MMP cruciate complications

Re: MMP cruciate complications

Rob Davis — Sat, 21 Sep 2013 10:33:54 GMT

I think you need to speak to the surgeon who did the original operations if you haven't already done so. They will be able to compare to the previous radiographs. They should also be aware of the poor outcome (not in terms of blame, but as part of their ongoing clinical audit). Some orthopods will do revision surgeries to correct complications at reduced cost, so may not be as expensive as you think.

Re: MMP cruciate complications

Julie Innes — Fri, 20 Sep 2013 19:04:33 GMT

Definitely not an arthropod (I tend to refer my cruciates!), but I had a similar case a few months ago- dog had had both cruciates done with some sort of implant (not v. sure which one ), was absolutely hopping lame- so lame that she wouldn't actually use either hind leg and bounced on her backside! The owners said she had prev improved when she was put on antibiotics. There was nothing on culture, but eventually in desparation I put her onto antibiotics and she has done amazingly, although she seems to need pulse therapy with the antib's or she deteriorates again. I'm thinking there may have been some infection at the implant site, but nothing obvious on Xray.

Re: MMP cruciate complications

mariette asselbergs — Fri, 20 Sep 2013 18:46:18 GMT

That sounds logical Martin, but for me when I forget my knee support when cycling or doing some exercise and it fills up, it immediately feels unstable, things crunch inside and ligaments feel painfully under tension. Once I put a tight elastic support on and the swelling disappears, the pain disappears completely too. Once the effusion is gone I can take the support off and all is fine. So don't know what comes first. But unfortunate that dogs have such funnelshaped knees!

Re: MMP cruciate complications

Chris Barker — Fri, 20 Sep 2013 18:14:18 GMT

Will be interested in Malcolm Ness' take on this but here's my take on it.

The implants are all extra-articular, in the MMP the titanium wedge is inserted without breaching the joint. The implants could be the source of pain but there is no immediate link between implants and the effusion.

I am concerned by the smooth edged lytic lesion evident in the distal end of the the femur.... Pathology...?

As to what evidence there is that dogs do better on the more complicated ops... To date anecdote but increasing evidence being built up I read an interesting article recently (think it was in a booklet of recent papers sent out by Boerhinger) which assessed one tibial advancing technique against the lateral suture technique by comparing 'diagonal symmetry' - I think it was a pressure plate analysis assessing the weight borne at the trot by the diagonal pairs of legs. This showed a faster return to weight bearing symmetry in the advancing ops as compared with the lateral support ops. And at 12 months those with advancing ops were virtually all diagonally symmetrical while consistently those with the support sutures were not. One study of one advancing op but encouraging for those surgeons performing them.

Re: MMP cruciate complications

John Flynn — Fri, 20 Sep 2013 09:57:45 GMT

[quote user="robloxley"]

[quote user="Robin Grimmer"] My question is: what advantages do these newer methods of cruciate repair offer?[/quote]

There was an interesting JSAP editorial asking the same question a couple of years ago which is worth a read. My (general practitioner) feeling is that in bigger, active/working dogs (and some westies!) the 'joint realignment' surgeries seem to offer a bit quicker and more reliable recovery, albeit at significantly higher cost and more potential for (potentially more serious) complications.

[/quote]

I'd echo what Rob says.

If you don't subscribe to JSAP, then there's this freely available from last year in Vet Ireland from John Innes of Liverpool uni:

http://www.veterinaryirelandjournal.com/images/stories/pdfs/sa/sa_jan_2012.pdf

A known skeptic amongst the academics of the TLA's for a number of years, possibly of the school that considers:

TPLO = "Totally Pointless Leg Operation"

TTA = "Tragic Tibial Assault"

TTO = "Top of Tibia Obliteration"

CWO = "Careless, wrecking operation"

CORA TPLO = "Can one really alter a Totally Pointless Leg Operation?"

etc.

Having said that, rumour has it that Liverpool is now so besotted with the MMP (Magical Mending placebo Procedure) that it's even trying to develop its own variation

In the case in question, however, I do wonder that if this was a question of ongoing stifle instability causing (or signifcantly contributing to) the lameness (I don't think it will be) what technique one would opt for? I might be tempted by a good ol' over-the-top (not something I've done for a number of years...) - any other thoughts?

Re: MMP cruciate complications

Mark Holmes — Fri, 20 Sep 2013 06:48:37 GMT

The tibial crest seems very lyric to me and that lyric patch in the proximal tibia is odd. If you zoom in youcan also get a subbursty impression on the periosteum if the tibial crest but not sure if this is the viewing media. try paying with the image (if digital) and see if any better view available. How about crank up its analgesia for a few weeks, give it strict rest and re - xray in a few weeks with a view to a biopsy. My analgesia protocol with something like this is 0.1 ml ketamine im, followed by NSAID and 10-20mg/kg paracetamol bid Empirical abs may be reasonsable in case the lysis is due to infection in that wedge

Re: MMP cruciate complications

Rob Loxley — Fri, 20 Sep 2013 00:09:14 GMT

[quote user="Robin Grimmer"] My question is: what advantages do these newer methods of cruciate repair offer?[/quote]

Re: MMP cruciate complications

Robin Grimmer — Thu, 19 Sep 2013 23:18:31 GMT

I understand what a TPLO is, but MMP, TTA, TTO is all gobbledygook to me. I do a fair amount of cruciates using the lateral fabellar suture (Veterinary Instrumentation) and generally get excellent results. My case selection tends to be the uninsured ones, and mainly smaller dogs < 20kg. My question is: what advantages do these newer methods of cruciate repair offer?

Re: MMP cruciate complications

Martin Atkinson — Thu, 19 Sep 2013 18:45:36 GMT

[quote user="mariette asselbergs"] What always surprises me is how effusion in the knee immediately makes it very [painful, and resolution of the joint effusion gives immediate improvement[/quote] Surely its the cause of the effusion that is painful not the effusion itself. My knees improve with a bit of effusion, I suspect it buffers the cartilage (or rather lack of it) a bit.

Re: MMP cruciate complications

David Mills — Thu, 19 Sep 2013 18:05:15 GMT

[quote user="Andy Elliott"]I would like to improve this dogs QOL and I need to ascertain if the lameness is a result of the OA or are the implants likely to be causing problems? At this stage is it just a case of conservative management for the OA or is further surgery likely to make a difference?[/quote]

I think you need someone to look at them who does these operations on a regular basis, and follows their cases up and so is used to dealing with complications. Often a local or distant orthopod will give you an opinion on radiographs - Malcolm Ness off here, for instance, does these, and so might pop along and give his slant. Otherwise a lot of it is guesswork.

For what it's worth, I don't do the op, but I have radiographed/seen radiographs post op (n=10). Looking at this radiograph, after 12 months, I'd be concerned about the proximal end of the wedge, the lack of bridging present and the lucency on the caudal edge, plus the area of lucency around the proximocranial aspect of the wedge. I've no idea what the pin is doing from this image. It may also be artefactual but there appears to be significant lucency at the cranial edge of the pin to the cranial edge of the tibial crest - is this the old pin track? And if so its large and appears non-unionised. You may be looking at a tibia in bits but for the metal work.

There, of course, may also be intracapsular pathology with meniscal tear etc high up on the list - they don't click that often IME.

I would, overall, be surprised if infection was responsible for the signs if they flare up with exercise - I would have expected a more progressive clinical course rather than waxing and waning, but this is related to plate implants etc in other areas.

I don't mean this disparagingly to the forum, but in something like this - a specialist procedure - it may not be the best place to ask about it. I would be going straight to my local orthopod with these images and making sure I was on the right track before subjecting this dog to further surgery to 'have a look around' (I appreciate you may have already asked orthopods)

Re: MMP cruciate complications

mariette asselbergs — Thu, 19 Sep 2013 15:40:46 GMT

Just 2 pence from somebody with OA knee myself. What always surprises me is how effusion in the knee immediately makes it very [painful, and resolution of the joint effusion gives immediate improvement. In other words, an elastic knee support is my solution for my knee as soon as I do anything exercise wise. Is there anything similar that can be used for dogs knees? Does the knee fill up with fluid during its 10 min walk/exercise?

Mariette

Re: MMP cruciate complications

John Flynn — Thu, 19 Sep 2013 13:56:28 GMT

[quote user="Andy Elliott"]Can we safely say that it is unlikely the broken orthofoam wedge is causing pain?[/quote]

I'm happy to say that - I'd go as far as to say that I don't think the lameness is associated with any of implants.

[quote user="Andy Elliott"]most useful next step assuming culture -ve would be arthrotomy/arthroscopy to examine the menisci.[/quote]

I think so. I'd definitely take a sample of synovium for tissue culture if doing this as much more likely to grow a bug if is one than on a synovial fluid sample. The thought of taking this sample at surgery would be my reason for not putting the dog on an empirical course of anitbiotics presently. However, I do appreciate that a dog having this number of surgeries and going on for a year that owners will understandably be quite reluctant for any further intervention, and if they weren't convinced enough for further surgical route then I would maybe try 3 weeks of empirical antibiotics and see if lameness improved (even if synovial culture came back negative).

There may be a degree of patella alta - you probably need a full set of pre-op and post-op radgraphs to get the most out of the current picture. I take it that the patella felt stable in the groove even in extension? (although with a lot of stifle thickening is hard to palpate I find)

Without a Cd-Cr view and hands on can't be sure that tibial tuberosity transposition hasn't resulted in patella luxation etc, but seems pretty improbable.

Patella tendon looks OK on this image to me.

What a horrible case to take over. I'm sure the original vet is pleased to see the back of it though!

Re: MMP cruciate complications

Hannah Wynne Richards — Thu, 19 Sep 2013 09:50:55 GMT

My bet , even if culturs neg would be osteomyelitis-the infection may be wallled off, but still causing lysis- however I'm not an orthopod.

I'm just glad it's your case, not mine! I feel really sorry for owners whose insurence has maxed out-they've done the right thing-but circumstances have been against them.

Wynne

Re: MMP cruciate complications

Andy Elliott — Thu, 19 Sep 2013 08:58:52 GMT

Thank you both for your comments. The stifle is thickened and it is not possible to definitively palpate the patellar tendon. There are no clicks, a fairly normal range of motion and the joint doesn't appear to be too painful when flexed and extended without weight-bearing.

I agree that the degree of lameness is more than would be expected for OA. Can we safely say that it is unlikely the broken orthofoam wedge is causing pain?

The previous vet has maxed out the insurance leaving me in a difficult position but I would agree that the most useful next step assuming culture -ve would be arthrotomy/arthroscopy to examine the menisci.

Re: MMP cruciate complications

Utlendigur — Wed, 18 Sep 2013 23:52:23 GMT

I'm not sure if I'm being helpful, and not really an orthopod....

What does the joint feel like - any clicks, any swellings/sinuses over the implants, pain, range of motion etc?

Is it just me or does the patella seem to be lying more proximal than normal. Does the straight patellar tendon feel ok?

Also - may be just being a pessimist/imagining things but there seems to be faint patches of lysis in the distal femur just deep to the trochlear ridge - any chance, given it's a boxer that there could be something neoplastic going on - unless it's just the contrast with the sclerotic bone.

Ditto re meniscal tears and/or infection

Re: MMP cruciate complications

John Flynn — Wed, 18 Sep 2013 21:46:31 GMT

you have a significant stifle effusion ongoing there.

my guess is that more so than i'dexpect due to progressive djd

could there be a boxer-style lateral meniscal tear? or a more regular medial one causing issues?

i'm not doing measurements, but tp-pt angle doesn't look far off 90deg and i think the advancement has gained mechanical advantage and is obviously stable in spite of implant issues.

assuming culture -ve, i'd go into joint from lateral standard artrotomy.