Arlington Veterinary Surgery Specialists
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Case Study: Champ's TPLO Surgery & Rehabilitation


History of the Case

Name: Champ

Age: 11 years

Breed: Labrador Retriever

Sex: Male, Neutered

Dog’s lifestyle/occupation: Household pet, family member

Brief history of dog’s family: Owned by family since puppy. Purchased from breeder.

Brief history of problem for which dog was referred: Acute onset of limping and holding rear leg up one day prior to seeing RDVM. No known trauma as dog woke up in the morning not using leg normally. Owners confined their pet for one day but lameness continued. Examined by RDVM 7/23/08 finding Grade III left rear lameness, painful stifle palpation, medial buttress and effusion, positive cranial drawer.

Interventions: Rimadyl injection, overnight hospitalization for surgery following day.

Referring veterinarian’s diagnosis: Left ruptured cranial cruciate ligament

 


Test Results

Radiographs:
Three view chest: no significant findings

Lateral and AP bilateral stifles:


Right: no significant findings


Left: Marked joint effusion, mild osteophyte formation along proximal trochlear ridges. Tibial plateau angle of 25 degrees.

Laboratory results: No significant abnormalities



 


Surgery

Left Stifle Arthroscopy and Tibial Plateau Leveling Osteotomy (TPLO)
Hydromorphone IV pre-op then q 6 hours for 24 hours.
Patient was placed in lateral recumbency. The limb was clipped and prepared for surgery using standard methods. The patient was draped for aseptic surgery using standard technique
An arthroscopic examination of the stifle was performed:

A 3mm incision was made midway between the inferior pole of the patella and tibial crest. An obturator was placed through this incision to exit proximomedial to the patella; an egress cannula was placed over the point of the obturator and pushed into the medial gutter of the joint. The obturator was removed and the same 3mm incision site used for the arthroscope portal. The superior, medial and lateral gutters were explored. An instrument portal was made medial to the patellar tendon at the same proximodistal level as the arthroscope portal. A motorized shaver was used to create a viewing window. The medial and lateral compartments were examined and treatment performed as needed.

Arthroscopic or arthrotomy findings:
Synovitis: moderate
Osteophyte formation: < 3mm height
Cartilage surface: normal
Cranial cruciate: partial tear >70%
Caudal cruciate: normal
Medial meniscus: normal
Lateral meniscus: normal
A medial meniscal release was not performed

An incision was made over the proximal tibia. Dissection sharply with a scalpel blade and electrocautery was used to expose the proximal medial tibial metaphysis and to reflect the musculature from the caudal surface. A gauze sponge was placed adjacent to the caudal bone surface to protect the surrounding soft tissue including the popliteal artery.
A bi-radial saw with 24 mm saw blade used to perform the osteotomy.
The tibial plateau was rotated and stabilized with a 3.5mm Left Broad TPLO plate
One locking screws was used in the proximal tibial segment with associated 8 screws.
The muscle fascia was closed over the plate with using 0 PDS in a simple continuous pattern. The subcutaneous tissues were closed using a simple continuous pattern with 2-0 Monocryl. The skin was closed using Staples
Post-operative radiographs show a tibial plateau angle of 7degrees with appropriate surgical repair.

Discharge Instructions
Leash restrictions outside, controlled low-key household activity only. Crate if necessary.
Monitor incision, E-collar as needed
Medications: Rimadyl, Tramadol, Keflex
Recheck for suture removal and beginning of rehab in 10-14 days.

 


Rehabilitation / Post-operative Treatment History

Acute Post-operative
Subjective
Patient is laterally recumbent waking up from anesthesia and surgery. Pain appears well managed.

Objective
Treatments and parameters:
           Cryotherapy: Ice-pack was applied to the stifle for 10-15 minutes at 2 hour intervals the remainder of the day (3 times). Ice-pack was again applied for 10-15 minutes at 2 hour intervals the following morning after bandage removal.
           Bandage: Robert Jones bandage was applied to the limb from toes to mid-femur overnight then removed in the morning.
Owner education: Client received handouts “Tibial Plateau Leveling Osteotomy – Patient Discharge Instructions” and “Home Rehabilitation Care for Tibial Plateau Leveling Osteotomy – The First Two Weeks Post-Operative.”
Home exercise program: “Home Rehabilitation Care for Tibial Plateau Leveling Osteotomy – The First Two Weeks Post-Operative”
Measurable outcomes: Patient was discharged weight bearing with a Grade III lameness and minimal bruising and swelling.
Observation of gait pattern, function: Walking with strength and Grade III lameness.

Assessment
Good post-operative recovery typical for TPLO

Plan
Evaluation in two weeks and beginning of clinic out-patient rehabilitation.

 

3 ½ Weeks Post-operative

Subjective
Owner not especially compliant with home rehabilitation program. Reports doing exercises every day or so.
Grade III lameness while walking and trotting. Bears weight on leg while standing and will plant foot to pull against leash while walking.

Objective
Treatment and parameters
      Cryotherapy: Ice pack applied to stifle 10 minutes end of session
      Obstacle course over low cavaletti’s, walking on mattress and egg crate foam, walking onto and across 4 inch boxes/grates – 5 reps
      AquaTherapy: Underwater treadmill 1.3 mph for 15 minutes with water at mid-thigh
Owner education: Owner given “Home Rehabilitation for TPLO Two to Eight Weeks Post Operative”
Home exercise program: TPLO Two to Eight Weeks Post Operative
Measurable outcomes: N/A
Observation of gait pattern: Grade III lameness with wide based stance and lateralization of left foot placement.

Assessment
Progress: Very little progress since hospital discharge (owner not following program) yet dog is strongly ambulatory and comfortable on the leg.
Deficits remaining from initial plan: CP deficits of left rear and loss of thigh musculature
Assessment of barriers: client compliance
Remaining problems and goals: same as initial goals

Plan
Continue clinic rehab every other day

 

4 Weeks Post-operative

Subjective
Owner reports that dog had a good time at rehab session and happy to come back. Owner thinks pet is doing well because he walks around the house well and pulls at the leash.

Objective
Treatment and parameters
      Cryotherapy: Ice pack applied to stifle 10 minutes end of session
       Obstacle course over low cavaletti’s, walking on mattress and egg crate foam, walking onto and across 4 inch boxes/grates – 10 reps
       AquaTherapy: Underwater treadmill 1.3 mph for 15 minutes with water at mid-thigh
Owner education: continue leash restrictions
Home exercise program: continue TPLO Two to Eight Weeks Post Operative
Observation of gait pattern, function: Grade III lameness with wide based stance and lateralization of left foot placement.

Assessment
Progress: No remarkable progress at this time

Plan
Continue clinic rehab every other day

 

4 ½ Weeks Post-operative

Subjective:
Seems to be doing a little better today

Objective
Treatment and parameters
      Manual Intervention: Massage and PROM stifle, hock, hip 5-10 minutes beginning of session.
      Cryotherapy: Ice pack applied to stifle 10 minutes end of session
      Therapeutic exercise
      Obstacle course over low cavaletti’s, walking on mattress and egg crate foam, walking onto and across 4 inch boxes/grates – 10 reps
      AquaTherapy: Underwater treadmill 1.5 mph for 15 minutes with water at mid-thigh
Owner education: continue leash restrictions
Home exercise program: continue TPLO Two to Eight Weeks Post Operative
Observation of gait pattern, function: Grade II to III lameness with less wide based stance and lateralization of left foot placement.

Assessment
Progress: Less lameness today, places foot a little better
Deficits remaining from initial plan: muscle loss and CP deficit
Remaining problems and goals: same as initial goals

Plan
Continue clinic rehab every other day

 

4 ½ Weeks Post-operative

Subjective
Owner reports that the dog is doing so well that he is allowing off leash running and playing. Dog is more lame and occasionally hopping.

Objective
Treatment and parameters
       Manual Intervention: Massage and PROM stifle, hock, hip 5-10 minutes beginning of session.
       Cryotherapy: Ice pack applied to stifle 10 minutes end of session
       Therapeutic exercise
       Obstacle course over low cavaletti’s, walking on mattress and egg crate foam, walking onto and across 4 inch boxes/grates – 10 reps
       AquaTherapy: Underwater treadmill 1.5 mph for 15 minutes with water at mid-thigh
Owner education: Of the other dogs that had this same procedure at about the same time, his dog is doing the worst. Owner needs to follow leash restrictions and home program.
Home exercise program: continue TPLO Two to Eight Weeks Post Operative
Observation of gait pattern, function: Grade III to IV lameness with occasional hopping. Muscle mass a little more equal to unaffected leg. Lateralized foot placement only at trot.

Assessment
Progress: Setback in function and increased lameness due to off leash activity
Deficits remaining from initial plan: all
Assessment of barriers: client compliance and over confidence
Remaining problems and goals: same as initial goals

Plan
Continue clinic rehab every other day.

 

5 Weeks Post-operative

Subjective
Less lame today but still occasionally holds foot off of ground. Places foot correctly – not lateralized when standing and walking. Owner much more dedicated to following instructions.

Objective
Treatment and parameters
       Manual Intervention: Massage and PROM stifle, hock, hip 5-10 minutes beginning of session.
      Cryotherapy: Ice pack applied to stifle 10 minutes end of session
       Therapeutic exercise
       Obstacle course over low cavaletti’s, walking on mattress and egg crate foam, walking onto and across 4 inch boxes/grates with the addition of bells to the tarsus – 10 reps
       AquaTherapy: Underwater treadmill 1.5 mph for 15 minutes with water at mid-thigh
Owner education: continue leash restrictions
Home exercise program: continue TPLO Two to Eight Weeks Post Operative
Observation of gait pattern, function: Grade II lameness with correct foot placement but occasionally hops on foot.
Muscle mass: Left @ 70% = 32 cm Right @ 70% = 32 cm
PROM

Range of Motion
Flexion (L / R)
Extension (L / R)
Hip 55 / 55 160 / 160
Stifle 60 / 45 143 / 160
Tarsus 20 / 20 150 / 150

Assessment
Progress: Less lameness today than setback last session
Deficits remaining from initial plan: lameness, decreased ROM
Remaining problems and goals: alleviate lameness and increase ROM

Plan
Continue clinic rehab every other day. Additional sessions recommended.

 

6 Weeks Post-operative

Subjective
Owner doing very well with home program and restrictions. Less lame and no hopping.

Objective
Treatment and parameters
      Manual Intervention: Massage and PROM stifle, hock, hip 5-10 minutes beginning of session.
      Cryotherapy: Ice pack applied to stifle 10 minutes end of session
      Obstacle course over low and high cavaletti’s, walking on mattress and egg crate foam, walking onto and across 4 inch boxes/grates with the addition of bells to the tarsus – 10 reps
      AquaTherapy: Underwater treadmill 1.5 – 1.8 mph for 15 minutes with water at mid-thigh down to mid tibia
Owner education: continue leash restrictions
Home exercise program: continue TPLO Two to Eight Weeks Post Operative
Observation of gait pattern, function: Grade I lameness

Assessment
Progress: Good progress with decreased lameness and no more hopping
Deficits remaining from initial plan: lameness, decreased ROM
Remaining problems and goals: alleviate lameness, normalize ROM

Plan
Continue clinic rehab every other day.

 

6 ½ Weeks Post-operative

Subjective
Owner doing very well with home program and restrictions. Owner does not perceive any lameness or problems

Objective
Treatment and parameters
      Cryotherapy: Ice pack applied to stifle 10 minutes end of session
      Obstacle course over low and high cavaletti’s, walking on mattress and egg crate foam, walking onto and across 4 inch boxes/grates with the addition of bells to the tarsus – 10 reps
      AquaTherapy: Underwater treadmill 1.5 – 1.8 mph for 15 minutes with water at mid-thigh down to mid tibia
Owner education: continue leash restrictions
Home exercise program: continue TPLO Two to Eight Weeks Post Operative
Observation of gait pattern, function: Grade I lameness

Assessment
Progress: Doing very well, almost normal
Deficits remaining from initial plan: mild lameness
Remaining problems and goals: alleviate lameness, normalize ROM

Plan
Continue clinic rehab every other day.

 

7 Weeks Post-operative

Subjective
Doing well

Objective
Treatment and parameters
      Cryotherapy: Ice pack applied to stifle 10 minutes end of session
      Obstacle course over low and high cavaletti’s, walking on mattress and egg crate foam, walking onto and across 4 inch boxes/grates with the addition of bells to the tarsus – 5 reps
      AquaTherapy: Underwater treadmill 1.1 5 min then 1.5 mph for 10 minutes with water at mid-thigh down to mid tibia
Owner education: continue leash restrictions
Home exercise program: continue TPLO Two to Eight Weeks Post Operative
Observation of gait pattern, function: Grade I lameness, stands on left (affected) leg to urinate.

Assessment
Progress: Doing very well, almost normal
Deficits remaining from initial plan: mild lameness
Remaining problems and goals: alleviate lameness, normalize ROM

Plan
Continue clinic rehab every other day.

 

7 ½ weeks Post-operative

Subjective
Doing well

Objective
Treatment and parameters
      Cryotherapy: Ice pack applied to stifle 10 minutes end of session
      Obstacle course over low and high cavaletti’s, walking on mattress and egg crate foam, walking onto and across 4 inch boxes/grates with the addition of bells to the tarsus – 5 reps
      AquaTherapy: Underwater treadmill 1.1 5 min then 1.5 mph for 10 minutes with water at mid-thigh down to mid tibia
Owner education: continue leash restrictions
Home exercise program: continue TPLO Two to Eight Weeks Post Operative
Observation of gait pattern, function: Grade I lameness

Assessment
Progress: Doing very well, almost normal
Deficits remaining from initial plan: mild lameness
Remaining problems and goals: alleviate lameness, normalize ROM

Plan
Continue clinic rehab every other day.

 

8 Weeks Post-operative

Subjective
Doing well, owner sees a limp occasionally

Objective
Treatment and parameters
      Cryotherapy: Ice pack applied to stifle 10 minutes end of session
      Obstacle course over low and high cavaletti’s, walking on mattress and egg crate foam, walking onto and across 4 inch boxes/grates with the addition of bells to the tarsus – 5 reps
      AquaTherapy: Underwater treadmill 1.1 5 min then 1.5 mph for 10 minutes with water at mid-thigh down to mid tibia
Owner education: Home Rehabilitaion Care for TPLO 9-12 weeks Post Operative
Home exercise program: Home Rehabilitaion Care for TPLO 9-12 weeks Post Operative
Observation of gait pattern, function: Grade I lameness
Muscle mass: Left @ 70% = 32 cm Right @ 70% = 33 cm
PROM

Range of Motion
Flexion (L / R)
Extension (L / R)
Hip 58 / 55 160 / 160
Stifle 50 / 45 155 / 160
Tarsus 20 / 20 150 / 150

Assessment
Progress: Doing very well, just mild, intermittent lameness
Deficits remaining from initial plan: mild intermittent lameness and mild decrease in ROM
Remaining problems and goals: alleviate lameness completely, normalize ROM

Plan
Finished with clinic rehab

 


Discussion

How many visits? Eleven (including acute post-operative)

Veterinarian feedback: The surgeon was pleased with the outcome of this case especially taking into account the dangerous client compliance. The dog fully recovered within the typical 6-8 weeks despite a setback midway.

Owner compliance: The owner did not perform much of the home rehabilitation initially and even let the dog dangerously run off leash 4 weeks after an osteotomy. However, compliance was much improved after it was explained that a major complication due to trauma off leash would result in more expensive surgery. Also, the owner seemed to respond well to the competitive challenge of pointing out that other people’s dogs were already doing better than his.

How did physical rehabilitation make a difference in this particular case? Physical rehabilitation for TPLO and TTA resolves lameness sooner and prevents loss of muscle and joint range of motion typically considered normal for this injury and surgery. For this particular patient, physical rehabilitation resolved a traumatic setback and got the patient back on track.

Without rehabilitation, this dog would likely have taken 4 weeks longer to recover completely. Also, because the dog was coming in frequently, we were able to find out about the off-leash activity and better educate the owner sooner - before the dog ended up with a much more serious complication.


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