Overview of common complications encountered following various equine veterinary procedures

1. COMPLICATION
S
When Things Go Wrong
Dane Tatarniuk, DVM

2. DISCUSSION POINTS
 Gastrointestinal  Orthopedic
 Adhesions  Casts
 Incisional Infections  Implant Infection
 Incisional Dehiscence
 Incisional Hernia
 Rectal Tears
 Ileus

3. “The one who does not operate does not have complications.”

4. ADHESIONS
 Prevalence of clinical adhesions:
 Range – 6% to 26% after small intestinal surgery
 More common in foals (up to 6 months) than weanlings and yearlings
 Foals < 30 days are at greater risk than foals >30 days
 Anastomosis & enterotomy sites
 Prolonged post-operative ileus
 Repeat laparotomy
 Peritonitis
 Abdominal Abscess
 Chronic intermittent colic or acute obstructive clinical signs
 Most complications from adhesions occur within the first 60 days

5. ADHESIONS
 Pathophysiology:
Theory: Detrimental process caused by inflammation and
ischemia, causing a depression in fibrinolysis.
 Peritoneal injury creates inflammation & ischemia
 Inflammation:
 Intestinal distension, abrasion of serosa, surgical manipulation of intestine,
infection, bacterial contamination, foreign material (suture, glove powder).
 Ischemia:
 Strangulating lesion, vascular compromise, intestinal distension, tight suture
placement.
 Creates an imbalance between fibrin deposition and fibrinolysis

6. ADHESIONS
 All comes back to the
coagulation
cascade…
 Peritoneal injury
stimulates intrinsic
and extrinsic cascade
 Principal modulator of
adhesion formation is
the fibrinolysis
system, which works
through the enzyme
plasmin
 Key regulators of
fibrinolysis are tissue
plasminogen activator
and urokinase
plasminogen activator

7. ADHESIONS
 Normally…
 Lysis of fibrin and fibrinous adhesions occur in 48 – 72 hours after peritoneal
injury
 Mediated through plasmin-mediated fibrinolysis
 Normal tissue restoration results
 However…
 If excessive ischemia or inflammation occur, a depression in peritoneal
fibrinolysis activity occurs
 Causes fibrin accumulations to become infiltrated with fibroblasts and
capillaries
 End result: Permanent fibrous adhesions, formed 7 to 14 days after surgery.
 Adhesions can obstruct bowel lumen, incarcerate small
intestine, distort or kink the mesentery or intestine.
 End result is recurrent colic!

8. ADHESIONS
 Prevention
 Gentle tissue healing
 Remove damaged tissue
 Meticulous hemostasis
 Minimize surgical time
 Frequent, copious lavage to keep bowel moist
 Medication
 Broad spectrum antibiotics
 Non-steroidal anti-inflammatories
 Dimethyl sulfoxide

9. ADHESIONS
 Abdominal Lavage
 At surgery, prior to closure
 Post-operatively, passive or closed suction drains
 Removes blood, fibrin & inflammatory mediators
 Mechanical separation of bowel
 Clinical research present that supports abdominal lavage
 Serosa abrasions and peritoneal drains placed in 12 horses at surgery
 6 received post-op abdominal lavage for 34 hours after surgery; 6 did not
(controls)
 Necropsied at 2 weeks post-op
 Severe adhesions in all 6 controls, none present in the lavage group
 No adverse reactions from lavage noted in treated group

10. ADHESIONS
 1% Sodium Carboxymethocellulose
 “Belly Jelly”
 Provides a mechanical barrier between serosal and
peritoneal surfaces
 Helps reduce trauma by acting as a lubricant
 0.4% Sodium Hyaluronate also used
 Bioresorbable Hyaluronate-
Carboxymethylcellulose Membrane
 Membranes that are applied to anastomosis sites
post R&A
 Act as a temporary protective barrier

11. ADHESIONS
 Carolina Rinse
 Used in human medicine for organ
transplants
 Decreases reperfusion injury
 Decreases migrations of neutrophils into
serosa
 Decreases fibroblast proliferation
 Applied topically and intraluminal
 Compounded, not commercial
 Systemic Heparin
 Cofactor of Anti-thrombin III
 Decreases production of thrombin
 Thrombin responsible for converting
fibrinogen to fibrin
 Also stimulates plasminogen activator
activity

12. ADHESIONS
 Omentectomy  Anastomotic Techniques
 Controversial  Small intestinal R&A sites are
 Studies showing that high risk for adhesion
prophylactic omentectomy development
reduces adhesion formation
 Goals:
 However, omentum may
provide blood supply to 1) Maintain proper tissue alignment
ischemic intestine 2) Promote optimal intestinal
 Facilitates healing within healing
the peritoneum
3) Complete mucosal coverage
 Surgeon preference
4) Minimal suture exposure

13. ADHESIONS
 Second Laparotomy
 Based on history and diagnostic findings
 Primary goal is to reduce adhesions
 Catch 22…
 Removal of adhesions incites serosal inflammation –
 Predisposes for further (recurrent) adhesion formation
 If adhesion mass is too large or cannot be exteriorized to the incision
–
 Consider gastro-intestinal bypass surgery
 Horses requiring a second look laparotomy due to adhesions have a
20% prognosis for survival

14. ADHESIONS
 Elective Laparoscopy
 Generally performed 7 to 10 days post-operative
 Time period when adhesions are fibrinous and easy to break down
 Visualization of adhesions is variable
 Dependent on area of scarring and position of adhesions
 Position of horse, standing or recumbent
 Acute colic:
 Sensitivity of 82%, Specificity of 66%
 Chronic colic:
 Sensitivity of 63%, Specificity of 33%

15. “Every operation in surgery is an experiment in bacteriology.”

16. INCISIONAL INFECTION
 Increases risk of incision dehiscence, abdominal herniation, eventration
 Retrospective reports show prevalence of infection between 7.4% and 37%
 Incidence after 2 or more celiotomies performed within 6 months time may be
as high as 87.5%
 Predisposing factors:
 Repeat celiotomy
 Increased duration of surgery
 Use of near-far-far-near pattern
 Chromic gut
 Leukopenia
 Edema
 Post-operative pain
 Weight (>300kg)
 1+ year vs. < 12months

17. INCISIONAL INFECTION
 Early indications:
 Fever of unknown origin
 Excessive tenderness with palpation
 Warm edema formation
 Systemic antibiotics usually delay drainage
 See drainage around 3 days post-operatively
 Can be delayed up to 14 days

18. INCISIONAL INFECTION
 Common sense preventative measures…
 Decrease surgical time
 Proper aseptic preparation of the abdomen
 Meticulous draping during enterotomy
 Minimize trauma to incision during draping
 Other measures…
 Decreased incidence when antibiotics are applied topically to surgical wound
at time of closure (Mair et al.)
 Decreased incidence when temporary drape is applied over incision during
recovery (Ducharme et al.)
 Can fall off easily
 Decreased incidence when an abdominal bandage was used post-operatively
vs. no bandage (Smith et al.)

19. INCISIONAL INFECTION
 Minimal research on suture type/pattern and incidence of incisions
 Guidelines:
 Perform closure with minimally reactive suture
 Braided, non-absorbable suture may cause suture sinus formation
 Avoid overtly large bites – creates excessive tension & predisposes to ischemia
 Optimal tissue bite for adult horses is 15mm from linea alba edge
 Management:
 Culture & sensitivity of incision is indicated
 Establish drainage
 May require removal of skin or subcutaneous sutures / staples
 Local & systemic antibiotics indicated if horse is febrile, or excessive
edema, cellulitis present

20. INCISIONAL INFECTION
 Management continued…
 Flushing of incision is not
encouraged – can propagate
infection down incision line
 Belly bandage important to
sustain abdominal support
(risk of dehiscence)

21. INCISIONAL DEHISCENCE
 Rare but potentially devastating complication
 Prevalence after ventral midline celiotomy less than 1%
 Factors:
 Interrupted suture patterns in linea alba less likely to dehisce
 However, continuous patterns have been showing to be stronger
 Increased surgical time
 Incisional trauma during surgery
 Recovery
 Rolling or abdominal impact during recovery
 Creates a sudden increase in abdominal pressure
 Post-operative debility
 Obesity, age (older), incisional infection

22. INCISIONAL DEHISCENCE
 Dehiscence usual occurs 3 – 8
days post op.
 Often preceded by incisional
drainage
 Brown serous-anguinous
 Abdominal bandages do not
prevent dehiscence
 But can prevent eventration of bowel
 If used, incision needs to be checked
frequently
 Failure of body wall can progress
rapidly

23. INCISIONAL DEHISCENCE
 Management
 Apply belly bandage, if not already in place
 Anesthetize horse
 Examine, decontaminate, and potentially repair the incision.
 Minimal contamination
 Early detection and minimal bowel ischemia
 Remove superficial contamination with lavage
 Marked contamination
 Lavage at surgery & place indwelling abdominal catheter for standing lavage

24. INCISIONAL DEHISCENCE
 Closure of abdomen
necessary
 Surgical debridement of
incision
 Remove necrotic, infected tissue
 Closure
 Full thickness vertical mattress
sutures
 Stainless steel wire (22 gauge)
 Stents 2-3cm apart from each
other
 5cm apart from wound edge
 Incision brought into
apposition
 Skin left open for drainage

25. INCISIONAL HERNIA
 Most important risk factor for incisional herniation is incisional
infection
 Relative risk factor of 17.8
 Ventral midline hernia incidence post-op between 1% & 10%
 Hernias are apparent within 3-4 months post-operatively
 Contributing factors:
 Increase intra-abdominal pressure from pain
 Entrapped fat between hernia edges
 Poor suture placement, suture selection, soft tissue handling
 93% of sutures fail at the knot
 Suture loops usually fail before fascial disruption occurs

26. INCISIONAL HERNIA
 Clinically, hernias are usually
noted cranially more than caudally
 Linea alba is thickest near
umbilicus & thins cranially
 Many can be managed
conservatively
 Skin incision non-healed,
 Consider sterile abdominal
compression bandages
 Abdominal bandaging for 1-2 months,
while treating any underlying infection,
helps reduce hernia size substantially

27. INCISIONAL HERNIA
 If hernia fails to heal, or enlarges after turn-out…surgery
 Hernia repair a cosmetic indication
 Large hernias can be repaired with synthetic mesh
 Knit polypropylene mesh
 Strong, elastic, inert, resists infection
 Tissue grows through mesh and incorporates into herniorrhaphy
 Need to make sure all infection is cleared prior to implanting mesh
 May require removal of infected suture material from sinus tracts first

28. INCISIONAL HERNIA
 Technique
 180° degree skin incision at margin of hernia
ring
 Follow through with fascia and fibrous tissue
 Fascia is removed using retroperitoneal
dissection
 Peritoneum is left intact
 Can be difficult if adhesion between fascia
and peritoneum intact
 Or, if very thin fascia present
 Inadvertent penetration of peritoneum
complication
 Some advocate mesh implant in
subcutaneous space rather than
retroperitoneal space

29. INCISIONAL HERNIA
 Technique continued…
 Thin layer of mesh cut to size
and incorporated
 Closure with horizontal
mattress sutures, #2
polypropylene suture
 Sutures are pre-placed –
make sure mesh lies flat and
snug – then tighten/tie sutures
 Reattach flap
 Belly bandage to prevent
edema/seroma formation very
important

30. INCISIONAL HERNIA
 Novel technique
 Laparoscopic mesh repair reported
 Removal of retroperitoneal fat
 Expose internal rectus shealth
 Introduce prosthetic mesh and
attach using trans-facial sutures
 Examined several months later –
no indication of adhesion formation
to mesh

31. “Do not congratulate yourself for saving a patient
from a trouble inflicted by you”

32. RECTAL TEARS
 Occur from diagnostic palpation of the rectum
 Usually veterinarian induced, sometime caretaker/owner
 Malpractice
 Copious lubrication & adequate restraint
 Causes
 Most occur from rupture of rectal wall as rectum contracts
around arm
 Not commonly from penetration with finger tips
 Less common causes
 Enemas
 Meconium extraction in foals
 Dystocia
 Chronic impactions at strictures
 Rectal thrombosis
 Sand impactions
 +/- Spontaneous tears

33. RECTAL TEARS
 Idiopathic tears
 Tend to be transverse
 One report of 5 horses revealed
 4 presented with colic
 1 occurred during lameness exam
 Suspect literature
 Idiopathic tears are usually presented as colic of variable duration
 No reason to suspect rectal tear – referral often delayed

34. RECTAL TEARS
 Avoidance
 Don‟t force against a peristaltic wave
 Special care in Arabians, smaller horses, horses with previous tears, fractious
horses
 Legal Recommendations
 Assess severity immediately (determine grade)
 Referral
 Inform owner
 Make no statements that imply admission of guilt or assume responsibility of
payment

35. RECTAL TEARS
 Classification: Four Grades
 Grades are important to dictate treatment
plan
 Grade 1
 Mucosa, Submucosa
 Grade 11
 Muscular layer torn, only
 Mucosa, Submucosa intact
 M, SM prolapse into defect
 Create area for fecal material to
accumulate
 More rare (3 of 85 in retrospective
review)

36. RECTAL TEARS
 Grade III
 IIIa – Involve all layers except serosa
 IIIb – Involve all layers except mesorectum, retroperitoneal tissue
 Grade 3b tears can pack with feces and create plane of dissection cranially and
dorsally
 Grade IV
 Involves all layers
 Most serious – fecal contamination of peritoneal cavity

37. RECTAL TEARS
 Indicators:
 Sudden release of pressure
 Direct palpation of abdominal organs
 Blood on rectal sleeve
 Within 2 hours after Grade IV tear, horse will show signs of
peritonitis, endotoxic shock, low-grade colic, depression.
 Feces may be stained hemorrhagic
 Defecation accompanied by straining
 Most involve dorsal rectum, are 15 to 55cm from anus, and are
parallel to the longitudinal axis.

38. RECTAL TEARS
 Stop straining
 Sedation
 Epidural
 Prior to examination of tear
 Eliminates straining and rectal contractions
 Buscopan
 Lidocaine enema
 Inspect tear using tube speculum or endoscope
 Rectal folds can obscure visualization of tear
 Alternatively, palpate digitally with gloved hand

39. RECTAL TEARS
 Non-surgical management
 Reduce activity of rectum
 Gentle removal of feces from rectum
 Treatment of septic shock, peritonitis
 Administration of epidural
 Packing of rectum
 Grade 1, 2 tears – antibiotics, laxatives, packing of rectum
 Rectal packing
 Prevent conversion of grade 3 to 4
 Protect tear from fecal contamination during healing period

40. RECTAL TEARS
 Material
 3 inch stockinet filled with moistened rolled cotton
 Soaked in povidone-iodine
 Outside lubricated with surgical gel
 Apply packing 10cm proximal to tear
 Close anus with towel clamps or purse-string
 Grade 1: Generally heal in 7 – 10 days

41. RECTAL TEARS
 Grade 2 – Can over-sew diverticulum via laparotomy
 Grade 3, 4 – Require some form of surgical management
 Standing repair per anus
 Expandable speculum
 Difficult to maneuver, blind approach
 Can be combined with diverting procedure if concern of integrity of repair
 Best in fresh, clean tears close to anus
 Can incise anal sphincter to improve access
 Simple & inexpensive

42. RECTAL TEARS
 Technique
 Epidural, evacuate rectum, clean tear with moist
4x4s, gentle gravity lavage
 Suture: 5 Dacron, 6 to 8cm, half cutting or trocar
point needle, needle halfway on suture thread
 Simple interrupted or cruciate
 Continuous = stricture, dehiscence
 May cause lumen reduction, edges turn into lumen
 Suture ends kept long to facilitate removal
 Rectal performed at 24, 48 hours
 Suture that feels slack from loosening, decreased
edema is removed & replaced
 Sutures removed in 12 to 14 days
 Learning curve

43. RECTAL TEARS
 Deschamps needle
 Similar to indirect hand sutured
technique
 Needle attached to extended long
arm with handle
 Both left, right configurations
 One hand works the instrument, the
other hand is placed rectally and
guides the tissue onto the needle

44. RECTAL TEARS
 Temporary Indwelling Rectal Liner
 Horse anesthetized, dorsal recumbancy
 Prolapse ring with rectal sleeve attached
 Pass well-lubricated ring through anus
 Surgeon guides ring proximal to tear
 Circumferential suture (#3 catgut) placed around small colon, followed by equidistant
retention sutures & Lembert apposition of serosa
 Pelvic flexure enterotomy
 Circumferential suture cuts through rectal wall in 9 – 12 days
 Allows passage of ring/liner in feces
 Four retention sutures keep ring in normal alignment, so that small colon does not
twist or obstruct lumen
 Failures caused by tearing of sleeve, retraction of sleeve, formation of recto-
peritoneal fistula

45. RECTAL TEARS
 Diverting “Loop” Colostomy
 Gravity prevents passage of feces into distal small colon
 Can be performed standing – incision into flank
 Made 1 meter from rectum, in small colon
 Fold small colon and suture together using absorbable material, lembert
 Sero-muscular layer of colon sutured to abdominal muscles, fascia
 Stoma made along the anti-mesenteric side of colon (size of colon lumen)
 Sutured to skin, simple interrupted, 2-0 nylon or prolene

46. RECTAL TEARS
 Colostomy Reversal
 Lateral recumbancy
 Resect the stoma
 Perform colonic anastomosis
 Incision infection very high
 Often place penrose drains, left in place, for ~3 days
 Complications of Correcting a Complication
 Dehiscence
 Abscessation
 Peri-stomal herniation
 Prolapse
 Spontaneous closure
 Rupture of colostomy
 Anastomotic impaction / dehiscence

47. RECTAL TEARS
 Complications of Surgical  Overall Prognosis:
Management:  Conservative 82%
 Peritonitis  Surgical 55%
 Rectal stricture
 Pelvic Abscesses
 Future techniques: Laparoscopic repair

48. “Nothing spoils good results as much as follow up.”

49. ILEUS
 Def: A disruption of the normal propulsive motility of the GI tract
 Risk factors:
 Prolonged surgical/anesthetic time
 Small intestinal lesions (particularly strangulating)
 Elevated PCV
 Indicators
 Post operative colic
 Elevated heart rate
 Anorexia
 Depression
 Prevalence: Occurs in 10 to 20% of colic surgeries

50. ILEUS
 Recognition: Pass nasogastric tube and reflux horse
 After nasogastric intubation, ultrasound/rectal can be performed
 Indicator of severity
 Ultrasound: Small intestinal distension with/without sedimentation
 Minimal to absent motility

51. ILEUS
 Gastric decompression, every 2-4 hours, is
important part of management
 Also helps provide a benchmark to evaluate response to
therapy
 Nasogastric tube may be left indwelling or re-
placed each time
 Left indwelling can delay gastric
outflow, perpetuating/prolonging problem
 Re-placement each time may cause more irritation and
distress to horse
 Pharyngeal trauma
 Esophageal rupture

52. ILEUS
 Fluid therapy: Adjust IV fluid rate to compensate for gastric reflux
loss
 Maintenance fluid rate (2 mL/kg/h) + Quantity of gastric reflux (L/h) = total
hourly crystalloid fluid requirement
 Anticipate hypocalcaemia & hypokalemia
 Calcium – smooth muscle in gastro-intestinal tract / vessels require
extracellular Ca for motility
 Consider parenteral nutrition in horses with long-standing ileus

53. ILEUS
 Pro-kinetic therapy
 Used in refractory
cases
 Lidocaine most
commonly used
 Others:
 Erythromycin
 Metoclopramid
e
 Neostigmine

54. ILEUS
 Lidocaine
 Affects contractility in the proximal duodenum only
 Well tolerated
 In-vivo, has been shown to decrease jejunal distension and peritoneal fluid
accumulation
 Improved time for fecal passage and shorter hospitalization stays
 In normal horses, have not been able to demonstrate pro-motility effects
 Current theory is that lidocaine acts as a pain modulator, thereby allowing
motility
 Toxicity: Tremors, muscle fasciculations, somnolence, collapse
 Stop therapy until signs resolve
 Effective for about 36 hours post-initiation

55. ILEUS
 Erythromycin
 Stimulates motilin receptors
 Affects contractility in the pyloric antrum and middle jejunum
 Where motilin receptors are most concentrated
 Macrolide antibiotic
 Very effective in improving gastric emptying time
 Complication : can create colitis / diarrhea

56. ILEUS
 Metoclopramide
 Affects contractility in pyloric antrum, proximal duodenum, and middle jejunum
 Administered intermittently or continuously
 Dopamine antagonist - Increases myo-mechanical activity
 Toxicity – when metoclopramide crosses the BBB into CNS
 Excitement
 Restlessness

57. ILEUS
 Failure to respond to therapy results from secondary
damage due to distension
 Distension causes injury to the muscle structure and myenteric
neurological control as a result of ischemia
 On histology
 Hemorrhage, edema, neutrophillic infiltrate
 Have not been able to demonstrate improved survival
rates with pro-kinetic use…
 Comes down to patience and crossed fingers

58. “The less it’s indicated; the more complications.”

59. CAST COMPLICATIONS
 Hard to avoid, if you place enough
casts
 Change the cast if:
 Diminishing comfort
 Focal heat
 Odor
 Discharge
 Develop from overly tight
application
 Dermal pressure necrosis
 Overly loose application
 Swelling decreases
 Muscle atrophy
 Compression of cast padding

60. CAST COMPLICATIONS
 Too short a half limb cast
 Severe tendon injury – limb is partially flexed
 Linear pressure on unprotected tendons
 Proximal dorsal cannon bone sore
 Can apply a heel wedge to offset pressure applied by cast
 Still recommended to change cast within 7 – 14 days
 Absolutely need to keep cast on…
 Consider trans-fixation pins
 Will limit motion within cast – possible decrease rub sores
 Complications include:
 Thermal injury & ring sequestra
 Pin breakage

61. CAST COMPLICATIONS
 Broken cast
 Ideally should be replaced
 However, can „patch‟ cast if the hinge at the break is minor
 Most casts break over point of a joint
 Apply 90% of cast material in longitudinal direction over compression side
 ie. dorsal fetlock
 Applying more cast material circumferentially usually re-fails

62. CAST COMPLICATIONS
 Cast Removal
 Oscillating saw – inadvertent damage to flexor tendons
on palmer aspect
 Cutting over infection or implant
 Seed infection - contamination of deep tissues
 Foals
 Post-coaptation laxity of tendons
 Pro vs. Con
 Decide whether stabilization more important than
potential laxity
 Helps to gradually decrease coaptation with
progressively lighter bandages, application of
splints
 Heel extension glue on shoes

63. “The source of most complications is in the operating room.”

64. IMPLANT INFECTIONS
 The most significant complication in
orthopedic surgery
 Contributes to the cost, cosmetic and
functional outcome of a case
 Increases cost 5 to 10 fold
 Infection can lead to instability of internal
fixation
 Possible outcomes include mechanical failure
or delayed/non-union healing
 The first step in treating implant infections is
recognizing that sepsis is present
 The earlier the realization = the better the
intervention

65. IMPLANT INFECTIONS
 Indications:
 Fever, otherwise non-explainable
 Decrease in comfort
 Failure of swelling to decrease post-operatively
 Return or development of swelling post-operatively
 Drainage
 Failure of incision to heal
 Blood-work
 Plasma fibrinogen best indicator
 Leukocytosis not conclusive; can be normal with infection present

66. IMPLANT INFECTIONS
 Radiographs
 Best indicator of mid to late stage infection
 Osteolysis
 Specifically radiolucency at implant – cortex
interface
 Increased soft tissue swelling or dissection of
soft tissue planes
 Periosteal proliferation
 Not associated with fracture healing
 Lysis extending into medullary cavity = end stage
 Ultrasound
 Exudate adjacent to implants

67. IMPLANT INFECTIONS
 Goal of therapy
 Local delivery of high doses of
antibiotics to infected tissue /
implants
 Allows high concentration of
antibiotic exposure to pathogens
 Avoidance of systemic side-effects
 More cost effective using regional
techniques
 Systemic antibiotics alone just
doesn‟t cut it

68. IMPLANT INFECTIONS
 Follow basic principles of treating infection…
 Drainage:
 Ultrasound area to visualize exudate
 Excise tissue intact skin or ventral aspect of
incision in a gravitational dependent area
 Culture:
 Sensitivity will help provide consistent results
 Prepare superficial tissues; culture depths of
draining tract
 Alternatively, ultrasound guided needle aspirate
of exudate

69. IMPLANT INFECTIONS
 Polymethylmethacrylate Beads
 Delivers high concentrations of antibiotics
 Biocompatible with tissue
 Diffusion of antibiotics from cement well studied
 Readily available in a sterile, easy to use form
 Disadvantage – non absorbable
 Disadvantage – can‟t incorporate with heat labile
antibiotics
 Ratio: 1 - 2 grams antibiotic per 10 grams PMMA
 Gentamicin, amikacin, tobramycin, enrofloxacin, cephalos
porins

70. IMPLANT INFECTIONS
 Plaster of Paris Beads
 Similar principle as PMMA
 Main difference is that POP
is slowly degraded &
absorbed by the body
 Set up time is slow, therefore
best to make POP beads
and then sterilize them
 Can be mixed with a
cancellous bone graft

71. IMPLANT INFECTIONS
 Regional Limb Perfusion
 Peripheral vessel & isolated limb via tourniquet
 Concerns:
 State of tissues close to implant (disrupted vasculature?)
 May induce vascular damage
 Enrofloxacin has been shown to induce vasculitis
 Placement
 Tourniquet above and below region the best
 Minimum is exposed vessel distal to proximal tourniquet

72. IMPLANT INFECTIONS
 Sedation
 Preventing movement is ideal for
adequate tissue penetration of
antibiotic
 Concurrent analgesia can be
considered
 Carbocaine (vs. saline) as volume
dilute
 Local nerve block
 Catheter
 Smaller the better
 Repeated injections require care to
preserve vessel integrity
 25 to 27 gauge butterfly catheter
 Volume
 1/3rd of antibiotic systemic dose
 Diluted to 30 to 60ml

73. IMPLANT INFECTIONS
 Technique
 Slow injection – needle bore small
 Leave tourniquet in place for 30 to 45 minutes
 Cover injection site with compression bandage
 Consider treating injection site with DMSO, Surpass
 Other indications for regional limb perfusion
 Wound therapy
 Joint therapy
 Pre-operative antimicrobial dosing

74. Complications are a price all veterinarians eventually pay.
Experience and increasing skill will decrease many of them but
certainly not all.
The most important thing is for the veterinarian to react correctly
to a complication. Acknowledge the mistake (or bad luck)
quickly, and take whatever steps you can to correct the problem.
Because so many equine cases have the potential for
complications, recognizing and responding properly to these
complications are imperative for successful outcomes.
- D.W. Richardson (in: Vet Clinics North America 2008)
QUESTIONS?