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15410 cover ITALIE 20-11-2006 12:21 Pagina 1

VOL. 16 - (2) - OCTOBER 2006 ISSN 1018-2357

Whatever the treatment, The European Journal of

we dont play around with urinary security.
Companion
Animal Practice
From now on, the entire Veterinary
Diet Feline* range bears the
S/O index logo, which guarantees
optimal urinary security.

THE EUROPEAN JOURNAL OF COMPANION ANIMAL PRACTICE - Vol. 16 - (2) - October 2006
Long-term analysis of the progression of hip arthrosis
after triple pelvic osteotomy 161

Retrospective study of owners perception on home

monitoring of blood glucose in diabetic dogs and cats 179

Inner ear dysfunction related to ear disease in

*Except RENAL (in dry form)

dogs and cats 127

Rehabilitation Therapies for musculoskeletal and spinal

disease in Small Animal Practice 137
- Photo : Y. Lanceau - 06/2006.

THE OFFICIAL JOURNAL OF FECAVA

Federation of European Companion Animal Veterinary Associations
www.fecava.org
Anno 16, Numero 2, 2e Semestre 2006 Spedizione in abbonamento postale - 45% Art. 2 Comma 20/B - Legge 662/96 - Filiale di Piacenza
Volume 16 (2) October 2006 The European Journal of
The Official Journal of the Federation of
European Companion Animal Veterinary
Companion Animal Practice (EJCAP)
Associations (FECAVA).

EDITOR
Dr. Keith Davies
Contents
43, Hill Top Road - Newmillerdam
GB-WF2 6PZ Wakefield The Federation of European Companion Animal
Tel.: (44) 1924 250486 (UK) Veterinary Associations (FECAVA) 114
(33) 4 68 39 50 29 (F) Editorial 117
Fax: (44) 1924 259572
Email: kdaviesejcap@compuserve.com News 120
PRODUCTION COMMITTEE
Dr Ellen BJERKS, FECAVA President EAR, NOSE AND THROAT
Dr. Keith DAVIES, Editor
Dr. Joaquin ARAGONES Inner ear dysfunction related to ear disease in dogs ans cats 127
Dr. Peter STERCHI G. ter Haar
Dr. Tiina TOOMET
Dr. Johan VAN TILBURG AFTERCARE AND NURSING
Dr. Simon KLEINJAN
EDITORIAL BOARD (FOR NEW WORK) Rehabilitation Therapies for musculoskeletal and spinal disease
Dermatology Didier-Nol CARLOTTI (F) in Small Animal Practice 137
Cardiology Anna TIDHOLM (S) M. Owen
Internal medicine ke HEDHAMMAR (S)
Orthopaedics Aldo VEZZONI (I) ORTHOPAEDICS
Surgery Simon ORR (GB) Diagnostic and genetic aspects of patellar luxation in small and
Imaging Ingrid GIELEN (B)
Eiliv SVALASTOGA (DK)
miniature breed dogs in Austria
Reproduction Stefano ROMAGNOLI (I) B. Vidoni, I. Sommerfeld-Stur, E. Eisenmenger 149
Dentistry Peter FAHRENKRUG (D)
Ophthalmology Ellen BJERKS (N)
Long-term analysis of the progression of hip arthrosis after triple
Neurology Andre JAGGY (CH) pelvic osteotomy
Endocrinology Mike HERRTAGE (GB) Th. Dembour , J-L Chancrin 161
Oncology Jane DOBSON (GB)
Stratification, blinding and placebo effect in a clinical trial of gold
New Material should be sent to: bead implantation in Canine Hip Dysplasia
Prof. Ellen BJERKS,
G.T. Jaeger, S. Larsen, L. Moe 171
Norwegian School of Veterinary Science,
PO Box 8146-Dep, N- 0033, Oslo.
ENDOCRINLOGY
ADVERTISEMENT BOOKINGS
Sould be sent to: The Editor (see above) Retrospective study of owners perception of home monitoring of
CIRCULATION blood glucose in diabetic dogs and cats
Members of the Associations belonging to the I. Van de Maele, N. Rogier, S. Daminet 179
Federation of European Companion Animal
Veterinary Associations receive the European Diagnostic specificity of canine thyrotropin in the diagnosis of
Journal of Companion Animal Practice at no Hypothyroidism in dogs
charge (30,000 copies). F. Boretti, C.E.Reusch 185
PURCHASE OF COPIES Bilateral adrenalectomy in a ferret (Mustela putorius furo) with
For others interested in purchasing copies the
price is 52 per Volume (2 issues). Orders should
hyperadrenocorticism
be sent to: J. Martorell , Y.Espada , A. Ramis 191
FECAVA HQ, rue Defacqz 1, B-1000 Brussels
THANKS
URINOGENTIAL SYSTEM
The production Committee of EJCAP thanks: Treatment of pyometra in the bitch: A survey among Norwegian
Dr. Owen Davies
Dr. Tim Hutchinson
small animal practitioners
Dr. Edmund Shillabeer V. Rootwelt-Andersen, W. Farstad 195
Dr. John E.F. Houlton
who have spent time correcting the translations. DERMATOLOGY
Editore SCIVAC-AIVPA, Via Trecchi 20 Contemporary aspects of the immunopathogenesis of autoimmune
I-26100, CREMONA, Italia.
Inscrizione Registro Stampa del Tribunale di
diseases of the epidermal basement membrane in the dog
Cremona N.257 del 1/2/1991; E. I. Papadogiannakis 199
Spedizione in abbonamento postale.
45% Art. 2 Comma 20/B - Legge 662/96 - 2er Book Reviews 204
semestre 2006 - Filiale de Piacenza.
Direttore Responsabile : Antonio MANFREDI. Calendar of main European national meetings and other continuing
Roto Smeets GrafiServices, education opportunities 209
p.o. box 7052, 3502 KB Utrecht,
The Netherlands. Tel +31 (30) 282 28 22
Secretariat or address to contact for information 211

DISCLAIMER
The Federation of European Companion Animal Veterinary Associations and the Production Committee of the European Journal of Companion Animal Practice
accept no responsibility for any omissions and/or errors in information printed in this journal.We specifically draw readers attention to the need to follow instructions
of manufacturers products. In any specific situation readers are strongly advised not merely to rely on the material contained in the journal. Any views and opinions
expressed are those of the writer and not the Federation or the Production Committee.

113
The Federation of European Companion Animal Veterinary Associations (FECAVA)

FECAVA Headquarters address:

C/O Federation of Veterinarians of Europe
rue Defacqz, 1 B-1000 Brussels
Tel: +32 2 538 29 63 Fax: +32 2 537 28 28

FECAVA Website: www.fecava.org

Participating Associations: SMASAP Serbia and Montenegro Association of Small Animal

Practitioners
AFVAC Association Franaise des Vtrinaires pour Animaux de Director: Dr. Denis NOVAK
Compagnie SSAVA Swedish Small Animal Veterinary Association
Director: Dr. Jean-Franois ROUSSELOT Director: Dr. Anne CARLSWRD
AIVPA Associazione Italiana Veterinari Piccoli Animali SVK/ASMPA Schweizerische Vereinigung fr Kleintiermedizin/Association
Director: Dr. Guiseppe TRANCHESE Suisse pour la Mdecine des Petits Animaux
APMVEAC Associao Portuguese de Mdicos Veterinrios Especialistas Director: Dr. Peter STERCHI
em Animais de Companhia SZVMZ Slovensko Zdruzenje Veterinariev Za Male Zivali
Director: Dr. Joaquim Vieira LOPEZ Director: Dr. Bojan ZORKO
AVEPA Associatin Veterinaria Espaola de Especialistas en Pequeos TSAVA Turkish Small Animal Veterinary Association
Animales Director: Dr. Mustafa AKTAS
Director: Dr. Juan Francisco RODRIGUEZ USAVA Ukrainian Small Animal Veterinary Association
BASAV Bulgarian Association of Small Animal Veterinarians Director: Dr. Vladlen Mykhaylovich USHAKOV
Director: Dr. Boyko GEORGIEV VICAS Veterinary Ireland Companion Animal Society
BHSAVA Bosnia and Herzegovina Small Animal Veterinary Association Director: Dr. Peter A. MURPHY
Director: Dr. Josip KRASNI VK Vereinigung sterreichischer Kleintier mediziner
BSAVA British Small Animal Veterinary Association Director: Dr. Silvia LEUGNER
Director: Dr. Ian MASON
CSAVA Czech Small Animal Veterinary Association Associate Associations:
Director: Dr. Jiri BERANEK
CSAVS Croatian Small Animal Veterinary Section EAVS European Association for Veterinary Specialisation
Director: Dr. Davorin LUKMAN Contact: Dr. Hans KOCH
DSAVA Danish Small Animal Veterinary Association ECVD European College of Veterinary Dermatology
Director: Dr. Joergen MIKKELSEN Contact: Dr. Dominique HERIPRET
ESAVA Estonian Small Animal Veterinary Association ECVS European College of Veterinary Surgeons
Director: Dr. Tiina TOOMET Mrs Monika GUTSCHER
FAVP Finnish Association of Veterinary Practitioners ESVC European Society of Veterinary Cardiology
Director: Dr. Kai SITTNIKOW Contact: Dr. Chris AMBERGER
GSAVA German Small Animal Veterinary Association ESFM European Society for Feline Medicine
Director: Dr. Peter FAHRENKRUG Claire BESSANT
HSAVA Hungarian Small Animal Veterinary Association ESVCE European Society of Veterinary Clinical Ethology
Director: Dr. Julianna THUROCZY Contact: Dr. Sarah HEATH
HVMS Hellenic Veterinary Medical Society ESVD European Society of Veterinary Dermatology
Director: Dr. Katerina LOUKAKI Contact: Dr. Chiara NOLI
LAK Letzebuerger Associatioun vun de Klengdeiere - Pracktiker ESVIM The European Society of Veterinary Internal Medicine
Director: Dr. Liz JUNIO Contact: Dr. Rory BELL
LSAPS Latvian Small Animal Practitioners Section of The Latvian ESVN European Society of Veterinary Neurology
Association of Veterinarians Contact: Dr. Gualtiero GANDINI
Director: Dr. Lita KONOPORE ESVOT European Society of Veterinary Orthopaedics & Traumatology
LSAVA Lithuanian Small Animal Veterinary Association Contact: Dr. Aldo VEZZONI
Director: Dr. Saulius LAURUSEVICIUS EVDS European Veterinary Dental Society
MSAVA Macedonion (Fyrom) Small Animal Veterinary Association President: Dr. Margarita GRACIS
Director: Dr. Pero BOVINOVSKI EVSSAR European Veterinary Society for Small Animal Reproduction
MVA Malta Veterinary Association Contact: Dr. Alain FONTBONNE
Director: Dr. L. Vella, Director: Dr. A. GRUPETTA
NACAM Netherlands Association for Companion animal Medicine FECAVA officers:
Director: Dr. Leen den OTTER
NSAVA Norwegian Small Animal Veterinary Association Dr. Ellen BJERKS NSAVA President
Director: Dr. Kjetil DAHL Dr. Andrew BYRNE VICAS Vice-President
PSAVA Polish Small Animal Veterinary Association Dr. Simon KLEINJAN NACAM Senior Vice-President
Director: Dr. Jerzy GAWOR Dr. Simon ORR BSAVA Secretary
RSAVA Russian Small Animal Veterinary Association Dr Johan van TILBURG SAVAB Treasurer
Director: Dr. S. SEREDA
SAVAB Small Animal Veterinary Association of Belgium
Director: Dr. J. van TILBURG
SCIVAC Societ Culturale Italiana Veterinari per Animali da Compagnia
Director: Dr. Dea BONELLO
SKSAVA Slovakia Small Animal Veterinary Association
Director: Dr. Tibor BRAUNER

114
 Editorial
EJCAP, the Fifteen years - past and the future

The basic philosophy of EJCAP has changed little, though its evolution in its first 15 years has been constant and
exciting. The underlying aim has always been to bring to European Companion Animal Veterinarians the best work and
knowledge from all parts of Europe, and from European colleagues working worldwide. The EJCAP , through the medium
of the English language, enables Veterinarians in Norway or Bulgaria, to benefit from knowledge and experience in
Portugal and Ireland!

At first all papers in the Journal were translated reprints, member countries submitting what they considered the best
work from their county, previously printed in other Journals, usually not in English. The best of these papers were
selected, translated into English and published in EJCAP.

In recent years submission of original work from Europe has been encouraged. An Editorial Board has been set up to
rigorously peer review papers.
Commissioned work has resulted in a series of practical papers of great relevance to readers in general practice. Papers
have been published based on lectures given at FECAVA European Congresses, FECAVA Symposia and CE Courses,
keeping readers up to date in a practical way. More recently, a series of papers on Practice management, sometimes
highlighting different types of practice have been featured.

It was decided some years ago that the Journal should concentrate on practical papers, rather than attempting to go down
the road of trying to achieve a high citation rating by publishing cutting edge research.

In 2004/5 a survey of readers was conducted and very positive feedback resulted. It was clear that our decision to
feature mainly practical papers was a good one. Some of the improvements suggested in the survey have already been
implemented. The new style cover and easy reference colour coding of paper topics are some examples of this. In this issue
new styles for the News and paper layout are introduced, hopefully making our pagers more reader friendly.

Exciting FECAVA projects such as Microchip standardisation, Veterinary Nursing Manuals in different languages and
the Blue Dog project (an interactive educational video for children) have all been brought to the attention of our 30,000
readers through EJCAP, a unique communication tool in Veterinary Europe.

But what of the future? The evolution must and will continue. A third annual issue is a not too distant reality, probably
focusing on a specific topic and produced by a sub-editor and production team. The cost of production of this could be
largely funded by the generosity of our advertisers, but distribution would cost readers in the region of 2.5 per issue.
Alternatavely, this issue could be published solely on line. What do you think of these alternatives?

The future of EJCAP must embrace the wishes of readers. Please join the increasing number of those providing feedback
by contacting me by e-mail: kdaviesejcap@compuserve.com . Only by more of you doing this can we ensure another
fifteen successful years!

Keith Davies, Editor

117

FECAVA NEWS
Council meeting returns
to Paris
FECAVA Council returned to its roots
after more than 15 years of activity
by holding the its May meeting at the
Headquarters of AFVAC. The meeting
was well attended and had a full agenda.
A short report on two important items
discussed is given below.
Need for a revised Strategic Plan
This was the first Council meeting
with new President Dr. Ellen Bjerks
at the helm. In her opening address,
she commented that although FECAVA
remained a strong and active association,
it was time to draw up a framework
outlining a clear strategy for the years to
come. New Directors found it difficult to
come to terms with all the information
they had to assimilate. It was proposed
to devise brief summary job description
sheets that would fill this gap when the
people that knew everything were no
longer active. Ellen stressed that it was
important that FECAVA remained active
within FVE and UEVP and took the lead
on European companion animal issues.
FECAVA brings its Vision
into Focus
From Astrid Bjerks, Writing for FECAVA
After 15 years of activity and significant
expansion, the FECAVA Board felt
that it was now time to scrutinize the
FECAVAs aims and ideas to see if they
are still valid or if the time has come for
a renewal of thoughts.
The board felt that there was not full
agreement within the organization on
what the main tasks of FECAVA should
be and as to whether our Federation
should be political, educational or both.
EJCAP - Vol. 16 - Issue
FECAVA 1 - April 2006
NEWS
The Board also felt that there might be
some feeling of frustration among the
Directors (the national representatives),
because the FECAVA aims and objectives
were not clearly defined, president Dr.
Ellen Bjerks explained.
To find out if this hypothesis reflected
the situation the Board decided to ask
opinion within the organization. A
questionnaire was sent out to 15 persons
who have shown a special interest in the
progress of FECAVA: Past Presidents,
Board members and some dedicated
Directors. Based on the answers received
a workshop involving all the Directors
was then held at the Council meeting in
Paris in May.
Both the workshop and the answers to
the questionnaire confirmed our feeling
that there is little alignment of what
FECAVA stands for. That means that we
have an important job in front of us, said
FECAVA president Dr. Bjerks.
The following questions were asked in
the questionnaire:
1. If you had to choose the 3 most
important objectives of FECAVA for
the next 3 years, what would they
be? Please rank them in order of
importance.
2. What are the strengths that the
FECAVA Council has to achieve the
objectives?
3. What are the biggest obstacles that
could hinder FECAVA achieving its
objectives?
4. Indicate the one greatest achieve-
ment of FECAVA in the past 10 years.
5. What is the number one driver
(motivation) to be a FECAVA board
member?
FECAVA Directors in workshop session
at the AFVAC HQ in Paris.
120
6. Suggestions/ Ideas that can make a
difference to FECAVA.
The questions below were asked in the
workshop:
1. What are the FECAVA core values?
2. What makes FECAVA unique?
3. Who are FECAVAs clients?
Vision and results
Dr. Betina Rama is assisting FECAVA
in the process of defining FECAVAs
aims and objectives. Dr. Rama, an
Argentinean veterinarian, is a human
resources professional working
with Procter and Gamble in Geneva,
Switzerland, specialising in Change
Management and Strategy. Dr. Rama
is also familiar with international
veterinary associations through her
previous positions and as a member
of the organisation of the 1998 WSAVA
Congress in Buenos Aires.
She explains why it is vital for an
organisation to have a clear idea of its
objectives saying :.
A vision inspires and motivates the
people involved to work together to
solve the tasks in hand. A clear vision is
absolutely necessary if you want to work
efficiently, and last but not least a vision
is essential to differentiate yourself from
other organizations and institutions.
Next steps
Based on the answers given in the Paris
workshop and in the questionnaire the
board will now, in cooperation with Dr.
Rama, decide on the next steps to be
taken.
FECAVA has now realized that because
of a lack of agreement on the FECAVA
vision, neither the goals nor the priorities
are clear. My advice is that the board
should ask the Directors to go back to
their countries and touch base with their
own national organisations and the local
members and find out/ discuss what
they need from FECAVA. In my opinion
the board should assist the Directors
with the necessary tools to complete the
task, and preferably the national debates
should be completed and summarised
within a set period of time, Dr.Betina
Rama advises.

Dr. Bjerks replied that these are among
the questions that the board now needs
to address. The workshop and the
questionnaire were the first step in the
process which we expect will last for 1-2
years. We are thankful to the Directors,
to those who answered the questionnaire
and to Betina Rama for giving us a good
base for this important process.
The FECAVA board will continue the
discussion of these matters at its next
meeting Prague in October.
Health Support Structures
in Europe a preliminary
report
Some countries already have organised
structures to support veterinarians
who have health or other problems.
For example, the UK has a Veterinary
Benevolent Fund, a charity offering a
variety of support services to veterinary
professionals including:
1. Financial support for veterinarians
and their families if a veterinarian
is ill, unable to work or has died and
dependants are consequently are
struggling to cope from day to day.
2. The Vet Helpline - a confidential
listening ear telephone service
manned by volunteer veterinarians
and their spouses to listen to
veterinarians struggling with health
issues of any kind and to refer them
on to appropriate agencies
3. The Veterinary Surgeons Health
Support Programme, which offers
services to veterinarians suffering
from alcohol and/or drug abuse
problems and related addictions such
as gambling, sex addiction, eating
disorders etc and their resulting
mental health problems.
In addition, there are ongoing
consultations to address the very high
rate of suicide in the profession with the
hope of offering solutions before suicide
is contemplated.
Thirteen associations responded
to a questionnaire on this subject.
6/13 claimed to have some form of
benevolent society, whereas only 2/13
reported having a telephone helpline
and a support structure for veterinary
surgeons with problems such as
addictive disease. In most countries it
seems that it is left to the veterinarians
personal choice as to whether or not to
take some form of insurance at his/her
FECAVA NEWS
own expense to give support in times of
need.
FVE Conference on
Veterinary Education
This took place in Brussels March 29/30
2006. The objectives were to review
veterinary education in Europe and
determine what veterinary skills our
society required. The evaluation process
for veterinary teaching establishments
was reviewed and the relevance of
Bologna Declaration on future veterinary
education was discussed.
The guidelines to what constitutes a valid
veterinary qualification is laid down by
the EU commission in Dir 2005/36/EC
which came into force in October 2005
and should be transposed into national
legislation before October 2007. The legal
right to practice veterinary medicine
is determined by the statutory body in
each country.
With regard to the visitation and
evaluation system, of the 95 member
establishments, 47 had been evaluated
and 39 approved.
Veterinary nursing
DASVENT Meeting March 2006
The members of the DASVENT project
met in Geel, Belgium on May 19th. This
project aims to establish a voluntary
accreditation scheme for Veterinary
Nursing Education in Europe.
The project so far has agreed a
memorandum of understanding
between the partners that defines the
scope and objectives of the project. A
project specific accreditation committee
of veterinary nursing education
(ACOVENE) (www.acovene.org ) has
been established for the duration of
the DASVENT project. This committee
Andrew Byrne the ACOVENE
FECAVA Representative
121
EJCAP - Vol. 16 - Issue 2 October 2006
consists of six members drawn from
nursing course providers, accreditation
bodies and the veterinary profession.
The DASVENT project members and
Acovene have completed drafts of the
Accreditation policies and procedures
and also a list of competencies. The
next stage of this project is to carry
out a trial visitation to colleges
participating in the project in order to
test and evaluate the practicality and
effectiveness accreditation procedures.
These visitation panels will consist
of four people including a veterinary
surgeon and veterinary nurses from
the host countries national veterinary
and veterinary nursing associations as
well as two members of the ACOVENE
committee. The pilot visitations will
be complete by June 2007. The project
is scheduled to conclude in September
2007. FECAVA is a participant in this
project and holds a position on the
ACOVENE committee.
FECAVA Policy Statements
The following FECAVA Policy statements
have been adopted previously, and are
available on the FECAVA Website: www.
fecava.org
look in Newsflash or Policy
Statements.
Mutilations in Companion Animals
Neutering Dogs and Cats
Permanent Identification in
Companion Animals
The Training of Veterinary Nurses
Animal Breeding
Two new policy statements were adopted
at the May 2006 Council meeting:
FECAVA Policy Statement - Cloning
of Companion Animals
1. FECAVA strongly feels that it is
unethical to clone companion animals
purely to provide pets with similar
characteristics.
2. FECAVA recognises that there may
be medical and scientific advantages
obtained from cloning companion
animals.
3. Any such cloning procedure should be
subject to the normal ethical controls as
regulated by the European Convention
on the use of animals in scientific
procedures.
FECAVA Policy Statement The
Availability of Medicines
1. FECAVA recognizes the paramount
importance of the role of veterinarians

in the relief of suffering and the
promotion of welfare of companion
animals.
2. To ensure this goal, FECAVA
recommends that the authorization
of medicines to relieve suffering
in companion animals should be
facilitated to provide easy access
throughout Europe to the medicines
vital to animal welfare.
3. FECAVA reconfirms that Companion
Animal medication does not represent
any risk to the human population
through food contamination.
4. FECAVA is aware of the great
responsibility vested in its members
to protect and ensure the welfare of
companion animals. In accepting
that responsibility, FECAVA strongly
recommends the introduction of
legislation to allow for full availability
of the medicines necessary to ensure
good veterinary practice for these
animals.
5. FECAVA recognizes the desire of
the EU Parliament and Council to
achieve this goal when it stated
clearly in the EU Directive 2004/28/
EC on Veterinary Medicines in
section 21 of the Introduction that
the administrative procedures for
supplying medicinal products for
pets, on the other hand, should
be simplified. FECAVA urges the
governments of member states to
reflect this aspiration in their relevant
regulations
Blue Dog -
Dog Bite
Prevention
Programme
The Blue Dog educational resource
consisting of written parent guide and
interactive CDRom will be launched
during the FECAVA/ WSAVA / CSAVA
Congress held in Prague in October.
Readers will remember that this is
aimed at children between 3 6 yeas of
age, helping them, with parental help,
to avoid potential risk situations when
interacting with their family pet.
A unique feature of the project is that
selected scenes of the CD have been
scientifically assessed by Dr Kerstin
Meints of the Psychology Department,
University of Lincoln UK, to show
whether children of this age learn from
the CD. The research was generously
funded by FECAVA and NACAM, with
an additional grant from BSAVA. The
results were very positive, and will be
FECAVA NEWS
presented at the Prague congress. A
summary of the work will be published
in a subsequent issue of EJCAP.
Further information about the Blue Dog
can be found on the website:
www.thebluedog.org
The Blue Dog Trust has been set up
as a non-profit legal entity to mange
the project. The next phase is to find
partners in different countries, who
would be keen to translate, produce and
distribute their language version in their
own country. A choice of contractual
arrangements is available. For more
information contact:
The Blue Dog Trust
196 Hall Lane
Upminster
Essex GB-RM14 1UY
International welfare and
behaviour conference in
Ghent
Three groups (ESVCE, VDWE and
ECVBM-CA) jointly hosted a three day
international conference in the historic
city of Ghent in Belgium in September
2006. The theme was Welfare and
Behaviour the science behind the art,
and this was well covered by a galaxy of
international speakers from Europe, USA
and Australia. Following the plenary
sessions, the delegates were divided into
separate sessions looking in more detail
into aspects of welfare relating to:
Shelter animals
Animals working in Social,
Therapeutic and Educational settings
Animals working in public services
122
Internationaal Congres over het
Gedrag en Welzijn van
Gezelschapsdieren
Welfare and behaviour
The science behind the art
Merelbeke
Faculteit Diergeneeskunde
Organisatie van VDWE, ECVBM-Ca en ESVCE
Alle aanvullende informatie:
www.behaviour2006ghent.be
Help needed to gain a UN
Declaration for animals
This initiative is being promoted by
the World Society for the Protection
of Animals (WSPA). The objective of
the Universal Declaration on Animal
Welfare campaign is to achieve a global
statement at the United Nations (UN)
that recognizes animals as sentient
beings, capable of experiencing pain
and suffering, and animal welfare as an
issue of importance as part of the social
development of nations worldwide.
UN Declarations are used to declare
certain aspirations at global level. It is
important to emphasise that although
such declarations are not legally binding,
they have led to increased recognition of
their respective issues by governments
throughout the World.
A five nation governmental steering
committee comprising representatives
from the following UN member
states; Costa Rica, Kenya, India, Czech
Ray Butcher was one of the first to sign the
WSPAs global petition

Republic & Philippines met and agreed
to champion the initiative amongst
governments in their region to build
support for a planned Ministerial
conference in 2007. This is supported by
the OIE (representing Chief Veterinary
Officers from approx 167 countries
worldwide) who feel it is complementary
to their own initiatives.
WSPA launched a global petition in
support of this initiative in June 2006,
using the simple statement ANIMALS
MATTER TO ME. The aim is to collect
10 million signatures you can help by
going on line at:
www.animalsmatter.org
The petition will be handed into the
United Nations and it is hoped that a
global voice of millions should heavily
influence an institution built on the
premise of representing the people.
Diary Dates future
congresses
2007 FECAVA/CSAVS
Dubrovnik March 28 April 1
Its is now autumn, with the prospect of
a long cold winter ahead! So why not
look forward to the springtime and the
return of the sun? And where better
than in the beautiful and historic city of
Dubrovnic, Croatia.
And while on the subject of future
Congresses, the FECAVA congress of
2009 will return to Lille where it will
be hosted jointly by the small animal
associations of France, Belgium and
Luxemburg.
More information is given on pages 190
and 203
2008 FECAVA/WSAVA/ VICAS
Dublin Ireland 20-24 August 2008
2009 FECAVA/SAVAB/LAK
And while on the subject of future
Congresses, the FECAVA congress of
2009 will return to Lille where it will
be hosted jointly by the small animal
associations of France, Belgium and
Luxemburg.
Why not get your diaries out now and
plan your future CE by looking on pages
209-210!
Microchips working
effectively
Importance of regular scanning
More and more pet owners are deciding
to travel throughout Europe with their
pets each year by taking advantage of
arrangements offered by the European
Happy reunion of lost pet following ID
scanning by Lancashire Police
Pet Passport. The entry requirements
for UK, Ireland and Sweden are more
stringent. These schemes simplify pet
travel.
Specific identification of the pet by
microchip is essential to verify the
Passport. It is important that the animal
is scanned before implantation to ensure
it has not already been chipped. Regular
scanning will demonstrate that the chip
is still functioning and is in the correct
place. All microchips now used in pets
in Europe should be of the ISO FDXB
type. However, dual readers that will
also recognise the original FECAVA
FDXA type should be used to avoid
missing those dogs that were identified
in the earlier years.
In the UK the process of preparing
animals for PETs is fairly simple and
straight forward but does require
advanced planning of at least 7 months.
Pets need to be micro chipped, and then
vaccinated against Rabies.. Four weeks
after the vaccination is given a blood test
must be taken to confirm the vaccine
has been effective. Provided this test is
positive the pet can travel but cannot
re-enter the UK until 6 months after the
date the blood was taken that led to the
positive test. It is this time scale owners
often fall foul of in their preparation
timing.
Owners must take some responsibility to
ensure that both the chip and paperwork
are in order before they travel. They
should always ensure their details
on the relevant database are accurate
and up to date and if necessary they
should record their travel address with
database. Europetnet offers an internet
communication between the various
different European databases such that
a dog lost in foreign country can be
123
EJCAP - Vol. 16 - Issue 2 October 2006
traced back to its original database and
the owner located.
It really works!
Recently a European microchip supplier
in the UK took a phone call from a
kennel facility in the Czech Republic
quoting a microchip number for a dog
they had taking into their care. The
chip was registered a UK address and
corresponded to the details held relating
the dog found. Fortunately there was a
mobile phone number recorded which
meant the owners could be contacted.
The owners were on a campervan holiday
and had left the dog in the campervan to
go shopping. They were totally unaware
the dog had escaped the van and were
amazed to have a telephone call reporting
their pet had been found! Fortunately dog
and owners were quickly re-united.
The Police, in Lancashire UK, recently
ran a campaign to check the identity of
the animals taking part in a major pet
event. Literally hundreds of Horses
and Dogs were scanned. A proportion
of them contained chips which checked
out as all in order, but on day two of
the Police Operation two stolen Spaniels
were identified , recovered and reunited
with their real owners. The police officer
involved said: In over 17 years of Police
service I can state that, to return the
animal to its owners after six months
as a stolen dog was one of the most
satisfying moments in my service The
owners were over the moon. They had
advertised in the local press and spent
a lot of money and effort attempting to
trace their animal without any success.
The happy events of the weekend were
only possible due to the chip id system.
A need for special care
When a microchip is implanted it is
important that it is placed accurately
(and not in the loose skin of the scruff
of the neck which leads to migration
and retention problems). There are
two preferred positions which should
always be checked when scanning, viz.
between the scapulae in the midline
and the left hand side of the neck.
The animal should be scanned before
implant and the chip should be checked
before and after the insertion. The site
should also be checked after chipping
to ensure the chip is in properly under
the skin and not in the coat or implant
hole. These problems occur very rarely
these days since accurate techniques
have been encouraged, but they need to
be checked when so much is relying on
the microchip during travel.

Chip manufactures sometimes receive
phone calls from veterinarians stating
that the number they have just scanned
is different from the one they just
implanted. Further investigation reveals
that the animal was not scanned prior
to being chipped and had already been
implanted on a previous occasion.
Obviously there is then a need to
discover whether the animal has been
previously registered and possibly lost
or even stolen.
Feline panleukopenia: the
killer disease
ABCD experts recommend three-
yearly boosters -Haarlem, 13 July
2006
A minimum interval of three years
for booster vaccinations is normally
sufficient to control Feline Panleukopenia,
according to new Guidelines published
today by the European Advisory Board
on Cat Diseases (ABCD), providing
initial vaccinations are given according
to the recommended protocol.
Feline Panleukopenia has been notorious
for wiping out local cat populations and
has therefore occasionally been referred
to as the Cat Plague. Mortality rates
from this highly contagious parvovirus
in susceptible cats are high and can
exceed 90% in kittens.
Indoor cats also at risk
Indirect contact is the most common way
for a cat to become infected, therefore indoor
cats are at risk, too, according to Professor
Uwe Truyen (Leipzig, Germany), ABCD
member and internationally recognised
specialist on parvoviruses. Feline
Panleukopenia virus can survive in the
environment for several months or even a
year, as it is highly resistant, which means
WSAVA Activities
From Dr Walt Ingwersen WSAVA Editor
WSAVA Standards for
Histological and Clinical
Diagnosis of Canine and
Feline Liver Diseases
WSAVAs first textbook is on the
shelves!
In a publishing partnership with
Elsevier, WSAVA is proud to announce
the availability of its first scientific
textbook, entitled WSAVA Standards
FECAVA NEWS
that cats dont need to meet other cats to
become infected.
Recommended Vaccination Protocol
The ABCDs recommended vaccination
protocol for feline panleukopenia-
consists of two kitten injections at nine
and 12 weeks of age, followed by a
first booster one year later. If this basic
programme is carried out correctly,
subsequent booster vaccinations can
normally be given at intervals of a
minimum of three years.
However, the ABCD stresses that
maternally derived antibodies (MDAs)
against feline panleukopenia virus
may persist for longer than previously
believed and may neutralise the
vaccinal antigen, thereby preventing
active immunisation. In particular,
kittens from environments with a high
infection pressure, such as cat shelters, or
from queens that have been vaccinated
regularly, for example in breeding
catteries, may still have MDAs at 16 or
even 20 weeks of age. In these situations,
a third vaccination at four months is
recommended.
In adult cats with an unknown vaccination
history, a single injection followed by
a booster after one year is sufficient.
Thereafter, boosters may be given at
intervals of three years or longer.
Herd immunity too low
Thanks to efficient vaccines, we rarely
see the disease today. But the virus is still
lurking out there and could and does
occasionally pop up unexpectedly,
Professor Marian Horzinek (Utrecht,
NL), ABCD chairman, added. In order
to keep the disease at bay, the vaccinated
percentage of any cat population should
be as high as possible certainly higher
than the estimated 30% it is today.
for Histological and Clinical Diagnosis
of Canine and Feline Liver Diseases,
representing a culmination of efforts
begun in 2000 and prompted by
discussions between the then WSAVA
president Hans-Klaus Dreier, president-
elect Claudio Brovida, and Dr. Jan
Rothuizen of Utrecht University. Born
from a WSAVA strategic initiative to
strengthen the relationship between
veterinary academia and veterinary
medical associations, this project is
124
EJCAP - Vol. 16 - Issue 1 - April 2006
Apart from supportive treatment (fluids,
antibiotics and possibly antisera or
antivirals) there is no cure for the
disease, and cats may die in spite of
intensive veterinary care. However,
vaccines currently on the market are
highly effective and efficiently protect
cats against the disease, providing they
are given according to the recommended
protocol.
For further details and downloads of the
full-text ABCD Feline Panleukopenia
Guidelines, please visit www.abcd-
vets.org. These guidelines also give
recommendations for specific situations,
such as immunocompromised cats,
breeding catteries and cats undergoing
corticosteroid treatment.
The guidelines on feline panleukopenia
were adopted at the third meeting of
the ABCD, held in Haarlem (NL) on 8-9
June 2006. At the meeting, the panel also
discussed feline herpesvirus disease,
for which guidelines are currently in
preparation.
Turkey gears up to
adapt to EU Veterinary
Regulations
EU Veterinary platform founded
The EU Veterinarian Platform is a
civilian initiative that was established for
providing studies related to formation
of information share, communication,
discussions and brain storming, healthy,
proper and quick adaptation process
for supplementing contributions to
Veterinarian profession within the
European Union adaptation process.
website: www.abveteriner.org
the first in a series of standardization
initiatives begun by the WSAVA in an
effort to provide clear direction in areas
of academic research that have a direct
impact on the practice of veterinary
medicine (for a historical overview of the
WSAVA standardization efforts, refer to
the October 2005 Monthly News on the
WSAVA website www.wsava.org).
The authors involved are a veritable
whos who of prominent, international
researchers in veterinary hepatology

and also includes one eminent human
liver researcher. The list of authors
include:
Jan Rothuizen DVM, PhD, Dip
ECVIM-CA; Utrecht University
Susan Bunch DVM, PhD, Dip ACVIM
Jenny A. Charles, DVM, PhD
John Cullen VMD, PhD; North
Carolina State University
Valeer Desmet MD, PhD; Leuven
University
Viktor Szatmari DVM, PhD; Utrecht
University
David Twedt DVM, Dip ACVIM;
Colorado State University
Ted van den Ingh DVM, PhD, Dip
ACVP; University of Pennsylvania
Tom van Winkle VMD, Dip ACVP;
University of Pennsylvania
Robert Washabau VMD, PhD, Dip
ACVIM; University of Minnesota
The textbook is designed to provide a
world standard of guidelines for the
diagnosis of liver diseases in dogs and
cats using both histological and clinical
criteria. Chapters include:
From Marc Buchet, Past President FECAVA, UEVP Treasurer
European Acknowledged
Veterinarian
In November 2005, during the General
Assembly Meeting, UEVP adopted
a policy paper concerning European
Acknowledged Veterinarians
The acknowledgment of a veterinarian
should be:
1 Based on a species (or a group of
species) orientation - such as for cattle,
companion animals, equines, pigs,
poultry etc;.
2 Preceded by a period of species
related, theoretical and practical
training together with a suitable level
of professional experience;
3 Issued by a national competent
authority (such as Chamber, Statutory
Body, Veterinary Organisation,
Ministry, Veterinary Faculty, Scientific
Organisation etc);
4 Supervised by a competent European
Authority in order that the
acknowledgement be recognised as a
European ;
5 Regular revalidation.
Sampling and handling of liver tissue
Ultrasonographic identification
and characterization of congenital
portosystemic shunts and portal
hypertensive disorders
Morphological classification of biliary
disorders
Morphological classification of
parenchymal disorders, including
Normal histology, reversible
hepatocyte injury, and hepatic
amyloidosis
UEVP NEWS
Several countries already have some
post-graduate qualifications and UEVP
thinks that it would be better to define
a European level as soon as possible
in order to obtain mutual recognition
instead of harmonizing later different
existing systems. The notion of
Acknowleged Vet will influence
positively the veterinary profession and
fulfil consumer (with regard to the need
for clear information) and stakeholders
requirements (e.g. insurance companies,
retailers...). This system of is totally
different from the EBVS specialisation
which is mainly discipline-orientated
and where qualification and expertise
are at a higher level .
Practical experience for recognition
as an acknowledged veterinarian will
only be possible after working for three
years within the last 5 years spending
at least 50% of the time with the species
concerned, based on a working week of
40 hours.
In addition, during this period the
applicant should have obtained in
average 35 CPD scientific attendance
125
EJCAP - Vol. 16 - Issue 2 October 2006
Hepatocellular death, hepatitis, and
cirrhosis
Hepatic abscesses and granulomas,
hepatic metabolic storage diseases,
and miscellaneous conditions
Morphological classification of
neoplastic disorders
This consolidation of international
science and opinion regarding the
diagnosis and staging of canine and
feline liver disorders represents a
critical step in elevating both the level
of care provided by the veterinary
profession for pets suffering from liver
disorders as well as ensuring that the
common language proposed facilitates
a greater degree of communication
between researchers and ultimately, our
understanding of these ailments.
For additional information and to order
the book, visit the Elsevier website at
www.elsevier.ca/product.jsp?isbn=
070202791X
The WSAVA would like to recognize
and thank Hills Pet Nutrition for their
generous sponsorship which made this
work possible.
hours a year relevant to the species
concerned.
Each country would have to evaluate
the level of abilities and skills of the
candidate before acknowledgment. This
should be either by a certificate issued
by the supervising competent veterinary
surgeons with whom he/she worked for
a certain time or after being examined
by a professional body (or both).
In order to maintain the acknowledgement
veterinarians should obtain at least
175 hours of CPD scientific attendance
hours over 5 years. The veterinarian
also has to continue to work at least 50%
of his/her work time within the field
acknowledged. Revalidation should be
done at least every 5 years.
UEVP hopes that the principle of
Acknowledged Vet will be supported
by each National Association and by
specialised groups such as FECAVA and
FEEVA.
 EAR, NOSE AND THROAT

FECAVA SPONSORED PAPER

Inner ear dysfunction related to

ear disease in dogs and cats
G. ter Haar(1)

SUMMARY

Inner ear disease can be either primary, with dysfunction of the cochlea or the vestibulum or both, as a result
of pathology of the inner ear itself; or secondary as a result of extension of disease from surrounding structures,
usually the middle ear. Inner ear dysfunction is usually demonstrated as peripheral vestibular ataxia, but hearing
loss is present with many diseases as well, although more difficult to detect. The clinical examination, neurological
and otoscopic examination findings and diagnostic work-up with radiography or CT-scan/MRI and brainstem-
evoked response audiometry of patients with primary or secondary inner ear disorders are discussed. In addition, the
aetio-pathogenesis and medical or surgical therapy of those ear diseases that can result in hearing loss or peripheral
vestibular ataxia are reviewed. These include chronic otitis externa, feline inflammatory polyps, aural neoplasia,
chronic otitis media and interna, ototoxicity, congenital deafness, age-related hearing loss, geriatric canine and
idiopathic feline vestibular disease and congenital vestibular syndromes. Surgical procedures discussed include
removal of inflammatory polyps via lateral incision in the vertical ear canal, total ear canal ablation, and lateral
and ventral tympanic bulla osteotomy.

This paper is based in part on
a lecture given at the ESAVA Congress* in Tallinn
Introduction
The inner ear lies safely protected within the osseous labyrinth
of the petrous part of the temporal bone. The membranous
labyrinth consists of three parts: the cochlea, responsible for
hearing, and the vestibule and the semicircular canals responsible
for maintaining balance. Inner ear disease can be either primary
with dysfunction of the cochlea or the vestibulum or both as
a result of pathology of these end-organs (e.g. ototoxicity and
age-related hearing loss) or secondary as a result of extension of
disease from surrounding structures (e.g. otitis media).
Inner ear dysfunction is usually demonstrated as peripheral
vestibular ataxia (head tilt, horizontal nystagmus, circling or
falling toward the side of the lesion) as hearing loss usually goes
unnoticed until complete deafness is recognized.
Hearing loss doesnt necessarily reflect primary or secondary
inner ear dysfunction however, for outer ear canal, middle ear,
brainstem and central nervous system pathology can affect
hearing as well. Conductive deafness results from a lack of
presentation of sound to the inner ear, usually secondary to
otitis externa or media, while sensorineural deafness occurs
with abnormalities of the cochlear system, cranial nerve VIII or
auditory pathways and higher brain centres. The most common
forms of sensorineural deafness are congenital deafness,
deafness as a result of ototoxicity and presbycusis or age-related
hearing loss. Usually, loss of balance is the result of disorders of
the peripheral vestibular system (the inner ear receptors and/or
the vestibular part of the eighth nerve), but central vestibular
disease (the brainstem vestibular nuclei in the medulla oblongata
and neurons in the flocculonodular lobe of the cerebellum) has
to be ruled out.
This article describes the diagnostic work-up of patients with
primary or secondary inner ear disorders and the technique
of brainstem-evoked response audiometry in particular. In
addition, the aetio-pathogenesis and medical and/or surgical
therapy of those ear diseases that can result in hearing loss and/
or peripheral vestibular ataxia are discussed.

(1) Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, PO Box 80154, NL-3508 TD Utrecht.
E-mail: G.terHaar@vet.uu.nl
*Sponsored by FECAVA, Tallinn, May 13-14, 2006.

127
 Inner ear dysfunction related to ear disease in dogs and cats - G. ter Haar
Fig. 1. Transverse CT image of a 1-year-old cat presented with left
sided peripheral vestibular ataxia as a result of inflammatory polyp
associated otitis media and interna.
Clinical examination in dogs and cats
with inner ear dysfunction
When confronted with an animal with either vestibular ataxia or
hearing loss, a complete history has to be taken and thorough
physical, neurological, and otoscopic examinations have to be
performed. In most cases, the differentiation between central
and peripheral vestibular disease and between conductive and
sensorineural hearing loss can be made without additional
examination.
The presence of a spontaneous vertical nystagmus, cranial nerve
deficits other than facial nerve paralysis and proprioceptive
abnormalities always indicate a central vestibular lesion, whereas
peripheral vestibular ataxia usually is accompanied by horizontal
nystagmus and is sometimes associated with a history of topical
ear medication or clinical signs of otitis externa or media [1].
Much information can be obtained with otoscopy which usually
can be performed in the awake animal even when ear flushing is
necessary for complete visualization of the tympanic membrane.
However, before flushing, material should be obtained from the
horizontal part of the ear canal for cytological examination,
culture and in some patients susceptibility testing. After flushing,
masses can easily be identified and samples can be taken for
histopathology. Bulging, increased opacity and hyperaemia of
the tympanic membrane may be present with otitis media. A
myringotomy can be performed in dogs with an intact tympanic
membrane to obtain samples for culture and susceptibility
testing and cytological examination.
When significant abnormalities are detected on otoscopy, the
diagnosis of peripheral vestibular disease and the presence of
at least some degree of conductive hearing loss can safely be
made. In absence of abnormalities, peripheral vestibular disease
cannot be excluded. Radiographs of the bullae may then be
useful to further differentiate between diseases, although they
are not very sensitive [2, 3]; ventrodorsal, lateral oblique and
open-mouth views are most helpful. Anaesthesia is necessary
for proper positioning. Abnormalities of the bulla indicating
disease include increased opacity, sclerosis and lysis. However,
128
Fig. 2. Representative sample of a brainstem auditory evoked
response after an 80 dB SPL click stimulus.
fluid cannot be differentiated from tissue (polyp, neoplasia) and
absence of radiographic changes does not rule out otitis media.
Advanced imaging with CT or MRI is necessary in most cases for
proper evaluation of the middle ear and inner ear to some extent
(see Fig. 1). CT is considered superior to MRI for bony changes,
whereas MRI is better for detection of soft tissue abnormalities
[3]. With these two techniques morphological abnormalities of
the petrous bone and inner ear structures can be recognized,
but functional abnormalities can only be diagnosed with
electrophysiological methods like brainstem-evoked response
audiometry.
Hearing assessment using brainstem-
evoked response audiometry (BERA)
Several methods have been employed to test hearing ability
in dogs, ranging from behavioural studies to measurement of
electrical responses after auditory stimulation, using impedance
audiometry (tympanometry, acoustic reflex testing), evoked
response audiometry (brainstem (BERA) and middle latency
(MLAER) auditory evoked responses), and cochlear microphony
[4,5]. Of these techniques, brainstem-evoked response audio-
metry is used most often in veterinary medicine. The brain
responds to auditory stimuli by consistent changes in electrical
activity; once the nerve impulse is generated in the cochlea, the
signal travels along the acoustic nerve to the cochlear nuclei in
the brainstem. From here, many projections lead to other nuclei
in the brainstem and ultimately to the primary auditory cortex.
These changes can be recorded from scalp electrodes [4].
The time between stimulation of the ear and electrophysiological
response is called latency. For the early latency components,
meaning the responses recorded between 0 and 10 milliseconds
after the stimulus, generators are thought to arise almost totally
within the brainstem. Therefore, this series of waves is referred
to as the brainstem auditory evoked responses. Responses after
10 milliseconds are called middle latency responses, generators
of these potentials are thought to be nuclei in the thalamus and
areas of the auditory cortex [5].

In the last two decades, brainstem auditory evoked responses
have been used increasingly to test hearing ability in veterinary
medicine. The acoustic signal usually consisted of a click stimulus,
which stimulates a large part of the cochlea, since it consists of a
wide spectrum of frequencies (many different tones).
Brainstem evoked response audiometry using clicks will suffice
for differentiating sensorineural from conduction deafness
and is of use in assessing some brainstem pathologic changes.
Frequency-specific information, however, is needed in assessing
the extent of neurological deafness, e.g. noise-induced deafness,
deafness caused by ototoxicity and presbycusis, which can all be
partial and frequency-specific (hearing loss limited to small areas
of the cochlea, for instance the high frequency area) [4].
In our laboratory a method was developed to deliver tone bursts
ranging in frequency from 1 - 32 kHz for frequency-specific
assessment of the canine cochlea. Brainstem auditory evoked
responses to a click (CS) and to 1, 2, 4, 8, 12, 16, 24, and 32
kHz tone burst stimulations (TS) were compared at 80 dB sound
pressure level stimulus intensity in 10 clinically-healthy dogs,
3.5 to 7.0 years of age. The responses were obtained with the
animals under a light plane of anaesthesia. All stimulations
yielded a 5-7 positive wave pattern, with the exception of the
1 kHz TS, which evoked a frequency-following response (see
Fig. 2). There were marked differences in the thresholds for
different stimulations, the lowest being for the click and for 12
and 16 kHz toneburst stimulations. The thresholds for all other
toneburst stimulations were significantly higher than for the click
stimulation. Our report demonstrates that hearing was best in
the high-frequency area in our dogs, with an optimum between
12-14 kHz (see fig. 14) and provides a normative database for
parameters necessary to evaluate the frequency-specific hearing
losses in dogs [4].
Otitis externa
Otitis externa is common in dogs and cats and has numerous
causes, usually classified as primary, predisposing or perpetuating
Fig. 3. Chronic proliferative otitis externa in a French Bulldog.
129
EJCAP - Vol. 16 - Issue 2 October 2006
factors [6]. Since chronic infections may result in stenosis or
occlusion of the ear canal and blockage of sound transmission
or may lead to chronic otitis media and/or interna, otitis externa
has to be treated appropriately without delay to prevent inner
ear dysfunction. Primary factors directly cause otitis externa and
include parasites (ear mite; otodectes cynotis), foreign bodies,
inflammatory polyps, tumours, hypersensitivities (atopy, food
hypersensitivity), endocrine abnormalities (hypothyroidism)
and keratinisation disorders [6]. Predisposing causes of otitis
externa make the ear canal more susceptible to inflammation
and secondary infection. These factors include anatomical
conformation (pendulous ears, narrow ear canals and excessive
hair growth) and changes in the external environment of the ear
canal (excessive moisture, excessive ear cleaning or trauma from
cotton swabs). Perpetuating factors exacerbate and maintain
the disease even after the primary factors are eliminated and
include secondary bacterial and/or yeast infection, otitis media
and inappropriate treatment [2, 6].
In most cases of chronic otitis externa, primary factors,
predisposing and/or perpetuating factors can and should be
identified and treated. In chronic cases, elimination of underlying
factors however, usually doesnt end the inflammatory process
[2]. Management should then be aimed at thoroughly cleaning
and drying the ear canal and administering appropriate topical
therapy for a longer period of time, sometimes even a life-
long treatment is necessary. Ointments with broad-spectrum
antibiotics and corticosteroids should be used with careful
attention to complete filling of the entire ear canal and tapering
off the frequency of treatment based on clinical effect and control
otoscopy. Total ear canal ablation is reserved for unresponsive or
proliferative chronic otitis externa, when the relief of chronic pain
and discomfort outweighs the disadvantage of the hearing loss
that will result after surgery (see Fig. 3). Hearing function was
measured in dogs with otitis externa using brainstem evoked
response audiometry. It was concluded that most dogs with
chronic otitis externa have some form of conductive hearing
loss with severe loss in dogs with severe otitis. Cleaning the ear
canal produced measurable improvements in hearing in several
dogs, indicating the profound effect of physical obstruction of
the external ear canal by debris [7].
Inflammatory polyps
Nasopharyngeal polyps, also called otopharyngeal or
inflammatory polyps are benign pedunculated growths of
uncertain origin but thought to arise as a result of chronic
inflammation [8, 9]. Polyps have been associated with rhinitis
and otitis resulting from various bacterial and viral agents,
a congenital origin has been suggested as well. They may
originate from the mucosal lining of the middle ear, auditory
tube and nasopharynx, all of which are similar histologically.
Otopharyngeal polyps occur in cats of any age, although most
animals are less than 2 years of age. Polyps in the external or
middle ear mimic signs of otitis externa, otitis media or otitis
interna [8, 9].
Otoscopy after flushing may reveal a visible pink or grey smooth,
spherical mass occluding the canal (see Fig. 4). Cytological or
histological examination of biopsies will reveal the nature of the
tissue when diagnosis is not straightforward. Some surgeons
perform a ventral bulla osteotomy but recurrence is uncommon
 Inner ear dysfunction related to ear disease in dogs and cats - G. ter Haar
Fig. 4. Video-otoscopic view of a feline inflammatory polyp in the
external ear canal, visible after flushing.
with simple traction-avulsion after an incision in the vertical ear
canal [2].
After aseptic preparation of the surgical site, an incision is made
in the skin in a dorsoventral direction over the palpable vertical
part of the ear canal. The subcutaneous tissue and parotid gland
are dissected with small scissors to free the cartilage of the
vertical ear canal, which is opened with a vertical stab incision.
Stay sutures are placed on both sides of the incision in the ear
canal cartilage to increase visualisation and avoid damage to the
cartilage. A small closed haemostatic forceps is then introduced
into the ear canal, meticulously following the direction of the
horizontal ear canal until the polyp is encountered. This forceps
is then opened and advanced deeper over the polyp until it
can be grasped as close as possible to the osseous meatus. The
forceps is then gently rotated and traction is applied until the
polyp is removed (see Fig. 5).
The middle ear cavity is flushed with warm saline and with
a small curette the osseous meatus and most lateral aspect
of the tympanic cavity is palpated to check for additional
inflammatory tissue which is removed with this curette when
encountered. The stay sutures are removed and the cartilage of
the ear canal is closed with 4-0 monofilament suture material
in an interrupted pattern. The subcutis is closed in a continuous
pattern with 4-0 absorbable monofilament suture material and
the skin is closed in a subdermal suture pattern using the same
suture material.
To date, there are no reports on pre-operative and post-
operative hearing assessments using brainstem-evoked response
audiometry in cats with polyps. It is very likely however that pre-
operatively a severe form of conductive hearing loss is present.
Since polyps are usually recognized after a history of chronic otitis
externa, media or interna, some form of sensorineural hearing
loss will be present in addition. The improvement in hearing
ability after surgery is therefore unknown and unpredictable at
the moment.
130
Fig. 5. Removal of feline inflammatory polyp via lateral incision in
vertical ear canal.
Aural neoplasia
Ear tumours occur in older cats (mean age of 7 and
11 years for benign and malignant tumours, respectively) and
dogs (9 and 10 years of age) [10, 11]. The most frequently
observed clinical signs are those of a unilateral otitis externa
with otic discharge, odour, pruritis, local pain and a mass on
otoscopy. Neurological signs are observed in approximately
10% of dogs with malignant tumours and 25% of cats with
either benign polyps or malignant tumours [10, 11]. Since
approximately 25% of malignant forms will have evidence of
bulla involvement, skull radiographs or computed tomography
are recommended as part of the diagnostic work-up. Benign
tumours are papillomas, basal cell tumours and ceruminous
gland adenomas, especially found in dogs, and ceruminous
gland cysts usually found in cats. Malignant tumours include
ceruminous gland adenocarcinoma (CGC, dog and cat);
squamous cell carcinoma (SCC, dog and cat) and carcinoma of
unknown origin (dog). Most benign ear canal tumours in dogs
and cats can be readily managed with conservative surgical
resection. But aggressive excision, including total ear canal
ablation and lateral bulla osteotomy, should be the treatment
of choice for malignant ear canal tumours in both species. A
good prognosis with a high likelihood of long-term survival
results from such a procedure in the dog [10]. A fair prognosis
in the cat can be expected for CGC, and a guarded prognosis
for SCC or carcinoma of undetermined origin [10].
Primary neoplasia of the bullae or bony labyrinth or
neurofibrosarcoma of the peripheral nerve (N VIII) are very rare
but should be included in the differential diagnosis of inner
ear dysfunction [2,8]. Local spread from tumours within the
ear canal is probably more common. Facial nerve paralysis
or Horners syndrome is common when tumours are located
in the middle and inner ear. These tumours can usually be
demonstrated with CT-scan or MRI. Diagnosis can be confirmed

Fig. 6. TECA: The ear canal is freed from the auricular cartilage
with strong scissors.
by biopsy findings. Because of the invasive nature of most of
these tumours, total resection is difficult but radiotherapy or
chemotherapy may be beneficial in some animals [8].
Total ear canal ablation (TECA)
Indications for TECA are chronic unresponsive or proliferative
otitis externa or neoplasia of the ear canal. A V-shaped incision
is made in the skin from the intertragic incisure to the ventral
limit of the vertical ear canal and from the tragohelicine incisure
to the same ventral point [2]. The skin flap is retracted dorsally
and the lateral aspect of the vertical ear canal is exposed. The
cartilage and the skin of the medial wall of the ear canal are
Fig. 8. LBO: The ventral and lateral wall of the bulla are removed
with rongeurs until visualization of the bulla is adequate.
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EJCAP - Vol. 16 - Issue 2 October 2006
Fig. 7. TECA: The cartilaginous part of the ear canal is removed
from the osseous canal with scissors.
separated from the cartilage and the skin on the inner side of
the base of the pinna by use of strong scissors (see Fig. 6). The
vertical ear canal is now dissected to the level of the horizontal
ear canal with appropriate care taken to avoid the facial nerve in
this area. The dissection is continued with freeing the horizontal
part of the ear canal from the surrounding tissues to the level
of the external acoustic meatus. The ear canal is then removed
with scissors and removal of all of the skin lining the osseous
external ear canal is accomplished with a small curette (see Fig.
7). When this is performed correctly, no lateral bulla osteotomy
is necessary in absence of chronic otitis media. With chronic
otitis media or para-aural abscessation and accumulation of
inflammatory tissue or thick exudate in the middle ear cavity, a
Fig. 9. TECA: The pinna is remodelled, a Penrose drain is placed
and subcutis and skin are closed routinely.
 Inner ear dysfunction related to ear disease in dogs and cats - G. ter Haar
Fig. 10. VBO: The opening in the ventral bulla can be enlarged
with rongeurs.
lateral bulla osteotomy (LBO) is performed from this point on.
After total ear canal ablation, the tissues from the lateral aspect
of the bulla are bluntly dissected as close to the bone as possible
and the lateral and ventral aspect of the bulla are removed with
rongeurs until adequate visualization of the middle ear cavity is
possible (see Fig. 8). Samples can be obtained for culture and
susceptibility testing and for cytology or histopathology. After
curettage the tympanic cavity is copiously lavaged with warm
saline and closure is as for total ear canal ablation.
After completion of the TECA or TECA with LBO, the pinna is
remodelled and sutured with absorbable suture material [2]. A
penrose drain is placed and subcutaneous tissue and skin under
the pinna are closed in a routine manner (see Fig. 9). Complications
after TECA are facial nerve paralysis, wound infection and
dehiscence and chronic fistulation, but most complications can
be avoided with meticulous surgical technique.
Another consequence of TECA is conductive hearing loss. In one
study it was determined by BERA that hearing was lost completely
with TECA and LBO except when the tympanic membrane and
ossicles were retained [12]. This should be avoided however to
prevent accumulation of keratinized cellular debris that could
result in infection or late abscessation.
Otitis media and interna
Bacterial otitis media in dogs generally develops as an extension
of otitis externa through a perforated tympanum, but pharyngeal
infections may, in rare instances, extend to the middle ear
through the auditory tube [13]. Cats may develop otitis media
through this route as a sequel to upper respiratory tract disease.
Involvement of the middle ear through haematogenous spread
is only rarely encountered [13]. Other causes of otitis media
include fungal infections (Aspergillus, Candida), neoplasia,
inflammatory polyps, trauma and primary tumours.
Organisms cultured most frequently from affected middle ears
include Pseudomonas species, Staphylococcus intermedius,
beta-haemolytic streptococcus, Malassezia, Corynebacterium
species, Enterococcus species, Proteus species, E. Coli and
anaerobes. Infections with these agents are usually associated
132
Fig. 11. VBO: All abnormal tissue should be removed from the
bulla with gentle curettage.
with perforating foreign bodies or they occur as a sequel to
chronic, usually proliferative or severe otitis externa. Bacteria
can directly infect the middle and inner ear, or the bacteria
can produce toxins that inflame the labyrinth. Clinical signs
associated with middle ear disease can therefore vary from
otalgia (otic pain), lethargy, inappetence and pain on opening of
the mouth or reflect concurrent otitis externa, especially in dogs,
or otitis interna. The diagnosis can be made on history, clinical
signs, otoscopy and diagnostic imaging as discussed before.
The therapy of otitis media and/or interna consists of systemically
delivered broad-spectrum antibiotics [2]. Amoxicillin potentiated
with clavulonic acid or enrofloxacin are first choice antibiotics.
Perforated tympanic membranes should close in 4 weeks, when
the infection is cured. No ototoxic topical medications should
be used when the tympanic membrane is not intact to avoid
ototoxicity. When the tympanic membrane is intact, but bulging,
a myringotomy could be performed under general anaesthesia.
When the tympanic membrane is intact, a concurrent otitis
externa can be treated with topical ointments containing
antibiotics and corticosteroids.
Chronic unresponsive or recurrent otitis media warrants surgical
intervention. Total ear canal ablation with lateral bulla osteotomy
should be considered in cases with severe secondary changes
of the external ear canal and concurrent otitis media. If the
external ear canal is not affected, a ventral bulla osteotomy may
be performed to remove gross exudates and establish drainage
from the middle ear.
Damage to the tympanic membrane has been shown to cause
conductive hearing impairment. Dogs with perforated tympanic
membranes had significantly elevated hearing thresholds
assessed by BAER testing, but values returned to baseline by
3 to 4 weeks [1]. In a study on the effects of ventral tympanic
bulla osteotomy, brain stem auditory evoked potentials were
measured using an air-conducted sound stimulus before and
after surgery and before killing. Even though nine out of 12
dogs had proliferation of subperiosteal new bone from the inner
surface of the tympanic bulla with some obliteration of the bulla,
the measured BERA sensitivity before killing was equivalent to
preoperative levels in 11 dogs [14].

Fig. 12. VBO: In cats, the dorsolateral compartment should be
opened separately.
Ventral bulla osteotomy (VBO)
An incision is made parallel with the midline, centred 2-3 cm
toward the affected side from halfway the mandible to the level
of the atlas, following the medial border of the rostral digastric
muscle [2]. The platysma muscle is incised and linguofacial
vein is retracted. Care should be taken to avoid damage to the
nerves of the pharyngeal plexus. The incision is deepened by
blunt dissection between digastricus muscle and hypoglossal
and styloglossal muscles until the bulla can be palpated. A
Steinmann pin can be used to make a hole on the ventral aspect,
the opening can then be enlarged with a small rongeur (see Fig.
10). The opening should be large enough to allow for gentle
curettage of the entire ventral compartment (see Fig. 11). In cats
the dorsolateral compartment should be opened after this using
the same technique (see Fig. 12). All abnormal material should
be removed and collected for culture, sensitivity testing, cytology
and histopathology, but curettage should be very careful to avoid
damaging the round and oval windows. The cavity is flushed
and drained with a penrose drain, after which closure is routine
(see Fig. 13). Aftercare consists of broad-spectrum antibiotics for
14-21 days depending on severity of middle ear infection and
analgesics for 3-4 days.
Ototoxicity
Over 180 compounds and classes of compounds have been
identified as ototoxic. Not all of them are equally toxic and
some effects are reversible, but in most instances the deficit is
permanent. In human medicine, the aminoglycoside antibiotics,
the antineoplastic drugs cisplatin and carboplatin, loop diuretics,
salicylates, quinine, deferoxamine, and various toxic substances are
recognized for their propensity to cause ototoxicity [15]. The best
recognized, and perhaps most frequent, agents of ototoxicity in
veterinary medicine are the amino glycoside antibiotics, especially
gentamicin, but polypeptides, chloramphenicol, erythromycin,
and (oxy)tetracycline are ototoxic as well. The importance of
disinfectant-based (clioquinol, chlorhexidine, cetrimide, iodine,
povidone-iodine and 70% ethanol) ototoxicity, for instance used
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EJCAP - Vol. 16 - Issue 2 October 2006
Fig. 13. VBO: After placement of a Penrose drain, closure is
routine.
for ear surgery, should not be underestimated however [16].
In order for a drug to exert ototoxicity, it must reach the inner
ear. This may be the result of haematogenous spread following
oral or parenteral dosage. Commonly however, ototoxicity
follows topical application of ototoxic agents into the external
ear canal and their subsequent passage into the middle ear via
a ruptured tympanum. Subsequent diffusion into the middle
ear is enhanced by the presence of otitis media, which induces
increased permeability through the round window membrane.
The agent passes through the membrane of the round window
and enters the perilymph in the tunnel of Corti. It thereby
comes in contact with the hair cells of the organ of Corti and
causes degeneration of the perceptive cells. This route of entry
was demonstrated for gentamicin in the guinea pig, but similar
structures in the vestibule make it likely that perilymph also
reaches the sensory cells of the vestibular labyrinth [17].
Clinical signs of vestibular damage may be reflected very early (as
soon as 10 minutes!) after the insult has been effected. Within
three days central compensation results in diminishing and
eventually disappearance of the nystagmus, gradual attempts
to stand, and beginning efforts to eat and drink, but the head
tilt is unchanged. Within three weeks the situation improves,
but jumping and walking down stairs often still results in falling.
The compensation is optimal after about three months [2]. The
head tilt however may still be obvious and permanent. There is
no such compensatory mechanism for cochlear hair loss, hence
deafness as a result of ototoxicity is permanent.
In general, ototoxic effects are dose related, therefore avoiding
ototoxic chemicals or reducing the dose and frequency of
administration is important [15]. Careful observation and regular
follow-up examinations of the patient may allow detection of
vestibular signs early enough to allow the clinician to suspend
therapy. It is difficult to detect early cochlear damage without
sophisticated investigatory tools, such as BAER, however. Much
research has been focused on medically preventing ototoxicity
as a result of cisplatin in human medicine. Some success has
been achieved by co-treatment with protective agents. Nearly all
these agents are sulphur- or sulfhydryl-containing compounds
(thio compounds), known as antioxidants and potent heavy
 Inner ear dysfunction related to ear disease in dogs and cats - G. ter Haar
Threshold (dB SPL)
Frequency (Herz)
Fig. 14. Hearing thresholds are significantly increased in old dogs compared to the middle-aged group, especially in the high frequency area.
metal chelators. Currently, the otoprotective action of the ACTH-
related neuropeptides is under investigation since preliminary
results suggest that it may be possible to stimulate recovery
from acute hearing loss using these neuropeptides [18].
Congenital deafness in dogs and cats
In most dog and cat breeds inherited congenital sensorineural
deafness results from perinatal degeneration of the stria
vascularis which leads to collapse of Reissners membrane and
the cochlear duct and to hair cell degeneration [1,19]. The strial
degeneration appears to result from absence of melanocytes
and begins as early as 1 day after birth, but is only clearly
evident histologically by 4 weeks. This disease is common in
many breeds of dogs and cats with a predilection for white
coat colours and a strong association of deafness with blue
irises. Deafness is most closely linked to the recessive alleles
of the pigmentation locus S, responsible for Irish spotting,
piebald spotting or extreme-white piebald spotting. The most
commonly affected breeds include Dalmatians, English Setters,
Australian Shepherds, Border Collies, and Shetland Sheepdogs,
but there are over 80 breeds reported [20]. In the Dobermann,
and probably other dog breeds not carrying the merle or piebald
pigment genes, the deafness results from direct loss of cochlear
hair cells without any antecedent effects on the stria vascularis
[19]. The percentage of affected dogs with unilateral deafness
ranged from 73% to 90% in one report [20]. Unilaterally deaf
dogs usually exhibit no clinical signs and without BERA testing
(as puppies or prior to breeding) these dogs continue to increase
the prevalence of the disorder. Currently, investigations focus
on finding genetic markers for the gene or genes responsible
for pigment-associated deafness to reduce the prevalence
134
in affected breeds [20]. Until these markers are found, BERA
testing will be the sole method for identifying affected dogs and
cats. Both unilaterally and bilaterally affected animals should be
excluded from breeding.
Age related hearing loss
Presbycusis is a form of hearing loss associated with ageing and
the most common form of sensorineural hearing loss in humans.
The precise mechanisms by which aging results in presbycusis
is not known, but noise, hereditary, and systemic degenerative
changes appear to contribute to its development in humans [21].
Although a similar disease condition most certainly exists in dogs
and probably also in cats, there are not many reports describing
the brainstem-evoked response audiometric changes in old dogs
and the correlation with histopathological changes. To evaluate
hearing in old dogs, animals older than 12 years of age were
examined in our laboratory with brainstem-evoked response
audiometry using the same method as mentioned before. The
results showed that their hearing range did not differ much from
the first group, but their thresholds were significantly higher,
especially in the high-frequency area (see Fig.14). The histology
of the cochlear changes was studied and preliminary results
show profound hair cell loss and neuronal loss, most prominent
in the basal coils of the cochlea, comparable to presbycusis in
humans.
There is no cure for sensorineural hearing loss, but ongoing
research in human and veterinary medicine regarding middle ear
implants, cochlear implants, neurotrophic factors and stem cell
research is yielding promising results.

Geriatric canine and idiopathic feline
vestibular disease
Geriatric canine vestibular disease is the most common cause of
unilateral peripheral vestibular disease in old dogs [22]. The cause
is still unknown. The mean age of onset is 12.5 years, and the
disorder is characterized by the very sudden onset of unilateral
peripheral vestibular signs. No other neurological abnormalities,
like facial nerve paralysis or Horners syndrome are observed.
The diagnosis is made on exclusion of other causes and on the
alleviation of clinical signs with time. The prognosis for recovery
is excellent. Occasionally vomiting is severe, and Hi histaminergic
receptor antagonists, M1 cholinergic receptor antagonists or
vestibulosedative drugs are administered for 2-3 days to alleviate
the emesis associated with motion sickness [22].
Feline idiopathic vestibular syndrome is an acute, nonprogressive
disorder similar to the previous syndrome in dogs and affects cats
of any age, particularly in the summer months [23]. This disease is
characterized by the peracute onset of peripheral vestibular signs
with no abnormalities of proprioception or in other cranial nerves.
The diagnosis is based on the clinical signs and the absence of ear
problems or other disease. The prognosis is excellent; spontaneous
improvement is usually seen within 2-3 days, with a complete
return to normal within 2-4 weeks [22, 23].
Congenital vestibular syndromes
Congenital peripheral vestibular syndromes have been reported
in the German Shepherd, Doberman Pinscher, Akita, English
Cocker spaniel, Beagle, Smooth Fox terrier and Tibetan terrier,
as well as in Siamese, Burmese and Tonkinese cats [22,23].
Peripheral vestibular signs, usually unilateral, may be present at
birth or develop during the first few months of life. Head tilt,
circling and ataxia may initially be severe but are non-progressive
and with time, compensation is common and many affected
animals make acceptable pets. The diagnosis is based on the
early onset of signs, before 3 months of age [22]. Radiography
and CSF analysis are normal. Deafness may accompany the
vestibular signs, particularly in the Doberman Pinscher, the Akita
and the Siamese cat and can be diagnosed using BERA [23].
References
[1] COOK (L.B.) - Neurological Evaluation of the Ear. Vet Clin Small
Anim, 2004, 34: 425-35.
[2] VENKER-VAN HAAGEN (A.J.) - The Ear. In: Venker-van Haagen
A.J., Ear, Nose, Throat, and Tracheobronchial Diseases in Dogs
and Cats. Hannover: Schltersche; 2005.
[3] BISCHOFF (M.G.) and KNELLER (S.K.) - Diagnostic Imaging of the
Canine and Feline Ear. Vet Clin Small Anim, 2004, 34: 437-58.
[4] TER HAAR (G.), VENKER-VAN HAAGEN (A.J.), DE GROOT (H.N.M.)
and VAN DEN BROM (W.E.) - Click and Low-, Middle-, and
High-Frequency Toneburst Stimulation of the Canine Cochlea.
J Vet Intern Med, 2002, 16: 274-280.
[5] SIMS (M.H.) - Electrodiagnostic evaluation of auditory function.
Vet Clin North Am Small Anim Pract, 1988, 18: 913-944.
[6] ROSSER (E.J.) - Causes of otitis externa. Vet Clin Small Anim,
2004, 34: 459-68.
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EJCAP - Vol. 16 - Issue 2 October 2006
[7] EGER (C.E.), LINDSAY (P.) - Effects of otitis on hearing in dogs
characterised by brainstem auditory evoked response testing.
J Small Anim Prac, 1997, 38(9): 380-6.
[8] FAN (T.M.), DE LORIMIER (L.) - Inflammatory polyps and aural
neoplasia. Vet Clin Small Anim, 2004, 34: 489-509.
[9] MUILENBURG (R.K.), FRY (T.R.) - Feline nasopharyngeal polyps.
Vet Clin Small Anim, 2002, 32: 839-49.
[10] VAIL (D.M.) and WITHROW (S.J.) - Tumors of the Skin and
Subcutaneous Tissues. In Withrow SJ and MacEwen EG (ed):
Small animal clinical oncology. Philadelphia, WB Saunders, 2001,
pp. 252-254.
[11] KIRPENSTEIJN (J.) - Aural Neoplasms. Semin Vet Med Surg (Small
Anim), 1993, 8(1): 17-23.
[12] MCANULTY (J.F.), HATTEL (A.) and HARVEY (C.E.) - Wound Healing
and Brain Stem Auditory Evoked Potentials After Experimental
Total Ear Canal Ablation With Lateral Tympanic Bulla Osteotomy
in Dogs. Vet Surg, 1995, 24: 1-8.
[13] GOTTHELF (L.N.) - Diagnosis and Treatment of Otitis Media in Dogs
and Cats. Vet Clin Small Anim, 2004, 34: 469-87.
[14] MCANULTY (J.F.), HATTEL (A.) and HARVEY (C.E.) - Wound Healing
and Brain Stem Auditory Evoked Potentials After Experimental
Ventral Tympanic Bulla Osteotomy in Dogs. Vet Surg, 1995,
24: 9-14.
[15] RYBAK (L.P.), KANNO (H.) - Ototoxicity. In: JJ Balenger and JB
Snow, Eds; Otorhinolaryngology: Head and Neck Surgery, 15th
ed., Baltimore, Williams & Wilkins, 1996, pp. 1102-1108.
[16] GALL (H.G), VENKER-VAN HAAGEN (A.J.) - Ototoxicity of the
antiseptic combination chlorhexidine/cetrimide (Savlon): effects
on equilibrium and hearing. Vet Quart, 1986, 8: 56-60.
[17] De GROOT (J.C.M.J.), MEEUWSEN (F.), RUIZENDAAL (W.E.),
VELDMAN (J.E.) - Ultrastructural localization of gentamycin in the
cochlea. Hearing Research, 1999, 50: 35-42.
[18] WOLTERS (F.L.), KLIS (S.F.), HAMERS (F.P.), DE GROOT (J.C.),
SMOORENBURG (G.F.) - Perilymphatic application of alpha-
melanocyte stimulating hormone ameliorates hearing loss
caused by systemic administration of cisplatin. Hear Res, 2004,
189: 31-40.
[19] STRAIN (G.M.) - Aetiology, prevalence and diagnosis of deafness in
dogs and cats. Br Vet J, 1996, 152: 17-36.
[20] STRAIN (G.M.) - Deafness prevalence and pigmentation and
gender associations in dog breeds at risk. Vet J, 2004, 167:
23-32.
[21] SAJJADI (H.), PAPARELLA (M.M.) and CANALIS (R.F.) - Presbycusis.
In: Canalis RF and Lambert PR, eds., The Ear: Comprehensive
Otology. Philadelphia; Lippincott Williams and Wilkins; 2000.
[22] TAYLOR (S.M.) - Head Tilt. In: Nelson RW and Couto CG, eds.;
Small Animal Internal Medicine, 3rd ed. St. Louis: Mosby; 2002.
[23] LECOUTEUR (R.A.) - Feline vestibular diseases new developments.
J Feline Med Surg, 2003, 5: 101-8.
How to contact the FECAVA Office and
Secretary
Our Secretary is Dr. Laureline Ziwny
You can contact Laureline:
By phone : +32 (0)2 533 70 26
By e-mail : laureline@fve.org
The times which you can speak to Laureline direct are:
Mondays to Thursdays from 9.30 am to 3.30 pm
The office is open from 8.30 am to 4.30 pm Monday to Friday
but outside Laurelines hours you may get a member of the FVE
Secretariat
 ENDOCRINOLOGY

COMMISSIONED PAPER

Rehabilitation Therapies for

musculoskeletal and spinal disease
in Small Animal Practice
M. R Owen(1)

INTRODUCTION

Increasingly, companion animal veterinary health professionals are seeking rehabilitation therapies for animals under
their care suffering from or recovering from musculoskeletal and or spinal injury/disease. In man, rehabilitation
therapy has the potential to assist, accelerate or enhance clinical outcomes following orthopaedic or neurological
compromise and this, amongst others, is the reason that rehabilitation features in human patient care. The same ideals
apply in veterinary care and under optimal conditions, rehabilitation forms part of best clinical practice and attention
to rehabilitation should not be reserved for attempted rescue of poor clinical outcomes. The increasing intimacy of the
professional relationship between physiotherapists (who have trained and who are registered for treating animals)
and veterinary surgeons has fostered the opportunity to provide rehabilitation therapies to companion animals.
Rehabilitation therapies and strategies are as yet still novel in veterinary care and there is still much to learn regarding
the application of and the indications for rehabilitation activities and therapies towards the spectrum of orthopaedic
and spinal disease encountered in small animal practice. Veterinary clinical research is providing evidence of efficacy
of designated rehabilitation programmes and practices for specific musculoskeletal problems. However, for the most
part, we are currently applying rehabilitation therapies to our veterinary patients considering the principles of basic
science of tissue healing, by extrapolating from human clinical practice and by reference to veterinary anecdote and
small case studies. Only further prospective controlled clinical studies will enable us to identify and evaluate the
treatment efficacy of specific rehabilitation practices and therapeutic modalities used in each of the clinical conditions
we treat. This article aims to provide the reader with a brief introduction to some of the therapeutic interventions and
exercises that are used in rehabilitation.

recovery period, when patients are not capable of unassisted

This paper was commissioned by FECAVA for
publication in EJCAP
Therapeutic exercise on land
Early return to function generally provides the best opportunity
for the fullest recovery following orthopaedic or spinal injury/
disease. This is because restoration of activity assists return of
normal tissue physiology and biological function. During the
voluntary function, therapeutic exercise activities are an
invaluable way of promoting musculoskeletal metabolic and
physiological function. In the authors opinion, whenever
possible, therapeutic exercises in which the patient actively
engages and uses musculoskeletal function are preferable to
passive movements performed by the operator, since the latter
do not necessarily promote return of voluntary function.
In a rehabilitation programme, specific therapeutic exercises
are selected and performed in accordance with the needs of

It is beyond the scope of this article to provide a comprehensive review of the subject and the interested reader is recommended
to refer to the texts in the Further Reading list.

(1) Dr Martin R Owen BVSc BSc PhD DSAS (Orth) MRCVS RCVS Specialist in Small Animal Surgery (Orthopaedics) Senior Lecturer in Small Animal
Surgery (Orthopaedics), Companion Animal Studies, Department of Veterinary Clinical Science, University of Bristol,
Langford House, Langford, Bristo l, GB- BS40 5DU. E-Mail: martin.owen@bris.ac.uk

137
 Rehabilitation Therapies for musculoskeletal and spinal disease in Small Animal Practice - M. R Owen
Figure 1 Paraplegic dog assisted to stand using harness
the patient and the goals of the rehabilitation programme.
During recovery, as tissues heal and neuromuscular and/or
musculoskeletal function improves, therapeutic exercises are
accordingly modified or increased in intensity to maximise
their therapeutic benefit. Examples of therapeutic land
exercises include postural exercises (sit to stand), controlled
leash activities, negotiating stairs and obstacles, dry treadmill
locomotion, dancing and wheel barrowing, controlled playing
with obstacles, reaching for toys/food etc.
Postural exercises (sit to stand, lie to stand transitions,
assisted standing, resisted joint flexions )
These activities are useful for patients with severe musculoskeletal
or neuromuscular injury/disease which are unable to support their
own weight and also for patients recovering from orthopaedic
Figure 2 Tetraparetic dog supported on a Physio Roll facilitating
postural exercises and proprioceptive training exercises
Lowri Davies, Smart Clinic, Swansea
138
injury/surgery. Animals that cannot support their own weight
can be assisted to stand so that muscular function is promoted.
Patients unable or unwilling to support their own weight can be
further assisted to perform these activities by supporting their
weight, either using a harness or slings [Figure 1] or exercise balls
or rolls [Figure 2]. Many patients appear more willing to attempt
to use their limbs when supported over a ball or roll than when
they are suspended in a harness hence use of the former is
generably foreferable. In patients with neurological compromise,
assisted standing exercise encourages neuromuscular function,
re-educates and enhances stamina of muscles and may assist
proprioceptive learning. Sit to stand exercises are the authors
preferred rehabilitation activity for dogs recovering from spinal
injury/disease since physiological movements of the limbs can
be simulated (even in animals with no voluntary movement in
the pelvic limbs) and positioning patients as if standing appears
to promote muscular contractions, rather than the muscular
relaxation observed when passive ranges of motion (ROMs) are
performed on recumbent patients. When dogs have the ability
to perform sit to stand transitions without assistance, voluntary
repetitions can be encouraged using treats and praise.
Use in orthopaedic patients
In orthopaedic patients, assisted postural activities encourage
patients to use their limb through a controlled range of motion
that is not achieved when the patient avoids using its limb, instead
maintaining a non-weight bearing lameness. Furthermore,
joints are encouraged to flex and extend and muscles are
actively flexed and passively stretched through greater ranges
than occur during ambulation. Excursions of limb segments and
the amount or duration of weight-bearing can be manipulated
using exercise rolls or balls to provide additional challenges for
the patient e.g. encouraging placement of the fore paws on
the roll. [Figure 3]. During therapeutic exercises patients should
be given rest periods so that fatigue does not limit their value.
Initially, 10-15 repetitions may be performed 3-5 times per day ,
with intensity of exercise increasing and the assistance provided
by the clinician decreasing during patient recovery.
Figure 3 Encouraging placement of the fore paws on the roll.

Figure 4 Walking on a treadmill can encourage limb use when a
dog is reluctant to use the limb on land. Treadmill activity can
promote normal gait patterns.
Modified locomotion activities
Perhaps unlike many human patients, once they are able to
walk, or use an injured limb, most of our companion animal
patients appear to attempt to return to levels of voluntary
activity and function achieved before injury/disease with minimal
encouragement. Consequently, for veterinary patients, as soon
as voluntary ambulation is possible and safe, these patients
can be challenged with modified locomotion exercise activities
designed to increase their strength, endurance, ROM and/or
proprioceptive function. Encouraging patients to actively move
their limbs through exaggerated ranges of motion (compared to
those achieved during normal gait) is generally better tolerated
than trying to achieve enhanced ROMs by passive movements.
In the early recovery period, normal limb use is generally
promoted best by restricting patient velocity, since at speed,
holding the limb off the ground is encouraged. Sometimes it is
necessary to enforce excruciatingly slow leash walks in order to
persuade patients to use their limb but speed can be increased
once the patient relearns a normal pattern of gait in which the
limb is used. In order to transfer increased weight on to the
limbs, patients can be made to negotiate slopes and steps/stairs.
Stair climbing should be performed in a slow controlled manner
to ensure that reciprocal limb use occurs, rather than hopping
or jumping. Compared to over-ground walking, stair climbing
results in greater excursions of the limb segments and the
challenge that stair climbing poses to patients can encourage
limb use where there is reluctance. Encouragement to negotiate
obstacles on the ground such as rocks, boxes, a ladder placed
on the ground or Cavaletti rails are all effective ways to
promote use of a limb in orthopaedic patients. The modified
gait required to negotiate the obstacles requires balance, it
results in recruitment of different muscle contraction activities
compared to simple flat ground walking and these activities
provide proprioceptive challenges for animals recovering from
neurological dysfunction.
Ambulatory function can be promoted by treadmill walking
[Figure 4]. Dogs generally adapt rapidly to treadmill locomotion
within a few minutes of exposure and resistance to the unfamiliar
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EJCAP - Vol. 16 - Issue 2 October 2006
Figure 5 Limb use can also be encouraged by wheel barrowing.
experience can be lessened if a handler walks alongside the
patient, or encourages the patient, at the front of the treadmill.
A harness is helpful to prevent the patient from migrating off
the side of the treadmill and raising the treadmill into an uphill
slope appears to assist accommodation to the experience in
naive patients. The challenge of the moving belt encourages
use of limbs that are not used during over-ground ambulation
and the ability to control patient velocity enables challenge to
co-ordination, balance and proprioception. The moving belt
provides passive extension of the limbs during stance and this
may facilitate extension of joints (hence ROM) that does not
occur during voluntary overground locomotion.
Limb use can also be encouraged by dancing and wheel
barrowing. [Figure 5] These activities result in increased extension
of the shoulders/hips and increased weight is carried by the two
limbs on the ground. Where it is safe, patients can be encouraged
to jump up into the dancing position to further encourage
limb strength. Patients are rapidly fatigued by wheel barrowing
and dancing and some may not take to these activities readily
initially, hence for some patients, for reasons of operator safety,
a muzzle should be used at least initially.
Once healing/recovery is sufficient and simple ambulatory
function is restored, increased intensity activities can be
introduced in order to promote a return to pre-injury levels
of function. When return to a previous level of significantly
athletic function is the goal of rehabilitation therapy, activities
including ball chasing, running around obstacle courses,
controlled jumping etc can be introduced. These will expose
tissues to stresses and movements early in the healing period, to
facilitate tissue remodelling during healing. Extreme care should
be taken to avoid applying excessive stresses to healing tissues
which may impair outcomes. At this stage of recovery, most
athletically inclined pets will take care of their own rehabilitation
programmes and will regain acceptable levels of pet function.
Some dog and cats will pursue the dot produced from a laser
pointer and this can be an effective way of promoting physical
activity indoors. Less athletically-minded pets can be motivated
to exercise or perform activities with judicious temptation with
treats, or using toys.
 Rehabilitation Therapies for musculoskeletal and spinal disease in Small Animal Practice - M. R Owen
Figure 6. Weight shifting exercise. The patients hind limbs are
placed onto a balance cushion and the hindquarters are displaced,
altering the bodys centre of gravity. This activity is intended to
assist proprioceptive learning
Proprioceptive Training
All voluntary musculoskeletal movements are controlled by
proprioception and therefore all patient motivated activity and
all the therapeutic exercises described may be considered to
contribute to proprioceptive training. Some addition to these
specific activities which require patients to perform or to resist
deliberate movements may assist or accelerate the return of
proprioceptive functions impaired by neurological injury/disease.
These include weight-shifting exercises, in which the patient
stands and its balance is challenged with a laterally applied push,
encouraging a sway. Patients that are unable to stand can be
assisted to stand (e.g. on an exercise roll) and the patients balance
can be challenged by displacing either the patient or the exercise
roll, both craniocaudally and from side to side. Maintenance of
balance requires controlled muscular contraction that resists the
swaying. The patients centre of gravity can also be redistributed
by lifting single limbs off the ground, one at a time. To maintain
balance, different muscle groups must be contracted according
to proprioceptive input. Balance boards, platforms, cushions and
trampolines can also be used to challenge the patients ability to
remain balanced whilst equilibrium disturbing displacements are
applied either to the patient or the surface on which the limbs
are placed. [Figure 6]. Ambulatory patients can be encouraged to
negotiate challenging surfaces such as partially inflated air beds,
Cavalettis (or a ladder placed horizontally), deep grass, or rocky
ground that require deliberate limb movements which differ from
locomotion on flat ground. [Figure 7] The value of these activities
in accelerating or improving proprioceptive function beyond
that which occurs with controlled normal activity in companion
animals remains to be quantified.
Aquatic therapy (swimming and
walking in water)
Aquatic exercise (known to some as hydrotherapy) has
become a popular activity used in assisting the recovery from
musculoskeletal and spinal disease in dogs. Immersion in water
is not generally accepted by cats and hence its application in
140
Figure 7. A horizontally placed elevated ladder provides a simple
alternative to Caveletti poles. Walking through the ladder provides
a challenging environment to the patient and this encourages
neuromuscular control and exaggerates normal musculoskeletal
function.
this species is limited. The therapeutic value of aquatic exercise
is due to the physical properties of water and the opportunities
for performing activities in the aquatic environment that differ
from those performed on dry land.
Physical properties of water and physiological effects of
the aquatic environment
Between the temperatures of 0 and 100oC, at atmospheric
pressure, water is a liquid and its density is markedly greater than
that of air. The specific gravity (a measure of relative density) of
pure water is 1.0. The specific gravities of body tissues range
from 0.8 (fat), through 1.0 (lean muscle) to 2.0 (bone). When
immersed in water, objects are apparently less heavy than they
are on land due to the effect of buoyancy. Buoyancy occurs due
to the displacement of water which occurs on immersion. The
buoyancy of an animal in water, specifically whether or not a
patient can float, is a function of its overall body density: animals
with a specific gravity of less than 1.0 will float in water, whilst
those with a specific gravity of greater than 1.0 will sink. If the
depth of water is sufficient, buoyancy, or relative weightlessness,
facilitates total non-weight bearing exercise (swimming) and at
shallower depths enables reduced weight-bearing ambulatory
locomotion (wading). The effect of depth of water on buoyancy
in the dog has been studied [1] and water depths to the level
of the hock result in 91% weight borne in water, whilst only
38% of weight is borne in water depth that reaches the greater
trochanter of the femur. [Figure 8 ].
Immersed body parts and tissues are subject to hydrostatic
pressure that is a function of the depth of immersion. This raised
pressure exerted on immersed tissues can assist extracellular fluid
return to the circulation and this environment may be beneficial
for swollen joint or oedematous tissues. [2]. The viscosity of water
is substantially greater than that of air. Consequently, movement
in water encounters marked resistance, requiring greater levels
of exertion than comparable movements on land, hence aquatic
exercise promotes muscular strength and cardiovascular fitness.
The density and viscosity of water also provides a dynamically

38%
85%
91%
Figure 8 The effect of water depth on effective body weight. When
immersed to the depth of the hock, effective body weight is 91%. In
water to the depth of the stifle, effective weight reduces to 85% and
water to the level of the greater trochanter reduces effective weight
to 38%.
stabilising environment since all body movements tend to be
retarded. Consequently, it is easier to maintain balance in water
than on land. The viscosity and relative density properties of water
can be exploited to modify exertion levels during aquatic exercise.
Judicious application of currents (or jets) of water can increase the
perceived resistance to movement [Figure 9] Increased resistance
to movement can also be achieved by increasing the surface area
of a body part moving in the water by applying fins.
What are the potential therapeutic effects of aquatic
environment exercise?
Evidence from studies in man show that exercise in water can
improve strength, cardiovascular and musculoskeletal fitness,
ranges of motion (ROM) and there can be some beneficial
analgesic effects [3.4]. Furthermore, aquatic exercise is more
energy demanding than similar exercise on land [5] and
consequently, modest velocities of movement in water can
promote levels of fitness that would require greater velocities
on land. The combination of reduced velocity of exercise
with buoyancy results in low impact activity in comparison
to overground activity in which the potentially deleterious
deforming forces to which limb segments are subjected during
exercise are reduced. Consequently, higher levels and intensities
of exercise can be performed in an aquatic environment than
on land with less risk of damage to injured and/or healing
tissues. An additional clinically relevant benefit of exercise in
water is the associated improved comfort of exercise because
movement is damped by the viscous environment in the water,
the modification of painful, undamped overground movement
to slower controlled movements may be the means by which
aquatic exercise can result in increased joint range of motion
and in reduced pain. In man, some closed-chain exercises
(under water cycling) appear to assist reduction in joint pain
and to reduce joint effusion following anterior cruciate ligament
surgery [6].
Water temperature must be controlled when aquatic exercise
is used as an intended therapeutic intervention and for dogs.
Temperatures in the range 26oC and 28oC are generally
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EJCAP - Vol. 16 - Issue 2 October 2006
Figure 9 Swimming against jets to increase exertion (Photo
courtesy of Westcoast Ltd)
recommended to gain maximal positive effects of water warmth,
without risking heat related complications.
Swimming
In comparison to walking, swimming is an activity characterised
by greater excursions of the limb segment joints. In healthy
dogs, swimming results in increased hip joint flexion compared
to overground walking and following surgery for cranial cruciate
ligament surgery, there is increased flexion of the stifle and
of the hock joint during swimming compared to overground
walking. [8]. The increased joint excursions achieved during
swimming and during water walking may be helpful in
reducing musculoskeletal stiffness and loss of ROM that is
characteristic of orthopaedic disease and surgery. For patient
safety, clinical cases should be fitted with a floatation device
during swimming, at least until the patients ability to swim
competently is established. [Figure 10 ]. Non-athletically minded
dogs can be encouraged to swim using toys, or if essential,
temptation with food treats. [Figure 11].
For dogs recovering from surgery for cranial cruciate ligament
disease, the benefits of high intensity, high frequency post
operative swimming had been demonstrated. In a controlled
study, a group of home exercise dogs were compared to a group
of dogs that were hospitalised for intensive rehabilitation on three
alternate weeks during their early recovery period. These dogs
swam twice daily for between 10 and 20 minutes, five days a
week on these three weeks. Using force plate analysis, six months
following surgery, the swimmers were less lame on their operated
limb than restricted exercised dogs and in swimming dogs, there
was no difference in limb function between their operated and
their normal limbs. In the exercise restricted dogs, six months
following surgery, limb function was still significantly less in
the surgical limbs compared to their normal limbs [7]. Though
differences were measurable between these groups six months
after surgery by force plate analysis, visual assessment of lameness
in dogs recovering from cranial cruciate ligament surgery suggests
a greater difference between swimmers and non-swimmers in
 Rehabilitation Therapies for musculoskeletal and spinal disease in Small Animal Practice - M. R Owen

Figure 10 During aquatic exercise for safety patients should be Figure 11 Encouraged to swim using toys. (Photo courtesy of
fitted with a flotation device. Westcoast Ltd).

the early post operative period than is evident six months after Aquatic exercise is a popular recommendation by veterinary
surgery. In order to investigate the efficacy of a less intensive post clinicians for dogs with a wide spectrum of musculoskeletal
operative swimming regimen that does not require hospitalisation, disorders including developmental, acquired, traumatic
but to maximise the acceleration in function obtained through degenerative conditions and even diseases for which a diagnosis
post operative swimming, we have proposed a twice weekly post remains a mystery. Interestingly, meta-analysis of clinical
operative swimming protocol for fit and healthy dogs recovering studies of aquatic exercise by the Cochrane Collaboration
from surgery for cranial cruciate ligament disease. (www.cochrane.org) for the management of pain control in
musculoskeletal disorders including osteoarthritis in man has
not shown superiority of aquatic exercise compared to over
Swim protocol for eight week post operative recovery ground exercise. In dogs, with the exception of the post surgical
period following cranial cruciate ligament surgery [9] treatment of cranial cruciate ligament disease, the therapeutic
value of aquatic exercise in the management of musculoskeletal
Swim Time (minutes) Pool Jet Power disease remains to be quantified through a published controlled
1 5 0 prospective clinical study.
2 5 0
3 7 0 Swimming for dogs with neurological disease
4 10 0 Immersion in water can provide a stimulus for voluntary limb
5 6 10% movement in dogs with neurological or neuromuscular disease.
6 8 10% Dogs that have insufficient function to display voluntary limb
7 10 10% movement on land can demonstrate limb movement when
8 6 25% encouraged to swim. This may due to the stimulus of the
9 8 25% immersion in water and perhaps the different neuromuscular
10 10 25% recruitment that occurs during swimming compared to
11 6 50% overground locomotion. Alternatively, movement may occur
12 8 50% because there is sufficient strength to move the limbs when the
13 10 50% body is buoyant in water but insufficient strength to support
14 8 75% body weight on land. Regular swimming sessions can be a useful
15 10 75% stimulus to encourage return of voluntary movement in plegic
16 10 100% dogs and when swimming, greater joint excursions are achieved
compared to impaired overground ambulation. Swimming also
When jets are used, swimming starts and also ends with an enables muscular strength and fitness training without injury
additional period of 1 minute swim without jets. For jet swims, through abrasion or falling on the ground. Swimming has been
for the first half of the swim the dog swims into the jet stream, suggested to be as an important aid in recovery following spinal
subsequently, the dog swims with the jet stream. dysfunction presumed secondary to fibrocartilagenous embolic
disease [10]. The beneficial effects of swimming for veterinary
neurological patients have not been quantified in comparison to
non-swimming matched controls in published clinical studies.

142

Figure 12 Using a Physio Roll as a safe back stop to encourage
walking on the belt during UWTM (Photo courtesy of Lowri
Davies)
Walking in water and under water treadmill (UWTM)
activity
In water, the nature of movement of the joints and limb
segments differs to compared to overground locomotion. For
dogs walking on water treadmills this effect is influenced by the
depth of water used. Typically, carpal and tarsal flexion increases
as water level increases from ground level up to the level of
the carpus. Additional increase in water level towards level of
the elbow/stifle joint appears to result in increased elbow/stifle
flexion. Water depth seems to have less influence on flexion of
the hip/shoulder. The modified gait exhibited by dogs walking in
water is also seen in dogs with mild neurological deficits and it
appears that when walking in water, the tendency for these dogs
to walk with their paws knuckled over is lessened. In such cases,
correct placement of the paws may be assisted by the waters
resistance to movement, that results in splaying of the toes, the
webbing between the toes acting as a fin. As the splayed toes
are pushed against the water, the feet tend to land properly.
Correct placement of the paws may assist proprioceptive
training though clinical studies are required to ascertain and
quantify the therapeutic benefit of this phenomenon in dogs.
In deep water, in addition to the paw positioning effect, there
is an effect of enhanced dynamic stability due to the combined
effects of buoyancy, viscosity and relative density of water.
Consequently a deep water environment can assist locomotory
function and musculoskeletal activity for dogs with weakness,
severe marked neuromuscular dysfunction or lameness. For dogs
showing progressive clinical improvement, the depth of water
used in the UWTM can be progressively reduced in accordance
with the improvement in locomotor function, working towards
return to unassisted locomotor function. The duration of each
period of activity in the UWTM should be short enough so
that fatigue does not limit function. Hence multiple repeats of
short periods of activity are recommended, allowing recovery
between active periods. The duration and intensity of exercise
can be increased (by increasing velocity of movement or depth
of water) in accordance with increase in function during clinical
recovery.
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EJCAP - Vol. 16 - Issue 2 October 2006
Figure 13 Buoyancy aid applied to the distal limb to modify limb
segment excursions in the UWTM. (Photo courtesy of Lowri
Davies)
UWTM for orthopaedic disease
Characteristically, following orthopaedic injury of surgery,
painful joints are held in a degree of flexion in order to protect
the limb from potentially injurious forces and the potentially
painful stimulus of load-bearing. For dogs recovering from
musculoskeletal injury and disease, the beneficial effects of
buoyancy created by deep water can be exploited to encourage
ambulatory limb function in diseased/operated limbs. Using an
UWTM, water depth can be adjusted (increased as necessary)
to ensure that the diseased limb is voluntarily extended and
that functional steps are made using the limb. The moving belt
of the treadmill is an unfamiliar experience for most patients
and reluctant walkers can be effectively assisted to walk on the
belt by an assistant restraining and encouraging the patient.
Placing a large soft object (e.g a gym roll or ball) into the water
behind the dog, at the back of the treadmill provides a soft
effective back of the treadmill, which encourages dogs to move
forward onto the advancing treadmill belt. [Figure 12] In deep
water, buoyancy can also be used to assist joint excursion by
application of a floatation device to the distal limb segment (e.g
to the carpus/tarsus). Such application increases passive elbow/
stifle joint flexion in deep water. In contrast, assisted extension
of an injured limb can be encouraged by applying a buoyancy
aid to the contralateral (normal) distal limb. [Figure 13] The
resultant increased swing phase on the normal limb encourages
extension and stance on the injured limb. Hence the aquatic
environment can be used to facilitate soft tissue stretching and
when limb use improves, this form of exercise can be employed
to improve muscular strength and to promote use of the limb
during overground ambulation. [11] have described the use
of under water treadmill exercise alongside postoperative
physiotherapy for a small group dogs recovering from surgery
for cranial cruciate ligament disease. Following suture removal
10 days after surgery, water treadmilled dogs were exercised
three times per week in the treadmill. Six weeks following
surgery, thigh muscle mass of the surgical limbs (measured as
thigh girth) was greater in UWTM dogs compared to home-
exercised dogs.
 Rehabilitation Therapies for musculoskeletal and spinal disease in Small Animal Practice - M. R Owen
Figure 14 Application of cold therapy to the stifle joint following
recent surgery. Cold packs should not be applied directly to the
skin. To avoid cold burns, a moistened towel can be used as an
insulating layer which facilitates transfer of heat energy.
Despite the popularity of the recommendation UWTM aquatic
exercise by veterinary clinicians for dogs with musculoskeletal
injury/disease, to date, the author is not aware of evidence
of efficacy of this exercise modality compared to over-ground
exercise from clinical studies of large numbers of dogs.
Physical Agents
Heat, cold, low frequency ultrasound, electrical stimulation,
laser and extra-corporal shock waves are some of the physical
agents used in rehabilitation programmes for musculoskeletal
and neurological injury and disease.
Cold (cryotherapy)
The application of cold is referred to as cryotherapy. The
intention of application of cold is to draw heat energy from body
tissues, resulting in a reduction in tissue temperature. Some of
the physiological effects of tissue cooling include (but are not
limited to) reductions in the following:
1. blood flow
2. inflammation
3. oedema
4. local tissue metabolism
5. pain sensation
6. spasticity
and an increase in the factors below:
1. tissue stiffness
2. muscle viscosity (resulting in reduced ability to contract/extend
rapidly)
Application of cold is indicated to assist the management of the
following conditions
1. acute injury
2. acute inflammation, swelling or oedema
3. to increase range of motion (ROM) when it is limited by pain
Care should be used during the application of cold to avoid
thermal injury to the tissues (frostbite). Injury should be prevented
144
Figure 15 Using a hair dryer to warm tissues
using the following guidelines:
1. Use cold therapy within the first 24-72 hours of acute injury
2. Use ice packs or commercial cold packs chilled to temperatures
not lower than -20oC
3. Do not apply ice or gel pack directly to the skin. Ensure
that a thermal insulating layer is used against the skin. This
is especially important when the animals hairy coat has
been clipped. A moist cloth provides some insulation whilst
facilitating transfer of some heat energy [Figure 14]
4. Apply cold source for up to 20 minutes at a time. (Often, 15
minutes on, 15 minutes off is recommended).
5. Ensure that tissues are given the opportunity to return to
their preferred physiological temperature at the end of the
treatment period. (Total treatment periods are generally
governed by practical constraints but are not normally
continued for more than one hour).
The relative analgesic efficacy afforded by cold therapy compared
to postoperative bandaging has not been investigated in
companion animals and in general, it is the authors preference to
apply dressings in the immediate postoperative period to control
swelling and to protect limbs from painful jarring movements.
Cold therapy can be applied through light postoperative dressings
since light bandages are not total insulators of heat/cold.
Heat
Superficial heat therapy
The intention of heat therapy is to increase the temperature
of the treated tissues. This can be achieved superficially (up to
2cm depth) using conduction, radiation and convection from

external heat sources. Examples of heat sources for superficial
warming include warm packs, spas and whirlpools, infra red
lamps and warm air heaters/hair dryers [Figure 15]. Warming
of deep tissues requires transfer of energy to deep tissue that is
absorbed and converted to heat energy. Heating of deep tissues
is achieved using ultrasound (US) and electricity (short wave
diathermy).
Some of the physical effects of heating tissues include (but are
not limited to):
1. relief of pain and spasm
2. increased tissue compliance
3. increased blood flow
4. increased tissue metabolism
5. increased muscle relaxation
6. increased capillary permeability (which can promote
oedema)
Application of heat is indicated in the following conditions:
1. chronic musculoskeletal discomfort
2. decreased ROM due to stiffness
Heat should be applied according to the following conditions:
1. Apply hot packs (generally not hotter than 75oC) using
thermal insulation padding.
2. Heat pack Temperature should be tested against the
operators skin if there is any uncertainty regarding the risk
of causing a burn to the patient.
3. Apply heat packs for 15 to 30 minutes.
4. Thermal baths and whirlpools should be used at temperatures
not exceeding 35oC. Locally applied warm water can generally
be used safely at higher temperatures (up to 40oC).
Heating of deep tissues
In small animals, even deep tissues may be heated using
superficial heat therapy. For example, the joints of small animals
will be warmed when heat packs are applied because the depth
of the tissue will not exceed 2 cm from the skin surface in many
patients. Heating of deeper tissues by an energy source requires
transmission of energy and conversion to heat energy because
sufficient transfer of heat from superficial application cannot
occur without burning. This can be achieved using relatively
low frequency (approximately 20 kHz to 3MHz) ultrasound
(US). Tissue heating so created tends to be of short duration
following treatment and treatment periods are generally in the
region of 10 minutes. A hairy coat absorbs US and results in poor
transmission of energy and consequently, skin must be clipped
to enhance energy transmission to the tissues. Debate continues
regarding the therapeutic efficacy of deep tissue heating in
human medicine [12] and its efficacy in companion animals is
also undetermined. However, commercial recommendations
suggest that emission intensity of 1.0W cm2 and higher for 10
minutes heats tissues. In order to achieve thermal effects an
elevation of tissue temperature of 1oC to 4oC is recommended.
Suggested clinical indications for tissue heating by US include
tendonitis and bursitis and joint contracture secondary to
chronic inflammation or immobilisation. Studies in man suggest
that US can accelerate soft tissue healing and fracture healing,
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EJCAP - Vol. 16 - Issue 2 October 2006
although enhanced fracture healing has not been demonstrated
in controlled conditions in dogs.
Treatment guidelines include:
1. use a water-soluble gel as a coupling agent to the skin to
facilitate US transmission.
2. use a coupling cushion if the US head does not conform to
the surface of the tissues treated.
3. follow the application guidelines applicable to the power
rating and the frequency delivered by the US unit used to
ensure tissue heating and to avoid thermal injury.
4. consider any vocalising or avoidance behaviour to be
attributable to discomfort and stop treatment. Use lower
intensity or duration of treatment next time.
5. treat for approximately 4 minutes for each position of the
sound head and for a maximum of four adjacent positions of
the sound head per session.
6. keep transducer moving at approximately 4cm per second to
avoid localised overheating of tissues.
Electrical stimulation
Electrical stimulation of tissues is primarily used in veterinary
care to assist pain control and to increase muscle strength.
Amelioration of pain is achieved by the depolarisation of sensory
nerve fibres whilst electrically induced muscle contraction is
achieved by motor nerve depolarisation.
Variables in electrical stimulation
A wide variety of electrical stimulators is commercially available,
many of which produce unique combinations and ranges of
electrical outputs. The variability of the output includes
frequency.
amplitude (the maximum electrical current delivered).
waveform (symmetric, asymmetric, balanced, unbalanced,
bi/mon/polyphasic etc).
polarity.
pulse rate.
ramp (rate of acceleration of amplitude from start of pulse to
peak amplitude).
Different models of stimulator claim to be more appropriate for
specific applications e.g. pain control.
Electrical energy is delivered to tissues using surface electrodes.
Ideally these are flexible so as to conform to the tissue to which
they are applied. Some (single use) electrodes can be trimmed
to size so that they fit well and so that they only stimulate the
tissues of interest. (If electrodes are too large, they will stimulate
unwanted muscle groups to contract). Electrodes should have
a low resistance and conduction to the skin can be increased
using appropriate gel.
Electrical stimulation for pain control
Guidelines for electrical stimulation for pain control in animals
are limited and are based extrapolation from use in man
and on small studies performed in dogs. One study showed
significant improvement in limb function in dogs with chronic
stifle osteoarthritis for up to 180 minutes following electrical
 Rehabilitation Therapies for musculoskeletal and spinal disease in Small Animal Practice - M. R Owen
stimulation [13] .Daily treatments are recommended although the
duration of analgesia provide by stimulation is poorly quantified.
Treatment periods of 20-30 minutes are recommended using 50-
150 Hz with pulse duration of 2-50 microseconds for acute pain
and 100-400 microseconds for chronic pain. The relative value
of interferential, premodulated interferential or pulsed current
(AC or DC) waveforms is, as yet, unquantified in companion
animals.
Electrically induced muscle contraction
When a patient is not or cannot voluntarily use its limb, electrical
muscle stimulation can help reduce loss of muscle strength. The
ideal delivery of electrical stimulation is unknown but small
clinical studies suggest that stimulation frequencies between 25
and 50 Hz produce strong titanic contraction whilst minimising
fatigue. A symmetrical biphasic pulse is preferred and is allegedly
the most comfortable waveform according to some reports in
man. Pulse durations of 100 to 400 microseconds with ramp
durations of 2-4 seconds should also maximise comfort in dogs.
[14]. Treatment frequencies of five times per week have been
used, though daily treatment may seem equally sensible.
Patient safety: Operators must receive appropriate training
before using electrically operated energy transmitting devices
in rehabilitation programmes
Laser treatment
The type of laser used in injury and disease is the low-level laser,
which typically produces an output of between 1 and 5 mW.
There are several types of emitters, but Helium-Neon (HeNe) is
one of the most popular laser used in human and in veterinary
work, emitting visible red light with a wavelength of 633nm. The
therapeutic application of lasers has been investigated since the
1970s and putative therapeutic indications include soft tissue
wound healing, osteochondral wound healing, management
of osteoarthritis, pain control and regeneration of spinal cord
following injury. The under pinning mechanistic theory of laser-
induced tissue response is that photons are delivered to tissues,
absorbed by chromophores and cytochromes resulting in oxygen
production, stimulating the formation of proton gradients across
cell membranes. These changes result in ATP production and
cellular metabolism and growth are up regulated. Unfortunately
the results of laboratory studies that document enhanced soft
tissue and osteochondral healing have not been reproduced
in published clinical studies in man or companion animals and
hard evidence to support laser therapy for enhanced tissue
healing in wounds in healthy animals is not currently available.
In man, the value of laser therapy has been investigated for
the management of knee pain due to osteoarthritis [15,16,17].
Interestingly, positive results appear more likely when the study
is published in a journal containing laser in its title.
Extracorporal shock wave therapy (ESWT)
In man, some clinical studies have demonstrated therapeutic
efficacy of ESWT in the management of delayed and non-union
fractures, and pain management of chronic conditions such as
lateral elbow pain (tennis elbow), plantar fasciitis, Achilles and
patellar tendonitis and osteoarthritis.
146
What is ESWT?
Shock waves are high energy, high amplitude acoustic pressure
waves generally in the range of 20-100 megapascals (MPa).
Shock waves are generated in a liquid medium by the conversion
of electrical activity to mechanical energy by electrohydraulic,
electromagnetic or piezoelectric transducers. The waves are
characterised by a massive rapid rise in energy and a subsequent
exponential decay, all of which takes place in approximately 300
nanoseconds. [Figure 16]. Shock waves travel through tissues and
energy is released at boundaries between different tissue densities,
at bone-tendon interfaces, for example, generating heat. Shock
waves have direct effects (compression and tension) and indirect
effects (cavitation, tension and shear) on tissues. The microscopic
disruption to tissue may be the mechanism by which ESWT
modifies tissue physiology. ESW treatment results in induction
of cytokines and growth factors including transforming growth
factor 1, substance P, osteocalcin and vascular endothelial growth
factor [18]. Nitric oxide synthase induction is also stimulated, and
this may an important part of the mechanism by which ESWT
influences bone healing. Inhibition of afferent pain signals may
occur secondary to stimulation of nociceptors.
Figure 16 Profile of an extracorporeal shock wave showing the
rapid rise in energy and short duration of the acoustic wave. As the
energy is released in the tissues, there is negative pressure.
Shock waves can be delivered to tissues in a focussed manner to
a small area of tissue, in which depth of penetration can reach
11cm. Radial application delivers to the surface of the body
resulting in dispersion of energy over a wide and predominantly
superficial area. [Figure 16]
Application of ESWT in veterinary medicine is established in
equine work for the treatment of a spectrum of musculo-skeletal
disorders including suspensory ligament desmitis, tendinopathies,
back pain, navicular disease, osteoarthritis and stress fractures.
[19,20]. There are reports of small numbers of dogs with
musculoskeletal disorders (including tendinopathy, tendonitis
and osteoarthritis) treated with ESWT [21,22,23]. One of these
reports [23] was a controlled study that investigated the efficacy
of ESWT in controlling pain in hip and elbow osteoarthritis in dogs.

Figure 17 Equipment for delivering
shockwave therapy (insert of
contact endpiece) (Photo courtesy of
GHSMedical [Woolf])
Improvements were documented in limb function (as measured
by force plate analysis) and in comfortable range of joint motion
following ESWT treatment but not in sham treated controls.
ESWT may be a useful adjunct to the management of painful
musculoskeletal disease in dogs, particularly if analgesia cannot
be safely provided using non-steroidal anti-inflammatory drugs.
However, heavy sedation or anaesthesia is required for most
forms of ESWT in dogs and this may limit widespread application
of the technique. Because ESWT is a local treatment, careful
identification of the regional anatomy of the diseased limb is
necessary to ensure accurate direction of the shock waves. Treated
areas must be clipped to allow transmission of shock waves
which is greatly facilitated using ultrasound coupling gel. The
potentially injurious effects of cavitation necessitate that EWWT
is not applied to the lung field, brain, heart or major blood vessels
or nerves Furthermore, care should be taken during treatment
because ESWT can produce local tissue damage resulting in
bruising, petechiation and haematoma. These effects can be
controlled by applying the transducer to soft tissue and not to
bony prominences. Excessive treatment can result in thermal
tissue damage and following treatment, dogs can be sore for
several days, during which analgesia may be required. Claims
of the long-term analgesic effect of treatment suggest efficacy
for up to 12 months. Currently, treatments are predominantly
147
EJCAP - Vol. 16 - Issue 2 October 2006
based on manufacturers recommendations extrapolated from
USWT in man. Recommended treatment protocols for canine
musculoskeletal disease are not readily available in the published
veterinary literature and controlled studies are needed to fully
evaluate and optimise efficacy of treatment.
Conclusions
Our knowledge and understanding of the activities, exercises and
practices that encompass rehabilitation in veterinary patients is
constantly expanding. The expertise in veterinary rehabilitation
is largely derived from practices used in human medicine and
the veterinary profession has gained much from our developing
relationship with our physiotherapy colleagues. Veterinary
clinicians should continue to work closely with physiotherapists
to ensure that patients under their care engage in appropriate
rehabilitation that provide them the best standard of care.
Further reading
Canine Rehabilitation and Physiotherapy. Eds, Darryl L Millis,
David Levine and Robert A Taylor, Elsevier Saunders, St Louis,
Missouri. (2004)
Rehabilitation and Physical Therapy, Eds David Levine, Darryl L
Millis, Denis J Marcellin-Little, Robert Taylor. Veterinary Clinics
of North America Small Animal Practice. 35 (2005)
Small Animal Spinal Disorders: Diagnosis and Surgery 2nd
Edition Nicholas JH Sharp and Simon J Wheeler. Elsevier
Mosby, Edinburgh (2005)
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[9] OWEN (M.R.) AND HUNT (R.) (2004) Personal communication
[10] GANDINI (G.), CIZINAUSKAS (S.), LANG (J.), FATZER (R.), JAGGY
(A.) - Fibrocartilaginous embolism in 75 dogs: clinical findings and
factors influencing the recovery rate. J Small Anim Pract. 2003,
44:76-80.
[11] MONK (M.L.), PRESTON (C.A.), MCGOWAN (C.M.) - Effects of
early intensive postoperative physiotherapy on limb function after
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[12] ROBERTSON (V.J.), BAKER (K.G.) - A review of therapeutic
ultrasound: effectiveness studies. Phys Ther. 2001, 81:1339-50.
[13] LEVINE (D.), JOHNSON (K.D.) - Price MN and others. The effect of
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[14] MILLIS (D.L.), LEVINE (D.), WEIGEL (J.P.) - A preliminary study
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[15] DJAVID (G.E.), MORTAZAVI (S.M.J.) - Basirnia A et al. Low level
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[17] ROCHKIN (S.) - The role of laser phototherapy in nerve tissue
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[18] WANG (C.J.), WANG (F.S.), YANG (K.D.), WENG (L.H.), HSU
(C.C.), HUANG (C.S.), YANG (L.C.) - Shock wave therapy induces
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[19] MCCLURE (S.R.), MERRITT (D.K.) - Extracorporeal shockwave
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 ORTHOPAEDICS

REPRINT PAPER (A)

Diagnostic and genetic aspects

of patellar luxation in small and
miniature breed dogs in Austria
B. Vidoni(1), I. Sommerfeld-Stur(2), E. Eisenmenger(1)

SUMMARY

During a period of eight years (1996 2004) 432 small and miniature breed dogs were screened for patellar luxation
(PL). In order to achieve the diagnostic accuracy required for genetic screening to assist breeding programmes, examinations
were based on the concept of a standardized examination protocol for patellar luxtion. Diagnostic criteria assessed by
physical examination, inspection and palpation focussed on lameness, evaluation of patellar tracking in the standing and
recumbent position, with special focus on patello-femoral instability, as well as on the deviation of the tibial tuberosity
and any perceivable crepitation of the stifle joint during manipulation. Evaluation of all findings was made on the basis of
PUTNAMs (1968) classification. Radiographic examinations were not performed.
Patellar luxation (unilateral or bilateral, medial and/or lateral) was diagnosed in 61.6 % of the examined dogs, but
permanent lameness was only present in 15.5 % (right stifle) and 12.8 % (left stifle), respectively. Intermittent lameness was
observed in only 3.5 % (right stifle) and 4.6 % (left stifle), respectively. This means that almost 40 % of all dogs with patellar
luxation are asymptomatic and their condition would not have been detected without diagnostic screening. The different
diagnostic criteria showed significant correlation between each other and with the final findings. In some parameters like
luxation in standing position and luxation in recumbent position, the correlation with final findings was particularly
high. Thus, the examination protocol used in this study appears to be suitable for PL screenings in dogs.
Investigation of the influence of parameters like body weight, age, gender and neutering on the presence of PL
showed that, except for gender, all attributes were associated with the occurrence of PL. An increase in body weight of
1 kg decreased the odds of suffering from PL to the 0.8fold (p<0.05), while an increase of age of one year increased the
odds to the 1.1 fold (p<0.051). For neutered dogs, the odds showed a 3.1 fold increase of being affected by PL (p<0.05). No
significant influence could be observed for the gender of the animals. In order to detect breed predispositions for patellar
luxation, odds ratios were calculated for all breeds represented in the study by more than ten animals. The breeds involved
were: Jack Russell Terrier, Pug, Papillon, Pekingese, Shih Tzu, Tibet Terrier, West Highland White Terrier, Poodle, Yorkshire
Terrier, Maltese Terrier and Chihuahua. Only two breeds showed odds ratios that were significantly different from 1: In the
Jack Russell Terrier, the odds ratio was significantly lower (0.31) (95 % confidence intervals 0.14-0.67), while the odds ratio
was significantly increased (5.62) in Poodles (Miniature and Toy Poodles) (95 % confidence intervals 1.93-16.41). This means
that Jack Russell Terriers have a comparatively reduced risk of suffering from PL, while the chance to develop the condition
seems increased in Poodles. These results are highly indicative of a genetic background but further investigation on the basis
of familial anamneses and heritability studies is required to support this postulate. A standardized examination technique
and official validation of the PL screening tests represent an essential precondition for the acceptance of PL screening
programmes by breeders.
Based on the results of this study, it is strongly recommended to implement a uniform, internationally valid and
highly accurate diagnostic screening programme for patellar luxation. At the moment, this screening protocol is used by
veterinarians in Germany, Switzerland and Austria.
Keywords: Patellar luxation, breed predisposition, small and miniature dog breeds, diagnostics, genetic screening, selective
breeding.

This paper originally appeared in: Wien.Tierarztl.Mschr.* (2005) 92, p170 181

(1) The University Clinic of Surgery and Ophthalmology, Department of Companion Animals (2) The Institute of Animal Breeding and Genetics, Department of
Animal Breeding and Reproduction - Vienna University of Veterinary Medicine, Austria e-mail: britta.vidoni@vu-wien
*Presented by VOK (Austria)

149
 Diagnostic and genetic aspects of patellar luxation in small and miniature breed dogs in Austria - B. Vidoni
Introduction
Patellar luxation (PL) was one of the first breed-specific disorders
of the locomotor system of small dogs that, together with some
diseases of the spine, were identified in the 1950s (BERREITER,
1956). This explains the strong interest in the genetic background
of the disease and possible measures to be taken when breeding
these dogs.
According to their aetiology, patellar luxations fall into two main
groups, i.e. traumatic (acquired) PL and congenital PL. Based on
the respective functional impairment, we distinguish between
intermittent and permanent PL. Luxation of the patella can be
medial or lateral (or both in very rare cases). It can affect one
stifle joint (unilateral) or both (bilateral). Congenital medial
patellar luxation is one of the most common derangements
of the canine stifle joint (PRIESTER, 1972; ROUSH, 1993) and
occurs most frequently in dogs of small breeds (BERREITER,
1966; SINGLETON, 1969; RODENBECK, 1971; SCHFER et al.,
1982; NUNAMAKER, 1985; HULSE, 1993; ANDERSON, 1994).
Bilateral medial patellar luxation is seen in 20 50% of the cases
(BRINKER et al., 1983; ROBINS, 1990). About 10 20% of all
luxations are lateral (ROBINS, 1990) and are seen more often in
large breeds, although they do occur in small and toy breeds
(ROBINS, 1990; NIEMAND and SUTER, 1994).
According to the classification devised by PUTNAM
(1968), there are four grades of canine patellar luxation
(Grades I IV):
Grade I: The patella luxates manually, but spontaneously
returns to the trochlea when released.
Grade II: The patella luxates spontaneously or on manipulation
and remains luxated at a certain angle of the stifle joint. It is
either spontaneously reduced on active flexion or extension
or can be manually reduced by the examiner.
Grade I and II are considered as intermittent PL.
Grade III: The patella remains luxated most of the time
but can be manually reduced. However, reluxation occurs
spontaneously.
Grade IV: The patella is permanently luxated and cannot be
manually repositioned.
Grade III and IV are considered as permanent PL.
SINGLETON (1969) and HARRISON (1975) added some
morphological criteria to the PUTNAM (1968) classification
system. For each of the four grades of PL, SINGLETON (1969)
defined varying degrees of deviation of the tibial tuberosity and
rotation of the tibia accompanied by a slight abduction of the hock
joint. Additional criteria were the morphological characteristics of
the trochlear sulcus and the presence or absence of crepitation.
HARRISON (1975) emphasized that dogs with patellar luxation had
a higher risk of rupture of the cranial cruciate ligament. He insisted
on considering additional criteria for classifying PL like retropatellar
chondromalacia, peritrochlear osteophytes and osteoarthrosis of
the stifle. In 1981, HULSE combined both classification systems to
create a new one. He defined the PL grades I to IV as a function
of the changes in angle and rotation observed in the femur.
KOCH et al. (1998) added further definitions to PL grades I-IV. A
patella riding high in the trochlea (incomplete articulation of the
patellar body with the trochlear groove [patella alta] ) is classified
as grade 0; Spontaneous luxation of the patella in the standing
150
dog is classified as grade III, even if spontaneous reduction on
active flexion or extension in the knee joint with or without tibial
rotation is possible.
As patellar luxation represents a frequently diagnosed disease
in small animal practice, it was of common interest to carry out
a cross-sectional study in order to assess the actual incidence
of PL in dogs of small and miniature breeds in Austria. In order
to gather information about a possible genetic basis of patellar
luxation, the authors scrutinized all data to find out if prevalence
of PL varies between the different breeds of this study. Another
aim of the present study was to examine all criteria used in PL
diagnosis and evaluate their suitability as screening tools for
breeding programmes.
Material and methods
Between 1996 and 2004 (8 years), a total of 432 dogs of 32
different small and miniature breeds (Table 7) were examined.
Of these, 190 dogs were male, 178 female, 21 castrated males
and 43 spayed females. Clinical examinations were performed
on supposedly normal dogs at dog shows, breeding shows, dog
training clubs and on outpatients at the Clinic of Surgery and
Ophthalmology at the Vienna University of Veterinary Medicine.
Imaging techniques (radiography, MRI and CT) were not used.
These are the details of the 432 dogs of this study:
170 dogs were presented to the clinicians for locomotor
dysfunction of the hind limbs either secondary to minimal
trauma or of unknown aetiology. In 93 dogs concurrent
disease was diagnosed in addition to patellar luxation:
rupture of the cranial cruciate ligament (n=27), Legg-Calv-
Perthes disease (n=2), gonarthrosis (n=12), diseases of the
vertebral column (n=29), luxation of the femur (n=4), muscle
contusion secondary to trauma such as bite wounds (n=14),
coxarthrosis (n=3) and femoral fractures (n=2).
262 dogs were either presented for breeding soundness
examinations regarding patellar luxation and other clinical
problems (e.g. ophthalmological disease) or were examined
at dog shows and dog training clubs. None of these dogs
showed signs of lameness. No premedication with analgesics
had been administered to any of the dogs.
None of the animals had been treated surgically for patellar
luxation prior to this study. Female dogs were in anoestrus or
not pregnant, respectively.
Clinical diagnosis
Breed, age, gender and body weight were assessed in all
animals, with the exception of 96 out of the 432 dogs where no
information on body weight was available.
Anamnestic data comprised any existing locomotor dysfunction
including its cause, duration (acute or chronic) and manifestation
(permanent or intermittent).
The dogs were examined by inspection in both a standing
position and during movement. Palpation of the stifle joint was
performed in both the standing animal and with the dog in
lateral recumbency (Table 1). In analogy to the PL classification
 EJCAP - Vol. 16 - Issue 2 October 2006

Table 1: Classification of findings in variables

Property (variable) Possible variants
Assessed in both right and left stifles
Inspection in movement:
Lameness: no
intermittent
permanent
Inspection in the standing position:
Axis deviation no / yes
Palpation in standing position:
Patella in situ no / yes
Patellar luxation elicitable no / yes / Patella already luxated
Palpation in recumbent dog:
Patella in situ no / yes
Patellar luxation elicitable no / yes / Patella already luxated
Patellar luxation elicitable by tibial rotation only no / yes
Crepitation no / yes
Deviation of the tibial tuberosity no / yes
Evaluation of findings: Classification after PUTNAM (1968):
Findings* medial Grade 0 to Grade IV
Findings* lateral Grade 0 to Grade IV
* for final evaluation, the findings of the worse stifle joint were taken into consideration including both
medial and lateral luxations.

Table 2: Inspection in movement - Distribution of findings

Number right stifle Percentage right Number left stifle Percentage left
No lameness 350 81.0 357 82.6
Intermittent lameness 15 3.5 20 4.6
Permanent lameness 67 15.5 55 12.8
432 100 % 432 100 %

Table 3: Palpation in standing position Distribution of findings

Number right Percentage right Number left Percentage left
Patella in situ 366 84.7 371 85.9
Patella not in situ 66 15.3 61 14.1
432 100.0 432 100.0
Patella impossible to luxate 206 47.7 201 46.5
Patellar luxation elicitable 160 37.0 170 39.4
Patella already luxated 66 15.3 61 14.1
432 100.0 432 100.0

system devised by PUTNAM (1968), the findings were classified
in groups I to IV according to the degree of severity of the
condition. Breeding soundness evaluation was made on the
basis of the most pronounced clinical findings, even if the other
leg was completely unremarkable regarding PL.
Statistical methods
For statistical evaluation of all data, examination criteria were
gathered in groups of variables (Table 1). These variables were
defined according to a study protocol (BRUNNBERG, 1996). Statistical
evaluation was made using the SPSS software for Windows 3.2,
version 6.0.1 (1994). These were the calculations made:
1. Frequency of single findings (Tables 2, 3, 4, 5, 6, 7)
2. Rank correlation coefficients between single diagnostic
criteria and final PL findings: For calculation of the rank
correlation between single diagnostic criteria and final PL
findings (Tables 8 and 9), a total of 339 dogs were evaluated.
Only dogs with no concurrent disease of the pelvic limbs
(n=77) and dogs presented for breeding soundness

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 Diagnostic and genetic aspects of patellar luxation in small and miniature breed dogs in Austria - B. Vidoni

Table 4: Palpation in recumbent position Distribution of findings

Number right Percentage Number left Percentage
right left
Patella in situ 389 90.0 394 91.2
Patella not in situ 43 10.0 38 8.8
432 100.0 432 100.0
Patella impossible to luxate 205 47.5 202 46.8
Patellar luxation elicitable without tibial rotation 58 13.4 70 16.2
Patellar luxation elicitable by tibial rotation 126 29.1 122 28.2
Patella already luxated 43 10.0 38 8.8
432 100.0 432 100.0
Patellar luxation elicitable by tibial rotation only - no 381 88.2 374 86.6
Patellar luxation elicitable by tibial rotation only - yes 47 10.9 52 12.0
Patella already luxated 4 0.9 6 1.4
432 100.0 432 100.0
No crepitation 402 93.1 414 95.8
Crepitation 30 6.9 18 4.2
432 100.0 432 100.0
No deviation of tibial tuberosity 355 82.2 353 81.7
Deviation of tibial tuberosity 77 17.8 79 18.3
432 100.0 432 100.0

Table 5: Direction of patellar luxation

being the variant free (no indication of patellar luxation)
right stifle joint left stifle joint and the other, not free (PL grade I to IV, medial and/or
% % lateral, unilateral or bilateral). For the final PL findings, the
(n) (n)
worse side was the determinative factor. Evaluations for
Not luxated 46.5% 45.1% breed predispositions were made on the basis of the effects
(201) (195) of age, neutering (neutered/intact) and body weight using
Medial 42.4% 42.4% a multiple logistic regression model with the following
(183) (183) equation (KREIENBROCK and SCHACH, 1997):
Lateral 5.1% 5.6%
(22) (24) logit (P) = a + bi * Xi + bj * Xj + bk * Xk + bl * Xl
being
Medial and lateral 6.0% 6.9%
logit (P) = logarithm of probability
(26) (30)
a = constant
100% 100% bi,j.k.l = partial logistic regression coefficient for breed,
(432) (432) sexual status (neutered or intact), age, body
weight
examination or with non-locomotor problems, as well as Xi,j.k.l = parameter values for breed, sexual status,
dogs presented in dog shows or working in dog training age, body weight
centres (n=262) were included in the study. Evaluation of
the correlation among the different individual parameters For the studied breeds, the Chihuahua, Jack Russell Terrier,
and between single criteria and overall findings was made by Maltese Terrier, Pug, Papillon, Pekingese, Poodle, Shih Tzu,
calculating the Spearman rank correlation coefficient (Tables Tibetan Terrier, West Highland White Terrier and Yorkshire
8 and 9), which in a 2x2 table has the same value as the Terrier, the respective remaining breeds were defined as
association measure Phi (BORTZ, 1999). category of reference. Regarding the neutering, intact male
3. Logistic regression model to screen for breed predispositions: and female dogs were the category of reference. Concerning
In order to assess differences in prevalence between the age and body weight, the odds ratio per additional year or
different breeds, data of 339 dogs were evaluated. Only kilogram (kg), respectively, was calculated. As no significant
breeds that were represented by at least ten dogs were influence of the gender on the prevalence of patellar luxation
taken into consideration (Table 10). Prior to evaluation, had been observed, this parameter was not included in the
the findings were gathered in two groups of variants, one logistic regression model.

152
 EJCAP - Vol. 16 - Issue 2 October 2006

Table 6: Distribution of final findings (PUTNAM classification, 1968)

right stifle joint medial right stifle joint lateral left stifle joint medial left stifle joint lateral
% % % %
(n) (n) (n) (n)

No signs 51.6% 88.8% 50.7% 87.5%

(223) (384) (219) (378)
Grade I 6.3% 4.9% 4.6% 6.7%
(27) (21) (20) (29)
Grade II 28.7% 6.3% 32.2% 5.1%
(124) (27) (139) (22)
Grade III 12.0% 10.9% 0.7%
(52) (47) (3)
Grade IV 1.4% 1.6%
(6) (7)
100% 100% 100% 100%
(432) (432) (432) (432)

Table 7: Evaluation of PL findings in breeds represented by more than ten dogs

Breed Number PL free % PL free PL not free % PL not free
(unilateral and/or bilateral,
medial and/or lateral)

Chihuahua 13 3 23.1 10 76.9

Jack Russell Terrier 31 23 74.2 8 25.8
Maltese Terrier 27 3 11.1 24 88.9
Pug 14 7 50.0 7 50.0
Papillon 32 11 34.4 21 65.6
Pekingese 25 5 20.0 20 80.0
Poodle (Miniature, Toy) 45 9 20.0 36 80.0
Shih Tzu 20 8 40.0 12 60.0
Tibetan Terrier 22 20 90.9 2 9.1
West Highland White Terrier 22 13 59.1 9 40.9
Yorkshire Terrier 79 12 15.2 67 84.8
Mixed breed dogs 18 2 11.1 16 88.9
Other breeds* 84 50 59.5 34 40.5
432 166 38.4 % 266 61.6 %
Other breeds*: Affenpinscher (Monkey Dog), Cairn Terrier, Caluga, Chinese Crested, Dachshund (Smooth, Wirehaired, Longhaired), Cavalier King Charles,
Brussels Griffon, Havanese, Japanese Pomeranian, Japanese Chin, Lakeland Terrier, Lhasa Apso, Petit Chien Lion, Miniature Pomeranian, Red-haired
Miniature Pinscher, Shetland Sheepdog, Tibetan Spaniel, Miniature Schnauzer, Miniature Pinscher,Toy Pomeranian.

Calculation of the odds ratio (OR) was based on OR = Expb,
while the 95% confidence interval (CI) of the odds ratio
was calculated using CI = Exp (b 1.96 x SEb), being Expb
the exponential function of the partial logistic regression
coefficient and SEb the standard error of the partial logistic
regression coefficient. The odds ratio indicates the relative
probability of disease in an animal with a given parameter
value in relation to the category of reference. The odds
ratio is defined as significantly different from 1 if the 95%
confidence interval does not include the value 1.
4. Age distribution by gender and sexual status (neutered/
intact) (Table 11): Comparison of age distribution
between male and female dogs and between castrated and
intact animals was made using the Mann-Whitney U Test. As
the exact age was not known of all the dogs of the study,
calculations were performed only with data of 425 animals.
Results
On inspection during movement (Table 2), no lameness was
observed in more than 80 % of the dogs (81 % in right pelvic
limb, 82.6 % in left pelvic limb). Most of the lame dogs showed
permanent lameness, while lameness was intermittent in some
animals only.
On palpation of the standing dog (Table 3), the patella was in
situ in 84.7 % (right) and 85.9 % (left), respectively. Manual

153
 Diagnostic and genetic aspects of patellar luxation in small and miniature breed dogs in Austria - B. Vidoni

Table 8: Rank correlations of the individual parameters (right )

Inspection Palpation Palpation in recumbent position Evaluation
in standing
position
Lameness Axis Patella in Patellar Patella in Patellar Patellar Crepi- Tibial medial lateral
(deviation) situ luxation situ luxation luxation tation tuberosity
elicitable elicitable elicitable
by tibial
rotation

Lameness 1.000 .076 .401(**) .408(**) .410(**) .386(**) .146(**) .227(**) .325(**) .421(**) -.045
Axis 1.000 .123(*) .078 .043 -.001 .137(*) .093 .141(**) .077 -.083
Palpation in 1.000 .592(**) .757(**) .501(**) .305(**) .235(**) .639(**) 574(**) -.002
standing position
Luxation in 1.000 .449(**) .918(**) .357(**) .227(**) .454(**) 894(**) .329(**)
standing position
Palpation in 1.000 .463(**) -.025 .267(**) .585(**) .454(**) -.016
recumbent position
Luxation in 1.000 .315(**) .191(**) .416(**) .856(**) .377(**)
recumbent position
Luxation by rotation 1.000 .120(*) .248(**) .343(**) .219(**)
Crepitation 1.000 .239(**) .234(**) -.072
Deviation of tibial 1.000 .491(**) -.004
tuberosity
Evaluation medial 1.000 .085
Evaluation lateral 1.000
*p < 0.05 **p < 0.01

Table 9: Rank correlations of the individual parameters (left )

Inspection Palpation Palpation in recumbent position Evaluation
in standing
position
Lameness Axis Patella in Patellar Patella in Patellar Patellar Crepi- Tibial medial lateral
(deviation) situ luxation situ luxation luxation tation tuberosity
elicitable elicitable elicitable
by tibial
rotation

Lameness 1.000 .059 .329(**) .347(**) .262(**) .360(**) .151(**) .133(*) .234(**) .364(**) -.009
Axis 1.000 .064 .014 .124(*) .011 .017 .130(*) .134(*) .022 -.079
Palpation in 1.000 .587(**) .655(**) .443(**) .393(**) .267(**) .636(**) .536(**) .167(**)
standing position
Luxation in 1.000 .398(**) .895(**) .435(**) .215(**) .477(**) 894(**) .344(**)
standing position
Palpation in 1.000 .419(**) .047 .310(**) .556(**) .421(**) .148(**)
recumbent position
Luxation in 1.000 .349(**) .189(**) .402(**) 827(**) .394(**)
recumbent position
Luxation by 1.000 .125(*) .412(**) .452(**) .089
rotation
Crepitation 1.000 .203(**) .213(**) .003
Deviation of tibial 1.000 .480(**) .114(*)
tuberosity
Evaluation medial 1.000 .113(*)
Evaluation lateral 1.000
*p < 0.05 **p < 0.01

154

luxation was impossible in 47.7 % (right) and 46.5 % (left)
of the cases. Luxation of the patella was present in 15.3 %
(right) and 14.1 % (left) of the dogs. On palpation with the
animal in lateral recumbency (Table 4), the patella was in situ in
90.0 % (right) and 91.2 % (left), respectively; manual luxation
was impossible in 47.5 % (right) and 46.8 % (left) of the cases;
patellar luxation was present in 10.0 % (right) and 8.8 % (left)
of the dogs. Crepitation was observed in 6.9 % (right) and
4.2 % (left) of the animals. Medial deviation of the tibial
tuberosity was seen in 17.8 % (right) and 18.3 % (left) of the
dogs. In those animals where the tibia was rotated towards the
side of luxation, the possibility of eliciting luxation was more
than 10 % higher than in dogs without tibial rotation (29 %
with tibial rotation versus 13.4 % without rotation (right stifle)
and 28.2 % versus 16.2 %, respectively, in the left stifle).
As can be seen in Table 5, medial patellar luxation was diagnosed
in 42.4 % (right and left stifle joint), while lateral PL was only
present in 5.1 % (right) and 5.6 % (left) of the dogs. Patellar
luxation towards both medial and lateral aspects was also
uncommon (6 % right and 6.9 % left). In 46.5 % (right) and
45.1 % (left) of the dogs, respectively, it was impossible to elicit
luxation by manual displacement.
Table 6 contains an overview of all findings classified according
to PUTNAMS system (1968). Grades II and III were more
commonly observed than grades I and IV. In most animals, grade
II was diagnosed.
Table 7 summarises the evaluation of all PL findings of breeds
represented by at least ten dogs on the basis of the parameters
free and not free, respectively, without taking into
consideration the grade of severity. No distinction was made
between unilateral and bilateral patellar luxation. Of the total of
432 dogs, 166 (38.4 %) were free of PL and 266 (61.6 %) were
affected by the condition.
Tables 8 and 9 show the rank correlation between the individual
parameters and between single diagnostic criteria and final PL
findings. With one exception only (axis deviation), the correlation
between the different diagnostic criteria was significant.
Correlation with the final findings of medial and lateral PL of the
right and left stifle joint was highest for the criteria luxation in
standing position and luxation in recumbent position. All the
other parameters, except the criterion luxation by rotation,
showed significant correlation with the finding medial PL, but
not with lateral PL. Correlation between the different single
criteria showed values ranging from 0.21 to 0.89.
The influence of the factors breed, age, body weight, gender and
neutering (neutered/intact) on patellar luxation is summarised in
Table 10. Both body weight and castration status had a significant
influence (p<0.05) on PL disease. Each additional kilogram of body
weight reduced the odds of being affected by PL to the 0.8 fold. In
contrast, the odds ratio for each additional year of age was 1.10,
which means that the chance of suffering from PL increases to the
1.10 fold with each additional year of age. Although the p-value
for this yearly increase is slightly higher than 0.05, the effects add
up with increasing age so that the criterion age was included in
the logistic regression model for evaluation of a possible breed
predisposition. Gender did not have any significant influence on
PL incidence. Neutering, on the other hand, increased the odds
of being affected by PL to the 3.1 fold. Neutered animals were
significantly older (p<0.001; Table 11) than intact dogs, both in
155
EJCAP - Vol. 16 - Issue 2 October 2006
the female and the male group as well as in the overall average.
For two of the breeds, calculated odds ratios were significantly
different from 1: with an odds ratio of 0.31 (95 % CI 0.14-
0.67), the Jack Russell Terrier had a significantly lower risk,
while the odds ratio assessed for the Poodle was 5.62
(95 % CI 1.93-16.41) which is indicative of a significantly higher
probability of being affected by patellar luxation (Table 10).
Discussion
Diagnostic screening for breeding selection programmes requires
the highest possible standardization of examination methods and
conditions in order to achieve maximum reproducibility of results.
In addition, all considered criteria must have a plausible relation
with the disease and must be consistent between each other.
Radiographic examination was not performed in this study as it
is of no importance for the diagnosis of patellar luxation within
the framework of breeding selection programmes. Radiographs
may yield false negative results due to reduction of a luxated
patella during manipulation for proper positioning (VASSEUR,
1993). KAISER et al. (1997) reported that PL grades II to IV
can be diagnosed radiographically by measuring the quadriceps
angle (Q angle). Unfortunately, the sensitivity of the proposed
angle measurement is not sufficiently high to enable clinicians to
differentiate exactly between the different grades of PL (KOCH
et al., 1998). For this reason, diagnosis of patellar luxation must
be made by physical examination (KOCH et al., 1998). KAISER
et al. (2001) have suggested using magnetic resonance imaging
of the Q angle to determine the grade of PL. Radiographic
examination is, however, essential when planning therapeutic
management (KOCH et al., 1998) as it is important to assess the
extent of skeletal deformities and the degree of degenerative
articular changes prior to surgery (VASSEUR 1993).
In the present study, physical examination of the dogs was performed
on the basis of a standardized protocol including inspection and
palpation of the standing and lying animal. For inspection of the
moving dog, lameness was one criterion. It was surprising to see
that only approximately 19 % of the dogs showed lameness (Table
2) when walking or running, although as much as 61.6 % of the
dogs were PL positive (Table 7). This confirms the statement made
by WILLAUER and VASSEUR (1987) that dogs with patellar luxation
may be asymptomatic for their entire life. It was also interesting to
observe that most lame dogs showed continuous lameness and to
a smaller extent only intermittent lameness (Table 2). This is in line
with the findings of a study performed by BRINKER et al. (1983)
who reported that dogs with intermittent lameness may show an
abnormal gait pattern but are not presented to the clinician until
the problem becomes acute due to a minor trauma with additional
soft tissue involvement or when severe pelvic limb dysfunction
secondary to painful mobilized gonotrochlosis has been noticed by
the owner (HUTTER et al., 1983). The present study confirmed that
lame dogs were predominantly presented to the veterinarian for
locomotor dysfunction after a minor trauma or for gait disorders
of unknown aetiology. In addition, these patients suffered
from several concomitant diseases. As a consequence, 40 % of
the PL dogs of this study must be considered as asymptomatic
carriers of the disease. This result clearly shows the need for
screening programmes for breeding dogs in order to detect such
asymptomatic carriers of patellar luxation.
 Diagnostic and genetic aspects of patellar luxation in small and miniature breed dogs in Austria - B. Vidoni

Table 10: Breed predisposition, taking into consideration the influencing factors age, body weight, gender and castration status
Influencing factors OR CI/ll CI/ul
Age (per year) 1.10 0.99 1.21
Body weight (per kg) 0.80 0.69 0.91
Gender 1.27 0.67 2.46
Castration status (castrated / intact ) 3.10 1.28 7.53

Breed Number % OR CI/ll CI/ul

Chihuahua 10 2.9 0.54 0,11 2,62
Jack Russell Terrier 29 8.6 0.31 0,14 0,67
Maltese Terrier 16 4.7 7.45 0,92 60,70
Pug 14 4.1 1.20 0,24 6,07
Papillon 31 9.2 0.93 0,30 2,85
Pekingese 14 4.1 2.10 0,54 8,19
Poodle (Miniature, Toy) 39 11.5 5.62 1,93 16,41
Shi Tzu 18 5.3 0.63 0,20 1,96
Tibetan Terrier 20 5.9 0.15 0,02 1,26
West Highland White Terrier 18 5.3 1.04 0,27 3,94
Yorkshire Terrier 46 13.6 1.20 0,50 2,91
Mixed breed dogs 11 3.3
Other breeds* 73 21.5
339 100.0
Other breeds*: Affenpinscher (Monkey Dog), Cairn Terrier, Caluga, Chinese Crested, Dachshund (Smooth, Wirehaired, Longhaired), Cavalier King Charles,
Brussels Griffon, Havanese, Japanese Pomeranian, Japanese Chin, Lakeland Terrier, Lhasa Apso, Petit Chien Lion, Miniature Pomeranian, Red-haired
Miniature Pinscher, Shetland Sheepdog, Tibetan Spaniel, Miniature Schnauzer, Miniature Pinscher,Toy Pomeranian.

OR = Odds ratio
CI/ll = Lower limit of the confidence interval (95 %) of the odds ratio
CI/ul = Upper limit of the confidence interval (95 %) of the odds ratio

Table 11: Age distribution by gender and sexual status (neutered/intact)

Gender Mean n Standard deviation
a
male 4.504 189 3.7274
female 3.557a.d 173 3.2333
male castrated 8.181b 21 3.7697
c
female speyed 5.995 42 3.2824
Total 4.448 425 3.6560
a,b c,d
p<0,05 p<0,05

Patellae with a tendency to luxate were more often in situ in the
recumbent than in the standing animal (Tables 3, 4). Similarly,
the luxated patella was more frequently diagnosed in the
standing dog than in the lying animal. This may be attributed
to the bowstring effect of the femoral quadriceps muscle
group that stretches across the patella and the patellar ligament
down to its insertion at the proximal tibia. HARRISON (1981)
indicated that under normal anatomical conditions the patella
is drawn proximally onto the femoral trochlea by contraction of
the femoral quadriceps muscle. In animals with varus deformity
of the femur, the patella is pushed medially on contraction of
the quadriceps muscle, resulting in medial dislocation of the
patella. According to NAGAOKA et al. (1995), the bowstring
effect of the quadriceps muscle causes medial rotation of the
tibia, resulting in medial luxation of the patella. This mechanism
gains in importance in the standing position. Accordingly, dogs
must be examined both in the standing and in recumbent
position when screening for PL. In approximately 29 % of the
cases (Table 4), patellar luxation could be elicited only when
rotating the tibia, while manual luxation without tibial rotation
was possible only in 14 % of the dogs. This strongly underlines
the recommendation (KOCH et al., 1998) to examine the stifle
joint in both the standing position and the recumbent position
with the leg in flexion and extension and with and without tibial

156

rotation. Medial patellar luxation can best be elicited with the
stifle and hip joint in full extension and with pronation of the
tibia. Lateral patellar luxation can best be provoked with a flexed
stifle and hip joint and supination of the tibia (HARRISON, 1975;
BRINKER et al., 1990).
In about 12 % of the cases, the patella could be luxated by
only using tibial rotation (Table 4). This means that rotation as
such has no importance unless it is combined with flexion and
extension.
Crepitation was observed only in 7 % of the stifle joints (Table 4).
According to ROBINS (1990) and ROY et al. (1992), crepitation is
a sign of chronic degenerative joint disease and a consequence
of chondral defects of the patella and trochlear ridge. The
relatively low percentage of crepitation in the dogs of our study
is indicative of a comparably low percentage of arthrotic disease;
this, in turn, is in line with the reduced number of dogs with
continuous lameness (Table 2; PAATSMA and KRKKINEN,
1981). Deviation of the tibial tuberosity was palpable in
17.8 % (right) and 18.3 % (left) of the dogs (Table 4). As more than
50 % of the dogs of our study were affected by patellar disease,
it may seem that displacement of the tibial tuberosity is not the
only criterion for luxation of the patella. This was confirmed by
GITTERLE (1991) and SEGUIN and HARARI (1994) who suggested
additional predisposing factors for PL like hypoplasia or aplasia
of the trochlear ridge or the trochlear groove, respectively.
As far as the direction of luxation is concerned (Table 5), the
results of the present study correspond with those presented in
the literature. In dogs of small and miniature breeds, congenital
medial patellar luxation is the most frequently diagnosed
condition (BRINKER et al., 1990). HAYES et al. (1994) proved in
their experimental study that dogs (n=55) with a body weight
of less than 9.1 kg display medial PL in 98 % of the cases, while
lateral PL was present in only 2 % of the animals. With increasing
body weight, the tendency to be affected by PL decreased, while
the percentage of congenital lateral patellar luxation increased.
The fact that some dogs tend to have both medial and lateral
PL, strongly underlines the need for a meticulous examination
procedure (KOCH et al., 1998; REICHLER et al., 1999).
Similarly to the results obtained by HAYES et al. (1994), patellar
luxation of grades II and III were also most frequently diagnosed
in the present study (Table 6). HAMMER (1979) and SCHFER
et al. (1982), in contrast, reported the highest percentages for
PL grades I and II, while grades III and IV occurred only rarely. In
order to exclude all possible sources of error when diagnosing
PL, KOCH et al. (1998) applied a stricter interpretation of the
PUTNAM classification system (1968) and added two more
definitions to the examination protocol: 1) riding patella alta
(incomplete articulation of the patellar body with the trochlear
groove, the patella is subluxated and riding on the trochlea ridge)
is classified as Grade 0; 2) Spontaneous luxation of the patella
in the standing dog is classified as Grade III, even if spontaneous
reduction on active flexion or extension in the stifle joint with or
without tibial rotation is possible, which according to PUTNAMs
classification would be a grade II. The worse finding represents
the definitive diagnosis even if there was only one single
spontaneous luxation of the patella. These criteria were not
taken into consideration in the present study as they were not
published at the time of this investigation. However, it is possible
that our number of PL grades III might have been slightly higher
157
EJCAP - Vol. 16 - Issue 2 October 2006
and the number of grades II lower, had we considered these
two criteria.
In order to obtain the best information possible about the present
PL status of the dog population, all the results were evaluated
when calculating the frequency of individual findings after
restriction of PL findings to free/not free (Table 7). On
doing so, the authors also took into consideration the fact that
primary disease like e.g. rupture of the cranial cruciate ligament
may cause patellar luxation.
Calculation of the rank correlations of the individual diagnostic
criteria (Tables 8 and 9) showed that the parameter axis was
not significantly correlated either with the final PL findings or
with the majority of the individual parameters, thus being of
no particular importance for the overall findings. Correlation
with the final PL findings of both medial and lateral PL in
the right and left stifle joint was highest for the individual
parameters luxation in standing position and luxation in
recumbent position. Therefore these two parameters are of
great importance for the diagnosis of medial and lateral patellar
luxation. The remaining parameters, with exception only of
the criterion luxation by rotation, all showed significant
correlation with the diagnosis of medial PL but not with lateral
PL. This may be due to the fact that lateral PL is only rarely seen
in dogs of small and miniature breeds. The correlation between
single criteria and final findings had a value ranging from 0.21
to 0.89. This means that all parameters, except axis deviation,
are consistent and of significance for the definitive diagnosis of
patellar luxation. The diagnostic protocol used in this study may
therefore be considered as a suitable screening programme for
the detection of patellar luxation in dogs of small and miniature
breeds. As differences in prevalence observed in different
breeds may be interpreted as an indication of a genetic basis
of the disease (LAFOND et al., 2002), the overrepresentation
and underrepresentation, respectively, noticed in certain breeds
of dogs in the present study is highly suggestive of a genetic
predisposition to patellar luxation. Heritability of PL should be
the subject of further investigations on the basis of familial
anamneses and the heritability studies (LAFOND et al., 2002).
No influence on PL could be observed for the parameter
gender, which is in line with the findings of SCHFER et al.
(1982) and ROBINS (1990). However, PRIESTER (1972), HULSE
(1993) and HAYES et al. (1994) reported a higher incidence of PL
in female dogs than in male dogs of small and miniature breeds.
PRIESTER (1972) attributed this to a certain hormonal influence
and/or X-chromosome-related genetic factors. According to
KOCH et al. (1998), female dogs show an increased disposition
to PL during oestrus and with an increasing number of litters.
Whether this is due to increased oestrogen levels or to any other
factors, remains unclear. The female dogs of the present study
were all in anoestrus. In the neutered dogs of this study, the
odds of being affected by PL was increased to the 3.1 fold in
comparison with intact animals (Table 10). This may be in direct
relation with the increased age of the neutered dogs (Table 11),
as it has already been said that PL chance increases to the 1.1
fold with each year of age. Laxity of the stifle joint that increases
with age due to acquired or genetic related connective tissue
weakness could be another influencing factor. Whether a
change induced by neutering in the hormonal status of a dog
could play any role in these mechanisms cannot be deduced
 Diagnostic and genetic aspects of patellar luxation in small and miniature breed dogs in Austria - B. Vidoni
from the data of the present study. Even the age at which the
animal was neutered could be of certain influence, but closer
investigation of that point was not possible in the present study
as relevant data were not available.
As far as the influence of the body weight on PL incidence is
concerned, it could be demonstrated that the PL risk decreases to
the 0.8 fold with each additional kilogram of body weight. This
allows the conclusion that miniaturization does play a certain
role in the development of patellar luxation, which confirms the
results that PRIESTER (1972) and WEBER (1993) obtained in their
respective studies.
Abbreviations
CT = computed tomography,
CI = confidence interval (95%), MRI = magnetic resonance imaging,
OR = odds ratio, PL = patellar luxation, Q angle = quadriceps angle.
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EJCAP - Hip L
 ORTHOPAEDICS

REPRINT PAPER (F)

Long-term analysis of the

progression of hip arthrosis after
triple pelvic osteotomy
Th. Dembour(1), J-L. Chancrin(1)

SUMMARY

A retrospective study was conducted in a single referral centre to evaluate osteoarthritis (OA) progression in hips
operated on by triple pelvic osteotomy (TPO) compared to unoperated joints. Fifty-nine operated hips in 41 dogs were
included (18 bilateral and 23 unilateral TPOs). A similar technique was used in all cases. A 30 acetabular ventroversion
with concomitant 5mm lateralisation was always accomplished. Iliac osteotomy was stabilised using a contoured
Chancrins TPO plate. Hip OA was estimated based on conventional, extended, ventrodorsal radiographic projection
using a linear, custom-made grading scale (0-14). All dogs were screened before, immediately after, and long-term
(12 months or more average 56.2 months) following surgery. An owners questionnaire-based assessment of clinical
outcome was correlated with radiological data. Forty-two operated, and 22 contralateral non-operated hips were
followed up radiologically. It appeared that OA tended to progress both in operated, and in dysplastic unoperated
hips. However, progression of OA was significantly less pronounced in hips subjected to TPO. Furthermore, a positive
correlation between functional recovery, as assessed by owners, and long-term OA grade was found.
Key words : Triple pelvic osteotomy osteoarthritis functional recovery

Conversely, no studies have been performed on significant

This paper originally appeared in: numbers of dogs on the progression of coxo-femoral
Prat Md Chir Anim Comp* 2005 40 p 17-26 osteoarthritis after TPO, nor the relationship of joint progression
with function.

Introduction The aims of this study were:

Triple Pelvic Osteotomies (TPO) have been used for a long time
in children for the correction of luxation and subluxation of hips
(hip dysplasia) [1,2]. The first report of using such a technique in
the veterinary field was made in 1971 [3].
Several surgical techniques have been used [4-10]. However all
of them have the same goal: ventroversion of the acetabulum
with the purpose of increasing the coverage of the femoral head
and so stabilising hips with clinically significant laxity.
Regarding functional outcome of operated dogs, several surveys
have demonstrated the efficacy of this surgical procedure [4-
6, 10-13]. Cosmetic outcome has also been analysed in depth
[12-14].
to measure the progression of osteoarthritis in dogs following
unilateral or bilateral TPO;
to compare those results with hips of non-surgical dysplastic
dogs
and finally to check if it is possible to correlate radiographic
results with clinical outcome
Materials and method
This retrospective study comprises two parts:
The first part is an analysis of functional results following
TPO, based on an owner-completed questionnaire.

(1) 414A Chemin des Canniers, Quartier Lagoubran, F- 83190 Ollioules E-mail : chancrin.dembour@wanadoo.fr
* Presented by AFVAC (F)

161
 Long-term analysis of the progression of hip arthrosis after triple pelvic osteotomy - Th. Dembour, J.L. Chancrin

Weight at the time of the surgery Age at the time of the surgery

20 18
16
15
14

Hip numbers
Hip numbers

12
10
10
5 8
6
0 4
2
5

0
0
/1

/2

/2

/3

/3

/4
10

16

21

26

31

36

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Weight (kg) Age (months)

Figure I Figure II

Table I : Number of surgical cases Table IIIb : Degree of lameness

Number of dogs 41 Lameness Number %
Number of operated hips 59 in each
category
Unilateral surgery 23 56%
Mild 13 39.5
Bilateral surgery 18 44%
Moderate 12 36.5
Radiologic follow up (hips) 42 71%
Severe 5 15
Not determined 3 9
Table II: Breed distribution Intermitent Without exercise 7 21
Breed % No. After exercise 1 3
German shepherd 24% 14 Not determined 7 21
Labrador and golden retriever 31% 18 Permanent Without and after 17 52
Eng. Setter /Gordon setter 19% 11 exercise
Rottweiler 12% 8 Not 1 3
determined
Belgian Shepherd 6% 4
Beauceron 1.5% 1
Bobtail 3% 2
The second part is a radiological analysis of hips during the
Pointer 1.5% 1 pre operative period as well as the immediate post operative
and at least one year after surgery

Table III : Clinical signs Only dogs that could be followed for more than a year were
Clinical signs No. % included in the study. Forty one dogs took part, which represents
a total of 59 operated hips. Twenty three dogs (56%) had
Lame 33 80
unilateral surgery and 18 (44%) bilateral.
Painful hip 28 68 The long term radiological evaluation was based on 42 hips
Difficulty standing 31 76 (71%) while the clinical evaluation focused on 38 dogs (92.7%
of the population) (table I).
Difficulty walking 20 49
The different breeds are listed in table II.
Exercise intolerance 2 37 Age range for surgery was between 4.5 months and 16 months.
Aggression 15 5 Weight ranged from 10 to 40 kg (figure 1 and 2).
All operated animals had a significant functional handicap
as a consequence of coxo-femoral dysplasia. The reasons for
presentation are mentioned in table III.

162

Figure 3 Radiograph of a dysplastic dog after abduction and
internal rotation of the pelvic limbs. The articular congruency is
good, the actabuluar cavity is empty
Selection criteria of candidates for TPO are described below and
on the whole follow the indications previously published by B.
Slocum [10] and even before that by other authors [4-6 and 8].
The presence of the Ortolani sign [15] is investigated in every
case. Ventro-dorsal and lateral radiographs were taken to reveal
an eventual hyperanteversion, with or without coxa-valga, which
represents an indication for an inter-trochanteric osteotomy. The
radiographs allow assessment of osteoarthritic changes and to
evaluate acetabular depth. [8,9]. A specific view is required to
measure acetabular depth. This view was taken, with the animal
in dorsal recumbancy, with hindlimbs internally rotated and in
forced abduction. This position tightens the capsules fibres and
forces the femoral heads to sink into the acetabulum (figure 3).
In that position, a femoral head, which otherwise would not
be in the bottom of the acetabulum, constitutes a fulfilment
of the cup and becomes a counter indication to TPO. If the
development of osteophytes is such that the space between the
greater trochanter and femoral head is remodelled, or if there is
too great a filling of the acetabulum to be able to ensure a good
post operation cover, the technique is abandoned in favour of
another therapy (conservative treatment, excision arthroplasty
or total hip replacement). The presence of a moderate degree of
arthrosis (modified craniodorsal rim, presence of osteophytes on
the base of the neck) did not constitute, in most cases, a contra-
indication to TPO.
Material
The repair of the iliac osteotomy was the same in each case.
The plate used was specific for this kind of surgery, called
Chancrins TPO plate named after its designer (Amplitude
Company Valence France).
These plates are right / left specific and were designed to enable
a modification of 30 degrees in ventroversion of the acetabulum.
A gap of 5mm between the two faces in contact with the bone
enables lateralisation of the acetabular rim and limits narrowing
of the pelvic canal following ventroversion of the acetabulum
(figure 4).
163
EJCAP - Vol. 16 - Issue 2 - October 2006
Figure 4 The Chancrin plate used in the study
The design of the plate enables the fixing of five screws cranially
and three caudally. The trefoil shape of the cranial portion of
the plate enables at least two screws to be fixed to the sacrum
and so limits the risks of loosening. The cranial part of the plate
is 3mm thick, allowing accurate contouring to the ilium. The
caudal part of the plate, has a curved shape perfectly adapted to
the cranial aspect of the acetabulum. The triangular orientation
of the screw holes enables the fixing of three screws strongly in
the ilial body behind the sacrum.
All eight screw holes accept 3.5mm cortical screws and allow an
angulation of the screw of 8 degrees. This enables a triangular
orientation of the screws and so avoids the risks of loosening.
The plate is manufactured from steel of INOX 316 L, implant
quality. (ISO norm 5832/1 Nuance D). The manufacturing
process enables optimal precision of the different angles settings
without affecting metal quality.
In the final phase of manufacture, the plates are manually
polished (to remove all sharp edges). An identification of the
side (L or R) is engraved by laser. Finally, decontamination and
wrapping in individual pockets (not sterile) guarantees that they
are free from contamination prior to sterilisation.
Method
Surgical technique
All the dogs underwent the same procedure, with identical
plates and surgical technique. With bilateral surgeries, the
second surgery took place 15 days later.
The dogs were premedicated with acepromazine at a dose of
0.02 mg/kg. After induction with thiopentone at 10 mg/kg, the
anaesthesia was maintained using 2% isoflurane in oxygen.
Post-operative analgesia was provided by non-steroidal anti-
inflammatory drugs: carprofen or ketoprofen.
 Long-term analysis of the progression of hip arthrosis after triple pelvic osteotomy - Th. Dembour, J.L. Chancrin

X Y

Figure 5: Percentage coverage of the femoral head was determined by the ratio of the femoral head within the acetabulum (X) and the
diameter of the femoral head at its centre (Y) [ xy x 100 = % coverage]

Line(s) under femoral head 1 pt

4 Morgans line 1 pt
Osteophytes in the trochanteric fossa 1 to 3 pts
6
Degree of deformation of the Mild 1 pts
3 5 3
femoral head
1 1
2 7 Moderate 2 pts
2 Pronounced 3 pts
Severe 4 pts
Osteophytes on the acetabulum Dorsal edge 1 pt

Figure 6 and 7 Two examples of the arthrosis score determined by Cranial edge 1 pt
the special system used in this study Percentage of acetabular filling 1 to 33 % 1 pt
1: First line under femoral 1: First line under femoral 34 to 66 % 2 pts
head (1 point) head (1 point) 67 to 100% 3 pts
2: Morgans line (1 point) 2: Morgans line (1 point)
3: Osteophytes in the 3: Degre of deformation of TOTAL
trochanteric fossa. the femoral head : mild
Table IV : Quotation grid of coxarthrosis, pt(s) = point(s)
Percentage of the fossa fill (1 points)
in (1 point)
4: Osteophyte on cranial Total: 3 points
acetabulum rim (1 point) mild arthrosis. The surgical technique was as described by Slocum [10] and
5: Ostophytes on dorsal modified by Legeard [16] (and it comes directly from the one
acetabulum rim irregular
acetabulum rim (1 point) proposed by Lecoeur [17] for humans). It constitutes an ostheomy
6: Degre of deformation of the of the pubis through a ventral incision either at the level of the
femoral head : pronounced acetabulum or an ostectomy of a part of the pubic branch
(3 points) when bilateral surgery was anticipated [18,19]. The longitudinal
7: Percentage of the cotyl ischial osteotomy was performed through a ventral approach
fill in : de 67 100% : (3
points) and the lateral approach to the ilium enabled an osteotomy to
be performed perpendicular to the ischial osteotomy, just caudal
Total: 11 points to the sacrum.
severe arthrosis.
The acetabulum was rotated 30 degrees in all cases. A 5mm
lateral movement of the acetabulum is produced by the plates
Table V : Clinical results for unilateral or bilateral surgery
Excellent Good Fair Poor Not determined
All surgeries 43 78% 10 18% 2 4% 0 0% 4
Unilateral surgeries 14 67% 5 24% 2 9% 0 0% 2
Bilateral surgeries 29 85% 5 15% 0 0% 0 0% 2

164

shape. This limits narrowing of the pelvic canal and increases
dorsal cover without increasing ventroversion.
Clinical survey
An owner questionnaire was used to establish functional results,
time to recovery and physical activity before and after TPO
surgery. The functional results were graded: excellent, good,
fair and poor. Each grade was defined and the inclusion criteria
presented to the owners in the following way:
Excellent: perfect support at all speeds; return to normal activity
without pain or lameness;
Good: normal posture; slight limp at one of the three speeds
(race-trot-step); return to normal activity with occasional pain or
an intermittent lameness
Fair: light permanent limp, worse after exercise and leading to
temporary suppression of weightbearing; mild, but permanent
reduction of physical activity
Poor: severe limp, permanent lack of weight-bearing; major
reduction of normal activity with permanent lameness
irrespective of the speed.
Owners assessed physical activity subjectively. Four grades were
used (good, average, fair, poor) and criteria were selected so as
not to influence owners answers. Time to functional recovery
was divided into 5 categories: less than one month, 1 to 2
months, 2 to 4 months, 4 to 6 months and more than 6 months.
It corresponds to the period of time after which no improvement
has been observed. This deadline is evaluated by the owners and
can be, if necessary, correlated with the data collected by the
veterinary surgeon during follow-up visits.
Rather than confirm what has already been largely discussed
in the literature, the goals of this functional evaluation were to
attempt to correlate pre- and post-operation radiographic results
with functional results, to try to define surgical indications and
finally to predict the hips functional and arthritic development
radiographically.
Radiographic Study
The radiographic study focuses on the quantification of the
degree of osteoarthritis observed on the pre-operation film
and a long term follow up, as well as on the calculation of the
percentage of the femoral head covered by the acetabulum, in
order to quantify the subluxation [8,9,11,12] (fig 5).
The degree of acetabular cover was measured pre- and
postoperatively so that the relevance of the cover could be
assessed in relation to osteoarthritic development.
The quantification of the osteoarthritis was calculated using
a grid (table n IV), especially designed for that purpose and
making it possible to calculate a linear radiologic score between
0 and 14.
The grid takes into consideration the visible radiographic changes
of a specific radiographic view, the ventrodorsal position with
legs extended and femurs parallel to each other and to the
table (classic radiographic positioning for hip dysplasia). The
following abnormalities are systematically assessed: subcapital
165
EJCAP - Vol. 16 - Issue 2 - October 2006
osteophytes, presence of Morgans line, presence of osteophytes
on the cranial acetabulum, irregularity of the dorsal acetabular
rim. Assessment was made of the degree of capital deformation
(minor, average, marked, severe) and finally the percentage of
acetabular filling (1 to 33%, 34 to 66%, 67 to 100%). The last
two criteria were subjective (fig 6 and 7).
The new system of assessing the degree of osteoarthritis had
been subjected to a pre-evaluation period before use in this
study. Twenty dysplastic hips radiographs taken in the standard
position described above were analysed by ten different readers,
who evaluated the degree of arthritis by using the quotation
grid. Although the readers worked independently, their results
were similar. This quantification system for coxo-femoral arthritis
was therefore selected for this study. However the authors
suggest that this grid should be tested and analysed on a larger
number of radiographs by a greater number of readers before
being definitely validated.
Parameters studied
functional recovery of the animals after TPO (excellent, good,
fair, poor);
comparison between functional recovery of dogs having
experienced uni or bilateral surgery (test of X);
time to functional recovery (less than a month, 1 to 2 months,
2 to 4months, 4 to 6 months and more than 6 months);
degree of physical activity after TPO (good, average, poor,
nil);
postoperative development of osteoarthritic changes:
parameter evaluated by the use of the quotation grid by
comparing pre- and post- operative results
relationship between the degree of arthritis and the functional
recovery. Analysis of variance ( significant for p <=0.005);
comparative development of osteoarthritis between operated
and unoperated hips. Analysis of variance (significant for p
<=0.005);
relationship between the degree of coverage of the
femoral head pre and post- operatively and the long-term
development of osteoarthritis; Analysis of variance (significant
for p <=0.005);
relationship between the coverage of the femoral head
immediately post-operatively and long-term. Analysis of
variance ( significant for p <=0,005);
Results
Results of the owner questionnaire showed that 79.9% of the
operated dogs had an excellent functional recovery, 17.9% had
a recovery considered as good and 4% an average recovery. No
poor results were observed (table V).
Regarding the functional results of the dogs having experienced
a unilateral or bilateral surgery, there was no significant
difference.
Time to functional recovery was mainly observed between 1 and
2 months after the surgery (58% of the operated animals) with
98% of the dogs having recovered in less than 4 months (table
VI).
No correlation was evident between the development of
 Long-term analysis of the progression of hip arthrosis after triple pelvic osteotomy - Th. Dembour, J.L. Chancrin

Table VI : Time to functional recovery When arthritic progression of operated hips is assessed, there
is a significant correlation between the arthrosis level and
Number % the functional recovery (coef of correlation: 0.416) with a
Under 1 month 13 25 better recovery for the dogs showing less arthrosis. The study
1 to 2 months 30 58 attempted to find prognostic data, but could not significantly
correlate the level of pre-operation coverage and long-term
2 to 4 months 8 15
arthrosis nor between the progression of arthritic changes and
Up to 6 months 1 2 the immediately post operative coverage, (coeff of correl 0.222)
Not determined 7 12 nor significant correlation between the pre-operation coverage
level and the post operation coverage level (coeff of correl
0.137).
Table VII: Level of activity before and after surgery
Before surgery After surgery All dogs without any pre-operation arthrosis had an excellent
functional recovery based on the comments of the owners.
Number % Number %
None 1 3 0 0 The functional results considered as good by the owners
Poor 11 33 1 3 corresponded to an average radiologic pre-operation score of
2.2 and an average radiologic score of 5.7 long-term.
Fair 18 55 20 61
The results considered as medium had an average radiologic pre-
Good 3 9 12 36 operation score of 3 and a radiologic score of 11 long-term.
Not determined 8 8
Discussion
arthritis and the time to functional recovery (coef. of correlation: Triple pelvic osteotomy is a surgical technique frequently used
0.163). in the correction of locomotor disorders linked to coxo-femoral
dysplasia. The aim is to increase the articular congruence and
The physical activity of the operated dogs improved with time. the cover of the femoral head by the acetabulum. It is hoped
There was a significant difference between the dogs activity that this will limit the progression of arthritic changes and so
before the TPO and activity scored long-term. However there restore optimal physical activity.
was no significant correlation between the progression of
arthritis and physical activity (coef of correlation: -0,097). TPO has, for a long time, been considered prophylaxic for
arthritis. However no study has measured quantitatively the
Analysis of the results obtained using the osteoarthritis quotation radiological progression of arthritis. In 1993, Koch [20] analysed
grid, measured how the hips improved from a radiologic point the post-operative arthrosis in terms of the presence or absence
of view (table VIII) (fig 8 and 9). of osteophytes around the hips. Osteophytes increased with
time. While 95 % of dogs treated by TPO presented with little
The average pre-operation score of the operated hips was 1.69 or no arthrosis pre-operatively, only 65% and 43% of them
against 2.73 for the non operated hips. This score progresses in respectively were similar 3 and 6 weeks after surgery.
both cases with an average long-term result of 5.29 for operated
hips against 8.92 for non operated ones. The difference of the This study attempts to objectify in a quantitative and more
arthrosis score between those two averages is 3.60 for the accurate way the progression of arthrosis long-term.
operated hips and 6.20 for the non operated ones.
The first part of the study, focusing on the functional recovery, the
The progression of osteoarthritis is statistically significant for the degree of physical activity and the time to recovery, was based
operated hips as for the dogs that did not have surgery. on the answers of a questionnaire submitted to the animals
owners. While this kind of evaluation is less accurate from a
There is also a significant difference between the operated purely clinical point of view, it enables a certain evaluation of
hips and the non-surgical cases, with the former showing less these clinical results. Moreover, several publications have already
development of osteoarthritic changes. demonstrated the efficacy of TPO in these areas [4-6,10,11].
The aim of this study was not to supplement existing work but
To take into account that the population was not the same in to correlate them with the new radiographic data. The clinical
relation to the degree of arthritis pre-operatively, it was divided results were so close to those already mentioned in the literature,
into different sub-populations and in an attempt to follow their that they can be considered as relevant.
progression as similar groups. The heterogeneity of individuals
comes from the fact that the survey sometimes focuses on older Subjectively the impression was that dogs having experienced
dogs and that the selection criteria of candidates for TPO have a bilateral TPO had a better functional recovery than those
changed over recent years. From a pre-operation arthritic point having experienced a unilateral operation. This difference was
of view, the results obtained by gathering similar animals are not statistically significant. This might come from the fact that
summarised in the table n VIII and in the figures 8 and 9. the population studied was too small to confirm statistically

166
 EJCAP - Vol. 16 - Issue 2 - October 2006

Table VIII : results obtained according to the quotation grid used in this study
Non operated hip Operated hip
NI Average Score BS Average Score LT NI Average Score BS Average Score LT
5 0 6.2 15 0 2 .867
8 1 9 7 1 5.25
1 2 4 5 2 4.4
3 3 10.3 10 3 9
1 5 13 3 4 4.3
1 10 11.2 1 6 12
BS : just before sugery
LT : Long term
NI : Number of dogs in each group

Non operated hip Operated hip

14 14
13 13
12 12
11 11
10 10
9 9
8 8
7 7
6 6
5 5
4 4
3 3
2 2
1 1
0 0
before after before after

Figures 8 and 9 Graphical representation of table VIII

the conclusions which appeared obvious. However, in order
to explain the average results collected during unilateral
surgeries, one should not forget the evaluation of the functional
recovery of the animal itself and not just the operated hip. In
one of the two cases of an average recovery, the animal had
to undergo, subsequent to the survey a total hip replacement
on the controlateral leg. It must be noted that in several
unilateral surgery cases further intervention was necessary
(either an excision arthroplasty of the femoral head or a total hip
replacement) on the unoperated side ( cases 1 : fig 10 and 11).
Further surgery was never necessary on a hip having experienced
a TPO. It might be that the less good results obtained on the
dogs operated on one side only (even if these results are not
significantly different from bilateral surgeries) come from a more
significant handicap on the contralateral unoperated hip.
Time to recovery was variable and almost always less than
4 months. The variability was not necessarily a sign of variation
in good radiographic progression but maybe simply comes from
individual variation between individuals or other events not
relevant to the ultimate joint degeneration.
The progression of arthritis did not significantly influence the
physical activity of the operated animal, but there was a real
correlation between the arthrosis and the functional recovery.
The physical activity was judged by the owners in a subjective
way.
Physical activity is a too subjective criterion in this survey and
probably does not accurately convey the eventual handicap. So
this criterion is not perfectly in correlation with the functional
recovery as defined in this study.
The final part of this study and certainly the most innovative
focuses on the analysis of the radiographs taken at least one
year after the TPO. It can be seen that, whatever the start point
is, a displastic hip will keep on progressing to more arthrosis.
Whether they are stabilised or not by a TPO, 100% of the hips
undergo significant degenerative phenomena. However, this
progression will differ depending on the initial situation and will
be faster for hips not operated on (cases 2: fig 12 and 13). It can
be asserted that TPO is prophylaxic, but only partially so, on the
arthritic development of dysplastic hips long-term.
It is important to point out that the more pronounced the initial
arthrosis is, the more the radiological score long-term will be
(cases 3: fig 14 and 15 + cases 1 and 2).
There is a correlation between the degree of long-term arthrosis
and the functional recovery.

167
Long-term analysis of the progression of hip arthrosis after triple pelvic osteotomy - Th. Dembour, J.L. Chancrin

Figure 11
Case 1 Follow up
Figure 10 radiograph (64
Pre-op radiograph months) of the
of a 6 months old previous dog.
Brittany Spaniel. (case 1) Significant
There is significant development of
laxity and a mild degenerative joint
arthrosis of the hip disease

Figure 13
Follow up
radiograph at 17
months (case 2).
The operated side
had a good clinical
and radiographic
Case 2 evolution. The
Figure 12 animal was
Pre-op radiograph severely lame on
of a 7 months old the opposite side on
Belgian Shepherd. which a total hip
Bilateral hip laxity replacement had to
more significant on be performed
the right side

Case 3
Figure 14 Figure 15
Pre-op radiograph Follow up
of a 5 month old radiograph (case
Belgian Shepherd. 3) at 5 years.
Bilateral hip laxity Excellent clinical
with no sign of outcome and mild
arthrosis arthrosis

168

For that reason, the pre-operation analysis that enables detection
of the first signs of arthrosis and to evaluate the joint depth is
a major step, which can, if not predict, at least estimate long-
term arthritis and through this the potential functional recovery.
From this, an animal with some arthritic signs pre-operatively is
an animal which presents at least a limited contra-indication to
the TPO.
However, the degree of articular laxity defined by greater or
lesser cover of the femoral head does not have some prognostic
value.
Moreover, it must be pointed out that the immediate post-
operative cover does not have prognostic value, nor does
the immediate post-operative covers degree reflect long-term
cover.
Finally, enhanced post-operative cover by using acetabular
ventroversion greater than 30 degrees cannot be justified. The
studies of L. Dejardin [21,22] concerning the TPO effects on the
strengths of articular reaction, the muscular tensions, the capital
cover and the articular congruence support the statistical results
collected in this study.
There is a final question: why does arthrosis develop after TPO?
Two answers are possible. Riser demonstrated in 1975 [23]
that micro-fissure at the level of the acetabular rim and at the
level of the articular cartilage of the femoral head were already
present in dysplastic dogs that were 20 weeks old. The average
age of dogs that undergo a TPO is 6.4 months old. Therefore at
this stage, the degenerative arthritic phenomena have already
begun.
Moreover, in the case of normal hips, the femoral articular
cartilage is thicker closer to the fovea and thinner to the edges
of the femoral head, while the acetabular articular cartilage
is thicker along the labrum. After TPO, some orientation
modifications of the articular contact areas can partially explain
the progression of the degeneration of the hip despite the
reduction of articular laxity [22]. Actually when the acetabular
ventroversion increases, the articular area of the acetabulum
moves away from the dorsal side of the femoral head. That
anatomic modification consequently puts in contact the thick
part of the acetabular articular cartilage with thinner cartilage
areas of the femoral head. Because of these relative differences
of the structural properties of the articular cartilage being in
contact, the acetabular cartilage will be subject to more rapid
degeneration.
The solution to these major problems firstly consists of making
an early diagnosis of the articular laxity in order to operate before
the start of the degenerative phenomena and secondly always
following the studies of L. Dejardin to limit the acetabulums
ventroversion to a maximum of 30 degrees and if possible to 20
degrees in order to limit the anatomic modifications of the hip.
Moreover, now that the choice between two Chancrin plates (20
or 30 degrees of ventroversion) is possible, some modifications
in the implant now enable an increase in the cranial cover of the
169
EJCAP - Vol. 16 - Issue 2 - October 2006
femoral head without increasing acetabular ventroversion. Those
modifications are similar to those of the iliac osteotomies in the
Graehler study [24] which measured the influence of the angle
of the iliac section on the structural anatomy of the pelvis.
The modification of the implant enables, in the authors
opinion, better cover and better articular congruency without
limiting movement, particularly in abduction, which is observed
following surgery giving increased cover.
The choice between 20 and 30 degrees of acetabular
ventroversion is made with regard to the articular laxity and
the evaluation of the development of the dorsal rim of the
acetabulum, analysed on a radiograph of the pelvis taken in its
longitudinal axis (DAR position of Slocum) [25].
This choice, which has to be made intuitively, should be defined
in a more accurate way and should become the focus of a more
advanced study.
Finally, it will be interesting to see if a ventroversion of 30
degrees, can have some favourable consequences on the
ultimate development of the arthrosis and hopefully give an
even better functional recovery!
References
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2 SLATER (R.B.) - Innominate osteotomy in the treatment of
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1961, 43-B: 518-538.
3 BRINKER (W.O.) - Pelvic osteotomy for treatment of hip dysplasia.
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4 CHANCRIN (J.L.) - Triple ostotomie pelvienne. Encyclopdie
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5 DVID (T.H.), KASPER (M.) - Triple pelvic osteotomy (TPO) with
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11 MCLAUGHLING (R.), MILLER (C.W.) - Evaluation of hip Joint
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12 PLANT (J.), DUPUIS (J.) - Long term results of conservative
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13 PLANT (J.), DUPUIS (J.) - Long term results of conservative
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the ground reaction forces. Vet Comp Orthop Traumatol 1997, 10:
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14 GAGURE-LUCAS (J.) - Etude clinique, coxomtrique et
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15 CHALMAN (J.A.), BUTLER (H.C.) - Coxofemoral joint laxity and
Ortolani sign. J Amer Anim Hosp Assn 1985, 21: 671-676.
16 LEGEARD (F.) - Ostotomie triple du bassin comme traitement de
la dysplasie de la hanche chez le chien. Etude comparative de trois
techniques. Prat Med Chir Anim Comp 1986, 21 (5): 325-347.
17 LECOEUR (P.) - Correction des dfauts dorientation de larticulation
coxofmorale par ostotomie de lischme iliaque. Rev Chir Orthop
1965, 51: 212.
18 SUKHIANI (H.R.), HOLMBERG (D.L.), HURTING (M.B.) - Pelvic canal
narrowing caused by triple pelvic osteotomy in the dog Part I: The
effect of pubic remnant length and angle of acetabular rotation.
Vet Comp Orthop Traumatol 1994, 7: 110-113.
19 SUKHIANI (H.R.), HOLMBERG (D.L.), HURTING (M.B.) - Pelvic canal
narrowing caused by triple pelvic osteotomy in the dog Part II:
A comparisson of three pubic osteotomy techniques. Vet Comp
Orthop Traumatol 1994, 7: 114-117.
20 KOCH (D.A.), HAZEWINKEL (H.A.), NAP (R.C.), MEIJ (B.P.),
WOLVEKAMP (W.) ThC - Radiographic evaluation and comparison
of plate fixation after triple pelvic osteotomy in 32 dogs with hip
dysplasia. Vet Comp Orthop Traumatol 1993, 6: 9-15.
21 DEJARDIN (L.) and al - The effect of triple pelvic osteotomy on hip
force in dysplasic dogs: a theoretical analysis. Vet Surg 1996, 25:
114-120.
22 DEJARDIN (L.) and al - The effect of triple pelvic osteotomy on
the articular contact area of hip joint in dysplasic dogs: an in vitro
experimental study. Vet Surg 1998, 27: 194-202.
23 RISER (W.H.) - The dog as a model for the study of hip dysplasia.
Vet Pathol 1975, 12: 229-334.
24 GRAEHLER (R.A.), WEIGEL (J.P.), PARDO (A.D.) - The effects of
plate type, angle of ilial osteotomy, and degree of axial rotation on
structural anatomy of the pelvis. Vet Surg 1994, 23: 13-20.
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170
 ORTHOPEADICS

REPRINT PAPER (N)

Stratification, blinding and placebo

effect in a clinical trial of gold bead
implantation in canine Hip Dysplasia
G. T. Jger(1), S. Larsen(2) , L. Moe(3)

SUMMARY

Stratification, blinding and placebo effect in a randomised, double blind placebo-controlled clinical trial of gold
bead implantation in dogs with Hip Dysplasia
The purpose of this study was to investigate the need for and choice of stratification factors, and the effects of blinding
and placebo in a clinical experiment. Eighty dogs with canine hip dysplasia (CHD) were included in a randomized,
placebo-controlled and double blind clinical trial with stratified parallel group design, in which body weight and
degree of CHD were used as stratification factors. Thirty-eight dogs were allocated to gold bead implantation and 42 to
placebo. After six months, 33 of the 42 placebo-treated dogs received gold bead implantation in an open study lasting a
further 18 months. The main outcome variable in the study was change in pain signs of CHD as assessed by the owner.
No significant difference in the main outcome variable, regardless of the treatment given, could be detected in the two
chosen stratification factors. The only factor to influence the main outcome variable significantly was age. The blinding
procedure used in the study, in which 60% of the owners correctly guessed the treatment given, was found sufficient.
Of those who guessed the treatment erroneously, 88% believed the treatment given was gold bead implantation. The
treatment efficacy after six months in the blinded treatment group was found to be significantly larger compared to the
efficacy obtained in the open study. A significant placebo effect was therefore detected. Conclusion and clinical relevance:
The age of the dogs influenced the outcome of the CHD treatment, and is recommended as a stratification factor. A
significant placebo effect has to be expected and an optimal blinding procedure is necessary in similar clinical studies.
Key words: canine; studydesign; hip dysplasia.

stratification factors could be found in the published literature.

This paper originally appeared in:
Acta vet.scand* 2005 46 p 57-68
Introduction
Different treatments for canine hip dysplasia (CHD) have been
described, with variable success. Durkes (1992) suggested that
the implantation of gold beads at specific acupuncture points in
dogs with chronic pain due to hip dysplasia seemed promising.
During the planning of a clinical therapy trial with implantation
of gold beads in CHD, no information on the most suitable
While CHD is a very common disorder in dogs and a large
number of publications exists on its etiology, risk factors for
development, breed prevalence, diagnostic methods, importance
of prognostic factors for the development of cox arthrosis, and
different therapeutic methods, good methodological studies of
factors influencing treatment outcome are lacking.
During statistical analysis of treatment results, it is highly desirable
to have as equal groups as possible regarding both the patient
characteristics and diagnosis of disease. Although methods of
statistical analysis exist to compensate for unequal treatment
groups, it is more convincing to present data from equivalent
groups, and stratification is a method for equalizing treatment

(1) Department of Companion Animal Clinical Sciences, (2) Department of Production Animal Clinical Sciences,
(1,2,3) Norwegian School of Veterinary Science, P.O. Box 8146 Dep., N-0033 Oslo .
Corresponding authors E-mail: Gry.jaeger@veths.no
* Presented by NSAVA (Norway)

171
 Stratification, blinding and placebo effect in a clinical trial - G. T. Jaeger
groups (Meinert 1986, Pocock 1983). If we know the factors
that may influence the outcome of a specific treatment, we may
need to stratify for those factors. Sometimes the same factor
that causes a disease may influence the outcome of treatment.
However, the etiological factors often are different from the
stratification factors that affect the results of treatment. In CHD,
heredity is an important etiologic factor, but is not necessarily
a factor that affects the outcome of a hip dysplasia treatment.
When comparing small treatment groups of up to 50 dogs, it is
important to eliminate or balance the factors that influence the
outcome (Peto et al. 1976, Meinert 1986).
How can stratification factors be identified? In smaller studies
this can be done by surmising all factors that could possibly
influence the outcome of the treatment. The number of such
factors may be large and the choice may be difficult. To stratify
the animals on too many factors will result in many groups
with few cases each. Consideration of earlier published trials or
related experiments may also indicate one or more factors that
may affect treatment outcome. Former treatment trials of CHD
with published stratification factors were not found, although
a related study of risk factors for degenerative joint disease
associated with hip dysplasia found that body weight and hip
joint laxity were such risk factors (Smith et al 2001).
It may be of psychological benefit if the person reporting the
treatment effect knows that the animal is receiving a new
treatment. In contrast, owners that know their animal is on a
standard treatment may react unfavourably if they are made
aware that other patients are privileged by receiving a new
therapy. Such attitudes towards the given therapy may affect
the owners co-operation in a study and may also influence the
reported efficacy of the given treatment, and any comparison
of treatments in a controlled clinical trial (CCT) in animal or
man may be distorted if the patient or animal owner, or those
responsible for treatment and evaluation, know which treatment
is being used. This problem can be avoided by performing a
double blind trial, in which neither patient or owner nor
physician or veterinarian are aware of which treatment the
patient or animal is receiving. The first study to include blinding
in CCT seems to have been published in 1927, and concerned
vaccines for the common cold (Ferguson et al. 1927). In the first
reported experiments with control groups (Ferguson et al. 1927,
Lind 1757), the allocation to treatment was arbitrary or simply
decided by the investigator.
Any blinded and balanced CCT should include an investigation
of a possible placebo effect. A placebo effect is any medical
intervention that has a favorable, non-specific, psychological,
or psycho-physiological therapeutic effect, but without specific
activity for the condition being treated. This non-specific effect
may also be negative, that is, unfavorable (McMillan 1999), in
which case it is called a nocebo effect. To the best of the authors
knowledge, Haygarth (1800) performed the first placebo CCT in
1799 and described the placebo effect for the first time. Placebo
effects are commonly reported in CCT studies where humans
are involved. In addition to Pavlovs morphine experiments on
dogs (Pavlov 1927), one of the first to describe this effect in
animals was Herrnstein (1962), who injected scopolamine
172
hydrobromide to laboratory rats and demonstrated that saline
injections to some extent imitated the effect of the drug. Other
studies of conditioning placebo responses have been performed
in animals (Newton & Ehrlich 1969, Riley 1981).
However, the prime reason for introducing placebo controls is
to distinguish between the effect caused by an active treatment,
and other effects due to reasons not related to the active
treatment. A possible placebo effect was discussed in a study
of gold wire implants in CHD where an equal improvement in
locomotion and pain as evaluated by owners was found in both
the placebo and treatment groups (Hielm-Bjorkman et al. 2001).
A placebo effect in companion animals that resembles those
reported in human CCTs, where treatment efficacy is assessed
by the dog owner several months after the treatment had been
given to the dog, seems not to have been shown in veterinary
clinical studies.
The aim of this methodology study was to examine the need for
and choice of stratification factors in the treatment of canine hip
dysplasia, and to investigate the effect of blinding and placebo
in a controlled clinical trial of pain treatment in CHD.
Materials and methods
Animals
A total of 80 dogs recruited from all parts of Norway, with pain
and difficulty of movement due to canine hip dysplasia (CHD),
were included in the study. The diagnosis of CHD was based
on radiographs and was graded as mild, moderate or severe
according to the guidelines given by the Scientific Commission
of the Nordic Kennel Union and Federation Cynologique
Internationale. Dogs between one and eight years of age, of
both genders and all breeds including mixed breeds, could
participate. The reference population for the study consisted
of all family dogs in Norway. The dogs were recruited through
advertisement in veterinary and breeder clubs magazines. This
resulted in 47 females and 33 males whereof six and one were
neutered, respectively. Twenty-eight breeds were represented.
Dogs with other diseases related to the nervous, muscular
or skeletal systems were excluded. Exclusion was based on a
thorough examination described below under clinical procedure.
Dogs with previous acupuncture experience were also excluded
from the study.
Study design
The study was carried out as a randomised placebo-controlled
and observer-blind clinical trial with stratified parallel group
design (Fig. 1). The main outcome parameter was change in
pain signs of CHD as assessed by the owner. The stratification
factors used were body weight in three groups and degree
of CHD diagnosed by radiography divided into two groups
(mild/moderate CHD and severe CHD). The design resulted in
six strata. Within each strata the patients were randomized
to receive either gold bead implantation or placebo once in
ratio 1:1 by using block randomization with a fixed blocksize
of four. An error occurred during classification of cases, which
resulted in an unbalanced group in the stratum mild/moderate
 EJCAP - Vol. 16 - Issue 2 - October 2006

G n=1
Mild/moderate CHD
R
n=1
Body weight P n=0
20.0 kg
n=6 G n=3
Severe CHD
R
n=5
P n=2

G n = 10
Mild/moderate CHD
R
Total n = 21
Body weight P n = 11
number
20.1 34.9 kg
of dogs
n = 39 G n=8
n = 80 Severe CHD
R
n = 18
P n = 10

G n=9
Mild/moderate CHD
R
n = 20
Body weight P n =11
35.0 kg
n = 35 G n=7
Severe CHD
R
n = 15
P n=8

Figure 1 - Flow chart of the study design of 80 dogs with different degrees of canine hip dysplasia (CHD) included in a double blind
randomized clinical trial. The numbers (n) indicate the number of dogs within each strata and randomized groups. (G) = Gold
implantation group. (P) = Placebo group. (R) = Randomized procedure.

hip dysplasia with body weight 35.0 kg, where 20 dogs were
distributed 11: 9 in the placebo group and the gold implantation
group, respectively. With a number of 20 dogs, ten dogs should
have been equally distributed in each treatment group with a
blocksize of four. A total of 38 dogs were treated blindly with
gold bead implantation and 42 with placebo (Table 1). The
treatment was blinded for both the owners and the responsible
researcher during the first six months of the trial period, after
which the randomisation code was broken and the placebo-
treated dogs were offered gold bead implantation. Of the 42
dogs in the placebo group, 33 subsequently received gold bead
implantation. The follow-up period was carried out as an open
study with a duration of a further 18 months, and included both
the dogs from the blinded six month study and the open study
group. The total follow up period was therefore 24 months from
the start of the study.
In the blinded six month period, two dogs from the active group
dropped out due to administrative reasons (Table 1). In the 18
month follow up period two of 36 dogs originally treated with
gold implantation dropped out due to administrative reasons and
two discontinued for reasons related to the treatment. Of the 33
dogs in the placebo group that were given gold bead implantation
at the start of the 18 month follow up period, one dropped out
for reasons not related to the treatment and three withdrew, two
of them for unknown reasons. The treatment results of the clinical
trial have been reported elsewhere (Jger et al 2004).

Table 1 - Number of dogs participating in a clinical controlled therapy trial of 80 dogs with different degrees of canine hip dysplasia. The dogs
were randomly assigned to receive either gold bead implantation or placebo in a blinded 6-month study. The dogs in the placebo group were
thereafter offered a crossover to gold bead implantation, and all dogs were followed in an open trial for another 18 months.

Double blinded controlled Open clinical trial

clinical trial over six months Follow up 18 months
Treatment Completed Drop out Withdrawal Completed Drop out Withdrawal
no. of dogs no. of dogs
Gold 36 2 0 32 2 2
Placebo 42 0 0 7 2 0
Gold, follow
up period * * * 29 1 3
Total 78 2 0 68 5 5
* = not applicable

173
 Stratification, blinding and placebo effect in a clinical trial - G. T. Jaeger

Factor Design strata Pain signs of canine hip dysplasia Total

Complete Large Mild No change in Mild Large number
recovery improvement improvement signs aggravation aggravation of dogs

Body- 20.0 kg 0 3 1 1 0 1 6
weight 20.1-34.9 kg 5 14 5 9 2 3 38
35.0 kg 6 11 7 9 1 0 34
Canine Mild/ 6 14 7 11 2 0 40
hip moderate
dysplasia Severe 5 14 6 8 1 4 38
Non-design
stratum
Gender Female 5 15 10 12 2 2 46
Male 6 13 3 7 1 2 32

Table 2 - Number of dogs with achieved treatment effect recorded as change in pain signs of canine hip dysplasia (CHD) assessed by the
owner, related to the two stratification factors bodyweight and degree of CHD. Distribution of dogs according to the non-design stratum
gender is also shown.

Clinical procedure Statistical analysis

At the enrolment consultation, the owner was asked about the All the results were expressed in contingency tables (Agresti
dogs clinical signs and medical history using a standardized 1990). Frequencies were expressed in percentages with 95%
questionnaire. Thereafter, all the dogs were thoroughly confidence intervals (CI) and calculated using the Binomial
examined with special attention to the gait and movement, the distribution (Agresti 1990).
lumbar spine and muscles and the skeleton of the hind limbs. Comparisons of groups were performed by categorical data
The examination included a neurological examination and hip analysis controlled for the actual treatment given (Agresti 1990).
extension test. All dogs were sedated and anesthetised, and In order to study the contribution of the independent variables,
then the coat was clipped over one or both hips. A veterinarian a multiple regression analysis weighted for the treatment
certified in veterinary acupuncture marked the acupuncture given, based on a second-degree polynome, was performed
points with one colour and marked another five non-acupuncture (Kleinbaum et al. 1998). All hypotheses were tested two-tailed,
points with a different colour. The same veterinarian performed and differences were considered statistically significant if the p-
the clinical examinations both initially and at every control visit value was found to be less than or equal to a level of 5%.
throughout the whole follow up period. Hip radiographs were
performed to confirm the diagnosis of CHD. Depending on
their body weight and radiographic hip score, the dogs were
Results
assigned to one of six different strata. Within each strata, dogs On request, 63 of the 78 participating owners blindly guessed
were randomly assigned a gold bead implantation or placebo the treatment given to their dogs (Table 3). The probability of
in accordance with a sealed pre-randomization list. Another correctly guessing the treatment was estimated to be 38/63 or
veterinarian specially trained in the technique performed the 60% (CI 47.2 72.4%). The divergence from the expected 50%
gold bead implantation through the acupuncture points, while was not significant (p = 0.10).
dogs allocated the placebo had the skin at the non-acupuncture
points penetrated with a needle of the same type and size as the
one used for gold bead implantation. Table 3 Owners guess of treatment given versus actual
treatment given and their prospective wishes regarding gold bead
The dogs were re-examined 14 days, three months and six implantation for their dog in a clinical controlled therapy trial of
months after surgery. At the six month visit the owners were 80 dogs with canine hip dysplasia. The two opinions of the owner
asked what kind of treatment, gold or placebo, they believed were requested at the end of the 6 month trial and before the
had been given to their dog. The main outcome parameter, randomization code was broken. One dog owner per dog expressed
their opinion.
change in pain signs of CHD as assessed by the owner, was
recorded on a six point fixed scale (see Table 2). Participation Owners guess Treatment Wanted gold
was free of charge and the owner signed a written consent. The of treatment actually given implantation if not
Norwegian Animal Research Authority approved the study. given given previously
Placebo Gold Yes No
Placebo 8 3 11 0
Gold 22 30 35 17
Dont know 12 3 13 2

174
 EJCAP - Vol. 16 - Issue 2 - October 2006

All the 11 owners who guessed that placebo was given wanted
gold bead implantation in case of correct guessing (Table 3).
Similar results were also found in the group of uncertain
owners. Of the 52 who believed that gold had been implanted,
Change in signs of pain

35 or 67% wanted gold implantation if their dog belonged to

the placebo group. There was a significant difference (p = 0.01)
between the gold implantation group and the placebo group
with respect to the owners negative reply regarding further
gold treatment if their dog had ended up in the placebo group.

On the basis of prior knowledge, both body weight and

Age in years
Figure 2. Regression analysis of age and pain signs in 80 dogs with
canine hip dysplasia (CHD). The straight line (red) represents
the linear relationship between the independent variable, age, and
the dependent variable, change in pain signs. The curved line
(green) indicates the relationship expressed by the second-degree
polynome. Change in signs of pain of CHD assessed by the owner
was recorded by a six point fixed scale where 1 = large aggravation,
2 = mild aggravation, 3 = no change in pain signs, 4 = mild
improvement, 5 = large improvement and 6 = complete
recovery.
Twenty-two of the 30 owners guessed that gold implantation
had been given to their placebo treated dogs, which is 73%
(CI 54.1 87.7) (Table 3). A total of 25 owners erroneously
guessed the treatment. Of those, 22 or 88% (CI 68.8 97.5%)
believed the treatment given was gold bead implantation, while
three owners or 12% (CI 2.6 31.2%) guessed placebo. When
the owner guessed that gold was given they also reported a
greater improvement (p < 0.01) in pain signs compared to those
who guessed placebo or were uncertain about the treatment
given (Table 4). No significant difference in change in pain signs
reported by the owner was found between these two last-
mentioned groups. Thus, a significant placebo effect (p < 0.01)
was detected (Table 3), and was supported by the findings in
Table 4.
degree of CHD were chosen as stratification factors in the
study design (Table 2). No significant differences in the main
outcome parameter, when accounting for the actual treatment
given, were detected for CHD (p = 0.25) or body weight (p =
0.44). However, the multiple regression analyses indicated that
the interactions between CHD and body weight contributed
significantly to explain the improvement in pain signs.
Gender was tested as a possible stratification factor. No
significant difference was found between the genders (p = 0.59)
in the main outcome variable, change of pain signs (Table 2).
Age was found to have a significant influence on change in pain
signs (Table 5). By dividing the observed age distribution into
quartiles, the four age strata were defined as 2.6 years, 2.7
4.5 years, 4.6 5.9 years and 6.0 years. A negative linear
correlation was found between age and change in pain signs (r
= 0.14). A stronger relationship was found using a second-
degree polynome (Fig. 2), leading to the following suggested
three age strata, 2.5 years, 2.6 - 6.0 years and 6.1 years
(Table 5). If only two age strata are requested, an age 4.0
years and > 4.1 years are suggested, based on the same linear
regression analyses.
After six months the randomization code was broken, and the
patients who previously received a placebo now received gold
bead implantation as an open treatment. All the dogs were
followed for a further 18 months, and the efficacy was recorded
additionally after six months. The treatment efficacy in pain signs
in the blinded study group of gold bead implantation was found
to be significantly larger compared to the efficacy obtained in
the first six months during the open treatment (p = 0.02) in the
previous placebo group that received gold bead implantation
(Table 6).

Table 4 Distribution of 78 dogs in a blinded clinical trial of canine hip dysplasia (CHD) with gold bead implantation or placebo treatment
according to the main outcome variable, change in pain signs of CHD, versus the owners guess of treatment given. The opinion of the
owner was requested at the end of the blinded trial period (six months), but before the randomization code was broken.

Owners guess Pain signs of canine hip dysplasia

of treatment Complete Large Mild No change in Mild Large Total number
given recovery improvement improvement signs aggravation aggravation of dogs
Placebo 0 0 1 6 2 2 11
Gold 11 28 10 3 0 0 52
Dont know 0 0 2 10 1 2 15

175
 Stratification, blinding and placebo effect in a clinical trial - G. T. Jaeger

Age strata Years Dogs (n) Probability of 95% confidence p- values

improvement intervals
2.6 20 87.5 % 71.0 % 96.5%
2.7 4.6 20 65.5 % 45.7% - 82.1 %
Four age strata 0.057
4.7 5.9 20 57.7 % 36.9 % - 76.7 %
6.0 18 74.1 % 53.7 % - 88.9 %
2.5 19 86.7 % 69.3 % 96.2 %
Three age strata 2.6 6.0 41 63.2 % 49.3 % 75.6 % 0.053
6.1 18 74.1 % 53.7 % 88.9 %
4.0 36 80.4 % 67.6 % 89.8 %
Two age strata 0.047
> 4.1 42 63.8 % 50.1 % 76.0 %
Table 5 - Estimated probability of improvement in pain signs of canine hip dysplasia related to four, three and two age strata. The results
are expressed in percent with 95% confidence intervals. (n) = number of dogs.

Pain signs of canine hip dysplasia Total no.

Treatment Complete Large Mild No change Mild Large of dogs
recovery improvement improvement in signs aggravation aggravation
Blinded gold 5 17 8 6 0 0 36
Open gold 1 14 9 2 4 2 32
Table 6 - Distribution of 68 dogs according to change in pain signs of hip dysplasia (CHD) after gold bead implantation in a controlled
clinical trial of CHD. The treatment effect for gold bead implantation is given in the blinded trial versus the open treatment trial.

Discussion
Several factors can affect the development of canine hip
dysplasia, and among them is body weight (Kealy et al. 1997).
We also know that joint stability is influenced both by the
amount of muscle mass surrounding the joint and the weight
the joint must support (Cardinet, III et al. 1997, Riser & Shirer
1967). In a comparable study in humans (Davis et al. 1989),
a significant correlation between obesity and bilateral knee
osteoarthritis was reported. In that study, however, body weight
itself was not found to have any influence on treatment efficacy
unless there was obesity and hence enhanced weight load on
the joint. As clinicians trained in the causes of a specific disease,
we can mistakenly come to regard a cause as a factor that can
influence the outcome of a treatment. Although we chose body
weight as a stratification factor, this did not actually affect the
outcome of the study.
Previous investigations have revealed a lack of correlation
between changes of the hip, determined radiographically, and
the clinical signs of hip dysplasia (Whittington et al. 1961, Riser
1973). However, to the best of our knowledge no information
exists on whether severe degrees of hip dysplasia are more
difficult to treat than milder degrees. The interactions between
CHD and body weight apparently contributed to explain the
improvement in pain signs in this study. Dogs with milder
degrees of hip dysplasia had a rising tendency of improvement
in pain signs with increasing body weight. The opposite occurred
with severe hip dysplasia, as the improvement in pain signs
decreased with increasing body weight. However, the number
of dogs in the analysis was too small to provide a conclusive
interpretation.
Age and gender are two other possible stratification factors that
could have been used in the study design. We found that dogs
younger than 2.6 years had the best effect from the treatment.
This is not surprising, since spontaneous improvement in limb
function may occur as dogs reach maturity (Riser 1973, Barr
et al. 1987). Due to this fact, one of the exclusion criteria was
dogs less than one year, even though many dogs do not reach
maturity until much later than this age, depending on their
final size and developed muscle mass. This result was confirmed
with multiple regression analysis, with best improvement in
pain signs in dogs less than 2.5 years of age. This analysis
also revealed that dogs older than six years had an increased
improvement in pain signs. One possible explanation for this
can be that dogs in this study were all carefully selected and
excluded if other diseases were present. Additionally, there
may be a difference in the pathobiology between the dogs in
the youngest and oldest age groups when entering the study.
Age is therefore a variable that may enhance the apparent
treatment effect, and is consequently recommended as a
stratification factor.
The placebo effect is well documented in animal trials (Herrnstein
1962, Batterman & Lower 1968, Phil & Altman 1971), and
explained by Pavlovian conditioning. Studies of the placebo effect
have, however, been limited primarily to laboratory animals in
laboratory environments, and animals living in a family home
under normal family conditions have been poorly documented.
The current study indicated a significant placebo effect, since
significantly more owners guessed erroneously that gold bead
was given than placebo, and since those who guessed that gold

176

bead was given reported more improvement in pain signs than
those who guessed that placebo was given.
We assumed that owners, by taking the decision to participate
in a trial, would have a positive attitude towards a new and
possibly controversial treatment using gold bead implantation
and acupuncture, and this attitude was a potential source of
bias. One of the exclusion criteria was therefore dogs with
previous acupuncture experience. Another contribution to the
placebo effect is a patients expectation of the treatment (Peck
& Coleman 1991, Feddersen-Petersen 1994). The owners
expectations of the treatment effect can induce a placebo effect
in both treatment groups. It may also reflect what treatment
they believe has been given to their dogs, since the owners
opinions were included in the evaluation of the effect. This was
confirmed when owners answered the question of whether
further gold treatment was desired or not. Another possible
explanation of the improvement in the placebo group is that
dogs may discern both their owners signals (Gliedman et al.
1957) and also attitude towards the treatment, the clinic and
the veterinarian, and thereby give their owners an impression
of improvement or aggravation. Dogs may behave differently
due to the owners new signals and may also be encouraged
to engage in forms of exercise that they previously were spared
for, but nonetheless, after a while were able to do without any
signs of pain.
When comparing the open versus blind studies, the best effect
was achieved in the blind study, which is in accordance with
other studies (Batterman & Lower 1968, Evans 1985). In the
blind study the placebo effect was included, and in the open
study probably the nocebo effect was included. The true effect
of the gold bead treatment probably lay somewhere between
these two results.
Conclusion
Age seems to be the proper choice of stratification factor in
therapy studies of canine hip dysplasia with a limited number
(50-200) of participating dogs. A significant placebo effect must
be expected, and blinding and randomization are necessary in
studies where the outcome of the treatment is based upon the
owners perception of improvement of the clinical signs.
Acknowledgements
The project was supported in part by grant no. NFR 123873/320
and NFR 141822/320 by The Research Council of Norway,
Dyreidentitet AS and The Norwegian School of Veterinary
Science.
The authors thank Mrs Bernadette Helmer and Lena Stenhaug for
technical assistance, Dr. David Griffiths for valuable comments
on the English language, and also the Norwegian Kennel Club
for supporting co-operation.
177
EJCAP - Vol. 16 - Issue 2 - October 2006
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 ENDOCRINOLOGY

REPRINT PAPER (B)

Retrospective study of owners

perception of home monitoring
of blood glucose in diabetic
dogs and cats
I. Van de Maele, N. Rogier, S. Daminet

SUMMARY

Home monitoring of blood glucose (HMBG) concentrations has been recommended in the monitoring of human
diabetics for 3 decades. During the last number of years, it has also gained popularity in long-term monitoring of
diabetic cats and dogs. The aim of this retrospective study was to evaluate the practical feasibility of and identify the
major problems encountered with HMBG in diabetic pets. A standard questionnaire was filled in by owners of 9 diabetic
pets monitored with HMBG. The need for more than 1 puncture to obtain a blood drop, the creation of a sufficient blood
drop, the need for assistance in restraining the pet, and the resistance of the pet were the most frequently encountered
problems during HMBG. The major obstacles for the owners to start with HMBG were also identified.
In conclusion, HMBG is a practical and simple technique for most owners and, overall, owners were satisfied.

physiological counter regulation following a hypoglycemic

This paper originally appeared in:
Can. Vet.J.* 46, p718 723
Introduction
Diabetes mellitus is a commonly diagnosed endocrine disease
in middle-aged to older dogs and cats. The diagnosis, based on
the presence of appropriate clinical signs (polyuria, polydipsia,
polyphagia, and weight loss), hyperglycemia, and glucosuria
is most often straightforward [1]. Treatment usually involves
appropriate insulin therapy, and adapted diet and exercise.
The major goals of treating diabetic patients are to alleviate
clinical signs of diabetes and to prevent complications,
including hypoglycemia [2]. The difficulty with the disease lies in
appropriate monitoring of therapy. The combination of history,
physical examination, and changes in body weight is effective for
initially assessing control of glycemia in diabetic dogs and cats.
However, correlation between owner observations and glycemic
control measured by laboratory findings was less reliable in cats
compared with dogs [3,4].
The measurement of glucose in the urine, although easy to
obtain, is not recommended. The Somogyi phenomenon is a
period (blood glucose < 3.6 mmol/L) which results in persistent
hyperglycemia for 24 to 72 h. Therefore, glucosuria can persist
for several days following insulin overdosage [1,2].
Serum fructosamine concentration reflects changes in serum
glucose concentrations over the preceding 1 to 3 weeks [5]. Both
sensitivity and specificity of serum fructosamine concentrations
for diagnosing diabetes mellitus in dogs are high, 0.93 and
0.95, respectively [6]. When serum fructosamine is increased,
it indicates poor glycemic control, but it does not identify the
underlying problem [1]. Some diabetic dogs and cats can have
normal serum fructosamine values, because in early diabetes
mellitus the duration or degree of elevated serum glucose
concentrations is insufficient to raise fructosamine values above
the reference range [7].
For all these reasons, serial blood glucose concentrations (BGCs)
are an excellent tool in evaluating the response of diabetic dogs
and cats to insulin therapy. But even more importantly, serial
BGCs allow identification of the cause of inadequate regulation.
The results of serial BGCs, together with history and clinical signs,
allow appropriate treatment adjustments to be made [1,2,8].
However, several factors can influence the results of serial BGCs
and, thus, the decisions made regarding insulin administration.

(1) Department of Medicine and Clinical Biology of Small Animals, Faculty of Veterinary Medicine, University of Ghent, Salisburylaan 133,
B-9820 Merelbeke. E-mail: Isabelvandemaele@hotmail.com
* Presented by SAVAB (Belgium)

179
 Retrospective study of owners perception of home monitoring of blood glucose in diabetic dogs and cats - I. Van de Maele

Most importantly, 24 hours of hospitalisation is required. During
the hospitalisation period, differences in the feeding schedules
and the amount of exercise of the diabetic pet often occur.
Also, stress due to an unfamiliar environment or repeated vein
punctures can lead to hyperglycemia, especially in cats [1].
Furthermore, serial BGCs are often time-consuming and costly
for the owner. For these reasons, BGCs are frequently performed
less often than required [9,10]. In humans, self-monitoring of
blood glucose (SMBG) was introduced in the late 1970s and is
now widely recommended in type I and II diabetic patients who
are pharmacologically treated [1113]. Self-monitoring of blood
glucose has been shown to result in better glycemic control in
humans [1416]. In accordance with human medicine, capillary
blood samples can be taken from the ear in pets [9,17,18] and
blood glucose concentrations measured using portable blood
glucose meters (PBGM) [19,20]. Most PBGMs require as little as
3-5 l of blood [21]. Since home monitoring of blood glucose
(HMBG) in pets is a fairly new procedure that has to be carried
out by the owner, the purpose of this study was to evaluate
retrospectively the practical feasibility and the major problems
encountered with HMBG in diabetic pets.
Materials and methods
All owners performing HMBG between November 2001 and
February 2003 were included in the study. Their dogs and
cats had been examined previously at the Department of
Medicine and Clinical Biology of Small Animals at the Faculty
of Veterinary Medicine, University of Ghent, Belgium, and
diagnosed with diabetes mellitus, based on the occurrence of
appropriate clinical symptoms (polyuria, polydipsia, polyphagia,
and weight loss), increased fasting serum glucose values, and
glucosuria.
A complete blood (cell) count (CBC), a serum biochemical
panel with serum fructosamine concentrations, and a urinalysis
with bacterial culture were performed as part of the routine
evaluation of diabetic patients. All pets received insulin s/c,
q12h, and individually adjusted dietary therapy.
The owners involved were educated on the treatment and
other aspects of diabetes mellitus at the first consultation.
They also received instruction on the optimal use of the PBGM.
The marginal ear vein technique was explained in detail and
the owners were allowed to practice this technique under our
supervision. The technique for HMBG most commonly taught to
the owners in our hospital is illustrated in Figure 1.
First, the required equipment (bandage roll, needle or lancet
device, PBGM, test strip, and gauze or cotton) is placed in close
proximity to the pet. Secondly, after localisation of the marginal
ear vein on the margins of the ear pinna and the creation of
a stable background with a hard cylindrical shaped object, the
vein is punctured with a needle or a lancet device. Thirdly, after
an adequate blood drop has formed, the PBGM is brought into
contact with the drop and blood is absorbed on the test strip in
the PBGM. Finally, while the PBGM is counting down for 30 s,
gauze is pressed against the puncture site to stop the bleeding,
if necessary.
Owners were advised to measure blood glucose concentrations
before the administration of insulin and then every 2 hours

Figure 1. Marginal ear vein technique. The marginal ear vein is easily recognised in dogs and cats. In longhaired pets, a small part of
the pinna can be shaved to obtain better visualization of the vein. A stable background is created with the use of a cylindrical shaped
object (bandage roll). The vein is punctured with a needle or a lancet device and a sufficient blood drop can be obtained. The use of alcohol
on the ear as a disinfectant is not advised because of the risk of dispersing the blood drop. A portable blood glucose meter (PBGM) is used to
measure blood glucose concentrations. The PBGM is fast (30 s) and easy to use, requiring as little as 3-5 l of blood. Afterwards pressure
is applied to the punctured area to avoid excessive bleeding.

180

for a 12 or 24 hour period. All blood glucose concentrations
were measured with PBGMs. Further controls and treatment
adjustments were planned according to the recommendations
made by the clinician.
A standard questionnaire was sent by mail to all owners
performing HMBG, after verbal approval was received by
telephone. Twenty-four questions were divided into 5 sections.
Each section contained a number of questions relating to the
following aspects: general information about the pet and the
pets illness; the technique used for the generation of serial
BGCs; the difficulties encountered during HMBG, initially and
subsequently; the reasons for reluctance to start HMBG initially;
and the perceived beneficial effects of HMBG by the owner for
their pet. A summary of the questionnaire is given in Table 1.
Table 2. Overview of the results concerning the major problems
encountered during home monitoring of blood glucose
Table 1. The standard questionnaire: summary
1/ General information about the pet and the pets illness
signalment
diagnosis of diabetes mellitus
treatment: type of insulin and dosage, diet, activity,
logbook
time between diagnosis and start of HMBG
any concurrent illness
2/ The technique used for generation of BGCs
type of PBGM, with lancet device or needle
number of BCGs
duration and time intervals of BCGs
preparation of the ear
3/ The difficulties encountered during HMBG when starting
and currently
resistance of the pet
restraining of the pet
need for more than 1 puncture due to the resistance
of the pet
creation of a blood drop
need for more than 1 puncture due to technical problems
formation of visible puncture sites due to local hemorrhage
absorption of blood on the test strip
need for more than 1 test strip
possible problems encountered with the PBGM
4/ The reasons for reluctance to start HMBG initially,
including insufficient clarity, insufficient guidance, the
responsibility, fear of hurting the pet, the complexity of
the technique, blood sampling, the use of the PBGM, the
costs, and the time required.
5/ The perceived beneficial effects of HMBG by the owner
communication with the veterinarian
evolution of the clinical signs
subjective beneficial effects
medical background or experience with diabetes mellitus
of the owner
any suggestions concerning HMBG
HMBG Home monitoring of blood glucose; BGC Blood
glucose concentrations; PBGM Portable blood glucose meter
181
EJCAP - Vol. 16 - Issue 2 October 2006
Results
General information about the pet and
the pets illness
Nine owners who were or had been performing HMBG between
2001 and 2003 were contacted. All 9 owners agreed to fill in the
questionnaire. Seven dogs between 7 and 14 years of age (mean
11 years) were included. The breeds represented were Fox Terrier,
Rottweiler, Keeshond, Border Collie, Golden Retriever, and mixed
breed (n = 2). All 5 female dogs were spayed and the 2 male
dogs were entire. Two female spayed cats, a Russian Blue aged
13 years and a mixed breed aged 15 years, were also included.
The time period between the diagnosis, the start of treatment
of diabetes mellitus, and the beginning of HMBG ranged from
1 month to 5 years (mean 14.5 months). The number of serial
BGCs performed per owner ranged from 1 to 8 (mean 4). All
pets were treated with insulin, s/c, q12h, at an individually
adjusted dose (initial starting dose 0.5 U/kg body weight [BW],
q12h). Eight pets received Caninsulin (Intervet, Boxmeer, the
Netherlands) and 1 cat received Mixtard 30/70 (Novo Nordisk,
Alphen aan den Rijn, the Netherlands). Three of the 5 female
dogs were spayed after diabetes mellitus had been diagnosed.
Both cats were spayed at young ages (1 and 2 y). Two dogs had
concurrent diseases. One dog had been diagnosed with primary
epilepsy several years before diabetes mellitus was diagnosed
and was treated with phenobarbital 0.5 mg/kg BW, q12h, and 1
female dog had a mammary gland tumor. Four of the 9 owners
kept a logbook of their pet.
The technique used for generation of BGCs
Slight differences in the technique were noted in comparison
with the technique described in Figure 1. These differences
consisted of a slightly different preparation of the ear, the
type of glucometer used, and the use of a lancet rather than a
needle. To prepare the ear, 4 owners shaved a part of the ear
for better visualisation of the marginal ear vein. Two owners
cleaned and dried the ear before puncturing it. One owner
applied gentle massage to the ear to achieve hyperemia. Most
owners used the Glucometer elite (Bayer, Antwerp, Belgium),
which is also the PBGM most commonly used in our hospital.
Three owners used 3 different PBGMs, Glucocard memory PC
(Menarini, Ricerche Sud, Pomezia, Italy), Gluco Touch (Johnson
and Johnson, Dilbeek, Belgium), and One Touch Basic (Johnson
and Johnson, Dilbeek, Belgium). Four owners used needles to
puncture the ear vein, 2 preferred to use the lancet enclosed
with the PBGM.
The protocol used for the generation of BGCs was adjusted to
suit the owner and the pet, mostly 24 hour curves were made
with measurement of blood glucose values every 2 hours during
daytime and every 2 to 3 hours at night. One owner performed
12 hour curves on occasion, namely, when the pet seemed
clinically well controlled. One owner always performed 12 hour
curves.
The difficulties encountered during HMBG initially and
subsequently
The difficulties encountered more than 50 percent of the time
with HMBG, initially, were the need for assistance in restraining
the pet (n = 4), the need for more than 1 puncture to obtain a
 Retrospective study of owners perception of home monitoring of blood glucose in diabetic dogs and cats - I. Van de Maele

Problems Never <50% of time >50% of time Always

At start Now At start Now At start Now At start Now
Resistance of the pet 5 5 1 1 1 0 1 2
Several punctures(a) 5 5 0 2 1 0 2 1
Extra person needed 4 5 0 0 0 0 4 3
Insufficient blood drop 3 3 3 3 3 1 0 0
Several punctures(b) 2 4 4 3 1 0 0 0
Visible puncture site 7 6 1 1 0 0 0 0
Absorption blood 4 5 3 2 1 0 0 0
Additional strip needed 2 3 6 5 1 0 0 0
Problems with use of glucometer 6 5 1 1 0 0 1 0

Table 2. The total of each problem does not always equal 9 because not all the questions were answered by all owners. For example, 1
owner performed only 1 blood glucose concentration (BGC) at home therefore the answers were considered to be in the beginning of home
monitoring of blood glucose (HMBG) and were not added to the now-column.
(a) Needed because of pet resistance
(b) Needed because of technical problems

blood drop due to pet resistance (n = 3), the creation of a blood
drop of sufficient size (n = 3), and the resistance of the pet (n =
2). Later, at the time the questionnaire was filled in by the owner,
3 owners had difficulties with the need for assistance, 2 owners
encountered resistance of the pet, 1 owner needed more than
1 puncture to obtain a blood drop due to pet resistance, and 1
encountered difficulties in creating a sufficient blood drop more
than 50 percent of the time.
Other difficulties were seen less than 50 percent of the time with
every blood glucose measurement. These included the need for
more than 1 test strip (n = 7 at start, n = 5 later), the need for
more than 1 puncture due to technical problems (n = 5 at start,
n = 3 later), and inadequate absorption of the blood drop (n =
4 at start, n = 2 later). A visible puncture site secondary to local
bleeding was seen in only 1 dog. These results are summarised
in Table 2.
Reasons for reluctance to start HMBG
The major reasons for the reluctance of the owners to start
HMBG, were the fear of hurting their pet (n = 5/9), taking a
blood sample themselves (n = 4/9), and the costs involved (n
= 4/9). Several owners also considered the complexity of the
technique (n = 3/9) and the fact that HMBG is time-consuming
(n = 3/9) to be drawbacks of the technique. On the other hand,
insufficient clarity about the technique or insufficient guidance,
the responsibility involved, or the use of the PBGM were not
considered to be obstacles to starting HMBG.
Subjective beneficial effects of HMBG
All owners believed HMBG helped in the glycemic control of their
pet. This belief was based on the improvement in the clinical
signs of the pet, the stability of the pets overall condition, and
the active participation of the owner in the management of his
pets illness. Despite these conclusions, 2 of the owners preferred
to have the serial BGCs performed by a veterinarian; both found
HMBG to be too time-consuming and 1 of them was also afraid
of hurting his pet too much.
Discussion
Self-monitoring of blood glucose concentration is considered
to be the most important step forward in the treatment of
diabetic humans since the discovery of and the treatment with
insulin [10]. In this retrospective study, all owners were able
to generate a blood glucose curve at home. A previous study
conducted in healthy pets showed that 7/7 owners and 3/7 cat
owners were able to generate a reliable blood glucose curve
[10]. Another recent study demonstrated that 10/12 owners
of diabetic dogs were able to perform blood glucose curves at
home [22]. Good communication and owner education were
essential in obtaining these results [10,22]. Also, in human
medicine, repeated educational sessions and proper patient
guidance were essential in obtaining improved glycemic control
in diabetic patients [11]. The fact that all owners in this study
were successful in completing a BGC at home was also due to
owner selection and motivation. The concept of HMBG was
only introduced at our hospital when the clinician judged that
treatment of diabetes mellitus was sufficiently understood by
the owner. Also, owners were able to refuse HMBG and these
pets were further evaluated in the hospital. Therefore, only
highly motivated owners interested in performing HMBG were
included in this study.
The need for assistance in restraining the pet was the problem
most frequently encountered. However, mostly only 1 extra
person was needed to keep the dog or the ear of the dog in
a fixed position to facilitate blood drop formation and blood
glucose measurement. A comparison between the results in
the beginning of HMBG and at the time the questionnaire was
filled in gives an indication of the fact that fewer problems were
encountered with increasing experience with the technique, in
keeping with previous studies [10,22].
Casella et al [22] reported that the problems initially encountered
with HMBG in diabetic dogs were the production of the
required negative pressure with the lancing device, the restraint
of the dog, the production of a blood drop, the absorption

182

of a blood drop, and the correct use of the test strips and the
PBGM. In their study, a different technique to obtain a blood
drop was described. An automatic lancing device that creates
negative pressure, (Microlet Vaculance, Bayer Diagnostics,
Zurich, Switzerland) was used to puncture the ear. Although
this technique was described as the best method in obtaining
capillary blood samples from the ear of a dog [10], it was also
responsible for most of the initial problems, including the fact
that too much pressure was applied on the outer pinna by the
owner, preventing the formation of an adequate blood drop.
In our study, owners were taught to puncture the marginal ear
vein, which can be identified visually in most dogs and cats.
This technique is similar to the one described by Thompson et al
[23]. Because it is a vein that is being punctured, a blood drop
forms quickly without the need for negative pressure. Therefore,
the most important problem concerning HMBG encountered
in other studies was avoided. The marginal ear vein technique
could represent a more accessible technique for owners. This
could positively influence the decision of the owner to start with
HMBG. In addition, the major problems initially encountered
with HMBG were the use of the PBGM and the test strips
[10,22]. In this study, 7 owners needed extra punctures due to
technical difficulties in the beginning of HMBG, but less than
50 percent of the time. This indicates that, although these
problems were frequently encountered, they did not represent
a major obstacle. In accordance with other studies [9,10], the
sites of blood collection were not painful and hardly visible. A
visible puncture site caused by local bleeding was recognised
after puncture in 1 dog (Keeshond).
It became increasingly difficult to measure reliable glucose
concentrations in 2 dogs (Keeshond and Fox Terrier), because
of increased resistance to the puncture. Both owners of these
dogs preferred to have the serial BGCs done by a veterinarian.
In contrast, both cat owners reported that their cats became
increasingly tolerant with time, especially when the punctures
were performed at a place freely chosen by the cat.
The limitations of this study are that is was a retrospective study
and different clinicians were involved in the follow-up of the
patients. This also explains the slight differences seen in the
technique used to perform HMBG and in the protocol used for
HMBG. The clinician was also responsible for making the initial
selection of owners. Only owners who were considered to be
accurately informed about all the aspects of diabetes mellitus
were selected to perform HMBG. The results of this study should
also be seen in light of the low case number. An additional fact
that could have influenced the results is that 3 owners had some
medical education: 1 owner was a non-practicing veterinarian
and 2 were veterinary students. Two owners had come in contact
with human diabetic patients in their home environment.
This study also identified some fields to which special attention
should be given in preparing an owner for HMBG. First, only
4/9 owners kept a logbook of their diabetic pet routinely.
Recommendations to keep written information about the pet,
including changes in appetite, attitude, body condition, water
intake, urination, and body weight, have been made previously
[1,5]. A logbook is a helpful tool in long-term follow-up of the
diabetic pet.
Secondly, good explanation concerning the PBGM and the test
strips, including maintenance and calibration, is important. Most
183
EJCAP - Vol. 16 - Issue 2 October 2006
PBGMs are delivered with information brochures concerning
maintenance and calibration. The owners should pay attention
to it and the veterinarian should go through the important issues
with the owner. Giving written handouts that cover all aspects
on HMBG serve as a guideline and allow the owner to read
through the procedure again.
Thirdly, when owners are performing HMBG, easy access to
veterinary consultation and advice should always be available.
Good education leads to better compliance and is associated
with improved metabolic control in human and veterinary
diabetic patients [10,16].
In diabetic dogs, serial blood glucose curves show significant
day-to-day variability. In the study of Fleeman et al [24],
significant differences in blood glucose measurements were
noted on 2 consecutive days when insulin dose and meals were
kept constant. Comparison of the BGCs obtained at day 1 with
those on day 2 led to the same recommendations regarding
insulin dose adjustment in only 57% of cases. This implies
important clinical implications, especially in well-controlled dogs.
Therefore, appropriate treatment adjustments should be based
on the results of serial BGCs, together with history and clinical
signs [1,2,12]. However, day-to-day variability of serial BGCs was
seen in a hospital environment with the same disadvantages as
discussed before, although special attention was paid to keep
the amount of food constant each day [24]. There are no studies
so far that have looked at this aspect in a home environment.
Human studies show that self-monitoring of blood glucose by
the diabetic patient is correlated with lower blood glycosylated
hemoglobin concentrations [15,16]. The effects of SMBG on
patient morbidity and mortality, however, have not yet been
evaluated. Few studies in dogs and cats have looked at this
aspect. Twenty-eight cats controlled with HMBG received higher
insulin doses compared with diabetic cats without HMBG,
but the difference was not statistically significant [25].
Therefore, further studies are needed to confirm that HMBG is
really effective in improving glycemic regulation in diabetic cats
and dogs.
One of the major problems encountered with SMBG in humans
is limited compliance with the technique [11]. The SMBG is an
invasive method. The fingertips of humans contain high numbers
of nerve endings and therefore repeated pricking is associated
with a painful sensation. Also, the cost to be paid by the patient
was an obstacle for good compliance. Only 1 veterinary study
has looked at compliance with HMBG in owners of diabetic cats
[25]. In this study, the long-term compliance with HMBG was
considered good and client binding was not altered. However,
identical obstacles to those in humans can be expected with
pets. Continuous glucose monitors have been developed for
use in human diabetics [26,27]. Minimally invasive glucose
sensors are placed on the skin and interstitial fluid glucose
concentrations are measured. Besides detecting fluctuations in
blood glucose over a prolonged period, these sensors do not
require repeated punctures. A continuous glucose monitoring
system was evaluated in 10 cats with diabetes mellitus [28].
Mostly the device was well tolerated and able to generate a
continuous glucose curve. However, stress hyperglycemia and
the working range of the monitor (between 2.2 to 22.2 mmol/L)
limited its practical use.
In conclusion, a slightly different technique to produce serial
 Retrospective study of owners perception of home monitoring of blood glucose in diabetic dogs and cats - I. Van de Maele
BCGs at home is described here. Also some fields requiring
special attention while applying HMBG are identified. For most
owners, HMBG is a feasible technique and is relatively easy to
perform, especially if adequate education of the owner by the
veterinarian is provided. Furthermore most pets seem to tolerate
it well. Therefore, it represents a useful tool in the follow-up of
diabetic pets.
Acknowledgments
The authors thank all owners involved in this study for their
collaboration without which this study would not have been
possible.
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[2] FLEEMAN (L.M.), RAND (J.S.) - Management of canine diabetes.
Vet Clin North Am Small Anim Pract 2001, 31: 855-879.
[3] BRIGGS (C.E.), NELSON (R.W.), FELDMAN (E.C.), ELLIOT (D.A.),
NEAL (L.A.) - Reliability of history and physical examination findings
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 ENDOCRINOLOGY

REPRINT PAPER (CH)

Diagnostic specificity of canine

thyrotropin in the diagnosis of
Hypothyroidism in dogs
F. S. Boretti(1), C. E. Reusch.(1)

SUMMARY

To determine whether measurement of canine thyrotropin (cTSH) would aid in the diagnosis of hypothyroidism,
serum samples of 65 dogs with clinical signs suggestive of hypothyroidism were evaluated. Diagnosis was confirmed
in 26 dogs and excluded in 39 dogs based on TSH-stimulation testing. Total thyroxine (T4) was significantly lower
and cTSH significantly higher in hypothyroid dogs compared to euthyroid dogs. Canine TSH was above
(> 0.6 ng/ml) in 15 (57.7%) and below the upper limit of the reference range in 11 (42.3%) of the hypothyroid dogs.
All of the euthyroid dogs had a cTSH < 0.6 ng/ml. In all dogs with a cTSH above the upper limit of the reference
range hypothyroidism could be confirmed. Therefore, our results show that measurement of cTSH has an excellent
specificity (100%) and is a valuable tool in confirming canine hypothyroidism. However, due to the low sensitivity
of cTSH assays (60%), it can not be recommended to exclude the disease.
Key words: thyrotropin - cTSH - thyroxine - hypothyroidism - dog

This paper originally appeared in:
Schweiz.Arch. Tierheilk* 2004 146(4) p 183-188
Introduction
Hypothyroidism is a common endocrine disorder in dogs most
often caused by idiopathic atrophy or immune-mediated
destruction of the thyroid gland (Feldman and Nelson, 1996).
Due to its non-specific clinical presentation the diagnosis can be
challenging for the clinician. Although low serum total thyroxine
(T4) concentrations are intuitively suggestive of hypothyroidism, it
must be considered that low T4 levels are frequently encountered
in euthyroid dogs with various non-thyroidal diseases and also
as a side effect of certain pharmacological agents (Nelson et al.,
1991; Miller et al., 1992; Gulikers and Panciera, 2002; Daminet
and Ferguson, 2003).
The increase in T4 after bovine TSH administration has been widely
used to estimate the functional status of the thyroid gland. The
TSH-stimulation test using bovine TSH is currently considered the
gold standard for the discrimination of true hypothyroidism from
other conditions with low T4 concentrations in dogs (Panciera,
1999). Unfortunately bovine TSH is not licensed for use in dogs
and is difficult and expensive to obtain. Furthermore, the test
is associated with considerable inconvenience and costs since
it requires hospitalisation of the animal and the collection of at
least two blood samples.
Determination of TSH levels in the circulation, which are expected
to be increased during states of low functional T4, has become
standard practice for the initial assessment of human patients
with suspected thyroid insufficiency (Ladenson, 1996). Within
the last few years, diagnostic test kits for measuring canine TSH
(cTSH) have become available in veterinary medicine. However,
studies from different countries revealed varying sensitivity and
specificity of these assays leading to controversial opinions
concerning their clinical value as a routine test for the assessment
of thyroid function (Peterson et al., 1997; Scott-Moncrieff et al.,
1998; Dixon and Mooney, 1999).
The aim of the present study was to evaluate cTSH as a first
line laboratory parameter for the diagnosis of hypothyroidism
in a population of 65 dogs with suspected hypothyroidism in
Switzerland.

(1) Clinic for Small Animal Internal Medicine Winterthurerstr. 260 CH-8057 Zurich. Corresponding Author E -mail: creusch@vetclinics.unizh.ch
* Presented by SVK/ASMPA (Switzerland)

185
 Diagnostic specificity of canine thyrotropin in the diagnosis of Hypothyroidism in dogs - F.S. Boretti
Animals, materials and methods
Case material and sample collection
The case material comprised a series of 65 dogs referred to the
Clinic for Small Animal Internal Medicine of the University of Zurich
between March 1996 and July 2002 for investigation of clinical
signs consistent with hypothyroidism. Dogs undergoing both
a TSH-stimulation test and determination of endogenous TSH
were included in the study. TSH-stimulation test was performed
by collecting blood samples (jugular venipuncture) immediately
before and 6 hours after the intramuscular injection of bovine
TSH (Thyrotropic Hormone, Sigma, St. Louis, MO) at a dose of 1
IU for dogs < 25 kg and 2 IU for dogs > 25 kg body weight.
After clot retraction, serum was harvested by centrifugation
and transferred to tubes for storage at 20 C for subsequent
hormone assay.
Hormone assays
Total T4 was measured by a commercially available radio-
immunoassay (canine DPC radioimmunoassay, Coat-A-Count,
Diagnostic Products Corp -DPC-, Los Angeles, CA). Serum
cTSH concentrations were determined by a homologous solid-
phase, two-site chemiluminescent enzyme immunometric assay
(Immulite canine TSH, DPC, Los Angeles, CA).
Case allocation
Dogs were classified as either euthyroid or hypothyroid based
on the results of the TSH-response test. Hypothyroidism was
defined as a post-TSH T4 of less than 1.6 g/dl or less than
1.5 times the basal concentration. Euthyroid was defined as a
post-TSH T4 > 2.5 g/dl and at least 1.5 times the basal
concentration. In dogs with a post-TSH T4 between 1.6 and 2.5
and an increase of at least 1.5 times the basal concentration,
additional criteria such as recovery from clinical signs without
the need for thyroid hormone supplementation were applied.
Statistical analyses
Data were analysed using SPSS (Statistical Package for the
Social Science, Software Package for Windows Version 11).
Ranges and median values are given. Correlations were tested
by Spearman Analysis. The Mann-Whitney-U-Test was used to
determine differences between groups. Values of P < 0.05 were
considered statistically significant.
Results
Case material
Hypothyroidism was confirmed in 26 dogs ranging from 2 to 14
years in age (median 7), comprising 10 female (7 neutered) and
16 male (6 neutered) dogs.
Euthyroidism was confirmed in 39 dogs ranging from 1 to 12
years (median 6), comprising 22 female (11 neutered) and 17
male (7 neutered) dogs.
No adverse reactions to bovine TSH administration were
recognized in any of the dogs.
Total T4
Median basal T4 concentration was significantly lower in
hypothyroid (median 0.25 g/dl, range 0.1-3.1) compared with
186
euthyroid dogs (median 1.7 g/dl, range 0.3-3.0) (Figure 1).
Of the 26 hypothyroid dogs, 18 (69.2%) had T4 concentrations
< 0.5 g/dl; 5 dogs (19.3%) between 0.5 and 1 g/dl and 3
dogs (11.5%) >1 g/dl. One of the 39 euthyroid dogs had a T4
concentration < 0.5 g/dl; 4 dogs (10.3%) between 0.5 and 1
g/dl; 11 dogs (28.2%) > 1.0 and <1.4 g/dl and 23 (59%) >
1.5 g/dl.
Post-TSH T4 values ranged from 0.1-3.4 g/dl (median 0.35)
in hypothyroid and from 1.7-7.3 g/dl (median 4) in euthyroid
dogs. Differences between the 2 groups were statistically
significant (p < 0.01).
One dog, which was referred because of episodical weakness,
had a basal T4 of 0.3 g/dl and a post-TSH T4 of 1.7 g/dl; the
signs resolved without supplementation of thyroxine. The low
T4 values of this dog were attributed to the fact that it was a
Greyhound, a breed known for low T4 concentrations, whereas
cTSH concentrations seem to be similar in Greyhounds and Non-
Greyhound breeds (Gaughan and Bruyette, 2001).
cTSH
Median serum cTSH concentration was significantly higher in
hypothyroid (median 0.94 ng/ml, range 0.03-19.3) compared
with euthyroid dogs (median 0.09 ng/ml, range 0.03-0.36)
(Figure 2), p < 0.01. Canine TSH was above the upper range of
the reference limit (> 0.6ng/ml) in 15 hypothyroid dogs (57.7%)
and within the reference range in 11 hypothyroid dogs (42.3%),
yielding a diagnostic sensitivity of 57.7%. All of the euthyroid
dogs had a cTSH < 0.6 ng/ml, diagnostic specificity 100%. Using
0.4 ng/ml as upper limit of the reference range the sensitivity
was 73% and the specificity remained unchanged 100%.
Correlation among hormone concentrations
When data for hypothyroid and euthyroid dogs were analysed, a
significant negative correlation was found between T4 and cTSH
concentrations (r = -0.34; Figure 3A) and between the difference
of post-TSH T4 and basal T4 and the cTSH (r = 0.5, Figure 3B).
Figure 1: Box plots of serum T4 concentrations in 26 hypothyroid
and 39 euthyroid dogs. The whiskers represent the 25th and 75th
percentile range with values outside this range being represented
by a dot. Differences between the two groups were statistically
significant; p<0.01.
3
2
(g/dl)
T4
1
0
Hypothyroid Euthyroid

Discussion
Determination of TSH concentration is routinely used in human
medicine for the diagnosis of thyroid dysfunction (Ladenson,
1996; Ridgway, 1996; Ladenson et al., 2000). TSH is expected
to be high as a consequence of the weakening negative thyroid-
pituitary feedback exerted by the failing thyroid gland.
In veterinary medicine only limited specificities of TSH for the
diagnosis of canine hypothyroidism have been shown (Peterson
et al., 1997; Scott-Moncrieff et al., 1998; Dixon and Mooney,
1999). Interestingly, and in contrast to these previous reports,
the diagnostic specificity of cTSH determination was excellent in
our study. None of the tested euthyroid dogs had elevated cTSH
levels even if the upper limit of the reference range was lowered
to 0.4 ng/ml. Several reasons may explain the different results
between our study and the results of earlier investigations.
Firstly, we did not evaluate severely ill dogs or animals with
concurrent medications known to affect serum cTSH levels. And
secondly, in our study the TSH- stimulation test was performed
by intramuscular injection of TSH and the doses used were
lower compared to earlier investigations (Peterson et al., 1997;
Scott-Moncrieff et al., 1998; Dixon and Mooney, 1999). To our
knowledge, the influence of the route of administration and
the dose of TSH, has not been investigated systematically. We
hypothesise, that the dose of TSH used may affect the diagnostic
accuracy of the stimulation test considerably. Higher doses of
injected TSH may lead to an overestimation of the functional
reserve of the failing thyroid gland and thus yield false negative
results in a significant fraction of animals with hypothyroidism
and elevated TSH levels. The term of subclinical hypothyroidism
has been introduced in human medicine to describe a condition
of mild or even absent clinical signs of thyroid dysfunction,
normal T4 concentration but consistently elevated levels of
endogenous TSH (Ladenson et al., 2000). A markedly reduced
functional reserve of the thyroid gland is suspected in these
cases.
However, it is important to appreciate that not every mild
elevation of TSH is consistent with reduced functional capacity of
the thyroid. Other causes of elevated TSH and normal levels of T4
that must be considered in the differential diagnosis, including
recovery from severe non thyroidal illness and the influence
of various medications for example long term administration
(more than 6 months) of phenobarbital to dogs has consistently
decreased T4 and led to an increased TSH (Gaskill et al., 1999;
Muller et al., 2000). In many of these conditions, the TSH
elevation is only transient.
Increased TSH concentrations are also described as an artefact
due to circulating heterophilic antibodies against TSH (Ward et
al., 1997; Ismail et al., 2002) or mutations causing inactivation
of the TSH receptor (Simanainen et al., 1999). The latter two
possibilities have not been described in dogs so far. Recovery
from non thyroidal disease and administration of sulphonamide
result in increased cTSH levels in otherwise euthyroid dogs
(Dixon and Mooney, 1999; Williamson et al., 2002). Thus,
it seems prudent to restrict application of the cTSH-assay to
animals without history of severe illness or medication known
to influence thyroid function. In dogs with an unknown history,
mild clinical signs of hypothyroidism and elevated cTSH, the
test should be repeated at a later time point after exclusion of
187
EJCAP - Vol. 16 - Issue 2 October 2006
20
19
4
cTSH (ng/ml)
3
2
1
0.6 ng/m
ng/ml
ml
m
0
Euthyroid
Hypothyroid
Figure 2: Box plots of serum cTSH in 26 hypothyroid and 39
euthyroid dogs. The upper limit of the reference range (0.06ng/ml)
is indicated by a horizontal dashed line. Differences between the
two groups were statistically significant; p<0.01.
confounding conditions. If TSH remains elevated consistently,
mild or even subclinical hypothyroidism should be considered.
In our study the sensitivity of cTSH was approximately 60% if a
reference limit of cTSH was set at 0.6 ng/ml, as suggested by the
manufacturer, and 73% if the upper limit of the reference range
was lowered to 0.4 ng/ml. Similar results ranging from 63-87%
were observed in other studies evaluating the value of cTSH
in diagnosing canine hypothyroidism (Peterson et al., 1997;
Scott-Moncrieff et al., 1998; Dixon and Mooney, 1999). Several
reasons have been suggested to explain the inappropriately low
cTSH concentrations in hypothyroid dogs. Significant circadian
and pulsatile variations in hypothalamic TSH secretion has been
demonstrated in euthyroid and hypothyroid humans (Greenspan
et al., 1986; Adriaanse et al., 1992). This could be confirmed in a
model of experimentally induced primary canine hypothyroidism
(Kooistra et al., 2000) and in a total of 6 adult dogs with naturally
developing hypothyroidism (Bruner et al., 1998). Thus it seems
unlikely to be the major reason for the limited sensitivity of cTSH
determination. Secondary hypothyroidism may be diagnosed
in a few hypothyroid dogs with low TSH. However, pituitary
failure is thought to occur only in about 5% of hypothyroid
dogs (Feldman and Nelson, 1996) and other signs of endocrine
dysfunction suggestive of pituitary disease are expected to lead
the diagnosis in these cases. Glucocorticoids have been shown
to suppress circulating TSH in both euthyroid and hypothyroid
people (Werner and Platman, 1965; Chopra et al., 1975) and
should thus be considered as a potential disruptive factor.
However, dogs with hyperadrenocorticism and high endogenous
glucocorticoid levels did not show altered cTSH concentrations
although T4 concentrations were low (Meij et al., 1997).
Controlled studies evaluating the influence of exogenously
administered glucocorticoids on cTSH in spontaneously occurring
hypothyroid dogs have not yet been performed. Severe illness
suppresses cTSH secretion in humans. None of our hypothyroid
dogs with very low levels of cTSH showed signs of an underlying
disease and none of these dogs had received medication during
 Diagnostic specificity of canine thyrotropin in the diagnosis of Hypothyroidism in dogs - F.S. Boretti

A B

20 20
Euthyroid
Hypothyroid
4 4

3 3

2 2
cTSH (ng/ml)

cTSH (ng/ml)
1 1

0 0
0 1 2 3 4 0 1 2 3 4 5

T4 (g/dl) Difference between Post-TSH-T4 and T4

Figure 3A: Scatterplot of serum T4 and cTSH concentrations for 26 hypothyroid (Red triangles) and 39 euthyroid dogs (Black circles).
The upper limit of the cTSH reference range (0.06ng/ml) is indicated by a horizontal dashed line (coefficient of correlation: r= -0.34).
B: Scatterplot of the difference between post-TSH-T4 and T4 value and cTSH for 26 hypothyroid and 39 euthyroid dogs (see figure 3A
for key) (coefficient of correlation: r=0.5).

or up to 4 weeks before presentation; thus these factors seem an
unlikely explanation for the low cTSH concentrations observed
in our dogs. A commonly proposed explanation for the low
sensitivity of cTSH is that the currently used cTSH assays fail to
recognize all isoforms of the protein due to significant variations
in their respective antigenic sites. Although not definitely proven,
this seems a likely reason for a significant proportion of false
negative test results in our study.
Conclusions
Determination of cTSH may be an attractive alternative for the
diagnosis of canine hypothyroidism. However, considerable
experience and knowledge of potential confounding factors is a
prerequisite for its use in practice. Due to the limited sensitivity
of the currently available TSH assays normal TSH concentrations
could not exclude the presence of hypothyroidism in our
population. However, development of novel assays with a higher
susceptibility to immunologically different cTSH isoforms might
further increase the accuracy of cTSH determination.
Acknowledgement
We thank Dr. J. Norman Flynn, University of Glasgow for critically
reading the manuscript.
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 ENDOCRINOLOGY

REPRINT PAPER (E)

Bilateral adrenalectomy in a ferret

(Mustela putorius furo) with
hyperadrenocorticism
J. Martorell(1) , Y. Espada(1), A Ramis(1)

SUMMARY

This case reports a 6-year-old spayed ferret with a history of severe generalized alopecia that began in spring.
The ferret had the same clinical signs two years before, but the problem resolved spontaneously in autumn.
Alopecia is a common sign during the breeding season, but in contrast, it must be considered abnormal in a
spayed female. Abdominal ultrasonography revealed that both adrenal glands were enlarged, suggesting a
process of hyperadrenocorticism. Both adrenal glands were surgically removed. The histopathological diagnosis
of both glands was adrenocortical adenoma. The animal received glucocorticoid treatment for one week following
surgery. Several examinations revealed that the hair had grown, and electrolyte levels were checked to rule out an
hypoadrenocorticism. Sodium and potassium levels were within normal values. These results suggested this ferret had
some accessory adrenal tissue, although it could not be identified by ultrasonography.
Key words: hyperadrenocorticism, bilateral adrenalectomy, ferret

effect [8]. Surgery is considered the treatment of choice for

This paper originally appeared in:
Clin.Vet. Peq. Anim.*, 25(3) 2005 p173-177
Introduction
Hyperadrenocorticism has been reported as a common endocrine
disease affecting middle-aged to older pet ferrets of either
sex and is usually reported in neutered animals [1, 2, 3]. It is
characterized by alopecia in both sexes and vulvar enlargement
in female ferrets [1]. While the underlying causes of the disease
are unknown, it has been proposed that the effect of premature
neutering [4, 5], the diet and the effect of longer light cycles at
home may play a role [1].
In ferrets, hyperadrenocorticism is not called Cushings disease;
clinical signs are due to an elevation of plasma sex steroid levels,
and serum cortisol concentrations are rarely elevated [1]. The
diagnostic tests used in dogs for this disease are not helpful
with ferrets. Clinical signs, ultrasonography findings and plasma
sex steroid concentrations are used to diagnose this disease in
ferrets [6, 7].
Although several medications have been recommended,
they are not the definitive treatment due to their short term
hyperadrenocorticism in ferrets. Unilateral adrenalectomy or
subtotal bilateral adrenalectomy have both been recommen-
ded [9-15]. Total bilateral adrenalectomy has been performed
in a ferret with hyperadrenocorticism, but no post-operative
electrolytes levels were measured to rule out a mineralocorticoid
deficit [16].
Clinical case
A 6-year-old spayed female ferret with a history of apathy and
severe generalized alopecia that began in spring was examined
at the Veterinary Teaching Hospital in August. The ferret lived
alone in, a wire cage, was fed with a commercial ferret formula
and had free access to water.
The ferret had presented with the same clinical signs two years
before, when the animal weighed 810 g and the dermatological
examinations were not conclusive. The problem resolved
spontaneously in autumn.
The examination revealed that the animal was obese and
weighed 1022 g, and had a severe generalized alopecia with
scaly dermatitis (Fig.1) It was estimated to be suffering from
10% dehydration. Dermatological examinations for fungi and

(1) Departament de Medicina i Cirurgia Animal, Facultat de Veterinria Universitat Autnoma de Barcelona, E- 08193 Bellaterra, Barcelona.
E-mail :jaumemiquel.martorell@uab.es
* Presented by AVEPA (Spain)

191
 Bilateral adrenalectomy in a ferret (Mustela putorius furo) with hyperadrenocorticism J. Martorell, Y. Espada, A Ramis
Fig.1. Obese ferret showing a severe generalized alopecia.
parasites were negative. Blood analysis revealed anaemia (8.2 x
106 rbc/ l), lymphopenia (4%), and high levels of urea (50.5 mg/
dl) and total proteins (7.6 mg/dl). On ultrasound examination,
both adrenal glands were enlarged, the right one measured 8.3
x 6.1 mm and the left one measured 8.3 x 6.3 mm (Fig. 2 and 3).
A provisional diagnosis of hyperadrenocorticism was established
based on clinical signs and ultrasonography .
Supportive therapy consisted of enrofloxacine (Baytril; Bayer
S.A., Barcelona, Spain) at 5 mg/kg/bid SC and Ringers lactated
solution at 80 ml/kg/day through an intraosseus catheter placed
in the right femur. The next day bilateral laparotomies and an
adrenalectomies were performed.
The ferret was anaesthetized using buprenorphine (Buprex
inyectable 0.3 mg, Schering-Plough S.A., Madrid, Spain)
0.02mg/kg sc, and ketamine (Imalgene 1000, Merial Lab
S.A, Barcelona, Spain) 20 mg/kg im. After induction with 3%
isofluorane (Isoflurano Inibsa, Rhodia Organigne Fine LTD,
Bristol, United Kingdom) and 1 L/min oxygen by face mask,
anaesthesia was maintained with 2% isofluorane.
The surgical area was prepared with chlorhexidine scrub
(Hibimax, Mab Dental S.A., Barcelona, Spain) and a left lateral
laparotomy was performed as previously described in cats
and dogs. Liver, pancreas and mesenteric lymph nodes were
examined and no abnormalities were observed. The left adrenal
gland was located craniomedially to the left kidney, near to the
left adrenolumbar vein. Excision was performed by dissecting
the adrenal gland free of the fat. The dissection revealed that
the adrenal gland was enlarged. Haemorrhage was controlled
with two haemostatic clips placed medial and lateral to the
left adrenal gland. Muscular and subcutis layers were closed
separately using a continuous suture pattern, and the skin was
closed using an interrupted suture pattern. All layers were closed
using a 3-0 polyglactin 910 (Vycril Ethicon, Jonson & Jonson,
St-Stevens-Woluwe, Belgium).
A right lateral laparotomy was performed to remove the right
adrenal gland as previously described for the left gland. An
192
Fig.2 . Ultrasound image of the enlarged right adrenal gland.
incision of the hepatic-renal ligament allowed us to retract the
hepatic right lobe cranially and the enlarged right adrenal gland
was identified. It was attached to the vena cava. Haemostasis was
achieved by placing three haemostatic clips between the right
adrenal gland and the vena cava. After completing the dissection,
the gland was removed and an absorbable gelatine sponge
(Gelfoam, Pharmacia Upjohn, Kalamazoo, Mich. USA) was
placed where the vena cava was incised. The lateral abdominal
layers and the skin were closed as described previously.
At the end of the surgery, dexamethasone (Resdex Schering-
Plough, S.A. San Agustn de Guadalix, Madrid, Spain) was
administered at 1 mg/kg/im.
Fluids, analgesia and antibiotics were administered for 24 hours
following surgery. The ferret was discharged next day with
oral enrofloxacine and prednisolone (Estilsona, Astra Ifesa, A
Corua, Spain) at dose of 0.1 mg/kg/PO.
The histopathological diagnosis of both glands was adrenocortical
adenoma.
The ferret was checked five days later. It had a decreased appetite,
its weight was 909 g and there was green mucus in the stool.
Oral prednisolone was discontinued and a sucralfate (Urbal
suspensin, Merck Farma y Qumica, S.A. Mollet del Valls,
Barcelona, Spain) at dose of 25 mg/kg/8h/PO was administered.
A haematological examination revealed no abnormalilies.
Three weeks after surgery the ferret was bright and alert,
weighted 830 g, and blood examination results were within the
reference ranges.
One month and a half after surgery, the hair was regrowing,
although less on the tail and the back area. The serum sodium
and potassium concentrations were 143 mmol/l and 4.8 mmol/l
respectively, within the reference ranges, and the Na/K ratio
was 29.8. Two months later, the fur continued growing, mainly
on the anterior part of the body (Fig. 4) and serum electrolyte
concentrations were within the reference ranges: sodium 146
mmol/l, potassium 4.3 mmol/, Na/K ratio 33.9.

Fig.3 . Ultrasound image of the enlarged left adrenal gland.
Discussion
Hyperadrenocorticism is one of the diseases to be included in
the differential diagnosis of bilateral symmetrical generalized
alopecia in any ferret [1-4].
The underlying causes of adrenal gland disease in ferrets are
unknown, but it is thought that the effect of premature neutering
[4, 5], the diet and the effect of longer light cycle at home may
have a role [1]. During embryological development, ovaries and
adrenal glands develop in close anatomic relationship. Some
undifferentiated gonadal cells may migrate to the adrenal gland
capsule. With proper stimulation, such as longer photoperiod
or early gonadectomy, there would be an increase in GnRH
production by the hypothalamus which because of its effects on
the pituitary gland, would cause a release of LH and FSH which,
in turn, would constantly stimulate the adrenal glands. It would
cause the development of a nodular adrenal gland hyperplasia
or a tumour in one or both adrenal glands that would lead to
an over production of sexual hormones, as has been observed
in mice [1, 2, 6].
Alopecia is the most common clinical sign seen in ferrets [17]
and begins on the tail, ventrum and dorsum. The hair can be
easily epilated and the skin becomes hyperkeratotic and less
elastic. Hair loss happens seasonally, close to spring, and hair
can regrow occasionally during the fall [1, 18]. Pruritus [6, 9],
polyuria and polydipsia [2, 6] are the other reported clinical
sings.
Vulvar enlargement and mucoid discharge can be observed in
females [1, 6]. Obesity could have masked the vulvar enlargement
in the case described. Hyperadrenocorticism is associated with
a nonregenarative anaemia caused by excessive amounts of
oestrogens [1, 17]. Severe anaemia was observed in this ferret
and it was a determining factor in deciding to perform surgery.
Dysuria due to prostatic hyperplasia can be observed in males
because of androgen production [1, 3].
193
EJCAP - Vol. 16 - Issue 2 October 2006
Fig 4 . Ferret three months after surgery. Hair growth is evident.
The provisional diagnosis of adrenal gland disease is based
on history and clinical signs [1, 17]. The enlarged adrenal
gland can be palpated in some cases, but imaging diagnostics
such ultrasonography and laparotomy will confirm the gland
enlargement [1, 7].
Adrenocorticotropic hormone stimulation test or serum cortisol
levels cannot be used to diagnose an adrenocortical disease
in ferrets; but some ferrets can show an elevated urinary
cortisol/creatinine ratio during the breeding season [19, 20].
The measurement of sexual steroids will reveal an increase of
androstenedione, dehydroepiandrosterone sulphate, 17 -
oestradiol and 17-hydroxyprogesterone [1, 5, 18]. No hormone
steroid blood determination or urine analysis was performed in
the case we describe, and the diagnosis was based on clinical
signs and the ultrasound examination.
Adrenal ultrasonography consists in measuring the length and
the width of the gland. The presence of hyperechoic fat helps
in distinguishing the adrenal glands as hypoechoic structures.
The use of a 7.5 MHz and 11 MHz electronic transducer is
recommended to perform a successful ultrasound examination
in ferrets. The width measurement reveals an enlargement of
the glands in ferrets with hyperadrenocorticism, where the
glands have a rounded appearance [22], as happened in the
case described.
Although ultrasonography may help to diagnose
hyperadrenocorticism in ferrets [7, 21] some authors do not
recommend its use in apparently healthy patients [22].
Several medications have been recommended for the treatment
of this disease: mitotane to destroy cells of the adrenal cortex;
leuprolide acetate, a synthetic analogue of GnRH to inhibit
its secretion; melatonin to suppress prolactin and sex steroids
production; tamoxifen and anastrazole as oestrogen blockers;
flutamide and finasteride as testosterone blockers, but surgery
is the definitive method of treatment for hyperadrenocorticism
in ferrets [8, 23-25].
 Bilateral adrenalectomy in a ferret (Mustela putorius furo) with hyperadrenocorticism J. Martorell Y. Espada, A Ramis
A ventral midline abdominal approach has been recommended,
but two lateral approaches were performed in the case described
due to the obesity of the ferret. Usually, there is only one
affected gland, frequently the left adrenal gland. Several studies
describe a bilateral condition in 16 to 68% of the cases [10].
In animals with bilateral disease, the recommended treatment
consists of a unilateral adrenalectomy plus a hemiadrenalectomy
of the remaining adrenal gland [10, 12] or a bilateral complete
adrenalectomy [16]. Complete excision of the left gland and
partial excision of the right gland is usually performed, but
some authors recommend the excision of right gland due to the
proximity to liver and vena cava and avoidance of invasion or
metastases [13].
A venotomy is indicated if adrenal tumour invades the vena
cava. Ligation of the vena cava is not recommended because of
the lack of studies of its effects [3].
It is important to examine the abdominal organs for possible
concurrent abnormalities, such as insulinoma [1], lymphoma [3,
10], heart disease [10, 24] or mammary hyperplasia [25].
Electrolytes levels need to be checked post-operatively to avoid
hypoadrenocorticism, especially if bilateral adrenalectomy has
been performed. Glucocorticoids can be supplemented after
surgery. In one study with total adrenalectomized ferrets, 0.9%
saline was given for drinking water, but electrolytes levels were
not measured [3, 16].
In one study, an accessory adrenal gland was found in 38% of
the ferrets [22]. This accessory tissue explained why electrolytes
levels were within reference range after a total bilateral
adrenalectomy, as in the case described above.
Adenoma is the most common histopathological diagnosis, but
nodular hyperplasia and adrenocortical carcinoma have also
been described [6]. Metastasis is rare, but some tumours can
invade the liver or the vena cava [3].
References
[1] QUESENBERRY (K.E.), ROSENTHAL (K.L.) - Endocrine Diseases. In
Quesenberry KE, Carpenter JW (ed): Ferrets, Rabbits and Rodents
Clinical Medicine and Surgery. Second Edition. Philadelphia, W.B.
Saunders, 2004; 79-90
[2] LEWINGTON (J.H.) - Endocrine diseases. In Lewington JH (ed):
Ferret husbandry, medicine & surgery. Edinburgh, Butterwort
Heineman 2003; 211-222
[3] WHEELER (J.), BENNET (R.A.) - Ferret Abdominal Surgical
Procedures. Part I. Adrenal Gland and Pancreatic Beta-Cell Tumors.
Comp Cont Educ Pract 1999; 21(9): 815-822
[4] SHOEMAKER (N.J.), SCHUURMANS (M.), MOORMAN (H.), LUMEIJ
(J.T.) - Correlation between age at neutering and age at onset
of hyperadrenocorticism in ferrets. J Am Vet Med Assoc 2000;
216(2): 195-197
[5] ROSENTHAL (K.L.), PETERSON (M.E.) - Evaluation of plasma
androgen and estrogen concentrations in ferret with
hyperadrenocorticism. J Am Vet Med Assoc 1996; 209(6): 1097-
1102
[6] ROSENTHAL (K.L.), PETERSON (M.E.), QUESENBERRY (K.E.),
HYLLER (E.V.), BEEBER (N.L.), MOROFF (S.D.), LOTHROP
(C.D.) - Hyperadrenocorticism associated with adrenocortical
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tumor or adrenal gland in ferrets: 50 cases (1987- 1991)
J AM VET MED ASSOC 1993; 203: 271-275
[7] ACKERMANN (J.), CARPENTER (J.W.), GODSHALK (C.P.), HARMS
(C.A.) - Ultrasonographic detection of adrenal gland tumors in
two ferrets. J Am Vet Med Assoc 1994; 205(7): 1001-1003
[8] JOHNSON-DELANEY (C.) - Medical therapies for ferret adrenal
disease. Sem Avian Exot Pet Med 2004; 13(1): 3-7
[9] LAWRENCE HJ, GOULD WJ, FLANDERS JA, ROWLAND P, YEAGER
AE - Unilateral adrenalectomy as a treatment of adrenocortical
tumors in ferrets: Five cases (1990-1992) J Am Vet Med Assoc
1993; 203: 267-270
[10] WEISS (C.A.), SCOTT (M.V.) - Clinical aspects and surgical treatment
of hyperadrenocorticism in the domestic ferret: 94 cases (1994-
1996). J Am Anim Hosp Assoc 1997; 33(6): 487- 493
[11] MULLEN (H.) - Soft Tissue Surgery. In: Hiller EV, Quesenberry KE
(ed) Ferrets, Rabbits and Rodents Clinical Medicine and Surgery.
Philadelphia, W.B. Saunders, 1997; 131-144
[12] WEISS (C.A.), WILLIAMS (B.H.), SCOTT (J.B.), SCOTT (M.V.) -
Surgical treatment and long-term outcome of ferrets with bilateral
adrenal tumors or adrenal hyperplasia: 56 cases (1994-1997). J
Am Vet Med Assoc 1999; 215(6): 850-823
[13] BEEBER (N.L.) - Abdominal Surgery in Ferrets. In: Bennet RA
(ed) Vet Clin North Am Exotic Anim Pract. Soft-Tissue Surgery.
Philadelphia, W.B. Saunders, 2000; 3(3): 647-662
[14] BENNET (R.A.), GEOFFREY (W.P.) - General Surgery. In: LEWINGTON
(J.H.) (ed) - Ferret husbandry, medicine & surgery. Edinburgh,
Butterwort Heineman 2003; 240- 250
[15] LUDWING (L.), AIKEN (S.) - Soft Tissue Surgery. In: QUESENBERRY
(K.E.), CARPENTER (J.W.) (ed) - Ferrets, Rabbits and Rodents
Clinical Medicine and Surgery. Second Edition. Philadelphia, W.B.
Saunders, 2004; 121-134
[16] FILION (D.L.), HOAR (R.M.) - Adrenalectomy in the ferret. Lab Anim
Sci 1985; 35(3): 294-295
[17] KELLEHER (S.A.) - Skin disesases of ferrets. En: SCHMIDT (R.E.) (ed)
- Vet Clin North Am Exotic Anim Pract. Dermatology. Philadelphia,
W.B. Saunders, 2001; 4(2): 565-572
[18] LIPMAN (N.S.), MARINI (R.P.), MURPHY (J.C.), ZHIBO (Z.), FOX (J.G.)
- Estradiol-17B-secreting adrenocortical tumor in a ferret. J Am Vet
Med Assoc 1993; 203 (11): 1552-1554
[19] GOULD (W.J.), REIMERS (T.J.), BELL (J.A.), LAWRENCE (H.J.),
RANDOLPH (J.F.), ROWLAND (P.H.), SCARLETT (J.M.) - Evaluation
of urinary cortisol: creatinina ratios for the diagnosis of
hyperadrenocorticism associated with adrenal gland tumors in
[20]
ferret. J Am Vet Med Assoc 1995; 206(1): 42-46
SHOEMAKER (N.J.), WOLFSWINKEL (J.), MOL (J.A.), VOORHOUT
(G.), KIK (M.J.L.), LUMEIJ (J.T.), RIJNBERK (A.) - Urinary
glucocorticoid excretion in the diagnosis of hyperadrenocorticism
in ferrets. Domestic Animal Endocrinology 2004; 27: 13-24
[21] BARTHEZ (P.Y.), NYLAND (T.G.), FELDMAN (E.C.) - Ultrasonography
of the adrenal glands in the dog, cat and ferret. Vet Clin North Am
Small Anim Pract 1998; 28(4): 869-895
[22] NEUWIRTH (L.), COLLINS (B.), CALDERWOOD-MAYS (M.), TRAN
(T.) - Adrenal ultrasonography correlated with histopathology in
ferrets. Vet Radiol Ultrasound 1997; 38(1): 69-74
[23] WAGNER (R.A.), BAILEY (E.M.), SCHNEIDER (J.F.), OLIVER (J.W.) -
Leuprolide acetate treatment of adrenocortical disease in ferrets. J
Am Vet Med Assoc 2001; 218(8): 1272- 1274
[24] FOX (J.G.), GOAD (M.E.), GARIBALDI (B.A.), WIEST (L.M.J.R.)
- Hyperadrenocorticism in a ferret. J Am Vet Med Assoc 1987;
191(3): 343-344
[25] MOR (N.), QUALLS (C.W.J.R.), HOOVER (J.P.) - Concurrent
mammary gland hyperplasia and adrenocortical carcinoma in a
domestic ferret. J Am Vet Med Assoc 1992; 201(12): 1911-1912
 URINOGENITAL SYSTEM

ORIGINAL WORK (N)

Treatment of pyometra in the bitch:

A survey among Norwegian small
animal practitioners
V. Rootwelt-Andersen(1), W. Farstad(1)

SUMMARY

A multiple-choice questionnaire concerning the treatment of pyometra in the bitch was sent to 130 Norwegian small
animal practitioners. The response rate was 88%. In terms of treatment choices, there was no difference between
male and female veterinarians, and no difference between veterinarians working part-time alone compared with
veterinarians working full-time with 3 or more colleagues. In pyometra with a closed cervix, 98% considered surgery
to be the primary treatment. In pyometra cases with an open cervix, 80% of the practitioners considered surgery to be
the primary treatment. When surgery was performed, 100% of the practitioners removed the uterus, 98% also removed
the ovaries. Antibiotics were prescribed by 99% and fluids adminsterd by 98%. When medical treatment was chosen,
99% of the practitioners gave antibiotics, 50% gave prostaglandins and 26% supplemented with fluids. Only 8% of
practitioners used other treatments such as aglepristone, cabergoline or methylergometrine maleate. The survival rate
of surgical therapy was reported to be 96%. The survival rate of medical therapy was reported to be 74% on a short
term basis and the prognosis on a long term basis with respect to future breeding potential was reported to be 37%.
In the treatment of pyometra in the bitch, the authors conclude that from the experience of Norwegian small animal
practitioners, ovariohysterectomy combined with antibiotics and fluids is favoured to medical therapy as described in
this study.
Key words: canine, pyometra, treatment

Introduction
Pyometra is the most severe stage of the canine Cystic
Endometrial Hyperplasia Complex and predominantly develops
in the metoestrus phase of the cycle of the mature intact bitch
[4, 9, 12]. Pyometra is common. An incidence of 24% before
10 years of age has been reported [9].
Early neutering prevents pyometra, but in Norway routine
neutering of dogs is prohibited according to the Animal Welfare
Act (1974) [13]. Neutering is only allowed for medical reasons,
or in dogs in official service. Therefore, most bitches are left
intact throughout their lifetime. Different treatment protocols
have been described. Ovariohysterectomy (OHE) is generally
recommended as the treatment of choice. Ovariectomy or
drainage of the uterine exudate are other less documented
alternatives [5, 7, 11]. Where breeding potential is considered
important, several medical protocols are described [2, 6, 8, 10,
14]. Optimal treatment requires correct diagnosis with adequate
assessment of the severity of the condition. Factors critical for Fig.1 . Lethargic Beagle bitch with distended abdomen due to
the success of treatment include: termination of the effect of pyometra.

(1) Department of Production Animal Clinical Science, Norwegian School of Veterinary Sciences, PO Box 8146, Dep., N-0033 Oslo,
E-Mail of corresponding author: rootwelt@online.no

195
 Treatment of pyometra in the bitch: A survey among Norwegian small animal practitioners - V. Rootwelt-Andersen
Fig.2 . Hyperechoic circular structures on ultrasonography are
typically seen in pyometra.
endogenous progesterone on the uterus, complete evacuation
of pus from the uterus, and re-establishment of extra-uterine
organ functions [3].
The aim of this study was to survey the methods used by
Norwegian small animal practitioners to treat pyometra in the
bitch, and the outcome of the treatment.
Materials and methods
In 2003, 130 questionnaires were sent to Norwegian small animal
practitioners. These practitioners included the small animal clinic
at the Norwegian School of Veterinary Science (n=1), all small
animal clinics approved by the Norwegian Veterinary Association
(n=13), all small animal specialists approved by the Department
of Agriculture (n=16) and a random sample of members of the
Society for Small Animal Practising Veterinarians (n=100). In an
accompanying letter, the veterinarians were informed about the
purpose of the survey. The questionnaire was divided into five
main parts: Part A General information about the veterinary
practice and the veterinarian; Part B What do you consider
to be the best treatment of pyometra in bitches, and what is
actually done in your own practice; Part C Factors influencing
treatment choices; Part D Treatment performed and Part
E Estimated post-treatment prognosis based on personal
clinical experience. The questions were answered by selecting
appropriate alternatives in the questionnaire, or by supplying
short written answers on indicated lines.
The definition of pyometra in the presented survey was based
solely on clinical examination: Enlargement of the uterus after
oestrus in the unmated bitch, with or without vulval discharge,
and with a variable degree of depression of general clinical
condition.
The statistical analysis of the results was performed using
a Student t-test and chi-square-test in the SPSS, 10.0 for
Windows 2001. A Fisher exact test was also applied. The level
of significance selected was p<0.05.
Results
Two questionnaires were returned due to unknown addresses.
Of the remaining 128, 65% of the practitioners responded
196
promptly and after one telephone reminder, 116 questionnaires
were returned (91%). Four veterinarians were no longer in
veterinary practice and did not complete the questionnaire.
Thus, the final response rate was 88 %.
The majority of the responders, i.e. 47.3%, reported that they
diagnosed and treated pyometra 1-4 times per month. In
pyometra cases with a closed cervix, 98% of the practitioners
considered surgery to be the treatment of choice. None of the
responding practitioners considered medical treatment to be the
first choice, but 2% answered that clinical findings should be
decisive. In pyometra cases with an open cervix, 80% of the
responding practitioners considered surgery as the treatment
of choice. Medical treatment was considered to be the best
treatment by 8% of the practitioners, and 12% replied that the
type of treatment should be selected based on clinical findings.
The main reason for preferring surgery as the treatment of
first choice was prevention of disease recurrence. There was
a discrepancy between the percentage of veterinarians who
considered surgery to be the treatment of choice, and surgery
actually performed. Only 59% of the practitioners performed
OHE in 80% or more of the pyometra cases when open and
closed pyometra were considered as one group. The average
percentage of OHE performed was estimated to be 73%.
Several factors concerning the bitch and the owner influenced
the final choice of treatment. These factors are shown in Table 1.
When surgical treatment was chosen, 100% of the practitioners
removed the uterus and 98% also removed the ovaries. A total
of 99% of the practitioners instituted antibiotic treatment
and 98% gave fluid therapy. When medical treatment was
Table 1: Factors influencing Norwegian small animal practitioners
in their choice of treatment of pyometra and percentage of
veterinarians who takes this into consideration.
General health 87%
Breeding status 56%
Owner`s capability to pay 50%
Open/closed cervix 47%
Expected prognosis 46%
Ethics 32%
Age 15%
Possibility to carry through 14%
given, 99% of the practitioners gave antibiotics, 50% gave
prostaglandins and 26% supplemented with fluid therapy. Only
8% gave other medication, such as aglepristone (Alizin; Virbac)
cabergoline (Galastop vet; Vetem) or methylergometrine
maleate (Methergine; Novartis). The mean survival rate when
bitches were treated surgically was reported to be 96%. The
mean survival rate when medical treatment was instituted was
reported to be 74% on a short-term basis (through the affected
cycle). The prognosis for medical therapy on a long-term basis
with respect to future breeding potential was reported to be
 EJCAP - Vol. 16 - Issue 2 October 2006

37%. The difference in prognosis between those who received

prostaglandins and those who did not, was not statistically
significant, either on short- or long-term basis (Fisher exact test,
p = 0.28 and p = 0.82). However, only 76% of the responders
estimated the prognosis on short term basis and 69% estimated
the prognosis on long term basis. The reason stated for not
giving a prognosis was limited personal experience with medical
treatment. There was no significant difference between male
and female veterinarians concerning prevalence of electing
surgery as treatment of first choice, and likewise there was
no difference between veterinarians who worked part-time
alone and veterinarians who worked full-time with 3 or more
colleagues.

Discussion
Surgery was considered the best treatment of pyometra with
either an open or a closed cervix. The most common reason given
for surgical treatment was prevention of disease recurrence.
When surgery was chosen, all removed the uterus and almost all
also removed the ovaries. Removal of the ovaries, in addition to
the uterus, may be due to the fear of a recurring inflammation
in the remaining part of the cervical stump if the ovaries were
not removed, or that the owners did not want the bitch to have
oestrus symptoms. The reason for some leaving the ovaries
behind, on the other hand, may be to avoid undesired side
effects of neutering caused by removal of the ovarian source of
oestrogens [5, 11].
The high percentage of the veterinarians who considered
surgery to be the best treatment of pyometra in the bitch is in
accordance with recommendations in the literature [5, 7, 11].
However, this study revealed a discrepancy between the high
number of practitioners who consider surgery as the treatment
of choice, and how often surgery was actually performed.
Different considerations concerning the bitch and its owner
might be reasons for this discrepancy. The bitchs general
health influenced the choice of treatment in almost 90% of
cases, whereas the age of the bitch surprisingly only influenced
the decision in 15% of cases. Breeding status is a factor that
naturally is of importance for the choice of treatment, as well
as expected prognosis. However, the percentage of practitioners
who attached importance to these factors was only around
50%. Also, the presense of an open versus a closed cervix, and
the owners ability and willingness to pay for the procedure
influenced the choice of treatment in approximately one half
of the cases. If one takes into consideration the relatively
few veterinarians who administered treatments other than
antibiotics when medical treatment was instituted, medical
treatment emerges as a cheaper treatment than surgery. This
would change if newer regimes of medical treatment had been
instituted. Therefore, in cases with more intensive medical
therapy, economic aspects might not be a determining factor.
Prostaglandins have been justified in cases where the cervix is
open, to facilitate evacuation of pus, and in cases where the
breeding potential of the patient has been considered important.
Fewer than 10% of the practitioners gave drugs other than
antibiotics and prostaglandins. The use of antiprogestins such
as aglepristone for the treatment of pyometra has in recent
years been reported to be successful [2, 8, 10, 14]. This survey
Fig.3 . Pus filled uterus with endometrial cyst and variably
thickened wall.
shows that Norwegian veterinarians, as of 2003, had limited
experience with such treatment, and also with antiprolactinic
drugs such as cabergoline. These drugs have only recently been
introduced into the Norwegian market. Indeed, aglepristone is
not registered in Norway, although it can be purchased. The drug
is not registered for the treatment of pyometra in any country.
Information concerning long-term prognosis after medical
treatment of pyometra is sparse. Therefore it is still a widespread
belief in Norway that medical treatment of pyometra only delays
surgical treatment.
The reported survival rate when surgical treatment was chosen
corroborates other studies [7, 11, 12]. Following medical
treatment, the Norwegian veterinarians reported a lower
survival rate than reported from other countries [1, 2, 10, 14].
The practitioners were also asked to report, based on their
experience, expected prognosis regarding future oestruses and
fertility following medical treatment. The results here were
lower than compared to other studies [2, 14]. This may be due
to the relatively infrequent use of other medical treatment in
combination with antibiotics.
The data received for all questions were not based on exact
statistics from the practitioners databases, but were only the
practitioners qualified estimates. This is a weakness of this study.
The strength of the survey is the high response rate. The study
should therefore give a representative view of the treatment of
pyometra undertaken by Norwegian small animal practitioners.
The authors conclude that Norwegian small animal practitioners
considered surgery to be the best treatment of pyometra in the
bitch. The responding veterinarians reported good prognosis
when surgery was performed. With medical treatment, the
practitioners experienced less favourable results.

197
 Treatment of pyometra in the bitch: A survey among Norwegian small animal practitioners - V. Rootwelt-Andersen
Acknowledgments
The study was supported by a grant from Astrid and Birger
Thorsteds legate. The authors are grateful to Professor Aage
Tverdal for statistical assistance.
References
[1] BLENDINGER (K.), BOSTEDT (H.) & HOFFMANN (B.) - Hormonal
state and effects of the use of an antiprogestin in bitches with
pyometra. Journal of Reproduction and Fertility Supplement 51,
1997, 317-325.
[2] BREITKOPF (M.), HOFFMANN (B.) & BOSTEDT (H.) - Treatment
of pyometra (cystic endometrial hyperplasia) in bitches with an
antiprogestin. Journal of Reproduction and Fertility Supplement
51, 1997, 327-331.
[3] BRRESEN (B.) - Pyometra in the dog. A pathophysiological
investigation. Oslo, PhD thesis - Norwegian College of Veterinary
Medicine, 1984, ISBN 82-990476-3-3.
[4] DOW, (C.) - The cystic hyperplasia-pyometra complex in the bitch.
Veterinary Record 69, 1957, 1409-1415.
[5] FELDMAN (E.C.), NELSON (R.W.) - Cystic endometrial hyperplasia/
pyometra complex in canine and feline endocrinology and
reproduction. 3rd edn. Eds R. Kersey and D. LeMelledo. Saunders,
2004, pp 847, 859-860.
[6] GABOR (G.), SIVER (L.), SZENCI (O.) - Intravaginal prostaglandin F2
alpha for the treatment of metritis and pyometra in the bitch. Acta
Veterinaria Hungarica 47, 1998, 103-108.
198
[7] GILBERT (R.O.) - Diagnosis and treatment of pyometra in bitches
and queens. Continuing Education Art#6, 14, 1992, 777-784.
[8] GOBELLO (C.), CASTEX (G.), KLIMA (L.), RODRGUEZ (R.) &
CORRADA (Y.) - A study of two protocols combining aglepristone
and cloprostenol to treat open cervix pyometra in the bitch.
Theriogenology 60, 2003, 901-908.
[9] HAGMAN (R.) - New Aspects of Canine Pyometra. Studies
on epidemiology and pathogenesis. PhD thesis. The Swedish
University of Agricultural Sciences, Uppsala, Sweden. 2004, ISBN
91-576-6682-2
[10] HOFFMANN (B.), LEMMER (W.), BOSTEDT (H.), FAILING (K.) - Die
anwendung des antigestagens aglpristone zur konservativen
behandlung der pyometra bei der hndin. Tierartzliche Praxis 28,
2000, 323-329.
[11] JOHNSTON (S.D.), ROOT KUSTRITZ (M.V.), OLSON (P.N.S.) -
Disorders of the canine uterus and uterine tubes in canine and
feline theriogenology. Eds R. Kersey and D. LeMelledo. W.B.
Saunders Company, 2001, pp 174, 216 and 220.
[12] NISKANEN (M.), THRUSFIELD (M.V.) - Associations between age,
parity, hormonal therapy and breed, and pyometra in Finnish
dogs. Veterinary Record 143, 1998, 493-498.
[13] NORWEGIAN ANIMAL WELFARE ACT 13, first link, point 1. Dec
20th 1974 nr 73, Chapter 2, Srlege fresegner om husdyr og
tamrein. Forbod mot visse inngrep.
[14] TRASCH (K.), WEHREND (A.), BOSTEDT (H.) - Follow-up
examinations of bitches after conservative treatment of
pyometra with the antigestagen aglepristone. Journal of
Veterinary Medicine 50, 2003, 375-379.
 DERMATOLOGY

REPRINT PAPER (GR)

Contemporary aspects of the

immunopathogenesis of auto-
immune diseases of the epidermal
basement membrane in the dog
E. I. Papadogiannakis (1)

SUMMARY

Autoimmune diseases of the epidermal basement membrane are the result of the immune system self-activation
against specific antigens of its essential structural elements. This group of skin diseases is characterized by
the destruction of connecting bonds between the membrane zone and the dermis which eventually leads
to dermoepidermal separation and the formation of subepidermal vesicles and bullae. In this article the
immunopathogenesis and the clinical, histopathological and immunohistochemical features of each of these skin
diseases are briefly reviewed. The autoimmune diseases of the canine epidermal basement membrane have been
recently classified as bullous pemphigoid, mucous membrane pemphigoid, linear IgA disease, epidermolysis bullosa
acquisita and bullous systemic lupus erythematosus. Recent advances in immunological and molecular techniques
have markedly facilitated the understanding of their pathogenesis thus giving the opportunity for the development
of new therapeutic strategies that may improve or eliminate the clinical signs.
Key Words: epidermal basement membrane, dog, autoimmune diseases, immunopathogenesis

presentation of cryptic determinant of intracellular self-proteins

This paper originally appeared in:
The Journal of the Hellenic Veterinary Medical Society*
2005 56(1) p 27-31
Introduction
Autoimmunity is defined as the inability of the immune system
to recognize self-antigens without being activated against
them. Immunological tolerance is achieved by two different
mechanisms. The first is positive selection in the thymus, where
only T cells that recognize peptides in Major Histocompatability
Complex (MHC) molecules are selected. The second is negative
selection where T cells that recognize self-antigens with too
much affinity are deleted by apoptosis and are not allowed to
enter the circulation [2, 1, 6].
Mechanisms inducing autoimmunity in the skin are related to
MHC and apoptosis genes. Additional proposed mechanisms
are a) the release of anatomically sequestered antigens, b) the
during the course of an inflammation process, c) the activation
of anergic T cells induced by the presentation of self-antigens
by non professional antigen presenting cells, d) the molecular
mimicry of certain peptide fragments of infectious agents to host
proteins and e) the immunological reaction against modified
self-antigens [4, 15, 6].
The autoimmune diseases of the canine epidermal basement
membrane have been recently classified as bullous pemphigoid,
mucous membrane pemphigoid, linear IgA disease, epidermolysis
bullosa acquisita and bullous systemic lupus erythematosus.
Bullous pemphigoid
Bullous pemphigoid represents 14% of autoimmune subepithelial
blistering dermatoses in dogs [6]. In contrast to humans, the
disease is uncommon in the dog and hence there has been no
reliable data regarding breed and sex predisposition [3, 12].
However, some authors have reported a breed predisposition for

(1) Dept. of Veterinary Public Health, National School of Public Health, 196 Alexandras avenue, GR-115 21 Athens. E-mail: vet-esdy@otenet.gr
* Presented by HVMS (Greece)

199
 Contemporary aspects of the immunopathogenesis of autoimmune diseases - E. I. Papadogiannakis
the Collie, Shetland sheepdog and Doberman pinscher [11].
Young and young adult dogs are mainly affected. Vesicles,
erosions, ulcers and crusts characterize the clinical picture
of canine bullous pemphigoid. Skin lesions can be seen on
the concave aspects of the ear pinnae, abdomen, axillae,
mucocutaneous junctions and oral mucosa [11, 7, 13].
In canine bullous pemphigoid, IgG autoantibodies are produced
against the epitope NC16A of the transmembrane part of collagen
XVII of the anchoring filaments of lamina lucida of the basement
membrane [5, 6, 7]. Collagen XVII constitutes a constructive
element of hemidesmosomes connecting the keratinocytes of
the basal layer of the epidermis to the basement membrane.
The formation of autoantibodies, in turn, fixes the complement
so that its chemotactic components C3a and C5a recruit masts
cells in the area. The latter release chemotactic factors, attracting
eosinophils and neutrophis which digest the anchoring filaments
of hemidesmosomes with the proteases and cytokines they
release. The overall process results in the detachment of basal
keratinocytes from the basement membrane and the formation
of vesicles and pustules [16].
On histopathological examination, dermoepidermal clefts are
seen in which the basement membrane is always located at
their base. Additionally, dermal infiltration with eosinophils and
neutrophils is also observed [3, 6, 7]. In direct immunofluorescence,
immunoglobulins (IgG, IgA & IgM) or complement (C3) are
deposited in a linear pattern along the basement membrane
[14, 16, 6]. The indirect immunofluorescence detects circulating
IgG autoantibodies. The latter are located on the epidermal side
of artificial clefts when animal or human salt-split skin substrates
Figure 1: Ulcers on the eyelids, medial canthus
and nasal planum in a dog with mucous membrane
pemphigoid. Depigmentation of the planum nasale as
well as hypotrichosis of the bridge of the nose are also
noted. Figure 2: Ulceration of the prepuce of the dog in fig.1
200
are used [6]. Immunoblotting studies have established that the
IgG autoantibodies in canine bullous pemphigoid identify a
180kDa antigen identical to the transmembrane domain of type
XVII collagen [3].
Mucous membrane pemphigoid
This appears to represent one of the most common subsets of
autoimmune subepithelial blistering dermatoses in the dog [6].
This disease most commonly affects adult German shepherds
and Siberian huskies [12].
The clinical picture is characterized by varying degrees of
depigmentation, erythema, vesicles, bullae, erosions, ulcers and
crusts. Skin lesions predominate in the oral cavity, mucocutaneous
junctions, nasal planum and perinasal area [6, 12] (Fig 1, 2, 3
and 4).
The immunopathogenesis of mucous membrane pemphigoid
is similar to that of bullous pemphigoid, the only difference
being that the established autoantibodies are directed against
a different epitope on the transmembrane segment of collagen
XVII [6, 12].
The histopathological lesions are characterized by the presence
of dermoepidermal clefts with minimal or no inflammation. The
basement membrane appears to be located on the dermal side
of the cleft [6, 13] (Fig 5 and 6). In direct immunofluorescence,
mainly immunoglobulin IgG and to a lesser extent complement
(C3) and IgM are deposited in a linear pattern along the
basement membrane [6, 12]. Indirect immunofluorescence and
ELISA detect circulating specific IgG autoantibodies [6].

Figure 3: Erosions and ulceration of the oral mucosa of the dog in
fig. 1
Epidermolysis bullosa acquisita
The incidence of this dermatopathy appears to be higher than
that of bullous pemphigoid but lower than that of mucous
membrane pemphigoid [6]. Epidermolysis bullosa acquisita
affects mainly young animals while a predisposition in Great
Danes and German shepherds has been recorded [7, 12].
In the generalized form of the disease, skin lesions are usually
accompanied by fever, lethargy, depression and anemia and
characterized by erythematous and urticarial patches on the
face, axillae, groin, footpads and oral cavity. These lesions evolve
rapidly into vesicles and widespread ulceration. In the localized
form, similar skin lesions are observed with no systemic signs,
mainly restricted to the concave aspect of the ear pinnae [6, 7].
In epidermolysis bullosa acquisita, IgG autoantibodies are
Figure 5: Dermoepidermal separation along with slight
inflammatory infiltrate in the dermis. Same dog as in fig.1 (H&E
x100)
201
EJCAP - Vol. 16 - Issue 2 October 2006
Figure 4: Depigmentation and ulcers of the edges of the right
nostril. Erosions and crusts on the planum nasale are also noted.
Same dog as in fig.1
directed against collagen VII of the anchoring fibrils located
under lamina densa of the epidermal basement membrane.
Then, with a mechanism similar to that mentioned in bullous
pemphigoid, the epidermis is detached from the dermis along
with the basement membrane, resulting in the formation of
bullae and ulcers [7, 12].
The histopathological lesions, being common in both clinical
forms of the disease, are characterized by early formation of
subepidermal clefts and the presence of neutrophils whilst
necrosis and epidermal ulceration are observed later in the
course of the disease [6]. In direct immunofluorescence,
immunoglobulins (IgG, IgA & IgM) and/or complement (C3) are
deposited in a linear pattern along the basement membrane,
while indirect immunofluorescence detects circulating IgG
autoantibodies which are located on the dermal side of
Figure 6: Higher magnification (x 400) of fig.5. The basement
membrane seems to be attached to the dermis.
 Contemporary aspects of the immunopathogenesis of autoimmune diseases - E. I. Papadogiannakis
artificial clefts in animal or human salt-split skin substrates
[6,12]. By immunohistochemical examination of skin biopsies
using monoclonal antibodies against collagen IV (the basic
constructive element of lamina densa of the basement
membrane), the dermoepidermal clefts are located below the
immunohistochemically labeled collagen IV [9].
Linear IgA disease
Since this dermatopathy is rare there is no data regarding age,
breed and sex predisposition [6].
Skin lesions, which basically are restricted to oral mucosa, face
and extremities, are characterized by vesicles, bullae and ulcers
[6,12].
In linear IgA disease, IgG autoantibodies formed are directed
against specific fragments produced by the proteolysis of the
transmembrane segment of collagen XVII of anchoring filaments
of basement membrane lamina lucida [5, 6, 7]. Then, with a
mechanism similar to that mentioned in bullous pemphigoid,
the epidermis is detached from the dermis along with the
basement membrane, resulting in the formation of bullae and
ulcers [7, 12].
The histopathological picture differs from that of bullous
pemphigoid in that both inflammation and eosinophils are
abscent [6].
Direct immunofluorescence reveals a linear deposit, mainly
of IgA, along the epidermal basement membrane, while the
indirect immunofluorescence detects circulating IgG and IgA
autoantibodies which are located on the epidermal side of
artificial clefts when canine or human salt-split skin substrates
are used [6,12].
Bullous systemic lupus erythematosus
In this also rare dermatopathy, extended areas of erosions and
ulcers in the oral mucosa, footpads, lips, concave aspect of the
ear pinnae, chest and axillae are observed [5]. As in epidermolysis
bullosa acquisita, the autoantibodies formed are directed against
collagen VII while a high antinuclear antibodies (ANA) titre is
also detected in blood serum [5]. Both the mechanism of lesion
formation and the histopathological and immunohistochemical
pictures of the disease are quite similar to that mentioned in
epidermolysis bullosa acquisita.
Lastly, the differentiation of bullous systemic lupus erythematosus
from systemic lupus erythematosus is mainly based on the
detection of autoantibodies against collagen VII in blood serum
(indirect immunofluorescence) [5, 7].
Conclusion
Contemporary immunological and molecular techniques have
contributed not only to the detection of new disease entities but also
to reclassification of autoimmune diseases of the canine epidermal
basement membrane, according to their immunopathogenesis.
The precise differentiation of these autoimmune diseases helps in
formulating a safer and more realistic prognosis while at the same
time directs small animal practitioners to the adaption of more
effective therapeutic protocols.
202
References
[1] AFFOLTER (V.K.) - The skin immune system, Proceedings of the
Workshop on skin immunology organized by ESVD, France, 2000,
65-93.
[2] DAY (M.J.) - Clinical Immunology of the Dog and Cat, Manson
Publishing, UK, 1999.
[3] IWASAKI (T.) - et al. Canine bullous pemphigoid (BP): identification
of the 180-Kd canine BP antigen by circulating autoantibodies. Vet
Pathol, 1995, 32: 387-393.
[4] JANEWAY (C.A.) and TRAVERS (P.) - Immunobiology, The immune
system in health and disease, 3rd edition, Current Biology and
Garland Publ., London, UK, 1997.
[5] OLIVRY (T.) - The epidermal basement membrane: From molecular
biology to dermatological diseases. Proceedings of the ACVD
Residents` Review, 1999, 1-18.
[6] OLIVRY (T.) - Mechanisms of Autoimmunity- Current concepts
and autoimmune subepidermal blistering dermatoses in domestic
animals: an update, Proceedings of the workshop on Skin
Immunology organized by the ESVD, Saint- Paul de Vence, France,
2000, 109-150.
[7] OLIVRY (T.) and CHAN (L.S.) - Autoimmune blistering dermatoses
in domestic animals, Clinics in Dermatology, 2001, 19: 750-760.
[8] OLIVRY (T.), DUNSTON (S.), FAHEY (M.), NGUYEN (N.) and
MARINKOVICH (M.) - Autoantibodies against the processed
ectodomain of collagen XVII (BPAG2, BP180) define a canine
homologue of linear IgA disease of humans. Veterinary Pathology,
2000, 37: 302-309.
[9] OLIVRY (T.), FINE (J.), DUSTON (S.) et al. - Canine epidermolysis
bullosa acquisita: circulating autoantibodies target the
aminoterminal noncollagenous (NC1) domain of collagen VII in
anchoring fibrils. Vet Dermatology, 1998, 9: 19-31.
[10] OLIVRY (T.), SAVARY (K.), MURPHY (K.), DUNSTON (S.) and
CHEN (M.) - Bullous systemic lupus erythematosus (type I) in a
dog. Vet Record, 1999, 145: 165-169.
[11] PEDERSEN (N.C.) - A review of immunologic diseases of the
dog. Veterinary Immunology and Immunopathology, 1999, 69:
251-342.
[12] RIVIERRE (C.H.) and OLIVRY (T.) - New autoimmune dermatoses
in the dog and cat. Part 2: Dermatoses targeting basement
membrane proteins. EJCAP, vol.14, 2004, (1): 83-91.
[13] SCOTT (D.W.), MILLER (W.H.) and GRIFFIN (C.E.) - Immune
mediated disorders In: Small Animal Dermatology, 6th edition,
W.B.Saunders Co, Philadelphia, 2001, 667-779.
[14] SCOTT (D.W.), WALTON (D.K.), SLATER (M.R.), SMITH (C.A.) and
LEWIS (R.M.) - Immune-mediated dermatoses in domestic animals:
Ten years after-part I, Compendium on Continuing Education for
Practicing Veterinarian, 1987, 9: 424-434.
[15] STEINMAN (L.) - Escape from Horror Autotoxicus: pathogenesis
and treatment of autoimmune diseases, Cell, 1995, 80: 7-10.
[16] SUTER (M.M.), DE BRUIN (A.), WYDER (M.), WURM (S.), CREDILLE
(K.), CRAMERI (F.M.) and MULLER (E.) - Autoimmune diseases of
Domestic animals: an update. In: K.W.Kwochka, T.Willemse and
C.V Tscharner (eds): Advances in Veterinary Dermatology, vol.3,
Butterworth Heinemann, Oxford, 1998, 321-334.

Small Animal Surgical Nursing:
Skills and Concepts
Sara J Busch
Published by Published by Elsevier Saun-
ders (http://intl.elsevierhealth.com/vet)
432 pages 450 illustrations Paperback
ISBN 0-323-03063-7 38.95, 25.99
This is an excellent book, produced in a
clear user friendly format. There are
fourteen different contributors, some vet-
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All are actively involved in the teaching of
technicians and this is reflected in the clear
style and emphasis on practical skills.
The book is organised into four main parts
pre-operative considerations, intra-op-
erative considerations, post-operative
considerations and finally a special sec-
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The separate chapters contain a wealth of
practical information presented in a clear
and concise way. The colour photographs
and line diagrams are of a high quality and
help bring the book to life. Specific proce-
dures (eg the placement of intravenous
canulae) are highlighted in box format and
there are numerous tables of information
for quick reference. Each chapter starts by
outlining the learning objectives and fin-
ishes with a summary of the key points
and a question and answer section. At the
end of the book there is a section of ap-
pendices providing at-a-glance access to
information on dosage calculations and
infusion rates.
Within the section on intra-operative pro-
cedures is a chapter on specific surgical
operations ranging from ovarohyster-
ectomies to bowel resections and ortho-
paedic procedures. I personally was very
impressed by this and felt the information
was presented in a way that encouraged
the student to read more. The nursing
staff in my clinic agreed this was especial-
ly useful as it helped to apply the lessons
of the previous sections to real life situa-
tions. This section also contained a very
BOOK REVIEWS
clear description of the use of rigid and
flexible endoscopes and my experience is
that such information geared to nurses /
technicians is not readily available.
The section on high volume neuter clinics
was a welcome inclusion, as it highlighted
the special considerations that need to be
addressed when working in such a situ-
ation.
In summary I feel the authors and publish-
ers should be congratulated on producing
such an excellent book. Within Europe, this
should be a recommended text for nurses
/ technicians who have English language
skills. Sadly this is not always the case, but
in situations where the veterinarians can
read English, they may still find the book a
useful tool when teaching their own staff.
Indeed, the wealth of practical informa-
tion might make it a valuable resource
for veterinary students or graduates who
have had minimal experience in gaining
appropriate practical skills.
Ray L. Butcher MA, Vet MB , MRCVS
(UK)
Diagnostic Atlas of Veterinary
Ophthalmology
Keith Barnett
Published by Elsevier Saunders( http://intl.
elsevierhealth.com/vet ) 352 pages Hard-
back ISBN 0723432805 72, 47.99
This book is a second edition, renamed
and modified, of a previous manual
named Veterinary Ophthalmology. This
new book can be considered essentially as
a visual and pictorial presentation of the
ocular diseases of animals.
The author, Keith Barnett is a well known
British veterinary ophthalmologist with a
solid reputation of great experience in this
field. As head of the comparative ophthal-
mology unit of the Animal Health Trust
(UK) for many years he made a substantial
contribution to both small and large ani-
mal (mostly equine) ophthalmology. One
cannot present such a large collection of
204
good illustrations without being an excel-
lent clinician.
In this book, each condition is richly illus-
trated by several photographs of excellent
quality.More than 700 photos in total make
the book a very useful tool in helping vet-
erinarians to recognise ocular conditions.
Two points deserve special comment. The
first relates to the inclusion of photos il-
lustrating ocular diseases of species other
than dogs and cats and the second to the
large development of the chapter on reti-
nal diseases. The latter will be very helpful
for many clinicians who may have difficul-
ty with the clinical differential diagnosis of
fundic lesions.
The book follows a classical classification
of chapters. Chapter 1 covers the globe
and orbit as a whole. Chapters 2,3,4 and
5 cover adnexal conditions. Chapters 6, 7
and 9 are related to the anterior segment
of the globe, chapter 8 deals with glau-
coma. Chapters 10, 11 and12 cover the
posterior segment of the globe.
The author has chosen not to extend the
text of the captions of illustrations and not
to enter into more precise descriptions of
the lesions shown in the illustrations.
In this new edition, the reader will also
find very useful descriptions and tables to
help in the diagnostic process.
This book can be recommended to veteri-
nary students and practitioners who will
appreciate the help of illustrations in the
diagnosis of ocular conditions in animals.
Dr Maurice Roze, DVM. DECVO.(F)
Small Animal Toxicology 2nd
Edition
Edited by M.E. Peterson and P.A.Talcott
Published by Elsevier Saunders( http://
intl.elsevierhealth.com/vet ) 1232 pages
Paperback ISBN 0721606393 71.95,
47.99
This soft cover 12.5 x 21 cm clinical manual
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all the information needed for the under-
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Under the editorship of Patricia A. Talcott
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Michael E. Peterson of the Reid Veterinary
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voted to general toxicological exposures
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tal of 56 alphabetically ordered chapters
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each containing detailed information on
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This excellent book addresses several areas
that differ from those covered by the usu-
al veterinary toxicology texts, such as for
example indoor environmental toxicants,
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pregnant and lactating animals. The new
edition also contains an interesting chapter
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tile. Finally, this most comprehensive man-
ual features a 72-page index that is intel-
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quickly and directly. Another useful index
has been compiled according to the clinical
symptoms elicited by toxic substances.
The manuals fundamental purpose of
providing accurate and well documented
information on the effects of poisons in
small animals makes it an invaluable tool
for practitioners, and students purchas-
ing the book will have continuing value
in its use as a reference throughout their
practice years. If you havent seen it, get a
copy immediately!
Prof. Hanspeter Naegeli, DVM (CH)
BOOK REVIEWS
Notes on Cardiorespiratory
Diseases of the Dog and Cat.
2nd edition
Mike Martin and Brendan Corcoran
Blackwell Publishing Ltd.( www.black-
wellpublishing.com) 205 pages Pa-
perback ISBN 10: 1405122641 29 99
(Approx 42)
This book is an excellent review of
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appendices on topics such as reference val-
ues for echocardiography and ECG, calcu-
lation of constant rate infusions of certain
drugs, digoxin dosages in dogs, classifica-
tion of pleural effusions, sedation regimes
205
for dogs and cats with cardiorespiratory
disease and doses of emergency drugs. A
glossary table of commonly used drugs is
placed at the end of the book.
This book is especially helpful for internists
not specialized in cardiorespiratory diseas-
es, veterinarians undergoing specialisation
in various fields and for students, as the
information is easily accessible and easy
to read. It is a very comprehensive book
despite its relatively small size and it will
be a helpful tool in everyday companion
animal practice.
Anna Tidholm, DVM, PhD, DECVIM (S)
Atlas of Radiology of the
traumatized dog and cat
Joe P. Morgan and Pim Wolvekamp
Published by Schlutersche,( www.schlue-
tersche.de) 557 pages, Hardback
ISBN 3-89993-008-8 99, 80
This excellent second edition of the atlas
is totally revised and expanded compared
with the first (1994) edition. The book now
includes all relevant radiographic features
of the traumatized dog and cat including
cases that may present acutely with le-
sions of a more chronic nature. It is an at-
las devoted exclusively to radiographic and
radiological aspects of the traumatized
animal based on the fact that radiology
is a fast, easy and a relatively painless way
to get information on the traumatized pa-
tient. The book has eight chapters cover-
ing an introduction, radiology of thoracic
trauma, radiology of abdominal trauma,
radiology of musculoskeletal trauma and
emergency cases, radiographic features of
soft tissue injuries, radiographic features
of gunshot injuries, radiographic features
in cases of abuse and finally a chapter on
poisoning. In all chapters there is an over-
view covering material related to the cases
presented including technical aspects and
specific radiological features.
The main focus is on the three larger
chapters on trauma to thorax, abdomen

and musculoskeletal system.
The authors use a case based approach
with great emphasis on the method
of radiological evaluation stressing the
significance of radiographic signs and
patterns. Throughout the book, cases are
presented in a very systematic way with
paragraphs on signalment and history,
physical examination, radiographic pro-
cedure, radiographic diagnosis, treatment
and management and often with addi-
tional comments. Details in figures are
highlighted and annotated as necessary
to assist understanding and the figures
are generally of a very high quality.
This book will be a very useful tool in eve-
ry day companion animal practise and a
definite must for clinicians handling trau-
ma cases.
Prof. Eiliv Svalastoga (DK)
Brinker, Piermattei, and Flos
Handbook of Small Animal Or-
thopedics and Fracture Repair
Donald L. Piermattei, Gretchen L. Flo,
Charles E. De Champ
Published by Elsevier Saunders, ( http://intl.
elsevierhealth.com/vet ) 832 pages, 1850
illustrations ISBN-13: 978-0-7216-9214-2;
ISBN-10: 0-7216-9214-1 Paperback
47.95 / 31.99
Twenty-three years have passed since
publication of the first edition of this book
and the fourth edition takes advantage of
considerable worldwide experience in this
field . Many veterinary surgeons already
know this comprehensive textbook and
have had an opportunity to appreciate its
usefulness in daily practice when manag-
ing all types of orthopaedic problems.
The format of the book is the usual one,
as in the previous editions, with a first
part dealing with the basic principles of
the diagnosis and treatment of fractures,
lameness and joint diseases, including
fracture classification and all types of im-
plants and systems of fixation. The second
part describes the treatment of fractures
BOOK REVIEWS
and orthopaedic conditions of the fore-
limb, while the third part considers the
hind limb. The fourth part describes the
approach to other fractures and to recon-
struction of bone deformity, whilst the
fifth part deals with miscellaneous condi-
tions of the musculoskeletal system. This
edition is considerably enriched by the ex-
cellent artwork of F. Dennis Giddings, the
artist who first become famous with the
milestone book for all orthopaedic sur-
geons, Piermatteis Atlas of Surgical Ap-
proaches to the bones and joints of the
dog and cat.
The approach to each musculoskeletal
condition is very comprehensive, fol-
lowing the original philosophy of Wade
Brinker, taking care in the description of
the pathology, the diagnostic work-up,
surgical indications and planning, surgical
approach, surgical techniques, complica-
tions and follow-up. For this reason this
textbook is very useful to all veterinary
surgeons when approaching veterinary
orthopaedic and traumatology problems
and willing to find the technical solution
to any musculoskeletal case they may find
in their daily practice.
For more experienced surgeons, already
used to consult the previous editions,
this fourth one will update their knowl-
edge on the most recent diagnostic
approaches, such as arthroscopy and the
recently developed new techniques such
as TPLO, guiding the reader in the choice
of new solutions for several orthopaedic
conditions. The addition of a new Author,
Charles De Champ, is a guarantee for the
continuous update of this textbook.
Aldo Vezzoni, (I) Med. Vet., SCMPA,
Dipl. ECVS
Saunders Manual of Small
Animal Practice
Edited by Birchard & Sherding
Published by Elsevier Saunders( http://intl.
elsevierhealth.com/vet ) ,2032 pages,
1000 illustrations, Hardback
ISBN 0721604226, 82.00, 139.00
206
Any book that attempts to cover the
whole of small animal medicine and sur-
gery in a single volume is, by necessity,
almost bound to fail. That said, this book
makes a good attempt and contains much
useful information.
There are 12 main sections, covering pa-
tient management, infectious disease,
haematology/oncology, endocrine and
metabolic disorders, skin and ear disease,
digestive system, urogenital, skeletal,
nervous system, ophthalmology, cardiop-
ulmonary and exotic pets. These sections
are further subdivided into 178 chapters,
a sixteen page formulary and a fifty page
index. Navigating the text is simple and
the consistent format of two-tone text,
clear headings and bullet pointing is user
friendly. Diagrams and tables are clear
and illustrate the text well, though not
comprehensively. The list of authors is im-
pressive, though almost exclusively North
American.
Each chapter covers a specific topic logi-
cally and mostly anatomically. Aetiology,
clinical signs, diagnosis and treatment are
then presented in bullet point format,
highlighted by tables and algorithms, with
key points emphasised by the use of red
font.
Although not a small book at 2000 pag-
es, the scope of subject matter inevitably
means that each topic is only dealt with
very briefly, with little discussion, although
the list of references is adequate. Anaes-
thesia is therefore contained in a mere 11
pages and the whole of stifle diseases in
just twelve. This brevity is simultaneously
the books best feature, but frustratingly
also its major draw-back. For a clinician
in practice, with little time to search texts
between cases, it offers a fantastic, eas-
ily accessible review and aide memoire.
However, when faced with an unfamiliar
case the book will pose as many questions
as it answers. Used correctly, therefore,
as a revision aid for the busy clinician it
deserves a place on every practice book-
shelf, though there is the risk of abusing
the volume if it is relied upon for short-
cut answers for a practitioner in unfamiliar
territory.
My one main criticism of the book is its
binding: it is not a lightweight volume and
presumably the intention is to be leafed
through regularly. It therefore deserves
a more substantial hard cover over the
present flimsy offering, which will rapidly
lose its support. At 82 it offers value for
money, but would be more valuable and
more appreciated at an increased cost and
in a stronger format.
Buy this book, but use it alongside the ex-
cellent range of BSAVA manuals.
Tim Hutchinson BVSc CertSAS. MRCVS (UK)
Calendar of main European National Meetings WSAVA & FECAVA Congresses (Red)
National meetings (blue)
and other continuing education opportunities
A list of the addresses and telephone numbers of the Secretariat or person holding information is attached.

2006
4th October BSAVA Gloucester BSAVA HQ Small Animal Medicine Modular - Upper Urinary Tract English
5th October BSAVA Gloucester BSAVA HQ Small Animal Medicine Modular - Lower Urinary Tract English
5-12 Ocober AFVAC-GECA Quebec,Canada CE Cardiology French
October 7-8 AIVPA Modena National Congress Italian/English
10-14 October FECAVA/WSAVA/ Prague 12th FECAVA/30th English & Others
CSAVA WSAVA/CSAVA Congress
13-15 October AFVAC-GEMEF Lyon CE Feline Pathology French
14 - 18 October ESAVS Berne / Switzerland Neurology III / Advanced Neurology / Neurosurgery English
27-29 October AVEPA Madrid National congress Spanish, English
21-22 October AIVPA-FE Perugia CE Cats and dogs Haematology and Cytology Italian
21 - 25 October ESAVS Berne / Switzerland Neurology I, English
28-29 October VK Vienna Oncology Seminar German, English
1 - 5 November ESAVS Palma de Mallorca / Spain Small Animal Therapy: Cardiology and Orthopaedics English
3-5 November SCIVAC Perugia 53rd SCIVAC Congress Italian, English
7th November BSAVA Gloucester BSAVA HQ Therapeutics Modular - Analgesia English
8th November BSAVA Gloucester BSAVA HQ Small Animal Medicine Modular - Antimicrobial English
Therapeutics
9th November BSAVA Basingstoke A cavity with a view - Advances in endoscopic surgery English
10th November BSAVA Basingstoke Wounds That Make Your Skin Crawl English
9 - 10 November SSAVA Uppsala Annual meeting Swedish
10-11 November DSAVA Aarhus Annual Meeting / National Congress English/Danish
10-11 November TSAVA Istanbul 1st Anadolum Congress English, Turkish
11-12 November VK Steyr Ultrasound Seminar (Abdomen Special Cases) German
12 November PSAVA Lublin CE Elbow and Hip Dysplasia Polish /English
13th November BSAVA Kettering Understanding Joint Disease English
13 - 24 November ESAVS Utrecht / Netherlands Internal Medicine II English
14th November BSAVA Kettering Fixing the Fractured Feline English
17-19 November SMASAP Belgrade SIVEMAP 2006 - National Symposium Serbian
18-19 November AVEPA Barcelona CE Oncology Spanish
18 November VK Vienna Practice Management/Marketing German
19 November AIVPA-FE Messina Study Day: Diagnosis and Therapy in Feline Dermatology: Italian
old confirmations and new acquisitions
23-24 November AVEPA Sevilla CE Trauma Spanish
25-26 November AVEPA Madrid CE Oncology Spanish
Bilbao CE Cardiology Spanish
Las Palmas CE Emergency Care Spanish
25-26 November VK Krems Radiography Seminar (Abdomen Techniques and Contrast German
Media)
26 November AIVPA Prato Seminar Nuovi Animali da Compagnia Italian
3 December AIVPA Agnano Seminar EndocrinologyEndocrinology in Clinical Practice Italian
of the Dog and Cat: how many times we dont evidence
symptoms?
5th December BSAVA Gloucester BSAVA HQ Therapeutics Modular - Cytotoxics and Chemotherapeutics English
6th December BSAVA Gloucester BSAVA HQ Therapeutics Modular - Cardiovascular Therapeutics English
7-9 December AFVAC/FAFVAC# Bordeaux Annual Congress French

2007
19 - 21 Jan VICAS Kilkenny Winter Conference Common Presentations in Pet Practice English
NursesThe Hidden Profit
4 Febrary AIVPA/FE Arezzo National Congress Italian
11February Aivpa-Sitov Parma CE Arthrosis In The Dog: A Pathology For All Ages Italian
24-25 March AIVPA Perugia Annual Congress Italian
March ESAVS Salzburg / Austria CE Cardiology III Advanced English
28 March- 1 April FECAVA/CSAVS Dubrovnik FECAVA/CSAVS/ESFM European Congress English and others
13-17 April BSAVA Birmingham Annual Congress English*
27-29 April NACAM Amsterdam Voorjaarsdagen Dutch, English and
others
3-5 May SVK/ASMPA Montreux Annual Congress German, French and
English

209
 6 May AIVPA-AVIEC Sarzana CE Canine Liver Pathology Italian
11-13 May GSAVA Goettingen CE Soft tissue surgery German, English
12-13 May PSAVA Warszawa Annual Congress . Neurology Polish/English
19-20 May AIVPA-FE Parma-Facolta Feline Ultrasonograpy and Ultrasound Italian
26-27 May SAVAB Antwerp Obesity Seminar English, Dutch
June/July ESAVS Luxembourg Dentistry I and II English
July/August ESAVS Vienna / Austria Dermatology II and III Diagnostic Ultrasound III English
July ESAVS Brno (CS) Endoscopy Intensive Course English
20-24 August ESAVS Berne / Switzerland Emergency and Critical Care II English
26-29 August WSAVA Sydney / Australia World Congress English and others
September 13-15 ECVIM-CA Budapest / Hungary Annual Conngress English
21st-23rd Sept GSAVA Duisburg CE The Asthenic dog German English
13-14 October AIVPA Modena National Congress-Neurology Note: on the 12th , IVDAO Italian/English
(Alternative medicine), SITOV (Orthopaedics) AVPA/FE and
AIVPA/F will hold Pre-congress meetings
19-20 October AVEPA ?? National Congress Spanish English
28-29th October CSAVA Hradec Kralove Annual congress English and Czech
6-9 December AFVAC Paris Annual Congress French
15-18. November GSAVA Berlin 53rd Annual Congress German English

ADVANCE NOTICE
2008 BSAVA 3-6 April SVK/ASMPA 22-24 May (Interlaken) AFVAC (26?) 27-30 November
Strasbourg
Voorjaarsdagen 24-26 April ECVS 17th Annual Scientific Meeting, FECAVA/WSAVA/ VICAS 20-24 August
July, Basel, Switzerland
2009 Voorjaarsdagen 23-25 April BSAVA 2-5 April FECAVA/AFVAC/SAVAB 29-29 November
Lille

# FAFVAC = Federation Francophone des Veterinaires danimaux de Compagnie

* 60 Veterinary surgeons or 70 Nurse registrations required for simultaneous translation to be provided

Notes for contributors to the European Journal of

Companion Animal Practice
CONTRIBUTIONS in the form of original research papers, review articles
and clinical case histories on all aspects of Companion Animal (excluding
Equine) veterinary medicine and surgery are invited. All submissions are
refereed by the EJCAP Editorial Board. The work should be essentially
European ie largely undertaken within Europe. Submissions are accepted
on the understanding that they have not been published elsewhere and
that they are subject to editorial revision. All material published is the
copyright of EJCAP.
Line figures and photographs will normally be reproduced at column
width (76 mm). The authors name, title of the paper and number of the
figure should be pencilled lightly on the back of each illustration. Black
and white transparencies and prints are acceptable. Colour is preferred.
Where transparencies are submitted, they should be accompanied by
a set of prints. Prints should be clear and sharp. Original x-rays should
be submitted if available to allow logotronisation. If this is not possible,
good quality prints will suffice.

Format References
Manuscripts should be typed, double-line spaced, on one side of the In the text references should be cited by a number eg. (1) (2) (Vancouver
paper only and with wide margins, in the English language. A covering style). A list of references at the end of the paper marked with the
letter and three copies of the manuscript should be submitted together appropriate number should show the names and initials of the author,
with three sets of any illustrations. All abbreviations should be spelt the title of the paper, the volume number (plus issues number if
out in full the first time they are used in the text. Medicines should be appropriate) followed by page numbers. Example: Brown B.M., Davies
referred to by the generic name only. (A footnote stating clearly the B.G., Distemper in Elephants, EJCAP XX(1) p. 50-55. (Vancouver style)
proprietary name, countries where available and manufacturers can be
included). Measurements
Measurements should be expressed in the metric system or in SI units.
Papers Temperatures should be given in C. Centrifugation speeds should be
Papers should include a title of not more than 20 words, the names, given in g.
qualifications and addresses of each author, and a summary of not
more than 200 words. They should be set out in the following sections: Ethics
summary, introduction, materials and methods, results, discussion, Papers may be rejected on ethical grounds if the severity of the
acknowledgements and references. Clinical papers or case reports experimental procedure does not appear to be justified by the value of
should follow a similar overall arrangements, modified appropriately. the work presented.
The text should be as concise as possible; the whole length should not
exceed 4000 words except by special arrangements (that is, about four Submission Address
to six pages of EJCAP (depending on illustrations). FAO Prof Ellen Bjerkas,
Norwegian School of Veterinary Science,
Tables and illustrations PO Box 8146 - Dep,
Tables should be presented separately from the text. The legend should N - 0033, OSLO,
clearly explain what data the table is presenting without the need to Norway.
refer back to the text. Tables should not duplicate information presented
in figures.

210
 Secretariat or address to contact for information
(Full Association names are given at the front of the Journal)
Contact Address for Information Tel/Fax E-mail/Website
AFVAC Secretariat: 40 rue de Berri F-75008 Paris Tel: (33) 1 53 83 91 60 Fax: (33) 1 53 83 91 69 contact@afvac.com
AIVPA Director: Dr Giuseppe Tranchese, Via G. Marconi 107 - I-800030 I- Tel: (39) 081 8856776 Fax: (39) 081 8856622 info@seltravet.it
800030 Mariglianella (Naples) Italy www.seltravet.it
APMVEAC Director: Dr. Vieira Lopes, Rua Amrico Durao No 18-D/as Olaias P-1900 Tel: (351) 1 840 41 79 fax: (351) 1 840 41 80 v.lopesvet.farm@mail.telipac.pt
Lisboa
AVEPA Secretariat: Paseo San Gervasio 46-48, E7E-08022 Barcelona Tel: (34) 93 2531522 Fax: (34) 93 4183979 www. avepa.es
BASAV Director: Dr. Boyko Georgiev, Tzarigradsko shausse 73 Sofia 1113, Tel: (359) 88 927160 Fax: (359) 66 44 50 boykog@netbg.com
Bulgaria
BHSAVA Contact: Dr. Josip, Krasni-Alipasina St. 37 7100 Sarajeva Bosnia and veterins@bih.net.ba
Herzegovina
BSAVA Secretariat: Woodrow House 1 Telford Way, Waterwells Business Park Tel: (44) 1452 726700 Fax: (44) 1452 726701 www.bsava.com
Quedgeley, Gloucester GB-GL2 4AB
CSAVA Director: Dr. Jiri Beranek, University of Veterinary and Pharmaceutical Tel: (420) 603 272 796 Fax: (420) 549246974 MED.PROD@worldonline .cz
Sciences Palackho 1/3 612 Brno Czech Republic
CSAVS Director: Dr. Davorin Lukman, Specijalizirana Ambulanta Varazdin Tel/Fax: (385) 42 331 895 dr.lukman@vz.htnet.hr
Trnovecka 6, 42000 Varazdin, Croatia
DSAVA Secretariat: Emdrupvej 28 A, DK 2100 Copenhagen Tel: (45) 38 71 08 88 Fax: (45) 38 71 03 22 ddd@ddd.dk
ESAVA Director: Dr. Tiina Toomet, Kopli 4A Tallinn, EE- 10 412.Estonia Tel: (372) 6413 11 Fax: (372) 641 3110 kevade@uninet.ee
FAVP Director: Dr. Kaj Sittnikow, Ykskoivuntie 32, FIN-23500 Uusikaupunki Tel: (358) 2 844 2580 Fax: (358) 2 844 2589 kai.sittnikow@pp.inet.fi *
GSAVA Contact: Dr. Friedrich Roecken, Christian-Albrecht-Str. 16, D-24837 Tel: (49) 4621 32404 - Fax: (49) 4621 31048 Friedrich.Roecken@t-online.de
Schleswig
HSAVA Director: Dr. Zsolt Kendik, Isvan u. 2 Budapest H-1078 Tel: (36) 305950750 zskendik@yahoo.com
HVMS Director: Dr. Katerina Loukaki, Protopapa 29, Helioupolis, GR- 163 43 Tel/Fax: (30) 2109932295 loukaki1@otenet.gr
Athens
LAK Secretary: Tom Angel, 28, rue de Syren L-5870 Alzingen Tel: (352) 36 9807 Fax: (352) 36 9807 tomangel@compuserve.com
LSAPS Director: Dr. Lita Konopore, Zvaigznju Gatve 2 Riga, LV-1082 Tel: (371) 7546 366 Fax: (371) 7606 202 lita@tl.lv
LSAVA Contact: Dr. Saulius Laurusevicius, Tilzes 18, LT-47181 Kaunas Tel: (370) 698 45876 - Fax: (370) 373 63490 sac@lva.lt
MSAVA Director: Dr. Pero Bozinovski, Ul. Lazar Ppo Trajkov 5-7 Skopje, Fyrom Tel: (389) 91 115 125 Fax: (389) 91 114 619 cocrevet@hotmail.com
MVA Director: Dr. C.L. Vella, Blue Cross Veterinary Clinic Msida Road, Tel: (356) 225 363 Fax: (356) 238 105 carmel.lino.vella@magnet.mt
Birkirkera, Malta
NACAM Director: Dr. Leen den Otter, Dorpsdijk 16 - NL - 3161 KE Rhoon Holland Tel: (31) 10 5012414 denotter@vetweb.org
NSAVA Director: Kjetil Dahl, PO Box 6781 St. Olavs Plass N-0130 Oslo Tel: (47) 22 994600 Fax: (47) 22 994601 kjetdahl@online.no
PSAVA Director: Dr Jerzy Gawor, Secretariat PSAVA 20-934, Lublin Tel: (81) 44 56 158 www.pslwmz.org.pl
RSAVA Contact: Dr. A. Tkachov-Kuzmin, V-Kojinoi, 23 121096 Moscow, Russia Tel/Fax: (7) 095 921 6376 movet01@mail.ru
SAVAB Director: Dr. J van Tilburg, Ernest Claeslaan 14 B-2500 Lier Tel: (32) 3 489 2309 Fax: (32) 3 480 1942 Vtilb001@skynet.be
SCIVAC Secretariat: Palazzo Trecchi Via Trecchi 20 I-26100 Cremona Tel: (39) 0 372 460440 Fax: (39) 0 372 457091 www.scivac.it
SkSAVA Director: Tibor Brauner, Uhrova 1 831 01 Bratislava Slovak Republic Tel/Fax: (421) 7 54 78 80 93 tibor@brauner.sk
SMASAP Director: Denis Novak, Dr Ivana Ribara 186/30, 11070 Belgrade, Serbia Tel/fax: (381) 11 2851 923; (381) 11 382 17 12; novak@ptt.yu
www.smasap.org.yu
SSAVA Director: Dr. Anne Carlswrd, Jnkping Small Animal Hospital Tel: (46) 36 34 18 80 Fax: (46) 36 34 18 85 anne.carlsward@hotmail.com
Oskarshallsgatan 6 8-553 03 Jnkping
SVK/ASMPA Director: Dr. Peter Sterchi, Mhlegrund CH-3807 Iseltwald Tel: (33) 845 11 45 peste@bluewin.ch
SZVMZ Director: Dr. Zorko Bojan, Veterinary Faculty, Gerbiceva 60, SLO-1000 Tel: (386) 14779277 Fax: (386) 647007111 Bojan.zorko@vf.uni-lj.si
Ljubljana, Slovenija
TSAVA Director: Dr. Mustafa Aktas, University of Istanbul- Faculty of Veterinary Tel: 0212-4737070/17297 Fax: 0212-4737240 aktasmus@yahoo.com
Medecine, Dept. of surgery. Avcilar Campus. 34320-Avcilar/Istanbul- www.anadolumcongress.org
Turkey
USAVA Director: Dr. Vladlen Mykhaylovich Ushakov, 8 Filatova str., Apartement Tel.: (380) 503369810 Fax: (380) 482 606726
24, Odessa 65000, Ukraine
VICAS Director: Dr. Peter A. Murphy, Summerhill Veterinary Hospital, Wexford, Tel: (353) 5391 43185 Fax: (353) 5391 43185 drpamurphy@eircom.net
Co. Wexford Ireland by request www.veterinary-ireland.org
VK Director: Dr Silvia Leugner, Royal Canin sterreich GmBH Hietzinger Tel: (43) 1879 1669 DWI8 - Fax: (43) 18791669-11 Silvia.leugner@royal-canin.at
Hauptstrasse 119, A-1130 Wien
Associate members
ESAVS Contact: ESAVS Office Birkenfeld, Schadtengasse 2 D-55765 Birkenfeld Tel: (49) 6782 980650 Fax: (49) 6782 4314 ewelina.skrzypecka@esavs.org
www.esavs.org
ECVD Contact: Dr. Dominique Hripret, Clinique Vtrinaire Frgis 43, avenue Tel: (33) 149 85 83 00 Fax: (33) 149 85 83 01 domheri@wandoo.fr
Aristide-Briand F-94110 Arcueil
ECVS Contact: Executive Secretary ECVS Office Vetsuisse Faculty University Tel: (41) 44 635 84 08 Fax: (41) 44 313 03 84 ecvs@vetclinics.unizh.ch
Zrich Winterthurerstrasse 260, CH-8057 Zrich www.ecvs.org
ESFM Contact: Claire Bessant, Taeselbury, Highstreet, Tisbury, Wiltshire, GB Tel: (44) 1747 871872 - Fax: (44) 1747 871873 Claire@fabcats.org or
- SP3 6LD, UK esfm@fabcats.org
ESVC Contact: Dr. Chris Amberger, 96, rue de la Servette CH-1202, Geneve chamb@bluewin.ch
ESVCE Contact: Dr. Sarah Heath, 11 Cotebrook Drive, Upton, Chester GB-CH2 Tel: (44) 1244 377365 Fax: (44) 1244 399288 heath@vetethol.demon.
1RA co.uk or:
admin@vetethol.demon.co.uk
ESVD President: Chiara Noli Tel: (33) 149 85 83 00 Fax: (33) 149 85 83 01 pitnoli@iol.it domheri@
wandoo.fr
ESVIM Contact: Dr. Rory Bell, Department of Veterinary Clinical Studies Tel: +44 141 330 5848 Fax: +44 141 330 3663 mail@esvim.org
University of Glasgow, Bearsden, Glasgow, GB- G61 1QH
ECVIM-CA For Congress: Sharon Green Avenue du Guret 1 B-1300 Limal Tel: +32 10 400 603 Fax: +32 10 400 703 www.ecvimcongress.org
congress@ecvim-ca.org
ESVN Contact: Dr. Gualtiero Gandini, Dipartimento Clinico veterinario Facolt ggandini@vet.unibo.it
di Medicina Veterinaria Universit degli Studi di Bologna I-Via Tolara di
Sopra 50 I-40064 Ozzano Emilia (Bologna)
ESVOT Contact: Dr. Aldo Vezzoni, SCIVAC Palazzo Trecchi 20 I-26100 Tel: (39) 0 372 23451 Fax: (39) 0 372 20074 www.esvot.org
Cremona
EVDS Contact: Dr. Margerita Gracis, Piazza del Carmine 2 I-20121 Milano Tel: (39) 2 338 187 4498 Fax: (39) 02 878 353 mgracis@tiscalinet.it
EVSSAR Contact: Dr Alain Fontbonne, Dept of Animal Reproduction The National afontbonne@vet-alfort.fr.
Veterinary College7, Avenue Gnral de Gaulle F-94700 Maisons-Alfort

211

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