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ОглавлениеPre- and postoperative considerations
Gustave E. Fackelman
3.1 The day before surgery
The patient should arrive safely at your facility having been given appropriate first aid and having been carefully transported, the details of which are described elsewhere [1]. The following discussion is intended as a checklist of activities to promote ideal operative conditions and enhance the probability of a satisfactory outcome.
Completeness of biographical data should be carefully checked. The patient's name, age, breed, previous surgical/anesthetic history, known drug sensitivities, the dates of injury and of arrival, along with the owners name, address and telephone number would be the minimum. Gathering this data, as well as recording much of which is described below can be facilitated by the use of an appropriate computerized format such as the AO Equine Fracture Documentation System [2].
The owner should be made aware of the alternatives to surgery, the risks involved in any operative procedure, and any dangers that are specific to the intended surgery in this particular horse. A clear description of these risks should be part of a written document that details the operation and the recommended aftercare. This document is countersigned by the owner as having been read and understood. On the same page, the owner is provided with an enumeration of the costs involved and an estimated value of the animal concerned. (This latter value may be left to the owner to fill in.) This information is important to patient care and client relations and also touches upon the medicolegal aspects of patient care, described at length in a recent text [3].
Perform a complete physical examination including a hemogram.
Assess lameness and associated lesions. (See Movie: Evaluation of the Equine Musculoskeletal System).
Start gathering data by using the AO Equine Fracture Documentation System.
Make the owner aware of the alternatives to surgery and have your description countersigned.
A complete physical examination and hemogram are performed. While focused on the musculoskeletal system, including potentially predisposing conformational defects, care is taken to evaluate the animal as a whole. Assessment of lameness and any associated lesions should follow a systematic approach [4] with which the clinician has become comfortable. In the so-called exercise induced fractures [5], particular attention is paid to the possibility of the lesions being bilateral. The pain on one side is usually greater than on the other, and masks the existence of the second fracture. The findings of the examination are carefully documented, and communicated to the owner and any interested colleagues in practice. The initial (referral) set of radiographs is reviewed and augmented when necessary with additional views. From these films, a preoperative plan is diagrammed indicating the location and size of the implants to be used in the surgical repair (Fig. S3A). This plan is initially used to serve as a check on the availability of implants in the size(s) indicated, and the appropriate instrumentation for their insertion, and later to guide the surgeon during the actual operation. Recently a Large Animal Preoperative Planner has been introduced.
Fig. S3A
The area surrounding the surgical site is clipped with a fine blade (#40). For fractures of the limbs distal to the carpus or the hock, this is carried out circumferentially to facilitate draping in a subsequent step. The entire animal is bathed to remove dirt, sweat, and detritus from its body and limbs (Fig. S3B), and the operative site is scrubbed with a soap containing tamed iodine. A sterile dressing is used to cover the site, and this is held in place with a light bandage (Fig. S3C).
Fig. S3B
Fig. S3C
Perioperative antibiosis is warranted even in elective surgeries [6]. When truly prophylactic, it is brief in duration, extending roughly from the day before surgery to the day after [7]. The nature of this therapy will be dictated by the condition of the surgical site [8], concerns about anesthetic interactions [9], the presence of infection at a distant locus [10], the identification of nosocomial organisms, or certain details of the procedure itself [11]. As a rule, the treatment is timed so that an effective level of drug is present at the time of surgery. Broad-spectrum antibiosis consisting, for instance, of a penicillin and an aminoglycoside is applied.
Withhold food for 12 hours prior to anesthesia.
Use antibiotics from the day before through the day after surgery.
In consultation with other members of the staff, the time of surgery is decided upon, assuring the presence of all necessary equipment and personnel throughout induction, surgery, and recovery phases. Food is withheld for 12 hours prior to the induction of anesthesia.
Position the horse for 360° access to the surgical site.
3.2 The day of surgery
A final check is carried out on the readiness of the surgical suite, the instrumentation, the personnel, and the anesthesia/recovery equipment. The patient is examined, and its vital signs are measured and recorded. Any significant changes since the initial evaluation are documented and communicated to the owners and/or their representative(s). The horse is positioned to allow easy access of the surgical team to the fracture site and to facilitate intraoperative radiographs (Fig. S3D). Final preparation of the patient, the surgical site (Fig. S3E), and the surgeon are described in detail elsewhere [12], and the salient points are covered below. Any points on preparation related to specific procedures are detailed in the chapters devoted to them.
Fig. S3D
Fig. S3E
Fig. S3F
Fig. S3G
Ideally the correctly positioned, adjusted, and carefully draped x-ray machine (Fig. S3F) will need only to be wheeled up to the table to make the exposures required (Fig. S3G). The films in their holders are also covered with sterile drapes prior to their being extended into the field. If facilities permit, image intensification offers the advantage of being much quicker, but similar precautions must be taken against contamination. Many ready-made sterile plastic covers are obtainable in sizes that fit most of the common pieces of equipment. Any staff that remain in the room during the radiographic examination (e.g., surgeon, anesthetist) are suitably attired in lead aprons (Fig. S3H) worn throughout the procedure underneath their gowns (Fig. S3I).
Fig. S3H
Fig. S3I
At the conclusion of surgery, a suction drain is usually inserted in those cases having a significant amount of soft tissue trauma and “dead space” that could potentially develop into a seroma. Bandaging, splinting, and casting will vary depending on the surgeon's preferences and the lesion(s) in question (Fig. S3J). This topic will be treated in detail in the chapters dealing with specific fractures.
Fig. S3J
Suction drains are inserted immediately postoperatively.
3.3 The day after surgery
Typically, perioperative prophylactic antibiotics are administered throughout the 24-hour post-surgical period, then discontinued. The horse's vital signs are monitored twice daily and recorded in the case record.
A report of the surgical procedure is generated and sent to the client, the referring veterinarian, and any other interested parties. The report should deal with any changes in diagnosis or prognosis made at the operating table and should detail the responsibilities of the animal's caretakers in the long and short terms postoperatively. In a practice or clinic with a heavy orthopedic load, it is probably best to develop certain standard aftercare programs that can be tailored to fit individual circumstances.
Physical therapy [13] and controlled exercise should begin as early as possible during the recovery phase and continue at home. This commitment to the animal's final well-being is extremely important to the successful outcome of any given surgical procedure. Many surgeries of the distal limb such as those considered later in this manual require little or no protection by external fixation in the postoperative period. This allows for early joint and tendon mobilization, and prevents the capsular fibrosis and stiffness that are otherwise almost inevitable. The use of non-steroidal anti-inflammatory agents in the early postoperative phase permits passive joint manipulation by limiting the development of capsular and subcutaneous edema. Movement reduces the formation of adhesions, improves the nutrition of articular tissues, and aborts progression of degenerative changes [14].
Plans for follow-up radiography are made and the dates calculated based upon the date of surgery. Computer programs with “datebook alarms” can be helpful in reminding the surgeon of these dates. The follow-up information is essential to an adequate documentation of results, and to developing improvements and modifications of technique for the future.
Generate the surgical report immediately postoperatively.
3.4 Summary—Checklist
Day before...
Completeness of medical record concerning biographical data and medical history checked.
Owner made aware of alternatives and risks.
Complete physical examination performed.
Preoperative plan developed, indicating needs for implants and instrumentation.
Patient bathed; operative site clipped, scrubbed, and protected with a sterile wrap.
Antibiotic therapy instituted.
Food withheld 12 hours preoperatively.
Begin physical therapy and controlled exercise as early as possible.
Day of...
Final check of patient, personnel, and equipment.
Positioning of patient determined based upon accessibility and ease of intraoperative radiographic monitoring.
Appropriate drainage of the surgical site provided (if necessary).
Day after...
Surgical report generated and distributed.
Physical therapy instituted, its continuance described in writing, and discussed with owner/trainer.
Dates set for follow-up radiographs and examinations.
3.5 References
1. Bramlage LR (1983) Current concepts of first aid and transportation of the equine fracture patient. Comp Cont Educ Pract Vet; 5(suppl):564.
2. Fackelman GE, Peutz IP, Norris JC, et al. (1993) The development of an equine fracture documentation system. Vet Comp Orthop Traumatol; 6:47.
3. Wilson JF (1992) Professional liability in equine surgery. In: Auer JA, editor. Equine Surgery. Philadelphia: W.B. Saunders Co, 13.
4. Stashak TS (1987) Diagnosis of lameness. In: Stashak TS, editor. Adams' Lameness in Horses. Philadelphia: Lea & Febiger, 103.
5. Peutz IP, Fackelman GE (1985) Fracture classification tables Pt I: Exercise induced fractures. Grafton MA, published by authors.
6. Taylor GJ, Bannister GC, Calder S (1990) Perioperative wound infection in elective orthopedic surgery [published erratum appears in (1991) J Hosp Infect; 17:155]. J Hosp Infect; 16:241–247.
7. Bodoky A, Neff U, Heberer M, Harder F (1993) Antibiotic prophylaxis with two doses of cephalosporin in patients managed with internal fixation for a fracture of the hip. J Bone Joint Surg [Am]; 75:61–65.
8. Moore RM, Schneider RK, Kowalski J, et al. (1992) Antimicrobial susceptibility of bacterial isolates from 233 horses with musculoskeletal infection during 1979–1989. Equine Vet J; 24:450.
9. Brown M (1990) Antibiotics and anesthesia. Semin Anesth; 10:153.
10. Cars O (1991) Pharmacokinetics of antibiotics in tissues and tissue fluids: a review. Scand J Infec Dis Suppl; 74:23.
11. Richardson JB, Roberts A, Robertson JF, et al. (1993) Timing of antibiotic administration in knee replacement under tourniquet. J Bone Joint Surg [Br]; 75:32–35.
12. Clem MF (1992) Preparation for surgery. In: Auer JA, editor. Equine Surgery. Philadelphia: W.B. Saunders Co, 111.
13. Kraus AE, Fackelman GE (1987) Immediate controlled mobilization (ICM) in the treatment of acute athletic injury. Proc Vet Orthop Soc; 14:123.
14. Zarnett R, Velazquez R, Salter RB (1991) The effect of continuous passive motion on knee ligament reconstruction with carbon fibre. An experimental investigation. J Bone Joint Surg [Br]; 73:47–52.
3.5.1 Online references
See online references on the PEOS internet home page for this chapter:
