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Hello,

I was wondering if you could give some thoughts/pointers on a new case I recently evaluated.

6 yr old MN Shepherd mix. 12 weeks post-op TPLO on left. At 4 weeks the surgeon evaluated him and he looked great. 8 week surgeon eval she noted that his patella on the surgical leg had moved laterally by palpation and radiograph. The owner hadn't noticed anything different between the two appointments.

On my evaluation the patella is around a grade 3-4 luxation. I can move it almost into the grove, but definitely won't stay. He didn't seem overly painful by my manipulation and his range of motion everywhere is great. His gait shows lateral abduction at the stifle and almost a pivot shift at his foot. He is still weighted shifted to the right when standing and has a grade 2/5 lameness on that leg. Owners have been walking him about 2 miles per day and continue his range of motion and stretching exercises they were told to do post-op.

I have never personally seen a lateral patellar luxation since I have been doing rehab and I definitely haven't seen one post-TPLO. This was apparently a first for the surgeon as well.

The dog doesn't have a particular job, but owners are just wanting him to be comfortable and deciding whether surgery is the best option.

Do you treat lateral patellas similarly to medial in that quad strengthening is in order as well as abductor and stabilizers. Anything in particular you recommend I focus on in addition? What is the likelihood after some rehab therapy this dog will be ok long term without surgery? Anything I should stay away from?

Thank you so much for your support and expertise!

By the way, I use the techniques I learned in the Advanced Spinal Manual therapy course every single day with fantastic results!!! Thanks again!!

E.W.

Hi Elizabeth,

Great question & discussion point.

So, I have seen a small handful of dogs whose patellas become 'looser' to the point of being detectable after some other injury, incident, etc that causes muscle wasting & deterioration in the affected leg (usually stifle or hip).
It's interesting to me that this would be so severe (Grade 3 - 4) without anything being noticed.

Anyways, it's the case you have now... so here would be my plan.

Strengthen GLUTES. Human literature is now focusing on glute strengthening for both knee as well as hip problems. Really, and isolated general leg strengthening will be useful. My favourite would be the e-stim on the glutes THEN adding a 3-leg stand (slide the good leg out backwards). Home program of glute tapping with the leg slide. I'd do squat blocks and maybe 1/2 squats - (i.e. sit to stands onto an elevated surface such as a stool.)
I would also try to normalize the leg position during gait. Not sure what he looks like, but I'd try bandaging into internal rotation of the hips, walk 3 minutes, remove the bandage and see if gait looks better. Then also try bandaging into external rotation, walk 3 minutes, remove and see if the gait looks better. (Normally TPLO dogs tend to externally rotate the legs, which would allow for a more medial pull on the patella... so it doesn't really make sense with this case.) Anyways, my usually tactic is to bandage into external rotation, to make the gait look worse, then walk the dog. In the bandage, the dog would activate internal rotators to fight the bandage and when you take it off, the dog's leg looks straighter. You're case may be different... (??)

I would also wonder if any soft tissue techniques to the lateral thigh could be in order - massage, MFR, stretches etc. to the TLF, & vastus lateralis.

I'd try some of this before jumping into surgery. It's always an option if the strengthening doesn't do the trick.

Good luck!

Cheers,
Laurie

Coming from the surgical perspective, I would be very disappointed to see this in one of my TPLO cases.
Certainly when rotating the plateau you have to be careful not to create any kind of varus or valgus or move the plateau medially or laterally. There is a technique where you can move the tibial plateau to help repair patella luxations, so it is not unreasonable that if the surgery is not done correctly that you could induce a patella luxation.
But in this case something mysterious happened between 4 and 8 weeks? Could poor conditioning or muscle tightening have caused this? If so then yes work on PT.
I've had patella luxation repairs look great at 8 weeks with a tibial tuberosity transposition, then allow them to gradually return to full function and they come back months later with the patella luxating again. Why? Did I not rehab them enough?
I agree with Laurie, if you can improve this without additional surgery that would be awesome.
But repeat radiographs and assessment of alignment may be needed to make sure nothing shifted.
Caroline

My thoughts were similar to yours Caroline. I didn't want to throw the surgeon / surgical technique under the buss (since, as a non-surgeon that can get me in a pickle)... but I did have concerns about that as well. Thanks for piping up!
Laurie