Rehabbing Stifle Instability Post-Op

[lehughes]

Hi Laurie

I saw a dog following his Tight rope repair. He is I believe about 6-7mo out-might have been repaired last fall
Intermittent lameness after high activity-NWB which lasts a couple of days
rechecked by Surgeon-identified 1/2 cm drawer-difficult to localize pain-no other findings on exam
High E explosive Hunting dog Labrador BCS 3/5 very fit
X-rays showed stable implants, NAF, no evidence of meniscal injury or sig OA

 

Sent to me for Rehab for "strengthening"

On exam functional ROM, Mild Glut and Hamstring atrophy, no sig pain on exam, definitely some stifle drawer and instability

I have had this happen several times where the dog has had drawer following Sx-less than optimal outcome and the dog is not using the leg well
and it is recommended they seek rehab before considering another Surgery or Surgical revision


If the stifle is unstable and causing pain/infl and decreased wb due to instability- am setting myself up and the Owners for failure?

I can't say that I have had great success with Rehabbing these dogs with stifle instability following Sx ( the few that I have had)-some dogs have had significant drawer
do I just approach this as I would with conservative managment?
Would I do sig activity restriction-3 mo on leash again? etc  Starting at the beginning?  This dog is tearing around 

Just wondering your thoughts and how you approach these cases

AMM

[lehughes]

Hey there!

This is a tough question.  And barring any issue not identified (i.e. iliopsoas strain, SIJ dysfunction, tarsal problem, or even MTrPs in the cranial thigh muscles), then it’s a guess as to how the dog will do.

Okay, so 1/2 cm of drawer is ‘liveable’ I think.  So, there is a chance that building up the muscles could help with dynamic stability and control of the joint.
And, the way I look at it, you have no guarantees that a repeat surgery will yield better results.  When they come for the rehab, you are doing all you can to prevent a ‘do-over’… which I think most people would appreciate.
So, I’d give it a good try - at least for a month or two to see improvement of some sort.

Now, what to do:
You can’t go back to ground zero.  You do need to cut back some of the ‘crazy’ but do some very targeted strengthening to build quads, glutes, & hams.  Not UWT.  Not simply going for walks.  But in-house Ther Ex (plus laser), and a home program that incorporates some aspects of his hunting tasks… nearer to 6 - 8 weeks.  So, yes, I’d think of it like conservative rehab (but more ‘mid stage’)… lots of specific strengthening exercises.

All in all, I think you have to give it a go for a while… 

Best of luck!  

Laurie

[lehughes]

That is great thank you
one more question
what about a leg weight or BIKO bands-could that be beneficial for this dog?

I also have alot of clients that won't do the Thx exercise sessions or can't do (they have health issues or limitations or just too involved for them)
or they have a difficult dog-high energy, exhuberant, dog is an expert compensators or not motivated (stubborn or dominant)

I have been recommending leg weight or BIKO bands for strengthening
Just wondering your opinion on these products and if they can achieve that in CCL cases

thank you

AM

[lehughes]

I think at this point. It’s all fair game! I’ve use leg weights, but never the BIKO for strengthening. (If you try and get a video… please pass it along!)

Laurie

[lehughes]

I had a dog that was Hit by Car and suffered sig injury, Traumatic disc, Fx pelvis, his lumbar spine was wasted away
I could not believe the gains made to his parspinal muscles and Gluts with the Biko bands-I couldn't believe it
so I have started recommending them more often
We will see what happens
amm

[David Lane]

I don't wish to be the wet blanket of the conversation, but....

There are some dogs that will do quite well with a 1/2cm drawer, but others that will not. My subjective experience is that for those that don't respond well to that sort of persistent laxity, it is hard to turn them around. If we are this far out from surgery and the stifle is this unstable, I would consider this a failed surgery and rather than fight it with rehab, I would proceed to revision surgery and hope to minimize secondary arthritis. If the owner elects for revision surgery, do not repeat the TR procedure; if it failed once, it will likely fail again. Switch to a TTA or TPLO instead.

Of course, depending on your situation, you may not get a say in whether or not revision surgery happens, and are simply stuck trying your best with the situation you have been handed. If so, then LEH's advice above is the route to go. If however, you do have influence and these owners want to return their dog to an active lifestyle, I would push for revision surgery sooner rather than later.

[drwall]

I have to agree with David in that your patient likely needs revision surgery followed by rehab. I also recommend a geometry altering procedure for this athletic patient. The caudal thigh muscles are the only ones that are agonistic to the CCL and you will not be able to strengthen them enough to compensate for the tibial thrust your patient is experiencing. In addition, how have you ruled out a meniscal problem?

Rick Wall, DVM

[lehughes]

Hey guys (David & Rick),

I've passed on your sentiments to the original person - she had e-mailed me this question.

I always find these cases tricky. I always think of it as "I'll give it a go for a short period of time." If no change, then I have something definitive to go back to the surgeon with to hopefully convince him/her that a revision is necessary. I've found that sometimes the surgeon doesn't want to do the 'do-over' either. So the more ammunition I have to say "this isn't working", the better.

Agreed as well that a Tightrope wouldn't be the way to go the second time around (or the first... in my opinion... I'm not a fan of that surgery.) But as referral practitioners, we are often stuck between a rock and a hard place.

Laurie