To amputate or not?

Re: To amputate or not?

Rod Hunt — Wed, 25 Jan 2012 17:08:36 GMT

With the multi-plane instability in this case, a normal stifle orthosis may not provide sufficient control and the tarsus might have to be included. We have recently been successful in fabricating one such device for a 60Kg + Wolfhound.

Re: To amputate or not?

Malcolm Ness — Wed, 25 Jan 2012 15:27:09 GMT

[quote user="Clive Ansell"]Would stifle arthrodesis be a viable option in preference to amputation?[/quote]

Horrible surgery - technically demanding, needs lots of cost;y implants, complications common and often major then the cosmetic and functional outcome is invariably disappointing. Cost-wise, a stifle arthrodesis is not much short of the cost of a total knee replacement which offers a much better outcome. Neither are appropriate (??yet) in this specific case.

Re: To amputate or not?

James Allsop — Wed, 25 Jan 2012 15:14:28 GMT

what about an external support whilst the tissues are fibrosing and healing?

http://www.orthovet.com/

Re: To amputate or not?

Clive Ansell — Wed, 25 Jan 2012 13:51:28 GMT

Would stifle arthrodesis be a viable option in preference to amputation?

Re: To amputate or not?

Nicola Lawlor — Tue, 24 Jan 2012 22:19:51 GMT

I don't know if this is of any use, but worth a consideration in the circumstances http://vetspecialists.co.uk/veterinary_professionals/pro_bono_scheme.html

Re: To amputate or not?

Michael Woodhouse — Tue, 24 Jan 2012 22:12:24 GMT

Thanks

Re: To amputate or not?

Malcolm Ness — Tue, 24 Jan 2012 22:06:50 GMT

[quote user="Michael Woodhouse"]Malcolm - if you are doing an extra capsualr technique for cruciate repair do you open the joint and inspect the meniscus?[/quote]

No, but we do a caudo-medial meniscal release.

I have a resident currently doing a systematic review of the literature on all things meniscal. You would be astounded by how sparse and weak the evidence for diagnosis and treatment of medial meniscal injury in the dog actually is.

Re: To amputate or not?

Michael Woodhouse — Tue, 24 Jan 2012 21:54:16 GMT

[quote user="Malcolm Ness"]the evidence base for interfering with the medial meniscus in dogs is remarkably poor considering how dogmatic some surgeons get![/quote]

Malcolm - if you are doing an extra capsualr technique for cruciate repair do you open the joint and inspect the meniscus?

Re: To amputate or not?

Malcolm Ness — Tue, 24 Jan 2012 21:49:05 GMT

[quote user="CatherineBoden"]I got advise from our local orthopaedic referral centre and they said that it would be reasonable for us to repair the collateral with screws and wire and also do an extracapsular cruciate stabilisation. He said the only proviso is that we should confident with the cruciate stabilisation and our ability to see and deal with any damaged meniscus. Do you not agree with this Malcom?[/quote]

No, I don't think that is a good idea. Although previously widely suggested, wire is a poor choice of material for ligament replacement. If the stifle is loaded and moves then the wire will fatigue and fail very quickly. If the stifle isn't moving then your surgery has failed. An extra capsular stabilising suture will only work if other ligamentous structures are intact, otherwise as it comes under tension the joint will twist destructively. I would delay doing anything with the medial meniscus unless it is grossly damaged - the evidence base for interfering with the medial meniscus in dogs is remarkably poor considering how dogmatic some surgeons get!

Re: To amputate or not?

CatherineThomas — Tue, 24 Jan 2012 21:30:34 GMT

[quote user="Malcolm Ness"]

Dogs have three legs and a spare so the patient will do good with three legs. BUT he will do much better with four . Amputation is a salvage procedure and should not be contemplated until all the better options have been rejected or tried and failed.

The ideal in this case would be to address the CCL rupture using an osteotomy technique - preferably TPLO because TTA will add strain to the collateral repair that should be made with screws and a prosthesis. That is not an option in this case and unfortunately there isn't a good surgical "plan B". Extracapsular stabilisations are contra-indicated in the absence of a functional collateral repair as the stifle will suffer femoro-tibial tosion due to the unopposed tension in the extracapsular suture.

That said, it is likely that this dog will improve quite substantially given time (3 mths or so) and pain control. At the end of that time you can decide whether or not function/pain-control is adequate. If it isn't then that is the time to consider amputation. In the interim, the owners might change their mind about surgery - there is no bursting urgency to repair this stifle though obviously, there will be a significant OA developing and the sooner it is sorted, the better.

To summarise - treat surgically only if you are confident of doing everything and doing it properly. Otherwise, manage conservatively and see how things develop over the coming weeks.

[/quote]

Thanks for the replys.

I got advise from our local orthopaedic referral centre and they said that it would be reasonable for us to repair the collateral with screws and wire and also do an extracapsular cruciate stabilisation. He said the only proviso is that we should confident with the cruciate stabilisation and our ability to see and deal with any damaged meniscus. Do you not agree with this Malcom?

Re: To amputate or not?

Malcolm Ness — Tue, 24 Jan 2012 20:39:08 GMT

To summarise - treat surgically only if you are confident of doing everything and doing it properly. Otherwise, manage conservatively and see how things develop over the coming weeks.

Re: To amputate or not?

Rob Davis — Tue, 24 Jan 2012 19:09:02 GMT

I have once amputated a forelimb from a 70kg Great Dane. I was very worried about how well he would cope, but by the time he came back for suture removal at 10 days post op, his owner had to have assistance bringing him in, not because he was struggling, but because he was getting too strong for her to hold on her own! Reason for amputation was an osteosarcoma, so predictably he was euthanased around 3 months later, but was very happy in the meantime.

Re: To amputate or not?

argyro koukouseli — Tue, 24 Jan 2012 19:05:40 GMT

very good sugestion.i totally agree.also tried once the "extracapsular repair" in a large mixed breed dog about 35 kg and it work remarkably well,along with pain control,and minimal exercise for the first 3 months and special nutricion_mobility rowal canin or.witch technic were you considering?definately do an x ray first

if it were me,i would charge almost the same for the amputation-its a large dog after all,could get tricky-and the surgery so that desicion isnt only a matter of money.

after all its their decision to make....

sometimes i really wonder,if only dogs could talk...

Re: To amputate or not?

Richard Carter — Tue, 24 Jan 2012 18:33:10 GMT

Can do bilateral fabella suture technique as described Piermattei/Flo for cruciate/collaterals. Managed to get a spayed lab about 20kg overweight back onto her feet when she managed to do in both stifles at same time. Try Malcolm as the resident orthopod?

Re: To amputate or not?

bob lehner — Tue, 24 Jan 2012 17:41:04 GMT

Give it lots of time - nature tries to heal most things.

My Missus had a riding mishap 3 months ago and bent her knee completely the wrong way, with lots of snapping noises ensuing.

The NHS eventually diagnosed ruptured medial, lateral and cruciate ligs via an MRI scan (took about 8 weeks to get the diagnosis).

No treatment - just a support splint for first month and then physio. It's doing fine -I'm not sure she would have gone for

amputation if it had been suggested.

Re: To amputate or not?

Mark Holmes — Tue, 24 Jan 2012 15:19:04 GMT

Still give it some time. If its still choosing three legs in 6 weeks chop it off.

Re: To amputate or not?

CatherineThomas — Tue, 24 Jan 2012 15:15:33 GMT

It's 10/10 lame on the affected leg, so is choosing to use 3 legs.

Re: To amputate or not?

Mark Holmes — Tue, 24 Jan 2012 15:10:35 GMT

Currently the dog could choose to use three or four legs and is choosing to use four. Surely that says that despite its injury the dogs preference is to use four rather than three. I would probably not rush into amputation but give it some time and analgesia as amputation could be done in 4-6 weeks with the same outcome.

Sorry Edit, I have just read the post better. maybe it isn't using the fourth leg presently but I think the argument still stands. Leaving the fourth leg in place for a while to see what the outcome is is of no detriment. Its on three legs now and will be if you rush into amputation but without the chance it will manage. If in 6 weeks it is walking on 3.5 then it is obviously prefering this to three legs.