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Mad Murphy’s torn cruciate

Murphy is a lovingly energetic Labradoodle who managed to injure his left back leg while playing like a mad thing in the park. His regular vet had identified the cause of the lameness; an injured cruciate ligament and referred him to NorthWest Veterinary Specialists to discuss treatment options. When Murphy presented to the hospital at only 6 months of age we knew we had a challenge on our hands. He was a big and bouncing puppy with an unusual presentation of a cruciate injury. Instead of the typical degenerative and progressive tearing that we usually recognise, Murphy had managed to detach the bone attachment site of the ligament.

Mad Murphy Image 1

Image 1

One treatment option for this problem is bone reattachment, but Murphy’s fragment was too small for this to be feasible. Instead we elected to stabilise his knee via modification of the tibial plateau levelling osteotomy (TPLO).

The typical TPLO technique is not suitable in puppies due to resultant damage to their open growth plates. Instead we performed a CORA-based TPLO which is a new approach to this problem in young dogs and preserves the growth plates by varying the orientation of the saw blade.

Surgery went to plan (image 1) and Murphy had an uneventful recovery. He was quickly using the leg and within a fortnight had no visible lameness. Murphy’s Mum and Dad performed the hardest job of the whole process by keeping him restricted during the first 6 weeks. He returned for reassessment and follow-up radiographs after this time (image 2) and was given a clean bill of health. He had managed to rapidly heal and completely remodel his bone. He has since returned to running in the park and we are hopeful that Mad Murphy will keep out of future orthopaedic trouble!

Daisy – Life threatening injuries

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Daisy was only a one and half year old cat when she was hit by a car. She received emergency treatments from her local veterinary surgery and was then referred immediately to Northwest Surgeons. Daisy had incurred multiple injuries. She had fractured her pelvis and ruptured both her body wall and bladder – urine was leaking into the abdomen and seeping into her muscles, fat and the skin of her tummy region. Left unchecked this would lead to a painful death for her.  Rupture of Daisy’s bladder was confirmed by injection of a water soluble contrast agent into her urethra via a urinary catheter.  The contrast dye, which shows up white on xray was seen leaking into the surrounding tissues.

The bladder and pelvis were repaired surgically, but there was already some evidence that the fat and skin infused abnormally with urine would start to die away as a result of the damage caused by the urine leakage. Approximately 10 days after surgery, a clear line of demarcation had formed between the normal skin of the belly and the dead and dying skin and fat. The latter was removed, leaving a very large open wound – the entire surface area of Daisy’s belly region was no longer present. The large wound was managed by tie-over dressings which allow a number of dressing products to be applied to a wound and tied underneath surgical swabs – in a parcel-like effect. This enabled Daisy to walk around without having her entire body wrapped beneath dressings whilst the body slowly started to fill in the wound cavity.

Six weeks later, the wound had progressively healed but had reached a static point and we had to use a skin grafting technique to fill the remaining wound bed. Daisy’s progress was hampered by a number of clinical set-backs resulting from the horrific nature of her original injuries. She developed acute kidney failure and became critically ill.  As a result of her weakened state, the skin graft failed and the wound bed became infected with a resistant bacterium that took advantage of her debilitation. At Northwest Surgeons, the importance of infection control is taken very seriously and it was the routine monitoring that takes place as part of our infection control procedures that detected this problem early.   Daisy was moved immediately into our isolation facility and strictly barrier nursed to prevent contamination of other patients and staff. Within two weeks of appropriate treatment and topical silver preparations (which have activity against bacteria), the infection was quickly controlled. However, the open wound took a number of combined medical treatments before it would support further wound healing. In total, Daisy stayed over 3 months in isolation, but she remained a bright, active and happy cat despite her continued isolation status for infection control. This was largely because part of Daisy’s treatment incorporated designated playtimes which she adored.  She also became expert and mischievous in buster collar avoidance skills!
Three and a half months later, the wound bed was again ready for surgery and this time, much to everyone’s relief, the flank fold skin flap healed 100%.  Finally, 6 months after beginning her emergency treatment at Northwest Surgeons, Daisy went home to her devoted owner and we are delighted to report that she now leads an active and normal life style.

 

George the hill runner

george1 george2George is a middle aged greyhound who presented to the hospital after an adventurous day in the hills. He spent the morning showing off his greyhound agility and speed by racing around and enjoying an open field. Unfortunately he became unstuck when he miscalculated his run and had a rough fall down a hill. Shortly after, he returned up the hill on three legs, holding his left front leg up with an obvious break above the carpus (wrist).

When he arrived at the hospital, he was started on intravenous fluids and injectable pain relief to keep him comfortable. Radiographs  (x-rays) were taken and surgery was planned to get George back on four legs. The radiographs revealed a completely displaced (no longer touching), transverse (straight across), distal (towards the carpus), diaphyseal (shaft) fracture of both the radius and ulna. This fracture was complicated by the presence of fissuring (hair line separation) of the proximal (towards the elbow) radius which further weakens the bone in this area.

We set about making a plan for repair of the fracture which is a complicated and challenging process. A successful fracture repair must combine the mechanical needs of the bone as well as respecting the biological demands of the animal in order for healing to take place. We elected to place a broad locking plate into the radius to both realign and span the fracture. This was placed adhering to the principles of minimally invasive plate osteosynthesis (MIPO). This involves making a small stab incision at the top and bottom of the bone through which the plate is placed and the screws are inserted. The initial repair looked good on the radiographs following surgery and George was bearing weight on the leg the next day.

George went home the day after surgery whereby he underwent a 10 week period of confined activity and regular leash controlled activities. Radiographs obtained two months after surgery confirmed successful healing of the fracture and no implant concerns. Four months after surgery George was back running in the hills and so far, he has managed to avoid any further visits to NorthWest Surgeons.

Ernie’s naughty knee!

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Ernie the Yorkshire terrier, was 3 years old, when he arrived at Northwest Surgeons for assessment of problem in his right back leg. It had started with intermittent limping but after that, the lameness was persistent and would not resolve even with anti-inflammatory drugs. The lameness was caused by a condition called medial patellar luxation. This is a condition where the patella, the kneecap, slips out of the groove, towards the inside of the knee, effectively a dislocating kneecap. This can be intermittent or in some cases the kneecap can stay out of the groove, which is what was happening to Ernie.

X-rays were taken and surgery was planned to improve the tracking of his kneecap. Patellar surgery involved moving the front part of the top of the shin bone, (tibial tuberosity transposition) which was held in place with a pin and wire. This improved the alignment of the kneecap tracking, a vitally important part of the surgery. The groove was also too shallow and this was deepened (wedge recession sulcoplasty) to allow the kneecap to sit in the groove better. The joint capsule was tightened at the end of the procedure. Ernie recovered well from surgery and following a period of confinement to allow the joint tissues and bone to heal he was out on lead walks again after six weeks.

Ernie recovered well from his surgery and he after the condition appeared in the left leg, which was also successfully treated, Ernie has never looked back. He is able to run and jump and play with the rest of the dogs in the park.

Barry – Cranial Cruciate Ligament Rupture

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Barry was presented to us with a severe limp in one of his hind legs. He was a very active dog and even took part in an energetic pastime called flyball. Flyball races involve two teams of dogs who race side-by-side over a 51 foot long course. Each dog must run in relay fashion down a set of jumps and trigger a flyball box that releases the ball. The dog has to catch or retrieve the ball, and return over the jumps. This is usually done by lightweight agile breeds such as border collies – not St Bernards!

Barry’s lameness had started suddenly and he was only able to walk a few yards before he became very lame. Investigations revealed that Barry had torn his cranial cruciate ligament. This ligament is one of the main stabilisers of the stifle (knee) joint and, in people, it is an injury not uncommonly seen in sports men and women (and recreational skiers!). In dogs, this injury can be managed in a number of ways but surgery is usually necessary. Our preferred technique in most patients, particularly larger dogs, is a procedure called a TPLO (Tibial Plateau Leveling Osteotomy). In this procedure we reshape the top of the tibia (shin bone) to help the patient cope without the cruciate ligament.

These patients are usually using the leg within a few days of surgery and able to go for short very controlled lead walks – ideal for Barry not losing too much fitness!

Barry made good post operative progress and was walking well on the leg when he came back for his check x-rays 6 weeks after surgery. Unfortunately we received a telephone call a few weeks later to say Barry had now gone lame on his other back leg. Further tests showed he had done the same thing on that side! This is quite common as in many dogs the cranial cruciate ligament fails because of an underlying weakness or predisposition to it stretching or tearing and not just due to a sudden severe injury breaking the ligament. The good news is that TPLO works very well in the most of patients and enables them to return to an active lifestyle with little or no lameness. Barry did well following surgery on his other knee and has returned to an active lifestyle….including Flyball!

Images (from top):
(1) Pre operative x-rays (side view) of Barry’s left knee. The pencil lines are part of the pre-operative planning.
(2) The same view immediately after surgery.
(3) A ‘front to back’ view of the knee after surgery showing the six screws used to attach the metal plate to the bone. The plate and screws keep the top of the bone in its new position whilst it heals.

Reggie – From Three Legs To Four

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At only 14 weeks of age Reggie developed a noticeable problem with his left front leg. Initially he was limping on the leg, but it soon became obvious that the limb wasn’t growing normally and that Reggie’s forearm was becoming very short and bowed compared to the normal side. It was at this stage that Reggie’s own veterinary surgeon referred him to Northwest Surgeons.

Given that Reggie still had much growing to do and that his left front leg was already short and deformed, it was clear that he would not be able to use the limb normally once he was fully grown. There was also a risk that progressive deformity in the forearm would cause secondary damage to his elbow and wrist joints, which might then become painful and function poorly.

We therefore advised a procedure to straighten and lengthen the limb using a device called an external ring fixator, sometimes referred to as an “Ilizarov” fixator after its inventor. This is a rigid adjustable frame that is attached to the bones with pins. It provides support for the bones, but also has an arrangement of linear motors and hinges that allow the frame to be gradually lengthened and the angles in the limb to be manipulated, thus lengthening and straightening the limb.

The bones in Reggie’s forearm were cut and the fixator frame applied to the limb. The limb was then straightened and the frame lengthened by just 1 millimetre each day. Three months later Reggie’s left leg was the same length as his normal one and almost completely straight, enabling us to remove the frame and gradually increase his level of physical activity. By 8 months of age Reggie was exercising normally, with both limbs of equal length.

Fudge – New Hips and a New Lease of Life

Fudge is a golden Labrador who first began to limp on her right back leg when she was six and a half years old. Her regular vet had advised her owners to manage the hip problem with anti-inflammatory medication. Unfortunately Fudge suffered from side effects of these drugs – such as vomiting and diarrhoea – and her limping became worse if the treatment was stopped, so she was referred to Northwest Surgeons to see if we could help.

Upon examination the pain did appear to come from her right back leg; however X-rays revealed arthritic changes in her left hip. Under anaeasthetic we carried out specific hip manipulations which are designed to detect instability in the hip joints. The results were interesting – Fudge demonstrated instability in her right hip joint although she had no signs of arthritic changes, which is often seen in much younger dogs but not usually in a dog of her years.

Over the following nine months we tried to control her pain with a number of different drugs, but it seemed that that her hip was definitely getting worse and having a severe impact on her quality of life. We all agreed that the only option was for a total hip replacement.

Northwest Surgeons is one of only a handful of specialist centres that carry out total hip replacements – where the bony parts of the hip joint are replaced with a plastic socket and metal ball. This type of procedure is not without risks, including fractures of the thigh bone or pelvis.

In 2007 Fudge had her right total hip replacement surgery and after six months of careful management by her owners she was happily running around the park again. Unfortunately her left hip started to give her some problems about a year later, which is unusual but Fudge seems to have a habit of that! So we agreed to replace her second hip and she is now living life to the full, needing no medication.

In August 2014 Fudge’s owner contacted and informed us that she was doing brilliantly!  She is a little grey in the muzzle at 13 years old but she is walking well and her owner still feels that without her new hips she wouldn’t have had quality of life and many years of happiness she has been given by having this procedure.

Fudge was treated by Steve Bright BVMS CertSAS DipECVS MRCVS