Rigid normograde rhinoscopy-assisted traction-avulsion removal of small middle ear polyps from the auditory tube in five cats.

CASE SERIES SUMMARY: This study aims to describe a novel minimally invasive technique for the removal of small middle ear polyps from the auditory tube openings in cats. Five cats with clinical signs of otitis externa and/or otitis media, and/or upper respiratory tract inflammation were included. All cats underwent pharyngolaryngoscopy under anaesthesia, CT scan of the head, neck and thoracic cavity, video-otoscopic examination, retrograde nasopharyngoscopy and normograde rhinoscopy. The five cats described in this study were all found to have significant respiratory tract inflammation (rhinitis, sinusitis, nasopharyngitis, otitis media) with small polypous protrusions from the auditory tube openings. A normograde rhinoscopy-assisted traction-avulsion (RATA) removal of these small polyps was performed in all cases without complications. The rostral nasopharynx was visualised by a unilaterally normograde advanced rigid endoscope passing the choana, and polyps were removed using a grasping forceps introduced in the contralateral nostril. Telephone follow-up revealed clear improvement in all cases. One of the cases was re-evaluated with a CT scan and endoscopy 4 weeks after treatment. The CT scan showed a significant improvement with no abnormalities in both external ear canals and air opacity in both tympanic bullae. Video-endoscopic examination revealed intact tympanic membranes with mild chronic abnormalities and patent auditory tube openings upon normograde rhinoscopy. RELEVANCE AND NOVEL INFORMATION: Rigid normograde RATA is a novel, minimally invasive and effective technique for the removal of small middle ear polyps from auditory tube openings in cats with otitis media.

Assessment of the effect of horseshoes with and without traction adaptations on the gait kinetics of nonlame horses during a trot on a concrete runway.

OBJECTIVE: To assess the effect of horseshoes with and without traction adaptations on the gait kinetics of nonlame horses during a trot on a concrete runway. ANIMALS: 5 nonlame adult light-breed horses. PROCEDURES: Kinetic data were obtained for each horse when it was trotted across a force platform within a concrete runway unshod (control) and shod with standard horseshoes; standard horseshoes with high profile-low surface area calks, with low profile-high surface area calks, and coated with a thin layer of tungsten carbide (TLTC); and plastic-steel composite (PSC) horseshoes. Kinetic data were obtained for the control treatment first, then for each of the 5 shoe types, which were applied to each horse in a random order. Kinetic variables were compared among the 6 treatments. RESULTS: Body weight distribution did not differ among the 6 treatments. Compared with the control, the greatest increase in forelimb peak vertical force was observed when horses were shod with PSC shoes. In the hind limbs, the greatest increase in peak braking force was observed when horses were shod with PSC shoes, followed by the TLTC and low profile-high surface area calked shoes. The PSC shoes yielded the greatest coefficient of friction in both the forelimbs and hind limbs. Stance time was longest when horses were shod with standard shoes. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggested that PSC and TLTC shoes provided the best hoof protection and traction and might be good options for horses that spend a large amount of time traversing paved surfaces.

Surgical resolution of uterine prolapse in three pet rabbits.

This report describes a surgical technique for resolution of uterine prolapse in rabbits. Three pet rabbits presented within 24 hours of parturition with a red mass protruding from the vagina, which was diagnosed as uterine prolapse. In the first case, an attempt to reduce the prolapse by manual compression was ineffective. A laparotomy was used to apply internal uterine traction while simultaneously using gentle external pressure with cotton-tip applicators and resulted in successful resolution. After repositioning, an ovariohysterovaginectomy was performed in all three rabbits. All rabbits recovered uneventfully. Laparotomic repositioning of the uterus and ovariohysterovaginectomy, not previously described in rabbits, was easy to perform and permitted resolution of uterine prolapse.

The Use of Intraoperative Skeletal Traction for the Repair of Pelvic Fractures: An Experimental Cadaveric Study.

OBJECTIVE: The purpose of this study was to evaluate the use of intraoperative skeletal traction for the surgical repair of pelvic fractures. Opposition and anchorage points for the application of traction were the same in all cadavers. MATERIALS AND METHODS: Cadavers from 10 adult dogs with a median body weight of 31.9 kg (range: 20-38 kg) were used. The fractures were experimentally created in all dogs to produce an oblique iliac fracture on the left side and a transverse fracture on the right (total of 20 fractures) at the same time. Dogs were positioned on an operating table in lateral recumbency and traction was applied first on the left side and then on the right after changing the position of the animal. Increasing amounts of traction were applied to each fracture and recorded until a distraction length of 2 cm was created between the bone fragments. The Kolmogorov-Smirnov test confirmed normality of the data, and a paired t-test was used to compare traction of the two fracture types. RESULTS: The measurement of traction and distraction of the bone fragments was possible in all fractures. A distraction of at least 2 cm was obtained with a mean peak traction force of 15.4 kg for transverse fractures and 18.6 kg for oblique fractures. CONCLUSION: Intraoperative skeletal traction provides a useful and reliable tool for the reduction in experimental oblique and transverse iliac fractures in dogs. There were strong correlations between body weight and the force required to obtain a distraction length of 2 cm in the fracture line; for oblique fractures, traction was related to the square of body weight, and for transverse fractures, the relationship between weight and required traction was near linear.

Effect of Caudal Traction on Mechanical Nociceptive Thresholds of Epaxial and Pelvic Musculature on a Group of Horses With Signs of Back Pain.

Direct muscular attachment from lumbar vertebrae to the caudal vertebrae of the tail suggests that caudal traction, also described as a tail pull, may affect lumbar vertebral segments and/or associated soft tissues in horses. Traction is a commonly used human manual therapy technique used for pain relief and anecdotally observed to relieve pain in horses. However, research is lacking validating the efficacy of manual caudal traction on the horse. The objective of this study was to determine if caudal traction has an effect on mechanical nociceptive thresholds (MNTs) in a group of horses with clinical signs of back pain. Pressure algometry was used to measure MNTs of five bilateral anatomical sites in the epaxial and pelvic musculature of 11 horses referred to physiotherapy because of clinical signs of back pain. Measurements were recorded both before and immediately after traction. A significant difference (P ≤ .05) was identified between mean before and after caudal traction algometry measurements in all described sites. The percentage of MNT increase was highest in the thoracic region (83%) compared with the lumbar (50%) and the pelvic (52.4%) regions. These results support an effect of caudal traction in increasing MNTs in the thoracolumbar and pelvic regions in horses. Further research to determine the clinical effect of this technique is warranted.

Resolução cirúrgica de pólipo inflamatório em ouvido médio de felino através da técnica de avulsão e tração por abordagem lateral: relato de caso / Surgical resolution of feline middle ear inflammatory polyp by lateral approach traction and avulsion technique: case report

O objetivo desse trabalho foi descrever um caso de pólipo inflamatório em ouvido médio de um felino e sua resolução cirúrgica através da avulsão e tração da massa após abordagem lateral. Um felino, fêmea, de 2 anos de idade, foi atendido no Hospital Veterinário Professor Sylvio Barbosa Cardoso, apresentando prurido intenso, dor e secreção fétida em região auricular. Pelo exame físico foi possível observar um nódulo em região de ouvido médio esquerdo. Associado a isso, o animal apresentava "headtilt" (inclinação da cabeça para o lado afetado). Foram solicitados exames hematológicos, radiografia de crânio e citologia da massa. O animal foi encaminhado para cirurgia de extirpação da massa. Foi feita uma incisão na pele sob o canal auditivo vertical palpável. A cartilagem foi liberada até o nível da junção entre as cartilagens auricular e anular. Com o auxílio de um fórceps, o pólipo foi agarrado e delicadamente girado até ser completamente extirpado de sua origem. A cartilagem e o subcutâneo foram fechados com material de sutura monofilamentar 4-0 e a pele foi fechada em um padrão de sutura subdérmica usando o mesmo material. A peça foi encaminhada para exame histopatológico, pelo qual confirmou-se a suspeita de pólipo inflamatório, através da observação de epitélio colunar ciliado. Utilizando a técnica cirúrgica TALA (avulsão e tração após abordagem lateral) foi possível obter melhora do quadro clínico do animal referido, rápida recuperação pós-cirúrgica e sem nenhuma complicação decorrente da técnica. Essa técnica, portanto, se mostrou satisfatória, melhorando significativamente a qualidade de vida do animal.

The aim of this study was to describe a case of inflammatory polyp in the middle ear of a cat and its surgical resolution through avulsion and mass traction after lateral approach. A female feline, two year old, was admitted at the Hospital Veterinário Professor Sylvio Barbosa Cardoso, presenting intense itching, pain and fetid discharge in the ear region. Physical examination revealed a nodule in the left middle ear region. Associated with this, the animal presented head tilt (inclination of the head to the affected side). Hematological examinations, skull radiography and mass cytology were requested. The animal was referred for polyp removal surgery. A skin incision was made under the palpable vertical ear canal. The cartilage was released to the level of the junction between the auricular and annular cartilages. With the help of a forceps, the polyp was grasped and gently rotated until completely removed from its origin. The cartilage and subcutaneous tissue were closed with 4-0 monofilament suture material and the skin was closed in a subdermal suture pattern using the same material. The piece was referred for histopathological examination, which confirmed the suspicion of inflammatory polyp by observing ciliated columnar epithelium. Using the TALA surgical technique (avulsion and traction after lateral approach) it was possible to obtain improvement of the clinical 3 picture of the referred animal, rapid postoperative recovery and without any complications resulting from the technique. This technique therefore proves satisfying, significantly improving the quality of life of the animal.

Middle ear polyps: results of traction avulsion after a lateral approach to the ear canal in 62 cats (2004-2014).

Objectives The objective of this study was to report the surgical outcome and complication rate of deep traction avulsion (TA) of feline aural inflammatory polyps after a lateral approach (LA) to the ear canal. Methods This was a retrospective analysis of data retrieved from an electronic database of 62 cats treated with TA after an LA (TALA) for removal of ear canal polyps. Long-term outcome was assessed via a telephone questionnaire survey with the owners. Results Domestic shorthair cats (48%) and Maine Coons (37%) were over-represented. The most common presenting clinical signs were otorrhoea, ear scratching and head shaking. Video-otoscopic examination confirmed a polypous mass in the ear canal in all patients. All 62 cats underwent TALA, with a mean surgical time of 33 mins for experienced surgeons (n = 4) and 48 mins (n = 12) for less experienced surgeons. The recurrence rate of polyp regrowth for experienced surgeons was 14.3% vs 35% for the less experienced surgeons. Postoperative complications included Horner's syndrome (11.5%) and facial nerve paralysis (3%). Otitis interna was not observed. Conclusions and relevance A lateral approach to the ear canal in combination with deep TA of an aural inflammatory polyp is an effective first-line technique that results in a low recurrence and complication rate.

Avaliação morfométrica de equinos do esquadrão de polícia montada dos municípios de lages, joinville e florianópolis-sc / Morphometric evaluation of equine from squadron of mounted police in lages, joinville and florianopolis-sc

O objetivo do presente trabalho foi avaliar as características morfométricas de equinos utilizados no patrulhamento ostensivo pertencentes aos Esquadrões de Polícia Montada localizados nos municípios de Lages, Joinville e Florianópolis - SC. Foram utilizados 101 animais (78 machos castrados, um garanhão e 22 fêmeas), com idade média de 11,9 anos e massa corpórea de 490,82±53,51kg. Foram tomadas 20 medidas lineares individuais, por meio das quais foram determinados 13 índices zootécnicos. Os dados foram avaliados segundo análise descritiva, e a comparação simples entre médias pelo teste t de Student (P<0,05). Houve diferença significativa entre machos e fêmeas com relação ao comprimento de garupa, largura da anca, perímetro da canela e IDT nos animais pertencentes ao Esquadrão de Florianópolis. Conclui-se que os equinos dos três Esquadrões avaliados são, em geral, animais baixos de frente, "longe de terra", eumétricos e longilíneos, e classificados entre animais de tração ligeira e de tração pesada.

The aim of this study was to evaluate the morphometric characteristics of horses utilized in ostensive patrolling belonging to Squadrons of Mounted Police located in the cities of Lages, Joinville and Florianópolis - SC. One hundred and one animals were used (78 geldings, a stallion and 22 females) with a mean age of 11.9 years and body mass of 490.82±53.51kg. Twenty individual linear measurements were taken, from which 13 zootechnical indexes were determined. The data was evaluated according to descriptive analysis and simple comparison between averages by Student's t test (P<0.05). There were significant differences between males and females in relation to hip length, hip width, cannon bone circumference and dactyl-thoracic index (DTI) in animals belonging to the Squadron of Florianopolis. We conclude that equines from three evaluated Squadrons are generally low front animals, "far from the ground", middleweight and large in shape, classified between light traction and heavy traction animals.

Evaluation of traction stirrup distraction technique to increase the joint space of the shoulder joint in the dog: A cadaveric study.

The objective of this study was to evaluate technical feasibility and efficacy of a joint distraction technique by traction stirrup to facilitate shoulder arthroscopy and assess potential soft tissue damage. Twenty shoulders were evaluated radiographically before distraction. Distraction was applied with loads from 40 N up to 200 N, in 40 N increments, and the joint space was recorded at each step by radiographic images. The effects of joint flexion and intra-articular air injection at maximum load were evaluated. Radiographic evaluation was performed after distraction to evaluate ensuing joint laxity. Joint distraction by traction stirrup technique produces a significant increase in the joint space; an increase in joint laxity could not be inferred by standard and stress radiographs. However, further clinical studies are required to evaluate potential neurovascular complications. A wider joint space may be useful to facilitate arthroscopy, reducing the likelihood for iatrogenic damage to intra-articular structures.

Neurological signs and pre- and post-traction low-field MRI findings in Dobermanns with disc-associated cervical spondylomyelopathy.

OBJECTIVE: To investigate whether the presence of neurological signs and magnetic resonance imaging findings could predict the presence of a traction-responsive lesion in Dobermanns affected by disc-associated cervical spondylomyelopathy. METHODS: Retrospective review of neurological signs and low-field pre- and post-traction magnetic resonance imaging abnormalities of the cervical spine (abnormal vertebral body shape and vertebral tipping, intervertebral disc degeneration, protrusion and ligamentum flavum hypertrophy) in Dobermanns with disc-associated cervical spondylomyelopathy. The main outcome of interest was response to linear traction (dynamic versus static) at C6-C7 intervertebral disc space. The association between investigated variables and response to linear traction was assessed. RESULTS: The study included 25 dogs. No association was identified between neurological status grading and the presence of a static or traction-responsive lesion. Of the investigated magnetic resonance findings, C7-T1 intervertebral disc degeneration was significantly (P = 0 · 03) associated with the presence of a traction-responsive lesion at C6-C7 intervertebral disc space. CLINICAL SIGNIFICANCE: The presence of C7-T1 intervertebral disc degeneration might help in predicting the presence of traction-responsive C6-C7 intervertebral disc lesions.

Per-endoscopic trans-tympanic traction for the management of feline aural inflammatory polyps: a case review of 37 cats.

Feline aural inflammatory polyps are benign growths originating from the tympanic cavity or the Eustachian tube. They usually occur in young cats, which present either signs of otitis externa and otitis media, or respiratory signs, depending on the direction of polyp growth. Neurological signs are also reported. Simple traction and ventral bulla osteotomy (VBO) are the most common techniques used for treating this condition in cats; corticosteroids are recommended to reduce risk of recurrence given the inflammatory nature of the disease. The most common complications after treatment are Horner's syndrome, polyp recurrence and facial nerve paralysis. The aim of this report is to describe the per-endoscopic trans-tympanic traction (PTT) technique for treating feline aural inflammatory polyps and to report the short- and long-term follow-up of this procedure. PTT allowed resolution of the aural inflammatory polyps in 94% of cats during a mean long-term outcome of 19 months. Three cats (8%) developed Horner's syndrome immediately after the PTT procedure, which resolved within a few weeks, and five cats had polyp recurrence (13.5%). Only two cats had a poor outcome and were diagnosed with chronic otitis media at 22 months, and chronic otitis media and polyp recurrence at 46 months after the PTT procedure, respectively. PTT was shown to be an effective technique for treating aural inflammatory polyps and registered fewer neurological complications (8%) than VBO (57-81%) or simple traction (43%), and a recurrence percentage (13.5%) similar to VBO (0-33%) and much lower than traction alone (57%).

Distraction-stabilisation of two adjacent intervertebral spaces in a Dalmatian dog with caudal cervical spondylomyelopathy.

A 4-year-old, 40-kg, male, entire Dalmatian was presented for evaluation of chronic neck pain and pelvic limb ataxia. Myelography revealed ventrodorsal (hourglass) extradural compression over the intervertebral space between the 5th and 6th cervical vertebra and ventral extradural compression between the 6th and 7th cervical vertebra. Cranial compression disappeared and caudal compression markedly diminished after performing cervical traction. MRI scan confirmed protrusion of intervertebral discs and spinal cord compression in previously mentioned intervertebral spaces. Surgical distraction-stabilization of both intervertebral spaces was performed using threaded pins and polymethylmethacrylate. The convalescence from surgery was uneventful and the dog was walking without any signs of paresis until 5 months after surgery when radiography revealed implants loosening. The dog recovered fully of the implant removal and remained asymptomatic for more than 30 months.

Surgical management of radial head luxation in a dog using an external skeletal traction device.

A five-month-old Airedale Terrier was presented with a history of right thoracic limb lameness. Clinical and radiographic examinations revealed caudolateral luxation of the right radial head. Surgical intervention involved an oblique proximal radial osteotomy and gradual craniomedial traction of the radial head using an external skeletal fixator (ESF) incorporating a traction device. The radial head was gradually reduced over 16 days. After radiographic confirmation of appropriate radial head reduction, a consolidation phase followed, with removal of the traction ESF after 24 days. Follow-up radiographs documented remodelling of the radial head. Clinical follow-up three years postoperatively revealed nearly normal ground reaction forces. Activity was unrestricted and there was no requirement for analgesic medications.

Therapeutic farriery: one veterinarian's perspective.

Therapeutic shoeing is best directed at a specific diagnosis, but in the absence of a specific diagnosis, it is frequently directed at a symptom. There are only so many ways to modify the function of the foot with trimming and shoeing. The design of a horse shoe may often be modified to improve one aspect of foot function. Modifying a horse shoe to improve one aspect of foot function almost invariably impacts another aspect of foot function. The application of horse shoes may be based on a specific diagnosis or directed at a symptom. The application of shoeing principles is best approached using theoretical reasoning based on the research data that are available and experience.

Device for lengthening of a musculotendinous unit by direct continuous traction in the sheep.

BACKGROUND: Retraction, atrophy and fatty infiltration are signs subsequent to chronic rotator cuff tendon tears. They are associated with an increased pennation angle and a shortening of the muscle fibers in series. These deleterious changes of the muscular architecture are not reversible with current repair techniques and are the main factors for failed rotator cuff tendon repair. Whereas fast stretching of the retracted musculotendinous unit results in proliferation of non-contractile fibrous tissue, slow stretching may lead to muscle regeneration in terms of sarcomerogenesis. To slowly stretch the retracted musculotendinous unit in a sheep model, two here described tensioning devices have been developed and mounted on the scapular spine of the sheep using an expandable threaded rod, which has been interposed between the retracted tendon end and the original insertion site at the humeral head. Traction is transmitted in line with the musculotendinous unit by sutures knotted on the expandable threaded rod. The threaded rod of the tensioner is driven within the body through a rotating axis, which enters the body on the opposite side. The tendon end, which was previously released (16 weeks prior) from its insertion site with a bone chip, was elongated with a velocity of 1 mm/day. RESULTS: After several steps of technical improvements, the tensioner proved to be capable of actively stretching the retracted and degenerated muscle back to the original length and to withstand the external forces acting on it. CONCLUSION: This technical report describes the experimental technique for continuous elongation of the musculotendinous unit and reversion of the length of chronically shortened muscle.

Anatomia dos tendões e ligamentos da região distal dos membros torácicos de asininos (Equus asinus) utilizados como veículo de tração animal e suas relações com a anatomia do eqüino doméstico / Tendon and ligament anatomy of the distal forelimb region in donkey (Equus asinus) used to traction role and relations with the domestic equine anatomy

A espécie asinina (E. asinus), desenvolve um papel fundamental na região Nordeste do Brasil, influenciando diretamente na renda familiar e conseqüentemente na economia local. Tendo em vista o grande número de afecções locomotoras e a falta de cuidados a que estão submetidos, realizou-se um estudo anatômico da região distal de seus membros torácicos, buscando-se subsídios à prática clínica e cirúrgica dedicada a esses animais, bem como a compreensão de sua maior resistência em apresentar sintomatologia frente a lesões locomotoras, quando comparado ao eqüino. A avaliação anatômica revelou características musculares semelhantes às já descritas para eqüinos. Os tendões e ligamentos desses animais apresentaram características particulares, mostrando suas origens e inserções, muitas vezes diferenciados do observado em eqüinos, emitindo projeções tendíneas que permitem uma melhor inserção articular e maior estabilidade do aparelho suspensório, garantindo mais segurança de movimentos durante as atividades físicas

The asinine species play an essential role in the northeast region of Brazil in the income of the local families and consequently in the local economy. Due to a large number of locomotor disorders and a lack of professional care, an anatomical study of the distal forelimb region of the asinine was carried out in order to gather information to improve the clinical and surgical practice in this species, and to explain the less susceptibility to locomotor disorders compared to equines. The anatomical study showed that asinine has similar muscular characteristics already described for equines. Tendons and ligaments showed proper characteristics with different origin and attachment already described for equines, emitting tendons projections that improve articular insertion and better stability in its suspensory apparatus allowing a bigger safety during the movement in physic activities

Distraction with bone cement plug as a treatment of caudal cervical spondylomyelopathy--report of three cases.

The aim of this report is the presentation of disc-associated caudal cervical spondylomyelopathy cases in dogs treated with the method of distraction and stabilization with the cement plug. Surgical operations were performed in 2 rottweilers and one cross-breed. In one case, two lesions were operated at the same time and in one it was a recurrence after 4 years (in the intervertebral space adjacent to the operated one--domino effect). Two cases were cured, in one the health state became worse and the patient was euthanitized. The applied method may give good clinical effects, however, some improvements could still be introduced.

The use of an external skeletal traction device for distal fractures in the dog. A clinical case series of 11 patients.

Metacarpal and metatarsal fractures in 11 patients were treated 'closed' with a specially designed External Skeletal Fixation (ESF) frame with a walking bar and traction applied to the digits. Mediolateral angulation had improved postoperatively in 10 of the 11 patients. Craniocaudal angulation had improved in eight patients and could not be evaluated in three due to ESF frame superimposition. At follow-up, eight patients had a good clinical function, whereas three patients were still slightly lame. Only minor ESF-related complications were seen (pin loosening, pin tract infection, cerclage wire breakage and bending of the frame), which resolved without intervention after frame removal.

Intraoperative skeletal traction in the dog: a cadaveric study.

A standard skeletal traction technique was applied to each major segment of the appendicular skeleton of ten fresh dog cadavers. Opposition points and anchorage points for the application of traction were determined for each skeletal segment. Traction was exerted by means of a micrometric traction stand, connected to the limb by bands or a stirrup. Traction was applied to the antebrachium and the tibia through nylon traction bands anchored to the metacarpus and metatarsus, respectively. A traction stirrup applied to the condylar region was used as the anchorage point to load the humerus and femur. Once a peak force of 25 kg weight was achieved, the load was monitored for half an hour to check for any variation. After that, each skeletal segment was osteotomized in the mid-diaphyseal region, and evaluated for any angular malalignment due to a mismatch between the axis of the bone and the applied loading. Any ensuing angular malalignment was successfully corrected by manoeuvres using the traction stand. The technique used in this study to perform intraoperative skeletal traction proved to be reliable and consistent for each segment of the appendicular skeleton.

Clinical application of intraoperative skeletal traction in the dog.

The purpose of this clinical study was to evaluate the technical feasibility of a method for pre-operative and intra-operative traction for reduction of fractures of the appendicular skeleton. Traction was used in 24 diaphyseal fractures in 21 dogs. For each dog, the data pertaining to signalment, limb circumference, fracture type, interval between fracture and surgery, and the traction modalities were recorded. In patients with a latency between trauma and surgery of less than three days, the duration of traction required to realign the bone segments was shorter than that required for older fractures (P = 0.02). Intraoperative malalignments were corrected by manoeuvres performed with the traction stand. Once realigned, fracture segments were kept stable for prolonged periods, without the need for a surgical assistant. Postoperative radiographs were evaluated for fracture reduction and axial alignment. Postoperative alignment was judged excellent in 21 fractures and good in three fractures. Fractures were stabilized using external skeletal fixation (n = 10), plates (n = 11) or locked nails (n = 3), depending on the fracture type. The use of the technique was straight-forward and easily applied in a surgical setting. However, its use requires careful application because of the potential for iatrogenic tissue damage.