Forequarter amputation vs proximal humerus

RE: Forequarter amputation vs proximal humerus

Evelyn Barbour-Hill — Sat, 19 Aug 2017 15:18:07 GMT

[quote user="David Mills"]When does personal opinion become dogma?[/quote]

When it's the personal opinion of a substantial number of eminent persons in the field (or perhaps just one extremely eminent person whom no-one else would dare to contradict) and is presented in teaching, whether undergraduate, postgraduate or popular articles for the general public as indisputable. As, for instance, the dogma that in cases of anterior cruciate ligament rupture the menisci should be inspected and any tatty bits cut off. The sort of thing that is stated in the Introductions to clinical papers with words such as "it is well established that....".

Of course a personal opinion may be expressed dogmatically, but that's a description of tone, of nuance. You appear to feel that Ms Corr's remark about bony protuberances was expressed dogmatically, and I sympathise with your view while not agreeing with it, but interpretation of tone is much within the brain of the beholder.

RE: Forequarter amputation vs proximal humerus

Anthony Todd — Sat, 19 Aug 2017 10:39:26 GMT

[quote user="David Mills"]When does personal opinion become dogma?[/quote]

When it is stated by someone teaching you or older than you?

RE: Forequarter amputation vs proximal humerus

Eilidh Corr — Sat, 19 Aug 2017 10:12:56 GMT

It seems that there are things about my approach which don't make any sense to you, Dave. You're entrenched in your view, and that's fine, but our difference of opinion doesn't invalidate my experiences. I'm not going to get into amputation top trumps.

I do apologise unreservedly if my posting has been condescending. That has never been my intent. I absolutely respect the greater experience and wisdom of many contributors here. I've been fledged a mere thirteen years which is but a fraction of the time many of those here have been in practice, and I am in no position to assume superiority.

RE: Forequarter amputation vs proximal humerus

David Mills — Sat, 19 Aug 2017 00:28:22 GMT

[quote user="Eilidh Corr"]it doesn't make sense to me to leave the scapula and any humerus, they just become uncomfortable bony protruberances. [/quote]

[quote user="Eilidh Corr"]I think there's a fine line between dogma and opinions formed through experience, and until we have a larger evidence base in veterinary medicine we should perhaps accept that our professional lives will be peppered with these nuggets.[/quote]

Oh come come. There is a world of difference between your first post and the second.

My objection was to the inevitability of it - "they just become bony protuberances" and the somewhat condescending "it doesn't make any sense to me". Having worked in charity practice for nigh on 7 years, with an amputation total of probably over 200 personally and probably over ?2000 as a charity in that time, I have never seen amputation by resection as issue except where the technical deficiencies mentioned above were present. Especially in older animals and sight hounds where it is less traumatic, haemorrhagic, and quicker.

I have done forequarters where indicated. Interestingly in humans, mainly so that prosthetics can be fitted, but also because it reduces phantom limb pain, they try to leave as much as possible. I do worry about residual nerve pain in scapulectomies.

RE: Forequarter amputation vs proximal humerus

Eilidh Corr — Fri, 18 Aug 2017 23:03:16 GMT

Wow. I'll think twice about boldly opining in here next time!

I've done several forequarter amputations over the years and have always found them straightforward enough (and I'm by no means a wild scalpel-jockey, I tend towards finding medical solutions wherever possible ). I presume that sympathetic surgical technique with due attention to anatomy will guard against the catastrophic outcomes Malcolm mentioned. The only one I've seen go wrong was many years ago, performed by a colleague I think in a cancer case and the wound broke down. That was a massive wound to manage, although I think the dog did recover eventually but it took weeks of dressings.

I think there's a fine line between dogma and opinions formed through experience, and until we have a larger evidence base in veterinary medicine we should perhaps accept that our professional lives will be peppered with these nuggets. Plenty scope to throw babies out with bathwater here.

RE: Forequarter amputation vs proximal humerus

David Mills — Fri, 18 Aug 2017 22:44:10 GMT

[quote user="Evelyn Barbour-Hill"]But there's no dogma in that post, only personal experience. [/quote]

Ha. What is the difference between strongly held, well, what sound like immovable opinions such as "they just become uncomfortable bony protuberances" (kudos for use of "protuberances" by Ms Corr, by the way) and dogma? When does personal opinion become dogma?

RE: Forequarter amputation vs proximal humerus

Anthony Dennison — Fri, 18 Aug 2017 16:06:51 GMT

[quote user="Niall Taylor"]

[quote user="Anthony Dennison"]What about disarticulating the shoulder joint?[/quote]

I refer the honourable member to my previous reply!

Niall

[/quote]

Serves me right for skim reading. I don't do a lot of amputations to be honest, few hind legs now and then, but the newer vets are so keen to do new surgeries and I'm more interested in medicine and imaging so just let them get on with it, and scrub in to help if needed.

RE: Forequarter amputation vs proximal humerus

Niall Taylor — Fri, 18 Aug 2017 15:42:30 GMT

[quote user="Anthony Dennison"]What about disarticulating the shoulder joint?[/quote]

I refer the honourable member to my previous reply!

Niall

RE: Forequarter amputation vs proximal humerus

Anthony Dennison — Fri, 18 Aug 2017 15:18:08 GMT

What about disarticulating the shoulder joint?

RE: Forequarter amputation vs proximal humerus

Evelyn Barbour-Hill — Fri, 18 Aug 2017 11:39:53 GMT

[quote user="Malcolm Ness"]

[quote user="Evelyn Barbour-Hill"]But there's no dogma in that post,[/quote]

I think the phrase,"... it doesn't make sense" is implicitly dogmatic and the statement," they just become uncomfortable bony protuberances" similarly so.

[/quote]

Well, I disagree in several ways.

Firstly, a dogmatic assertion is not a statement of dogma.

Secondly, I think it clear from the context that Miss Corr was recounting her experience and briefly stating her reasoning. Restore the words "to me" that were used after "it doesn't make sense"; insert the implied words "in my experience" after "they just become uncomfortable bony protuberances".

Other than that, I agree entirely with[quote user="Malcolm Ness"]amputating through the proximal third/quarter of the humerus taking some care to cut the bone cleanly (no jaggy bits) and then suture the remaining muscles (cut deliberately lower than the bone) over the stump [/quote]

I'd call that basic amputation technique. (In my opinion, in my experience, etc...... )

RE: Forequarter amputation vs proximal humerus

Gillian Mostyn — Fri, 18 Aug 2017 11:34:52 GMT

[quote user="Bob Russell"]A bit of relief that Malcolm suggests sectioning the humerus! [/quote]

Snap. I've only ever done it this way...and was starting to think I was alone...!!! (Never had a reason to take the shoulder joint too... Yet...)

RE: Forequarter amputation vs proximal humerus

Bob Russell — Fri, 18 Aug 2017 10:02:35 GMT

A bit of relief that Malcolm suggests sectioning the humerus!

I was going to do one a couple of years ago but was advised it was better to do fore-quarter. I did a couple of cadaver trial runs and found them horrendous.

Decided to go for my original plan leaving the scapula. A lot less stressful and result was absolutely fine.

I hate this type of surgery!

RE: Forequarter amputation vs proximal humerus

Malcolm Ness — Fri, 18 Aug 2017 08:31:38 GMT

[quote user="Evelyn Barbour-Hill"]But there's no dogma in that post,[/quote]

I think the phrase,"... it doesn't make sense" is implicitly dogmatic and the statement," they just become uncomfortable bony protuberances" similarly so.

Most of the time, I would advise amputating through the proximal third/quarter of the humerus taking some care to cut the bone cleanly (no jaggy bits) and then suture the remaining muscles (cut deliberately lower than the bone) over the stump before closing the skin. I protect the skin wound with a sutured-on gauze dressing. Plan the skin incision such that the wound lies rather more lateral than ventral after surgery. The surgery is relatively simple, relatively quick and produces a good clinical and an acceptable cosmetic outcome. The shoulder and thoracic muscle certainly reduce in bulk to some extent following surgery but they do not completely atrophy - in fact, many amputations are done for reasons of chronic lameness which has already caused substantial muscle loss which sometimes recovers a little.

Fore-quarter amputation is a substantially bigger operation, takes longer, technically more complex and with some additional risks. It is indicated in cases of shoulder pathology and in some cases where a wider margin is desirable. The extent of the muscle dissection has been mentioned as well as the proximity of some (very) major blood vessels - the subclavian artery coursing around the first rib is involved and if you take the time to dissect this region of a cadaver, you will find the upper chambers of the heart quite worryingly close to your surgical site. This is not a theoretical concern - I have post-mortemed a dog that died following a tear to major vessel adjacent to the heart during fore-quarter amputation and twice during my career I have been consulted by colleagues who have had similar catastrophic intra-operative complication. I am not convinced by the suggestion that the cosmetic outcome is superior - these are still three-legged dogs and very obviously so.

RE: Forequarter amputation vs proximal humerus

Evelyn Barbour-Hill — Fri, 18 Aug 2017 02:10:07 GMT

Accepted, Mr. Todd.

RE: Forequarter amputation vs proximal humerus

Anthony Todd — Fri, 18 Aug 2017 01:57:03 GMT

[quote user="Evelyn Barbour-Hill"]

Anthony, I didn't say it, Mills did.

And I know the definitions of dogma.

Which is why I corrected him.

[/quote]

Profound and deepest apologies, how could I ever think you didn't know?

It was the [actual] source of the quote and the proximity to the definition.

RE: Forequarter amputation vs proximal humerus

Evelyn Barbour-Hill — Fri, 18 Aug 2017 01:50:08 GMT

[quote user="Anthony Todd"]

[quote user="Evelyn Barbour-Hill"]I do love it when threads descend into dogma[/quote]

a fixed, especially religious, belief or set of beliefs that people are expected to accept without any doubts

from http://dictionary.cambridge.org/dictionary/english/dogma [ironic no?????]

Nor any decent evidence in many most cases.

[/quote]

Anthony, I didn't say it, Mills did.

And I know the definitions of dogma.

Which is why I corrected him.

RE: Forequarter amputation vs proximal humerus

Anthony Todd — Fri, 18 Aug 2017 01:46:40 GMT

[quote user="Evelyn Barbour-Hill"]I do love it when threads descend into dogma[/quote]

a fixed, especially religious, belief or set of beliefs that people are expected to accept without any doubts

from http://dictionary.cambridge.org/dictionary/english/dogma [ironic no?????]

Nor any decent evidence in many most cases.

RE: Forequarter amputation vs proximal humerus

Anthony Todd — Fri, 18 Aug 2017 01:41:09 GMT

[quote user="James Dunne"] As for the scapula providing protection to the thorax [/quote]

# scapula [with no muscle mass left] Versus # ribs, if they didn't "bend"???

Crikey though, chances are pretty small but someone will say they had one yesterday.....

RE: Forequarter amputation vs proximal humerus

Evelyn Barbour-Hill — Fri, 18 Aug 2017 00:28:48 GMT

[quote user="David Mills"]

[quote user="Eilidh Corr"]

I've always taken the forequarter, it's straightforward enough (and when you're in mixed practice the vessels don't seem comparatively that big ). They usually heal nicely and don't take long to do. Fossum has a good description and diagrams. Particularly in elderly dogs or sight hounds it doesn't make sense to me to leave the scapula and any humerus, they just become uncomfortable bony protruberances.

[/quote]

I do love it when threads descend into dogma

[/quote]

Don't we all.

But there's no dogma in that post, only personal experience.

RE: Forequarter amputation vs proximal humerus

David Mills — Fri, 18 Aug 2017 00:12:26 GMT

[quote user="Eilidh Corr"]

[/quote]

I do love it when threads descend into dogma

RE: Forequarter amputation vs proximal humerus

James Dunne — Thu, 17 Aug 2017 21:03:55 GMT

Hi Everyone - I guess it is a matter of personal preference unless you are taking off a mass that needs large margins, in which case forequarter resection is better. One other little thing - if the dog has an arthritic shoulder on radiographs, amputate the whole limb not just through the humerus because despite not being weight-bearing postop, they can still be left quite sore if you leave an OA joint behind. Hope that is of some use. As for the scapula providing protection to the thorax - interesting idea - I guess that most of the muscles overlying the scapula will atrophy postop and it isn't going to then be too significant if it comes up against a high-speed ton of metal. don't know if anyone has researched this!

RE: Forequarter amputation vs proximal humerus

Neil Wheadon — Thu, 17 Aug 2017 20:12:09 GMT

Slightly different take, but if you leave the scapula, would this provide the same protection for the chest wall, blunt trauma etc?

Neil

RE: Forequarter amputation vs proximal humerus

Eilidh Corr — Thu, 17 Aug 2017 18:57:06 GMT

RE: Forequarter amputation vs proximal humerus

David Mills — Thu, 17 Aug 2017 17:31:30 GMT

They're probably both as traumatic but IME forequarter are more painful after, presumably because you're cutting through the brachial plexus.

I suspect those who haven't got on with humeral amputations failed to leave enough padding. Another technical issue is leaving enough humerus so that you don't create necrotic bone. Humeral are far quicker (I never understand why surgical textbooks over complicate the descriptions - ligate brachial artery and vein and cut and stitch) and has the advantage of maintaining the scapula for thorax protection. The muscles will waste to some extent, but the animal will still move them. I've seen many baggy forequarter amputations a few months down the line so the cosmetic argument doesn't work for me. I'm also a little confused by the presence of an assistant being a determining factor, you don't need one for either.

RE: Forequarter amputation vs proximal humerus

Rob Loxley — Wed, 16 Aug 2017 23:50:12 GMT

[quote user="cathal rafferty"]We use transxamic acid for a fee days in sighthounds to prevent bleeding[/quote]

That's an interesting thought