed elbow disease featuring cartilage eburnation of the medial elbow compartment (medial compartment disease--MCD). STUDY DESIGN Case series. ANIMALS Dogs (n=49) with severe or persistent lameness attributable to MCD. METHODS Signalment, lameness history, and preoperative imaging findings were recorded. A custom, locking, stepped SHO plate was applied to the medial aspect of the humerus, stabilizing a mid-diaphyseal transverse osteotomy, medially translating the distal segment relative to the proximal segment. Three variants of technique of application were used and outcomes compared between respective patient groups. Outcome measures included lameness scoring, anatomic measures, VAS scoring of elbow pain, and owner assessment of function. Measures recorded preoperatively, 12, and 26 weeks postoperatively were compared. RESULTS Of 59 limbs that had SHO, 39 had preoperative focal treatment of the diseased medial aspect of the coronoid process. Mean +/- SD dog age was 45.5 +/- 37.48 months and body weight ranged from 13.6 to 46.7 kg. Mean preoperative duration of lameness was 14.7 +/- 18.50 months. Lameness improved for all limbs by 26 weeks, and resolved in 21/32 limbs. Significant improvements in postoperative elbow pain scores and most owner assessments of function were observed. Incidence of major complications requiring surgical intervention was 17.2%, 22.2%, and 4.8% for each of the 3 technique variants described. Histologic examination of 2 elbows at >12 months revealed fibrocartilage cover of medial aspect of humeral condyle. CONCLUSIONS Canine SHO with or without focal treatment of the diseased medial aspect of the coronoid process ameliorates lameness and pain associated with MCD at medium-term follow-up. Application technique is critical to minimizing morbidity. CLINICAL RELEVANCE SHO is appropriate for clinical management of pain and lameness in select cases of canine MCD.

Subtotal Coronoid Ostectomy for Treatment of Medial Coronoid Disease in 263 Dogs

OBJECTIVE To document clinical outcomes after subtotal coronoid ostectomy (SCO) for treatment of medial coronoid disease (MCD). STUDY DESIGN Prospective clinical study. ANIMALS Dogs (n=263) with MCD. METHODS MCD was treated by a combination of SCO via mini-arthrotomy, cage confinement (6 weeks), leash restricted exercise (12 weeks) and pentosan polysulfate administration. Outcomes were assessed by clinical examination in the short-term (324 elbows), owner questionnaires (146 dogs), clinical examination (90 dogs), subjective assessment of gait (110 elbows) and radiographic examination (180 elbows), 4 months to 7 years 7 months after surgery. RESULTS One intraoperative complication occurred (1 elbow with fissuring of the ulna) and 8.2% elbows had immediate postoperative complications, the most common being wound infection (7%). Improvement in subjective lameness assessment to a score of 0 was noted at 5 weeks in 74.4% of elbows (veterinary) and 45.6% (owner) and at 12 weeks in 71.5% (veterinary), and 91.2% (owner). Subjective assessments of outcomes in the medium-term revealed 81.9% dogs remained sound, with significantly (P<.05) improved daily function scores compared with preoperative values, 83.5% of dogs received no NSAID. Clinical examination revealed good limb function and subjective assessment showed 51% of limbs were free from lameness. Radiographic progression of osteophytosis occurred on average by one grade. CONCLUSION Management of MCD using the described management regime, including SCO via mini-arthrotomy, deserves consideration and comparison with existing treatment methods. CLINICAL SIGNIFICANCE Management of MCD by SCO can be considered when gross fissuring or fragmentation of the MCP is not evident. This technique does not require specialized instrumentation.

Intraosseous Transcutaneous Amputation Prosthesis ( ITAP ) for Limb Salvage in 4 Dogs

OBJECTIVE To report clinical application of intraosseous transcutaneous amputation prosthesis (ITAP) for limb salvage. STUDY DESIGN Retrospective case series. SAMPLE POPULATION Client owned dogs with malignant neoplasia of the distal aspect of the limb. METHOD Distal limb amputation allowed press-fit insertion of the ITAP into the radius (n = 3) or tibia (1). Remaining soft tissues including skin were attached directly to the ITAP. Limb stump and ITAP were protected by bandaging (1) or external skeletal fixation (3) for 5-6 weeks before exoprosthesis attachment. Measures of outcome included subjective assessments of limb function by owners and veterinarians, radiographic (4) and histologic (1) examination. RESULTS Dermal integration with the ITAP was achieved by 3 weeks and dogs were walking in a pain-free manner by 8 weeks. One dog was administered adjunctive carboplatin chemotherapy. No evidence of local tumor recurrence occurred. In 1 dog, ITAP fracture occurred at 10 weeks and was successfully managed by ITAP replacement. Three dogs were euthanatized because of confirmed or assumed metastatic disease at 8, 12, and 17 months. Histologic examination of the ITAP-limb interface at 1 year documented osseous and dermal integration. CONCLUSION Implantation of ITAP to the distal limb of dogs is feasible and can result in favorable functional outcomes. Biological integration of osseous and dermal tissues with ITAP is reliable and robust.

Early Clinical Experience with Osteochondral Autograft Transfer for Treatment of Osteochondritis Dissecans of the Medial Humeral Condyle in Dogs

OBJECTIVE To establish whether osteochondral autograft transfer (OAT) procedures for osteochondritis dissecans (OCD) of the canine elbow would restore articular contour, resurface osteochondral defects with hyaline cartilage, and resolve lameness in the short term. STUDY DESIGN Case series. ANIMALS Dogs (n=27) with medial humeral condylar OCD. METHODS After arthroscopic assessment, the medial humeral condyle was exposed by arthrotomy. Medial coronoid disease (MCD) was managed by subtotal coronoid ostectomy, then the OCD lesion debrided and OATS instrumentation used for resurfacing the defect with osteochondral core grafts collected from the stifle. Recipient sockets were created to maximally resurface OCD lesions. Six elbows also had proximal ulnar osteotomy. Outcomes measures included subjective clinical, radiographic, and arthroscopic examination at 12-18 weeks. RESULTS Of 33 treated elbows, 30 also had MCD. Accurate reconstruction of the medial humeral condylar surface was achieved in all joints. Lameness resolved in 3-13 weeks in 26 of 31 limbs with follow-up. Arthroscopic outcomes for elbows with concomitant MCD but without proximal ulnar osteotomy were variable (14/24 good, 5/24 intermediate, 5/24 poor). Short-term outcome for OCD without MCD (n=2) and when proximal ulnar osteotomy (n=5) was performed were positive. Long-term assessments of 7 dogs suggested minimal donor site morbidity. CONCLUSIONS OAT procedures are technically feasible in the canine elbow. In elbows with concurrent MCD, proximal ulnar osteotomy may improve likelihood of positive clinical outcome. CLINICAL RELEVANCE OAT procedures warrant further evaluation as a treatment option for selected cases of OCD involving the canine medial humeral condyle.

Tibial tuberosity transposition-advancement for treatment of medial patellar luxation and concomitant cranial cruciate ligament disease in the dog. Surgical technique, radiographic and clinical outcomes.

OBJECTIVE To report surgical technique, morphometric effects and clinical outcomes for tibial tuberosity transposition-advancement (TTTA), sulcoplasty and para-patellar fascial imbrication for management of concomitant medial patellar luxation (MPL) and cranial cruciate ligament (CCL) disease in 32 dogs. STUDY DESIGN Case series. METHODS A previous technique for tibial tuberosity advancement was modified to incorporate lateral and distal tibial tuberosity transposition. Preoperative, immediate, and six to eight week postoperative radiographs were reviewed with morphometry of a range of tibial and stifle anatomic parameters. Findings of sequential clinical examinations to six to 20 months postoperatively were recorded. RESULTS Thirty-nine stifles were treated by surgery. Medial patellar luxation grade ranged from II to IV/IV. The CCL rupture was complete in 17/39 stifles, and incomplete in 22/39. Complications occurred in 11/39 stifles including MPL recurrence (n=4). Resolution of subjectively-assessed lameness occurred in 29/39 stifles at the six to eight week assessment. Resolution of lameness was eventually documented in 35/39 stifles (4/39 lost to follow-up), and was maintained at the six to 20 month reassessment where available. The TTTA induced relative patella baja in 31/39 stifles. Magnitude of actual tibial tuberosity advancement was lower than that predicted by cage size. CLINICAL SIGNIFICANCE Tibial tuberosity transposition-advancement is a potential treatment modality for concomitant CCL disease and MPL in the dog, but refinement of planning is required, while biomechanical and kinematic effects remain unknown.

Contact mechanics and three-dimensional alignment of normal dog elbows.

OBJECTIVE To evaluate the effects of antebrachial rotation at 3 elbow flexion angles on contact mechanics and 3-dimensional (3D) alignment of normal dog elbows. STUDY DESIGN Ex vivo biomechanical study. ANIMALS Unpaired thoracic limbs from 18 dogs (mean ± SD weight, 27 ± 4 kg). METHODS With the limb under 200 N axial load, digital pressure sensors measured contact area (CA), mean contact pressure (MCP), peak contact pressure (PCP), and PCP location in the medial and lateral elbow compartments, and 3D static poses of the elbow were obtained. Each specimen was tested at 115°, 135°, and 155° elbow flexion, with the antebrachium in a neutral position, in 28° supination, and in 16° pronation. Repeated measure ANOVAs with post-hoc Bonferroni (P ≤ .0167) were performed. RESULTS Both pronation and supination decreased CA by 16% and 8% and increased PCP by 5% and 10% in the medial and lateral compartments, respectively. PCP location moved 2.3 mm (1.8-3.2 mm) closer to the apex of the medial coronoid process in pronation and 2.0 mm (1.8-2.2 mm) farther away in supination. The radial head and medial coronoid process rotated 5.4° and 1.9° internally during pronation and 7.2° and 1.2° externally during supination. CONCLUSIONS Contact mechanics and 3D alignment of normal dog elbows varied significantly at different elbow poses.

Shoulder Arthrodesis in14 Dogs

OBJECTIVES To report surgical technique and clinical outcome of shoulder arthrodesis in dogs. STUDY DESIGN Multicenter clinical case series. ANIMALS Dogs (n = 14). METHODS Shoulder arthrodesis featured craniolateral plate and screw application, with application of a 2nd plate and screws craniolaterally or caudolaterally in 5 shoulders. Implants included the locking string of pearls (SOP)™ plate in 7 shoulders. Subjective preoperative, 5-8 weeks postoperative, and 11-16 weeks postoperative clinical and radiographic findings were documented. Owner questionnaire evaluation of outcome was performed 6-20 months postoperatively. RESULTS Mean angle of arthrodesis was 114° (range 102°-122°). Progression of arthrodesis was noted in 13/14 cases at both the 5-8 and 11-16 weeks postoperative radiographic assessments. Nine complications occurred in 7/14 dogs, graded as catastrophic in 2/9, major in 2/9, and minor in 5/9. Where morbidity was successfully managed, 11-16-week and 6-10-month postoperative limb function was positive on both veterinary and owner evaluations in almost all cases, and in several, functional lameness was considered sufficiently mild as to be imperceptible on subjective veterinary evaluation. Where present, limb circumduction was noted as the major feature of persistent lameness. CONCLUSIONS Shoulder arthrodesis in dogs results in acceptable limb function and should be considered for the management of debilitating shoulder pathology despite a high incidence of complications. Application of the SOP plate to aid shoulder arthrodesis warrants further study.