This sporting dog’s life……

Given the seismic shift in the foundations of our lives and community in these COVID19 times, the eighth of March seems like a date from an ancient history class. However, it was the day of the 2020 Chester 10km Road Race. The first 10k that either I, or my son Finn had ever attempted! Important facts initially – my time was nine minutes faster than I had predicted, and quite respectable. Finn did the decent thing and let his old man finish first! What on earth has this to do with the world of Veterinary Surgery? When I run, my mind tends to drift off and given that I was pushing myself at about the 8km mark going uphill towards the city centre, I began to tick off my list of personal rugby-related injuries – from Achilles tendon tears, to sutured forehead and lip, subluxated shoulder, broken nose (twice – first time it was crooked and the second reset it!) and finally to a hip resurfacing procedure. As I ran, despite this extensive list, I decided that in a bizarre way I had dodged the proverbial bullet by avoiding a most common football and rugby injury – the ruptured cruciate ligament!

Known as an anterior cruciate ligament (ACL) injury in people, rupture of the cranial cruciate ligament (CCL) is incredibly common in dogs. In part this is because the average dog even if a canine couch potato, would be an accomplished amateur athlete in the human world. However, we frequently see the injury much more in some breeds of dog than others, particularly medium and large breeds, sometimes as young as eight months of age – a common patient is the Labrador Retriever.

The knee should only move in the manner of a hinge, but because it is often under stress through a range of angles from fully straight (extension) to bent (flexion), it contains an array of structures to combat these forces. Effectively the cranial cruciate ligament exists to keep the tibia (the shin bone) and the femur (the thigh bone) in a predictable position relative to one another. When the CCL is torn, partially or completely, then the tibia tends to slide forwards in respect to the femur. The resulting lameness varies from subtle, to the dog only touching its toes to the ground – due in part to the sense of instability as the patient tries to put weight through the leg, and in part to the inflammation and swelling in the joint. There are also two discs of cartilage between the femur and tibia which act to stabilise the bones rather like a chock behind a wheel. The inner one (the medial meniscus) is commonly damaged along with the cruciate ligament.

It is accepted that nearly all dogs will benefit from surgical treatment of a cruciate related lameness, however small dogs can make a reasonable recovery with rest, anti-inflammatories, then physiotherapy – although recovery time can be protracted. Surgical treatment of the injury is often the best option. Traditionally the instability within the knee was addressed by direct stabilisation using a variety of materials to replace the function of the ligament. These could be grafts of tissue harvested from the knee area, or synthetic material. These standard procedures served us well for many years, but it is recognised that these ligament replacements may stretch or fail completely leaving the knee joint unstable. Recovery can sometimes be quite protracted. We now recognise that we can neutralise the forces within the knee that drive the tibia forwards by altering the shape of the tibia itself. There are several procedures used by surgeons to accomplish this: TPLO (tibial plateau levelling osteotomy) and the TTA (tibial tubercle advancement) are the principle ones. It is also important to inspect and treat the medial meniscus, if damaged, at the time of surgery.

In the TTA, the front of the tibia where the patellar or knee-cap tendon attaches is moved forwards by a distance measured on digital radiographs. The bone is then held in place using a cage and screws, or a cage and plate. Although uncommon, complications can occur which can include infection, further damage to the meniscus, persistent instability or fracture.

While injury to the cruciate ligament in people or dogs is a serious occurrence, in the veterinary world as with human orthopaedics, surgical treatment performed by a surgeon experienced in the techniques can give great results and patients will often return to their sporting life!

Post operative radiograph of the TTA Rapid procedure (Tibial Tubercle Advancement)

Spaying female dogs? Why? What? How?

Recently a lovely lady with a super young female dog appeared in my consult room wanting to know about laparoscopic spaying or neutering. She was a client at another practice but her vet, a friend of mine, had suggested she seek us out! It was great to speak to someone who had done a lot of research herself so I thought I’d write an article based around that conversation.

It has long been accepted that we should consider spaying or neutering female dogs. However, as it is a choice that we, as pet owners have to make, we should ask ourselves what the reasons for this are. Population control, avoidance of unwanted pregnancies is an obvious reason. Social reasons, the prevention of signs of a bitch coming in to heat – vaginal bleeding or being chased around the park by overly enthusiastic male dogs – again is straightforward. There are health benefits to your bitch which for some reason, we often forget about. The Royal Veterinary College (RVC) in London have a detailed disease surveillance programme, involving many veterinary practices and hence literally thousands of dogs. One of the simplest statistics to come from this is simply that neutered dogs live longer than entire or un-neutered ones. In the female dog we prevent ovarian and uterine cancers. Mature bitches who have never bred or who haven’t had a litter for many years can commonly develop a serious and potentially life-threatening womb infection, called a pyometra. Pyometra can be treated surgically but surely this is best prevented. If a bitch is spayed earlier in her life there is a dramatic reduction in the incidence of mammary carcinomas (breast cancer) in her later years. We see this in practice – many years ago, surgery for mammary tumours was frequently performed in the surgery, but now, with the majority of older females being spayed, we perform significantly fewer procedures. So we can argue that spaying your female dog is an important part of preventative health care.

So, we have decided to neuter our lovely female dog. What does this actually entail?

The traditional spay performed in the U.K. would be an ‘open’ surgical procedure. This means that the surgeon creates a wound in the abdomen, large enough to allow direct access for the fingers, hands and surgical instruments to the contents of the abdomen. The operation would usually involve the removal of both ovaries and the uterus. This is called an ovariohysterectomy (OVH). The alternative surgery involves the removal of only the ovaries (an ovariectomy or OVE). Surgical procedures can involve complications, however rare, and studies have shown no difference between OVH and OVE regarding the incidence of womb infections or incontinence.

Now we know just a little about what the neutering surgery entails do we have any other considerations? Well, yes!

Nowadays the choices available are further broadened by the development of Minimally Invasive Surgery (MIS) or laparoscopic assisted surgical techniques, sometimes called ‘keyhole surgery’. The range of surgeries we can perform laparoscopically mirrors that of human surgical practice. Neutering a female dog and removing retained abdominal testicles (which have a high risk of undergoing cancerous change) in a male dog, are surgeries that lend themselves to MIS. Rather than completely opening the body cavity we place surgical tubes (or cannula) between 5.5mm and 10mm in diameter through the abdominal wall to gain surgical access, using special scissors, forceps and sealing devices. The patient’s abdomen in inflated with carbon dioxide gas to create a space in which to perform the surgery. The whole procedure is viewed via a digital camera on a high definition monitor.

Is laparoscopic surgery better than open surgery? This is a question I am often asked. There is nothing wrong with traditional open surgery. It is safe and surgeons are well practiced with techniques and in fact when performing an MIS laparoscopic procedure we are always prepared to convert to an open procedure. What else could we do if our camera broke? However many studies in both the human field and Veterinary surgery have demonstrated lower complication rates with wound infection or haemorrhage, lower pain levels and a more rapid return to normal activity. A study in 2009 showed that female dogs undergoing OVH via an open procedure were 62% less active in the 24 hours after surgery, while those undergoing OVH laparoscopically were only 25% less active. Typically our patients are exercising normally a week after surgery.

Are there any disadvantages to laparoscopic surgery? Learning laparoscopic surgery has a steep learning curve but as with all things with experience the procedure become straight forward. The procedure is more expensive performed laparoscopically because of the high cost of equipment and the extensive training required. However for reasons of reduced post operative pain and a much reduced return to normal activity, laparoscopic surgery offers a good alternative to traditional open surgical neutering.

Dugie Gemmill is the Clinical Director, and principal surgeon in his own Veterinary practice on the Wirral, with an interest in laparoscopic surgery and orthopaedics. He has been performing laparoscopic surgery for over eight years and as well as offering the procedures in his own practice, also operates at certain practices in North Wales.

Laparoscopic Keyhole Spays

Parkside Veterinary Practice is committed to working at the forefront of veterinary medicine, for the benefit of our patients. As such we are pleased to be the first practice in the region to be able to offer laparoscopic spaying, in addition to current services, to our clients and referring practices.Minimally Invasive Surgery using rigid endoscopic equipment allows for better visualisation of the surgical area, as well as less internal tissue trauma for the patient. With keyhole surgical incisions being between 0.5cm and 1.0cm in length, patients are much more comfortable and recovery time is dramatically reduced.1,2 This means less pain and discomfort for the patient and a much speedier recovery and a quicker return to normal activity.

If you are interested in utilising this service please contact us and ask to speak to Mr Gemmill.

Click below to view a video of a Laparoscopic Spay procedure

References

1Davidson EB et al. Comparison of laparoscopic ovariohysterectomy and ovariohysterectomy in dogs.Vet Surg. 2004;33:62-9

2Culp WTN et al. The effect of laparoscopic versus open ovariectomy on postsurgical activity in small dogs.Vet Surg. 2009;(38):811-817