Alternative to cruciate surgery??

Re: Alternative to cruciate surgery??

Paul Manning — Wed, 26 May 2010 17:53:30 GMT

Hi Malcolm,

<<The abscence of (or failure to recognise) radiographic or other signs of stifle OA at presentation does not rule out degenerative CCL disease.>>

But it does not prove it's there either.

How would you define the presence of degenerative disease in a joint?

Regards,

Paul.

Re: Alternative to cruciate surgery??

Malcolm Ness — Wed, 26 May 2010 17:46:03 GMT

[quote user="Paul Manning"]greyhounds are subjected to is arguably just as much or more than other breeds, but they don't get cruciate ruptures[/quote]

Greyhounds DO suffer CCL ruptures, though in my experience they are uncommon and all my cases have been the result of significant, unusual and observed trauma. None has gone on to develop a cruciate lesion in the contra lateral stifle and I have yet to see a greyhound CCL injury that might be considered degenerative.

Cruciate related stifle instability in skeletally immature dogs is almost always traumatic and the lesion is typically an avulsion of the insertion of the ligament and not a true rupture.

However, the vast majority of cruciate failures in dogs are degenerative and not exclusively traumatic (many degenerative cases are misdiagnosed "traumatic"as because the signs are first noted following a relatively minor trauma). The abscence of (or failure to recognise) radiographic or other signs of stifle OA at presentation does not rule out degenerative CCL disease.

Re: Alternative to cruciate surgery??

Paul Manning — Wed, 26 May 2010 06:52:18 GMT

Yes I think it can because I have seen total rupture of the CCL in puppies 6-12 months old with no other apparent joint abnormalities.

Regards,

Paul M.

Re: Alternative to cruciate surgery??

Rob Loxley — Tue, 25 May 2010 22:45:57 GMT

[quote user="Paul Manning"]Whilst the trauma cases might be arguably more common in humans than in dogs, they do occur in dogs as well including in young dogs where the arthritic degeneration is non existent or minimal[/quote]

Does the absence of osteoarthritic changes on xray rule out 'degenerative disease' of the CCL as the underlying cause for the problem rather than 'pure trauma'? If there is even 'minimal' arthritis, and the dog was presented acutely, can acute trauma alone account for this?

Re: Alternative to cruciate surgery??

Paul Manning — Tue, 25 May 2010 22:05:53 GMT

Hi Malcolm,

Whilst the trauma cases might be arguably more common in humans than in dogs, they do occur in dogs as well including in young dogs where the arthritic degeneration is non existent or minimal. Secondly, I think it could be argued that the trauma that greyhounds are subjected to is arguably just as much or more than other breeds, but they don't get cruciate ruptures.

Regards,

Paul.

Re: Alternative to cruciate surgery??

Malcolm Ness — Tue, 25 May 2010 10:45:09 GMT

If (and it remains a big "if) it proves possible to define a gene associated with CCL failure in Newfoundlands, it will not be possible to extrapolate the information directly between breeds let alone between species (that is why they are studying one specific breed rather than collecting samples from generic dogs). What's more, the only similarity between human cruciate rupture and canine CCL failure is the target organ - the condition in dogs is usually degenerative while the human injury is invariably traumatic - Paul Gascoignes cruciate snapped for the same reason as Michael Owen's snapped, because they were exposed to a massive external force with which they couldn't cope. It had nothing whatsoever to do with their parentage and everything to do with physics.

Re: Alternative to cruciate surgery??

Paul Manning — Tue, 25 May 2010 07:14:01 GMT

That's interesting because I have felt for my whole career even in secondary school in my Biology days that there were useful comparisons between animals and humans with medical and surgical opportunities. One criticism of my own work in the postgraduate phase when I compare the surgical techniques that surgeons use on humans to those I /we use on dogs has been that many veterinary surgeons appear not to believe that comparisons on human/animal cruciate disease are valid. I believe that they certainly are, taking account of bias where appropriate and important.

It will be interesting to see where this work at Liverpool goes. Certainly at Bristol they found that the reason greyhounds didn't get cruciate ruptures whereas retrievers did was strongly linked to the strength of the fibres in the cruciate ligament in the different breeds.

Regards,

Paul

Re: Alternative to cruciate surgery??

Andre Escudeiro-Vieites — Tue, 18 May 2010 14:44:36 GMT

Look what they are doing in L'pool!!

http://www.guardian.co.uk/science/2010/may/18/dogs-bad-knees-sport-injuries-stars

I didn't know. It would be interesting to see if there is genetic predisposiotion of a different pathogenesis to that related to size/weight/mechanics!!

Re: Alternative to cruciate surgery??

Malcolm Ness — Sun, 11 Apr 2010 17:18:10 GMT

Hi Mary,

Sorry for the delay in responding to your post - I have been away at BSAVA.

I would persevere with conservative/medical management in this case. At 42kg the dog is probably overweight and there might be some benefit in reducing its weight. I would keep the patient on long term NSAID - minimum eight weeks initially and I would encourage the owners to exercise the dog as normal - there is little benefit to be derived from resting the patient (you won't slow or stop the OA and you won't stop the other CCL from failing). If the dog can cope with normal exercise, even if some minor lameness/stiffness persists then I wouldn't worry too much - the patient and the owner will be much happier if the dog can be allowed normal activity.

If significant lameness persists or progresses, then surgery is the next step. However, as previously implied, I would not be in a hurry to cut - bear in mind that very many dogs do very well without cruciate surgery of following cruciate surgery that cannot possibly have "stabilised" the stifle. If the dog does become a surgical candidate the owners may still opt to continue with conservative/medical management accepting a reduced level of function. Crucially, any decision to operate should be made because of the clinical PROBLEM (pain, lameness, disability) and emphatically not on the basis of diagnosed ABNORMALITY (instability, clicking, ugly radiographs etc). In a dog of this size coming to surgery, my first choice would be TPLO. TTA, providing the tibial plateau angle was suitably low would be equally appropriate. A fabello-tibial suture (appropriate technique and materials assumed) would be a valid option, but in my view, a definite "plan B".

Happy to discuss this case in more detail off-line if you want.

Re: Alternative to cruciate surgery??

Paul Manning — Fri, 09 Apr 2010 14:30:33 GMT

Dear Mary,

It will be interesting to see what Malcolm says about this. In welfare cases such as the Rottie you describe, I sometimes offer to do a skin graft with the two bone tunnel technique for £500 as a total price. In cases such as this the audited results are of high value to the clients who really want reassurance and evidence that spending money they haven't got or is hard to come by will be worthwhile, hence the results published on my website.

If the second leg also has a ruptured cruciate, the owner may have to consider whether another £500 would be worth spending after the first leg is operated on. I don't normally do both legs at the same time.

Hope that is of some help.

Regards,

Paul

www.astonlee.co.uk

Re: Alternative to cruciate surgery??

Mary Thomson — Fri, 09 Apr 2010 10:02:13 GMT

Malcolm,

I know you're an extremely busy person, but having read through this forum post I wondered whether you would be willing to comment on a dog one of my colleagues has seen recently.

The dog is a 5yo FN Rottweiler weighing 42kg. She was first examined with a left hindlimb lameness in November 2009. There is swelling, instability and a 'click' on manipulation of the joint. Both owners have been made redundant, and have procrastinated until now on what to do with the dog (it is not insured). It has been rested and had NSAIDs intermittently since November, but is still lame. I have used the lateral fabellar suture on a semi regular basis in the past, but am not happy about using this technique in a dog of this size with this history. Another colleague who has examined the dog has also expressed some concern about the stability of the right stifle.

The dog shows improvement while on NSAIDs but the lameness returns when the treatment stops. Financial issues mean we don't see it for reassessment frequently enough to know whether the owners are compliant with rest/treatment instructions.

My colleague has asked if I am willing to operate on this dog and I have said no! Given that referral is not an option, would you feel that continuing to rest and treat this dog with NSAIDs is the most appropriate course of action? I feel a bit stuck between a rock and a hard place with this one!

Thanks

Mary

Re: Alternative to cruciate surgery??

Paul Manning — Fri, 02 Apr 2010 22:30:35 GMT

Malcolm,

It's on my website :

http://www.astonlee.co.uk/content.php?Content=Vets+Section

I have added some histology and the histologist's report at the end of the paper. This is only one case 7-8 years post op when I had to euthanase a 15 year old labrador, whose owner was very keen to help the research process having witnessed what she considered to be considerable benefits for her dog of the cruciate procedure. There are plenty more dog owners like her.

Regards,

Paul.

Re: Alternative to cruciate surgery??

Malcolm Ness — Fri, 02 Apr 2010 20:56:33 GMT

Paul,

Why not publish your Skin graft cruciate paper in its entirety here and let others critically review your work and draw their own conclusions?

PS - we charge around £2500-00 including tax for a unilateral TPLO in a giant breed dog. £4000=00 would get you both legs operated on the same day.

Re: Alternative to cruciate surgery??

Paul Manning — Fri, 02 Apr 2010 19:02:41 GMT

Dear Malcolm,

What evidence do you base your opinion that intra or extracapsuar sutures would be money wasted? This could be from your experience, other surgeons' experiences, articles published, peer reviwed articles : interested to know what you base your opinion on.

I recently replaced a ruptured CCL in a Mastiff using a skin graft, which was doing very well just 7 days post op. One of the reasons why the client came to me as opposed to going to another surgeon for a TPLO recommended by her vet was that the owners did not like the principles of TPLO compared to ligament replacement, and also the cost paid by one of their friends on TPLO's plus complications for a Mastiff with both hindlegs needing surgery was £21,000. I had thought that most people doing TPLO's were charging aboiut £4000 plus complications for each leg, so I was surprised at that figure.

It could be a useful case comparison, although as has been commonly said it is always very difficult to compare on a caseby case basis because oif many variables.

I have heard that many practitioers have good success rates with extracapsular suture, and that is probabvly the most commonly used procedure in practice today.

Regards,

Paul.

Re: Alternative to cruciate surgery??

Malcolm Ness — Mon, 29 Mar 2010 11:24:41 GMT

The lack of radiographic signs of OA plus the cranial tibial displacement mean that this is almost certainly an acute rupture and, as indicated previously, these cases in my experience tend to do better than the other, more common "degenerative" CCL failures. This, and the fact that she is doing quite well at the moment makes me optimistic. I would encourage return to near normal levels of activity as soon as possible.

"The best surgeons know when not to operate" - for the time being at least, your JRT is one of those cases!

Re: Alternative to cruciate surgery??

Vikki Moran — Mon, 29 Mar 2010 09:58:00 GMT

the history of the case is that the dog (older JRT bitch) was out walking and slipped down a riverbank, becoming acutely lame. about 5/10 though i suspect if she had 4 legs she might be more lame. cr dr +ve with stifle effusion, radiographs showed no evidence of OA but there certainly was tibial advancement. this was about 2-3 weeks ago. we have been treating with restricted exercise and nsaids (meloxicam as this dog has vomited on carprofen in the past). she seems relatively comfortable at the moment.

there's no way i will be attempting tplo or tta on this or any other dog!!

Re: Alternative to cruciate surgery??

Malcolm Ness — Mon, 29 Mar 2010 08:30:16 GMT

[quote user="Vikkivet"]

so what would be plan A? and what would be plan B?

[/quote]

Plan A would be NSAIDs and increasing exercis back towards normal (ie previous levels for this dog) over eight weeks or so. Most cruciate cases present lame because of an acute flare of the chronic OA and this must be given a chance to settle before we are in a position to know how much of a problem (ie pain, lameness, disability) this patient will have as a result of the abnormality (ie the failed CCL). If this is a fresh, acute CCL rupture then the same delaying tactic applies because many dogs with cruciate deficient stifles will settle to a functionally acceptable clinical equilibrium. (If this is a genuine acute rupture then the prognosis for function without surgery is probably good)

Most dogs will do well without the need for surgery - especially if the patient is not a large, very active or working dog.

If the patient remains significantly disabled at the end of a lengthy period of conservative/medical treatment then surgery (TPLO or TTA) is the only thing likely to bring about any good functional improvement. Both these procedures, in the right hands, will allow the patient to weight bear immediately after surgery (we often do bilat TPLO on the same day). Any surgery on tripod dogs is more challenging, not only because of the increased weight bearing but also because of sometimes massively altered limb use and gait - this is not a case for a surgeon still on the steep bit of the learning curve. My view is that any money spent (in this case and after that medical treatment) on any kind of inta or extra-capsular "stabilising" would be money wasted.

If cash is really tight then consider the use of phenylbutazone as NSAID - terribly unfashionable these days but it can still hold its own in terms of efficacy.

Happy to discuss specifics of case off line if you want.

Re: Alternative to cruciate surgery??

Vikki Moran — Sun, 28 Mar 2010 18:36:33 GMT

[quote user="Malcolm Ness"]

Interesting assumption about costs - in fact less than 50% of my referral caseload is insured.

[/quote]

actually NOT an assumption about your costs - but driving from manchester to your neck of the woods would firstly be expensive, and secondly as i said this is a dog belonging to a girl aged 17 on minimum wage, so practically speaking any referral outside the practice is not an option.

so what would be plan A? and what would be plan B?

as i said this dog is already missing the foreleg on the same side as this rupture, so a big concern is immediate post op mobility!

oh and also - within this practce - we refer all our orthopaedic cases as I am not a competent orthopod - nor am i very confident at tackling more than amputations, disarticulating dew claws, and though i have done lateral sutures for cruciates, i'm not happy with them either! I am an orthophobe!! so any plan needs to be pretty foolproof!

Re: Alternative to cruciate surgery??

Vikki Halliday LLB — Sun, 28 Mar 2010 15:37:15 GMT

[quote user="Malcolm Ness"]my plan A would almost certainly be less costly and my plan B (should it be necessary) would almost certainly be more effective.[/quote]

Malcolm,

What are your plan A and B? I'm interested in case I get a similar scenario in the future.

Vikki

Re: Alternative to cruciate surgery??

Malcolm Ness — Sun, 28 Mar 2010 15:17:31 GMT

Interesting assumption about costs - in fact less than 50% of my referral caseload is insured.

If an injection of blood is the planned treatment, then my plan A would almost certainly be less costly and my plan B (should it be necessary) would almost certainly be more effective.

Re: Alternative to cruciate surgery??

Vikki Moran — Sun, 28 Mar 2010 12:32:49 GMT

even if that were a possibility from a geographical point of view, it's an uninsured case belionging to a veterinary nurse, so financially out of the question too!

Re: Alternative to cruciate surgery??

Vikki Halliday LLB — Fri, 26 Mar 2010 23:51:40 GMT

I'd refer it to Malcolm............

Re: Alternative to cruciate surgery??

Vikki Moran — Fri, 26 Mar 2010 22:06:54 GMT

slightly off at a tangent, or rather back to the original point in fact:

one of our nurses has a 3 legged dog (missing a foreleg) and has unfortunately managed to rupture a cruciate on the corresponding hindlimb. so..... maybe this would be a case where this intra-articular clot would be an option? she's certain (and probably quite right) that it's just not going to be an option to try and repair the damaged ligament,

any suggestions?

Re: Alternative to cruciate surgery??

Andre Escudeiro-Vieites — Fri, 26 Mar 2010 20:54:11 GMT

I recently started going for a pint with my son's friends' parents from pre-school on Wenensdays. One of them is an orthopaedic suregeon(human). We talked about cruciate surgery and he commented on the hamsting and the patella tendon techniques.

He did some sort of internship in the states and worked with someone who was investigating cruciate surgery in dogs there, then the conversation followed a different pathway. I will ask him what was that work about as may be of interest to the people in this forum

Re: Alternative to cruciate surgery??

warwickshire vet — Fri, 26 Mar 2010 16:54:56 GMT

I think the tplo comment about human surgery was probably just salesperson waffle!

I found an interesting web page about the history of acl repair form 1893 onwards

http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/87_colombet/colombetus.shtml

They do like their bone tunnels!