toggle vs iliofemoral suture in cat

RE: toggle vs iliofemoral suture in cat

Martin Atkinson — Mon, 25 Sep 2017 18:54:50 GMT

[quote user="David Mills"]There are lots of vets doing goodness solid competent ortho work but we don't hear of it. It would be refreshing to have clinical research from primary care practice. I presented a case series on fixing humeral fractures in dogs and cats with pins and wires at BSAVA. This somewhat fkies in the face of accepted wisdom (all 50 plus did well). [/quote]Funny how if its your experience its valid but if its anyone else's, especially mine, its anecdotal.

RE: toggle vs iliofemoral suture in cat

David Mills — Mon, 25 Sep 2017 01:50:28 GMT

A different way of looking at this.

Why don't more GP vets promote these skills? Not as in marketing but putting their figures out there. So, for instance, I presented a case series on fixing humeral fractures in dogs and cats with pins and wires at BSAVA. This somewhat fkies in the face of accepted wisdom (all 50 plus did well).

Instead there is an information mismatch with lots of "knowledge" coming from referral centres and universities. There are lots of vets doing goodness solid competent ortho work but we don't hear of it. It would be refreshing to have clinical research from primary care practice.

RE: toggle vs iliofemoral suture in cat

Evelyn Barbour-Hill — Sun, 24 Sep 2017 23:51:53 GMT

[quote user="Elizabeth Billimore"]You don't want to be sending a dyspneic cat with a chest full of fluid in a long car ride to a referral practice just because you've never drained a chest before (this happens). [/quote]

Isn't draining a chest a Day 1 competence? Or at least a Day 3 competence?

[quote user="Elizabeth Billimore"] trying a fracture repair for the first time on a dog you've not offered the option of referral to would be wrong I think. [/quote]

It would depend on the fracture. Isn't pinning a femur a, shall we say, Day 2 competence? Again the usefulness of ordinary Sherman plates was not diminished by the invention of locking plates. Doesn't every practice have some basic orthopaedic kit and expertise?

RE: toggle vs iliofemoral suture in cat

Michael Woodhouse — Sun, 24 Sep 2017 22:57:45 GMT

[quote user="Elizabeth Billimore"]One of the essay titles in Module A of the RCVS CertAVP is about this very subject. It's all about discussing the "tackle all attitude" that the profession is known for, about referrals, and when you draw the line trying something novel personally. [/quote]

Yea I know. I have one too

[quote user="Elizabeth Billimore"]I do think it's wrong to crack on with something you've never done before, without any guidance, if it's not urgent and you have not at least offered the option of referral. [/quote]

I quite agree.

It's all about managing client expectations. This is a tangent from my pyothorax thread (cat doing fine BTW) and that cat was unsuitable to transport elsewhere so either we treat it or it was PTS. We offer referral a lot but at a guess (I CBA to crunch the numbers) our take up is less than 5% (1 or 2%). Most things we send are eyes and neuro. I don't think we've referred anything orthopaedic this year. Send the odd PITA client for medicine or derm because they won't listen.

The job would be so dull if we did nothing other than spaying cats. Plating bones is pretty straightforward surgery. A lateral suture for a cruciate dog is much easier than a bitch spay.

We're generally vastly cheaper and the animal is already here - referral centres are far away. People will generally take the slight increase in risk when its all explained to them.

RE: toggle vs iliofemoral suture in cat

Bibs — Sun, 24 Sep 2017 02:09:22 GMT

[quote user="Richard Carter"]

In the real world meanwhile working in a similar environment to Michael where many of my clients are on limited funds and the nearest referral centre for just about all disciplines is in the next county, we often have to make do with what we have.

I really do feel the profession is losing its usefulness to the general public if we heading the same way as the GPs in NHS and are just a sorting office for specialists.

[/quote]

GP practices aren't just sorting offices. GPs make lots of difficult decisions and have lots of worries. It's not just about sending people to hospital or not sending people to hospital which can be difficult enough. They stitch people up, deal with child safeguarding issues, mental health problems, make decisions about treatment etc.. I live with one so I get to hear about it all.

I hear what you're saying though. I think you mean we are not being all round surgeons any more.

RE: toggle vs iliofemoral suture in cat

Bibs — Sun, 24 Sep 2017 01:59:06 GMT

One of the essay titles in Module A of the RCVS CertAVP is about this very subject. It's all about discussing the "tackle all attitude" that the profession is known for, about referrals, and when you draw the line trying something novel personally.

I think the key here is about the circumstances: If the surgery is new to you and a bit out of your comfort zone, I think it depends if it's an emergency situation or not, how far away a referral hospital is, and if the owner can afford referral or not etc. You've got to weigh it up.

I do think it's wrong to crack on with something you've never done before, without any guidance, if it's not urgent and you have not at least offered the option of referral.

On the other hand it's really sad if you're not operating on things that could have been fixed and putting them to sleep or amputating instead. The problem is that if you have no mentorship and no chance to learn you get a bit stuck when these novel cases that you can't refer come in. This is where confidence and the have a go attitude comes in useful it seems. The problem is that you need to grow this confidence suddenly to try this new surgery when the client's circumstances demand it but be cautious and refer at other times. The two sides don't always balance well and where do you get the experience from in the end?

You don't want to be sending a dyspneic cat with a chest full of fluid in a long car ride to a referral practice just because you've never drained a chest before (this happens). On the other hand, trying a fracture repair for the first time on a dog you've not offered the option of referral to would be wrong I think.

RE: toggle vs iliofemoral suture in cat

Richard Carter — Thu, 21 Sep 2017 14:29:27 GMT

I really do feel the profession is losing its usefulness to the general public if we heading the same way as the GPs in NHS and are just a sorting office for specialists.

RE: toggle vs iliofemoral suture in cat

J G Wray — Thu, 21 Sep 2017 11:55:59 GMT

[quote user="Michael Woodhouse"]

[quote user="J G Wray"]An example - a patient with a pericardial effusion now needs to see a referral centre with a cardiologist.......and a thoracic surgeon. There are many more of course.[/quote]

Show me this written down somewhere, because I simply don't believe you.

[/quote]

Sure. Go and have a look at our Inspirational Pet of the Month "Bing" and read the account of his treatment

[quote user="Michael Woodhouse"]If I take your example as extremely as you write it then no one can ever do a new operation - Noel FP must be shaking in his boots[/quote]

Are you claiming to be of the same calibre of orthopaedic surgeon as Professor Fitzpatrick?[quote user="Michael Woodhouse"]Just because you've not done something before does not make it out of your area of competence.[/quote]

Quite, but you may not be the sole arbiter of your competence.

[quote user="Michael Woodhouse"]There's a lot more 'risk' with a new grad spaying a bitch than me toggling a hip on a cat when I've done thousands of operations, reasonable number of orthopaedic operations and toggled hips in dogs. I really don't think novelty is as much of an issue as you seem to think.[/quote]

Oh I get the impression that you regard your competence highly. However, others may not hold their competence in such a way and if there is a nebulous pressure from a Regulator backed by the Disciplinary process hanging over them then the effect, as reported by Dr Barker, will happen. I see parallels here with the Chikosi case and the Dyer survey response where perception of RCVS behaviour was all - except in Yorkshire.

RE: toggle vs iliofemoral suture in cat

Nicola Cole — Wed, 20 Sep 2017 18:49:44 GMT

There used to be some kind of guidance list (10-15 years ago) of small animal surgical procedures graded A-C on difficulty. 'A' being something all vets should beable to do, 'B' being those a bit trickier but once surgically competent should aim towards and 'C' being those that should be left to a specialist or those with further training...does that still exist?

I can't remember who produced the list but I was given it in my first small animal practice. Gave you a fairly clear idea of what would be considered within your competence for doing new procedures.

RE: toggle vs iliofemoral suture in cat

Evelyn Barbour-Hill — Wed, 20 Sep 2017 17:43:04 GMT

[quote user="Robin Grimmer"]All too often I hear "I've never done one before." [/quote]

The answer to that used to be "Well, now's your chance".

RE: toggle vs iliofemoral suture in cat

Robin Grimmer — Wed, 20 Sep 2017 17:38:21 GMT

I agree Michael. Many is the time I've done an op with the surgery text book out. I do a pretty good LWR and VCA both learned from a textbook. I think it's sad that newer vets won't attempt anything outside their comfort zone. All too often I hear "I've never done one before." Everyone has to do an op for the first time once.

RE: toggle vs iliofemoral suture in cat

Michael Woodhouse — Wed, 20 Sep 2017 15:09:52 GMT

[quote user="J G Wray"]An example - a patient with a pericardial effusion now needs to see a referral centre with a cardiologist.......and a thoracic surgeon. There are many more of course.[/quote]

Show me this written down somewhere, because I simply don't believe you.

If I take your example as extremely as you write it then no one can ever do a new operation - Noel FP must be shaking in his boots. Just because you've not done something before does not make it out of your area of competence. There's a lot more 'risk' with a new grad spaying a bitch than me toggling a hip on a cat when I've done thousands of operations, reasonable number of orthopaedic operations and toggled hips in dogs. I really don't think novelty is as much of an issue as you seem to think.

RE: toggle vs iliofemoral suture in cat

J G Wray — Wed, 20 Sep 2017 07:32:29 GMT

[quote user="Michael Woodhouse"]To be absolutely clear I don't believe anything I'm doing is professionally risky or reckless or risking animal welfare.[/quote]

It's naive to believe that you are the sole arbiter of whether you are risking animal welfare. You have a professional regulator. The aspect of the Code relating to these activities is one of the more unequivocal and it only takes a client complaint to have this tested for you.

In following through that complaint you can be sure the regulator will, by their own process, dissect all aspects of the patient's case handling, from whether there was truly informed consent given for the novice to operate through to clinical outcome and now and in the future whether the client has reason or not to be unhappy with the outcome.

The RCVS have this process, but what is lacking for the general practicing profession in my view has two elements. Firstly, there is no discussion around how a vet might go through a process, recognised by RCVS, and get to a point where operating is a reasonable thing to do for a novice. Secondly, RCVS has hamstrung itself by only recognising knowledge by benchmarks of narrow qualification, which serve to mark a level of knowledge in one area yet in the same breath define what the limits of knowledge are.

An example - a patient with a pericardial effusion now needs to see a referral centre with a cardiologist.......and a thoracic surgeon. There are many more of course.

As Dr Barker has alluded, what seems like a perfectly reasonable idea has consequences.

Oh and I forgot to mention, that the other element missing from this area of regulation is that for most this discussion needs to take place in a commercial environment.

RE: toggle vs iliofemoral suture in cat

David Mills — Wed, 20 Sep 2017 00:57:19 GMT

[quote user="Michael Woodhouse"]

[quote user="David Mills"]Trying to be more, er, accepting after turning 34 last week.Work in progress...[/quote]

Spring chicken. I'm 35 very soon. No plans whatsoever of behaving.

[/quote]

Yep but you're married with dogs. I'm single kicking about in London. One learns... Restraint.

RE: toggle vs iliofemoral suture in cat

Michael Woodhouse — Wed, 20 Sep 2017 00:07:08 GMT

[quote user="David Mills"]Trying to be more, er, accepting after turning 34 last week.Work in progress...[/quote]

Spring chicken. I'm 35 very soon. No plans whatsoever of behaving.

RE: toggle vs iliofemoral suture in cat

David Mills — Tue, 19 Sep 2017 23:51:47 GMT

[quote user="Malcolm Ness"]Remarkably diplomatic for you! The pin in question is poorly placed.[/quote]

Trying to be more, er, accepting after turning 34 last week.Work in progress...

RE: toggle vs iliofemoral suture in cat

Kate Richardson — Tue, 19 Sep 2017 22:52:28 GMT

So, with these surgical approaches, how much cage rest do these cats need?

RE: toggle vs iliofemoral suture in cat

Michael Woodhouse — Tue, 19 Sep 2017 22:32:31 GMT

[quote user="Chris Barker"]I consider myself a competent first opinion surgeon, capable of a broad range of surgical techniques. [/quote]

As do I.

[quote user="Chris Barker"]Guess when I qualified...?[/quote]

Before 2006?

[quote user="Chris Barker"]

The Code of Professional Conduct insists that (1.2) ‘veterinary surgeons must keep within their own area of competence and refer cases responsibly.’

The Code's supporting guidance requires that (1.3) ‘veterinary surgeons should recognise when a case or a treatment option is outside their area of competence and be prepared to refer it to a colleague, organisation or institution, whom they are satisfied is competent to carry out the investigations or treatment involved’.

Effectively ensuring the welfare of animals by discouraging the have-a-go professional.

[/quote]

Just because I've never placed a chest tube in a cat before doesn't mean that doing so is 'outside my area of competence'. I have lots of surgical experience and checked proper technique. We make it very clear when doing orthopaedics that we are not specialists and this is only a small part of our workload, but we generally get good results. I've lost count of the number of times I've told people I've never done something before, but I'm still happy doing the op and the owners have never changed their mind at that point.

To be absolutely clear I don't believe anything I'm doing is professionally risky or reckless or risking animal welfare.

RE: toggle vs iliofemoral suture in cat

Chris Barker — Tue, 19 Sep 2017 21:03:45 GMT

[quote user="J G Wray"]

The erstwhile Registrar/Head of RCVS Professional Conduct Mr Hockey made it his personal mission, from when he first arrived, to root out "have a go" vets. It's a long time ago now but I never forgot.

I wonder what RCVS policy on this sort of thing is now?

[/quote]

The Code of Professional Conduct insists that (1.2) ‘veterinary surgeons must keep within their own area of competence and refer cases responsibly.’

Effectively ensuring the welfare of animals by discouraging the have-a-go professional.

However there is the contrary view. That as a result of obediently ‘keeping within their own area of competence’ vets have become defensive, reluctant to try new/to them 'novel' techniques. That first opinion practice is becoming deskilled, with owners increasingly poorly served by having to visit referral centres for all but the most basic of surgeries. That as a consequence veterinary surgeons have become dissatisfied with their lot, consulting from eight to eight, watching all interesting surgeries either referred or ‘hogged’ by the bosses of the practice. Who began their own professional careers at a time when the only referral centres were the Universities, when if you didn’t have a go then for many pets it didn’t get done, Dr Google had yet to be invented, and fear of legal redress was far, far lower…

I consider myself a competent first opinion surgeon, capable of a broad range of surgical techniques. Guess when I qualified...?

RE: toggle vs iliofemoral suture in cat

Malcolm Ness — Tue, 19 Sep 2017 19:12:20 GMT

[quote user="David Mills"]Yes I saw that paper, and I think we have to very careful with such small numbers and the methodology isn't clear (or even the surgical technique). Interestingly the radiograph in it suggests suboptimal placement of the pin.[/quote]

Remarkably diplomatic for you! The pin in question is poorly placed.

[quote user="David Mills"]Malcolm, do you adhere to the opinion that on radiographs if there's a bone fragment within the joint space (from the avulsed teres) that closed reduction is more likely to be unsuccessful? I've never seen it but it always interested me.[/quote]

Intra-articular bone fragments certainly add difficulty, not least with diagnosis - it can be very difficult to identify the origin of the fragment and equally difficult to know its size. In cats, this is a relatively uncommon occurrence. That said, if the hip goes back in and stays and the cat starts using the leg again confidently and quickly then you haven't lost anything.

[quote user="David Mills"]Do people still whack closed reductions with a copy of Fossum??[/quote]

I was taught to do that, though not with Fossum (Dr Fossum was probably still in junior school at the time, she certainly hadn't yet started on her publishing career). I am not sure that there is any point and it isn't something I do now.

RE: toggle vs iliofemoral suture in cat

John Wessels — Tue, 19 Sep 2017 19:02:43 GMT

Wray:

'Weeeeeelll, in a way I do, because one man's have-a-go vet because they have an inflated view of their capacity, is another man's personal and professional development where they've got to start somewhere.''

Who has the inflated view?

RE: toggle vs iliofemoral suture in cat

Rob Loxley — Tue, 19 Sep 2017 18:48:49 GMT

[quote user="David Mills"]Do people still whack closed reductions with a copy of Fossum??[/quote]

in the 21st century, careful not to crack your ipad screen...

RE: toggle vs iliofemoral suture in cat

David Mills — Tue, 19 Sep 2017 13:56:12 GMT

[quote user="Michael Woodhouse"]

[quote user="David Mills"]Transarticular pin is my favoured approach.[/quote]

http://veterinaryrecord.bmj.com/content/early/2016/01/29/vr.103319

May I ask why and not toggles?

[/quote]

Yes I saw that paper, and I think we have to very careful with such small numbers and the methodology isn't clear (or even the surgical technique). Interestingly the radiograph in it suggests suboptimal placement of the pin.

It was the way I was taught on a CPD course by an experienced orthopod (whose opinion I greatly trust) and by a former Diplomat colleague as the most straightforward, adaptable technique and I have used it a few times successfully since (as they had). I can see the merits of toggling but I have had no reason to deviate and it does appear a little fiddly to me. With pinning, as many things, there are certain technical points that must be adhered to.

[quote user="Malcolm Ness"]Preferred option is to attempt open reduction - locate and excise torn ends (both) of Teres ligament (which is swollen and prevents good hip reduction). Reduce hip and carefully re-appose remaining joint capsule and other adjacent soft tissues. Do not attempt to imbricate, tighten or "stabilise", just suture as much back where it should be as you are able. Although the intra-operative appearance might seem very tenuous, the majority of hip laxations can be effectively managed like this with the expectation of a good long term outcome.[/quote]

This is very interesting though as I've always been put off by the apparently ragged remnants in most cases, but I'll try this next time rather than reaching for metalwork.

As luck would have it we had a cat in yesterday with a luxated hip - sounds like happened 3 days ago - replaced and was sure it would come out, but it's still in. Disappointing in the best way.

Malcolm, do you adhere to the opinion that on radiographs if there's a bone fragment within the joint space (from the avulsed teres) that closed reduction is more likely to be unsuccessful? I've never seen it but it always interested me.

Do people still whack closed reductions with a copy of Fossum??

RE: toggle vs iliofemoral suture in cat

J G Wray — Tue, 19 Sep 2017 13:29:06 GMT

[quote user="John Wessels"]Do you really care?[/quote]

Weeeeeelll, in a way I do, because one man's have-a-go vet because they have an inflated view of their capacity, is another man's personal and professional development where they've got to start somewhere.

There has been a discussion about the stifling of ambition through the degree course and proximity of academics reinforced by the threat of regulatory process if you go outside some loosely determined personal ability, leading to absence of personal development and a mentality which is geared to referral - breathless sentence.

RE: toggle vs iliofemoral suture in cat

John Wessels — Tue, 19 Sep 2017 13:20:55 GMT

[quote user="J G Wray"]

[quote user="Michael Woodhouse"]As I did say in the other thread - I'm not a cat vet. I just like fixing things and doing something different[/quote]

Just sayin'

I wonder what RCVS policy on this sort of thing is now?

[/quote]Do you really care?