My first CCLR operation

RE: My first CCLR operation

Ian Paterson — Fri, 08 Jan 2016 22:43:51 GMT

Very late to this, but always interested in what others are doing. I still always perform a mini-arthrotomy as part of my CCL routines to visualise the damaged ligament (& remove redundant portions) and meniscI. Many years ago I didn't open the joint and instead performed meniscal releases medially. Figured this was not justified since I probably damaged many normal structures so stopped. Habit is a difficult thing to change but perhaps time to go back in time, not open the joint at all, but leave the medial meniscus alone. After all, probably statistically more sensible to re-operate on the very few that need it to perform meniscal surgery than to perform multiple arthrotomies that aren't necessary. The one breed I will always visually check menisci in though is the Boxer - had a couple over (many) years with lateral meniscal tears which just did not respond to any form of surgery/debridement/stabilisation/TPLO.

RE: My first CCLR operation

ChrisBVSc — Tue, 06 Oct 2015 23:29:08 GMT

I'm doing a lateral suture tomorrow on a collie cross with an acute traumatic CCL rupture, first one I've done for a few months and in the past I've always opened the joint - haven't done a huge number but so far haven't found any obvious meniscal damage. So, having read this thread, do I open it or don't I... looks like it'll have to be a coin toss before I scrub up!

RE: My first CCLR operation

Anthony Todd — Mon, 21 Sep 2015 23:05:05 GMT

[quote user="John Flynn"]I think the things that would put me off are:[/quote]

The big argument seems to be, though, whether the menisci are involved or not ie is it a failure of whatever stabilisation technique has been used or is it a "late"meniscal injury, which seems odd seeing as the cruciate ligament is in the same space....

Local into the stifle joint shouldn't be too difficult I would have thought [never having done it though].

Seems to me, that if you get a normal pain free gait after local injection then it may a meniscal involvement?

Can't see the point in opening the joint if there is no pain reduction, or elimination, after local injection.

RE: My first CCLR operation

John Flynn — Mon, 21 Sep 2015 07:54:09 GMT

[quote user="Anthony Todd"]Why couldn't the stifle joint just be filled with local to see whether the lameness disappeared; should be easy to do, quick and cheap?[/quote]

There are techniques described for diagnostic local anaesthesia in dogs - I've never personally tried them, but have considered it on occasions for instance in suspected shoulder lameness in a dog that jumped and yelped if put hands anywhere near it.

I think the things that would put me off are:

Lack of familiarity (I never liked doing this in horses either...)
Unecessary hassle (generally can localise lameness with physical exmaination in most dogs; treat 95% of lame dogs with meloxicam and lead-restriction irrespective of any diagnosis)
The sort of patient I would consider doing this in will likely need a general anesthetic to get needles where I'd like them, though I'd probably try under medetomidine/midazolam so could rapidly reverse if I thought would work OK.
Risk of iatrogenic damage (especially if not GA'd)
If chemically restraining a dog, not much hassle to radiograph whole limb and look for pathology such as soft tissue swelling to suggest where source of lameness may be.

If doing shoulder arthrography anyway, I can kind of see the idea behind blocking the joint at same time, but not sure how this would pan out practically in my own clinic setting:

http://vcot.schattauer.de/index.php?id=4087&L=1&schattauer_issue[issueId]=1766&schattauer_issue[manuscriptId]=19613&schattauer_issue[manuscriptMode]=show&cHash=dd4e4c89f12cb67bf0df8e61c7a7a4cc

RE: My first CCLR operation

Anthony Todd — Sun, 20 Sep 2015 22:26:02 GMT

Has anyone done what the horse vets do in diagnosis of leg lameness namely block the lower leg and see if the lameness disappears?

Why couldn't the stifle joint just be filled with local to see whether the lameness disappeared; should be easy to do, quick and cheap?

RE: My first CCLR operation

Martin Atkinson — Tue, 15 Sep 2015 14:28:24 GMT

[quote user="Robin Grimmer"]I recently read an article that said that the risks involved in general anaesthesia and arthroscopy in knees of middle aged men outweighed the benefits and that many achieved as good results with conservative management eg physiotherapy. [/quote]The meniscal injury in my left knee left me unable to run and after trying to let it resolve unsuccessfully for several months I finally allowed myself to go under the knife. It then took several more months before I was able to run pain free. I now suffer intermittent symptoms in my other knee but until they become crippling then a surgeon is going no-where near it. The menisci are there for a purpose removing them or parts of them alter the physio-dynamics of the joint and leads to other issues most notably premature onset OA. Many a footballer who has had torn menisci in order to continue to play has ended up with knackered knees. It is a career choice in their case but one they may regret later in life unless they're counting the millions. I would apply the same logic to my patients.

RE: My first CCLR operation

Robin Grimmer — Tue, 15 Sep 2015 00:07:19 GMT

[quote user="Malcolm Ness"]

[quote user="Anthony Todd"]well developed human industry in examining and doing something to human menisci and someone, by now, would have said it's a waste of time wouldn't they?[/quote]

The enthusiasm for treating every meniscal injury/problem in humans that appeared with the development of arthroscopy is waning - many more human knees are managed conservatively with intervention reserved for the persistent cases. There was some unhappiness around an investigation performed by a surgeon working on US sailors who did no arthroscopic surgery but instead just put the scope into the knee and flushed fluid through. It seems that his patients did as well as those who had had the full works. It is not at all clear whether the controversy arose because the surgeon was doing "placebo" surgery or because his results undermined the "nice little earner" that knee arthroscopy had become.

An interesting abstract I read recently reported 47% meniscal injuries on MRI of clinically normal human knees.

[/quote]

This is true. I recently read an article that said that the risks involved in general anaesthesia and arthroscopy in knees of middle aged men outweighed the benefits and that many achieved as good results with conservative management eg physiotherapy.

RE: My first CCLR operation

Malcolm Ness — Mon, 14 Sep 2015 20:51:30 GMT

[quote user="Evelyn Barbour-Hill"]Considering the anatomy and the function of the menisici, why would a meniscal injury cause non-self-resolving lameness? I can see that a split would allow the condyle to poke through, as it were, and contact the opposing tibia – but how would removing the split bit help there? Also, or so we were taught, a small split portion would be constantly flipping around in the joint, and that would especially apply to the famous "bucket-handle" tear; so removing these portions would make sense.[/quote]

We think similarly. All but the outside margin of the menisci is devoid of nerve endings. It seems likely that the painful cases relate to tension on the joint capsule arising from the larger sudo-medial portion being forcibly "sub-luxated". I can see no merit in trimming bucket handle tears - if the "poking through" were painful then by removing part of the meniscus you have facilitated rather than mitigated the poking.

RE: My first CCLR operation

Malcolm Ness — Mon, 14 Sep 2015 20:45:33 GMT

[quote user="cathal rafferty"]Given this statement, how then do you approach the dog with an obvious meniscal click on examination before any surgery. Would you leave even these ones alone?[/quote]

In the first instance, yes. Most meniscal clicks resolve with time and without surgery. I persisting pain is a feature then I will explore and perform partial meniscectomy.

RE: My first CCLR operation

cathal rafferty — Mon, 14 Sep 2015 11:31:11 GMT

[quote user="Malcolm Ness"]It is abundantly clear that almost all "meniscal damage" is clinically insignificant given that the only thing we can do upon discovering meniscal damage is to modify that meniscal damage. The neatly derided meniscus is still a damaged meniscus.[/quote]

Given this statement, how then do you approach the dog with an obvious meniscal click on examination before any surgery. Would you leave even these ones alone?

RE: My first CCLR operation

Evelyn Barbour-Hill — Sun, 13 Sep 2015 17:09:06 GMT

[quote user="Malcolm Ness"]just put the scope into the knee and flushed fluid through.[/quote]

Well, it was flushing away all those nasty cytokines and things – inflammatory mediators – so there was some logic beyond placebo?

RE: My first CCLR operation

Evelyn Barbour-Hill — Sun, 13 Sep 2015 17:05:00 GMT

From the genuine curiosity of one who doesn't do stifle surgery any more but did a good few in the Patsaama days:

Considering the anatomy and the function of the menisici, why would a meniscal injury cause non-self-resolving lameness? I can see that a split would allow the condyle to poke through, as it were, and contact the opposing tibia – but how would removing the split bit help there? Also, or so we were taught, a small split portion would be constantly flipping around in the joint, and that would especially apply to the famous "bucket-handle" tear; so removing these portions would make sense.

In those days gone by, I always tried/pretended to examine the menisci, but had to be honest with myself and admit that there were lots of bits I could not see or get at .Later I invested in a whopping great stifle distractor, which helped, but there were still bits I could not see. I was simultaneously wondering if this forcible distraction, this wrenching apart of the joint which is not constructed to be wrenched apart, was not in itself causing further lameness, if not actual injury.

RE: My first CCLR operation

Malcolm Ness — Sun, 13 Sep 2015 16:49:41 GMT

[quote user="Anthony Todd"]well developed human industry in examining and doing something to human menisci and someone, by now, would have said it's a waste of time wouldn't they?[/quote]

An interesting abstract I read recently reported 47% meniscal injuries on MRI of clinically normal human knees.

RE: My first CCLR operation

Malcolm Ness — Sun, 13 Sep 2015 16:40:39 GMT

[quote user="robloxley"]by doing arthrotomy at initial surgery we may not detect all meniscal damage[/quote]

The plethora of different techniques reported along with varying, and sometimes conflicting, data about numbers very strongly suggests that you will be missing many injuries. If you are expert and experienced at using arthroscopy + a stifle distractor + a probe, you will probably miss the fewest. If you routinely ignore the lateral meniscus (as most surgeons do) then you will be missing 50% or more.

[quote user="robloxley"]likewise some meniscal damage may be clinically insignificant [/quote]

It is abundantly clear that almost all "meniscal damage" is clinically insignificant given that the only thing we can do upon discovering meniscal damage is to modify that meniscal damage. The neatly derided meniscus is still a damaged meniscus.

[quote user="robloxley"]and addressing it has no benefit[/quote]

We have systematically reviewed the veterinary literature and can find no good evidence of any measurable benefit. However, there is lots and lots of firmly held and loudly expressed opinion!

[quote user="robloxley"](?could be detrimental?)[/quote]

Could be - though there is no direct evidence to show that it is. (remember that pretty much any clinical question with "could" will have "yes" in the answer.)

[quote user="robloxley"]by not doing arthrotomy at the outset we leave it to the clinical progress of the dog to inform us whether it is subsequently needed[/quote]That is pretty much what we do in every other sphere of medicine and surgery. The exception is when there might be a prophylactic benefit with early interference. Again, the literature provides no evidence whatsoever to show any prophylactic benefit from exploring the stifle at the time of surgery.

[quote user="robloxley"]is there evidence of longterm detriment of 'unnecessary' arthrotomy at the outset[/quote]

Apart from the inevitable cost of a surgery that has no definable benefits to the client or the patient, I know of no good evidence to quantify the detriment - mainly because it hasn't been considered or measured. (In fact, there is not a single report of cruciate treatment in dogs that features an appropriate control group). It would be a very unusual surgical procedure if there was not some incidence of complication.

[quote user="robloxley"]is there evidence that arthrotomy at the outset results in fewer late meniscal injuries and futher surgery down the line?[/quote]

No, none that we could find.

RE: My first CCLR operation

Anthony Todd — Sun, 13 Sep 2015 12:27:18 GMT

[quote user="robloxley"]by doing arthrotomy at initial surgery we may not detect all meniscal damage[/quote]

You certainly won't detect any at all if you don't have some sort of a look!

There is a well developed human industry in examining and doing something to human menisci and someone, by now, would have said it's a waste of time wouldn't they?

RE: My first CCLR operation

Rob Loxley — Sun, 13 Sep 2015 12:16:16 GMT

[quote user="Malcolm Ness"]realisation that "injury" and "problem" are not the same thing[/quote]

Correct me if I'm getting this wrong:
by doing arthrotomy at initial surgery we may not detect all meniscal damage
likewise some meniscal damage may be clinically insignificant and addressing it has no benefit (?could be detrimental?)
by not doing arthrotomy at the outset we leave it to the clinical progress of the dog to inform us whether it is subsequently needed

Some questions - is there evidence of longterm detriment of 'unnecessary' arthrotomy at the outset
is there evidence that arthrotomy at the outset results in fewer late meniscal injuries and futher surgery down the line?

RE: My first CCLR operation

Malcolm Ness — Sun, 13 Sep 2015 08:38:38 GMT

[quote user="Anthony Todd"]

[quote user="Malcolm Ness"]so-called late meniscal lameness.[/quote]

It may not be "late".

[/quote]

That is why I use the term "so-called". I refer to the "lameness" rather than "injury" - it is important to appreciate that very many, and almost certainly most meniscal injury are clinically silent.

RE: My first CCLR operation

Malcolm Ness — Sun, 13 Sep 2015 08:34:29 GMT

[quote user="Anthony Todd"]How could anyone tell unless they opened the joint at the same time as the cruciate replacement?.[/quote]

They can't and in fact, even if they do look, it seems that they will miss a proportion of the abnormalities (aka injuries) - there are lots of papers comparing techniques for inspection and though there is consensus that arthroscopy and probing detects most injuries and is therefore "best", the data presented across the literature presents only relatively weak evidence to support that contention.

The thing that changed my thinking about this was the realisation that "injury" and "problem" are not the same thing - many dogs have an injured meniscus that causes no problems. Some will speculate that this injured meniscus will go on to cause trouble later but that contention is contradicted first by the literature and also by common sense - menisci don't heal so the surgical response to a naturally occuring meniscal injury is to cut bits of it away, leaving, in effect, an iatrogenic meniscal injury!

There remains a considerable range of opinion on this subject but the evidence to support the universal exploration of stifles and meniscal interference simply isn't there.

[quote user="Anthony Todd"]I can't understand why a relatively atraumatic exploratory arthroscopy [if that's the word, ie opening the joint capsule] should be so painful and increase morbidity?[/quote]

Arthroscopy is arguably less painful than arthrotomy but it is still costly and not complication-free. Difficult to justify, for me, unless there is a demonstrable advantage to the patient, and as I have said, documenting a ragged, torn meniscus and turning it not a tidily torn meniscus is not an obvious advantage. Stifle arthroscopy is technically challenging and if the caudal horn of the medial meniscus is to be effectively viewed then instrument-assisted, and robust, stifle distraction is necessary. This is not a benign procedure.

RE: My first CCLR operation

Anthony Todd — Thu, 10 Sep 2015 17:53:15 GMT

[sorry, also pasted in the other "cruciate thread.]

Yeah, in an article that I can't copy, even the link, 40-60% of cruciate ruptures have concurrent meniscal pathology and they go on to say that the menisci should always be examined at the time of cruciate surgery.

https://s3.amazonaws.com/assets.prod.vetlearn.com/mmah/43/ed020ceadc4f9f88ae1df1ad826fb5/filePV1010_franklin_CE.pd

Managed to paste the link, which seems to suggest examining the menisci is a good idea when you have a cruciate rupture.....

RE: My first CCLR operation

Anthony Todd — Thu, 10 Sep 2015 17:05:05 GMT

[quote user="Malcolm Ness"]so-called late meniscal lameness.[/quote]

It may not be "late".

It may have happened when the cruciate ruptured, and you don't know unless you've looked, surely?

RE: My first CCLR operation

Anthony Todd — Thu, 10 Sep 2015 17:00:43 GMT

[quote user="Martin Atkinson"]Question is: was that injured at the time of the original injury and should have been dealt with at the time or did it develop separately later?[/quote]

How could anyone tell unless they opened the joint at the same time as the cruciate replacement?.

The idea, that the miniscus injury occurred after the cruciate repair seems totally devoid of evidence unless you've opened the joint at the time of cruciate repair and had a look!

I can't understand why a relatively atraumatic exploratory arthroscopy [if that's the word, ie opening the joint capsule] should be so painful and increase morbidity?

RE: My first CCLR operation

Martin Atkinson — Thu, 10 Sep 2015 15:59:17 GMT

[quote user="Malcolm Ness"]If you are able to explore the joint without additional cost to the client, without additional morbidity, without additional risk of complication then your point is a good one. How do you describe the benefit of exploring the joint given that there is no evidence of any benefit in terms of immediate pain control (the opposite is likely) nor any evidence of mitigation of the risk of so-called late meniscal lameness. What are you hoping to achieve with your conversion of a naturally injured, untidy meniscal injury into a neater, tidier but larger meniscal injury.[/quote]It is interesting how the opinions for orthopods have changed in just a short time. I don't know what your position was on this previously but it seems it was only a little while ago that the consensus was that we should all be exploring joints to remove torn menisci and were verging on negligence if we didn't.

For one I have found that exploring the joint has only ever resulted in increased surgical complications and prolonged recovery time. So I now never do and, although we've had words on this before, I claim an almost 100% return to full function within 3 months with the lateral suture method.

However my personal experience post torn ACL was that 2 years later I had to have a partial menisectomy in the same knee after I developed intractable pain. Question is: was that injured at the time of the original injury and should have been dealt with at the time or did it develop separately later?

RE: My first CCLR operation

Malcolm Ness — Thu, 10 Sep 2015 15:00:38 GMT

[quote user="Lucas Beierer"]I've seen too many cases of meniscal pathology (whether be a late meniscal injury following my TPLO, or a meniscal injury referred to me for management) to accept this is not a significant source of morbidity [/quote]

1. Menisci do not heal, so every meniscus that you have ever "treated" is, and remains, a "meniscal injury" - the onus is on the meniscal treaters to show that their iatrogenically injured meniscus is good while a naturally injured meniscus is bad. And then supply a plausible explanation.

2. What you choose to accept, or otherwise, is entirely up to you. However, current consensus amongst medical scientists is that the evidence should guide our practice.

[quote user="Lucas Beierer"]I don't see any benefit from not exploring the joint except saving time.[/quote]

If you are able to explore the joint without additional cost to the client, without additional morbidity, without additional risk of complication then your point is a good one. How do you describe the benefit of exploring the joint given that there is no evidence of any benefit in terms of immediate pain control (the opposite is likely) nor any evidence of mitigation of the risk of so-called late meniscal lameness. What are you hoping to achieve with your conversion of a naturally injured, untidy meniscal injury into a neater, tidier but larger meniscal injury.

I am not at all interested in your opinions unless they are supported with evidence.

RE: My first CCLR operation

Lucas Beierer — Thu, 10 Sep 2015 14:14:21 GMT

Malcolm,

I respect your opinion and heard you make this argument at ESVOT last year. I enjoyed the talk and spent some time contemplating your argument. I however, am not buying what your selling at this moment in time.

To argue that the absence of evidence is enough justification makes no sense to me. No one has explored amputation as a treatment for cruciate deficiency but I am not going to jump into this approach. I also think it is very important that a concurrent meniscal pathology at the time of the original surgery is distinguished from late meniscal injury (one that occurs subsequent to surgery). You simply cannot make this distinction if you have not assessed its integrity at the time of the original surgery.

I've seen too many cases of meniscal pathology (whether be a late meniscal injury following my TPLO, or a meniscal injury referred to me for management) to accept this is not a significant source of morbidity for dogs. I need to be able to sleep at night and I can only doing this knowing I've explored the joint and;
- confirmed a CrCL tear is present and characterised
- assessed both menisci, managed pathology if present and documented if not
- assess the CaCL

I don't see any benefit from not exploring the joint except saving time. To argue this induces significant inflammation or accelerates degenerative changes does not make sense to me given that you have such a marked inflammatory process taking place owing to the primary degenerative process.

Michael - if your claiming you've performed 40-50 lateral sutures, never opened a joint and never had a complication (except for a single neoplasm) then your a better surgeon (or lucky enough that a lotto win is on the cards) than anyone I've seen operate. Those sort of numbers defy anything published on the technique over the past 20 years.

Interesting discussion, however stifle exploration is, in my opinion, critical to the successful management of cruciate pathology.

Lucas

RE: My first CCLR operation

Malcolm Ness — Wed, 09 Sep 2015 15:41:18 GMT

It isn't an either/or situation.

There is absolutely no evidence that stifle exploration and meniscal surgery at the time of cruciate repair has any [beneficial] effect in terms of relieving pain or resolving lameness in the short term and similarly no evidence that the likelihood of lameness due to late meniscal injury is reduced. Bear in mind that in almost every case series of cruciate surgery published to date, stifle exploration and meniscal surgery is the norm yet the most commonly reported reason for re-operation of these same dogs is to deal with lameness presumed due to late meniscal injury.