To TPLO, or not to TPLO? Chronic case

[Bwood]

Hi! First time poster here. Would appreciate some feedback based on the case report below:

PMHx: 20 month old agility dog with 6 month hx of waxing/waning Grades 1-3 lameness made worse with daily exercise, CM producing no effect on functional measures. Spay at 8 weeks, otherwise unremarkable medical hx. Suspected partial CCL tear, spinal/hip/hock pathology r/o.

Subjective hx: Dog is depressed, withdrawn, sensitive to pain, symptoms made worse with exercise, poor sleep. Dog was kept in exceptional fitness prior to injury and has a long history of conditioning for athletic performance.

Special tests: positive for pain when conscious, no tibial thrust, slightly delayed capsular endfeel cranial drawer R hind possibly(?) Ortho surgeon reports all normal under anaesthetic.

Thigh girth: equal bilat, dog has a border whippet, "slight" (tall and skinny) conformation, is well conditioned but has very little muscular bulk. Quad/hamstring dominance with poor reciprocal abdominal/glute motor patterns.

DX Imaging: Rads: TPAs 30 degrees bilat, R thickened patellar ligament, moderate effusion bilat, loss of definition of jt borders.

Posture: Intermittent signs- lumbar flexion with wide hind BOS, offloading to front post-exercise, posture returns to quiet/normal post-UWTT.

Gait: Grades 1-2 at rest, 2-3 after daily exercise
Walk: Ataxic, R femoral MR + ADD, intermittent circumduction and hip hiking.
Trot: Significant front loading. Stifle instability can be seen intermittently bilat.
Canter: Loping bunny hop style with offloading to front

First orthopaedic surgeon was following for ~5 months, did not consider to be sx candidate due to lack of cranial drawer and tibial thrust. Plan for care was to do cartrophen injections, ReAx, then scope if no change. TPLO as last resort if lameness unresolvable. Assesses according to Slocum's theory.

Second orthopaedic surgeon was consulted recently and feels both CrCLs are torn, wants to do TPLO on both, with the R being operated on first. Assesses based on a suspicion that degeneration is progressive and non-reversible, and may be caused by autoimmune/immune-mediation.

I would appreciate some input given the polarity between the assessments of the local orthopaedic surgeons. Is a R TPLO the right choice for full return to function? I am a little uneasy about being in the middle of two such different clinical opinions and appreciate your discussion!

[lehughes]

Hey there!

So this sounds like a complicated case!

My questions:
What has the pain management been with this case?
What therapies have been tried?
Have you tested for a meniscal tear?
What has the owner been doing? - i.e. Therapeutic Exercise vs Allowing free exercise/off leash
Have you checked the lumbosacral junction? (I just read a paper that discussed how a sciatic nerve impingement could predispose a stifle to a cruciate injury b/c of the subsequent hamstring weakness.)
Which then begs the questions: How are the hips, SIJ, and rest of the lumbar spine? Iliopsoas? (i.e. is there something else missing?)

I think there is something else going on with this case. I'd not advise surgery until you can get an idea of the full clinical picture on this dog. The more I re-read this case, the more I am concerned about the lumbosacral junction.

Okay, so back to you!!

Laurie

[Bwood]

Hi Laurie:

Sorry for not getting back to your questions sooner! All of the questions you posed I have considered previously and r/o other pathologies, so I am delighted to hear that I had investigated all of the usual DDX suspects! How lucky I feel to have all of your online education available.

I let my physiotherapy "gut" guide me on this one- The dog went for the TPLO this week under the care of the second surgeon consulted and I just got the post-sx report.

Once sedated he found a significantly late and boggy endfeel on the dog's R cran drawer, and feels the L is capsular. Now onto post-op... Thanks for your help.