Download Lake Country Veterinary Specialist Hospital

Lake Country Veterinary Specialist Hospital
10564 Powley Court - Unit A, Winfield, BC V4V 1V5
PHONE (250) 766-6699
FAX (250) 766-6693
E-MAIL [email protected] www.lakecountryvet.ca
Mark E.H. Smith BSc, DVM, MVSc, Diplomate, American College of Veterinary Surgeons
Referral Report
Date:June 1, 2012
Owner - Name:Mike Bjerstadt
Patient – Name: Duncan
Sig:16 month MN English Mastiff
Referring Hospital:Crescent Falls Veterinary Hospital
Doctor: Kristina Ringness DVM
Weight: 68 kg
History:
Chronic left forelimb lameness; recent acute onset of left hind limb lameness which has improved moderately
with NSAID tx, to which no adverse reactions have been observed.
Examination:
BAR; moderate lameness of LF and LH limbs; thoracic auscultation, general exam are unremarkable; good (lean)
body condition; there is palpable effusion of both stifles with resentment of full stifle extension; the hocks and
hips are normal on palpation; there is no effusion in the left elbow;
Radiographs:
Duncan was sedated:
i) Cr-cd and lateral views of both hind limbs from stifles to hocks; mild osteoarthritis and marked effusion
in both stifles; no evidence of OCD lesions; the talus is normal in appearance (no OCD lesions).
ii) Lateral, flexed lateral and cr-cd views of both elbows; osteophytosis along dorsal aspect anconeal process
supportive of elbow osteoarthritis; blunting/malformation of medial aspect of coronoid process
suggestive of fragmentation (FCP).
iii) Lateral view of left shoulder and humerus; diaphysis normal; no sign of OCD.
iv) Hips – VD projection provided by rDVM shows normal hips – well seated, no osteoarthritis.
Assessment:
i) Left forelimb lameness: findings are consistent with FCP; this requires CT scan or arthroscopic
assessment for a definitive diagnosis; a CT scan is recommended as this condition is often bilateral, in
which case, both elbows can be scoped during one anesthesia.
ii) Stifles – changes are consistent with bilateral, partial tears of the cranial cruciate ligaments (CCL); partial
tears do not heal and eventually progress to complete tears;
Recommendations:
We discussed the best order of events and agreed that:
i) Admit for left stifle arthroscopy and TPLO to confirm and treat the CCL injury. Prior to this, the elbows
can be CT’d under sedation to assess the coronoids.
ii) Monitor right stifle function. I have advised it is highly likely that surgery will be required due to the
degree of effusion present.
iii) Arthroscopic retrieval of FCP’s if confirmed on CT, as a separate procedure.
Prognosis:
Prognosis for the stifles after surgical stabilization is very good for return to normal function. Antiinflammatory
medication will be needed intermittently for stiffness.
If a loose coronoid fragment is identified in one or both elbows, there is significant relief to be gained by
retrieving them. The waters become a little muddier in terms of improvement with resection of a malformed
coronoid. Given the degree of lameness in the left forelimb, I suspect that arthroscopy will be indicated.
Duncan’s overall prospects for a healthy, happy level of function are good, with appropriate treatment.
Thank you, Kristina, for the referral of this patient –super dog! Please contact me if you have any questions.
Kind Regards,
Mark Smith DVM Dipl ACVS
August 13/12:
Duncan was readmitted today for a CT scan of his elbows and recheck of his TPLO operative site.
i) He was sedated and both elbows and shoulders were scanned. Please see report from Dr Crews.
Findings: Bilateral elbow dysplasia with suspected fissure right elbow and only malformation visible in left;
shoulders are normal (ie: no OCD or other pathology).
I spoke with Duncan’s owner. If the coronoid is only malformed, it is more difficult to predict whether
arthroscopic resection of the abnormal area will help. As he has a fissure in the right, arthroscopic exam is
warranted and so I recommended we scope left elbow also under same anesthesia.
Arthroscopy allows one to assess the coronoid with good magnification and illumination, and to resect abnormal
areas with a small osteotome. It also allows assessment for “kissing lesions” where the coronoid has been rubbing
on the opposing humeral condyle, suggesting incongruity, and also to definitively r/o OCD of the humeral
condyle. Radioulnar congruity is also assessed.
The expectation of treatment of FCP of the elbows has to be improvement and not a normal joint. This was
discussed in some detail. These dogs improve, but still develop osteoarthritis due to other malformations in the
joint which are part of this syndrome. Ongoing medical management with NSAIDs, Omega-3 fatty acids,
glucosamine, weight control (CRITICAL) and low impact activity are recommended.
ii)TPLO site – Incision is CDI; no tibial thrust; very good function; a lateral radiograph was made and shows
advanced osteotomy healing and stable implants.
I have suggested we scope his elbows in a few weeks time, after his TPLO site has had a little further time to heal.
Kristina – thank you again for the referral of this patient! Please contact me with any questions.
Kind Regards,
Mark Smith DVM DACVS
September 12, 2012
Duncan was admitted today for bilateral elbow exploration.
Operative Report:
The patient was clipped and aseptically prepared in standard fashion and with an Ioban adhesive drape. The left elbow was
operated first.
A 16 ga egress needle was placed caudomedially and saline used to distend the joint; a 22 ga needle was used to locate the
joint distal to the epicondylar ridge, and an incision made with a No 11 blade; the joint was penetrated with hemostats,
followed by an obturator/sheath and then a 2.4 x 30 degree arthroscope; an instrument portal was then created in a similar
manner, distal to the medial epicondyle, under direct arthroscope visualization. Joint cartilage is healthy in appearance; there
was no loose coronoid, however cartilage over the region of the medial aspect of the coronoid was abnormal being dull,
fibrillated and soft on palpation; there was a distinct demarcation between this area and normal appearing adjacent cartilage;
An osteotome was introduced under direct visualization and subtotal coronoidectomy was performed; fragments were
removed with a combination of graspers and punches; a good result was achieved; the opposing humeral articular surface was
healthy; there was some malformation in the middle of the coronoid close to the origin of the lateral coronoid, which
appeared as a depression in the articular surface; the joint was lavaged vigorously several times and the scope reintroduced to
confirm debris had been removed; Portals were closed with 3-0 Monocryl inverted cruciate and SIP in skin.
Right elbow; multiple attempts were made to establish a clear field of view in this joint with the arthroscope but visualization
was hampered by blood clots and debris; to avoid unnecessary prolongation of anesthesia time, conversion to mini open
arthrotomy was performed; the medial collateral ligament was preserved; a fissure was visible in the medial aspect of the
coronoid; this was not detached and so an osteotome was used to resect it; the site was flushed; fascia apposed with 2-0 PDS,
SQ 3-0 PDS and skin 4-0 nylon.
Polysporin, Bioclusive dressings were applied to both incisions overnight.
Pain Management: Injectable hydromorphone; IV fluids were continued until the patient was eating. Percocet was begun
once the patient was eating.
Home Care Instructions for Owner
1. ACTIVITY:
i)
ii)
Keep Duncan confined to 5 minute leash walks several times daily in the yard for the next 3 weeks.
From 3 weeks to 6 weeks, continue to restrict leash walks as above, but you can add max 5 minutes of
swimming per day, provided he cannot run out of control down the beach.
2.
Incision Care: Cleanse the incisions daily, only as needed x 7 days, with the chlorhexidene antibacterial soap &
gauze. DAB don’t rub, the incisions as this is irritating and delays healing.
3.
MEDICATIONS:
A: Meloxicam : Give as directed; monitor for stomach upset. Signs include: loss of appetite, vomiting, black or
bloody stool. If this occurs, STOP the drug and call us.
B: Glucosamine – give orally each day for the next 6 months. A natural sugar with mild anti-inflammatory
properties. Give an adult human dose daily on an ongoing basis.
C: Omega-3 Fatty Acid Supplementation – can reduce joint inflammation. Available from your veterinarian.
Give on an ongoing basis.
D: Percocet. Oral Narcotic. Give as directed for pain control.
E: Hibitane antibacterial soap, gauze. Moisten gauze with tap water, add soap, dab gently to loosen secretions.
4.
REEXAMINATIONS:
a. 10-14 days – suture removal.
b. Progress check in 2 months.
PROGNOSIS: Good. Removal of the abnormal bone generally improves lameness significantly. Recovery will take
approximately 6-8 weeks. Some mild osteoarthritis is present and will progress in the joints over the years. Meloxicam can
be given as needed, for episodes of stiffness. Be vigilant in always monitoring for signs of gastric ulceration as described
above.
Keeping Duncan on the slim side of normal (ribs immediately felt under the skin) will help a lot, as dogs carry 60% of their
body weight on the front limbs.
Good luck with the big man! Please call us if you have any questions about his care.
Sincerely,
Mark Smith DVM
Diplomate ACVS