Meet Dr Chris Tan: Specialist surgeon & VetPrac Educator

VetPrac is feeling very privileged to welcome Dr. Chris Tan to the education team at the TPLO workshop on September 27-29, 2019. Chris is a busy man! He works as a specialist surgeon at Sydney Veterinary Emergency and Specialists, but also continues to follow his passion for teaching and research in multiple roles. These include tutoring for the Centre for Veterinary Education, lecturing at the Prince of Wales Clinical School and being a faculty and board member with the AO foundation, a not for profit organisation which aims to improve patient outcomes through research and worldwide education programs for practitioners.

I recently interviewed Chris; I’m sure you’ll agree that his responses to my questions demonstrate his huge commitment to excellence in surgical technique, dedication to research and passion for teaching.


What inspired you to become a veterinarian and then go onto specialise in surgery?
“I have always loved working with animals and was lucky enough to have fantastic mentors who could guide me along the path to specialisation. I really enjoy the challenge of surgery and the fact that outcomes are performance based and we can always find ways to do things better.”

Tell us a little about your PhD project.
“My PhD was investigating canine tarsal bone kinematics and how the distal limb can act as a biological spring to help conserve energy during locomotion.”

Briefly outline your roles at the Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, and the AO foundation.
“I am post-doctoral research fellow and conjoint lecturer at the Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, where I collaborate with medical researchers, students and orthopedic and neurosurgeons. I am a faculty member and board member with the AO foundation, a not for profit organization which strives to advance the treatment of orthopaedic disease through education, research and implant development.”

What do you enjoy about teaching?
“I really love taking difficult concepts and finding novel ways to present them. There is no better feeling than seeing that “lightbulb” moment when a learner grasps a concept for the first time. I also love watching learners improve their technical skills with practice and the odd tip or trick that we have learnt over time. Learning is a two-way street and I find that I always learn something at every course I teach.”

 

By the way, Chris was awarded the Excellence in clinical teaching award: University Veterinary Teaching Hospital, University of Sydney in 2016.

 

Any advice for new grads? What about general practitioners that wish to pursue further education in surgery?
“To me, surgery is about good decision making and technical skills. It is important to have a growth mindset, whereby we are constantly striving to improve both our knowledge and surgical skills.”

What practical surgical tips that you learned from experience would you share with general practitioners?
“Good surgical technique is about efficiency. This starts with developing a sound surgical plan. During the procedure, try to avoid unnecessary dissection and tissue handling whilst ensuring you have adequate exposure to perform the task well. Know the steps of your procedure well and practice as much as you can beforehand to ensure there is no unnecessary delay during the surgery.”

How do you spend your days off?
“What are they???”

 

Chris can be contacted at chris.tan@sves.com.au
Website: www.sydneyvetspecialists.com.au/

 

Case Study: The importance of planning for TPLO

“Failing to plan is planning to fail”

We hear this quote so often; one situation when it’s especially true is when performing TPLO surgery. The importance of planning when performing TPLO is highlighted in the case study below.

VetPrac thanks Dr James Simcock, one of the educators at the upcoming VetPrac TPLO workshop, for providing this case study of a tibial crest avulsion fracture following TPLO procedure.

 


VetPrac’s 2019 TPLO Workshop is at capacity. We are coordinating a Patella & Stifle Surgery workshop in June 2020. Join our VIP Waitlist to receive early opportunity to register before enrolments are to everyone else.

CLICK HERE to join the waitlist.


 

A 4YO male castrated ridgeback cross presented with an acute onset of right pelvic limb lameness. The pain was isolated to the stifle. Effusion, buttress and cranial drawer were palpable in the stifle. Radiographs were taken of the right stifle and were consistent with cranial cruciate ligament rupture. Stifle arthroscopy confirmed that the cranial cruciate ligament was ruptured. The medial meniscus was normal and no meniscal release was performed. The remainder of the joint was considered normal. A TPLO was performed; during the procedure, challenges were noted maintaining appropriate rotation of the proximal segment. This required a second anti-rotational pin to be placed through the tibial crest. The post operative radiographs are shown in Figure 1.

FIGURE 1: Post operative lateral radiograph. Red arrow- insertion point of the patella tendon, Blue arrow- Location of anti-rotational pins.

 

Two weeks following surgery the owners re-presented due to acute onset lameness following a period of activity (leash walks). On clinical examination there was pain with ROM of the stifle and palpation over the tibial crest. Radiographs were made of the stifle (Figure 2) that revealed a minimally displaced fracture through the tibial crest. Due to the non- displaced nature of this fracture it was elected to manage this conservatively with strict activity restriction (5 min leash walks only). The lameness improved and no further treatment was required. Eight-week post operative radiographs were made (Figure 3) and revealed that the tibial crest fracture had migrated proximally a small amount but appeared to be healing.

 

FIGURE 2: Two week post operative radiograph showing minimally displaced tibial crest fracture (red arrow)

 

Tibial crest fracture is a noted complication following TPLO. It is reported to occur between 0.4 – 4.8% of cases.1 Numerous risk factors have been identified that increase the risk of tibial tuberosity fracture.1,2,3

These include:
* Decreased thickness of the tibial tuberosity
* Tall and narrow tibial tuberosity
* The narrowest point of the tibial tuberosity being below the insertion of the patella tendon
* Insertion of one or more anti-rotational pins below the patella tendon insertion
* Single session, bilateral TPLO
* Increased patient body weight
* Loss of rotation of TPA at follow up

 

FIGURE 3: Six week post operative radiograph. The tibial osteotomy is healing as expected, the tibial crest has displaced a small amount proximally but the fracture appears to be healing (red arrow).

 

Another commonly cited risk for tibial tuberosity fracture is rotation of the proximal segment past the theoretical ‘safe point’ of the insertion of the patella tendon on the tibial tuberosity. Rotation of this magnitude is occasionally required when there is a relatively high tibial plateau angle and/or there is a relatively high insertion point of the patella tendon. Numerous studies have shown that rotation past this safe point is not an increased risk of fracture. 1,4,5

In the case presented, placement of multiple pins below the insertion of the patella tendon has likely contributed to the tibial tuberosity fracture that was identified.

Like all things in surgery it’s possible to ‘break the rules’ or ignore risk factors and still have a good outcome – ‘get away with it’. It is important not to be lulled into a false sense of security if and when this happens. If you continue to perform surgery and not adhere to the recommendations then eventually you will experience a complication. In addition, if you break more than one of the rules then the risk of a complication will likely increase. In the case of tibial tuberosity fracture following TPLO if you place the anti-rotational pin below the insertion of the patella tendon this might be ok if the width of the tibial crest is very wide compared to its height. However, if your cut is too low and/or cranial making the tibial crest height relatively high compared to the width then this is likely to further increase the risk of fracture.

TPLO is a technically challenging procedure that can be performed safely if the recommended guidelines are followed. When learning this procedure it is important to follow the recommendations and be aware of possible complications and their associated risk factors (if known). Most of the complications that result in failure of the construct or fracture of the bone are related to technical issues when the surgery is performed.

When learning to perform TPLO careful planning of the procedure is an essential part of getting it right and having consistently good results. Remember that the proximal tibial morphology/shape can vary dramatically between patients and this can have an impact on planning of the procedure and where the osteotomy is positioned. It is important to accurately measure the tibial plateau angle, be aware of the insertion point of the patella tendon (low or high), assess if there is a scalloped shape to the proximal tibial crest, identify concurrent medial patella luxation and to assess for excessive valgus/varus, internal/external rotation of the tibia.

 

References:

1. Bergh M, Peirone B. Complications of tibial plateau levelling osteotomy in dogs. Vet Comp Orthop Traumatol. 2012;25(5):349.

2. Bergh MS, Rajala-Schultz P, Johnson KA. Risk factors for tibial tuberosity fracture after tibial plateau leveling osteotomy in dogs. Vet Surg 2008;37(4):374-382.

3. Mehrkens LR, Hudson CC and Cole GL.Factors associated with early tibial tuberosity fracture after tibial plateau leveling osteotomy. Vet Surg 2018, 47 (5): 634-639

4. Priddy NH, Tomlinson JL, Dodam JR, Hornbostel JE. Complications with and owner assessment of the outcome of tibial plateau levelling osteotomy for treatment of cranial cruciate ligament rupture in dogs: 193 cases (1997-2001). J Am Vet Med Assoc. 2003;222(12):1726-1732.

5. Witte PG, Scott HW. Tibial plateau leveling osteotomy in small breed dogs with high tibial plateau angles using a using a 4-hole 1.9/2.5mm locking T-plate. Vet Surg. 2014;43(5):549-557.

 


 

VetPrac’s 2019 TPLO Workshop is at capacity. We are coordinating a Patella & Stifle Surgery workshop in June 2020. Join our VIP Waitlist to receive early opportunity to register before enrolments are to everyone else.

CLICK HERE to join the waitlist.

Case Study: Brachycephalic Airway with a Co-Morbidity of Hiatus Hernia

With the recent increased popularity of brachycephalic dog breeds, and their all too common respiratory problems, it’s not surprising that VetPrac’s upcoming “Fix the Face” workshop filled up quickly. If you’re one of the lucky vets that managed to snare a spot for this year’s workshop, we thought we’d whet your appetite with a few case studies demonstrating the importance of thorough clinical and radiographic investigation prior to surgery, as well as always warning owners about the risk of recurrence of elongation of the soft palate post-resection surgery. Thanks to Dr. Charles Kuntz and Dr. Abbie Tipler for providing these case studies. Both Charles and Abbie are educators at the workshop this year; VetPrac looks forward to welcoming Charles and Abbie back to the education team; they always give 110 % at the workshop and we love having them both in our team.

If you missed out on this years’ workshop, register your interest in future Fix the Face workshops via this Waitlist Link.


Case report by Dr Abbie Tipler: Brachycephalic Airway with a Co-Morbidity of Hiatus Hernia

 

Signalment: 2-year-old male French Bulldog, Charlie

History: 1-year history of daily regurgitation. This had resulted in several bouts of aspiration pneumonia; he had been treated with several courses of antibiotics which seemed to help temporarily. There was no history of airway signs, for example snoring, exercise intolerance, stertorous breathing, cyanotic or collapse episodes and the primary presenting sign was regurgitation with secondary aspiration pneumonia leading to coughing. His airway had been previously assessed as normal.

Physical examination and investigations: On upper airway examination, the soft palate was elongated, the laryngeal saccules were oedematous, and the nares were stenotic.

The workup for Charlie included routine bloods, chest radiographs and upper GI endoscopy.

Chest radiographs revealed signs of aspiration pneumonia.

Upper GI endoscopy revealed fluid pooling in the caudal oesophagus, dilation of the gastro-oesophageal sphincter, oesophagitis, and a mild hiatal hernia.

 

Diagnosis: Aspiration pneumonia secondary to regurgitation with background of hiatus hernia, and elongated soft palate, oedematous laryngeal saccules and stenotic nares.

Decision making: The decision to be made was whether to treat just the airways in the hope that the hiatal hernia would settle with reduced upper airway pressure, or to concurrently repair the hiatal hernia. There is some controversy amongst specialists in the approach to take here.

In this case, given the ongoing aspiration pneumonia, we wanted to give the best chance of a resolution of the regurgitation. There is also current research around the anatomy of the oesophageal hiatus, in French Bulldogs particularly, and it appears that they are particularly prone to anatomical laxity of this region (increasing the risk of upper GI signs).

 

Treatment: Charlie was treated with a further one week of broad-spectrum antibiotics and omeprazole to help treat the aspiration pneumonia and regurgitation prior to surgery, however, given the chronicity of the changes in the lungs and the ongoing regurgitation, it was not expected we could completely resolve this prior to surgery.

Charlie was anaesthetised and we repaired (firstly) the hiatal hernia with a herniorrhaphy, oesophagopexy and gastropexy, and then corrected the airways with a staphylectomy, sacculectomy and nares wedge alarplasty. In general instances, we avoid performing concurrent procedures with airway surgery, however, if we do, we perform the concurrent procedure first. The reason for avoiding concurrent procedures is that we try to reduce the time under anaesthetic so there is the least possible compromise to the lungs during recovery from anaesthesia, which is a risk period. In this instance, however, the regurgitation/aspiration was also a risk to the overall airway recovery. The patient’s recovery was uneventful. All post-operative precautions were taken including careful one-on-one monitoring, micro-dose medetomidine on recovery if stressed/panting, oxygenation as required.

Discharge medications: 6-week course of amoxicillin-clavulanic acid antibiotic at 20mg/kg for the aspiration pneumonia, and 6 weeks of BID omeprazole 1mg/kg.

Recheck at 6 weeks: the aspiration pneumonia had cleared; the patient was no longer regurgitating.

Take-home messages for this case:
Always consider plain film radiographs of the chest prior to airway surgery.
Consider further diagnostics e.g. upper GI endoscopy if there are signs of regurgitation. Hiatal hernias are reasonably common in brachycephalic dogs, however, in many instances the GI signs will resolve when the airways are corrected.
Always examine the upper airway for yourself, as this was an example of where the upper airway had been previously noted to be normal.
Consider post-operative medical management of GI symptoms post airway surgery.

 

CLICK TO READ ANOTHER CASE STUDY BY DR. CHARLES KUNTZ

 

Case Study: Brachycephalic Airway Syndrome with Stenotic Nares

With the recent increased popularity of brachycephalic dog breeds, and their all too common respiratory problems, it’s not surprising that VetPrac’s upcoming “Fix the Face” workshop filled up quickly. If you’re one of the lucky vets that managed to snare a spot for this year’s workshop, we thought we’d whet your appetite with a few case studies demonstrating the importance of thorough clinical and radiographic investigation prior to surgery, as well as always warning owners about the risk of recurrence of elongation of the soft palate post-resection surgery. Thanks to Dr. Charles Kuntz and Dr. Abbie Tipler for providing these case studies. Both Charles and Abbie are educators at the workshop this year; VetPrac looks forward to welcoming Charles and Abbie back to the education team; they always give 110 % at the workshop and we love having them both in our team.

If you missed out on this years’ workshop, register your interest in future Fix the Face workshops via this Waitlist Link.


Case report by Dr. Charles Kuntz: Brachycephalic Airway Syndrome

 

Signalment: Derby is a 4-year-old male neutered Boston Terrier

History: He presented one year ago for increased respiratory noise since he was a puppy. He had exacerbation of clinical signs with exercise and heat.

Physical examination: He had stertorous breathing during examination. There was stenosis of the nares bilaterally. Normal on thoracic auscultation and abdominal palpation.

Diagnosis: Brachycephalic airway syndrome with stenotic nares, redundant soft palate and low-grade laryngeal collapse (eversion of laryngeal saccules). No further diagnostics were performed.

Treatment: The nasal fold was resected using a wedge technique and reconstructed using 4-0 PDS. The soft palate was resected using a 3 stay sure technique and was closed using 3-0 PDS in a simple continuous pattern. Laryngeal saccules were resected using Metzenbaum scissors. The soft palate was iced before and after surgery and methylprednisolone (15 mg/kg) was administered IV.

Discharge medications: Codeine liquid for pain relief and omeprazole for 2 weeks.

One week recheck: He was doing really well. No concerns were stated, and his breathing was much better. He had stopped snoring.

10 months after surgery, he presented for recurrence of clinical signs over the preceding 6-10 weeks. His snoring had deteriorated and was as bad as ever. He sometimes sounded like he is really struggling to breathe.

Physical examination: Mild increase in respiratory noise. Some serious discharge from both nares. Review of owner videos confirmed severe snoring.

Diagnosis: Recurrence of redundant soft palate.

Treatment: Resection of redundant soft palate using 3 stay suture technique, assessment of laryngeal collapse.

Discharge medications: Codeine liquid for pain relief and omeprazole for 2 weeks. Owners counseled to monitor for progression of laryngeal collapse with possible modified laryngeal tie-back if this occurs.

Outcome: Resolution of excessive snoring in the short term (the last recheck was 26th August 2019).

Recurrence of elongation of the soft palate is an uncommon outcome following brachycephalic airway surgery. This illustrates that it is important to let owners know that recurrence is possible, usually due to progression of the laryngeal collapse.

 

CLICK TO READ ANOTHER CASE STUDY FROM DR. ABBIE TIPLER

 

Dr Kat Crosse – From skiing accident to PHD in airway disease in Brachycephalic dogs

VetPrac welcomes Dr Kat Crosse to the education team for the Fix the Face workshop in September 2019. We think she’s the perfect choice for this workshop – she’s currently doing a PhD in airway disease in brachycephalic dogs AND she has a great teaching philosophy!

Kat hails from the UK, and originally intended not to do any small animal work. She can’t remember a time when she didn’t want to be a vet. Her first job was mixed, but mostly large and equine. It became increasingly clear to her, however, that the frustrations of never quite reaching a diagnosis and a lack of ability to treat her large patients made her small animal work seem more and more enjoyable. A moment of “being an idiot on her skis” and tearing her cruciate, with subsequent crate rest with toilet walks only, meant she spent a lot more time in the small animal part of the clinic. It was only then that she started to foster her interest in surgery, and was soon volunteering for “ops days” 5 days a week.

When studying through her residency at Massey University, she found huge holes in the understanding of airway disease in brachycephalic dogs. At the same time the population of these dogs was increasing exponentially. She had too many questions that she couldn’t find answers for and she had too many dogs clearly suffering who needed the veterinary profession’s help. The aim of her PhD is to really try to identify what the difference is between the good and bad brachycephalic dogs and by using airway flow dynamics, assess what is the best way to improve their airways.

When teaching, Kat loves the background work of trying to distil the most complex of theories and practices into succinct and easy to understand lessons. “It takes a lot of work to be able to explain something complex in simple terms, and I like the fact this pushes me to really understand the things I am teaching.”

Since finishing her residency at Massey University and becoming a diplomate of the European College of Veterinary Surgeons in 2016 she has worked as a small animal surgeon at Massey University. One extremely worthwhile project at Massey that was coordinated by Kat was a charity outreach clinic in Samoa. She took veterinary students to Samoa, where they performed desexing of local animals. She loved working there and could see the benefits to the Samoan community and the students alike. Unfortunately, the project became a victim of slashed funding. Kat welcomes any donations to allow the project to resume – she would happily take the students back to Samoa if she could access $20,000 per year.

Kat fills her spare time to the brim with either mountain biking, yoga, painting, crafting, hiking, planning pranks on my colleagues, hanging out with her dog Fennel…. the list goes on!

So, if you’re registered for the workshop, take advantage of her superior educational skills, quiz her about her PhD findings, but above all, watch out for her pranks! It should be a fun workshop!

 

Kat can be contacted at k.crosse@massey.ac.nz