WHAT WOULD YOU DO? Acute onset lameness in a hind limb where cruciate disease is suspected

RE: WHAT WOULD YOU DO? Acute onset lameness in a hind limb where cruciate disease is suspected

cairncross — Wed, 06 Mar 2024 09:03:02 GMT

I am in NI so geographically limited and client base increasingly financially limited and I am at fault in a number of ways outdated understaffed and overstretched.

RE: WHAT WOULD YOU DO? Acute onset lameness in a hind limb where cruciate disease is suspected

Andy Moores — Wed, 06 Mar 2024 08:50:43 GMT

Sounds like you need to find a more approachable referral option -they are out there!

RE: WHAT WOULD YOU DO? Acute onset lameness in a hind limb where cruciate disease is suspected

cairncross — Wed, 06 Mar 2024 03:51:10 GMT

I get good results with lateral suture if there is good owner compliance which might well back up that rest alone has a big role . We do get good results in large breeds with good compliance also . 2500 is out of reach for the vast majority of our client base

RE: WHAT WOULD YOU DO? Acute onset lameness in a hind limb where cruciate disease is suspected

cairncross — Wed, 06 Mar 2024 03:44:53 GMT

As you explain as a GP surgeon I don't feel qualified to make referrals professionally and safely , the referal landscape is a constantly advancing field which I have no time or ability to keep up with . Referral forms now ask a multitude of questions I don't have the knowledge to answer yet want my responsibility for doing so on record , often I am refering the case specifically because I don't know which of the techniques or tests I am expected tick the box for are appropriate or the best option. Some of the forms can't be completed electronically if you leave boxes unticked I have to print out a screen shot and tick those I can answer though that is no longer accepted by some . , lift the phone ? Speak to the referral vet? used to happen all the time now it seems that person is often contracted to turn up for surgeries and leave I guess economies of scale and footfall they fly in and out and are in different regions on different days or weeks. Used to be the regional eye or what ever "expert" saw opthalmic cases as necessary and made up his time between with spays and the run of the mill practice work so was usually available

Possibly a regional thing and my position within , as very few cases and clients nowadays afford referal I don't have a relationship with referal centre I could be a year until I need the same or similar service and often staff and technique preferred has changed centres ownership may well have changed .

RE: WHAT WOULD YOU DO? Acute onset lameness in a hind limb where cruciate disease is suspected

cairncross — Wed, 06 Mar 2024 03:07:40 GMT

Around 1 to 2 cases per year here now choosing referal costs in the 1000s simply not feasible and insurance that works a rarity. . Staff time per case very limited due to high and increasing demand for affordable care with the quantum that represents affordable still falling. . We get more people unable to afford 30 pound consult fee in a day than we get able to afford referal in a year.

What percentage of each consult should be spent on discussing the full range of referal options from laser treatment to experimental joint replacement at costs which I have no ability to keep up to date with nor do I know who or what procedure will be favored at what centre regionally as these seem a constantly movable feast for the last period of years .

Can I give a professional appraisal of referral based on no up to date knowledge or experience ? Last referred case has been excellent outcome so far but the surgeon has moved on one previous to that not great same referal centre different surgeon different technique very different owner and breed ?

We have a sign in reception making owners aware that other options are available at a range of other specialist centres ( I don't say referal as that suggests to public I am providing a reference ) for almost every condition. That these will provide a range of different treatments at a range of different costs all of which they would need to enquire about within those establishments .

RE: WHAT WOULD YOU DO? Acute onset lameness in a hind limb where cruciate disease is suspected

David Mills — Wed, 06 Mar 2024 00:28:48 GMT

Can of worms warning.

For the original Q, 2w of NSAIDs and reassess. Check cranial draw in consult if possible. If not sedated exam.

Question is then what to do afterwards.

In terms of op selection this has been done to death a little on here, TPLO vs others. As Malcolm Ness once said someone got a bot over excited at LVS one year and it seems the dogma towards TPLO has swung since then. There is no convincing evidence it is better.

Smaller dogs, even bigger dogs, have been studied with conservative tx and similar results to TPLO.

I suppose ultimately it depends on owner choice. Which is a bit strange. Even an hour with a powerpoint wouldn't be enough.

Anecdote time no1 - we didn't fix any cruciates during covid, all conservative. Did any develop crippling disease 4y later? No.

Anecdote time no2 - people doing lateral sutures generally seem happy with the results. As do owners. So these tales of dogs being crippled later in life simply have no significant value.

RE: WHAT WOULD YOU DO? Acute onset lameness in a hind limb where cruciate disease is suspected

Alistair Graham-Evans — Mon, 04 Mar 2024 12:45:52 GMT

I remember a specialist telling me that if you don’t have complications then you probably aren’t doing enough surgery. Everyone eventually gets that case that becomes a nightmare!

I think we all do a good job considering the extreme stresses that pets put on their limbs post-op and how small and brittle those bones are in some of our elderly patients! I think the success is often dictated by the choice of technique and patient selection as much as the execution.

Personally I have always found specialists to be very supportive and generous with their time and advice and I am amazed at the depth of the knowledge they are required to absorb to qualify to a higher standard.
We just don’t have the numbers of cases in studies compared to humans and it is so difficult so get precise objectivity. Overall I think we all do pretty well without the massive resources available to human surgeons and when discussing stifles with owners I am often struck by the high complication rate experienced when owners are recounting their owhat experiences with knee and other orthopaedic surgery and the different subjective opinions amongst human surgeons.

I see some second or third opinion cases and I am always careful not to be openly critical no matter what my personal opinion as I hope they would do the same for me!

Charging for correction of complications is always tricky especially if the second surgery is more advanced and complex than the original! Personally I show the full fee in the invoice and then discount to cost price and usually everybody is satisfied at the end and it’s definitely a time when communication can strengthen or break the vet/ client relationship.

RE: WHAT WOULD YOU DO? Acute onset lameness in a hind limb where cruciate disease is suspected

Michael Woodhouse — Sun, 03 Mar 2024 23:36:19 GMT

[quote userid="3513" url="~/f/clinical-questions/30904/what-would-you-do-acute-onset-lameness-in-a-hind-limb-where-cruciate-disease-is-suspected/243895#243895"]for example the environment the surgery is performed in (better lighting, better ventilation, cleaner environment can all be expected to make a surgery more successful)[/quote]

It's an interesting idea, but I'm unconvinced. In our old surgery we were in a small linear building. The office was at the end, through theatre. We had no prep so animals were anaesthatised and operated on the same table. Through traffic, including dogs (!). Dentals on same table. Vets wearing outside clothes (sometimes off farm). When we moved to the new surgery we had more space. Separate prep/dirty ops and clean theatre. Changed into scrubs. No extra staff. No puppies passing the animal in surgery for a pee. A six month, detailed, clinical audit found zero difference in complications, post op infections etc. I was disappointed given the increased cost!

[quote userid="3513" url="~/f/clinical-questions/30904/what-would-you-do-acute-onset-lameness-in-a-hind-limb-where-cruciate-disease-is-suspected/243895#243895"]n my position as a specialist surgeon, I will from time-to-time be referred cases that have been treated by less qualified colleagues and which have had complications or the original surgery has failed. The owners of such patients are often unhappy with the original treatment[/quote]

This is not a 1 way street, either. We refer very few ortho cases and can cope with most things in house (pin, plates, ex fix, hip toggle, lat suture) but in the limited caseload that we do send to a very good orthopaedic referral centres - I've fixed 3 of their disasters over the years. One TPLO as a very new grad that fell apart and ended up as PTS. One open fracture of a metatarsal that the owners wanted to save, tiny little ex fix that got infected, ended up as amputation (as I initially advised). One fracture repair that fell apart and again, I amputated and did fine on 3 legs. I've screwed a handful of fractured humeral condyles back on in spaniels and they have all done well. I can think of 2 that were done by specialists with endless problems (implant failure, persistent lameness).

I always liked Malcolm Ness view of ortho surgery with a guarantee. I know of 1 person who used it and the 2nd surgery was absolutely free. I will explain to owners that we are general practitioners and we could send to a specialist, if it's something I think we can fix. IF it did go wrong, then I would do revision surgery or amputation FOC. I've done that once - multiple metatarsal fracture that seemed to lose blood supply and ended up with a cold foot. Whilst the proportion of orthopaedic cases we refer is small and the more complex ones - on paper they can have a MUCH higher level of complication than the ones we see in house.

Just because someone is a specialist doesn't mean things can't go wrong. Their caseload is also biased to the weird and wonderful. I suppose with a simple fracture, that 20 years ago most GP vets would fix, they will have very good results.

RE: WHAT WOULD YOU DO? Acute onset lameness in a hind limb where cruciate disease is suspected

Alistair Graham-Evans — Sun, 03 Mar 2024 05:55:20 GMT

Blimey

Things cost a lot in the UK

We are in QLD, Australia

Suspect cruciate will get Xray cruciate package ( GA, assess, bilateral lateral stifle, VD hips and lumbo -sacral views) equivalent to £350.

TPLO ( if greater than 12 kg) equivalent to £2,500.

Done by GP surgeon (me) but referral offered.

Our results favourably compare to specialist referral.

If small then other procedures offered but I no longer do lateral sutures as unconvinced they achieve anything other than rest and time. Small dog’s stifles are very different in anatomy and function to large dogs and there is often rotational laxity with patella luxation too.

Now I am comfortable with TPLO am considering getting smaller kit options for <12kg ( at present I do mini- TTA( but not all suitable) or refer or conservative rest.

I wonder if Michael gets good results with lateral sutures as his patients tend to be fit working dogs and traumatic ruptures? Ours are nearly all unfit pets with bilateral degenerative cruciate disease.

RE: WHAT WOULD YOU DO? Acute onset lameness in a hind limb where cruciate disease is suspected

Gillian Mostyn — Sat, 02 Mar 2024 18:18:54 GMT

[quote userid="2100" url="~/f/clinical-questions/30904/what-would-you-do-acute-onset-lameness-in-a-hind-limb-where-cruciate-disease-is-suspected/243894#243894"]And surely the answer to that is, on the balance of probabilities, yes.[/quote]

The problem is that many surgeons/practices simply don't do good quality clinical audits. We're all guilty of finding good reasons for complications/failures, or forgetting about them, when it's still a fact that some people get more complications than others - even with the same typical case loads.

RE: WHAT WOULD YOU DO? Acute onset lameness in a hind limb where cruciate disease is suspected

Andy Moores — Sat, 02 Mar 2024 18:17:48 GMT

[quote userid="4181" url="~/f/clinical-questions/30904/what-would-you-do-acute-onset-lameness-in-a-hind-limb-where-cruciate-disease-is-suspected/243893#243893"]And does the extra level of qualification and cost equal better outcome, they will ask. [/quote]

A very valid question Rob and a very difficult one to answer with objective data. There are lots of things that will contribute towards outcome. Qualification/expertise will certainly be high on the list, but there are others, for example the environment the surgery is performed in (better lighting, better ventilation, cleaner environment can all be expected to make a surgery more successful) and of course how the patient is managed after surgery. Experience counts as well of course. There will be very experienced long-term certificate holders who will be better surgeons than young specialists who have only recently passed their Diploma exams. However, every Specialist that has been through the 3 year residency training required of a Diploma will have invariably had more one-on-one training from an experienced surgeon than a certificate holder who has not been through that process, and every Specialist will have been examined to a far higher level than a certificate holder. So, in general, your average Specialist is going to be more experienced and more knowledgeable than your average certificate holder. This should stand to reason I hope, just like you would expect consultants in a hospital to be more experienced and knowledgeable than registrars. Is it easy to show this makes a difference? -no. Is it likely to make a difference? I believe so.

Cost is a separate issue. You are automatically assuming that choosing a Specialist is going to be more expensive. Many specialist referral centres will be more expensive and I believe some of the corporate referral centres have really shot themselves in the foot with their high pricing, but I frequently encounter owners being charged similar or higher prices than those in our clinic for treatment by a certificate holder. Regardless, many owners do prefer to pay a premium for additional expertise, and shouldn't this be their choice? As I point out already, I have no issue at all with certificate holders being referred cases. I'm sure the profession would collapse without them. My point (which is actually just the RCVS guidance) is that owners should have the choice of a specialist referral and be able to make an educated judgement of what works for them and their pet. Not giving owners that choice and leading owners to believe that a certificate holder is a specialist (which is invariably what an owner believes if no choice is given) is disingenuous and contrary to the code of professional conduct.

There are potential real-world consequences to this issue which it is maybe useful to highlight. In my position as a specialist surgeon, I will from time-to-time be referred cases that have been treated by less qualified colleagues and which have had complications or the original surgery has failed. The owners of such patients are often unhappy with the original treatment, which may or may not be justified, and they are even more unhappy if on being referred to our specialist clinic they realise that the surgeon performing the original surgery was not a specialist, because they had assumed they were and had not been told any different. The key point here is that they are generally going to be unhappy not only with the original surgeon but also their GP vet who referred them to that surgeon in the first place. Now you have a potential scenario where that client may complain to the RCVS, and the complaint would most likely be against the referring vet who did not follow the RCVS guidance on referrals, rather than against the surgeon who may not have done anything wrong. I don't think I have yet had a client make an RCVS complaint in this scenario but I can see that it might happen and those clients do vote with their feet and switch practices.

RE: WHAT WOULD YOU DO? Acute onset lameness in a hind limb where cruciate disease is suspected

Arlo Guthrie — Sat, 02 Mar 2024 18:12:30 GMT

And surely the answer to that is, on the balance of probabilities, yes.

RE: WHAT WOULD YOU DO? Acute onset lameness in a hind limb where cruciate disease is suspected

Rob Loxley — Sat, 02 Mar 2024 16:47:20 GMT

[quote userid="3513" url="~/f/clinical-questions/30904/what-would-you-do-acute-onset-lameness-in-a-hind-limb-where-cruciate-disease-is-suspected/243873#243873"]The clear implication is that owners should be offered a range of available referral options (internal and external) and the level of qualification of each explained[/quote]

And does the extra level of qualification and cost equal better outcome, they will ask.

RE: WHAT WOULD YOU DO? Acute onset lameness in a hind limb where cruciate disease is suspected

Clive Ansell — Sat, 02 Mar 2024 08:54:53 GMT

[quote userid="2100" url="~/f/clinical-questions/30904/what-would-you-do-acute-onset-lameness-in-a-hind-limb-where-cruciate-disease-is-suspected/243876#243876"]

I wonder if that's reflective of your client base, and whether if you asked affluent clients in a metropolitan area, they might place a greater importance on advanced qualifications. Especially, perhaps, those who have private medical insurance and who like being referred to the leading expert for their own medical needs.

Just a thought.

[/quote]

I think you are absolutely right.

My work occasionally takes me to 2 practices in more affluent/posh/snobby areas. These clients are far more demanding and pedantic (PITA most of them), and will expect all treatment options to be discussed ranging from conservative management, in house surgery, visiting certificate holder or RCVS recognised specialist , although there is still an expectation to pay as little as possible and we have to have the obligatory Supervet vs Yorkshire vet (Sorry Michael) conversation ever time.

Another trend I have noticed in the posh practices; waiting room gossip sometimes includes a p***ing contest as to who has spent the most money on their pet, along the lines of "we were referred to X and Benji cost us £3000" someone else will interject "you got off lightly, our Sophie cost us £7000" funny old world.

RE: WHAT WOULD YOU DO? Acute onset lameness in a hind limb where cruciate disease is suspected

Arlo Guthrie — Sat, 02 Mar 2024 08:28:19 GMT

[quote userid="3169" url="~/f/clinical-questions/30904/what-would-you-do-acute-onset-lameness-in-a-hind-limb-where-cruciate-disease-is-suspected/243875#243875"]Widely know, and literally nobody cares. I don't think I've EVER had anyone say they would rather have a specialist do something that a GP or advanced practitioner, when offered a choice. [/quote]

Just a thought.

RE: WHAT WOULD YOU DO? Acute onset lameness in a hind limb where cruciate disease is suspected

Michael Woodhouse — Sat, 02 Mar 2024 00:44:09 GMT

Widely know, and literally nobody cares. I don't think I've EVER had anyone say they would rather have a specialist do something that a GP or advanced practitioner, when offered a choice. TBH it's why I let my AP statuses lapse - no one gave a stuff. More annoyingly people more impressed by celebrity - occasionally had suggestions of going to see the "Supervet" or, frustratingly, the Yorkshire vet

RE: WHAT WOULD YOU DO? Acute onset lameness in a hind limb where cruciate disease is suspected

Andy Moores — Sat, 02 Mar 2024 00:26:17 GMT

Hi all, sorry, late to the thread. Some thoughts from the surgeon's perspective. The query is 'suspected' cruciate disease, and so on this basis I agree it is not unreasonable to trial NSAIDs/rest and see what happens over a week or two. Presumably this means the stifle is not obviously unstable. However, if there is clear instability in the stifle (cranial drawer or cranial tibial thrust) then there is no doubt in the diagnosis and no value in waiting and surgery (ideally TPLO if an option) should be considered sooner rather than later. Delayed surgery will increase the risk of additional meniscal injury which will worsen the long term prognosis in terms of OA development. I would advise this for all sizes of dog. Sure, smaller dogs may 'cope' without surgery but in my experience many don't, the recovery can be prolonged and the persistent instability is likely to promote OA change in the joint. I actually think a large part of the 'small dogs do ok' dogma is because it is generally more difficult to assess lameness in smaller dogs and chronic low-grade lameness may not be appreciated as readily as it is in larger dogs.

Going back to the specifics of the original question though, the diagnosis is not clear and so let's assume the stifle is stable (at least to tibial thrust on conscious examination). Always a good idea to sedate the dog and check for cranial drawer as well, especially if the dog is not improving, since a partial rupture may be stable to cranial tibial thrust (readily tested in the conscious dog) but unstable to cranial drawer (which will require sedation in the vast majority of dogs; always check in flexion and extension, partial ruptures tend to have drawer in flexion only).

If there is no drawer, then it may still be early cruciate disease. Other suggestive findings are: radiographic/clinical effusion, osteophytes on XR, medial buttress (firm swelling over the MCL), pain on full extension of the stifle (make sure to extend the hip a little when checking this or you will just cause pain by stretching the hamstrings), a history of short-lived lameness after resting after previous exercise. Always compare to the other side but beware of bilateral cruciate disease! If in doubt consult a surgeon! Stable cruciate disease tends to grumble on and on and the secondary OA progresses all the time, and so I would advise surgery (TPLO) for stable cruciate cases if there is enough evidence to support the diagnosis.

Neil/Janine, interested in your comments about peripatetic surgeons. I believe the peripatetic surgeons play a very important role in our industry and provide an important service to many owners. I also believe that owners should be able to make educated choices about who treats their pet. The vast majority of peripatetic surgeons are of course certificate holders/advanced practitioners rather than specialists, and this is relevant when interpreting RCVS guidance on referral. The guidance to the RCVS Code of Professional Conduct states "The referring veterinary surgeon has a responsibility to ensure that the client is made aware of the level of expertise of appropriate and reasonably available referral veterinary surgeons, for example, whether they are veterinary specialists or advanced practitioners." The clear implication is that owners should be offered a range of available referral options (internal and external) and the level of qualification of each explained. I have met many vets who are unaware of this guidance. Is it widely known/followed?

RE: WHAT WOULD YOU DO? Acute onset lameness in a hind limb where cruciate disease is suspected

Michael Woodhouse — Sat, 02 Mar 2024 00:11:53 GMT

[quote userid="8958" url="~/f/clinical-questions/30904/what-would-you-do-acute-onset-lameness-in-a-hind-limb-where-cruciate-disease-is-suspected/243848#243848"]Would I lateral suture? No, not in a dog over 10kg, Michael I think you are kidding yourself that you can do it properly that fast. It's the equivalent of putting a zip tie round the stifle and pulling it as tight as you can, anyone can do that[/quote]

There is a 'feel' to the tightness, but absolutely don't pull as tight as you can. Partially squeeze the crimp so it holds the nylon but can still slide. Tight enough to remove all cranial draw and no tighter. Honestly, 15-20 mins from 1st cut to skin closed. If you are talking pre-med to walking around afterwards, obviously much longer.

Had 3 failures/significant complications. One turned out to have a chondrosarcoma that lead to the cruciate rupture. One broke the crimp around the 1 month mark and was cured by a repeated nylon suture of larger size. I had to remove one crimp about 6 months after the op due to a draining tract that responded to antibiotics. Chrondrosarcoma dog was dead at 3 months but everything else "so much better".

I PTS a dog last month who was 14 years old. Moved from another local practice who were treating with NSAID and had bilateral ruptured cruciates. I operated on both at the same time, beastie had a bad couple of weeks and never looked back. Did have some Loxicom for the last couple of years, but many old dogs without cruciate disease end up on NSAIDs. I can check the computer but I will have operated on him something like 8-10 years ago (was at the old surgery and we moved here in 2016). Fixed a Newfoundland with a double leader line and double crimp (advised refer, couldn't afford).

I've even done one on an expensive tup/ram. That was more than a 15 min op, and it turns out sheep don't have fabellae.......

Smallish practice with pretty bonded clients. I see these dogs for the rest of their lives, they don't turn into crippled arthritic messes a couple of years later. Done lots of working gundogs and sheep dogs.

RE: WHAT WOULD YOU DO? Acute onset lameness in a hind limb where cruciate disease is suspected

Gillian Mostyn — Fri, 01 Mar 2024 09:46:44 GMT

I give a week or 2 of NSAIDS but will discuss that unless the dog shows a significant improvement in that time I'd recommend immediate referral for a TPLO. I offer rads in house but, as Neil says, CCL rupture is usually such a high likelihood with signalment and lamness that I'd rather their money went towards the surgery. Worst case scenario is the the rads are clear, or show up a different problem when the referral practice takes them - owners are happy with that.

Even just a few years ago I used to see chronic CCL rupture dogs that were constantly having joint flare ups, both with and without surgery, that were maintained on long term NSAIDS, physio, and almost always crippled in old age. Most of the dogs we refer we don't see again for lameness - until their other leg goes!

I guess its easy for our own opinions to bias what we do - but I do think early referral, even with the costs involved, can be easy to 'sell' if you warn them of the long term consequences of untreated CCL rupture. And the costs are often higher in the end ... both literally and in terms of limited QOL.

RE: WHAT WOULD YOU DO? Acute onset lameness in a hind limb where cruciate disease is suspected

cairncross — Thu, 29 Feb 2024 08:21:37 GMT

Similar to Clive and Michael , can't quite claim Michaels speed or success rate .

Referal uptake rate is 1 or 2 dogs per year and falling very few have insurance which will work for this.

Few years ago considered learning new "advanced " technique from friend who was very proficient but he pointed out I hadn't got the time I needed more staff unavailable and uneconomic in my area if i personally wanted to treat fewer cases with a lengthier procedure. Good Argument I thought . Maybe he was finding a polite way to discourage me for other reasons.

Many cases surgical mine or others or conservative do develope Arthritis which can be managed and is often managed better than my own personal Arthritis .

RE: WHAT WOULD YOU DO? Acute onset lameness in a hind limb where cruciate disease is suspected

Neil Wheadon — Thu, 29 Feb 2024 00:56:10 GMT

Agree with Much that Janine says

I can spot a cruciate and guess many vets can, it's almost a classic presentation, trick is to always watch an animal walk into the room and get it outside round the car park

I don't wait 14 days now, more like 3, the faster you know the better

Personnal question at London Vet Show this year. Dogs rarely get Menscal tears, so it will be a cruciate

Radiograph and feel for draw. Nearly all the places I work at have an orthopod who will look at the radiographs for free

Would I operate? Yes. A dog is a dynamic creature, it lives to chase balls and time is short for them, so get on and operate. A good surgeon and the dog will be so much better in 3 months.

Would I lateral suture? No, not in a dog over 10kg, Michael I think you are kidding yourself that you can do it properly that fast. It's the equivalent of putting a zip tie round the stifle and pulling it as tight as you can, anyone can do that. If I were a 5 year graduate, I'd learn to TTA as many of my colleagues have learnt to do. 2 local independant vets do these and the results are very very good.

If you need to refer, consider travelling orthopods, I use https://vet.ratavetsurgery.co.uk/ if at all possible. Others are about and are as good I expect

Neil

RE: WHAT WOULD YOU DO? Acute onset lameness in a hind limb where cruciate disease is suspected

janine redman — Wed, 28 Feb 2024 19:26:13 GMT

It is dependent on age of dog , breed size and future expectations.

usually if I am confident it’s not a fracture and I consider osteosarcoma unlikely I will rest and analgesia for a couple of weeks and then review . If the stifle is definitely unstable and the owner has a young dog where expectations are of a return to normal or competitive function are high I will offer early referral to our peripatetic orthopaedic surgeon .

I have found that even smaller dogs with instability seem to do better long term with surgery than conservative management although really dedicated owners can rehabilitate dogs well with assistance , restricted activities time and .physiotherapy, laser etc

Many stifle strains over the years have recovered within a 6 months time frame but a lot go on to suffer from chronic osteoarthritis in later years which is reduced with early stabilisation. My own collie had a CCL injury but recovered over three months whilst I was waiting for a suitable surgery date . She was arthritic in her later years but with management did well until she died at 17 .

each dog is an individual but I am lucky to live and work in an area of affluence and with a reasonable level of insurance cover which helps but usually it is a long conversation with owners and a frank and open discussion.

RE: WHAT WOULD YOU DO? Acute onset lameness in a hind limb where cruciate disease is suspected

Michael Woodhouse — Wed, 28 Feb 2024 00:01:06 GMT

[quote userid="5012" url="~/f/clinical-questions/30904/what-would-you-do-acute-onset-lameness-in-a-hind-limb-where-cruciate-disease-is-suspected/243841#243841"]GA and rads now in the region of £500 - £700, [/quote]

Arlo Guthrie - remind me what are the rules on profanity?

Generally, I'd expect I could diagnose cruciate injury in 75% by physical examination. Would generally rest and NSAID for 2 weeks and see back. If significant lameness exists, then rads and take to surgery for lateral suture. Consumable items less than £15 for the lateral suture, crimp and needle. Surgical time similar to a cat spay. I'd very happily do GA, rads and a definitive fix for £700 or less, and still be on farm scanning cows for 10.30.

Would offer referral if young or insured, but remain unconvinced of the superiority of the vastly more expensive procedures. Had very good results from lateral sutures (many dogs back to full work), and doesn't preclude more invasive surgery IF it fails (and it generally doesn't).

RE: WHAT WOULD YOU DO? Acute onset lameness in a hind limb where cruciate disease is suspected

Clive Ansell — Tue, 27 Feb 2024 21:35:22 GMT

An easy one to answer in most of the practices I work.

Most folk have no money or insurance, and cannot afford investigation. Surgical referral out of the question. Most will get Metacam, suck it and see. Some cannot even afford metacam now (Recently came across an invoice from an OOH provider where 100ml Metacam was £102)

Would start off with a thorough clinical examination and history, to try and rule out obvious fractures or dislocations.

If it were a large breed dog and I was confident it was cruciate disease that needed surgery, I would refer straight away and would not perform radiographs in house. GA and rads now in the region of £500 - £700, and the referral surgeon would almost always repeat and get their own radiographs anyway. Last one I referred that had a TPLO procedure was £6600, so don't get too many takers where I am from

In others where I'm not entirely sure, cases where surgery would not be an option, or smaller dogs I would in most cases prescribe a NSAID like Metacam and see back for euga/rads INB.

As usual, there isn't a one sized answer that fits all cases.