Bilateral Cruciate

RE: Bilateral Cruciate

Anthony Todd — Mon, 28 Nov 2016 08:50:08 GMT

[quote user="Emily Rainbow"]

Maybe beacause most insurance companies now class cruciate rupture as a disease so if he second one 'goes' more than 12months after the first they are no longer covered.

(I'm fighting the corner for one who was clinically normal for 4.5years after the first TPLO and had just needed the second done. Insurance company saying it's the same thing and therefore they will not pay)

so this is still ongoing!

The insurance company has asked me to explain the exact aetiology for each rupture as they automatically class them as being caused by the same underlying disease process. Whilst I appreciate they could be related how can they prove the aetiology that it is?

[/quote]

It would be the client who would have to contest the refusal, as the policy holder, I assume?

I would have thought it might be worth the client's taking the claim to the insurance ombudsman. The VDS, or even the BVA, +- various experts should be willing to help as a matter of scientific fact.

Otherwise no "cruciate" will soon be insurable.

RE: Bilateral Cruciate

Emily Rainbow — Mon, 28 Nov 2016 08:36:34 GMT

[quote user="Emily Rainbow"]

Maybe beacause most insurance companies now class cruciate rupture as a disease so if he second one 'goes' more than 12months after the first they are no longer covered.

[/quote]

so this is still ongoing!

RE: Bilateral Cruciate

Anthony Todd — Thu, 10 Nov 2016 19:05:39 GMT

[quote user="David Mills"]This is our experience too.[/quote]

+1 [and I don't often see eye to eye with the poster but this time.

Mind you a mal-union probably hasn't pain, just painless disability to a greater or lesser extent.

I wonder whether [being a dinovet] you, are not in grave danger of doing the "best" or "gold standard" or "state of the art" because some of you can.

Trouble is, with the current and developing hierarchic tiers of practice, where a plain vet is basically a tradesman with a degree, if an owner wants an animal "fixed" to the highest and best standard referral is the only option.

I'm not sure that the animal is grateful for the developing distinction.

RE: Bilateral Cruciate

David Mills — Thu, 10 Nov 2016 16:01:48 GMT

[quote user="grumpyoldman"]

[quote user="janine redman"]However this would not seem to be an option these days as it is perceived to be cruel?[/quote]

[/quote]

This is our experience too.

I went on a fracture course and the point was made that animals with fractures have been healing themselves for 1000s of years.

However, some will either not heal or heal with disability and ongoing pain. The key is to pick out those that will do fine with cage rest (those either presenting with a stable fibrous callus and roughly alligned bones and reasonable locomotion) and those that need intervention. It's not easy - I've posted several on here, and there is often a wealth of replies. Cats seem to be better in this respect that dogs, with the exception of small young dogs/pups.

I've currently a cat who was presented as a stray on my knee at home that decided it didn't want my beautiful pin and cerclage wires in his humerus, and has been room rested (ish) for the last 8 weeks. He is now is sound on that leg as the normal one. He's due some x-rays tomorrow so I'll post them up if I remember. This was one that looked like it needed intervention, but, functionally now, probably didn't.

RE: Bilateral Cruciate

grumpyoldman — Thu, 10 Nov 2016 15:12:42 GMT

[quote user="janine redman"]However this would not seem to be an option these days as it is perceived to be cruel?[/quote]

We see many stray and feral cats with lameness from old injuries that have healed themselves .some are motoring well some extremely lame and very uncomfortable ,not sure you can generalise but many do seem to recover without direct intervention . However If you do nothing with the wrong client and it goes off to a rival small business who immediately get the wooden spoon out your immediately sitting in a shit storm from client and possibly the great and good who know and see everything .

RE: Bilateral Cruciate

janine redman — Thu, 10 Nov 2016 14:19:27 GMT

Do we know how much is pain and how much is instability which affects the ability to stand and move. There are some two legged and lots of three legged dogs around. I think the option of surgery or not is multifactorial. it depends on the level of pain and discomfort both short term and long term, the level of disability short term and long term , the owners expectations and ability to manage a disabled dog. This included managing a large breed dog with mobility issues.

i know that in previous years I managed several cats with broken back legs by pain relief and cage rest. I think even in retrospect they managed better in the long term than those that have amputation surgery because owners cannot afford fracture fixation. Most healed really well, sometimes with a bit of a limp due to limb shortening . However this would not seem to be an option these days as it is perceived to be cruel?

RE: Bilateral Cruciate

Anthony Todd — Thu, 10 Nov 2016 14:14:12 GMT

[quote user="Hannah Wynne Richards"] You can deal with post-op pain by giving adequate analgesia. How do you lessen suffering in a dog that can't stand on either hind leg?[/quote]

You can't and, as others have said, they have been PTS but, as I have repeatedly pointed out, read the anecdoatal evidence!

RE: Bilateral Cruciate

Hannah Wynne Richards — Thu, 10 Nov 2016 13:38:31 GMT

You can deal with post-op pain by giving adequate analgesia. How do you lessen suffering in a dog that can't stand on either hind leg?

Wynne

RE: Bilateral Cruciate

Anthony Todd — Thu, 10 Nov 2016 12:23:30 GMT

[quote user="Hannah Wynne Richards"]and there's worst practice which is leave the animal to suffer.[/quote]

Not what the oceans of anecdotal evidence say though!

Of course post-op pain and rehab doesn't count as suffering....

RE: Bilateral Cruciate

janine redman — Thu, 10 Nov 2016 09:22:45 GMT

My understanding is that cruciate ligament failure causes instability in the joint. Instability leads to arthritis. The treatment options all seek to stabilise the joint and minimise joint movement. So all the techniques , including cage rest, are designed in one way or another to achieve this. We then rely on the bodies healing abilities to perform its own joint stabilisation, and then we have to rebuild and realign the soft tissue structures to maintain that stability through gradual return to exercise. So any method which tightens the joint will help and by changing the TPA we stabilise joint faster so minimise the arthritic change .

many agility and flyball dogs return to active participation in sport whichever method is used and the rehabilitation plays as big a part as the surgery

RE: Bilateral Cruciate

Thomas Johnson — Thu, 10 Nov 2016 08:27:43 GMT

[quote user="Robin Grimmer"]

Apparently all lateral sutures will eventually fail due to fatigue, but they still seem to do really well. I guess by that time fibrosis has occurred to stabilise the joint.

[/quote]

Yes, my understanding is that 6 months after surgery the lateral suture will generally no longer be supporting the joint. I have taken out lateral sutures from 2 dogs that developed seromas around the metal crimp a couple of years after surgery, and both had no recurrence of lameness after the removal.

RE: Bilateral Cruciate

Anthony Todd — Wed, 09 Nov 2016 22:53:45 GMT

[quote user="Evelyn Barbour-Hill"]An embrocation would be a really good idea.[/quote]

He meant "imbrication", I think.

Medical Definition of imbrication. : an overlapping, especially of successive layers of tissue in the surgical closure of a wound.

Just in case all of us didn't know.....

RE: Bilateral Cruciate

Robin Grimmer — Wed, 09 Nov 2016 21:22:42 GMT

[quote user="Anthony Todd"]

[quote user="Robin Grimmer"]Apparently all lateral sutures will eventually fail due to fatigue, but they still seem to do really well. I guess by that time fibrosis has occurred to stabilise the joint.[/quote]

As usual a measured reasonable comment getting one anonymous star.

This distorts any thread, Arlo, and is very bad journalism and serves no purpose.

I hope it isn't from a vested interest.

Stop it without a qualification or reason.

[/quote]

Thanks for the support, doesn't bother me but does seem a bit pointless! Incidentally, I've often hit 'report post as abuse' by accident! Not sure what this does!

RE: Bilateral Cruciate

Anthony Todd — Wed, 09 Nov 2016 21:07:29 GMT

As usual a measured reasonable comment getting one anonymous star.

This distorts any thread, Arlo, and is very bad journalism and serves no purpose.

I hope it isn't from a vested interest.

Stop it without a qualification or reason.

RE: Bilateral Cruciate

Evelyn Barbour-Hill — Wed, 09 Nov 2016 19:07:33 GMT

An embrocation would be a really good idea. Who needs surgery?

RE: Bilateral Cruciate

Robin Grimmer — Wed, 09 Nov 2016 18:53:29 GMT

Apparently all lateral sutures will eventually fail due to fatigue, but they still seem to do really well. I guess by that time fibrosis has occurred to stabilise the joint.

RE: Bilateral Cruciate

Anthony Todd — Wed, 09 Nov 2016 18:46:26 GMT

[quote user="Thomas Johnson"] no obvious lameness.[/quote]

Yes it may be that "clinical lameness" is off the scale if it was tested with force plate gait analysis.

Folk who haven't paid a fortune, may see their dog's slight limp a bit differently.....

RE: Bilateral Cruciate

Thomas Johnson — Wed, 09 Nov 2016 18:18:30 GMT

[quote user="Anthony Todd"]

[quote user="Thomas Johnson"]There is published evidence comparing outcomes for different surgical techniques.[/quote]

Thanks, hard to argue with both citations; hard to get these though and anecdotal evidence seems to disagree, on here certainly.

[/quote]

It is a difficult area, I'm quite happy doing lateral sutures, particularly in dogs under 20kg, and have seen a couple of dogs recently that I operated on several years ago that are still doing very well with no obvious lameness.

RE: Bilateral Cruciate

Anthony Todd — Wed, 09 Nov 2016 17:39:27 GMT

[quote user="Thomas Johnson"]There is published evidence comparing outcomes for different surgical techniques.[/quote]

Thanks, hard to argue with both citations; hard to get these though and anecdotal evidence seems to disagree, on here certainly.

This is unconnected but of interest:

The cost of medical and surgical management of CCL rupture was estimated to be >$1.3 billion annually in 2005, and has likely increased since.

from: http://onlinelibrary.wiley.com/doi/10.1111/vsu.12445/epdf?r3_referer=wol&tracking_action=preview_click&show_checkout=1&purchase_referrer=onlinelibrary.wiley.com&purchase_site_license=LICENSE_DENIED

PS Nice to have these if an insurance company queries a claim......

RE: Bilateral Cruciate

Hannah Wynne Richards — Wed, 09 Nov 2016 16:44:25 GMT

There's best practice which requires specialised equipment/expertise. There's intermediate practice which involves surgery within the scope of the average GP, and there's worst practice which is leave the animal to suffer.

Wynne

RE: Bilateral Cruciate

Thomas Johnson — Wed, 09 Nov 2016 16:19:48 GMT

[quote user="Anthony Todd"]Of course, but as the functional results seem to be similar, and independent of minor or major procedures, yet all of them involve time, rest and managed exercise which may be the key component, certainly in those that recover with no procedure at all![/quote]

There is published evidence comparing outcomes for different surgical techniques. For example this paper suggests that long-term outcomes are better for tibial plateau levelling osteotomies than tibial tuberosity advancements, which are better than lateral sutures:

https://www.ncbi.nlm.nih.gov/pubmed/26768085

And this paper suggests that for dogs under 15kg long-term outcomes are better after tibial plateau levelling osteotomies than lateral sutures:

https://www.ncbi.nlm.nih.gov/pubmed/26568171

RE: Bilateral Cruciate

Anthony Todd — Wed, 09 Nov 2016 15:38:19 GMT

[quote user="Richard Carter"]well we do usually go from dog not using leg to dog using leg so hopefully some of that is down to us?[/quote]

Of course, but as the functional results seem to be similar, and independent of minor or major procedures, yet all of them involve time, rest and managed exercise which may be the key component, certainly in those that recover with no procedure at all!

Which is analogous to "trace high blistering" to give a reason to rest the horse and allow recovery when it got pneumonia.

RE: Bilateral Cruciate

Richard Carter — Wed, 09 Nov 2016 13:00:19 GMT

well we do usually go from dog not using leg to dog using leg so hopefully some of that is down to us?

Got to go and feed the leeches...

RE: Bilateral Cruciate

Anthony Todd — Wed, 09 Nov 2016 12:54:24 GMT

[quote user="Richard Carter"]I do open the joint and take out the loose bits jamming under the condyles/ meniscus space, trim back osteophytes and then close with embrocation of lateral ligaments [/quote]

Seems logical to get rid of "joint mice" etc. but the experts say "never" and "extreme pain".

Comments on opening stifle joint sequelae needed.

[remember all the comments on cartilage damage "occurring" after stifle surgery....]

Is "embrocation" a typo???

Just beginning to "trend" that all the surgery does, like blistering horses with pneumonia "trace high", is rest the joint and allow coincidental fibrosis and/or repair to develop.

RE: Bilateral Cruciate

Richard Carter — Wed, 09 Nov 2016 11:59:17 GMT

also done 2 bilat cruciate repair by lateral suture using the rather wonderful braided vetisco material as both dogs > 40kg (overweight labrador and elderly akita) came in with bilateral rupture and unable to stand - option pts , referral or try lateral and both are walking and still on the go. Probably not going to win any races though.

I do open the joint and take out the loose bits jamming under the condyles/ meniscus space, trim back osteophytes and then close with embrocation of lateral ligaments so couldn't tell you which part is actually getting the dog back on its feet again. Hopefully it is the fancy suture material