FYI Articles 4

 

CRUCIATE INJURIES   

DIAGNOSIS, TREATMENT AND FOLLOW-UP CARE
 

 

What is a cranial cruciate ligament injury?

            The cruciate ligament is found inside the knee joint, and connects the bottom of the femur bone to the top of the tibia bone. Often times, if ruptured, very sudden partial or complete lameness occurs in that back leg. Most often this occurs in dogs that are running full speed, and suddenly rotate their knee in a hard twist, or catch their foot in a hole. This hyperextends the joint while the rest of the body continues forward. In human medicine, this is a common football injury called an ACL rupture. Although the majority of injuries are traumatic in origin, some predisposing factors have been identified such as obesity, abnormal leg conformation, younger more active dogs and long term steroid treatments or Cushings disease that may weaken ligament strength. Sometimes, a dog may have a partial tear for a period of time that is undiagnosed, and eventually a complete tear occurs.

 

How is this diagnosed?

            When an animal presents for sudden lameness in the back leg, this is a top rule out. We palpate the entire limb, and do a thorough orthopedic exam at rest and moving to interpret the type of lameness. Radiographs can be useful to rule out fractures or other injuries that could also cause severe sudden lameness. To diagnose a cruciate rupture, there is a characteristic abnormal motion to the knee that can be performed by the veterinarian during exam called “drawer motion”. In this test, the bottom of the femur is held in place by one hand, and the top of the tibia is moved slightly cranial (to the front) by the other hand. A normal knee with an intact cruciate ligament will not allow this motion; however a dog with a rupture has a noticeable laxity. Some nervous dogs or patients with high muscle tone need sedation to relax the leg enough to detect this subtle change. Some severe injuries will also have joint fluid present with a swollen knee joint.

 

OK, how do we treat it?

            This is a complex decision based on multiple factors: anesthetic risk, severity of knee instability, age, weight, and also the financial flexibility of the owner. Some older patients that weigh less than 25 pounds may show enough improvement on anti-inflammatory and joint supplements after 3 to 6 weeks, that they can have a reasonable quality of life without surgery. Patients weighing more than 25 pounds, patients with concurrent meniscus or collateral injuries of the knee, or very young and athletic dogs that are difficult to cage rest may improve over time, but will rarely have the previous level of activity. Also reoccurring lameness and chronic degenerative osteoarthritis will occur over time. These patients will have a faster and more complete recovery with surgery.

         Surgery is the treatment of choice by stabilizing the knee and decreasing instability that can over time wear down cartilage and underlying bone by abnormal motion and create secondary osteoarthritis. Estimates are given at the time of diagnosis and include the orthopedic evaluation, radiographs, pre-anesthetic blood work and IV catheter, anesthesia and the cruciate surgery, 2-3 days of hospitalization, two weeks of antibiotics, anti-inflammatories (usually Rimadyl), Fentanyl pain patch applications, and all follow-up bandage applications and suture removals.

 

What does the surgery involve?

            There are various modifications on the same idea, to place a permanent thick sterile nylon suture in a figure-8 fashion behind the knee around a tiny sesamoid bone called the fabella, through the patellar ligament over the joint, and back through a bony tunnel created in the top of the tibia and tied with a slip knot technique to create tension and strength. Also, many patients require exploration of the joint space to remove remnants of the ruptured ligament, evaluate the condition of the meniscus, and close the capsule to add strength to the knee. Also, the connective tissue beside the knee joint is closed in an overlapping fashion to add stability, tightness, and limit the motion of the knee during recovery.

 

What preparation is involved in this type of procedure to minimize contamination of the explored joint or the permanent suture?

We pre-treat the patient with IV antibiotics the morning of surgery, as well as treat with oral antibiotics two weeks prior. Also, we surgically clip all the hair of the leg receiving surgery up to the top of the hip, attach the leg by tape to a pole in a hanging fashion, and surgically clean all sides of the leg with Nolvasan and alcohol. Also, we cover the foot with autoclaved material, as well as drape all of the lower half of the animal with surgical drapes except the surgical area. The doctor is draped in surgical gown, cap, mask, gloves, and during surgery, strict attention to aseptic technique is performed at all times.  (You can see our doctors in surgery on the WebCam page and the surgery suite itself on the Virtual Tour page.)

 

What preparation is done to help minimize pain associated with this surgery?

            Ideally, it is best to pre-treat with anti-inflammatories for 4-7 days prior to surgery to reduce tissue swelling in and around the joint before surgical stimulation. Also, we pre-apply a Fentanyl patch (a continuous pain patch that provides pain management through skin absorption for 3-5 days after application) 12-24 hours before surgery. In addition, if requested, intra-joint anesthetics can be applied, as well as caudal spinal epidurals of sterile anesthetic to minimize pain during the procedure. If interested in these options, please ask more details with your doctor regarding indications and risks involved.

 

Now that my pet has had cruciate surgery, what should I do as an owner to help allow the best recovery possible?

            Since 40-60% of cruciate patients can have contra-lateral cruciate injuries in the other knee within 12-18 months, its very important to be conservative with exercise restriction and allow a slow increase in level of activity.

 Week 1-2:

Shortly after surgery, it is normal to see a dog only toe touching the injured leg for the first 2 weeks. During this time, they may have leg bandages the first 6-9 days. They should be cage rested, or in a very small indoor enclosure to avoid any running, jumping on furniture, or any stairs. This is the most severe of the restriction process, and the most critical time for wound healing and minimizing contamination of the wound. Owners can slowly walk outside for urination/defecation, the use of a towel stirrup can be helpful under the belly to help support weight if the animal missteps or slips to avoid full weight bearing on the injured leg. Sutures will be removed 10-12 days after surgery. Usually twice daily Rimadyl, and the joint supplement Cosequin can be very helpful to reduce pain and inflammation in the joint.

Week 3-4:

Many patients start to partially weight bear between 2-4 weeks. At this point, they can be in a small room that still minimizes chance of running, and still no jumping or stairs. They may no longer need towel walking, and may be more independent in leash walking outside to use the bathroom. Cosequin and Rimadyl are still helpful at this point, some patients can tolerate once daily Rimadyl at this point.

Week 5-6:

        By six weeks, most patients are regularly placing partial weight on the leg with each step, however if they try to speed up will show a noticeable limp. Most patients can do well on once daily Rimadyl, and Cosequin still is helpful.

After week 6:

          Clinical studies have shown secondary stabilization and beneficial changes in the joint up to 6 months after surgery. Patients usually show a steady and positive improvement in their form, many are back to full function in 6 months if no underlying arthritic changes were present before surgery. Often times, Rimadyl can be used as needed for pain/symptoms of lameness, and Cosequin still is beneficial as a long term supplement until no symptoms are present for several months.

 

Recommended Follow-up Rechecks with the Vet after surgery (May slightly vary depending on preference of veterinarian):

            Day 3-4:  Bandage Change and Fentanyl patch change if applied

            Day 7-8:  Removal of Second Bandage

            Day 10-12:  Suture Removal

    1 month:  Recheck to palpate knee for stability and examine for any signs of
                  infection, abnormal swelling, or pain.

            3 months:  Phone consultation or recheck to evaluate progress in activity.

 

If you still have additional questions, please contact your doctor at 540-366-3433, and we will be happy to discuss any additional information you need.

 

 

Flea Control

 

INTRODUCTION

 

 

 

Fleas are the most common external parasite of companion animals. Flea allergy dermatitis is the most common skin disease of dogs and cats! Flea control has always been a challenge for veterinarians and pet owners because the adult fleas cause the clinical signs, yet the majority of the flea population (eggs, larvae and pupae) are to be found off the pet in and around the home. The ideal flea control program utilizes products that target the various stages of the flea life cycle, not only the adult fleas on the pet. In order to help you to select the most appropriate products to achieve a flea-free existence for an allergic pet, we will start by telling you about the life cycle of the flea.

THE LIFE CYCLE OF THE FLEA Ctenocephalides felis

 

 

 

Eggs are laid in the hair coat and are designed to fall off the host. They are resistant to insecticides, but susceptible to various Insect Growth Regulators. Larvae develop in the host's environment and feed on adult flea feces (blood) that fall out of the hair coat of the pet. Larvae are susceptible to traditional insecticides, borates and insect growth regulators. Larvae eventually spin cocoons (often within carpet fibers) for pupation. Pupae are resistant to freezing, desiccation, and insecticides. Pupae can lie dormant for many months; they are stimulated to expupate as emergent adults by vibration, warming and increased CO2. Normally, expupation occurs when a host is near and the new flea finds the pet within seconds of emergence. Emergent fleas are fairly mobile and can survive a few days without a host, if in a suitable environment. New fleas begin feeding within hours of finding a dog or cat. Once a blood meal has been taken, the flea can survive only a short time if it is dislodged from the host. New fleas experience very high mortality on healthy adult hosts. Most fleas do not survive 72 hours on an animal that is itching and able to groom itself. Unfortunately, limited egg production does occur even on allergic animals. The entire life cycle of C. felis can be completed in as few as 16 days!

FLEA CONTROL RECOMMENDATIONS

For the flea allergic patient 100% flea control is required to remain symptom-free. Even very minimal exposure may be sufficient to perpetuate itching in a hypersensitive patient (one or 2 bites per week are enough!). Until very recently, veterinarians and pet owners have had to control fleas by treating the environment of the animal for the immature stages of the flea. This approach, although effective when properly instituted, is labor intensive and requires frequent repetitive applications. Application of adulticides on the animal has merely been of palliative value. The safe insecticides previously available to us did not kill fleas instantly or were not long-lasting enough to ensure adequate protection from flea bites. The female flea survived long enough to lay a few eggs and perpetuate the life cycle.

TODAY'S FLEA CONTROL PRODUCTS

Recently, some new products have been added to our flea control arsenal. These appear to be highly efficacious, long lasting and have a very low potential of harmful side effects. It may well be that these promising products will revolutionize flea control in the United States.

SENTINEL® (LUFENURON) from Novartis

This is available as a once a month to be given with a full meal. This ia a prescription drug. Adult fleas that feed on animals treated with lufenuron produce sterile eggs. The product does not kill adult fleas. It is a very easy way to break the life cycle but pets remain fully susceptible to the emergence of any fleas from pupa already present in the environment. Therefore, 4 -7 months may pass before the flea-free state is reached. In order to stop the life cycle, every animal in the patient's environment must receive lufenuron. Pets should be sprayed for fleas with an adulticide during the first few weeks of starting Sentinel®. Sentinel also controls heartworms and intestinal worms.

FRONTLINE® SPRAY, FRONTLINE PLUS® and FRONTLINE TOP SPOT® (FIPRONIL) from Merial

Fipronil is a broad spectrum insecticide available as a spray or a drip-on. Fipronil binds chemically to the hair and is absorbed through the hair follicle by the sebaceous glands. In spray formulation fipronil kills fleas at 95% for over 80 days after application on dogs and for 1 month with biweekly bathing. It is labeled for puppies and kittens of 8 weeks (10 weeks for Top Spot®) and the product is not washed off by bathing. It is also affective against ticks. The major problem with the spray is the high volume of alcohol-based product that must be applied. Many cats will show minor adverse reactions with this application technique. The product must be applied no more than once a month. Frontline Plus® contains the insect growth regulator, S-methoprene and so provides control of eggs and adult fleas.

REVOLUTION® SELAMECTIN from Pfizer

This product is designed as a once-a-month heartworm preventive and flea preventive for dogs and cats as young as 6 weeks old. It also kills adult fleas and can be used to treat Sarcoptic mange, ear mites and ticks. It also helps control roundworms and hookworms in cats. The product is placed on the skin at the back of the neck, but is absorbed into the body to have its effect when female fleas ingest it with a blood meal. Adult fleas will die slowly, but more importantly, any eggs laid prior to death will never develop. It is most useful as a preventive for flea infestation and in the presence of a flea problem in an allergic pet, other insecticide treatment will be recommended at first. It is a prescription drug.

CAPSTAR® NITEMPYRAM from Novartis

This is an oral tablet for dogs and cats as young as 4 weeks of age. It offers extremely rapid and complete killing of adult fleas on the pets after administration. It is safe enough that the tablets may be used as needed, as often as once per day, whenever you see fleas on your pet. It is designed to be used in combination with an insect growth regulator to knock out the flea life cycle. It can also be used when the pet has visited a flea-infested environment for rapid protection.

TRADITIONAL INSECTICIDES

 

Shampoos are considered inferior to sprays or dips because they have little to no residual activity. For cats, pyrethrins as sprays or are useful. Examples include Mycodex® (these products have a reduced level of alcohol which is much more easily tolerated by cats). For dogs, permethrin sprays are recommended.

 

Our recommendations for your pet:

 

 

 

 

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