# Got any random ortho questions?



## Maren Bell Jones (Jun 7, 2006)

So I know I'm not hardly on this forum nearly as much as I used to for various reasons :wink:, but I start my orthopaedic surgery elective rotation this week. I'm pretty freaking nervous, but also very excited. Dr. Jimi Cook DVM, PhD, DACVS (Diplomate of the American College of Veterinary Surgeons) is going to be on clinics during that time. He's one of the top orthopaedic surgeons in the country and the one who developed the new Tightrope method for cranial cruciate ligament repair. 

So don't send me x-rays and ask me to show them to him or a massive PM of your own dog's issues or anything, but if you have any GENERAL (not specific, we can't diagnose over the internet) "hey, I always wanted to know..." ortho questions, I'll do my best (no guarantees!) to bring them up in a GENERAL sort of way. :grin:


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## Jeff Oehlsen (Apr 7, 2006)

How much of hip dysplasia is really genetic ?

Is there any thought to studying an environmental impact ?? I have always wondered if anyone would be doing a study where they xray pups at birth, 8 weeks, 4 months ect.

It has been something that I have always been curious about. I haven't thought about it in years, I have gotten to the "**** it" stage. 

Maybe he has something to offer. Breeders have been hacking away at this problem for years. 

I was always curious as Rotts are not the most aware dogs when it comes to what they are running into, or stepping on. I started choosing more "girly" females and had no dysplasia at the end of my run. I have also seen radiographs that looked like the pup got a paw directly on his back.


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## maggie fraser (May 30, 2008)

My dog was diagnosed with IVDD almost three months back, a narrowing of a disc space could be seen on the xrays as well as a spondylosis. Conservative treatment hasn't effected a recovery and on a reurn visit to the vet yesterday, cruciate disease is now what is being thrown about, my vet thinks it very likely he will require surgery and we have a referral within the next couple of weeks. Previously fit gsd male just turned three yrs old.

My question.... is this common, is there a link with ivdd and cruciate disease ?

Does one consider surgery on the knee(s) when there is back trouble also ?


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## leslie cassian (Jun 3, 2007)

For a severely dysplastic 8 year old Labx, lean at 95lbs. At this point in his life is surgery a worthwhile option? What surgery? Would the benefits be worth the costs, both financially and as far as the dog's ability to withstand and recover from surgery.


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## Sue Miller (Jul 21, 2009)

Jeff Oehlsen said:


> How much of hip dysplasia is really genetic ?
> 
> Is there any thought to studying an environmental impact ?? I have always wondered if anyone would be doing a study where they xray pups at birth, 8 weeks, 4 months ect.
> 
> ...


Same exact questions as Jeff


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## Cesar A. Flores Dueñas (Oct 1, 2009)

Jeff Oehlsen said:


> How much of hip dysplasia is really genetic ?
> 
> Is there any thought to studying an environmental impact ?? I have always wondered if anyone would be doing a study where they xray pups at birth, 8 weeks, 4 months ect.
> 
> ...


There are several researches about genetic characteristics of dyspasia i would post several references tomorrow.

But as simple as look at the high incidence of hip dysplasia on GSD to see a genetic factor there

The genetic characteristics of hip dysplas is a fact log time ago


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## Jeff Oehlsen (Apr 7, 2006)

The genetic thing is all fine and dandy, but there is not much explanation of environmental factors. 

How about 1 hip being crap, and the other hip just fine ?


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## Cesar A. Flores Dueñas (Oct 1, 2009)

Jeff Oehlsen said:


> The genetic thing is all fine and dandy, but there is not much explanation of environmental factors.
> 
> How about 1 hip being crap, and the other hip just fine ?


As you alreay know hip dysplasia is equal to an artrosis of the coxofemoral joints, this means a degeneration of any mean at the level of the pelvis and femur articulation, this commonly leads to luxation , can be on one side only or bilateral.

Of course there are factors that can accelerate the process, like work demand or pressure, nutrition, exercise etc.

I went a year ago to a WSV conference and one WSV breeder and judge , told us he recommend not to much protein on puppies in order to reduce the chance of hip dysplasia, he told also that this approach help him to reduce dysplasia on his kennel, a Show kennel.

I think is not a matter of avoid things, to reduce the incidence of dysplasia , dysplasia is a genetic pathology and the puppy should be treated normally (exercise and nutririon) that way the selection process will be more accurate , taking out dogs with dysplasia problems doesnt matters the degree of disease.

A dysplasia free dog will remain the same, no maters the enviromental factors,and using that dogs on breeding programs will help to reduce the problem as an example on GSD.


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## Maren Bell Jones (Jun 7, 2006)

Jeff Oehlsen said:


> The genetic thing is all fine and dandy, but there is not much explanation of environmental factors.
> 
> How about 1 hip being crap, and the other hip just fine ?


What I would look at for environmental factors is two breeds of dogs that are of about the same size, same weight, same body type, same relative popularities and compare them. So for example, if you look at the Newfoundland, ~25% of the submitted entries to OFA are dysplastic. Then you look at the Great Pyrenees, of which only about 9% are dysplastic. So even though these two breeds are relatively similar build, popularity (according to the AKC, Newfs are 45 for popularity, Great Pyrs are 60), and size, a Newf is more than twice as likely to be dysplastic. That tells me there is something a bit more than just environment going on, but it's definitely not solely genetics alone. It's pretty multifactorial.


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## Debbie Skinner (Sep 11, 2008)

Does there seem to be more or less ortho problems in animals spayed/neutered as pups vs intact dogs?


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## Cesar A. Flores Dueñas (Oct 1, 2009)

Debbie Skinner said:


> Does there seem to be more or less ortho problems in animals spayed/neutered as pups vs intact dogs?


Several Studies had shown that spay and neuter , tend to increase the incidence of hip dysplasia (when surgery performed before 10 months old), this is related with taller and bigger dogs after surgery when performed on puppy stage ( fast growing stage).*

By the way Debbie, congratulations on your breeding program, i like you aproach to breeding on malinois, the results you are having, and the dogs that i know from your kennel, most of them my kind of dog, and the kind of dog is improving the breed.


*(Salmeri KR, Bloomberg MS, Scruggs SL, Shille V.. Gonadectomy in immature dogs: effects on skeletal, physical, and behavioral development. _JAVMA_ 1991;198:1193-1203)


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## Nancy Jocoy (Apr 19, 2006)

What about recent advances on stem cell therapies for dogs with HD? There was a rash of interest on the web then it kind of fizzled out.

Good studies on vitamin C? [had an ortho vet tell me that too much v C during growth can cause too much bone remodeling] Supplements?


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## Cesar A. Flores Dueñas (Oct 1, 2009)

I Have the idea there are 2 kind of Hip Dysplasia Dog Groups

Positive HD dog and Negative HD dogs

A Free Dysplasia dog doesnt matters : nutrition factors, exercise, enviroment, that dog will remain free of dysplasia.

For the Other group there is only an option, acetabular surgery and Neuter or Spay.


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## Maren Bell Jones (Jun 7, 2006)

Friday I assisted Dr. Cook on a brand new total hip replacement surgery system (uses a cementless system called Helica Hip with screws that's from the human ortho side of things) and it was only the second day and third patient ever used at our teaching hospital. Way cool! I cannot post the before radiographs because of patient confidentiality, but wow, what a difference. Before the femoral head was completely out of the acetabulum of the pelvis just kind of floating off on its own and the muscles on that side had definitely atrophied with noticeable lameness. Now the patient is already pulling on the leash during towel walking just 48 hours post op. Super cool...

http://www.medicatechvet.com/


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## Connie Sutherland (Mar 27, 2006)

Maren Bell Jones said:


> Friday I assisted Dr. Cook on a brand new total hip replacement surgery system (uses a cementless system called Helica Hip with screws that's from the human ortho side of things) and it was only the second day and third patient ever used at our teaching hospital. Way cool! I cannot post the before radiographs because of patient confidentiality, but wow, what a difference. Before the femoral head was completely out of the acetabulum of the pelvis just kind of floating off on its own and the muscles on that side had definitely atrophied with noticeable lameness. Now the patient is already pulling on the leash during towel walking just 48 hours post op. Super cool...
> 
> http://www.medicatechvet.com/


VERY cool.

About how long did the procedure take?


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## ann schnerre (Aug 24, 2006)

indeed-way cool! but what's the cost? Brix was a candidate for hip replacement, both hips, when he was xrayed at 13 months; at that point the doc said about 3K per hip.

wish i could've scrubbed in/assisted at that one--but i love sx.


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## Nicole Lit (Jan 21, 2009)

With alll the surgical advances for HD, I would be very curious as to whether there has been much progression in the way of elbow replacements....


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## Maren Bell Jones (Jun 7, 2006)

From pre-medding in anesthesia, prepping for surgery, the procedure, the post op radiographs, and the move to the ICU afterwards took about 3-3.5 hours. The actual procedure took ~75 minutes. The prep took quite a while because for a total hip replacement, you have to be extremely sterile. Along with cap, mask, sterile gown, gloves, shoes with booties as usual, we also had to double glove and wear special hood things that look a bit like a ski mask but disposable to minimize any possible contamination. The doors of the surgery theater also remained completely closed and the anesthesiologist had to talk to the others outside with a walkie talkie. The implants themselves were about $1500 and the price of surgery was about $1500, but because it was a new procedure and the attendings and the residents were learning it, the teaching hospital basically bought the price of the implants, so it would have been $3000 per hip.

Good question, Nicole! I'll try to ask at some point. I've already seen some hylauronic acid injections for some Rottweilers with bad elbows. I'll have to ask about replacements for dogs like mine (yes, a Rottie) with end stage arthritis in their elbows.


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## Bob Scott (Mar 30, 2006)

Ortho questions?

My knees hurt, my back hurts, my toes hurt, my shoulders, arms and fingers hurt! Even my nose and hair hurts. 
How long is this gonna last?............#-o................................Nevermind! 
I'm old! ](*,)](*,)](*,):wink:


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## Nicole Lit (Jan 21, 2009)

> Good question, Nicole! I'll try to ask at some point. I've already seen some hylauronic acid injections for some Rottweilers with bad elbows. I'll have to ask about replacements for dogs like mine (yes, a Rottie) with end stage arthritis in their elbows.


That would be awesome if you could! I've found some info re: the TATE Elbow replacement but I believe even that may be a bit dated now? Sure would be nice to hear of any newer advances that may be out there that have met with success.

Enjoy your ortho rotation - sounds as though it will be excellent and what a cool field of practice!


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## Maren Bell Jones (Jun 7, 2006)

leslie cassian said:


> For a severely dysplastic 8 year old Labx, lean at 95lbs. At this point in his life is surgery a worthwhile option? What surgery? Would the benefits be worth the costs, both financially and as far as the dog's ability to withstand and recover from surgery.


Good question, Leslie! I was able to ask that during a stifle arthroscopic surgery today, which incidentally was on a 8 year old standard poodle in good shape. She had the Tightrope stifle surgery done a while back for a torn cranial cruciate tear (ACL) and her meniscus partially tore, so Dr. Cook went in with the arthroscope to work on it a bit. 

So he said as far as age goes, it really depends a lot on the owner. Basically, what are the goals for the dog in terms of what it can do, how it can perform (if that's an issue), and medical versus surgical management versus both. For age, as long as the dog is healthy, age is not a huge concern. I have done a couple recheck appointments on total hip dogs and as long as the owners do correct post op work (STRICT crate rest for 6-8 weeks being the most important), they tend to do very well. The owner I did a recheck on his 6 year lab said he had never been happier with how she was, even though she still was not at 100%. As far as cost, it's about $3000 per hip here (just like with humans, you only do one hip at a time). And it seems in a lot of the cases I've seen so far, the dog is standing within 24 hours on its own and can discontinue pain meds after 3-7 days. However, they do need extensive rehab too, so the surgery is just the beginning. In some cases, depending on the goals for the dog, just doing one hip might actually be okay to get them at a greater comfort level. Hope that helps!


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## Nicole Stark (Jul 22, 2009)

Nancy Jocoy said:


> What about recent advances on stem cell therapies for dogs with HD? There was a rash of interest on the web then it kind of fizzled out.


My initial thought is that at the moment it's simply too cost prohibitive for most, then there's the "other" conflict that some have with the fundamentals, apparently. I looked into it myself but could not get a straight answer on what benefits, if any, could be achieved in a dog with an old cruciate rupture that had already experienced arthritic changes in the joint. I was willing to offer my dog up as a test subject but at $3500 through a clinic who didn't seem to be well versed with the procedure I abandoned the idea.


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## Nicole Stark (Jul 22, 2009)

Maren Bell Jones said:


> Good question, Leslie! I was able to ask that during a stifle arthroscopic surgery today, which incidentally was on a 8 year old standard poodle in good shape. She had the Tightrope stifle surgery done a while back for a torn cranial cruciate tear (ACL) and her meniscus partially tore, so Dr. Cook went in with the arthroscope to work on it a bit.
> 
> So he said as far as age goes, it really depends a lot on the owner. Basically, what are the goals for the dog in terms of what it can do, how it can perform (if that's an issue), and medical versus surgical management versus both. For age, as long as the dog is healthy, age is not a huge concern. I have done a couple recheck appointments on total hip dogs and as long as the owners do correct post op work (STRICT crate rest for 6-8 weeks being the most important), they tend to do very well. The owner I did a recheck on his 6 year lab said he had never been happier with how she was, even though she still was not at 100%. As far as cost, it's about $3000 per hip here (just like with humans, you only do one hip at a time). And it seems in a lot of the cases I've seen so far, the dog is standing within 24 hours on its own and can discontinue pain meds after 3-7 days. However, they do need extensive rehab too, so the surgery is just the beginning. In some cases, depending on the goals for the dog, just doing one hip might actually be okay to get them at a greater comfort level. Hope that helps!


I understand that THR, barring the cost factor, is a very viable option for severely dysplastic dogs. Recovery goes well generally and the success rate last I read, was about 90% or better. I have personally found in older dogs that dietary changes, putting the cross hairs on the right supplement(s), coupled perhaps with Adequan injections or even when necessary a combination of prescribed meds will achieve what you need for the life of the dog. Also, while it may not be true for every dog keeping them active does seem to be absolutely critical.


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## leslie cassian (Jun 3, 2007)

Thanks for asking about and answering my question Maren. Any other options outside of total hip replacement? What about femoral head removal? Still an option at 8 yrs old?


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## Nicole Stark (Jul 22, 2009)

I know you asked Maren but off the top of my head I think that's not a viable option for a dog his size/age. I have always understood that it's a much better and recommended choice for smaller dogs. I mentioned his age because even if it were an option, building and retaining muscle mass in an older dog is quite a bit more difficult which could work against you in the long run. It's been a bit since I've read up on this so I am interested in seeing what she has to say to learn how much of this has changed, if at all.


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## Maren Bell Jones (Jun 7, 2006)

Nicole Stark said:


> I know you asked Maren but off the top of my head I think that's not a viable option for a dog his size/age. I have always understood that it's a much better and recommended choice for smaller dogs. I mentioned his age because even if it were an option, building and retaining muscle mass in an older dog is quite a bit more difficult which could work against you in the long run. It's been a bit since I've read up on this so I am interested in seeing what she has to say to learn how much of this has changed, if at all.


Excellent question! We just did a femoral head and neck excision surgery on a dog today. The resident who did it said that he's seen dogs as large as Rottweilers have it done and do okay if they're pretty sedentary pets, but in general, for a dog that large, total hip replacement is the preferred way to do it. The dog that we did today was a young Yorkshire terrier who was just a pet, so that was perfect for her. Incidentally, they now recommend removing not just the head but part of the neck of the femur too (why it's called a femoral head and neck excision instead of just a femoral head osteotomy) to prevent the femur from rubbing on the acetabulum. I think ideally for a dog that size and age, THR is going to be the way to go. 

And yeah, it's usually around a 90% success rate if the owners follow up with strict cage rest for 6-8 weeks (probably on the longer side of that for an older dog) and rehab to build the muscle back up. Also if you're just looking at medical management, a $3000 hip for a 8 year old lab who may live another 5-7 years works out to less than $2 a day over the next few years. With supplements, pain meds, joint injections, etc, that would probably be at least that if you managed it medically with conservative treatment. Just a thought...


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## Connie Sutherland (Mar 27, 2006)

What does the rehab entail? Would swimming be as good for this as it seems to be for so many ortho problems?


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## Maren Bell Jones (Jun 7, 2006)

There's a ton of rehab exercises, similar to human physical therapy, that are used. It basically comes down to what the owner will be able to do. Swimming is excellent about 6-8 weeks post op and the radiographs come back and show the implant is looking good. You can do it in either a lake, poor, or underwater treadmill tank. The nice thing about the underwater treadmill is you can vary the amount of water in the tank, which supports them less or more, and also the dog can wear a dog life preserver to add extra buoyancy. It basically all depends on where the dog is at, but swimming is excellent.


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## Maren Bell Jones (Jun 7, 2006)

Oh yeah, speaking of joint injections, we didn't have a ton of surgeries today, so I brought Elsa my Rottweiler in and I did my very first hylauronic acid joint injection into the elbows today! :grin: Basically you sedate the dog, shave the area, and sterilely insert a special kind of needle and syringe into the joint space between the lower part of the humerus and the anconeal process (the part of the ulna bone where the humerus sits on top to form the elbow joint). The hylauronic acid solution is then slowly injected into the arthritic joint. Once she was back from sedation, I noticed an almost immediate improvement. Pretty cool...


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## leslie cassian (Jun 3, 2007)

More questions...

How long would you expect the hyalauronic acid injection to last before she starts to deteriorate? Is this the treatment of choice for arthritic elbows? 

Mostly asked about options out of curiosity and a slight feeling of quilt. Wish there was more I could do, but I think for my dog, his options are pretty limited aside from the usual supplements, exercise, keeping him lean, etc. THR is financially not possible and in addition to hip issues, there are likely elbow issues as well, (suggested by OVC, but never xrayed) He's a real mess and my number one reason for a serious dislike of back yard breeders.


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## Maren Bell Jones (Jun 7, 2006)

To be honest, I forgot to ask our surgery resident about elbow replacement surgery while he was watching me do my dog's injection cause I didn't want to hurt her since it is tricky to get the injection just right. :wink: But I will try to remember before I'm off this rotation!  I think it's kind of an individual thing how the HA injections go. He wants to see her again in 3 weeks to see how it goes because some dogs (and humans and horses) respond really well, others not much at all. I think the goal is to do a series and then taper and repeat periodically several times a year as necessary. They want me to try another in 3 weeks and see how she responds. They cost me today $75 for the injections in both elbows, but the resident didn't charge me for the sedation or the exam. I may also ask him his opinion on Adequan (the injectable chondroitin) as well.

And don't worry, I don't judge if you're just wanting to do medical management. My Rottie is not getting hip replacement surgery either. :wink: You may also want to talk to your vet about a good NSAID as well if you get bloodwork done ahead of time. There's a ton to choose from and not all work for all dogs (same thing in people), so you may experiment a bit. I asked about the whole labs/carprofen (Rimadyl) thing in rounds this morning and they said it's idiopathic why it causes liver damage in a very small number of dogs, particularly labs, but they think it may be because labs are the most common dog seen for arthritis pain just because of sheer numbers and carprofen is the most commonly prescribed. So it's not that carprofen is necessarily bad or evil, it's just that it's more popular right now than metacam, Deramaxx, Previcox, etc, so we just seen those potential cases purely because of sample sizes. If one of the other ones were more commonly prescribed, we'd probably see issues with those too.


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## Sarah ten Bensel (Mar 16, 2008)

Have there been any advances in the repair of ACL tears? My female had TPLO done many years ago and it went well. My sister's red heeler needs surgery and they recommend TPLO also for this dog. Any recent techniques that have been proven? Just curious thanks!


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## Connie Sutherland (Mar 27, 2006)

Maren Bell Jones said:


> Oh yeah, speaking of joint injections, we didn't have a ton of surgeries today, so I brought Elsa my Rottweiler in and I did my very first hylauronic acid joint injection into the elbows today! :grin: Basically you sedate the dog, shave the area, and sterilely insert a special kind of needle and syringe into the joint space between the lower part of the humerus and the anconeal process (the part of the ulna bone where the humerus sits on top to form the elbow joint). The hylauronic acid solution is then slowly injected into the arthritic joint. Once she was back from sedation, I noticed an almost immediate improvement. Pretty cool...


Can you explain in laymen's terms why/how the fluid stays there? 

I mean, why/how did synovial fluid leave the joint? What disrupts the synovial membrane, or how else does it escape? And then when you inject the fluid, what keeps the new fluid from heading out to wherever the original fluid went?

I know there's something basic I don't get yet when I'm looking at diagrams of joints and the lubrication mechanisms.


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## Connie Sutherland (Mar 27, 2006)

Can I also say how much I appreciate this thread?! :smile:


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## Nicole Stark (Jul 22, 2009)

Sarah ten Bensel said:


> Have there been any advances in the repair of ACL tears? My female had TPLO done many years ago and it went well. My sister's red heeler needs surgery and they recommend TPLO also for this dog. Any recent techniques that have been proven? Just curious thanks!


Yes, if it interests you check out stem cell therapy. There's likely more now but I understand that there has been about 200 dogs who have had the procedure so far. Several thousand horses have received it as well. It's what I mentioned earlier about being an option that's cost prohibitive for most at the moment. When I first looked into it about 5 years ago the procedure was about $5000, it's about half now give or take.

http://dog-care.suite101.com/article.cfm/adult_stem_cell_therapy_in_dogs


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## Maren Bell Jones (Jun 7, 2006)

Sarah ten Bensel said:


> Have there been any advances in the repair of ACL tears? My female had TPLO done many years ago and it went well. My sister's red heeler needs surgery and they recommend TPLO also for this dog. Any recent techniques that have been proven? Just curious thanks!


Wow, that's a $10,000 question. The short answer is that there's no one best way to do an cranial cruciate ligament rupture repair surgically. It depends on a lot of factors, like size of the dog, the dog's purpose (working/performance dog versus active pet versus couch potato), the cost, and how much rehab the owners are willing to do. This was also brought up in afternoon rounds yesterday and one of our professors has hunting Drathaars that come from field trial lines, so he does understand the different demands that a performance dog has versus a your weekend warrior golden retriever. He said the standard for a very active/performance/large dog (the classic being a field trial Labrador) is generally going to be your tibial plateau leveling osteotomy (TPLO) because of the mechanics and stability further in the post operative period. TPLOs are usually done by board certified surgeons and what happens is that they use the radiographs of the dog's stifle (knee) as a reference point and basically resection the bone to level the plateau of the tibia (the bone, along with the fibula, between the stifle and hock joints) so it's closer to what a human's knee is like. It basically changes the mechanics of how the joint flexes. I'm hopefully going to get to see one tomorrow morning, so I'm hoping to get to see how it works beyond the diagrams in our surgery book. :wink:

The other main way to do it is through a suturing technique. The lateral suture is the oldest and what it does is uses either an athroscope (ideally) or the joint capsule is incised by a scalpel. Once the tissue in the joint capsule of the stifle has all the nasty, no longer functioning bits removed (torn off menisci, frayed ligament, debris), there are some holes that are drilled through the tibial crest (the bony crest on your lower leg right below your knee cap), then a big thick suture is threaded through the drilled holes and knotted with the other end of the suture, which is sent in behind the bones of the knee joint. The sutures basically make a rectangle around the joint and are knotted very tightly. 

Mechanically, the suture is taking the place (but not the location) of the cranial cruciate ligament so that the knee gets more stability and doesn't slide forward on its own (called cranial drawer in dogs, anterior drawer in humans if anyone in the audience has had this done on their knees). The lateral suture method is pretty nice because it's the cheapest, requires the least amount of technical skill by the surgeon and some general practice doctors do this (I got to do one on a cadaver this summer and I think I would feel somewhat comfortable doing them myself with practice), but the suture material does eventually fail. It must use the fibrosis to keep the joint in place once the suture fails. So as you may imagine, this is not necessarily the best thing for very active dogs, but is less invasive than TPLO, particularly if you can use the arthroscope. 

The newest kid on the block is the TightRope method, which was invented by Dr. Jimi Cook at our vet school (the one I mentioned on the first page of the thread). The TR method is basically a modified lateral suture, but it uses a different stronger material, but similar basic technique of drilling tunnels through the bone to accommodate the TR suture. It has only been done for the last year or two and Dr. Cook is teaching other board certified surgeons this technique, so not many know it. Though I was about two feet from Dr. Cook this morning in the OR while he did one on an Aussie. :grin: Both the lateral suture and the TR are not going to be as costly as a TPLO, but for a working/performance animal, TPLO is still likely going to be a better choice. For pet dogs, especially on the smaller side, particularly where cost is more of a concern, TR or lateral suture may be the better choice. Just depends on those factors we talked about at the beginning. Like I had a big female English mastiff come in this afternoon with a CCL rupture for a surgical consult and the attending orthopaedic surgeon didn't even mention the TR/lateral suture to them, just the TPLO. So...it's going to be a lot of the personal preference of the surgeon, costs, what the dog is used for it, etc.


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## Maren Bell Jones (Jun 7, 2006)

Connie Sutherland said:


> Can you explain in laymen's terms why/how the fluid stays there?
> 
> I mean, why/how did synovial fluid leave the joint? What disrupts the synovial membrane, or how else does it escape? And then when you inject the fluid, what keeps the new fluid from heading out to wherever the original fluid went?
> 
> I know there's something basic I don't get yet when I'm looking at diagrams of joints and the lubrication mechanisms.


Sure! So just in case anyone else has a similar question, I'll go back to basics a bit. So every major joint (hip, shoulder, elbow, knee, etc) has a joint capsule. This is the covering that surrounds the joint space so that it keeps the joint and its fluid in place, which is important in maintain nice smooth, painfree motion. It's actually pretty tough, so if you ever get in a deer (or whatever) carcass from a hunter friend for dog food, try opening up the stifle (knee), hip, shoulder (where the shoulder blade connects with the humerus), etc, with a sharp blade. You'll feel the blade go into the joint capsule and some joint fluid should run out. If you touch it, it should "string" away from you as you draw your finger away, kind of like you put your finger in maple syrup (though it's more watery than than). Healthy joint fluid should be reasonably viscous. Unhealthy joint fluid, like what I saw Elsa have yesterday, is more watery because of inflammatory and degenerative changes in the joint space. Healthy joint fluid is what helps nourish the cartilage because cartilage has very limited blood supply (part of the reason why something like a meniscal tear in your knee may take freakin' forever to heal), so thehylauronic acid is a component of healthy joint fluid and it's supposed to help .

So when you inject hylauronic acid into the joint space (or anything into the joint space, if you were doing something like a joint tap), going into it with a needle is like going into a ripe tomato with a thick skin with a needle. You can actually feel a little pop as the needle slides in (kind of like an epidural or spinal tap) and then the hylauronic acid stays in the joint space when the small needle is extracted. So it's not supposed to leak outside the joint space. Hope that makes an easier visual picture of what's happening.



Connie Sutherland said:


> Can I also say how much I appreciate this thread?!


Thanks Connie. :wink: I got home from the teaching hospital at 8 PM tonight and we have to be there tomorrow morning no later than 5 AM to prep for 3 morning surgeries and 1 afternoon surgery, so I'm spending my whole 2 hours of mental freedom before I have to go to bed with you guys explaining this. So I don't want to hear any shrill bitching from ANYONE that ALL vets are money hungry, don't really care, and are all stupid, COMPRENDE?! :twisted::twisted::twisted:


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## Connie Sutherland (Mar 27, 2006)

Maren Bell Jones said:


> ... I got home from the teaching hospital at 8 PM tonight and we have to be there tomorrow morning no later than 5 AM to prep for 3 morning surgeries and 1 afternoon surgery, so I'm spending my whole 2 hours of mental freedom before I have to go to bed with you guys explaining this.


I knew that. =D>


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## Connie Sutherland (Mar 27, 2006)

But what I was trying to figure out is, where did the original fluid go? And wherever it went, what will keep this new injected fluid from going the same way?

Or, if the original fluid is still in place but has simply become unhealthy (watery, less viscous), don't you have to get it out of there to make room for the good new fluid?


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## Maren Bell Jones (Jun 7, 2006)

Sorry, forgot about that part! My very basic understanding is that not only is the quantity probably not as good, neither is the quality (less viscous, may contain blood, etc). I haven't read the primary or secondary literature on this in quite a while, but I would suspect that there is a recycling component so that it gets absorbed gradually and more is being made, but just the production may be lower and the quality is not as good. I'll see if I can look that up in my surgery textbook tonight since I've got something else to look up in there in the whole 30 minutes left I have of being awake. ;-)

Edit: OMG, I just re-read my previous post and it barely made sense to me. I think I need a vacation. :lol:


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## Connie Sutherland (Mar 27, 2006)

Maren Bell Jones said:


> Sorry, forgot about that part! My very basic understanding is that not only is the quantity probably not as good, neither is the quality (less viscous, may contain blood, etc). I haven't read the primary or secondary literature on this in quite a while, but I would suspect that there is a recycling component so that it gets absorbed gradually and more is being made, but just the production may be lower and the quality is not as good. I'll see if I can look that up in my surgery textbook tonight since I've got something else to look up in there in the whole 30 minutes left I have of being awake. ;-)
> 
> Edit: OMG, I just re-read my previous post and it barely made sense to me. I think I need a vacation. :lol:


This is plenty good enough! THANKS!!!!


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## Maren Bell Jones (Jun 7, 2006)

So on Friday, I was the lead assistant on a TightRope cranial cruciate ligament rupture with Dr. Cook. Being as though he's the inventor of the technique, he knows the system very well. We were talking during the surgery and I asked him questions about active/performance dogs vs. more couch potato dogs and the TightRope procedure. He says he's performed about 1000 TRs and he knows of at least three field trial dogs to become field trial champions after the procedure. He's got a success rate of about 95%, which is right about the same as the TPLO. So I asked him why the difference or why surgeons would pick one or the other and what makes one successful. He says it's not so much the technique, it's more the aftercare (crate rest is hugely important) and professional rehab that really makes or breaks either technique. He is partial to the TR of course because it's less invasive than the TPLO. So there you go, right from the man himself. :smile: 

I'm also going to see if he can do HA injections on Elsa my Rottie's hips as well as elbows in January because I'm very impressed with how well she's done with her elbows. You cannot turn back time, but I'm liking them a lot. Also asked about Adequan (the injectable chondroitin) and he says he read an independent paper saying it does work, so maybe another option. I hate the hours of this block (14-16 hour days almost every day and we have to come in during the weekends for several hours a day), but it's been a real treat from a learning perspective.


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## Connie Sutherland (Mar 27, 2006)

Thanks, Maren!


BTW, this is also influencing one of my sisters, a human :lol: ,who is now scheduled for knee injection like the elbow one you described.

Her doctor referred her to this explanation of how long the injected stuff remains where you put it:
_
"The exact mechanism of action of viscosupplementation is unclear. Although restoration of the elastoviscous properties of synovial fluid seems to be the most logical explanation, other mechanisms must exist. The actual period that the injected hyaluronic acid product stays within the joint space is on the order of hours to days, but the time of clinical efficacy is often on the order of months. Other postulated mechanisms to explain the long-lasting effect of viscosupplementation include possible anti-inflammatory and antinociceptive properties, or stimulation of in vivo hyaluronic acid synthesis by the exogenously injected hyaluronic acid."_

http://www.aafp.org/afp/20000801/565.html


VERY cool stuff to be learning!! Thanks again.


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## Maren Bell Jones (Jun 7, 2006)

Cool! Hope it helps her knees out! Yeah, our surgery resident mentioned the half life of hylauronic acid is only like 12 hours, so we don't really know why the clinical effects seems to stay around for significantly longer. I have only seen elbow injections so far, but I wonder if doing the stifle injections of a dog (or a horse) is like they describe in the article for doing humans as far as were the injection site goes (described as just medial to the distal pole of the patella). Will have to inquire about that!


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## Terrasita Cuffie (Jun 8, 2008)

Interesting regarding clinical effects vs. how long its supposed to be active. After you do the 8 injection series with Adequan, you then do maintenance injections as needed. I wonder if they have utilized any of the topical applications.

Terrasita


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## Zakia Days (Mar 13, 2009)

Maren Bell Jones said:


> So I know I'm not hardly on this forum nearly as much as I used to for various reasons :wink:, but I start my orthopaedic surgery elective rotation this week. I'm pretty freaking nervous, but also very excited. Dr. Jimi Cook DVM, PhD, DACVS (Diplomate of the American College of Veterinary Surgeons) is going to be on clinics during that time. He's one of the top orthopaedic surgeons in the country and the one who developed the new Tightrope method for cranial cruciate ligament repair.
> 
> So don't send me x-rays and ask me to show them to him or a massive PM of your own dog's issues or anything, but if you have any GENERAL (not specific, we can't diagnose over the internet) "hey, I always wanted to know..." ortho questions, I'll do my best (no guarantees!) to bring them up in a GENERAL sort of way. :grin:



Hello Ms. Jones!!! My dog has had an injury to her toe? First "digit" phalange of right toe. There is a localized area of swelling there. Minimal exercise for approx. 3wks decreased/almost eliminated the swelling. When present it feels hard-ish, it is bothersome as dog pulls away with too much or too harsh palpation. It seems "normo"thermic and is non-pitting. It is dark in color as is the skin in that area (not discolored) from what I can see. Dog was taken to the vet and I was told "we've seen this before, but we're unsure of its origin. We treat it and if keeps coming back we amputate the toe." I thought to myself WTF?!!! Okay well WHAT IS IT?!!! Diagnosis please? None was given. I was given "the regimen" (antibiotics, antiinflammatories). Little to no resolution with this treatment. It seems to become inflammed/aggravated when dog cuts hard when running or flies into things with front paws. Also can you recommend any sports vets in my area (East coast No. Central NJ)? Thanks.


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