Appendices B & C – Technique: Laser Treatments / Bumblefoot

Article by:  Jeannine Miesle, M.A., M.Ed 

Main Article about Bumblefoot  

Appendix B

Case Studies

Case Study I: Technique: Advancement of a Skin Flap as a Novel Treatment for Pododermatitis in a Red-tailed Hawk, Sander, et.al., JAMS (27), 2013

A novel technique for healing of Stage VII pododermatitis in a captive Red-tailed hawk was discussed in the Journal of Avian Medicine and Surgery by Samantha Sander, et.al. of Urbana, Ill. In this case, a captive hawk presented with inability to fly, and upon examination it was noted that a severe case of pododermatitis was present. This was due in part to the previous amputation of the second digit on the right foot, forcing the bird to put enough stress on the left foot to cause a tibiotarsal fracture. Over the next several months, the infection progressed from Grade I to Grade VII, and a multitude of treatments and preventive measures were taken, including medical and surgical treatments and environmental strategies. The left foot healed significantly, but damage was done to right foot during that time. The lesions on the right foot reached Grade VII, and despite treatment, were consistently more severe than the lesions on the left foot. 19

As the condition of the right foot deteriorated, additional treatments were utilized, including surgical debridement and closure of wounds. Aerobic culture yielded Streptococcus species, Pseudomonas species, and Coliform bacteria. During this time, the hawk stood primarily on his left foot. Seven and a half months after admission to the clinic, the primary pododermatitis lesion on the right foot encompassed the entire metatarsal pad. Ulcers developed on the skin and soft tissues on the plantar surface of the foot, and the tendon sheath was exposed. 19

Longer, more complex surgery followed. The wound was debrided and all diseased tissue removed. The granulated tissue was resected (surgically removed), and a single flap was created using the skin tissue between the remaining digits. The edge of the flap was advanced over the affected tissue, covering the entire lesion with healthy foot skin. The area was padded and bandaged, and a bandaging cast was applied to reduce pressure on the flap during weight bearing. 19

At first, it seemed that the wound was healing well; there was scabbing with partial dehiscence (opening of the wound), but that was managed. However, after four weeks, the area still had not healed. More debridement and treatment followed, and there was some improvement. Since the wound was healing appropriately, it was released to a wildlife rehabilitator for conditioning and evaluation of release status. But because the bird was forced to perch at a slight angle because of the missing digit on the other foot, it could not land on perches or grasp items. It was then euthanized because of its inability to apprehend live prey. This is the first time this new skin-flap technique was used. 19

Figure 40. “Grade IV pododermatitis lesion encompassing the metatarsal pad of the right foot of a  red-tailed hawk before surgery. The hawk experienced a traumatic amputation of digit 2 of the  right foot before admission. The digit was amputated later at the metatarsal-phalangeal joint”

Figure 40. “Grade IV pododermatitis lesion encompassing the metatarsal pad of the right foot of a red-tailed hawk before surgery. The hawk experienced a traumatic amputation of digit 2 of the right foot before admission. The digit was amputated later at the metatarsal-phalangeal joint” 30 (images courtesy Sander: Advancement of a novel skin flap as treatment for pododermatitis in a red-tailed hawk, AAV: JAMS, [27] 2013).”

Figure 41. “Pictorial re-creation of the advancement flap procedure in a red-tailed hawk. (A) The lesion as it appeared before surgery.

Figure 41. “Pictorial re-creation of the advancement flap procedure in a red-tailed hawk. (A) The lesion as it appeared before surgery. The ulcerate pododermatitis lesion is represented by the shaded circle at the level of the metatarsal pad, and the amputation site of digit 2 is represented by a hashed line. (B) Bilateral incisions (dashed lines) from the axial and abaxial edges of the debrided wound bed are made to develop a pedicle advancement flap by using the interdigital web skin between the third and fourth digits. The incisions extend over the web dorsally (not shown). (C) The pedicle advancement flap is created by elevating the skin from the subcutaneous tissue (light shading) and splitting the interdigital skin (dark shading). (D) The pedicle advancement flap is then used to cover the defect and is secured in place over the recipient bed.”

Figure 42. “The appearance of the surgical site 6 weeks after a pedicle advance flap was sued to surgically manage an advanced chronic pododermatitis lesion in a red-tailed hawk.”

Figure 42. “The appearance of the surgical site 6 weeks after a pedicle advance flap was sued to surgically manage an advanced chronic pododermatitis lesion in a red-tailed hawk.”

Case Study II: Technique: Use of a Vascular Access Port for Antibiotic Administration in the Treatment of Pododermatitis in a Chicken, Doneley, AAV: JAMS (29) 2013

In this case, a chicken was presented to Dr. Robert Doneley of Queensland, Australia with chronic pododermatitis in one foot. It had been treated conservatively at first, but later surgically. Various antibiotics had been used, and several attempts at bandaging with antibiotic-impregnated beads had been made, both with poor outcomes. Cultures revealed E coli infections and Klebsiella species. The E. coli infection was resistance to most antibiotics. The plantar surface contained deep ulcerations and swelling, and the bird was moderately lame. The foot was radiographed and swabbed for sampling. The radiographs showed moderate degenerative joint disease in the bones of the foot. The bird was sent home with instructions to clean the wounds daily and to give the bird antibiotics and pain killers on a daily basis. 7

Because the medications were not working as well as expected, the decision was made to implant a Vascular Access Port (VAP) in the right jugular vein to facilitate intravenous administration of the drugs. The chicken was hospitalized for two days then sent home with the owner with instructions on how to deliver medications through the port, cleanse the wounds, and change the bandages. Cultures were performed every two weeks, and after three consecutive negative culture results, treatment was discontinued. 7

After three months, the wound was healed; however, severe degenerative arthritis was present in many of the foot joints. This was managed with medications. Since there was no evidence of infection, the VAP was removed, and the bird went on to live a normal life with its medications. 7

Trauma to the plantar aspect of the foot leads to secondary infections with pathogens. These include Staphylococcus. aureus, Staphylococcus. epidermidis, Corynebacterium species, E. coli, Streptococcus faecalis, Pseudomonas species, Bacteroides species, Clostridium species, Candida albicans, and Aspergillus species 7

Figure 43. “Placement of a vascular access port in a domestic chicken for administration of long-term intravenous antibiotics. The right jugular vein (arrow) has been identified and mobilized.”

Figure 43. “Placement of a vascular access port in a domestic chicken for administration of long-term intravenous antibiotics. The right jugular vein (arrow) has been identified and mobilized.”

Figure 44. “Same as Figure 1. A tunnel has been created (arrows), connecting the incisions made for the placement of the port chamber and the catheterization of the jugular vein.”

Figure 44. “Same as Figure 1. A tunnel has been created (arrows), connecting the incisions made for the placement of the port chamber and the catheterization of the jugular vein.”

Figure 44. “Same as Figure 1. A tunnel has been created (arrows), connecting the incisions made for the placement of the port chamber and the catheterization of the jugular vein.”

Figure 45. Same as Figure 1. The “peel-away” sheath is removed after the intravenous cannula (arrow) has been introduced into the jugular vein.”

Figure 46. Same as Figure 1. Suturing the port chamber to the subcutaneous fascia.”

Figure 46. Same as Figure 1. Suturing the port chamber to the subcutaneous fascia.”

Figure 47. “Same as Figure 1. The vascular access port in situ after skin incisions have healed.”

Figure 47. “Same as Figure 1. The vascular access port in situ after skin incisions have healed.”


Appendix C

Technique: Laser Treatments

In 2014, ten veterinarians met during an Association of Avian Veterinarians conference to discuss the use of therapeutic lasers in treating avian and other exotics patients. Lasers are being used in veterinary medicine with positive clinical results, and low-power therapeutic lasers have proven effective for the treatment of wounds, reduction of inflammation, and modulation of pain. 17 The results of the discussion are as follows: 

  • All of the attending clinicians had used therapeutic laser treatment with birds and other exotics in their clinical work.
  • These uses included:
    • Healing wounds that have resisted previous therapies
    • Painful conditions 
    • Wounds and skin infections 
    • Postsurgical incision treatment
    • Osteoarthritis
    • Pododermatitis
    • Any inflammatory condition or traumatic lesion. 17

When asked about the kind of response they observed with therapeutic laser treatment compared to routine care, the practitioners responded positively: 

  • One practitioner responded that several cases of pododermatitis in small mammals and birds had improved, in some cases dramatically, with the addition of therapeutic laser treatments 
  • Another mentioned that he had seen faster healing, a decrease in the severity of his wound cases, and improved mobility in the orthopedic cases.
  • A third mentioned accelerated healing time, particularly in the dermal wound healing of the foot.
  • Another clinician saw considerable improvement in a chicken with bumblefoot, both in improved weight-bearing and decreased inflammation, after just one treatment. 34
  • One veterinarian found that laser treatments greatly reduced the bacterial colony in a wound.
  • Another clinician noted that the animals appear to tolerate the treatment very well and are even able to relax a little during the treatment. 17

 

Figure 48. “A cockatiel with a chronic long- term self-mutilation site responded to his one session two weeks ago and received another one just in case. Figure 48. “A cockatiel with a chronic long- term self-mutilation site responded to his one session two weeks ago and received another one just in case. We had performed a complete set of appropriate tests on him over the last two years including bloodwork radiographs as well as a removal and biopsy of the affected skin to rule out damaged nerves” (image courtesy Vanessa Rolfe, The Bird and Exotic Hospital; used with permission). http://birdexoticvet.com/lasertherapy/)

A discussion of the advantages and disadvantages of therapeutic laser treatment in avian patients yielded the following results:

  • The benefits: 
    • An increase in the level of healing for pododermatitis patients
    • An adjunct to medical therapy alone
    • Improved speed of treatment and response time, leading to less stress on the patient and better recovery and survivability of the patient. 17 
  • The drawbacks:
    • Difficulty in objectively determining the effectiveness or success of the laser treatments
    • The lack of specific protocols for the use of the laser
    • The large amount of mis- or disinformation being spread, which serves to confuse the clinician 
    • The lack of scientific studies in the literature about laser use. Those that are published sometimes have limited access, so clinicians may not have been able to read them and thus may not feel comfortable with their use. 17

All concluded that the advantages significantly outweighed the disadvantages. Although lasers have been used for some time by veterinarians, they have not been used as long by avian and exotic veterinarians. All agreed that the differences between avian tissue and mammalian tissue warranted more careful study of the techniques involved and results gleaned from such use, and far more care needs to be taken when applying laser treatment to birds.17

 

 

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Jeannine

Jeannine Miesle, M.A., M.Ed, Allied Member, Association of Avian Veterinarians is an important contributor to Beauty of Birds. Jeannine has done considerable writing, proofreading and editing for journals and newsletters over the years. She had taught English and music in the schools and presently is an organist at Bethany Church in West Chester, Ohio. She also administrates a Facebook group, The Science of Avian Health (https://www.facebook.com/groups/872079712863055). Jeannine takes in rescued cockatiels and presently has twelve birds. When they come to her they remain as part of her flock.