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)

Gastric dilation and torsion, or bloat in dogs and laparoscopic gastropexy – a preventative surgical procedure

Gastric dilation-volvulus (GDV) syndrome is a painful and life-threatening condition in which the stomach becomes hugely distended with gas and fluid and rotates on its axis, often through 1800 to 3600. Gross gastric dilation can occur without rotation of the stomach.

Any breed of dog may be affected but large and giant breeds are predisposed – Great Danes, German Shepherds, Gordon and Irish Setters, Bassett Hounds, Airedales, Wolfhounds, Weimeraners and Rottweilers to name a few. A study found that 18% of all Great Dane deaths were due to GDV (Evans and Adams 2010). The specific cause is unknown but several risk factors beyond breed have been identified (Glickman 2000); a high ratio between chest height and chest width (deep-chested individuals), increasing age, having a first-degree relative affected, speed of eating, using an elevated food bowl. Other factors affecting incidence include male gender, low body weight, eating one meal per day and a fearful or anxious temperament.

Dogs may present following a period of restless behaviour, non-productive retching and hypersalivation. They will have a dramatic and progressing distension of their abdomen. They may be pale, with a rapid heart rate, breathing difficulties and may be collapsed.

Stretching of the stomach wall, and twisting, compromises the blood flow to the wall, reducing oxygen supply which can lead to death of the tissue. The spleen, which is attached to the stomach, can undergo twisting or torsion as well, leading to similar effects. The dilated stomach compresses the vena cava. Compression of this vein reduces the return of blood to the heart from the abdomen and hind legs of the dog. The dilated stomach presses on the diaphragm reducing its movement and consequently the ability for the lungs to expand normally. The circulatory and respiratory effects lead to a reduced supply of blood and oxygen to tissues, resulting in shock and if untreated eventually death.

Treatment includes aggressive intensive care and fluid therapy to combat the fatal effects of shock, decompression and if necessary, de-rotation of the stomach. In some cases, removal of the spleen (splenectomy) or resection of part of the stomach (partial gastrectomy) is required. Even with prompt treatment mortality rates can be high – published results range from 10% (Brockman 1995) to 33% mortality (Mackenzie 2010). The prognosis is better where there is dilation but no twisting (Brockman 1995). However, where gastrectomy and splenectomy are required the mortality rate has been reported as high as 55% (Brourman 1996).

The incidence of gastric dilation and volvulus can be influenced by selective breeding and management of feeding – avoid stress at mealtimes, feed more than once per day, do not feed from a height, slow down rate of eating. A gastropexy is a surgical procedure where a permanent adhesion is created between the stomach and the body wall. It is performed for the prevention of a gastric dilation and volvulus (GDV) either in animals suffering from an episode of GDV or as a preventative procedure. Dogs treated for GDV with de-rotation of the stomach but no gastropexy had a recurrence rate of 50%, whilst those treated with a gastropexy had a rate of less than 5% (Glickman 1997). A study of five predisposed breeds (Great Danes, Irish Setters, Rottweilers, Standard Poodles and Weimeraners). Ward, M.P (2003) found a reduced lifetime risk of mortality ranging from 2.2-fold in Rottweilers to 29.6-fold in Great Danes.

There are several different open abdominal techniques to achieve a gastropexy, however these require significant exposure of the abdomen to achieve the result. There are also laparoscopic-assisted procedures where the surgeon uses a telescope and camera to identify and grasp the stomach before suturing to a reduced abdominal incision up to 6cm long. However, the gold standard procedure is to perform the procedure entirely laparoscopically. While this technique requires significantly more skill and experience on the part of the surgeon, in such hands the comfort of the patient and recovery rate are much enhanced.

Laparoscopic gastropexy should be considered in at risk breeds. The procedure can be performed as a single procedure in male dogs or at the time of ovariectomy ovariohysterectomy in females.

  1. Brockman, J.D., Washabau, R.J., Drobatz, K.J., (1995) Canine gastric dilation-volvulus syndrome in a veterinary critical care unit: 295 cases (1986-1992) Journal of the American Veterinary Medical Association 207: 460-464
  2. Brourman, J.D., Schertel, E.R., Allen, D.A. et al (1996) Factors associated with perioperative mortality in dogs with surgically managed gastric dilatation-volvulus: 137 cases (1988-1993) Journal of the American Veterinary Medical Association 208: 1855-1858
  3. Evans, K.M., Adams, V.J. (2010) Mortality and morbidity due to gastric dilation-volvulus syndrome in pedigree dogs in the UK. Journal of Small Animal Practice 51: 376-381
  4. Glickman, L.T., Glickman, N.W., Schellenberg, D.B., Raghavan, M., Lee, T.L. (2000a) Incidence of and breed-related risk factors for gastric dilatation-volvulus in dogs. Journal of the American Veterinary Medical Association 216: 40-45
  5. Glickman, L.T., Glickman, N.W., Schellenberg, D.B., Raghavan, M., Lee, T.L. (2000b) Non dietary risk factors for gastric dilatation-volvulus in large and giant breed dogs. Journal of the American Veterinary Medical Association 217: 1492-1499
  6. Mackenzie, G., Barnhart, M., Kennedy, S. et al (2010) A retrospective study of factors influencing survival following surgery for gastric dilatation-volvulus syndrome in 306 dogs. Journal of the American Animal Hospital Association 46: 97-102
  7. Ward, M.P., Patronek, G.J., Glickman, L.L. (2003) Benefits of prophylactic gastropexy for dogs at risk of gastric dilation-volvulus. Prev Vet Med 60: 319-329