Ortho teaser

RE: Ortho teaser

David Mills — Mon, 09 May 2016 09:34:10 GMT

[quote user="James Dunne"] did not look at where David worked, my apologies if any offence was caused.[/quote]

No offence at all. We do have occasional clients who can afford referral by selling their car/stash. I've not seen one as bad as this before, and the thought of trying to chip the avulsion off and start again filled with dread somewhat. As a I suspected, was not something to be entered into lightly!

RE: Ortho teaser

David Mills — Mon, 09 May 2016 09:31:05 GMT

Thanks for all replies and interesting discussion, esp Malcolm for his detailed response.

Compliance (and, as ever, cost) a real worry in this dog/owner so any surgical intervention needs to be carefully considered. Also the dog is a typical untrained staffie. I suspect finances/o commitment will dictate the decision but very useful to know there are surgical options that we could attempt. We do a large amount of orthopaedics here, last chance saloon stuff in a lot of cases, but hamstrung in many cases by owner commitment e.g. last humeral # we did (beautiful repair) a week ago on a cat the owner let out after a week and it came back in bits (now tripod).

RE: Ortho teaser

grumpyoldman — Sun, 08 May 2016 17:31:28 GMT

Wedge osteotomy cranial closing and latero-medial correction : works well in bulldogs with patella alta although sometimes you need to take a lateral wedge out of the distil femur as well . We see lots of SBTs with untreated TC avulsions that end up like this , problem is that if they cannot afford the original minor repair, dog recovers and just limps a bit so they wait until it gets worse. It ends up in a rescue ,then nice people get it fixed.

RE: Ortho teaser

Virginia Campbell — Sat, 07 May 2016 10:15:41 GMT

Interesting learning case for popcorn crunchers like me (though not so fun to have to deal with). Thanks for posting it.

RE: Ortho teaser

James Dunne — Fri, 06 May 2016 22:04:13 GMT

HI Wynne. Thanks for clarifying that; I did not look at where David worked, my apologies if any offence was caused. Agreed that the success of surgery is dependent on the input of owners (or lack of it...) as well as ourselves.

RE: Ortho teaser

Hannah Wynne Richards — Thu, 05 May 2016 11:39:56 GMT

James. David works in an RSPCA hospital, so referral isn't an option for him.

I'd be reluctant to perform surgery (even if it was within my capabilities) due to the history of repeated missed appointments. Owners who take 3 months to present in the 1st place aren't likely to observe post-op instructions.

Wynne

RE: Ortho teaser

Malcolm Ness — Thu, 05 May 2016 08:29:38 GMT

I think that amputation would be premature - this is a still growing young dog with potential to improve if left alone so that is a better option (than amputation) at this stage. Although the dog is lame at present (3/5) the rads show good muscling so I suspect that the leg is being reasonably well used much of the time.

There are multiple abnormalities, probably all consequent to an earlier injury of the proximal tibial physis that has caused a marked angular deformity in two planes - the most important is a caudal tipping of the proximal tibia with a centre of rotation only a few centimetres from the stifle joint. There is a lesser, but still significant, medio-lateral angulation. The proximal tibial physis is closed/closing with shortening of the tibia. It appears that there has been some compensatory lengthening of the ipselateral femur. The tibial plateau is very much steeper than normal and the patella is much too proximal and this appears related to the tilting of the tibial plateau and attached tibial tuberosity rather than an overlong straight patellar ligament.

What to do? I am not worried by the ugly appearance of the tibial tuberosity and equally I do not think that translocating this distally would be beneficial, or a good idea. The angular deformities are probably the key abnormalities to address. The steep tibial plateau angle will predispose this dog to cruciate failure and needs sorting. I would plan a cranial closing wedge osteotomy to reduce the tibial plateau angle below 10 degrees. A complex wedge can be planned to simultaneously address the medio-lateral deformity. Complex planning, but in essence just two bone cuts. Fixation will be a challenge. Ex fix is inappropriate given the small proximal fragment and the large tensile forces along the cranial aspect of the tibia. Bone plate(s) and screws supplemented with a cranial tension band would be my choice. The osteotomy surgery will move the tibial tuberosity distally and bring the patella back into a more appropriate location on the femur.

The prognosis is reasonable - a good functional outcome can be expected though some lameness/gait alteration will persist. There is some risk of complication and the surgery is not technically simple but certainly "do-able". If surgery is not an option (and the existence of an uncooperative owner might excluded it) then I would persevere with normal activity and NSAIDs until the dog passes skeletal maturity.

RE: Ortho teaser

John Flynn — Thu, 05 May 2016 00:11:10 GMT

I'd most likely amptuate that.

RE: Ortho teaser

James Dunne — Wed, 04 May 2016 18:44:09 GMT

Hi Tim

I think this one would benefit from referral. There is marked patella alta present. The tibial plateau looks to be steep also; I think that if you transpose the tuberosity distally there will be a large bending moment on the proximal tibia and your repair may fracture. Also, as you have already mentioned, the quads are under some tension already so you would expect some patellar tendinitis postoperatively. If referral isn't an option then I would warn the client bluntly about potential complications before attempting repair. The surgery itself might be reasonably straightforward but the repair will be under pressure afterwards. Protecting the repair with an 'A-bar' ESF would help, but in a young dog like this stifle ankylosis might develop quickly also. If you operate the occasional orthopaedic case, this is one to let someone else deal with. I'd be interested to hear other opinions.

RE: Ortho teaser

Tim Browning — Wed, 04 May 2016 16:43:15 GMT

I would be concerned if I cut it off, in an attempt to move down it might be difficult as muscles retracted now???

RE: Ortho teaser

Utlendigur — Wed, 04 May 2016 16:37:46 GMT

I wonder whether it would be possible to take an osteotome to the displaced tibial tuberosity then transpose it to somewhere approximately the right position with a pin and tension band. The proximal tibial growth plate looks like it's closed but the dog is still young so there may be some potential for the bones to remodel if the forces are in the right direction. Might be worth it if amputation is only other option - but owner compliance might be a problem??

I had a vaguely similar case years ago - 6mnth collie with a traumatic patellar luxation. Despite the dog being 100% lame after being found hanging from a gate by a back leg, they waited a couple of weeks before bringing her in - by which time the proximal tibia looked more like a hockey stick on the craniocaudal view and there was virtually no trochlear groove (because no patellar - that was forming a false joint on the medial condyle). Needed an extremely deep wedge trochlearplasty and I had to almost belay the tibial tuberosity under the tibial plateau because the tibial shaft was so far medial. I wasn't very hopeful but she did really well and was still using the leg well at 14-15yrs old.

Just a GP vet so expecting to be shot down in flames

RE: Ortho teaser

Richard Carter — Wed, 04 May 2016 16:36:39 GMT

use chisel to knock off displaced tibial crest and repair with nice pins/ fig 8? or is this a trick question?