Cranial draw 10 weeks post lateral suture placement

RE: Cranial draw 10 weeks post lateral suture placement

Malcolm Ness — Sun, 13 Sep 2015 09:01:52 GMT

[quote user="Will McMullan"] I know it doesn't rule out infection or late meniscal injury but the stifle is not obviously swollen or painful when manipulated so conservative management is what we're sticking with for now. We shall see in 4 weeks or so how he's doing.[/quote]

+ 1 for wait and see.

To the differential list, you must add progression/flare of the inevitable stifle OA. I would speculate that is the most likely scenario here and that is good because the dog is likely to do well in the medium and longer term.

As previously discussed, infection is less likely at this stage (though always a possibility, esp with multifilament prostheses); late meniscal lameness is typically associated with more effusion/synovitis and joint pin than is implied here. It is very likely that the meniscus is, by now, "injured" but most meniscal injuries are clinically benign. I would not attach too much importance to the palpable instability - all extra capsular techniques become less stable with time and the mechanics-modifying osteotomies are never stable.

My approach to this case would be to use NSAIDs while encouraging increasing activity (rest will only exacerbate the muscle loss etc and perhaps disguise a problem that requires a more aggressive approach). I would keep a close eye for evidence of infection that would lead me to remove the implants and an equally close eye for evidence of marked stifle effusion/synovitis which, in the presence of continuing lameness, would lead me to suspect so-called late meniscal lameness which should resolve following medial arthrotomy and removal of the damaged cause-medial meniscal horn.

RE: Cranial draw 10 weeks post lateral suture placement

Will McMullan — Fri, 11 Sep 2015 08:43:50 GMT

Thanks for all the replies, very helpful. TPLO was not an option in this case due to finances, otherwise they would definitely have been referred! I think that instability secondary to suture failure is the most likely issue here. Perhaps moderate muscle wastage and lack of use of the limb is contributing too as the dog seems more comfortable the more weight it bears. I know it doesn't rule out infection or late meniscal injury but the stifle is not obviously swollen or painful when manipulated so conservative management is what we're sticking with for now. We shall see in 4 weeks or so how he's doing.

RE: Cranial draw 10 weeks post lateral suture placement

grumpyoldman — Thu, 10 Sep 2015 22:50:46 GMT

Labrador = TPLO

RE: Cranial draw 10 weeks post lateral suture placement

Anthony Todd — Thu, 10 Sep 2015 19:52:57 GMT

[quote user="Robin Grimmer"]The op did examine the menisci at the time of surgery and said they were intact.[/quote]

Sorry, my reply was supposed to apply to another thread regarding the requirement, or not, to examine the menisci, where it appears this is not necessary yet in this thread the menisci were examined and intact.

RE: Cranial draw 10 weeks post lateral suture placement

Robin Grimmer — Thu, 10 Sep 2015 19:44:38 GMT

I would wait and see as Martin says. I think an infection at this stage is unlikely. The op can feel some drawer so it is likely the prosthesis has failed. They break anyway at some point. I think the dog will do ok in the long run. Some hydrotherapy may help. There could be an argument for doing a tplo, but I'm guessing the owners would be keener on conservative management.

RE: Cranial draw 10 weeks post lateral suture placement

Robin Grimmer — Thu, 10 Sep 2015 19:26:15 GMT

[quote user="Anthony Todd"]

[quote user="Lucas Beierer"] meniscal pathology,[/quote]

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.....

[/quote]

The op did examine the menisci at the time of surgery and said they were intact.

RE: Cranial draw 10 weeks post lateral suture placement

Michael Woodhouse — Thu, 10 Sep 2015 18:05:18 GMT

The advice from Vet Instrumentation that we use as part of the discharge instructions states:

Post Operative Care

A Robert Jones Dressing may be applied for three days.

For the next seven days there should be strict rest other than

toilet walks.

Over the next two months leash exercise gradually increasing

mobility of the stifle.

Swimming is beneficial to build muscle mass without weight

bearing.

Final stability of the repair is due to periarticular fibrosis. The

nylon will typically fail between 6 to 10 weeks if it is still

stabilising the stifle at this time. Loop failure at this time does

not affect outcome but may show itself as a transient lameness

of 1-2 days

This is exactly what you expect to happen. I don't believe for a second that the dog has developed an infection after 10 weeks. Continue to build exercise as you are - the dog will be fine.

[quote user="Anthony Todd"]they go on to say that the menisci should always be examined at the time of cruciate surgery.[/quote]

That is just their opinion. I can't see a conclusive link to meniscal injury, opening the joint and improvement in the dog.

RE: Cranial draw 10 weeks post lateral suture placement

Anthony Todd — Thu, 10 Sep 2015 17:50:44 GMT

[quote user="Lucas Beierer"] meniscal pathology,[/quote]

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: Cranial draw 10 weeks post lateral suture placement

Lucas Beierer — Thu, 10 Sep 2015 17:35:10 GMT

Will,

There are 3 common reasons for post-surgical lameness following lateral suture at this time point post operatively; meniscal pathology, instability or infection.

If the dog's function has deteriorated then investigation is warranted. Arthrocentesis and submission for cytology/analysis and culture is a straight forward, minimal moribidity approach with a relatively low cost. This can hopefully rule out infection.

Menisci could be inspected non-invasively using MRI but this is a high cost procedure with false negative finding possible.

Meniscal inspection would require either an arthrotomy or arthroscopy. If performed, you would need to be prepared to replace the failed suture if meniscal pathology was not identified as you are only left with instability at this time. If meniscal pathology is present, I would probably leave the suture alone.

I would approach this case in the same fashion as above but would elect a TPLO rather than repeat lateral suture as it is more predictable in my hands.

However, the wait and see approach is reasonable also. The decision to go down this route will probably be guided by owners finances and their approach to risk as much as any medical justification. If the dog is comfortable and the deterioration is only recent, perhaps reviewing in 4-6 weeks would be sensible.

As a side note, it would be worth reviewing your technique (tunnel position, knot type and suture selection) and delving into the owners post operative care to see if any other factor has contributed to suture failure that you could perhaps alter next time around.

Lucas

RE: Cranial draw 10 weeks post lateral suture placement

Martin Atkinson — Thu, 10 Sep 2015 17:11:48 GMT

Whatever you do there is an 80% chance is will work! Given my understanding is that the suture would break down eventually and fibrosis around the joint provide stability, then at what point do say its job done? The sceptics may say they get better despite our treatment not because of it!

So if it was mine I would wait and see how it goes for another few weeks. The only caveat would be if its a young dog that some clever orthopaedics like TTA or TPLO would have been better in the first place especially as it now appears it may be bilateral.

Awaiting Malcolm.