Pivot Shift

[lehughes]

Good Afternoon Laurie,

I have attached a video of a patient we are currently rehabing. Paddock had a left TPLO about a year ago which he recovered fine. Four month ago we had to perform a TPLO on his right rear leg which he had a much harder time recovering from. After his 8 week recheck his radiographs showed that his osteotomy has healed however he did have bilateral iliopsoas strains as well as lumbar pain around L4-L5.

He has good ROM in both his stifle and hocks and shows no signs of discomfort on full flexion. We have been lasering him for the past 4 weeks (both iliopsoas and lumbar spine) and performing strain counter strain on the iliopsoas muscles.

My questions is....when he is walking it appears to have a pivot shift (which could be due to his muscle atrophy), but I am wondering if this is a neurological issues or am I just missing something?

At your earliest convenience could you please watch the video and let me know your thought.

Thanks
CS

[lehughes]

Hey C.!

The video didn’t come along for the ride across the airwaves, but that’s okay.

So, the reason for the delay and difficulty to heal could be the pivot shift itself. Essentially they may need to go back in and perform an extracap in order to prevent the rotational shifting at the stifle joint at this point. From what I can see in other postings, if this is the problem, surgery is the only good fix.
I’d try doing some specific strengthening to build quads. (sit to stands onto a block, step ups, squat blocks, hill walking, 3-leg stands with e-stim, tug of war…) But know in your head that the answer may be surgery.

Best of luck!

Laurie

[David Lane]

If a pivot shift is detectable on examination, but the patient is doing well or almost well clinically, I have good success in resolving it with rehab strength training. If however, there is dysfunction with virtually every step (I haven't seen the video), then that is a deeper hole to climb out of and an anti-rotational suture should resolve it. (basically, what LEH said). I would first resolve the identified muscular pain, and work on some isometric exercises (weight shifting etc.) with your hand over the knee. If you can feel the musculature engaging without the tibia pivoting, then rehab is worth a try. If it pivots doing just the basics, then I would be quick to return to surgery. Having said that, I can't think of the last case that did not resolve non-surgically... its been a while.