Meniscal Repair - 207lb Mastiff

[lehughes]

If you don’t mind I could really use your experience on this case. 5yr MN Mastiff that had a CCL deficient R stifle and owner declined surgery (bc another mastiff that had a TPLO and the implants failed and he had a horrible experience with it) so I was using a conservative rehab plan of hydrotherapy and laser therapy with some mild range of motion exercises.

He has had a meniscal click noted during the last session and I tried your technique that you taught us at the 2018 STAAR conference to try and manipulate it but with no success bc he’s 207lbs. Next tuesday will be the 3rd attempt at manipulating it but I suspect it will be just as unsuccessful. They don’t want to sedate him because he’s so difficult to handle after (difficult to get in/out of car, in/out to potty bc he’s a lightweight with pain meds). They basically want to do everything except sedating and surgery. They have talked to other Mastiff owners who suggested robert jones bandages but owner says not sure if that was for CCL tears or meniscal tears.
We have access to PRP. What options do you give an owner for a patient of this size that has a CCL tear and meniscal tear?

I educated them about if we don’t treat it, it will cause lifelong pain in that joint - only treatment then could be joint injections for pain relief. High risk of tearing CCL/meniscus in the other hindlimb. High risk of osteoarthritis.
It sounds like these owners will euthanize this pet before they consider a TPLO. Any help is very much appreciated bc I’m feeling helpless at this point.

Kind Regards,
J.M., DVM, CCRT, CERP

[lehughes]

Hi J !

Well, this case puts you between a rock and a hard place doesn’t it??!!

I would advise for surgery as well… even if just an extracapsular repair. We still have some big dogs having them done… they can work well. And even if they fail, then the meniscus has still been cleaned out and you’ve been able to work on strengthening. Maybe they’d go for that! I’d present it as an option for sure.

Okay, so if they don’t then try another round of the meniscal technique… pull on the leg with all your might, just pull twist and hang on. Don’t stabilize, let the dogs own body weight provide the ‘resistance’. So if you’re not visualizing this: Hang onto the leg above the tarsus, pull and rotated. Let the dog pull back / resist. Essentially play slow twisty tug of war with the dogs leg!
High dose laser the stifle, acup and/or shockwave if you have it. U/S if you have that. Essentially anything you can throw at it. Oh, PEMF (HealFast or Assissi Loops for home use).

So, now they already know the risks. So, you go down the path of… well, if you do nothing, then arthritis sets in sooner than later. Arthritis will set in anyways. But this speeds it up. There are worse things in the world than arthritis. So if the owner chooses to NOT proceed with surgery. Arthritis is a reality… and what have you got for that? Nutraceuticals / Supplements, Pain Meds, Modalities, Ther-Ex, joint injections on down the line...
You could look at a stifle brace. To be honest, with a meniscal tear… I don’t know that you get much more from a brace than you would with not using a brace. The brace helps the instability but not the meniscal tear. The meniscal tear impedes how much the dog uses the leg anyways, and so perhaps the instability is a moot point.
Along similar lines of thinking, I’d not bother with the Robert Jones Bandage either… you’ll just end up with a skinny leg and a more likely faster blowing out of the other cruciate. The bandaging won’t help the meniscus.
I’m not sure what to tell you about PRP… other than it can’t put the meniscus back together. So I would hang onto that little gem for when the arthritis is the primary cause.
In the mean time… strengthen.

Essentially, I’d let the owners know that without doing something to remove the offending meniscal bit, the dog will be lame. Likely forever lame. If they’re okay with that… then there are things you can treat. If there expectation is a dog that doesn’t limp, then they need to do surgery.
There is plenty of middle ground between TPLO or Euthanize…

I tend to present all options. I let them know what would be best, and move down the line from there. It’s their choice, and let them know that you will support them no matter what. That you can help them along the way no matter what. What one owner is willing and able to do is different than the next. I always feel like it is important to maintain an ‘arms length’ objectivity and figure out a way to help the patient-client with whatever path they choose, and provide education and assistance along the way… even if it’s not the gold standard, or what WE would like them to do.

I hope this helps!

Best of luck,

Laurie

[lehughes]

Thank you for your response Laurie. It confirmed everything I was thinking. We spoke this afternoon and again they are declining any surgical intervention due to cost and their previous bad experience. Today was the 3rd attempt at the meniscal maneuver & I even got in the underwater treadmill to try it bc the water helped support his weight while I pulled and pinched, etc to try and manipulate the stifle.
First time I tried it with him laying on the floor. Second time I tried it with him standing and another person help steady him while I pulled the heck out of the leg. Lastly was today in the water treadmill. All with no success but he is a 207lb dog so I’m not surprised.

They are fully aware of the long term lameness and compensatory issues that may ensue. Our plan is to continue hydrotherapy, laser therapy, joint supplements, starting acupuncture, and resorting to joint injections when he can no longer stand up or walk.

On the upside they report he’s more mobile Than he’s been in a really long time (although he’s only putting 10% weight on the affected limb). We will continue moving forward and will do my best to keep him mobile for as long as possible.

Since I started this practice over a year ago I haven’t had a single patient euthanized for mobility issues and my fear is that he will be my first. I know eventually I will have one but cases like this is when compassion fatigue sets in. Fortunately I have a great support system and know a lot about self care.

Thank you for being a resource I could reach out to with this difficult case. Hope to see you again next year at the STAAR conference.

Kind Regards,
JM, DVM, CCRT, CERP

[lehughes]

Ah… well then, you just keep on doing what you’re doing!

In regards to compassion fatigue, I’ve found it most useful to view life in the following way. Excuse me for getting a bit ‘flakey’ on you!

I figure we are all ‘here’ to learn about things, whatever they may be (i.e. compassion, remorse, regret, grief, letting go, love, caring, joy, happiness, etc, etc...) AND to try to leave humanity & the planet a wee bit better for your having been in it.
So, everyone in your life is there for a reason - to teach you something, to be a catalyst for something, and so on. I believe this included our pets and the animals we encounter.

In the case of the dog you describe below. I would look at it as the owner and the dog have a ‘pre-existing contract’ to learn from / teach the other about something… and you are there to do the best you can within the confines of the ‘contract’ they have together. It’s not to say that you don’t provide them with information about what would be ‘best’, but rather you do that AND work with them through whatever journey they are on together as it pertains to your interaction with them.

This is the way that I like to view the world, and it does seem to help minimize the compassion fatigue in cases where you think the ‘best’ isn’t being done for the animal.

Best of luck!

Laurie

[David Lane]

Just to add a post script: I had a meniscal tear case that refused surgery and despite my pessimistic skepticism, wanted to PRP instead... and it worked well. I was pleasantly surprised about the amount of pain control we got. By the time it wore off, I think the dog had ground the meniscus down enough that the symptoms never returned as badly. Still was not my 1st line Tx, but for what it's worth, it worked well in this case.

PPS, I've done more Ex Caps on big umbering mastiffs than I can recall offhand, and they all went well (despite the large size, these guys never push the post-op exercise protocol). None of them were 200+ lbs, and a TPLO or TTA would be my 1st and 2nd choice, but an Ex Cap isn't a ridiculous idea.