Online Continuing Education

I have been looking at different ways to offer content on this site and have recently been exploring and experimenting with Online Continuing Education. To this end I have set up a Portal that offers full seminars covering topics in Small Animal Orthopaedics.
My first series looks at the Canine Hip in Health and Disease. You can access the portal by clicking on the links below. Each seminar includes notes and an exam at the end. It is a fair amount of work putting these together and so there is a small charge for accessing the content (equivalent of £10 per seminar). When you take the content though, it is yours to view at your leisure. The content is free for surgeons in the developing world.
Each webinar is a complete presentation with narration. If you have any ideas for future content, why not drop me a line and I will look to include suggestions in future webinars.
The portal is here:

I hope you enjoy! This is going to be a major project for 2015.

Orthopaedic Consult Part 2

Orthopaedic disease has a variable impact on the quantity, enjoyment and after effects of exercise. Different patients will have different expectations regarding the “normal” levels of exercise. The information derived from questions relating to activity will have relevance to our understanding of the impact of the current Orthopaedic Problem on our patient’s quality of life. Of course this will be important when assessing the later impact of our therapy on the clinical condition and also when attempting to match our proposed level of intervention with the patient’s perceived problem level. This is after all the key goal of our consult. We have many options as surgeons regarding our treatment of any given problem. There are some conditions with a more or less mandatory surgical mode of therapy such as Cruciate disease for example whilst Hip Dysplasia may in certain patients for various reasons be reasonably well managed with Lifestyle changes and intermittent medical management.
So the questions here are:
  1. What exercise did you and your dog engage in one month prior to the onset of the current problem?
  2. How long was each session and how much time per session was off lead activity?
  3. Did your dog ever show signs of fatigue during exercise sessions (sitting down during exercise, prematurely stopping play with other dogs for example).
  4. Did you exercise your dog more at weekends versus weekdays. If so did this result in reduced tendency to exercise on Mondays.
  5. Since you noticed the problem, have you changed your dog’s exercise pattern? If so…how have you modified the activity regime?

It is important to remember that much of this information will only be an accurate representation of the “truth” when the questions are directed to the “dog-walker” of the household. Often one member of the family will have this role. In other households, working commitments may mean that the Morning walk is performed with on family member whilst the possibly longer afternoon or evening session is performed by another family member. The experiences of these two people may reveal interesting and important patterns. It can be worth having a questionnaire that you can give the attending owner to take home to ask other members of the family to describe their experiences.

Medication: Efficacy and Adversity
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If the patient has been prescribed medication for the current Orthopaedic problem, we need to understand whether this has had a positive effect on the clinical problem and also whether it has resulted in any Adverse reactions.
Assessing Efficacy

The assessment of efficacy will be dependent on the prominent signs associated with the pathology. The three key areas are:
  • Influence on indicators of pain.
This will depend on the owner’s appreciation of levels of discomfort prior to use of the medication. For some owners, an absence of vocalisation indicates an absence of discomfort. It is important to guide owners in their appreciation of discomfort in their dog. This is often better combined with the later questions on demeanour.
  • influence on visible evidence of lameness/stiffness.
Have the owners noted a reduction in lameness since beginning the medication? This may only be seen for a short period following administration or may appear to wane as the time for re medication approaches. It may be that it only improves lameness in a domestic setting but that lameness at exercise is unchanged.
  • Influence on Demeanour
To me, this is the most important aspect as it informs the surgeon of the patient’s experience of the problem. This should be the most important guide to appropriate management. A significant return to “naughty” or playful behaviour after beginning analgesic medication will tell us directly that the pathology is associated with the experience of significant levels of discomfort on a daily basis. This can help the owner understand that pain is a feature even if their pet does not sit around groaning or squeal in pain on moving. Asking the owners to describe what was missing during the unmedicated phase, provides a basis for assessing future response to therapy whether medical or surgical.
Assessing Adverse Reactions
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The commonest adverse reactions on Non Steroidals relate of course to Gastrointestinal disturbances. Vomiting and diarrhoea are the most obvious indicators, but inappetance, excessive grass eating, back arching and so forth may indicate abdominal pain. If opioids are used, assessing any impact on mentation and alertness and other behavioural aspects are important lines of questioning.
Adverse reaction to a class of drug required to control the experience of discomfort may be a significant factor when deciding to pursue surgical management. NSAID intolerance in a patient with clinical Hip Dysplasia for example would be a strong argument for Total Hip Replacement as this will eliminate the need for analgesic support completely in most patients.
Conclusion 
 
This section of the consultation is an attempt to understand the impact of the condition on the patient themselves and is therefore of great importance when it comes to making a Risk:Benefit analysis on the various modes of therapy for the given condition.

Orthopaedic Consult Part 1

Everyone knows what a consultation is and what it involves…don’t they? It is a process of questions, answers, observation and examination followed by a conclusion. The conclusion should lead to a Plan to achieve definitive diagnosis following which a plan for intervention is established. Alternatively the conclusion may lead to empirical therapy with planned review of response.

In Veterinary Medicine the consultation has been initiated by the observation of a problem in a non verbal family member, perhaps we can take the analogy of a Missing Persons interview for the initial part of the process. The investigator (surgeon) discusses the patient with Family members. The trained investigator is trying to gain information from interested but untrained observers. Orthopaedic disease will often lead to a “missing person” phenomenon as the previously active and mobile dog becomes replaced with a dog of variable disability and comfort. A young pup may become replaced by a dog of much older appearance and behaviour.
The attempt at this stage is to establish enough background information to understand the patient as an individual and then to proceed to gain more information about the impact and nature of the problem. Not asking the right questions here…and just as importantly not listening to the answers, will likely reduce the power of the Gait evaluation and Physical examination phases and most definitely will make evaluation of response to therapy very difficult. Since the magnitude of any intervention should match the magnitude of the problem, any failure at this stage to understand the day to day impact of the Orthopaedic Disease will make a later Risk:Benefit analysis of the proposed intervention difficult and may lead to inappropriate levels of management.
The following is a list of question categories. There is some overlap between the groups but this can permit us to ask the same question in a different way. Repeating questions is an important part of history taking as we may get different answers to the same question depending on how we ask the question.
We should begin by asking the following questions before proceeding to the detailed questions:

 

Foundation Questions

In Which Limb or Limbs have you noticed the problem?

Make sure you get the owner to point to the limb if they identify a single limb as some owners will define the left and right sides based on viewing their dog from the front.

Do the owners have more than one dog?

This may be important in terms of aetiology but is of significant importance if you ask the owner to rest the dog for example. Many owners of multi dog households will consider that not taking the lame dog for a walk is resting the dog, despite the fact that continued free play with the other household dog is still permitted. As part of this line of questions you should enquire as to whether they have had a dog before and whether they have had dogs of this breed before. Clearly first time dog owners have less innate knowledge of dogs than owners who have had many dogs of the same breeds. This may influence our view of reliability of responses later on.

Diet and Knowledge of Litter Mates

This is particularly important in relation to Juvenile onset Orthopaedic disease.

 

 Detail Questions
Before proceeding down this line of questions, try to make sure that you and the owners share the same definitions of terms that you will use. In particular we often talk about stiffness, lameness and pain and we have specific thoughts in our head regarding the definition of these. It is key therefore that we explain these to our clients otherwise we are not communicating effectively as we are in effect speaking in a different language to our client from the one that they use. This will not be very useful.

Onset and progression of the problem. 

This is particularly important when the Orthopaedic problem has been present for two weeks or more. One of the most useful ways to approach this question is to ask the owner to draw a graphic representation of the problem. Draw the axes of a graph and ask them when they became aware of the issue. Mark this point at the intersection of the axes. Indicate to the owner that they should use the Y-Axis to indicate the severity of the problem and then mark another point on the X-Axis representing today. They are asked to draw a line between these points representing their pet’s status over the intervening period. They don’t need to be precise what we want to see is whether the problem “appeared out-of-the-blue”, whether there has been a recent acute deterioration or improvement, whether the problem is up and down and so forth. For some clients it can be useful to draw a graph yourself and indicate to them what this represents. Most owners are pretty good at this, although some may need more coaching than others.
Bear in mind that with many slow onset problems, the owners may not be sufficiently sensitive to the early phases of the disease. This is particularly the case in symmetric joint pathologies as a considerable degree of training is often required to see an absolute lameness or “poverty of action”. Asymmetric pathologies are usually picked up more quickly by owners than symmetric pathologies for this reason.
It is a good idea to file this graph as it can be used later on in the management of the problem to get a feel for the patient’s response to our therapy. If the graph is on a white board, then take a photograph of it with your Smart Phone and either add this to the patient’s medical records or, if you use something like Evernote for example, make a “My Patients” notebook and add the image with a note and title to this notebook.
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Intra day Variations (Diurnal Variation).

Here we are trying to understand whether the problem is variable through the course of a day. Clearly the accuracy here will depend on the amount of observed time there is in the pet’s day and whether you are addressing the person who spends most time with the pet.
 Often it is best to begin by “framing the day”. Ask how visible the problem is first thing in the morning, after a full night’s sleep. Obviously you want to address this question to the person who first observes the dog. Does the pet take a while to get up from bed? After the pet is up, does he appear stiff for a period? If so how long? Is this the best part of the day? Some owners need the same question asked a number of different ways before you will get a satisfactory response.
The next element in the “frame for the day” is how the pet appears at night time. This is often when many family members will be around to observe and therefore you may get a consensus view. Asking whether they now have to coax the dog out last thing at night for toiletting is useful. Following on from this point, it is certainly worth asking whether the pet sleeps soundly at night and at other prolonged rest periods. If the dog is constantly changing position or cannot get settled, this may indicate discomfort.
We should ask whether there is a point in most days when the pet is at his best or at his worst. If the owners have seen this pattern, ask what they see or do not see that makes them feel that one period of the day is worse than another. Clearly it is likely that it will be the lameness that is being used as the arbiter here but ask whether there are any differences in demeanour noted during these phases.

Inter Day variations.

This line of inquiry is to establish whether there are good days and bad days. If so, it is worth asking the owner whether she feels that there is any pattern to this. In particular we are interested in the effect of a strenuous day’s activity or a day of minimal activity on the subsequent day or days observation of lameness.
Often people will exercise their dog more at a weekend because they have more free time. Asking how the dog appears on a Sunday and Monday therefore is a good way of establishing the role of activity (duration and type) in the severity of the observed problem.

Activities that exacerbate the problem.

This leads on from the previous point but looks at specific activities rather than simply duration of activity. For example if the exercise session includes ball-chasing or interaction with other dogs, will this exacerbate the lameness. If so, will this manifest during the session, on the slow walk home or later in the same day? Asking whether the dog will ever pull up lame or spontaneously abandon the activity are also useful questions here.
Within this group of questions, the effect of walking on a gradient is useful. Is the lameness worse on descent of hills or ascent of hills?

Activities that ameliorate the problem.

Often this is really a question about the effect of reduced activity or stopping the  activities that were noted to exacerbate the problem. Within this group of questions however we can include the effect of massage or other contact that seems to give the pet relief.

The ability to perform common domestic activities.

This refers to ascent or descent of steps and stairs, getting into or out of the car, getting on and off furniture and so forth. We should also ask about whether there has been a change in the posture adopted for eating. Some dogs with Elbow and/or Hip pain for example will often lie down to eat rather than stand and eat from a bowl on the floor. Perhaps the owners noted a problem and have begun to raise the bowl. The postures adopted for urination and defecation are also important. In male dogs, suddenly stopping cocking the limb or making efforts to cock a specific leg may give additional information. Dogs that begin defecation in one spot and then move to another to continue defecation may be experiencing discomfort associated with maintaining hip and stifle flexion for example or pain in the elbows that precludes supporting their weight on the forelimbs for an extended period of time.

Tendency to play and behaviour at play with toys in the house.

Dogs with chronic pain will often show a reduced tendency to engage in play. They seem to build an “is it worth it?” equation in their head and this will tend to get stronger over time.
Asking whether the dog will get up and move to a distant toy or “commando-crawl” over to get it may indicate discomfort on rising. If a dog tends to play from the floor this may also indicate difficulty on rising.

Enthusiasm for exercise.

Young dogs in particular may maintain an enthusiasm for exercise sessions despite the fact that they know that they will be more painful after. This is the equivalent of knowing that the fun you are having at the party will give you a hangover, but carrying on anyway! If there has been a reduced enthusiasm for exercise, then again this tells us about the impact of the problem on the patient themselves. A tendency to spontaneously limit activity during the session by lagging behind for example or sitting down frequently may indicate reduced enthusiasm.

Behaviour with other dogs when out for exercise (has this changed).

Dogs with orthopaedic pathology will often feel weak and vulnerable when associating with other dogs in the park for example. Animals have an innate “Fight or Flight” response and if you have orthopaedic problems then both of these mechanisms will be impacted. In some dogs this will lead to a tendency to submissive behaviour whilst in others it may lead to a tendency to  pre emptive aggression towards other dogs. The owners may have noticed this change.

By the end of this process the aim is to have as complete a picture as possible of the history, current status and details of the problem.

The next part of this series will be available within the next couple of weeks.

New Series Coming Soon: The Orthopaedic Consult

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Over the coming weeks I plan to run a series of blogs examining the processes that define the Orthopaedic Consultation. We all know what a consult is but breaking it down and looking at the purpose behind the components seems like a worthwhile basis for a new series.  Whilst the breakdown will be based on the luxury that I have of one hour consultations, it should be relevant to those who perhaps work within a more constrained time scale.

The first post looking at the goals of the Orthopaedic consult should be here by the weekend. I hope you can tune in for this series.

OrthoCal 2014

Last year I released OrthoCal, a Free App for iPhones and iPods. The new version has just been released to the App store.

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This version has the following new features:

  • Sync events between OrthoCal and your default Calendar. You will be asked if you want to grant the App permission for this. If you agree, your Orthocal events will be published to your calendar.
  • All Day events can be made in OrthoCal.
  • A monthly quiz. Each month a new quiz becomes available. This is not massively tricky but if you get a high score, you can now post it to Twitter and/or Facebook.
  • Book CPD events.
  • Refer patients.

I hope you enjoy the new App. Screenshots are below:

newCalScreenScreenshot 2014.02.04 11.29.02iOS Simulator Screen shot 4 Feb 2014 09.48.47

iPlan TTA: TTA Planning on your iPad!

iPlan TTA

 

Yesterday I received news from Apple that my iPad version of TTA Plan had been approved and is available on the App Store! You can download it by following this link:

US App Store Link

 

The beauty of this being on the iPad is that you can use the iPad camera to take images of non digital radiographs and plan with those directly. Of course you can easily add images to your iPad from a Mac by importing into iPhoto or if you have a Windows computer, by e mailing the image to yourself and saving the attached image to your Photos App on the iPad.

When you have finished planning, simply hit “Send” and this will attach a PDF plan and the planned image to your e mail. It literally couldn’t be simpler.

Good planning is the key to optimal outcomes in TTA surgery, this will hopefully bring benefit to you as a surgeon in terms of confidence but also to your patients.

The iPad version does not have all of the features of the Desktop version (Database, Post Op Audit) but if you enjoy the experience on the iPad, you can always get the Mac version which you can download here:

Download_on_the_Mac_App_Store_Badge_US-UK_165x40_0824Screencast coming shortly. Another great reason to get an iPad or iPad Mini!

iPlanTTA iPad and iPad Mini
iPlanTTA iPad and iPad Mini

 

Walk through of Planning using TTA Plan (Part 1)

I have just uploaded a video showing the process of planning and generating checklists for TTA surgery. The planning section is in real time (not speeded up) and shows how quickly a plan can be generated using the App. Of course though, there is no need to rush and careful point selection will always give the best results!

 

 

 

TTA Planner Version 1.2 Now Available on Mac App Store

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First post of 2014! Happy New Year.

My TTA Planning App has been updated and the new version (1.2) is available on the Mac App Store now. In this update I have completely overhauled the user interface to reflect the current “Flat UI” paradigm and to make the experience of using the App more intuitive and “Apple-like”.

The step by step instructions used in the planning process is now in a visual form which makes first use and learning much easier for the user.

Surgeons can now edit the image associated with their patients. You can crop, change contrast and brightness and apply standard filters to images. This is particularly useful if images are added to the App that have been taken using a camera for example. If the radiograph is felt to be inadequate for accurate planning (excessively flexed stifle, rotated femur or tibia) a new image can simply be dragged and dropped into the app and after editing saved to that patient file.

Points made in the planning session can now be undone and adjusted easily (using the arrow keys on your keyboard) in this new update.

I feel that these and further changes will make the use of the App more intuitive and more visual than the previous versions. If you have already downloaded the App, the new version will be available in your Update section of the App store. If you have not yet downloaded the App, just search TTA Plan in the App Store.

The App is compatible with Mountain Lion (OSX 10.8) and Mavericks (10.9). All images are Retina display ready but will switch between image qualities depending on your display. Check it out and optimise your TTA Planning in 2014. Of course you can still audit your post op images to check whether you achieved the 90 degree relationship between the Common Tangent and Tibial Tuberosity, which will give your patient a stable stifle and protect patients with intact meniscus from Late Meniscal Injury.

Make Optimal Advancement your resolution for 2014.

 

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Czech Republic Orthopaedic Conference

Czech Orthopaedic Conference.

This weekend I am guest speaker at the Czech Republic Orthopaedic Conference in Brno. The conference is focussing on conditions and surgical management of Stifle Pathology. It should be interesting.
My seminars will be:
* Optimal management of Cranial Cruciate Ligament deficiency.
* Planning for TTA.
* Rationale for TTA.
* Patellar Luxation.
* Patellar Groove Prosthesis.
* Managing concurrent Patellar Luxation and Cranial Cruciate Ligament pathology.

I aim to blog from the conference over the weekend. Time permitting of course….

Excellence in Small Animal Orthopaedics