Complications in Canine Cranial Cruciate Ligament Surgery. Ron Ben-Amotz

should be considered, when possible.

      2.2.3 MRSP Carrier Status

As Staphylococcus spp. have been identified as one of the most common bacteria contributing to the development of SSIs following TPLO, and MRSP SSIs are increasing in frequency, monitoring for carriers of MRSP has been investigated [4, 13, 21,31–34]. In one study, 4.4% of animals were identified to be MRSP carriers preoperatively and carriers were 6.72 times more likely to develop an SSI. While screening for MRSP may help to determine those animals at higher risk for SSI, current screening tests are time‐consuming and not practical for routine implementation as this would result in delaying surgery [21]. Additionally, in human medicine, the goals of methicillin‐resistant Staphylococcus aureus (MRSA) screening are to allow for decolonization preoperatively [35–38]. In veterinary medicine, preoperative decolonization of MRSP is a challenge, due to not only the limited number of effective antimicrobials against MRSP, but also the inherent challenges of topical treatment of the sites most commonly colonized – the nasal passages, pharynx, and rectum [21].

Table 2.3 American society of anesthesiologists (ASA) scores.

      Source: Based on Eugster et al. [2].

ASA I	Normal, healthy patients
ASA II	Patients with mild systemic disease
ASA III	Patients with severe systemic disease
ASA IV	Patients with severe systemic disease that is life‐threatening
ASA V	Patients that will not survive 24 h without surgical intervention

      While decolonization may not be feasible, it is reasonable to alter perioperative antimicrobial prophylaxis in MRSP carriers undergoing higher risk procedures like TPLO. This may include measures such as adding a single dose of amikacin preoperatively to the typical (e.g., cefazolin) antimicrobial regime, assuming renal health has been evaluated.

      2.2.4 Dermatitis, Clipping, and Skin Preparation

As mentioned, Staphylococcus spp. are amongst the most common bacteria causing SSIs. S. pseudintermedius is a commensal bacteria within the normal microbiome of dogs [39]. Assessment of the animal's skin for evidence of local or distant dermatitis is recommended, to reduce the risk of contamination of the surgical site (Figure 2.1). Despite this logical recommendation, 17.5% of all animals undergoing TPLO in one study had evidence of active local or distant dermatitis. Of those with local dermatitis, 16.7% developed an SSI and 10.2% with distant dermatitis developed an SSI [27]. As there was no significant difference identified between local and distant dermatitis resulting in SSI, the risk for SSI development should not be considered lower for animals with dermatitis not affecting the direct surgical site, as anecdotally thought, and postponement of elective orthopedic surgeries with local or distant dermatitis should be considered [27].

      Identifying the underlying cause of the skin disease is paramount for improving the skin barrier and reducing the risk for SSI development. Depending on the type and severity of the dermatitis, cleansing with medicated shampoos, application of topical antimicrobials or antifungals and/or systemic antimicrobials or antifungals may be required. When managing bacterial dermatitis, local to or distant from the surgical site, culture and susceptibility testing is recommended to guide antimicrobial therapy and determine if MRSP is present. While awaiting these results, empirical treatment is recommended with cephalexin (22–30 mg/kg, PO q8h) or clindamycin (11 mg/kg, PO q12h). Antimicrobials should be continued for 1 week beyond resolution of clinical signs.

      Ideally, the surgical site should be free of skin lesions prior to considering surgery. In circumstances where postponing surgery is not possible, topical treatment is recommended, along with the addition of amikacin to the routine perioperative antimicrobials. When lesions are located at sites other than the surgical site, topical treatment is recommended + systemic medications as determined by the extent of the disease process. Bathing these patients with a chlorhexidine shampoo the night prior to surgery can also be considered [40].

Before skin preparation can occur, hair is clipped from the proposed surgical field to facilitate direct skin preparation and the limb is suspended (Figure 2.2). Clipping should be performed following induction of general anesthesia and not sooner due to the increased risk for SSI development [41, 42]. This risk is likely associated with the greater potential for direct skin trauma that may occur when attempting to clip hair on a conscious patient. Any microtrauma caused by rough clipping or poorly maintained clipper blades may also play a role in increasing the risk for SSI development.

Skin preparation (Figure 2.3) begins with the removal of surface dirt and oils using a neutral, nonmedicated soap as antiseptic agents are not active in the presence of organic material. Antiseptic agents are subsequently applied to reduce the bacterial load present on the skin at the time of surgery. Antiseptic agents commonly used in veterinary medicine include povidone‐iodine and chlorhexidine gluconate (Figure 2.4). These antiseptic solutions are applied to the skin using a scrub technique or a paint or spray technique. Ultimately, contact time, meaning the time the antiseptic solution is in direct contact with the skin, is the most important aspect of skin preparation. Both the World Health Organization and the Centers for Disease Control and Prevention recommend the use of alcohol‐based solutions for surgical skin preparation [43, 44]. However, in veterinary medicine, aqueous solutions of povidone‐iodine and alcohol solutions of chlorhexidine gluconate have been proven to be equally effective in reducing bacterial colony‐forming units on canine skin [45, 46]. As many different antiseptic skin preparation solutions exist, following the instructions for your chosen product to ensure adequate contact time is key for appropriate skin preparation.

Figure 2.1(a) Mild bacterial dermatitis with pustules and plaques. (b) Mild to moderate localized dermatitis without pustules or plaques. (c) Moderate generalized dermatitis. (d) Severe generalized dermatitis over the medial aspect of the pelvic limb.

      Source: All photos courtesy of Dr Charlotte Pye, DACVD.

Figure 2.2 Hanging leg technique for limb suspension. (a) A piece of 2 in. tape is applied to the lateral aspect of the unclipped distal limb, with an equal amount of tape contacting the limb and extending beyond the distal aspect of the limb. (b) Using the 2 in. tape roll, a second piece of tape is placed on the medial aspect of the unclipped distal limb, mimicking the lateral aspect. The two sticky surfaces of tape are adhered together distally, with the entire tape roll remaining attached (for later use). (c) A third piece of 2 in. tape is wrapped from proximal to distal around the circumference of the unclipped distal limb. (d) The taped distal limb is covered in nonsterile Vetrap^TM. (e) Using the 2 in. tape roll that remains