Laurie's Blogs.

This is a question I have been posed more than once, “How would your rehab protocol differ with a DeAngelis (extra-capsular) technique versus a TPLO procedure?”   My short answer is, “It doesn’t”.  However, I thought it might be helpful to go into the thought processing for how you could create a protocol for any procedure when one doesn’t exist.

So, when I evaluate a procedure and decide how to approach it from a rehab perspective, I first go to the question, what was done?

TPLO

Muscles were lifted off of bone.


Joint was inspected (meniscal lesions were removed if present)


Bone was cut.

Bone was plated.

Muscles were stitched back to each other & fascia.

Extracapsular / DeAngelis Technique

Joint was inspected (or it should have been) and addressed if need be.


Drill a hole through the tibial tuberosity

Suture material was placed (circle the lateral fabella, loop through the hole in the tibia, and crimp the ends together with a special crimp)

Yes, I am over simplifying… but for this purpose, we just need to hit the highlights.  Next, we think about what is compromised, what needs to heal, and what can go wrong.

TPLO

Needs the bone to heal.


Needs the muscles to heal.


Needs the joint to settle.


Needs to strengthen.

Problems can include late onset meniscal tears (likely due to altered mechanics), infection under the plate (that was likely introduced at the time of surgery), incisional infection, patellar tendon desmitis (tendonopathy), and other less common issues.

Extracapsular / DeAngelis Technique

Needs muscles to strengthen.

Needs the joint to settle.

Problems can occur late onset meniscal tears (due to different altered mechanics), loosening or coming apart of the suture repair, infections, and other less common issues.

If we look at things this way, we can see that there is more to heal with a TPLO. Essentially, a TPLO repair is a plated fracture, and there are a few additional complications to watch out for.  An extracapsular / DeAngelis repair on the other hand has a greater chance of failure.

So, both techniques require appropriate rehab management and careful home management to minimize the occurrence of adverse events.  Both techniques also need encouragement to weight bear and build muscles.  Both techniques can be rehabbed in a very similar fashion.

What do I worry about with TPLO repairs?  I worry that if the dog goes off leash too soon or plays with another dog too soon, he will tear the meniscus.  

What do I worry about with an Extracapsular / DeAngelis repair?  I worry about the meniscus as well as failure of the repair if this dog does too much free activity too soon.



What I don’t worry about is graduated, well planned therapeutic exercise that doesn’t exacerbate inflammation, lameness, or soreness.  This is why it is so important for a rehab program to be designed by a trained rehab professional who can monitor for problems, who understands healing of tissues, and who can stage rehabilitation by setting appropriate goals and coming up with therapies to address them.

So, in regards to a ‘protocol’, the answer is, “Yes, you can follow the same post-op CCL repair protocol.”  What is more important is how you create your treatment plan and choose your therapies to best fit the patient in front of you!

(My only caveat to this is the Tightrope proceedure... in which the synthetic ligament seems to act as a 'bone saw' with what would be considered normal rehab activities. So, rehab of this technique is painfully slow in comparison to the others.)

Another lesson in the Clinical Reasoning 101 series!


On that note, have a great week ahead!


Cheers!  Laurie