Vet Gazette

The most common orthopedic injury in dogs is a torn cranial cruciate ligament (CCL). Every year, the orthopedic surgery team at the OSU Veterinary Teaching Hospital performs hundreds of tibial-plateau-leveling osteotomies (TPLO) to stabilize the stifle joint after CCL rupture.

Now there is a relatively new, and minimally-invasive, alternative for young dogs with CCL injuries. Recently, Dr. Wendy Baltzer performed a proximal tibial epiphysiodesis (PTE) on a six month-old Golden Retriever named Sydan.

Sydan had been experiencing chronic lameness in his right hind leg for several weeks. Dr. Ruth Loomis at the Brookswood Animal Clinic in Bend took radiographs, diagnosed a CCL rupture, and referred Sydan’s owner to the VTH. Because of his age, Dr. Baltzer decided he was a good candidate for a PTE. “This surgery is specifically for immature dogs with open growth plates who have ruptured their cranial cruciate ligament,” she says.

Using tiny incisions, and a fluoroscope for guidance, Dr. Baltzer inserted a lag screw into the most proximal part of the tibial plateau, in its medio-lateral center, aiming into the tibial shaft. As the caudal aspect of Sydan’s growth plate continues to grow around the screw, it will alter the slope of the tibia, creating a more stable joint.

Sydan went home on six weeks of exercise restriction to allow healing, and his owner was given a set of passive, range-of-motion exercises to do with him. By his eight-week recheck, he was no longer experiencing lameness, and follow-up radiographs showed that the procedure was producing the correct tibial plateau angle.

The National Institute of Health spends $30 billion each year on human health research. In contrast, funding for health-related research dedicated to companion animals is a fraction of 1% of that amount: approximately $16 million per year.

The American Veterinary Medical Association states: “Continued improvement in companion animal and equine health care requires research with specifically targeted deliverables for dogs, cats, and horses. At the current low level of investment, most advances in animal health care applications are derived as by-products of human clinical research.”

With little empirical data to support their work, how do veterinarians know they are providing the best treatment for the myriad of health issues they see in their practices? In a recent presentation at the OSU College of Veterinary Medicine, Dr. Connie White addressed that concern: “We rely on experience. We take our best guess. It can be very stressful.”

Dr. White practices veterinary medicine at the Fremont Animal Clinic in Portland. She is also working on a MS degree in epidemiology, and has a passionate interest in evidence-based medicine, or the lack thereof, in American veterinary medicine. “There is very little research providing evidence-based knowledge to primary care veterinarians,” she says. “And there is almost no information on the prevalence of disease, and on risk factors in dogs and cats.”

On a recent trip to England, Dr. White learned more about several university-sponsored projects that are tackling this problem with technology and collaboration. “The Brits are on this in a big way,” she says.

How do you gather data from thousands of busy practicing veterinarians? The Royal College of Veterinary Medicine (RCVM) has solved that problem by creating software that automatically uploads clinical information from existing computers at participating practices. The RCVM system then compiles, analyzes, and shares the results on a website called VetCompass.

The VetCompass database currently holds 11 million cases from 450 different veterinary practices. Already, that data has been used to complete studies on a wide variety of health issues. Examples:

• The effectiveness of antimicrobials for the treatment of canine pyoderma.
• The prevalence of degenerative mitral valve disease in dogs, the survival characteristics of affected animals and the prognostic value of clinical measurements and biomarker blood tests.

“One study revealed that seven percent of cats over the age of nine were hyperthyroid,” says Dr. White. “I found that very interesting.”

There are several other British websites that provide veterinarians with evidence-based information. The British Small Animal Veterinary Association, in partnership with the University of Liverpool, has created a system called SavsNet that monitors disease in companion animals using data from diagnostic laboratories, as well as from private practices. The University of Nottingham created VetsRev, a freely accessible online database of citations for systematic reviews of relevance to veterinary medicine. It includes BestBETs for Vets an easy search function that can answer very common and specific clinical questions.

There are no publicly-available databases of this kind in the U.S. Dr. White is hoping to change that by spreading the word and inspiring action. “Veterinarians work so hard,” she says. “They are very busy people, so we need clever ways to get evidence to them.” She says none of the British projects were ‘hugely expensive’, and hopes U.S. universities will take up the cause.

What do General Electric and a veterinary hospital have in common? Both employ groups of people with special skills who work together as a team on complex projects.

What can the OSU Veterinary Teaching Hospital (VTH) learn from GE and other industries? Process improvement.

In the 1980s many U.S. industries adopted new process improvements using a set of techniques and tools called Six Sigma, which seeks to identify and remove the causes of inefficiencies and defects using empirical methods.

Last week, the VTH small animal hospital, under the direction of Dr. Helio deMorais, did something out of the norm. They began a Six Sigma project with the help of the OSU College of Engineering. “The VTH is always seeking to improve quality and outcomes, employing new technologies and research to provide top-notch care,” says deMorais.

Now, experts from the school of Mechanical, Industrial, and Manufacturing Engineering are stationed around the hospital observing day-to-day operations and gathering data on everything from reception to surgery. They will then use that data to analyze processes, identify inefficiencies, and make recommendations.

In the past decade, several human hospitals have adapted the Six Sigma techniques to a medical setting with good results. A case in point is the Cleveland Clinic in Ohio. In 2012, they hired engineers to streamline operating room and post-anesthesia time, reduce employee turnover, and improve office efficiency. The results of the project were reported at the 2014 annual meeting of the Central Surgical Association. Two examples:

• The average number of days from the client’s initial contact to their first appointment dropped from fourteen to eight.
• The average wait time from the first consultation to surgery fell from 39.9 to 33.9 days.

“This is a long-term project that should result in better efficiency in the VTH,” says Dean Susan J. Tornquist.

When the small animal hospital study is completed, a Six Sigma study will be initiated in the large animal hospital.

The large animal radiology room in the Veterinary Teaching Hospital was recently remodeled to accommodate new digital radiography equipment that that will provide immediate viewing of images, a big time saver for a busy hospital. It will also reduce exposure to radiation. “The digital radiography equipment requires less radiation and is therefore better for staff in the room,” says Dr. Susanne Stieger-Vanegas, head of diagnostic imaging. “Less radiation also means we can now radiograph areas like the spine in horses.”

The new unit, which replaces one installed when the hospital was built in 1979, has better mobility, allowing technicians to perform procedures more quickly. “It will be helpful for clinicians working up cases, and help make the flow through the hospital better,” says Dr. Stieger-Vanegas.

Initial funding for the new equipment was provided through a grant from the OSU Research Equipment Reserve Fund. Friends and donors of the hospital contributed matching funds, including a $100,000 gift from The Willard L. and Ruth P. Eccles Foundation.

“We are grateful for the gifts from our donors. The learning, diagnostic, and research opportunities they have provided are invaluable,” says Dean Susan J. Tornquist.

Figure 3: Craniocaudal and neutral lateral projections of the right elbow of the Bernese mountain dog with dyssynchronous physeal closure and bilateral MCD at 11.4 months of age. The open physes of the distal radius are indicated with white arrows, and the closed physes of the proximal radius and distal ulna are indicated with grey arrows.

Elbow dysplasia is a common cause of progressive, crippling osteoarthritis in dogs. It is most prevalent in large and giant breed dogs like German Shepherd, Rottweiler, Mastiff, Newfoundland, and Bernese Mountain dogs. Elbow dysplasia is an umbrella term for multiple diseases of the elbow including medial coronoid disease (MCD), ununited anconeal process (UAP), and osteochondrosis of the humeral condyle. MCD is the most common.

The incidence of elbow dysplasia has declined in some populations of high risk breeds, largely due to the efforts of groups such as the International Elbow Working Group, who identify affected dogs and recommend their removal from the breeding pool. These dogs are primarily identified through grading elbow radiographs of one-year-olds.

While selective breeding using this method has decreased the prevalence of elbow dysplasia, it does not select out dogs that are bred before one year of age. A method is needed for diagnosing elbow dysplasia in young, growing dogs in order to remove them from the breeding pool, and to develop methods of early intervention in dogs that are at high risk for elbow dysplasia.

Dr. Sarah Nemanic, Assistant Professor of radiology, recently completed a clinical trial in the OSU Veterinary Teaching Hospital, with the objective of identifying radiographic risk factors for the development of elbow dysplasia in giant breed dogs less than one year old. In the study, twenty-five giant breed puppies received elbow radiographs monthly or bimonthly from 2-12 months of age, until the radius/ulna growth plate closure. This was followed by two months of elbow computed tomography (CT).

Parameters measured in the study included presence of a SCOAP, presence of medial coronoid disease (MCD), UAP, humeral osteochondrosis, as well as length of the radius and ulna, the radius-to-ulna ratio, and date of closure of the radial and ulna physes.

Fifteen dogs completed the clinical trial. Although, the presence of a SCOAP was seen in 8/9 Bernese Mountain dogs, and in 4/6 English Mastiffs, none of the dogs with a SCOAP developed UAP. However, the dogs who did develop MCD had a radius/ulna ratio lower than those who did not develop the condition, and they had dyssynchronous closure of the physes of the radius and ulna.
The study concluded the presence of a SCOAP was not a radiographic risk factor for development of elbow dysplasia, but dyssynchronous closure of the physes of the radius and ulna, and a decrease in the radius-to-ulna ratio, could be a risk factor.

Further research is required in larger numbers of dogs, and in other breeds affected by elbow dysplasia, before applying the results of this study to clinical cases.

Dr. Susanne Stieger-Vanegas, Rebecca Camden, Dean Susan Tornquist.

Last week, CVM advisory council member Rebecca Camden, and her dachshund Maude, presented Dr. Susanne Stieger-Vanegas’ with the Camden Endowed Professorship in Diagnostic Imaging.

OSU Provost Sabah Randhawa thanked Ms. Camden for her continued support of the college and emphasized the importance of endowed professorships to support outstanding faculty, and allow them to pursue cutting-edge research while continuing their commitment to quality teaching.

“Having an endowed professor illustrates the importance of diagnostic imaging, and the commitment of our friends and donors to excellence in areas where we shine,” says Dean Susan Tornquist.

After accepting the award, Dr. Stieger-Vanegas spoke about her experience traveling in third-world countries and how fortunate she feels to live and work in a safe, healthy place. She said the professorship will inspire her to ‘think outside the box’ and expand her research in computed tomography.

The Camden Endowed Professorship in Diagnostic Imaging is the second endowed position created at CVM. The first was the Glen Pfefferkorn and Morris Wendorf Endowed Professorship of Camelid Medicine awarded to Professor Chris Cebra.