Re: 7 month Post TPLO - Possible torn meniscus

February 11, 2007

In human sportsmed / orthopaedics, even a confirmed dx of meniscal tear per MRI doesn't necessarily mean surgery is the only viable option. I frequently see human patients with a dx of menical tear who instead opt to try a conservative route. Some of them make considerable progress and are able to avoid surgical intervention while others are not. Many variables come into play there - type of tear (radial, bucket handle, etc), location of tear, integrity of joint surfaces otherwise, integrity of ligamentous restraints, dynamic strength of surrounding muscles and soft tissues, patient size / weight, level of patient daily activity,etc.

If your patient is doing well -- which you say he is -- I would certainly hesitate to surgically enter a joint when that may not be necessary. For what it's worth ---

Stahl, PT, LVT

Findlay Animal Hospital

Findlay Area Sports Therapy and Rehabiliation

February 11, 2007

Hi Sam, In my clinic I have seen a lot of dogs with ACL repairs and most of these dogs (90 %) had a pelvis rotation present (ventral/dorsal rotation ilium). I believe, from an osteopathic stand point of view, that this might be a set up for tearing the ACL and meniscus over a period of time. Also it could come from an ankle dysfunction which over time alters the knee mechanics. Your lab might have intermittent lameness not from the meniscus but from an sacro-iliac dysfunction and/or lumbar 7-sacrum dysfunction. Sad wise most practioners are not able to differential diagnose from a knee dysfunction or lumbo-pelvis dysfunction. See if any one in your neighbor hood has some osteopathic background to help you out. Otherwise, I would leave your happy dog alone especially if she is doing great! Hope this helps, Kortekaas P.T. www.fullspectrumcaninetherapy.com 7 month Post TPLO - Possible torn meniscus My 9 year old lab had a TPLO done on her right stifle last June. It was determined at that time that the meniscus was still intact. She underwent a rehab protocol developed by the ortho surgeon which was pretty conservative and involved just therapeutic exercises. Back in December we started to noticed that she had intermittent lameness after activity (would not even toe touch). Current radiographs looked normal (besides some mild arthritic changes which were present before the surgery) but the surgeon THINKS that she may have torn her right meniscus. We are now faced with whether or not we go back in surgically and remove it (which there is still a chance that it is not even torn) or we just see how she does - currently she is doing great!! No lameness, very active and full of spunk. Any thoughts? Any suggestions on a rehab program when dx. is not confirmed?Cheers!Sam

February 11, 2007

brings up a good point re: ilial rotation after CCL repair. I see this quite a bit as well. I see it, though, after the repair, not on the "well dog" prior to rupture. I think it has quite a bit to do with the length-tension issues of the quadriceps and antagonists as well as the alteration of biomechanics due to the repair. Yes, there seems to be back pain (L7-SI) associated as well. We have to think of this as a whole dog, not just a "cruciate patient."Amie Amie Lamoreaux Hesbach, MSPT, CCRPPresident, Animal Physical Therapy Special Interest Group, Orthopaedic Section, American Physical Therapy Associationwww.orthopt.orgInstructor, The Canine Rehabilitation InstituteWellington, Florida USAwww.caninerehabinstitute.comCEO, For Paws Rehabilitation, LLCPort Republic, land USAwww.forpawsrehabilitation.comManager, Physical Rehabilitation, The Mid-Atlantic Animal Specialty Hospital, LLCHuntingtown, land USAwww.vetmash.com Hi Sam, In my clinic I have seen a lot of dogs with ACL repairs and most of these dogs (90 %) had a pelvis rotation present (ventral/dorsal rotation ilium). I believe, from an osteopathic stand point of view, that this might be a set up for tearing the ACL and meniscus over a period of time. Also it could come from an ankle dysfunction which over time alters the knee mechanics. Your lab might have intermittent lameness not from the meniscus but from an sacro-iliac dysfunction and/or lumbar 7-sacrum dysfunction. Sad wise most practioners are not able to differential diagnose from a knee dysfunction or lumbo-pelvis dysfunction. See if any one in your neighbor hood has some osteopathic background to help you out. Otherwise, I would leave your happy dog alone especially if she is doing great!Hope this helps, Kortekaas P.T.www.fullspectrumcaninetherapy.com ----- Original Message -----From: kevethanwillSent: Sunday, February 11, 2007 10:33 AMTo: VetRehab Subject: 7 month Post TPLO - Possible torn meniscus My 9 year old lab had a TPLO done on her right stifle last June. It was determined at that time that the meniscus was still intact. She underwent a rehab protocol developed by the ortho surgeon which was pretty conservative and involved just therapeutic exercises. Back in December we started to noticed that she had intermittent lameness after activity (would not even toe touch). Current radiographs looked normal (besides some mild arthritic changes which were present before the surgery) but the surgeon THINKS that she may have torn her right meniscus. We are now faced with whether or not we go back in surgically and remove it (which there is still a chance that it is not even torn) or we just see how she does - currently she is doing great!! No lameness, very active and full of spunk. Any thoughts? Any suggestions on a rehab program when dx. is not confirmed?Cheers!Sam

February 12, 2007

Hi Sam,

I have done many fascial strips, TPLOs, and TTAs for ACL

incompetency/deficient knees. If I have a patient that becomes lame

after surgery that had a normal meniscus at the time of surgery, the

first thing I consider is a torn medial meniscus (reported 2 years ago

was about 2% tear post-op no matter what technique used and no matter

whether the meniscus was released at surgery). However, I have never

seen a dog that tears the meniscus post-op become sound as you are

describing. It seems to be a very painful injury(it was in me!) and

most dogs will bear more weight within 24 hours after the meniscectomy

to remove the damaged tissue than before surgery. Also, since neither

TPLO or TTA limit internal rotation I have seen several dogs that

develop temporary lameness due to a rotational injury. Lastly, if your

dog had a partial ACL tear and they left the remaining ligament with

the idea of "unloading" it by getting rid of the cranial tibial thrust

with the TPLO or TTA, I have seen several cases where they continue to

tear more ligament until the rest completely tears, then they go

sound. There was a presentation at the ACVS and much discussion on

removing the rest of partial tears. No real consensus, but alot of

surgeons have seen lameness from continued tearing due to rotational

movement. Personally, I now remove the rest of a partial tear unless

it has a VERY minimal tear of maybe 10% or so. I think based on the

return to being sound that it would be surprising in my experience for

your dog to have a meniscal tear. I think the thoughts of the others

to look at the LS area are good. Also, I have seen several dogs that

have had iliopsoas insertion injuries by trying to return to normal

activity to soon after TPLO or TTA. Try internal rotation and

extension of the hip to look for pain. If the pain returns on that

leg, i have used a bupivicaine injection into the knee to see if pain

resolves for 4-5 hours post-injection to localize. But the bottom line

is that if he is not lame, then why consider surgery? If he was my

case, I would not operate him. If the lameness returns and it

localizes to the knee then consider MRI or exploring it. The surgery

for a meniscectomy is way less invasive and does not create

instability, and they recover within about 2 weeks.

Hope this helps,

Mark B. Parchman, DVM, CVA, DACVS

Bend Veterinary Specialists

Bend, Oregon

kevethanwill wrote:

My 9 year old lab had a TPLO done on her right stifle last June.

It was

determined at that time that the meniscus was still intact. She

underwent a rehab protocol developed by the ortho surgeon which was

pretty conservative and involved just therapeutic exercises. Back in

December we started to noticed that she had intermittent lameness after

activity (would not even toe touch). Current radiographs looked normal

(besides some mild arthritic changes which were present before the

surgery) but the surgeon THINKS that she may have torn her right

meniscus. We are now faced with whether or not we go back in surgically

and remove it (which there is still a chance that it is not even torn)

or we just see how she does - currently she is doing great!! No

lameness, very active and full of spunk. Any thoughts? Any suggestions

on a rehab program when dx. is not confirmed?

Cheers!

Sam

February 12, 2007

I may have missed this in some of the

previous text but in the initial post it was mentioned that the meniscus was

intact. Was a caudal release performed? It is my understanding that in an

intact meniscus a release should be performed to prevent tearing in the future.

I am not a boarded surgeon but I have done many extracaps and I always try to

release the intact meniscus. I assumed that all surgeons (boarded ones) did

this routinely with all ccl repairs of any technique. Is this not the case?

Cheers

Jeff Bowra DVM

Certified Canine Rehabilitation Practitioner

drjeff@...

Aldergrove Animal Hospital

www.familypetdoc.com

The Spaw

Canine Sports Medicine & Rehabilitation

www.thespaw.ca

26841

Fraser Highway

Aldergrove, BC, Canada

V4W 3E4

February 12, 2007

Hi Jeff - I am going to have to get back to you on this. I will check her surgery report tomorrow.

Cheers!

Sam

To: VetRehab From: jcb@...Date: Sun, 11 Feb 2007 19:40:29 -0800Subject: RE: 7 month Post TPLO - Possible torn meniscus

I may have missed this in some of the previous text but in the initial post it was mentioned that the meniscus was intact. Was a caudal release performed? It is my understanding that in an intact meniscus a release should be performed to prevent tearing in the future. I am not a boarded surgeon but I have done many extracaps and I always try to release the intact meniscus. I assumed that all surgeons (boarded ones) did this routinely with all ccl repairs of any technique. Is this not the case?

Cheers

Jeff Bowra DVM

Certified Canine Rehabilitation Practitioner

drjeffthespaw (DOT) ca

Aldergrove Animal Hospital

www.familypetdoc.com

The Spaw

Canine Sports Medicine & Rehabilitation

www.thespaw.ca

26841 Fraser Highway

Aldergrove, BC, Canada

V4W 3E4

Live Search: New search found Try it!

February 12, 2007

Jeff,

The original recommendation by Slocum was to perform a meniscal

release to protect the medial meniscus from shear forces that may

occur within the stifle following the TPLO procedure. Most recent

reports by Fox, Cook, and many others have demonstrated that a

release is not needed, and in fact can be detrimental. I stopped

performing the meniscal release back in 2004 and have had a very low

occurrence of latent meniscal injury (less than 5%). These are

easily diagnosed and treated arthroscopically. The meniscus has a

very important job, why are we cutting it in half?

Sherman

Sherman O. Canapp, Jr., DVM, MS

Diplomate ACVS

Veterinary Orthopedic & Sports Medicine Group

10270 Baltimore National Pike

Ellicott City, MD 21042

(fax)

www.vosm.org

>

> I may have missed this in some of the previous text but in the

initial post

> it was mentioned that the meniscus was intact. Was a caudal release

> performed? It is my understanding that in an intact meniscus a

release

> should be performed to prevent tearing in the future. I am not a

boarded

> surgeon but I have done many extracaps and I always try to release

the

> intact meniscus. I assumed that all surgeons (boarded ones) did this

> routinely with all ccl repairs of any technique. Is this not the

case?

>

> Cheers

>

> Jeff Bowra DVM

>

> Certified Canine Rehabilitation Practitioner

>

> drjeff@...

>

> Aldergrove Animal Hospital

>

> www.familypetdoc.com

>

> The Spaw

>

> Canine Sports Medicine & Rehabilitation

>

> www.thespaw.ca

>

> 26841 Fraser Highway

>

> Aldergrove, BC, Canada

>

> V4W 3E4

>

> _____

>

February 12, 2007

Hi all, for what it is worth, I agree with

! Especially if the pup is doing well at this time!

Pam Nichols

From:

VetRehab [mailto:VetRehab ] On Behalf Of jstahl9744@...

Sent: Sunday, February 11, 2007

1:40 PM

To: VetRehab

Subject: Re: 7 month

Post TPLO - Possible torn meniscus

In

human sportsmed / orthopaedics, even a confirmed dx of meniscal tear per MRI

doesn't necessarily mean surgery is the only viable option. I frequently

see human patients with a dx of menical tear who instead opt to try a

conservative route. Some of them make considerable progress and are able

to avoid surgical intervention while others are not. Many variables come

into play there - type of tear (radial, bucket handle, etc), location of tear,

integrity of joint surfaces otherwise, integrity of ligamentous restraints,

dynamic strength of surrounding muscles and soft tissues, patient size /

weight, level of patient daily activity,etc.

If your patient is doing well -- which you say he is -- I would certainly

hesitate to surgically enter a joint when that may not be necessary. For

what it's worth ---

Stahl, PT, LVT

Findlay Animal Hospital

Findlay Area

Sports Therapy and Rehabiliation

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February 12, 2007

We have had about a 50% success rate with

meniscal tears healing by using the PST. These joints were not opened and

the knees did not have an MRI. They were diagnosed by lameness with a

meniscal click. But again it is another option to surgery.

Laurie

From:

VetRehab [mailto:VetRehab ] On Behalf Of jstahl9744@...

Sent: Sunday, February 11, 2007

2:40 PM