Association of Avian Veterinarians

A Novel Approach to the Treatment of Bumblefoot in Penguins Author(s): Thomas H. Reidarson, James McBain and Laurie Burch Reviewed work(s): Source: Journal of Avian Medicine and Surgery, Vol. 13, No. 2 (Jun., 1999), pp. 124-127 Published by: Association of Avian Veterinarians Stable URL: http://www.jstor.org/stable/30135216 . Accessed: 14/03/2013 21:47
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Journal of Avian Medicine and Surgery 13(2):124-127, 1999 C 1999 by the Association of Avian Veterinarians

A Novel Approach to the Treatment of Bumblefoot in Penguins

Thomas H. Reidarson, DVM, James McBain, DVM, and Laurie Burch
Abstract: Bumblefoot in penguins is a serious disease that, if left untreated,can lead to death. Althoughunprovenin penguins,the cause may be analogousto that in raptorswhere environmental conditions and husbandrypractices are central to the cause and preventionof the problem. We developed a treatmentprotocol for bumblefoot in penguins that involves surgical debridement, flushing,complete closure, topical wound dressings,and bandagechanges every 2 to 3 days. At 10 to 14 days after surgery, the penguin is fitted with a neoprenebootie, or "iceflo," which can be worn for 2 to 3 months to protectthe surgicalsite and improvehealing. The procedureis palliative and unfortunately not curativein all patients.The key to resolvingthis conditionrests in prevention, colder ambienttemperature, increasedfeeding in the water,and forced includingimprovedsubstrate, swimming of individualbirds that tend to stand on land for long periods of time.
Key words: bumblefoot, pododermatitis, neoprene shoe, Adelie penguin, Pygoscelis adeliae

Introduction Bumblefoot (pododermatitis) is a serious problem in several species of Antarctic and sub-Antarctic penguins.'-3 Although unproven, the cause of bumblefoot in penguins may be analogous to that described by Harcourt-Brown in raptors.4 The process is multifactorial and is principally related to an avascular necrosis of the plantar surface of the foot as a consequence of standing for excessive periods. The major contributing factors to bumblefoot development are the bird's weight, the substrate surface type, and an abnormally sedentary life style. Because of abnormal weight-bearing on one portion of the foot, perfusion of dermal tissue becomes compromised, ultimately allowing normal epithelial microbial inhabitants to breach the dermis. Local trauma, poor hygiene, and nutritional deficiencies also may be contributing factors. To date, clinical staging schemes of bumblefoot in penguins have not been standardized; therefore, most clinicians rely on either the three- or five-stage classification schemes described by Cooper5 and Remple,6 respectively. We prefer to use Cooper's three-stage classification of lesions. A type 1 lesion is mild and localized (with or without heat and swelling of the central metatarsal pad), and is either degenerative, causing a flattened epithelium, or proliferative, causing hypertrophy of the epithelium
From SeaWorld of California, 500 Sea World Drive, San Diego, CA 92109, USA.

and eventually a corn. A type 2 lesion is more extensive and results from progression of a type 1 condition. The lesion is chronic and always infected with a variety of bacteria. As the infection spreads to the dermis and soft tissues of the foot, the pad becomes warm and painful and the penguin eventually becomes non-weight-bearing. A type 3 lesion is chronic, infected, and degenerative. The infection is deep enough to involve tendons, bone, and joints, similar to that seen in untreated or unresponsive bumblefoot lesions in raptors. Of the six species of penguins exhibited at SeaWorld of California's Penguin Encounter, the Adelie penguin (Pygoscelis adeliae) has the greatest incidence of bumblefoot. In a 1994 survey of penguins in this collection, 64% (69 of 107) of Adelie penguins had some degree of bumblefoot, and 83% of affected penguins had lesions on both feet (Reidarson, unpublished data, 1994). Disease was observed in all age classes of penguins, with type 1 disease observed in birds as young as 1 year of age. Classified by the three-stage method, 25% of penguins had type 1 lesions, 36% had type 2 lesions, and 4% had type 3 lesions. No differences in prevalence due to gender or method of rearing (handreared versus parent-reared versus wild-caught) was found. In this report, we describe a unique approach that we developed for treating bumblefoot in penguins. This approach involves surgery, bandaging, protection with a neoprene shoe, and long-term foot care. 124

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Potential causes of bumblefoot in penguins and methods of prevention are discussed. Clinical Technique Penguins with bumblefoot usually present because of a slight limp. On examination, a raised or indurated transverse lesion is present on the central portion of the plantar metatarsal pad (type 1). More severe lesions include swollen red pads (type 2). In some birds, cellulitis extends up the entire limb, whereas in others, infectious tenosynovitis, osteomyelitis, or deep-seated abscesses involve the metatarsal pad, tendons, or both (type 3). Usually only 10% of these abscesses are sterile; the remainder are infected with aerobic bacteria including (in descending order of prevalence) Escherichia coli, Corynebacteria species, Staphylococcus aureus, Aerococcus viridans, Bacillus species, Group D Enterococcus, and Enterococcus faecalis. Other less frequently cultured microorganisms include Candida stellatoidea, Moraxella species, Plesiomonas shigelloides, Serratia liquefaciens, Bacillus species, and other Staphylococcus and Streptococcus species. Surgery is performed on all penguins with painful, infected, enlarged metatarsal lesions (type 2 or 3). On the morning of surgery, the patient is treated with either clindamycin (Cleocin, Biocraft Laboratories, Elmwood, NJ, USA) at 75 mg/kg IM or enrofloxacin (Baytril, Miles, Shawnee Mission, KS, USA) at 10 mg/kg IM, or both. The penguin is anesthetized with isoflurane administered by mask. The bumblefoot lesions are completely debrided and flushed with 1:20 dilution of chlorhexidine (Nolvasan, Fort Dodge Laboratories, Fort Dodge, IA, USA) to saline. The skin is then closed with 3-0 polyglactin 910 (Vicryl, Ethicon, Somerville, NJ, USA) in a one-layer simple interrupted pattern of the dermis and epidermis. A topical solution, consisting of 22.7 mg of enrofloxacin, 1 ml of dimethyl sulfoxide (Diamond Laboratories, Des Moines, IA, USA), and 2 mg dexamethasone is applied to a 2 x 2-inch cotton gauze and placed over the wound, followed by a layer of elastic bandage (Equi-flex, Vetus Animal Health, Burns Veterinary Supply, Rockville Centre, NY, USA). Bandages are changed every 3 days, and the incision site is cleaned with a dilute chlorhexidine solution before the topical dressing and a new bandage is reapplied. Most penguins are treated with enrofloxacin (10 mg/kg PO ql2h), clindamycin (75 mg/kg PO ql2h), or both, based on results of culture and sensitivity testing of swab or tissue samples of the bumblefoot lesions. Depending on the severity of the lesions

Figure 1. A neoprene shoe constructedfrom a wetsuit bootie designed to protect a penguin's foot after surgery for bumblefoot.Notice the tall heel, which preventsslippage, and the Velcro fasteners, which allow fine adjustments for a better fit. The shoe can be worn for 2 to 3 months duringthe long healing process. and the progression of healing, antimicrobial therapy is continued for 1 to 3 months. Because bumblefoot lesions heal slowly, longterm protection of the foot is necessary. Usually, the lesion improves significantly within 10 to 14 days, at which time topical therapy is discontinued and the bird is fitted with a custom-designed shoe (or "iceflo," Fig. 1). The iceflo is made from a neoprene wetsuit bootie and provides excellent protection of the foot as well as an aesthetic wrap for birds on display. The iceflo shoe is constructed as follows. The heel from a small wetsuit bootie is cut out to a length that is short enough to allow the penguin's nails to be exposed. To prevent the shoe from riding up around the penguin's ankle, the height of the heel is at least 5 cm. Two Velcro straps (Velcro USA, Manchester, NH, USA) are used to secure the shoe to the penguin's foot. The first is placed above the heel support by cutting two vertical slits in the heel support through which the Velcro is weaved. The Velcro strip is positioned outside the heel support to minimize contact with the skin. Two horizontal slits are cut on the side of the bootie above the sole. The second piece of Velcro is passed through each slit so that the soft side is facing up, then the Velcro is slid along the sole of the shoe and glued to the sole. The Velcro is trimmed as needed to fit around

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the penguin's foot. To protect and insulate the surgical site, a heel insert is cut in the shape of the metatarsal pad from a piece of neoprene. A hole is cut in the center to accommodate the shape and size of the lesion, and the insert is then glued into the heel of the shoe. Although most penguins have bilateral disease, all surgeries thus far have been unilateral, and all patients have been fitted with a single shoe. After making necessary fitting adjustments, nearly all patients have tolerated the iceflo quite well. The shoe maintains suture integrity long enough to provide complete healing at the incision site. Usually the shoe remains in place for 2 to 3 months, at which time the sutures are removed if they have not already fallen out. The foot is examined and cleaned with a dilute chlorhexidine solution or clean water at least every 3 to 7 days while the bird is wearing the iceflo. Long daily swims are important in treatment. Swimming relieves pressure from the wound, provides a natural cleansing, and increases pedal circulation to aid in healing. Treated birds usually exit the pool unencumbered by the shoe. Not surprisingly, most penguins that are lame or non-weight-bearing before surgery stand and walk dramatically better immediately after surgery. They continue to improve after being fitted with the iceflo shoe. Discussion Bumblefoot or pododermatitis is an inflammatory and degenerative condition of avian feet that most commonly arises as a consequence of avascular necrosis. If left untreated or inadequately treated, bumblefoot can lead to deep-seated abscesses and bony changes.7-'" The pathogenesis of bumblefoot in penguins is undetermined. However, contributing factors include malnutrition, vitamin A and E deficiencies, systemic diseases, changes in the mechanics of weight-bearing mechanics of the metatarsal pads, inappropriate perching substrate, and inactivity leading to extended periods of time that the bird is standing. 8-10 Although poorly studied, bumblefoot in penguins seems to share many of the characteristics of that seen in other susceptible avian species. Likewise, prevention and therapy should be similar to that in those species. Understanding the natural history of penguins may illuminate some of the causes of bumblefoot. In the wild, most penguins spend less than 20% of their time on land (during breeding, chick-rearing, and moulting), with the remainder of their time spent in water.'2 The high incidence of

bumblefoot in Adelie penguins at SeaWorld may be related to their spending long periods of time defending nesting territory during nonbreeding times when they should be in the water.'3 Additionally, the penguins in this collection are fed predominantly on land rather than in water, which encourages individuals to spend more time on land. As with raptors that are forced to perch for extended periods, bumblefoot appears to be more common in these penguins. The type and quality of substrate (ie, snow, ice, rocks, and dirt) are extremely important to the health of the foot. Although they nest on smooth river rocks, Adelie penguins spend most of their time on land, standing on ice or snow. To ensure that clean and dry substrate is always available, ice and snow are cleaned and replaced daily, and the ambient temperature is maintained at -5 to -30C. To reduce the amount of time spent standing on land, all individuals are placed into the water as often as possible and encouraged to swim by increasing feeding opportunities in the water. These practices have reduced the incidence of bumblefoot quite dramatically. The neoprene shoe we developed provides a protective surface against abrasion, while allowing the incision site to breathe. Because penguin feet are well adapted to extreme cold with a very efficient countercurrent heat exchange mechanism,t2 the shoe may also aid in insulating the exposed lesion to improve healing. The piece of neoprene within the sole of the shoe, modified with the center cut out in the shape of the lesion, acts to elevate the healing wound from the shoe and relieve pressure over the incision site. In addition, the Velcro fasteners allow fine adjustments to be made for better fit. The surgical procedure and postoperative care we describe are only palliative and are not curative for all cases of bumblefoot in penguins. In most penguins, scar tissue forms at the surgical site, creating an uncomfortable corn and providing a new avenue for infection. However, the scar seems smaller and softer in penguins fitted with the iceflo shoe compared with those without it. Most importantly, penguins treated with a shoe seem to be more comfortable for much longer periods of time. In fact, one penguin has worn two iceflo shoes for more than 2 years (Fig. 2). We have performed more than 30 surgeries on birds with type 2 and 3 lesions, with all individuals improving to varying degrees. Seven individuals with type 2 disease required two to three additional surgeries and three later progressed to type 3. The key to resolving bumblefoot in penguins rests in improving environmental and husbandry

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flo. This manuscript is SeaWorld Contribution 9707-C. References

1. Ellis S, Branch S. Penguin husbandry manual. Detroit, MI: American Zoo and Aquarium Association, 1994. 2. Stoskopf MK, Kennedy-Stoskopf S. Aquatic bird (Sphenisciformes, Gaviiformes, Podicipediformes, Procellariiformes, Pelecaniformes, and Charadriiformes). In: Fowler ME (ed). Zoo and wild animal medicine. Philadelphia: WB Saunders, 1986:293-313. 3. Stoskopf MK, Beall FB. The husbandry and medicine of captive penguins. Proc Am Assoc Zoo Vet 1980:81-96. 4. Harcourt-Brown NH. Foot and leg problems. In: Beynon PH, Forbes NA, Harcourt-Brown NH (eds). Manual of raptors, pigeons, and waterfowl. Ames: Iowa State University Press, 1996:147-164. 5. Cooper JE. Veterinary aspects of captive birds of prey. Gloucesterhire, UK: Standfast, 1978. 6. Remple JD. Raptor bumblefoot: a new treatment technique. In: Redig PT, Cooper JE, Remple JD, Hunter DB (eds). Raptor biomedicine. Minneapolis: University of Minnesota Press, 1993:154-160. 7. Remple JD, Al-Ashbal AA. Raptor bumblefoot: another look at histopathology and pathogenesis. In: Redig PT, Cooper JE, Remple JD, Hunter DB (eds). Raptor biomedicine. Minneapolis: University of Minnesota Press, 1993:92-98. 8. Redig PT. Bumblefoot. In: Fowler ME (ed). Zoo and wild animal medicine--current therapy 3. Philadelphia: WB Saunders, 1993:181-188. 9. Degernes LA, Talbot BJ, Muller LR. Prevention and treatment of bumblefoot in raptors. Wildl Rehab 1991;9:73-78. 10. Halliwell WH. Bumblefoot infections in birds-ofprey. J Zoo Anim Med 1975;6(4):8-10. 11. Redig PT. Raptors. In: Altman RB, Clubb SL, Dorrestein GM, Quesenberry K (eds). Avian medicine and surgery. Philadelphia: WB Saunders, 1997:927. 12. Williams TD. Introduction. In: Perrins CM, Bock WJ, Kikkawa J (eds). The penguins, Spheniscidae. New York: Oxford University Press, 1995:1-9, 108112. 13. Ellis-Joseph S. Patterns of incubation behavior in captive-housed Adelie penguins: implications for long-term penguin breeding programs. Am Assoc Zool Parks Aquariums Region Conf Proc 1990:115120.

Figure 2. An Adelie penguin (Pygoscelis adeliae) wearing two neoprene iceflo shoes after bumblefoot surgery. Note the toes extending beyond the shoe to allow airing of the lesion and traction on the snow. This individual has worn these shoes more than 2 years; however, most penguins wear a shoe 2 to 3 months postoperatively. practices. As long as penguins are allowed to spend long periods of time on land and the substrate quality is poor, penguins will be predisposed to bumblefoot. Because of this observation, several changes have been made in penguin husbandry at our facility. These include additional feedings in water rather than on land; colder environmental conditions to maintain cleaner, drier snow and ice; additional snow for better cushioning of the feet; and forced swimming for those individuals that tend to spend long periods of time on land. Further studies are needed to quantify the effect of these environmental, husbandry, and medical changes. However, until we can improve measures to prevent bumblefoot, we must continue to improve our treatment methods. We want to thank senior aviculAcknowledgments: turists Christy Simeone, Debbie Denton, and Michelle Graack for their valuable contributions to the design, construction, and implementation of the ice-

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