Practice Review

As we enter the end of the year, preparing to embark upon a new Millennium, we will endeavor to highlight the major procedures we do in our practice. Space limitations presented confine our subject material to the knee joint, by far our most commonly operated-upon joint, and the reader is encouraged to delve further into issues of interest utilizing available references.  Some reference material may be accessed through our website for those with internet access.  The topics of discussion are not presented necessarily in order of importance or frequency.  On average, we operate 5 to 7 knees per week!

1. Cruciate Ligament Injury

A general consensus among surgeons at the recent ACVS meeting is that the occurrence of cranial cruciate ligament injury is becoming increasingly prevalent.  An ambitious multi-center study is currently underway to do a prospective study of the incidence of cruciate ligament repairs performed by surgeons in the private sector as well as university surgeons.  It seems that we are seeing certain breeds, such as the Labrador retriever and the Rottweiler, incurring a greater frequency of this type of ligamentous injury; a genetic propensity is suspected.

New surgical modalities for the treatment of the cranial cruciate-deficient stifle joint show promise, but long-term studies are currently unavailable.  Arthroscopic repair, and the tibial plateau leveling osteotomy are currently being critically evaluated.  These techniques will probably ultimately find a particular niche in our surgical armamentarium.

2. Medial Patellar Luxation Repair

Repair techniques for medial patellar luxation are relatively unchanged, with the trochlear wedge recession sulcoplasty plus translocation of the tibial tuberosity remaining the Gold Standard of repair techniques.  Preservation of articular cartilage has been shown to be far superior to early surgical techniques which crudely gouged out a new groove in the bone.  Left to develop a fibrocartilage surface, this created a poor substitute for the patella to glide upon compared to preservation of  the normal hyaline articular cartilage.

“Pulling” the patella laterally with sutures is no longer acceptable technique.  The tibial tuberosity translocation laterally has proven biomechanically and physiologically to result in a more permanent realignment of stress.

 A question not addressed adequately in the literature is when is the optimum time to repair a medial patellar luxation?  Repair of patellar luxation before closure of the distal femoral physis creates the risk of iatrogenic damage to the growth plate and induced skeletal deformity.  Delay of correction after physeal closure may result in further articular degeneration and subsequent progressive degenerative joint disease (DJD).  In this author’s opinion, the carefully performed early surgical correction is preferred over delay until physeal closure.

3. Concurrent Patellar Luxation & Cruciate Ligament Rupture

Many times, medial patellar luxation is not noted until an acute lameness is observed.  It has been my experience in numerous cases that many of these dogs have sustained an acute rupture of the cranial cruciate ligament.  This should always be evaluated when an acute non weight-bearing lameness and concurrent medial patellar luxation are noted.  The displaced patella allows a disproportionate amount of the stress placed upon the stifle joint to be borne by the cruciate ligament, and acute lameness seen is usually the result of the cruciate ligament rupture, rather than the chronic medial patellar luxation.  Progression of DJD in these joints can be expected to occur more rapidly than in those joints having only medial patellar luxation.

4. Thank You!

To all of the veterinarians whom we have had the pleasure of getting to know, we wish you a very Merry Christmas and a Happy New Year.
 
 

Newsletter, 1999

Vol. 5, Issue 3

Pelvic fractures are a common injury in both the dog and cat, often secondary to motor vehicle trauma. Management of pelvic fractures can be complicated, depending on the bone or bones involved, location of the fracture(s), and associated soft tissue injuries.

The vast majority of pelvic fractures are closed fractures, and are not contaminated by exposure to the external environment. The initial management in pelvic fracture cases is therefore geared towards patient stabilization and evaluation of internal injuries. With the exception of acetabular fractures, there is no hurry to fix the fracture before the patient is fully stabilized. Of particular importance is evaluation of the urogenital tract, and of the respiratory tract. Often, there is damage to the bladder or urethra which needs to be evaluated, and the thoracic cavity should always be assessed for diaphragmatic integrity as well as pulmonary contusions, pneumothorax, etc.

Treatment of these injuries may range from open surgical management to conservative cage rest.
During initial patient evaluation, rectal examination may indicate pelvic fracture and the need for radiographic examination of the pelvis. Rectal tears may be indicated by bright red blood on the exam glove, and all digital exams should be done cautiously to avoid iatrogenic damage to the rectum. Very few pelvic fractures result in full-thickness rectal tears which require surgical intervention. Most tears involve the mucosal layer and can be managed with antibiotic therapy.

Radiographs should include a lateral and VD view of the pelvis and caudal lumbar spine.
The sciatic nerve should be evaluated, especially with caudal acetabular fractures and markedly displaced SI luxations. The pudendal nerve to the bladder should be assessed with sacrococcygeal fracture/luxation.

Many pelvic fractures can be managed conservatively, and economics may dictate conservative management of fractures which would otherwise be better handled surgically. Some general guidelines for conservative vs. surgical management can be set forth:

Conservative Management

• Fracture of the ischium (fractures caudal to the acetabulum).
• Fractures of the pubis.
• Relatively non-displaced sacroiliac (SI) luxations.
• Most sacrococcygeal fracture/luxations.

Surgical Management

• Any fracture cranial to the caudal acetabulum.
• Fractures of the ilium.
• Fractures of the acetabulum.
• Unstable or displaced fracture/luxations of the sacroiliac joint.

 

When Should I Refer a Case?

The following article is reprinted with permission from the author, A..D. Elkins, DVM, MS, Dipl. ACVS

Over the past 28 years, I have been on both sides of this fence. I was a general practitioner for 15 years and have been in a surgical referral practice for the past 13 years. It is now easier and more widely accepted to refer difficult cases. Legally, you are held to the highest standards in your area. If you have a case that you know is outside your realm of expertise, it is your duty to recommend referral. The owner may not choose to follow through, but you have discharged your obligation. 

Years ago, there were no specialists in private practice. All referrals had to go to veterinary schools. Many times, it was difficult to get cases seen and you might never hear about the outcome. University teaching hospitals have been forced to do a better job due to the competition from private referral practices. Yes, I said competition. No matter how you slice it, we may be colleagues but each practice is in competition for your referral business. Most veterinarians will refer cases to a practice, either private or university, if several criteria are met. They want a user friendly practice. This means they can speak to the clinician in charge of the case. They want to be able to get a case seen on short notice. The clients must have a positive experience and relay this to the referring practitioner. They want to be kept informed! Many times, a case goes to a university and you never hear back on it for several weeks. This is not acceptable since clients depend on their family veterinarian for advice in these situations. Most private practices do a much better job in communication because their business depends on goodwill established with the general veterinarian.

Most large metropolitan areas now have referral groups that cover all the medical disciplines. General practitioners should foster a working relationship with an individual in each discipline. This will allow you to consult and refer cases on an individual basis. In the future, secondary level care will be delivered primarily at the local level by private groups. Only cases requiring in-depth care such as radiation therapy will be referred to the university or tertiary centers. The marketplace is driving this phenomenon and will demand more in-depth care at the local level in the future.

Many times, money is not the determining factor in whether a client accepts a referral. It is convenience and the confidence the generalist has in the referral specialist. Case referral is a symbiotic relationship. Everyone should win in the situation. The animal should get the best care possible, the generalist should have a convenient place to send difficult cases or difficult clients and the specialist should enhance their referral base. This only works if the communication lines are kept open.

When should you refer a case? When you feel the animal and client can receive more advanced care than you are able to offer. It should be a practice builder when cases are referred to the right individual. The specialist should make you look good for sending the case. If this does not happen, you may want to find another outlet for your referral cases. 
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I would like to thank Dr. Elkins for allowing me to reprint this article. It articulates the philosophy we have tried to adhere to, in making your referrals a positive reflection on everyone involved. It is a pleasure and a privilege to serve you and your clients.
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Please note on your calendar that our office will be closed Memorial Day, May 31st. We are also going to be closed Tuesday and Wednesday, June 1st and 2nd. We will be back in the office on Thursday morning, June 3rd. We will make arrangements to have the phone answered during the day, or you may leave a message on the recorder. We will also try and schedule non-critical cases in advance.
 
 
 

Newsletter, 1999

Vol. 5, Issue 1

Patellar luxation, seen frequently in the dog (especially miniature and toy breeds) is much less commonly encountered in the cat. When luxation of the patella is seen in the cat, it is most often a medial patellar luxation (MPL), and certain breeds seem to be more prone than others to this condition.

In our practice, the most commonly affected breeds seem to be the Siamese, Himalayan and Burmese. Also reported as being more frequently affected with MPL is the Devon Rex.

The same criteria for grading luxation of the patella in the cat is used as in the dog, i.e. the luxation is rated on scale of I to IV, with grades II to IV luxations most commonly associated with lameness.

Diagnosis is most often made during physical examination. At the time the patella is evaluated, the knee should also be examined for concurrent injury to the cranial cruciate ligament, especially if an acute lameness has been noted. The decision as to whether or not radiographs of the stifle joints are needed should be made on a case-by-case basis. The hip joints should be included in the radiographic projection on the ventrodorsal view.

Treatment varies depending on the severity of the luxation and the presence or absence of concurrent cruciate ligament damage. Commonly performed as mainstays of therapy are deepening of the trochlear groove, translocation of the tibial tuberosity, imbrication of retinacular tissue and releasing incisions to alleviate contracted tissues. Combinations of the above techniques are utilized based upon the degree of correction required. An absolute adage that must be adhered to is the tenet that "you cannot alleviate an orthopedic abnormality with a soft tissue procedure". It must also be remembered that, although patellar luxation is, by definition, a problem within the stifle joint, the abnormality is in actuality a problem involving the entire limb. Early work on medial patellar luxation in the dog suggests that the abnormality may begin in the hip joint, resulting in abnormal forces acting upon the patellar tendon-bone-ligament complex and producing the changes recognized as medial patellar luxation in the stifle. This work may be transposed to suggest the same etiology for MPL in the cat.

While not occurring as commonly in the cat as in the dog, medial patellar luxation does occur and should be evaluated for when a hindlimb lameness is found in a cat. Surgical correction is uniformly rewarding and should be considered early in the course of the condition. I do not like to operate animals younger than 6 months of age for fear of causing iatrogenic damage to the physes. Delaying surgical correction can lead to corresponding changing in the joint angles and bone structure which may be deleterious to long-term limb function due to abnormal forces on the joints.