Complications in Equine Surgery. Группа авторов
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Thoracic radiography and ultrasonography may aid in confirmation of pleural cavity involvement.
Monitoring
Diagnosis is made by clinical signs described and initial efforts are directed toward stabilization of the patient. Arterial blood gas sample may be performed and analyzed to assess ventilation and gas exchange to dictate further treatment. Shock may result in cases with significant blood loss or respiratory compromise.
Treatment
Emergency treatment of pneumothorax focuses on stabilization of the patient by closure of thoracic wounds and immediate removal of pleural air [22].
The wound is closed to reduce the severity of the pneumothorax and the chest is sealed temporarily.
Pleural air is removed by inserting a sterile teat cannula, 14‐gauge catheter or thoracostomy tube into the dorsal aspect of the thorax at the 11th to 15th intercostal space. Air is slowly removed using an extension set, three‐way stopcock and 60‐ml syringe. A one‐way valve is attached to allow continuous exiting flow of air upon initial removal of pleural air and fluid.
Oxygen supplementation is indicated in most cases of respiratory distress resulting from pneumothorax or hemothorax. Oxygen supplementation may be provided via nasal O2 insufflation at a flow rate of 15 L/min in adult horses [22].
Intra‐tracheal oxygen administration increases the fraction of inspired oxygen and may help to speed the absorption of air from the pleural cavity in cases of pneumothorax.
Emergency treatment of hemothorax focuses on restoring intravascular fluid volume, cardiac output, and tissue perfusion.
Draining blood from the pleural cavity may be indicated to improve ventilation and perfusion matching and decrease intrapulmonary shunting of blood if the horse demonstrates signs of respiratory distress. However, leaving blood in the chest may actually inhibit bleeding, and some of the red blood cells may autotransfuse [22].
Expected outcome
Puncture of the thoracic or pericardial cavity may result in pulmonary collapse or catastrophic cardiovascular event. Euthanasia may be necessary if emergency medical intervention is not sufficient to stabilize the patient.
Late Postoperative Complications
Suboptimal Integration of Bone Graft
Definition
Partial or total failure of the graft to survive and to achieve osteogenesis, osteoinduction and/or osteoconduction at the recipient site
Risk factors
Suboptimal handling of the graft
Donor site selection
Use of allografts or xenogafts
Instability at recipient site
Morbidity at the recipient site
Fatigue failure of implants during healing in equine long bone fracture repair
Pathogenesis
Suboptimal handling techniques of the graft during harvest and implantation (prolonged harvest‐implantation time, exposure to air, saline, and antibiotics, and/or breach of aseptic technique) will have a negative effect on graft cell viability. Selection of the bone graft harvest site is chosen based upon quantity of graft material required, intraoperative access to donor site, and desire to minimize postoperative morbidity.
Autogenous cancellous bone graft is used most commonly in the equine patient but graft rejection resulting in nonunion, fatigue fracture and implant failure has been reported [6], and rejection will be more likely with use of allo‐ or xenografts.
The slow rate of fracture healing in the adult horse contributes to poor overall survival rates for adult equine fracture patients. Adult horses often require 4 to 6 months or longer for complete fracture healing, in comparison to canine patients, which may heal in 2 to 4 months [15, 23, 24]. See Chapter 46: Complications of Orthopedic Surgery, for further details. Instability at the fracture site as well as early postoperative complications such as incisional infection, dehiscence or osteomyelitis [3, 12, 13, 18, 25] will have a negative effect on graft survival.
Utilization of bone grafts in long bone fracture repair should contribute to decrease fracture‐repair failure as a result of implant fatigue, improving prognosis for equine fracture patients. While autogenous cancellous bone grafting enhances and stimulates bone healing, fatigue failure of implants during the healing process continues to be a major postoperative complication in equine long bone fracture repair [26, 28]. The osteogenic potential of equine autogenous cancellous bone graft from various donor sites including tuber coxae, sternum, proximal tibial metaphysis, and fourth coccygeal vertebrae has been investigated [15]. During the early stages of bone healing, new bone formation at the fracture site may result from viable graft cells or cells from the environment surrounding the graft [6, 28, 29]. Therefore, transplantation of viable osteogenic cells in bone graft or donor tissue is critical to early bone healing [10, 28, 30, 31]. When the host environment is traumatized, as with most adult equine fractures, new bone formation is a product of osteogenic cells from the graft bone that remain viable following transplantation [29].
Prevention
Optimizing transplantation of tissue from a donor site to yield a greater number of viable osteogenic cells should lead to greater new bone formation [15]. Results of comparison of osteogenic potential of donor sites revealed that the tuber coxae most consistently yielded viable osteogenic cells with an acceptable percentage of osteoprogenitor cells, while the sternum and tibia were less reliable in providing osteogenic cells [15]. Two additional donor sites have been examined; the fourth coccygeal vertebra and the tibial periosteum, were tissues with good osteogenic potential, and may be considered when the tuber coxae is not accessible or does not provide an adequate amount quantity of cancellous bone.
Autografts have greater osteogenic capacity in comparison to either allograft or xenograft, and are the most commonly used type of bone graft in equine surgery [1, 32–34]. The use of allografts would eliminate the need for a second surgery to harvest the graft, thereby reducing morbidity postoperatively. However, allogeneic bone demonstrates lower osteogenic capacity and therefore slower new bone formation and may be subject to rejection by the recipient immune system. Bone allografts are subject to the same immunologic factors as other tissue grafts [6]. The rejection of bone allograft is considered to be a primarily cellular immune response, although the humoral component of the immune system may play a role as well. Host response is related to antigen concentration and total dose. Rejection of bone allograft is observed clinically and histologically as an inflammatory process with callus bridging, nonunions, and fatigue fractures [6]. The use of allogeneic bone has declined in human medicine due to concern over the possibility of viral contamination of graft material and possible transmission of disease to graft recipients [35]. Xenogenic bone is not generally considered useful as an alternative to autogenous bone, as the antigenic response elicited upon grafting results in failure of the graft in the majority of cases [32]. Partial deproteination and defatting of xenograft have been shown to decrease the antigenic response, but this process also removes the majority of osteoinductive proteins [36].
Diagnosis
Graft rejection may be recognized clinically as a non‐union fracture, slow‐healing fracture or fatigue fracture. Histologically, evidence of an inflammatory process with callus bridging may be apparent.
Monitoring
Monitoring of graft acceptance in the recipient site may be monitored indirectly with radiographic and clinical signs indicative