Innovative approaches discussed at WVOC - Veterinary Practice
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InFocus

Innovative approaches discussed at WVOC

DONAL NUGENT reports on the third World Veterinary Orthopaedic Congress held in Bologna in September

NEW research, expert updates and
state-of-the-art lectures were at the
heart of the third World Veterinary
Orthopaedic Congress, held in
conjunction with the 15th meeting
of the European Society for
Veterinary
Orthopaedics and
Traumatology
(ESVOT), in
Bologna from 15th to
18th September.

More than a
thousand delegates
from around the
world gathered to hear
scientific presentations
from over 80 speakers
on emerging
developments in
orthopaedics and
traumatology, and
innovative approaches
to diagnostics and
therapy.

Prime focus

The state-of-the-art lectures included
the latest findings on mesenchymal
stem cells in human orthopaedics and
the long-term success of post-
traumatic knee and cartilage
resurfacing with ACI and MACI.

In his lecture “Stem cell therapy
for tissue repair: the stem cell-host
interaction”, Frank Barry of the
National University of Ireland
explained the interest in mesenchymal
stem cells due to their potential use in
regenerative medicine and tissue
engineering.

The study he oversaw evaluated
stem cell-host interaction in three
disease models:

  1. osteoarthritis (OA)
    of the knee;
  2. myocardial infarction
    (MI); and
  3. human breast cancer
    xenografts.

“The results of these
studies lead to the conclusion that
neither extensive engraftment nor
differentiation of the transplanted cells
are prerequisites for a useful
therapeutic response,” he explained.

Tim Briggs of the Royal National
Orthopaedic Hospital in the UK, in
his presentation “Cartilage resurfacing
with ACI and MACI: have they stood
the test of time?”, reviewed the
experience of the hospital with
autologous chondrocyte implantation
(ACI).

Explaining that chondral damage
to the knee is common and may lead
to degenerative osteoarthritis if
untreated, he told delegates: “The
intermediate and long-term function
and clinical results [of ACI] are
promising.”

Small animal programme

The small animal programme focused
on “old favourites” such as the stifle,
elbow, patellar luxation and hip trauma,
while “newer” topics included
revisions, distal limb trauma, legislation and clinical research,
and tools to measure
clinical success were
also prominent.

In his presentation
“Managing cruciate
disease – where are we
now?”, Randy
Boudrieau of Tufts
University in the USA
noted that over 40
different surgical
techniques exist for
repairing a dog’s knee
with a cranial cruciate
ligament (CrCL)
injury.

“Results indicate a
reported success rate of approximately 90% (good to excellent
function), regardless of the surgical
technique used,” he said. Of the TPLO
or TTA techniques (and similar
techniques) performed at Tufts, he
said: “They are all effective based on a
single mechanism – the alteration of
the patellar tendon angle, which alters
the tibiofemoral shear forces.”

The “small animal complications”
stream included a presentation by
David Lloyd of the RVC on “Multi-
resistant bacteria: current status
including management” in which he
explained that measures to control
infections and guidelines on
responsible use of antimicrobials in
practice are now being created.

FECAVA, for example, has established a Working Group on
Hygiene and the Use of Antimicrobials
in Veterinary Practice. “An important
component of this process is client
education on the avoidance of non-
essential antimicrobial administration
and full compliance with dosage
regimens,” he said.

Addressing another growing
concern among vets across Europe,
John Houlton of the Veterinary
Defence Society spoke on “Negligence
claims: can you reduce them?”

Problems often arise when there is
a mismatch between the realistic ability
of the veterinary surgeon to meet the
unrealistic expectations of the client,
he said, highlighting the value in
obtaining a client’s informed consent
(preferably in writing) and providing
them with “a jargon-free and readily
understood evaluation of the
implications of a diagnosis and the risk
involved in a chosen treatment
programme”.

Good communication is essential
throughout and “veterinary surgeons
should keep their clients fully appraised
of mounting costs as well as their
animal’s clinical progress”, he said.

Fractures

Thursday’s “in-depth seminar on
challenging fractures” included a
presentation by Noel Fitzpatrick of
Fitzpatrick Referrals on “Challenging
elbow fractures”. Sixty per cent of
distal humeral fractures involve the
condyle in dogs and 90% of
unicondylar fractures of the distal
humerus are reported to occur in
association with minor trauma.

“Decreased range of elbow joint
motion is a common complication
associated with elbow fracture repair
and minimising the degree of
periarticular fibrosis by utilising optimal
surgical technique and early post-
operative mobilisation of joint
movement, including active and passive
physical therapy, is imperative,” he said.

In his presentation on skull
fractures, as part of the “facial trauma”
stream, Thomas Turner of VCA
Berwyn Animal Hospital in the USA
explained that a variety of fixation
techniques can be employed, with
some of the more common being
interfragmentary wiring, bone plates
and external fixators.

“The goals of fracture treatment are precise restoration of the bony
architecture in order to achieve normal
dental occlusion and support and to
restore the dorsal buttress of the facial
bones to the upper skull,” he said.

In the “new trends in canine and
feline orthopaedics” stream, Sorrel
Langley-Hobbs of the Cambridge
veterinary school looked at a number
of conditions including osteoarthritis
(OA) and arthritis in her presentation
“Feline forelimb lameness – what if it’s
not a fracture or an abscess?”

While cats commonly suffer from
OA, the clinical signs tend not to be as
pronounced as in dogs. “OA is more
common in the forelimb as compared
to the hind limb,” she explained,
adding that “while it is difficult to
modify a cat’s exercise, regular
movement and weight loss should be
encouraged”.

Imaging

The programme on advanced imaging
included a presentation by Thorben
Schulze, of the Equine Clinic Burg
Müggenhausen in Germany, on “The
pre-purchase MRI of horses –
definition and clinical implications”.

Dr Schulze explained that standing
MRI has developed into an important
diagnostic tool for equine orthopaedic
medicine. “MRI scans allow us to
evaluate all anatomical structures in
detail and spot all potential changes. It
is, also, not rare that multiple problems
are seen and that there are findings on
lame-free limbs.”

However, in pre-purchase
examinations, where there is no sign of
lameness or pain, it can be difficult to
give a clear picture of what any
discovery through the scan could mean
for the specific horse. Given the risk of
liability to a vet interpreting MRI
findings, he said the sensible course of
action is to point out the changes only
and to avoid any further estimation and
comments.

Equine

Presentations in the equine
orthopaedics stream included “Critical
review of regenerative cell therapy: fat-
derived, tendon-derived and synovial-derived cells” in which
Allison Stewart
(University of Illinois,
USA) stated that “most
of the current
literature demonstrates
the source of
progenitor cells will
significantly impact the
progenitor cell
function and ability to
regenerate tissue.”

Two clinical trials
on the use of fat-
derived cells for the
treatment of
osteoarthritis in dogs
showed improvement in associated
lameness for over three months, while
the treatment of injured tendon in
horses with tendon-derived progenitor
cells improved tendon healing at a
histological level.

Practical advice

Finally, Rico Vannini offered delegates
practical advice in “The orthopedic
examination – tips and tricks to a
successful diagnosis”.

“A good orthopedic examination is
the key for a successful diagnosis and
treatment of a dog with a chronic
lameness,” he explained, adding that “it
starts with a detailed, careful history”
and should always go through the same
basic steps: (1) observe the animal
while it is moving, standing and sitting;
(2) palpate and manipulate the dog; and
(3) perform specific examinations.

“A systematic approach helps to
avoid missing important pieces of
information,” he said. “Where
palpations and manipulations do not
help to localise the problem, all joints
should be systematically examined. The
joint most commonly causing lameness
of the rear in dogs is the stifle and the
joint most commonly causing lameness
in the front limb is the elbow joint. So,
if a dog is lame on its front it is the
elbow and if a dog is lame on the rear
it is the stifle, until proven otherwise.”

Pain management symposium

T0 mark the European launch of
Equioxx (firocoxib) at the WVOC,
Merial hosted its first Equioxx
European Pain Management
Symposium as part of the pre-congress
schedule.

Keynote speaker at the symposium,
Professor Wayne McIlwraith of the
University of Colorado, explained that
the purpose of therapeutic procedures
must be “to prevent the progressive
loss of articular cartilage, rather than a
purely analgesic role” and said that
“veterinarians are giving the new
generation of selective NSAIDs to
minimise inflammation and not only to
block pain”.

Prof. McIlwraith’s
research group at the
university has studied
the starting point of
inflammation in horses,
and believes that deeper
understanding of the
“inflammatory cascade”
is crucial to managing
osteoarthritis (OA).

“The use of
NSAIDs allows us to
select our level of
intervention at fairly
specific levels,” he
continued, pointing to
evidence from the human literature which showed that
“we can preserve cartilage better with a
COX -2 inhibitor”. He also highlighted
emerging studies that show a much
lower level of side effects such as
gastro-intestinal toxicity, which are
linked with the use of phenylbutazone
in ponies and young foals, as a key
reason for choosing COX-2
selective/COX-1 sparing drugs.

Prof. Willem Back of Utrecht
University in Holland presented
delegates with the findings of a pivotal
study, “The use of force plate
measurements to titrate the dosage of
a new COX-2 inhibitor in lame
horses”, which brought together
research from Europe and the US and
assessed 64 horses with grade 2 to 3
lameness based on the five-point
(AAEP) scale.

The force plate method allows
researchers to specify exactly where
pressure is exerted in joint movement
and all participating horses exhibited
chronic lameness due to osteoarthritis
in at least one of the front limbs.

The study found that treatment by
firocoxib reduced lameness on
average by 0.5 grades on the first day
and by 1.1 grades after six days of
treatment. It also established the
optimum dosage. “We concluded that
the 0.1 dosage was the effective dose
in the control of pain and
inflammation associated with OA,” he
said.

Dr Matthias Pollmeier of Merial
in France presented results from a
field trial validation of the efficacy
and acceptability of firocoxib in a
group of 96 lame horses. He
explained that, in addition to efficacy,
one of the key messages from the
study was to do with safety.

“Vets often do not see the side
effects of commonly used NSAIDs,
as they will often only see the horse
at the beginning and the end of a
treatment programme. The study
proved that firocoxib, even when
given at doses up to five times the
recommended level for up to 42 days,
was not only highly effective for the
control of pain and inflammation but
well tolerated in 98% of horses.”

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