help with post-op patellar luxation

[Guest guest]

Patient: 3yr old Havanese.  Dog has been intermittently skipping on the R rear leg since she was a pup.  Grade 1 MPL. At 1.5 years of age, had surgery on the knee. These are the surgeon's notes: Only a grade I MPL, but since intermittently lame, performed surgery. TTT stabilized laterally with 2x 0.035 k wires and lateral imbrication. 

The dog's lameness did not improve after surgery.  3 months later, a second opinion was sought by another surgeon who determined that the dog had a grade II luxation. The dog was still skipping intermittently.  He did a second surgery: Removed 2 k-wires, performed an abrasion trochelarplasty, imbricated capsule and fascia. 

Both surgeons noted that the ACL and meniscus were OK. The dog is still intermittently lame.  She will skip about every 5th step, particularily at a run. She has decreased muscle mass on the RR leg (1cm difference), and her stifle extension is 15% less then the left knee.  Otherwise she seems normal.  She doesn't seem painful on palpation.  There is thickening of the R stifle. 

I saw her for PT and wanted to help increase weight bearing and stifle extension.  I showed the owner how to do PROM on the leg, and had her do 3-legged stands on that side, and had her walk the dog for a couple of minutes a day with an irritant (bootie) on the left rear leg.

4 weeks later the owner reports that her lameness is worse.  When I saw her, I agreed that I thought she was skipping more frequently.  Her exam was about the same, only my thigh circumference showed that she had gained 0.5cm of muscle mass (there's probably this much normal variation in measuring anyway, but maybe she truly did build up some muscle).  

I tryed her on a 2 week course of rimadyl to see if she was painful, but the owner noticed no change. I had her try some other exercises (sit-beg-stand), balance on a bottom step, hill walking.  I haven't followed up with her yet, but I'm worried that she'll be either worse or no better when I follow-up.  

Does anyone have thoughts?  Thank you so much!teresa

[Guest guest]

My question would be why toy breed dogs with intermittent lameness from a Gr1

MLP are getting surgery in the first place!!!! I have many of them in my

practice who are diagnosed as puppies and live long and healthy lives skipping

every once in a while with no pain.

Jeff Bowra DVM

>

> Patient: 3yr old Havanese. Dog has been intermittently skipping on the R

> rear leg since she was a pup. Grade 1 MPL.

>

> At 1.5 years of age, had surgery on the knee. These are the surgeon's notes:

> Only a grade I MPL, but since intermittently lame, performed surgery. TTT

> stabilized laterally with 2x 0.035 k wires and lateral imbrication.

>

> The dog's lameness did not improve after surgery. 3 months later, a second

> opinion was sought by another surgeon who determined that the dog had a

> grade II luxation. The dog was still skipping intermittently. He did a

> second surgery: Removed 2 k-wires, performed an abrasion trochelarplasty,

> imbricated capsule and fascia.

>

> Both surgeons noted that the ACL and meniscus were OK.

>

> The dog is still intermittently lame. She will skip about every 5th step,

> particularily at a run.

> She has decreased muscle mass on the RR leg (1cm difference), and her stifle

> extension is 15% less then the left knee. Otherwise she seems normal. She

> doesn't seem painful on palpation. There is thickening of the R stifle.

>

> I saw her for PT and wanted to help increase weight bearing and stifle

> extension. I showed the owner how to do PROM on the leg, and had her do

> 3-legged stands on that side, and had her walk the dog for a couple of

> minutes a day with an irritant (bootie) on the left rear leg.

>

> 4 weeks later the owner reports that her lameness is worse. When I saw her,

> I agreed that I thought she was skipping more frequently. Her exam was

> about the same, only my thigh circumference showed that she had gained 0.5cm

> of muscle mass (there's probably this much normal variation in measuring

> anyway, but maybe she truly did build up some muscle).

>

> I tryed her on a 2 week course of rimadyl to see if she was painful, but the

> owner noticed no change.

>

> I had her try some other exercises (sit-beg-stand), balance on a bottom

> step, hill walking. I haven't followed up with her yet, but I'm worried

> that she'll be either worse or no better when I follow-up.

>

> Does anyone have thoughts? Thank you so much!

>

> teresa

>

[Guest guest]

I agree- I don't know if I would have recommended surgery in this pup.  But now what?

[Guest guest]

Has the lumbar spine been cleared for any pathology? I sometimes see a "hitching" or "skipping" gait with spine problems with radiculopathies.

Bedenbaugh, PT, CCRP

Re: help with post-op patellar luxation

I agree- I don't know if I would have recommended surgery in this pup. But now what?

[Guest guest]

Hi ,I haven't done vertebral rads, but there is no pain on palpation of the back, or neuro deficits.  Assuming this is all knee related, could it be a mechanical problem like he can't extend his R stifle as much as the left making the stride shorter on the R, and we may not be able to fix that since there is significant thickening on that knee?

[Guest guest]

,

Great job so far! Yes, it's very possible that this dog has decreased stride

length because her hamstrings (semitendinosus, -mebranosus, gracilis, and caudal

part of the biceps femoris muscle) have decreased flexibility. Be careful not to

over-exercise her and make her sore.

On exam, with the dog's back straight, you should be able to extend the right

stifle forward (flexing the hip)so that the RR foot touches the right elbow.

Palpate the above muscles carefully with the RR leg in this position (dog on her

left side), to feel for pain, tightness, bands, and trigger points. This should

identify which muscle(s) to work on. Walking, deep massage, or therapeautic

ultrasound to warm up the muscles, then gentle stretching. I think pulsed signal

therapy (PST) would be great for this dog. Do you have access to this? Have you

used Assisi rings?...the clients could use the ring at home.

If this is the pblm site, owners could stretch 1-2 times daily at home, then

recheck with you weekly/monthly for stretch and strengthening therapy. You got

access to a laser?

Lastly, be sure to get as specific a diagnosis as you can before therapy starts.

Is the neck/back sore? X-rays?

I'm kinda nutty about pain management too, especially rehabbing post-op. I think

this dog would benefit from Adequan injections, and an NSAID-opiod combo

(Rimadyl and Tramadol).

I hope someone with more experience in rehab will give their thoughts.

Keep up the good work! ...and keep us posted too.

Chris

>

> Hi Chris- thanks for your email!

> This girl has thickening of the stifle, but no drawer, crepitus or movement

> of the patella. She has symetrical goniometer measurments in the front and

> tricep circumference. She has reduced extension by about 10 degrees? (I'm

> trying to recall- and can't remember specifically, but it was around that)

> on the RR, but flexion is the same as the opposite leg. She has a normal

> neuro exam. (Normal CP,paper slide test, gluteal strength test etc.).

>

> She is about 1lb overweight and we are working on reducing the number of

> treats. We switched her to J/D and put her on cosequin. We also did a

> rimadyl trial to see if that helped when she seemed to get a little worse

> with the very basic exercises I gave her. The owner didn't think that the

> rimadyl helped, and I did not appreciate a pain response when manipulating

> her back or leg at all.

>

> I have not taken rads, so that is something I will definately do. I'm

> wondering if there is just a mechanical problem now where her stride length

> on the R is less then the L since she can't extend as far? Is that

> possible?

>

> Thanks again for your thoughts

> Regards,

>

>

[Guest guest]

,

I have a lot of questions and unfortunately few answers or suggestions. From

your description it sounds as if you have continued dynamic patellar luxation,

especially if you are of the opinion that the gait alteration is more due to

intermittent functional impairment (patellar luxation) rather than lameness

associated with pain. Even with two past surgeries it still could be possible

that the limb alignment issues causing MPL still have not corrected. Sometimes

the degree of tibial varus, femoral varus and/or femoral rotation may not be

corrected with standard MPL surgical procedures. I guess that there is also the

possibility that greater joint dysfunction was caused by the surgeries in a

patient that may not have needed correction to begin with, something Jeff

previously touched on. Consider radiographs to evaluated for the above limb

alignment issues.

I really think that Chris's comments are interesting. I tend to see more

problems in the cranial thigh muscles with stifle dysfunction rather than the

caudal thigh. I do often recognize mild myofascial pain in the m. gracillis

and/or the m. adductor with stifle dysfunction but not to the degree seen in the

cranial muscles. If the m. sartorius, m. tensor fascia late and m. rectus

femoris are painful, with taut bands, then they are shorter and could thus

effect dynamic movement of the patella.

Thanks for your comments, they stimulate thought!

Rick Wall, DVM

Certified Canine Rehabilitation Practitioner

Diplomate, American Academy of Pain Management

Certified Myofascial Trigger Point Therapist

Center for Veterinary Pain Management and Rehabilitation

The Woodlands, TX

www.vetrehabcenter.com