Complications in Canine Cranial Cruciate Ligament Surgery. Ron Ben-Amotz
antimicrobial protocols should be considered. Many factors can contribute to an individual's estimated risk for developing an SSI and these should be considered together before deciding to use postoperative antimicrobials. Postoperative antimicrobials should never be used as a surrogate for aseptic technique and good surgical practices.
2.6 Surveillance
Infection control in veterinary medicine tends to be reactive instead of proactive. SSIs are often identified only when animals present for clinical signs associated with SSIs or when incidentally identified during a routine follow‐up examination. This is considered to be a form of passive surveillance, where no specific effort is made to identify SSIs [68]. Alternatively, active surveillance occurs when specific outcomes or indicators are sought to increase the rate of detection [85].
The goals of an active SSI surveillance program are to create a monitoring system that will determine the baseline level of expected SSI within a facility. By determining the baseline, a critical limit (a value beyond the expected SSI rate) can be established to determine when interventions should be employed to reduce the risk of SSI [84]. For active surveillance to be universal, definitions of outcomes must be provided. This would require defining what constitutes an SSI (see Chapter 3 for further details) as well as defining clinical signs that may be associated with an SSI and thus warrant further direct investigation of the patient. In relation to postoperative SSIs, active surveillance can be achieved through scheduled owner contact using telephone interviews or electronic questionnaires or by communication with referring veterinarians [1, 86]. During this contact, questions can be posed with regard to incisional healing, local tissue recovery, limb use, as well as if medical interventions have been required. Ideally, these forms of communication would be performed more than once during the patient's recovery period, encompassing timeframes associated with early development (within 30 days of surgery) and late development of SSI (within 90 days of surgery) [87].
In veterinary medicine, two prospective studies using active postdischarge surveillance for assessment of SSIs identified that 27.8–35% of all SSIs would have been missed without active surveillance [1, 86]. This is not an insignificant finding and therefore should encourage the development of active surveillance practices for SSI assessment.
2.7 Conclusion
Overall, TPLO has higher reported rates of SSI than other methods of stifle stabilization for cranial cruciate ligament ruptures (6,10,12–20,22,24,25). This may be due to the increased soft tissue dissection, thermal necrosis of the bone, and increased surgical times compared to extracapsular repairs. When compared to other tibial osteotomies, the overall higher incidence of SSIs may only be due to the increased frequency with which TPLOs are performed and thus reported.
As SSIs lead to further medical or surgical interventions, they have been identified to cause an increased financial burden for owners, along with increased morbidity for our veterinary patients [28, 88]. Despite the increased costs, protracted recoveries and increased patient morbidities, owner assessment of long‐term outcome was not significantly affected [23]. While not all risk factors can be controlled, many risk factors can be addressed with diligent surgeon and patient preoperative preparation. Additionally, active surveillance may help to improve the rate of identification of SSIs, which may lead to earlier interventions.
References
1 1. Turk, R., Singh, A., and Weese, J.S. (2015). Prospective surgical site infection surveillance in dogs. Vet. Surg. 44: 2–8.
2 2. Eugster, S., Schawalder, P., Gaschen, F., and Boerlin, P. (2004). A prospective study of postoperative surgical site infections in dogs and cats. Vet. Surg. 33: 542–550.
3 3. Nicholson, M., Beal, M., Shofer, F., and Brown, D.C. (2002). Epidemiologic evaluation of postoperative wound infection in clean‐contaminated wounds: a retrospective study of 239 dogs and cats. Vet. Surg. 31: 577–581.
4 4. Fitzpatrick, N. and Solano, M.A. (2010). Predictive variables for complications after TPLO with stifle inspection by arthrotomy in 1000 consecutive dogs. Vet. Surg. 39: 460–474.
5 5. Beal, M.W., Brown, D.C., and Shofer, F. (2000). The effects of perioperative hypothermia and the duration of anesthesia on postoperative wound infection rate in clean wounds: a retrospective study. Vet. Surg. 29: 123–127.
6 6. Frey, T.N., Hoelzler, M.G., Scavelli, T.D. et al. (2010). Risk factors for surgical site infection‐inflammation in dogs undergoing surgery for rupture of the cranial cruciate ligament: 902 cases (2005–2006). J. Am. Vet. Med. Assoc. 236 (1): 88–94.
7 7. Vasseur, P.B., Levy, J., Dowd, E., and Eliot, J. (1988). Surgical wound infection rates in dogs and cats: data from a teaching hospital. Vet. Surg. 17 (2): 60–64.
8 8. Aiken, M.J., Hughes, T.K., Abercromby, R.H. et al. (2015). Prospective, randomized comparison of the effect of two antimicrobial regimes on surgical site infection rate in dogs undergoing orthopedic implant surgery. Vet. Surg. 44: 661–667.
9 9. Pratesi, A., Moores, A.P., Downes, C. et al. (2015). Efficacy of postoperative antimicrobial use for clean orthopedic implant surgery in dogs: a prospective randomized study in 100 consecutive cases. Vet. Surg. 44: 653–660.
10 10. Casale, S.A. and McCarthy, R.J. (2009). Complications associated with lateral fabellotibial suture surgery for cranial cruciate ligament injury in dogs: 363 cases (1997‐2005). J. Am. Vet. Med. Assoc. 234: 229–235.
11 11. Dulisch, M. (1981). Suture reaction following extra‐articular stabilization in the dog. Part II: a prospective study of 66 stifles. J. Am. Anim. Hosp. Assoc. 17: 572–574.
12 12. Rappa, N.S. and Radasch, R.M. (2016). Post‐operative complications associated with the Arthrex Canine Cranial Cruciate Ligament Repair Anchor System in small‐ to medium‐sized dogs: a retrospective analysis (2009–2012). Can. J. Vet. Res. 57: 847–852.
13 13. Nazarali, A., Singh, A., and Weese, J.S. (2014). Perioperative administration of antimicrobials during tibial plateau leveling osteotomy. Vet. Surg. 43: 966–971.
14 14. Clark, A.C., Greco, J.J., and Bergman, P.J. (2020). Influence of administration of antimicrobial medications after tibial plateau leveling osteotomy on surgical site infections: a retrospective study of 308 dogs. Vet. Surg. 49: 106–113.
15 15. Wolf, R.E., Scavelli, T.D., Hoelzler, M.G. et al. (2012). Surgical and postoperative complications associated with tibial tuberosity advancement for cranial cruciate ligament rupture in dogs: 458 cases (2007–2009). J. Am. Vet. Med. Assoc. 240 (12): 1481–1487.
16 16. Yap, F.W., Calvo, I., Smith, K.D., and Parkin, T. (2015). Perioperative risk factors for surgical site infection in tibial tuberosity advancement: 224 stifles. Vet. Comp. Orthop. Traumatol. 28: 199–206.
17 17. Costa, M., Craig, D., Cambridge, T. et al. (2017). Major complications of tibial tuberosity advancement in 1613 dogs. Vet. Surg. 46: 494–500.
18 18. Serratore, V.R. and Barnhart, M.D. (2018). Results and complications after removal of tibial tuberosity advancement cage for treatment of surgical site infections: a retrospective study. Vet. Surg. 47: 768–773.
19 19. Tuan, J., Solano, M.A., and Danielski, A. (2019). Risk of infection after double locking plate and screw fixation of tibial plateau leveling osteotomies in dogs weighing greater than 50 kilograms. Vet. Surg. 48: 1211–1217.
20 20. Watson, F.C., McMullan, W., Jordan, C.J. et al. (2019). The use of absorbable staples for skin closure after tibial plateau leveling osteotomy. Vet. Surg. 48: 35–41.
21 21. Nazarali, A., Singh, A., Moens, N.M.M. et al. (2015). Association between methicillin‐resistant Staphylococcus pseudintermedius carriage and the development of surgical site infections following tibial plateau leveling osteotomy in dogs. J. Am. Vet. Med. Assoc. 247 (8): 909–916.
22 22. Hans, E.C., Barnhart, M.D., Kennedy, S.C., and Naber, S.J. (2017). Comparison of complications following tibial tuberosity advancement