fourleg.com

Hi I'm hoping someone can share their experiences to compensate for my lack of experience!
Last week I saw a 7 year old bichon x Maltese. He had a complete ccl rupture and tear of the posterior horn of the medial meniscus. He had an MMP and a medial menisectomy. The surgeon noted he had than extreme tibial plateau angle. He was discharged and about a week later the owner contacted the vet surgeon because the dog was not using his leg at all. On review it was seen that the tibiofemoral joint had dislocated, with the femur slipping back entirely off the tibial plateau. The dog had to wait 1 week for a second surgery which involved placing 2 lateral sutures. Post surgery the dog's stifle flexion was extremely limited so he was sedated and the vet tried to work on his flexion range but couldn't get more than 30'. When I assessed him he was non weightbearing and I could achieve 20' flexion, 1 week later I can't measure any passive flexion, however he is starting to weight bear if he is walked slowly. So my questions are around if anyone has rehabbed a dog with this degree of rom loss and can they compensate and be functional enough to have a good quality of life? He can step over floor height cavalettis with hip circumduction. However I'm worried about the long term effects of this hugely altered gait pattern. Would he be better off if the leg was amputated? The vet surgeon has mentioned it but the owner is reluctant.
I would be really grateful to hear of anyone's similar experiences. Thanks.

Holy smokes Kristie! This sounds like a very unique case! So I can't give you any 'experiential knowledge' on this, but I can give you speculative ideas on what to do, try, prognosticate etc.

So, firstly, I would wonder / speculate as to whether the surgeon did up the lateral sutures a bit too tight. I've seen this with some extracapsular techniques. Given this scenario, it could very well be that in a state of "Holy Crap" the surgeon may have over tightened for fear of a repeat dislocation.

If that's the case, then you need / want a little stretch from those lateral sutures. To that end, you could try some myofascial techniques and high doses of laser. Maybe CW ultrasound (for heating) before you stretch. As well, work lots on pain management.

For cases of stiff stifle (in particular I'm thinking of quads contractures as my comparison scenario), I have found that prolonged sitting on a small elevated or narrow surface can help to achieve active flexion. Therefore, this could be something you test in clinic and prescribe for your home program.
In clinic, try UBER slow stretches - not into pain. But slow slow slow so that you are trying to get fascial stretching and releasing. (i.e. try to slowly stretch for 2 - 5 minutes).

AND... if 20 degrees is all he ever gets, then that is liveable, and better than an amputation. If the pain can be managed (assuming there is or will be pain), then a peg-leg that is still functional is going to be better than no leg at all - especially as the dog ages.

PLEASE keep us posted on this case!

Laurie

A couple of thoughts, all tethered to the disclaimer that I haven’t seen the patient or the rads etc., and therefore may be totally off base…

Small dogs tend to have steeper TPAs and with cruciate rupture, it isn’t uncommon for the femur to slide right off the back of the tibia. For this case to be more unstable than that relatively routine situation, I would wonder if the CdCL was torn, at which point a more elaborate repair is needed. I’ve only seen both cruciates torn with a known trauma, and involvement of at least one of the collateral ligaments as well.

If there is a marked reduction in flexion post-op, then I too wonder if it didn’t reflect surgical technique, at which point it will be hard for you to make big changes.

I mostly wanted to comment on the amputation question. Amputations (like euthanasias) are one of those things that are easy to perform, but not so easy to reverse. Therefore, if considering an amputation, make sure you have solid evidence that it is the correct treatment choice.

To consider amputation, I would want to be sure that the leg is either (a) a source of ongoing uncontrollable pain, or (b) is so non-functional that it actually impairs movement. Even if we don’t get full use of it, if it can only be used as a crutch during stance, or toe touching on certain gaits, at least the dog is getting some benefit from it. If that is the case, I would err on the side of keeping it. If the leg just drags along and trips the dog up, and is never functional, only then I would consider removing it.