Case Studies

Patient Signalment: Nine-year-old Quarter Horse Mare
Diagnosis: Right Hind Dorsal Fetlock Laceration and Trauma

INITIAL SURGERY

Diagnosis and Procedure (April 3, 2024):

Mare presented with a severe right hind dorsal fetlock laceration and trauma. The injury included torn joint capsule transected digital extensor tendon. surgical intervention included:

• Surgical debridement: Removal of damaged tissue to prevent infection.
• Regional limb perfusion: Infusion of 500 mg of Meropenem and 60 cc of saline to deliver antibiotics directly to the affected area.
• Fetlock joint lavage: Cleansing of the joint using Povidone-Iodine in Lactated Ringer’s.
• Vetlen Pouch placement: Dosed with 9 ml Amikacin (250 mg/ml) daily.
• Wound closure: Skin laceration was closed, although much of the subcutaneous tissue was too damaged to repair fully.

Assessment: Despite the extensive trauma, including a shredded extensor tendon and avulsed joint capsule, initial surgery aimed to stabilize the limb and minimize infection. A cast was applied to immobilize the fetlock, critical for healing given the tissue damage. The Vetlen Pouch's efficacy would be monitored, and the cast might be changed based on the mare’s comfort and healing progress.

Follow-Up Examination & Vetlen Pouch Explantation (April 18, 2024) Examination Findings:

• Healing status: The wound and joint capsule were healing well with minimal skin loss.
• Lameness: 5/5 Lame initially post-injury.
• Suture removal and cast change: The wound showed favorable healing, indicating effective management of infection and tissue repair.

Prognosis and Recommendations: The extensor tendon typically requires 3-4 months for functional healing. The next cast change was scheduled for May 1st, transitioning to a bandage cast and eventually a splint to protect the fetlock from excessive flexion.

Follow-Up Examination (May 2, 2024)

Four weeks post-trauma, mare showed significant healing of the fetlock joint capsule avulsion, long digital extensor tendon transection, and dorsal fetlock laceration.

Examination Findings:

• Lameness: 0/5 Lame at the walk, indicating significant improvement.
• Wound condition: Healthy granulation tissue filled the wound, though some skin loss due to disrupted blood supply was noted.
• Radiographs: Normal, with no bone or joint damage.
• Cast change: Transitioned from an immobilizing cast to a bandage cast to allow controlled motion while preventing excessive flexion.

Prognosis and Recommendations: The prognosis remained favorable. Continued stall rest and careful monitoring were advised. The bandage cast would be split into a splint in one week to protect the healing tendon. The support shoe on the left hind foot would remain for another 1-2 weeks. Hand grazing would commence in two weeks, with targeted purposeful walking starting two months post-injury.

Future Management: Mare’s recovery trajectory was positive, with careful management ensuring the tendon and joint capsule heal without complications. Monitoring for any signs of infection or discomfort remained crucial, with adaptive treatment based on her progress.

Conclusion: Mare’s case demonstrates the potential of the Vetlen Pouch in managing severe equine wounds by providing sustained local antibiotic delivery. Her recovery, though complex, highlights the importance of innovative veterinary devices in improving treatment outcomes for traumatic injuries.

Patient Signalment: Seven-year-old Male (Neutered) German Shepherd

Diagnosis: Chronic multi-drug resistant wound (> 1 year) lateral to anus

INITIAL SURGERY

History and Vetlen Pouch Placement:

• The patient presented with a chronic wound of greater than one year lateral to the anus. This is not a perianal fistula.
• Culture shows multi-drug resistance (MDR) Staphylococcus pseudointermedius.
• Due to the location, closure rather than open wound management was desirable.
• The Vetlen Pouch was placed on April 19, 2024.
• Treated with Amikacin – 5 mL @ 250 mg/mL for 1 week.

Assessment:

The Vetlen Pouch offers an additional option for longer-term administration. The pouch was great for this patient as it spared them the potential adverse effects from systemic administration. The Vetlen Pouch was removed on April 26, 2024.

The patient healed well and there has been no recurrence.

Patient Signalment: Six-Year-Old Quarter Horse Gelding

Diagnosis: Infected Supraspinous Bursa (Fistulous Withers)

INITIAL SURGERY

Diagnosis and Procedure:

Current case is an infected supraspinous bursa, failed medical management. Resection of the affected nuchal ligament and bursa performed after about four weeks of medical management. Picture of wound prior to pouch placement on December 16, 2023.

• Antibiotic prescribed: Amikacin 250 mg/ml
• Daily dose administered: 5 ml
• Days of treatment: 26 days
• Additional treatments: Ceftiofur sodium and gentamicin systemically dosed for the first 16 days of treatment.
• Culture result: A very resistant Enterobacter cloacae susceptible to amikacin and imipenem.

Vetlen Pouch Explanation

Infused 20 ml lidocaine (two percent) one hour prior to removal, and mildly sedated the patient at time of removal. The pouch came out seamlessly without any issues and was a very painless experience for both the patient and doctor.

Vetlen Pouch Assessment

The Vetlen Pouch allowed for targeted antimicrobial therapy when dealing with a deep surgical site infection, which cultured a multi-drug-resistant bacteria. Systemic administration of the necessary antimicrobial would have been extremely cost prohibitive, and the pouch allowed for easy, daily dosing (once) at a much smaller, but locally effective volume. Additional wound care and treatment of the surgical site was also possible while leaving the pouch in situ. I would absolutely consider the use of this product for other cases in the future.

Diagnosis and Procedure: Degenerative arthritis of the fetlock joint, pain leading to overloading the other foot. Fetlock arthrodesis was performed.

Treatment:
Amikacin 250 mg/ml
Daily dose administered: 6 ml
Days of treatment: 5 days

Conclusion: Vetlen Pouch worked well. The surgeon liked the ability to instill the antibiotics onto the plate for 5-days post-op. The mare has done well and is back home.

Patient Signalment: Two-Year-Old Mustang

Diagnosis: Thoracic Puncture Wound Leading to Splenic
Abscess

Treatment: Vetlen Pouch placed inside wound and treated with
10 mL ceftiofur every 24 hours for 4 days.

Outcome: Response to Vetlen Pouch for this case was impressive.

History:

Dog diagnosed with probable torn Achilles in March and treated with Gabapentin and Galliprant. Dog had previously torn CCL on RH and has a history of seizures. Toe touching lameness progressed into flattening of the left hind limb and dog was referred for potential surgical correction.

Diagnosis:

• Achilles tendon rupture – left complete, degenerative, possibly early right degeneration
• Cranial cruciate ligament tear – right extracapsular stabilization with persistent instability

Surgical Treatment Timeline:
The tendon was debrided and repaired by reattaching to the calcaneous. The repair site was wrapped in porcine collagen sheeting and injected with PRP to aid in healing. A screw was placed from calcaneous into tibia/fibula to maintain the tarsus in extension. Cast placed, recheck in one week.

9 Days Post-op: Grade III/IV lame in left and right rear limbs. Left cast in place, purulent discharge noted from incision. Culture obtained and cast replaced with a mepilex bandage. Right stifle remains unstable.

Culture confirmed surgical site infection, patient prescribed Baytril and Chloramphenicol. Bandage was intact and incision was intact with serosanguinous drainage. Calcaneal tendon and tibiocalcaneal screw palpated stable.

21 Days Post-op: Surgical site infection persisted and patients experienced intermittent vomiting and reduced appetite. Chloramphenicol discontinued and replaced with amikacin 750mg SC SID for 10 days.

36 Days Post-Achilles Repair: Dog underwent TPLO surgery for right hind CCL repair.

42 Days Post-Achilles Repair: A draining tract was present on the lateral aspect of the tarsus and the tissue around it was swollen. Culture taken and radiographs revealed lysis of the calcaneus due to suspected osteomyelitis. The tibiocalcaneal screw was intact. Amikacin 750mg SC SID prescribed.

47 Days Post-Achilles Repair:

Implant removed and Kerrier beads placed

Calcaneal screw was removed, screw was loose. Tendon palpated intact with sutures and discolored periseal visualized. Numerable amikacin Kerrier beads placed in the screw tract and around the site to capacity. Cast replaced.

15 Days Post-Bead Placement, 62 Days Post-Achilles Repair: Cast removed with marked malodorous discharge from proximal incision, purulent with beads being extruded. Culture obtained, site cleaned, and honey bandage placed with lateral component of splint. Owner advised if infection cannot be controlled, aggressive debridement and long-term support via custom orthotic or pantarsal arthrodesis once infection is 100% cleared.

43 Days Post-Bead Placement, 90 Days Post-Achilles Repair: Multiple rechecks over the last 30 days show persistent infection with the Kerrier beads extruding. Grade III/IV lame left rear limb with plantigrade stance and persistent purulent discharge from proximal aspect of the lateral hock incision and strike through on the bandage. Recommend custom orthotic brace and re-cultured to determine treatment plan.

48 Days Post-bead Placement, 95 Days Post-Achilles Repair

Vetlen Pouch Placement to Treat MSRP Infection and Implant Removal

Under brief anesthesia, a lateral approach to the left Achilles was performed. The previously placed periseal and all identifiable prolene sutures were removed. Copious lavage and sponge debridement. A Vetlen Pouch was placed and the tube exited proximal lateral tibia. Pouch secured via 3-0 PDS distal tacking suture and tube secured via tacking sutures. Site closed via 3-0 PDS SC and skin staples. Vetlen Pouch doses with 750 mg of amikacin daily.

15 Days Post- Vetlen Pouch Placement: The pouch was removed without incident, with some of the pouch already migrating out of the wound.

11 Weeks Post Implant Removal: Grade I/IV lame, patient stable with custom orthotic. No sign of infection.

Assessment: The Vetlen Pouch was very easy to place (similar to any JP drain) and simple for owners to use at home with the daily injections. It was very well tolerated by the dog in this case.