Hey Laurie! I have a quick question for you, if it’s not a quick answer and you would rather have a chat I am open to that as well.
I have a case of a post TPLO whippet, where the plate was removed 6 months post op and is still having lameness problems after a series of joint injections and rehab. The ortho surgeon has no idea why she continues to become lame and elected to just continue steroid injections, but owners were not willing. They asked me about a stifle brace. I have never used a stifle brace after an osteotomy was performed and so I reached out to Ashley at Gohero and she mentioned that you had used it for an MCL before.
In the patients stifle I feel there is a bit more internal rotation instability, but no varus or valgus pain. Before we jump into the extensive nature of casting and bracing I wanted to see if you felt the brace stabilized for the MCL? Also have you used this brace in a pup with an osteotomy?
Thanks in advance!
LM
Hero brace for post op TPLO - with issues
Re: Hero brace for post op TPLO - with issues
Okay, it’s not exactly a simple answer. Yes, we have used the Hero braces to help stabilize MCL or LCL because we felt it was better than nothing, AND in the end, it worked great.
However, what I’m missing from your question is what do you think is the issue with your dog. An increase in Passive internal rotation can mean nothing. What is more important is do you see the rotation or bowing of the leg when walking? What’s being called a ‘Pivot Shift’ in vet medicine (it’s actually a borrowed term from human medicine that has been used incorrectly… but that’s the term being thrown around in the vet circles - so I’m stuck using it.)
What else have you checked or evaluated? L/S, SIJ, Iliopsoas, tarsus. Did the steroid injections work at all? Can you find any pain / discomfort along the plate (think skinned whippet - maybe it’s a soft tissue rub?) Any abnormal, unusual swelling at the joint? (I have a vet owned dog that did poorly with astounding atrophy - turned out to be a synovial neoplasia) Is there pain in the joint, (ie. end ranges) that you can detect? What about meniscal tests? (I’ve seen this often… and in cases where the surgeon says, “maybe let's remove the plate” and I beg, “please look in the joint while you're there.” And low and behold there’s a meniscal tear.
So… I’m not sure I’d start with a brace at this stage of the game. There are more things that would make sense for a poor-doer at this stage.
Back to you!
Laurie
However, what I’m missing from your question is what do you think is the issue with your dog. An increase in Passive internal rotation can mean nothing. What is more important is do you see the rotation or bowing of the leg when walking? What’s being called a ‘Pivot Shift’ in vet medicine (it’s actually a borrowed term from human medicine that has been used incorrectly… but that’s the term being thrown around in the vet circles - so I’m stuck using it.)
What else have you checked or evaluated? L/S, SIJ, Iliopsoas, tarsus. Did the steroid injections work at all? Can you find any pain / discomfort along the plate (think skinned whippet - maybe it’s a soft tissue rub?) Any abnormal, unusual swelling at the joint? (I have a vet owned dog that did poorly with astounding atrophy - turned out to be a synovial neoplasia) Is there pain in the joint, (ie. end ranges) that you can detect? What about meniscal tests? (I’ve seen this often… and in cases where the surgeon says, “maybe let's remove the plate” and I beg, “please look in the joint while you're there.” And low and behold there’s a meniscal tear.
So… I’m not sure I’d start with a brace at this stage of the game. There are more things that would make sense for a poor-doer at this stage.
Back to you!
Laurie
LAURIE EDGE-HUGHES
Re: Hero brace for post op TPLO - with issues
Let me start at the beginning of this long journey with Fiona. Bare with me while it is long….
TPLO performed October 22, 2019: meniscus intact, released the caudal ligament
No formal rehab program
Owners searched for rehab exercises on the internet, patient recovered well per owners
April 23, 2020: presented to surgeon with lameness after jumping onto the bed and missed.
Surgeon report says rads mild DJD, no infection completely healed osteotomy
Directions to give previcox and gabapentin, there is nothing wrong per surgeon.
May 5, 2020: presented to me and this is the report from owners: Since the surgery Fiona has not regained full use of her affected limb. Owners said in the reported to their Vet that Fiona had difficulty doing the at home exercises and that she would limp after doing them. In the last few months, Fiona was playing fetch in backyard. She missed the toy and fell/rolled on her back legs. Fiona started limping again
My exam revealed excellent muscling bilaterally, stance analysis 11% left rear, 27% right rear. Spasm in stifle hyperextension, crepitus with click through ROM and Modified McMurry particularly in the lateral joint. No thrust present. Cranial tibialis muscle tender. No pain in iliopsoas, proximal sartorius was tender. My rule outs were meniscal injury or plate infection. Secondary soft tissue discomfort present but didn’t seem to be the primary reason for her discomfort.
Referred to another surgeon for second opinion.
May 12, 2020: He went in an removed the TPLO plate and gave hylartin injection with diagnosis of POSSIBLE implant reaction and mild DJD.
I was trying to get into his surgery notes, but I seem to be unable to open them at this time. I sent her there specifically wondering about a meniscal tear, so I ASSUME he took a look… but you never know.
Surgeon did 3 injections of hylartin. After each injection Fiona would walk pretty well.
June 2, 2020: Presented back to me partial weight bearing osteotomy site was uncomfortable, more crepitus than before. Extension primarily uncomfortable. Performed shockwave on osteotomy site and at stifle joint to compliment the joint injections.
Jun 25, 2020: Recheck owners thought doing really good. Stance still 11% Left rear, discomfort still in extension. Still on gabapentin and previcox. Started more home exercises and in house therapeutic exercise.
July 29, 2020: Doing well. Stance 18%. Comfortable through ROM. Owners will begin to increase her activity to light jog. Try to wean off previcox.
August 26, 2020: Lameness returned. Spasms throughout muscle in limb, crepitus in ROM. Performed therapeutic massage and chiropractic.
Sept 10, 2020: TPLO osteotomy site still uncomfortable. ROM: Extension spasm and crepitus going into extension. Crepitus improves with PROM. No tibial thrust or discomfort. Noting muscle atrophy again. Went through owner exercise program: They were performing sit to jumps (vertical) that they had found online. I asked them to follow our home exercise program and avoid the explosive type moves until we get her more comfortable. 3 more shockwaves scheduled over the osteotomy site.
October 7, 2020: Osteotomy site comfortable with appropriate medial buttress forming. Click through range of motion. Small thrust noted with minor discomfort. Easy home exercise plan continued.
October 14, 2020: Owner called and said she was still limping and bunny hopping. Sent her back to surgeon for evaluation.
October 20, 2020: Surgeon is concerned with bruising over the medial aspect of the groin and runs coag panel, which returned normal. Otherwise feels leg is ok and doesn’t appreciate a lameness. So I instructed the owners to take her off Previcox and gabapentin to show surgeon she is lame. Video she was hard playing and then fully non-weight bearing lame afterwards. Surgeon elected for triamcinolone injections every few weeks.
November 6, 2020: My last visit with Fiona. She had back pain per her rDVM. She was in the middle of her steroid joint injections. Stifle tender in extension, no clicks, TrP in rectus femoris. More apparent spasms in thoracic and lumbar paraspinals. Massage and adjustment performed.
Email from owner December 6, 2020:
"Hello Dr. M.,
Hope all is well with you and I hope you had a wonderful Thanksgiving!
I was wondering about a few things.
1) Have you ever heard of “Posh Dog Knee Brace”? Custom crafted for your dog for CCL tears.
Note: I believe their site has a PO Box in De Leon Springs, but directions on google say there’s an office in Palm Coast.
Normally people order these either to go the conservative route instead of surgery or get one to help the dog heal better as soon as surgery is over.
In Fiona’s case, well, we know how long it’s been and how far along she’s come. However, she’s still not there. She’s still limping, but eventually after rubbing arnica 35 on her, resting her, etc. she gets better, only to repeat the cycle.
We opted to not do any further injections on her. The last time was so hard on her and it didn’t last long, it seems. Just didn’t want to put her through all of that again.
On top of all that, we never mentioned anything to anyone, but we were looking to move. We found a place, and we have 30 days to get a buyer for our house or we lose the contract.
So, my next thing I was wondering was...
2) With Fiona being so far along she does get around OK. Not great, but ok. She limps a little after lying around a while, stretches and shakes and most of the time she is ok. Still can’t seem to get back to regular play without limping later, so we stick to baby play. The brace is around $900, I believe.
I have no problem paying for it myself, but Don feels she’s already too far along and doesn’t need one. He says she just needs more time. And of course, trying to get a loan so we can buy a house doesn’t help either.
But, something in my head keeps thinking that if she had one on that knee, she could play and it would be stabilized and she wouldn’t keep twisting it or whatever is happening that’s causing the pain. And possibly if something is rubbing because of the way she’s walking or maybe she’s overcompensating and it’s in a weird position or maybe it’s just arthritis?!?!
Heck if I know! 
I did join a FB group that is a support group for “Dog ACL/CCL injuries-Conservative Recovery” and it’s been real encouraging to see the dogs that recovered without surgery.
I am in the process of weaning Fiona off of the Gabapentin again. She hasn’t taken anymore Previcox since she saw you last.
It was mentioned that Collagen type 1 2 3 will help knit the knee back together. It will make scar tissue stronger. So I ordered some for all 3 of us to try!
It just came in tonight so we will start it tomorrow.
3) If you don’t mind, what are your thoughts on a custom brace for Fiona at this point?
If she would really benefit to make it worth it, I would like to try to get it before we move. Especially since it appears they are in Florida.
Any observations/opinions you have are welcomed since you are familiar with her case. You’ve treated her, seen her play and limp later on (although it was very little I caught).
P.S. Where we are moving there are dogs (friendly) that freely walk onto your property and around the neighborhood. Although we’ll put a fence up, I know Fiona will run back and forth along the fence barking when she sees them. That scares me as far as her re-injuring this knee or hurting her other leg!
”
So as you can see this has been an extensive process over the past several months. My response to the owners was just as you would expect, that I was not sure how much the brace would help but that I would reach out and see. I will send you a video of her playing as well so that you can get an idea of where she is at. I don’t have surgeon notes regarding what the meniscus looked like.
Thanks for your help on this!
LM
TPLO performed October 22, 2019: meniscus intact, released the caudal ligament
No formal rehab program
Owners searched for rehab exercises on the internet, patient recovered well per owners
April 23, 2020: presented to surgeon with lameness after jumping onto the bed and missed.
Surgeon report says rads mild DJD, no infection completely healed osteotomy
Directions to give previcox and gabapentin, there is nothing wrong per surgeon.
May 5, 2020: presented to me and this is the report from owners: Since the surgery Fiona has not regained full use of her affected limb. Owners said in the reported to their Vet that Fiona had difficulty doing the at home exercises and that she would limp after doing them. In the last few months, Fiona was playing fetch in backyard. She missed the toy and fell/rolled on her back legs. Fiona started limping again
My exam revealed excellent muscling bilaterally, stance analysis 11% left rear, 27% right rear. Spasm in stifle hyperextension, crepitus with click through ROM and Modified McMurry particularly in the lateral joint. No thrust present. Cranial tibialis muscle tender. No pain in iliopsoas, proximal sartorius was tender. My rule outs were meniscal injury or plate infection. Secondary soft tissue discomfort present but didn’t seem to be the primary reason for her discomfort.
Referred to another surgeon for second opinion.
May 12, 2020: He went in an removed the TPLO plate and gave hylartin injection with diagnosis of POSSIBLE implant reaction and mild DJD.
I was trying to get into his surgery notes, but I seem to be unable to open them at this time. I sent her there specifically wondering about a meniscal tear, so I ASSUME he took a look… but you never know.
Surgeon did 3 injections of hylartin. After each injection Fiona would walk pretty well.
June 2, 2020: Presented back to me partial weight bearing osteotomy site was uncomfortable, more crepitus than before. Extension primarily uncomfortable. Performed shockwave on osteotomy site and at stifle joint to compliment the joint injections.
Jun 25, 2020: Recheck owners thought doing really good. Stance still 11% Left rear, discomfort still in extension. Still on gabapentin and previcox. Started more home exercises and in house therapeutic exercise.
July 29, 2020: Doing well. Stance 18%. Comfortable through ROM. Owners will begin to increase her activity to light jog. Try to wean off previcox.
August 26, 2020: Lameness returned. Spasms throughout muscle in limb, crepitus in ROM. Performed therapeutic massage and chiropractic.
Sept 10, 2020: TPLO osteotomy site still uncomfortable. ROM: Extension spasm and crepitus going into extension. Crepitus improves with PROM. No tibial thrust or discomfort. Noting muscle atrophy again. Went through owner exercise program: They were performing sit to jumps (vertical) that they had found online. I asked them to follow our home exercise program and avoid the explosive type moves until we get her more comfortable. 3 more shockwaves scheduled over the osteotomy site.
October 7, 2020: Osteotomy site comfortable with appropriate medial buttress forming. Click through range of motion. Small thrust noted with minor discomfort. Easy home exercise plan continued.
October 14, 2020: Owner called and said she was still limping and bunny hopping. Sent her back to surgeon for evaluation.
October 20, 2020: Surgeon is concerned with bruising over the medial aspect of the groin and runs coag panel, which returned normal. Otherwise feels leg is ok and doesn’t appreciate a lameness. So I instructed the owners to take her off Previcox and gabapentin to show surgeon she is lame. Video she was hard playing and then fully non-weight bearing lame afterwards. Surgeon elected for triamcinolone injections every few weeks.
November 6, 2020: My last visit with Fiona. She had back pain per her rDVM. She was in the middle of her steroid joint injections. Stifle tender in extension, no clicks, TrP in rectus femoris. More apparent spasms in thoracic and lumbar paraspinals. Massage and adjustment performed.
Email from owner December 6, 2020:
"Hello Dr. M.,
Hope all is well with you and I hope you had a wonderful Thanksgiving!
I was wondering about a few things.
1) Have you ever heard of “Posh Dog Knee Brace”? Custom crafted for your dog for CCL tears.
Note: I believe their site has a PO Box in De Leon Springs, but directions on google say there’s an office in Palm Coast.
Normally people order these either to go the conservative route instead of surgery or get one to help the dog heal better as soon as surgery is over.
In Fiona’s case, well, we know how long it’s been and how far along she’s come. However, she’s still not there. She’s still limping, but eventually after rubbing arnica 35 on her, resting her, etc. she gets better, only to repeat the cycle.
We opted to not do any further injections on her. The last time was so hard on her and it didn’t last long, it seems. Just didn’t want to put her through all of that again.
On top of all that, we never mentioned anything to anyone, but we were looking to move. We found a place, and we have 30 days to get a buyer for our house or we lose the contract.
So, my next thing I was wondering was...
2) With Fiona being so far along she does get around OK. Not great, but ok. She limps a little after lying around a while, stretches and shakes and most of the time she is ok. Still can’t seem to get back to regular play without limping later, so we stick to baby play. The brace is around $900, I believe.
I have no problem paying for it myself, but Don feels she’s already too far along and doesn’t need one. He says she just needs more time. And of course, trying to get a loan so we can buy a house doesn’t help either.
But, something in my head keeps thinking that if she had one on that knee, she could play and it would be stabilized and she wouldn’t keep twisting it or whatever is happening that’s causing the pain. And possibly if something is rubbing because of the way she’s walking or maybe she’s overcompensating and it’s in a weird position or maybe it’s just arthritis?!?!
Heck if I know! 
I did join a FB group that is a support group for “Dog ACL/CCL injuries-Conservative Recovery” and it’s been real encouraging to see the dogs that recovered without surgery.
I am in the process of weaning Fiona off of the Gabapentin again. She hasn’t taken anymore Previcox since she saw you last.
It was mentioned that Collagen type 1 2 3 will help knit the knee back together. It will make scar tissue stronger. So I ordered some for all 3 of us to try!
It just came in tonight so we will start it tomorrow. 3) If you don’t mind, what are your thoughts on a custom brace for Fiona at this point?
If she would really benefit to make it worth it, I would like to try to get it before we move. Especially since it appears they are in Florida.
Any observations/opinions you have are welcomed since you are familiar with her case. You’ve treated her, seen her play and limp later on (although it was very little I caught).
P.S. Where we are moving there are dogs (friendly) that freely walk onto your property and around the neighborhood. Although we’ll put a fence up, I know Fiona will run back and forth along the fence barking when she sees them. That scares me as far as her re-injuring this knee or hurting her other leg!
”So as you can see this has been an extensive process over the past several months. My response to the owners was just as you would expect, that I was not sure how much the brace would help but that I would reach out and see. I will send you a video of her playing as well so that you can get an idea of where she is at. I don’t have surgeon notes regarding what the meniscus looked like.
Thanks for your help on this!
LM
Re: Hero brace for post op TPLO - with issues
Thank you for all of this! It’s helpful. (And FYI, I have put the first part of the Q & A on the FourLeg forum… but removing names… and would like to include this as well… because it adds so much.)
So, the pieces of this that jump out at me.
May 5 - lameness returned after an injury while playing. Your exam pointed to meniscus.
May 12 - Plate removal - unsure if meniscus was looked at or dealt with.
Seemingly improving there-afterwards
Sept 10 - Deterioration. Owners had been doing jump from a sit. RED FLAG. As you know, the TPLO does not stop drawer in flexion, so asking for this kind of burst activity with a TPLO stifle, could easily shear the joint and lead to meniscal derangement (again… or a new part of it - IF the surgeon had addressed it to begin with in May.)
Oct 7 - you find click t/o ROM
Oct 20 - Surgeon does not appreciate lameness
So, if I look at the redacted notes (i.e. the parts that jumped out at me). I’m going to place my bet at Vegas on Meniscus again. Maybe a bucket handle tear or flap that moves.
A stifle brace won’t help this. I’d be wanting a look inside the joint. So, now you're up against a rock and a hard place - to convince a surgeon to see it the same way, because what IS being done isn’t working.
OR, you try the manual meniscal release technique (distraction rotation technique I use), add in laser and shockwave. Stop the owners from doing the ball / frisbee tosses or bad exercises… and see if you can get it to heal conservatively as your second option if you can’t get anyone to take her on surgically.
I hope this helps!
Cheers,
Laurie
So, the pieces of this that jump out at me.
May 5 - lameness returned after an injury while playing. Your exam pointed to meniscus.
May 12 - Plate removal - unsure if meniscus was looked at or dealt with.
Seemingly improving there-afterwards
Sept 10 - Deterioration. Owners had been doing jump from a sit. RED FLAG. As you know, the TPLO does not stop drawer in flexion, so asking for this kind of burst activity with a TPLO stifle, could easily shear the joint and lead to meniscal derangement (again… or a new part of it - IF the surgeon had addressed it to begin with in May.)
Oct 7 - you find click t/o ROM
Oct 20 - Surgeon does not appreciate lameness
So, if I look at the redacted notes (i.e. the parts that jumped out at me). I’m going to place my bet at Vegas on Meniscus again. Maybe a bucket handle tear or flap that moves.
A stifle brace won’t help this. I’d be wanting a look inside the joint. So, now you're up against a rock and a hard place - to convince a surgeon to see it the same way, because what IS being done isn’t working.
OR, you try the manual meniscal release technique (distraction rotation technique I use), add in laser and shockwave. Stop the owners from doing the ball / frisbee tosses or bad exercises… and see if you can get it to heal conservatively as your second option if you can’t get anyone to take her on surgically.
I hope this helps!
Cheers,
Laurie
LAURIE EDGE-HUGHES
Re: Hero brace for post op TPLO - with issues
Thanks Laurie! I have developed a nice relationship with this surgeon and I feel I can ask him to look at the meniscus without causing too much strife so I will try. Sometimes I wish I had the ability to just get the surgeons to do this the first time.
I am familiar with your meniscus release technique (you showed it to me at STARR) so I am happy to try this with her as well continue to treat with other modalities, but the owners are moving to Mississippi soon. So I will try and get the surgeon to take a peak for me.
I appreciate your assistance and helping me with this case!
Take care and be safe!
L
I am familiar with your meniscus release technique (you showed it to me at STARR) so I am happy to try this with her as well continue to treat with other modalities, but the owners are moving to Mississippi soon. So I will try and get the surgeon to take a peak for me.
I appreciate your assistance and helping me with this case!
Take care and be safe!
L