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\listoverridecount0\ls25}}{\info{\title Interpretation of Results:}{\author HP Authorized Customer}{\operator Peter Shires}{\creatim\yr2001\mo4\dy27\hr13\min44}{\revtim\yr2001\mo4\dy27\hr13\min44}{\version2}{\edmins1}{\nofpages10}{\nofwords2986}
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{\pntxtb (}{\pntxta )}}\pard\plain \sl360\slmult1\widctlpar \cgrid {
\par }{\b Interpretation of Results:}{
\par 
\par }\pard\plain \s1\sl360\slmult1\keepn\widctlpar\outlinelevel0\adjustright \ul\loch\af4\hich\af4\dbch\f4\cgrid {\hich\af0\dbch\af4\loch\f0 Blood work:
\par }\pard \s1\fi720\sl360\slmult1\keepn\widctlpar\outlinelevel0\adjustright {\ulnone \hich\af0\dbch\af4\loch\f0 
 The first abnormality in the blood work was an increased white blood cell count of 12.7 (3.2-10.7).  This could be the result from a stress leukogram, or inflammation.  There is also a decreased albumin level of 2.\hich\af0\dbch\af4\loch\f0 
4 (2.7-2.8).  This decrease in albumin could be from increased vascular permeability due to a swollen limb, inflammation, and effusion of joint.  The calcium is also decreased with a value of 9.6 (9.7-11.6), which is probably from the decreased albumin.  
\hich\af0\dbch\af4\loch\f0 S\hich\af0\dbch\af4\loch\f0 
ince albumin carries half of the calcium, but the lab measures all the calcium in the body, the number needs to be adjusted to account for the decreased albumin.  The equation is the measured Ca + (3.5 \endash 
 measured albumin) = the adjusted calcium.  The adju\hich\af0\dbch\af4\loch\f0 s\hich\af0\dbch\af4\loch\f0 ted calcium level is 10.7 mg/dl, which is within the normal limits.
\par }\pard\plain \sl360\slmult1\widctlpar \cgrid {\tab So, the significant findings are the increased white blood cell count probably due to inflammation of the joint and a stress leukogram and the decreased albumin, which is probably from ef
fusion and inflammation of the joint.
\par 
\par }{\ul Joint Fluid Analysis:}{
\par \tab The joint fluid is a reddish colored clear fluid and normal fluid should be clear or maybe slightly yellow tinged.  The reddish color fluid could be hemorrhage from trauma to the joint.  There i
s a good mucin clot, which is a normal finding. The cell count is approximately 3500 per high powered field, with neutrophils and monocytes.  There is probably joint effusion and inflammation, which explains the presence of the phagocytes.  The absence of
 bacteria rules out a septic joint.
\par 
\par }{\ul Radiographs:}{
\par \tab The radiographs of the stifle joint seem to be normal, but due to the image quality, we speculate there is also joint effusion and there may be the start of some osteophyte formation in the intercondylar gr
oove of the medial femoral condyle.  There is a narrowing of the medial aspect of the joint space and this could be due to positioning of the animal, the cranial cruciate ligament injury, or if the film was a compression film (horizontal radiograph while 
standing).  All these findings support the diagnosis of a complete tear of the cranial cruciate ligament.
\par \tab 
\par }\pard \fi720\sl360\slmult1\widctlpar {Overall, the results seem to indicate that there has been trauma to the stifle joint, and with the physical exam, the diagnosis is probably a complet
e tear of the cranial cruciate ligament.  The resulting inflammation, with joint effusion, is supported by the decreased albumin in the blood work and the increased cellularity and hemorrhage in the joint fluid analysis.
\par }\pard \sl360\slmult1\widctlpar {\b 
\par Diagnosis:
\par }\pard\plain \s16\fi720\sl360\slmult1\widctlpar\adjustright \loch\af0\hich\af0\dbch\f4\cgrid {\hich\af0\dbch\af4\loch\f0 There are several facts\hich\af0\dbch\af4\loch\f0  gathered from this case that lead us to believe that the cause of Bonnie\rquote 
s lameness is a result of chronic degenerative changes within the cranial cruciate ligament manifesting as a completely torn ligament. In cases of CrCL degeneration, it is speculate\hich\af0\dbch\af4\loch\f0 d\hich\af0\dbch\af4\loch\f0 
 that the cruciate ligament may undergo progressive weakening with age and hence become more likely to rupture. Chronic conditions tend to have a more insidious history of lameness often exacerbated by physical exertion. A minor injury or simply a sprain 
\hich\af0\dbch\af4\loch\f0 t\hich\af0\dbch\af4\loch\f0 hat occurred during normal activity may accelerate this process. In Bonnie\rquote s case, the regular strenuous bouts of exercise took a toll on her cruciate ligament.
\par }\pard\plain \fi720\sl360\slmult1\widctlpar \cgrid {As joint changes occur, the cruciate ligaments undergo alterations including hyalinization of c
ollagen fibers and reduction of ligament tensile strength making it more susceptible to damage even with minimal trauma. It has been reported that degenerative changes in dogs over 5 years old in combination with increasing body size may be factors that e
xacerbate degeneration of the ligament. 
\par The supporting evidence for this degenerative ligament rupture includes the fact that Bonnie is an obese dog who exercises frequently with her owner. We feel that the combination of her obesity and the stress placed 
on the cruciate ligament while exercising contributed to the progressive wearing down and eventual rupture. Additionally, Bonnie is a six-year-old Labrador retriever, at the prime age for a CrCL. The ultimate result of CrCL rupture is chronic instability 
that leads to chronic degenerative joint disease.
\par }\pard \sl360\slmult1\widctlpar {Among diagnostic evidence supporting a cranial cruciate ligament rupture is a positive cranial drawer sign of her left stifle. A positive test is defined as craniocaudal movement in excess of the normal 0-2 
mm motion found in normal joints. According to one source, a partial tear will usually reveal only 2-3 mm of instability. Bonnie\rquote 
s cranial drawer motion presented as a 4-5 mm movement leading us to speculate that she has completely ruptured her ligament. Additionally, Bonnie\rquote 
s right stifle was tested for comparison and exhibited normal movement at less than 2mm of motion. These cranial drawer sign figures may aid in determining whether a partial or complete tear is present, if you are aware of the stifle fl
exion angle used during the test. We do not have access to that information, thus are diagnosing a complete cruciate rupture based on the history, clinical pathology, and radiographs. Partial tears are also associated with greater joint inflammation. Bonn
ie\rquote s synovial fluid joint tap results revealed a normal total white blood cell count of approximately 3500 hpf. 
\par }\pard \fi720\sl360\slmult1\widctlpar {Once damage has been done to the CrCL a series of changes normally occur. With rupture, the joint distension that occurs will then limit joint l
axity.  The ruptured ligament will appear to retract and fan out. We were not provided arthroscopy results, thus were unable to ascertain the true state of the ligament and menisci. Soon thereafter, osteophyte development takes place around the margins of
 
the bone involved. Signs associated with chronic stifle joint instability include thickening of the medial aspect of the joint, prominence of the tibial crest, muscle atrophy, and osteoarthritic changes along the trochlea.  Dogs with chronic cruciate dise
ase will demonstrate a thickened joint, especially medially, and will also demonstrate degenerative joint disease.
\par Ideally, both stifles would have been radiographed for comparison. Radiography did provide clues to support the diagnosis of a CrCL rupture. U
nfortunately, the cruciate ligaments and menisci are not visible radiographically. However, the following signs were evident: synovial joint effusion, thickening of the medial fibrous joint capsule, periarticular osteophytes as well as intra-articular ost
e
ophytes of the femoral medial condyle, possible sub-chondral sclerosis, oesteophyte formation along the trochlear ridge and joint space narrowing between the femoral medial condyle and the tibial medial condyle (we are not aware of the positioning of the 
dog for radiographs, therefore are not certain of this find.)  
\par Arthrodial joint centesis provided information regarding hemorrhage and effusion that were noted within the stifle joint appearing as a reddish colored fluid. The low cell count, absence of bac
teria and a good mucin clot enabled us to rule out immune mediated or inflammatory disease processes within the stifle joint, further confirming our diagnosis. The hemorrhagic effusion is indicative of a cruciate tear as the CrCL is covered by synovium an
d
 the synovid covering provides major blood supply to the ligament.  These synovid or paraligamentous vessels give rise to smaller vessels that penetrate the ligament and freely anastomose with a network of longitudinal endoligamentary vessels. Upon ruptur
e of the ligament, the vessels suffered trauma, which resulted in intra-articular hemorrhage.
\par Bonnie\rquote s physical exam video was enlightening as it is apparent that she is walking with a \ldblquote toed in, hock out\rdblquote  gait confirming ligament insufficiency This is a com
mon occurrence in dogs with CrCl ruptures. More convincing evidence includes the partial weight bearing, barely toe touching when standing, difficulty rising, and pain on stifle manipulation. 
\par Another consideration for Bonnie is the possibility of meniscal
 damage accompanying the CrCL rupture. The orthopedic exam revealed an absence of joint noise, however this does not eliminate the possibility that the menisci are damaged as well. Dogs, with chronic cranial cruciate tears have an 80% chance of incurring 
meniscal damage as well. Therefore, in Bonnie\rquote s case, we are going to postulate that she has a meniscal tear which will be either verified or disproved during her upcoming surgical repair of the ligament.
\par In conclusion, Bonnie is suffering from a complete cranial cruciate ligament rupture in the left hindlimb as a result of chronic degenerative changes to the stifle joint possibly accompanied by meniscal damage and degenerative joint disease.
\par }\pard \sl360\slmult1\widctlpar {\b 
\par Cranial Cruciate Rupture Management:
\par }{
\par }\pard \fi720\sl360\slmult1\widctlpar {Surgery is the preferred, i
deal treatment for every dog with a Cranial Cruciate Ligament rupture.  It is strongly recommended and necessary in larger breed dogs. There are numerous surgical techniques that may be used to restore functionality of the CrCL. Among them is primary repa
r
ation of the ligament including suture technique for midsubstance tears (not used in dogs) or tension band fixation of bony avulsion injuries, an intra-articular method whereby the ligament can be replaced or reconstructed using various materials, and las
tly the joint may be stabilized by transposition of periarticular structures or placement of suture materials outside of the joint referred to as extra-articular repair. No one method has been proven superior to another. Often it comes down to the surgeon
\rquote s preference and in this case, we have chosen intra-articular ligament reconstruction utilizing the over-the-top technique (Arnoczky).
\par The first consideration in intra-articular ligament reconstruction is graft selection.  Choice for materials include: biol
ogical tissues (autograft, allograft, xenograft), synthetic material or a combination of biological material and synthetic material (composite grafts).  In autogenous grafting the materials most often used are the patellar tendon and the fascia lata or a 
c
ombination of the two.  An advantage of using autogenous tissues is the fact that they are acquired directly from the host. Thus, an immune response is not a concern, and there is the convenience of harvesting the graft directly from the patient.  The mai
n
 disadvantage is that the graft will not be as strong as the original CrCL.  The goal of the graft is to function like a normal ligament by preventing cranial drawer motion and hyperextension of the stifle, and enabling twisting along with the caudal cruc
iate to limit internal rotation of the tibia on the femur.
\par Graft placement is the next consideration.  Grafts used in reconstruction are cords or sheets of tissue with less discrete points of attachment than the original cruciate ligament. If the distance b
etween the points changes during joint motion then problems can occur. Such problems include excessive lengthening which can over stress the graft or cause fixation failure.  Shortening of the graft may also occur resulting in compromise of the joint stab
i
lity.  Isometric points of attachment are attempted. They are used to enable the points of attachment to maintain the same relative distance as the joint moves.  The femoral attachment site is considered more critical and is recommended to be placed proxi
mal and caudal within the origin of the CrCL.  On the other hand the tibial attachment site is within the craniomedial area of the tibial attachment site of the ligament.  
\par Because Bonnie has evidence of DJD, a notchplasty is likely to be performed. As a re
sult of CrCL rupture, osteophytes often form on the inner margin of the lateral femoral condyle.  A cranial notchplasty is the removal of the osteophytes and reshaping of the cranial margins of the intercondylar notch.  This bone tweaking will enable less
 restrictive passage of the intra-articular grafts through the intercondylar notch. It will also prevent the impingement of the graft during extension of the joint. 
\par }\pard \sl360\slmult1\widctlpar {Another potential sequela to the CrCL rupture is damage to the menisci.  After visualization and inspection of the stifle joint, a decision will be made as to whether or not a meniscectomy is called for.
\par 
\par }{\b The Over-The-Top Technique (Arnoczky): 
\par Preoperative Management:
\par }{The client will be informed to limit Bonnie\rquote s activity before surgery to prevent any further damage to the articular cartilage.
\par }{\b Patient Preparation:}{
\par {\pntext\pard\plain\s15 \f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard\plain \s15\fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls11\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls11\adjustright \cgrid {
The hair is clipped from the hock proximally to the dorsal midline around the circumference of the limb.
\par {\pntext\pard\plain\f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard\plain \fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls12\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls12 \cgrid {
The skin is cleaned aseptically
\par {\pntext\pard\plain\f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard \fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls13\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls13 {A stockinette is put on the limb

\par {\pntext\pard\plain\f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard \fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls14\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls14 {Cefazolin (20m
g/kg) or Oxacillan (30mg/kg) is given IV after general anesthesia begins and is continued every 6 hours IV for 24 hours. 
\par }\pard \sl360\slmult1\widctlpar {
\par }{\b Lateral Approach to the Stifle Joint:}{ A craniolateral skin incision is centered over the patella followed by an incision of the subcu
taneous tissues along the same line. This will enable visualization of the septum between the superficial leaf of the fascia lata and biceps femoris muscle proximally and lateral retinaculum distally. An incision will be made through the fascia lata proxi
m
ally with the incision carried through the fascia lata and lateral retinaculum distally.  Next, the joint capsule is incised and the incision continued proximally adjacent to the patellar tendon.  Incise along the border of the vastus lateralis toward the
 fabella.  Finally, the patella is displaced medially to expose the cranial surface of the joint.
\par 
\par }{\b Over-The-Top Procedure:}{
\par }\pard \fi720\sl360\slmult1\widctlpar {Before embarking on the CrCL repair, a lateral arthrotomy will be used to enter the joint (described above.)  It is crucial to inspect
 the joint thoroughly for any additional problems such as eroded cartilage surfaces, disrupted menisci, and intra-articular osteophytes. Ruptured ligament remnants should be removed and the joint irrigated thoroughly with lactated ringers. Based on radiog
r
aphic results and the presence of intra-articular oeteophytes, notchplasty will be performed first to remodel the intra-articular surface of the stifle joint. A 6mm-bone gauge is used to remove the osteophyte formation, followed by a bone rasp to smooth o
ut the condylar margin. 
\par A meniscectomy is also a possibility, as the absence of joint noise does not eliminate possibility of a meniscal injury. Also, as high as 80% of dogs with chronic, complete cranial cruciate ligament ruptures experience a torn menisc
us.  The medial meniscus will be exposed and evaluated for damage.  If it is torn, the medial and lateral attachments of the menisci will be excised.
\par According to most literature, the intra-articular method of repair provides a more biomechanically sound r
epair than the extra-articular stabilization. The over the top procedure has been chosen for Bonnie, and is performed in the following manner (source: taken from Small Animal Orthopedics, pp. 933-934):
\par }\pard \sl360\slmult1\widctlpar { The medial one third of the patella-patellar ligament
 complex is isolated by a longitudinal incision in the ligament and an osteotomy of the anteriomedial aspect of the patella.  The incision is carried proximally into the fascia lata.  The length of the incision proximal to the patella should be at least 1
.
5 times that the distance of the patellar tibial tuberosity to ensure adequate graft length. A parallel incision is then made to free the graft, leaving it attached to the tibia tuberosity. A vertical incision is made in the lateral femoral fabellar ligam
e
nt and, with the joint in flexion, a curved hemostatic forceps is inserted into the incision and passed in to the intercondylar notch of the femur taking care to preserve the posterior joint structures by staying close to the bone.  The tips of the forcep
s
 are manipulated until they can be visualized within the joint, lateral to the caudal cruciate ligament.  A stay suture is placed in the proximal portion of the graft and the graft is pulled gently through the joint and over the top of the lateral femoral
 
condyle. Flexing and extending the joint during this procedure will facilitate the passage of the graft.  Once the graft is in position, it is held under gentle traction and the joint is tested for cranial drawer movement.  All craniocaudal instability sh
ould be eliminated throughout the ROM with the graft in place.  The graft is attached to the soft tissues of the lateral femoral condyle with simple interrupted sutures of 3-0 stainless steel.  
\par Following surgery, since Bonnie is a larger dog, she will require a lateral plaster of paris splint for the first two postoperative weeks. 
\par 
\par }{\b Postoperative care:
\par {\pntext\pard\plain\f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard \fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls15\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls15 {
Maintenance of the plaster of paris cast for the first 2 weeks
\par {\pntext\pard\plain\f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard \fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls16\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls16 {
Restriction to short leash walks for a minimum of 6 weeks 
\par {\pntext\pard\plain\f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard \fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls17\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls17 {Gradual increasing levels of activi
ty are permitted until 12 weeks, and then full activity can be attempted
\par {\pntext\pard\plain\f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard \fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls18\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls18 {
Swimming to strengthen muscles and regain joint motion
\par {\pntext\pard\plain\f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard \fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls19\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls19 {Ice packing
\par {\pntext\pard\plain\f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard \fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls20\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls20 {ROM exercises
\par {\pntext\pard\plain\f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard \fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls21\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls21 {Massage
\par {\pntext\pard\plain\f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard \fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls22\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls22 {Muscle electrical stimulation
\par }\pard \sl360\slmult1\widctlpar {
\par }\pard\plain \s1\sl360\slmult1\keepn\widctlpar\outlinelevel0\adjustright \ul\loch\af4\hich\af4\dbch\f4\cgrid {\hich\af0\dbch\af4\loch\f0 Diet modification:
\par }\pard\plain \sl360\slmult1\widctlpar \cgrid {Bonnie\rquote s DER is being calculated based on a predisposition to obesity (weight estimated to be 36 kg) and the need to lose weight. The ideal weight for an adult female Labrador retriever is  25-32 kg. 

\par RER based on 32 kg = 941 KCAL
\par DER=1.0 X RER
\par RER= 941 KCAL
\par DER= 941 KCAL
\par Daily Hills Maintenance diet= 2.6 cups per day
\par Eliminate snack foods from the diet
\par 
\par }{\b Potential complications:
\par {\pntext\pard\plain\f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard \fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls23\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls23 {
Infections occur in only 1-2% of all cases
\par {\pntext\pard\plain\f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard \fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls24\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls24 {
Injury or overexertion will sometimes cause breakdown of the repair within the first 1-2 weeks
\par {\pntext\pard\plain\f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard \fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls25\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls25 {
Lameness occurring months or years later may be attributed to damage involving the medial meniscus
\par }\pard \sl360\slmult1\widctlpar {\b 
\par Client Education: 
\par }\pard\plain \s15\fi720\sl360\slmult1\widctlpar\adjustright \cgrid {It is very important to follow discharge instructions to enable proper healing of the CrCL so that Bonnie can once again resume her normal routine.  Bonnie\rquote s left stifle wil
l never have the same load carrying capacity that the original cruciate ligament did, but the good news is that the reconstruction is proven to be successful 90% of the time.  
\par }\pard\plain \sl360\slmult1\widctlpar \cgrid {Bonnie will be placed in a plaster of paris cast for two weeks to support her s
tifle while healing takes place. We would like to see Bonnie at two weeks for a check-up and cast removal. We will schedule future appointments at that time as well.  Please keep the cast dry and clean. If it is degraded in some way, call and set up an ap
p
ointment to have it replaced. After removal of the cast her leg will be radiographed and re-evaluated. At that time a determination will be made as to whether or not any further casting support is required and whether or not healing or progressing normall
y
. It is very common for lameness to be more pronounced when the bandage is removed. At six weeks post-op we expect Bonnie to be able to place her weight on her leg most of the time.  Lameness though is typically still present six weeks post-op. Total recu
peration time for Bonnie will most likely be in the range of three to five months. Be aware that some dogs take six to eight months to fully recover.
\par }{\b Special Instructions:
\par {\pntext\pard\plain\f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard \fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls10\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls10 {
Administer antibiotics and anti-inflammatory pain medications as directed
\par {\pntext\pard\plain\f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard \fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls1\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls1 {Restrict to
 short leash walks for a minimum of 6 weeks
\par {\pntext\pard\plain\f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard \fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls2\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls2 {
Gradually increase activity over a 12-week period. This will be based on the condition of her stifle.
\par {\pntext\pard\plain\f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard \fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls3\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls3 {
After cast removal, hydrotherapy is recommended to strengthen muscles and regain joint motion
\par {\pntext\pard\plain\f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard \fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls4\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls4 {Ice packing is r
ecommended to decrease swelling
\par {\pntext\pard\plain\f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard \fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls5\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls5 {
Physical therapy 3 times per week for ROM exercises. This can take place the same day as the hydrotherapy. These exercises may be performed until acceptable ROM is achieved.
\par {\pntext\pard\plain\f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard \fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls6\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls6 {
Massage and electrical stimulation are also alternatives
\par }\pard \sl360\slmult1\widctlpar {The next important topic we need to discuss is Bonnie\rquote 
s weight. It is imperative that she loses weight in order to facilitate healing and prevent a recurrence of injury.  I have devised the following weight reduction plan for Bonnie: 
\par {\pntext\pard\plain\f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard \fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls7\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls7 {Bonnie weighs 
36 kg (estimated). Her goal weight is 25-32 kg.
\par {\pntext\pard\plain\f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard \fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls7\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls7 {Continue with the Hill\rquote 
s Science Diet Adult Maintenance formula
\par {\pntext\pard\plain\f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard \fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls8\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls8 {
Feed Bonnie 2.8 cups per day. You can break this up into two feedings at 1.4 cups in the morning and 1.4 cups in the evening.  Provide plenty of water for her as well.
\par {\pntext\pard\plain\f14 \loch\af14\dbch\af0\hich\f14 \u-3929\'a7\tab}}\pard \fi-360\li360\sl360\slmult1\widctlpar\jclisttab\tx360{\*\pn \pnlvlblt\ilvl0\ls9\pnrnot0\pnf14\pnstart1\pnindent360\pnhang{\pntxtb \'a7}}\ls9 {
At this time, I am going to ask that you refrain from feeding Bonnie snack food at least until she has attained her goal weight.
\par }\pard\plain \s15\sl360\slmult1\widctlpar\adjustright \cgrid {\b 
\par Prognosis}{
\par }\pard \s15\fi720\sl360\slmult1\widctlpar\adjustright {In conclusion, the prognosis for Bonnie is very good. Infections have only been reported in 
1-2% of all cases. As mentioned before, do not allow Bonnie to over exert herself as this can lead to breakdown of the repair within the first 1-2 weeks.  If lameness does occur somewhere down the road (months to years from now) it can probably be attribu
ted to meniscal damage. Please contact us with any questions or concerns.
\par }\pard\plain \sl360\slmult1\widctlpar \cgrid {
\par }\pard \widctlpar {Diagnosis: Kim, Pam, Mary
\par Management, Client Education, Prognosis: Pam
\par Compiler: Katherine
\par }}