Client Communication
Group 11

Initial consultation

	Bonnie has a cranial cruciate ligament rupture in her left knee.  This ligament normally limits the movement of her knee, and keeps it stable when she uses it.  The best treatment option for this condition is surgery to make a new ligament to stabilize the joint. Surgical repair provides the best prognosis for Bonnie.  It speeds recovery, decreases arthritic changes in the knee, and enhances function of the joint for the future. There is an 85% success rate associated with surgery.  However, surgery does not totally eliminate the chance of degenerative joint disease and a complete return of athletic function is uncommon.  Because we are a mixed animal practice, this is a procedure for which we will refer you to a hospital that performs this surgery.  No technique has proven superior to another, but we have recommended and have had good success with a combination of techniques where the joint is stabilized with heavy suture and a new ligament is created with tissue from her thigh.   This technique decreases rehabilitation time as compared to some other techniques.   It is important to know before the procedure that 20-40% of dogs that rupture one cruciate will rupture the one on the opposite leg within 17 months.  Also it is going to take extensive post-surgical care for a bare minimum of 6 weeks, preferably 12 weeks.  If you don't have a crate or a playpen for her to stay in after surgery, you will want to get one before she comes back for surgery in two weeks. If you don't wish to pursue surgical repair, conservative medical management for dogs Bonnie's size provides improvement or resolution of lameness in 6 months in only 20% of cases.  This option is inferior to surgery, and there will be considerably more degeneration of the joint if you chose the conservative approach.  Without surgery, Bonnie will have reduced athletic function and will experience periodic pain in her leg for the rest of her life.
	She is also overweight and would benefit from losing a few pounds whether you choose to pursue surgery or not.  Today we will send you home with a weight loss diet called r/d made by Hills.  It is a low calorie food that will help you with her diet.  We will send you home with a measuring cup, and you must measure out the amount of food she is to receive daily [we don't know her weight so we can't figure it out at this time].  We would like to keep her on the diet for the next two weeks until she goes in for surgery.  Ideally we would like her to lose 4 pounds by this time, so it is important that she is not supplemented with table scraps or treats.  Please bring her back a week from today to check on her weight so that we can adjust her diet if we need to.  After surgery, she will have to stay on a diet in order to maximize the recovery from her injury, and to reduce the chances of a similar injury on her right side.
	We will send you home with some pain/anti-inflammatory medication called Rimadyl for Bonnie, which she will need twice a day.  She may feel better with this medication, but you must restrict her activity to a minimum to prevent further damage to the knee.  Please restrict her activity to minimal leash walking.  There are intestinal side effects possible with this medication so discontinue its use if you see any signs such as vomiting or diarrhea with or without blood and call us.

If conservative option chosen:
Continue initial consultation

	Bonnie will need to be strictly confined to a crate or playpen for the next 4 weeks to allow her knee to heal, at which time we would like you to bring her back in for a recheck.  During this time she should only leave the crate for bathroom breaks, and at no time should she be allowed unsupervised exercise.  She may need to be confined for an additional 4 weeks, depending on her progress at that time.  We will refill Bonnie's Rimadyl prescription as needed to control pain and inflammation.  And again, weight loss is key to maintaining Bonnie's quality of life and decreasing the chances of her rupturing the ligament in her right knee.  
	Once we determine that Bonnie no longer needs to be confined to the crate, she will benefit from strict, controlled exercise to maintain the muscle mass that is now helping to support her knee.  Leash walking and swimming are both good options.  


If Surgical option chosen:
Postoperative consultation at referral practice (one day after surgery)

	Please help Bonnie into the car and out of the car when you get home.  We can assist you getting her into the car if you need help.  When you get home, Bonnie will have to stay in her crate or playpen for 2 weeks with only leash walking into the yard for bathroom breaks.   After 2 weeks she can be let outside for controlled leash walking and/or swimming.  She should be confined in her crate during this time when you are not at home or are unable to observe her directly.  This should continue until 12 weeks from now, gradually increasing time and distance of walks.  After 12 weeks, Bonnie can be gradually increased to normal activity.
	Check the incision daily and call us if you see any additional swelling, redness, or drainage.  To prevent infection we gave her antibiotics while she was here and are sending you home with some oral antibiotics called cephalexin to give her three times daily for one week.  You can start her on her first dose tonight.  In addition, we will send you home with more Rimadyl to give twice daily for 5 days and then as needed for pain.  Intestinal and allergic side effects are possible, so watch for them, and call us with any concerns.  A drug to protect cartilage like Glycoflex may help limit cartilage damage and degradation.  We can send some home with you if you would like.
	You can use cold compresses to decrease swelling in the leg and then after swelling has subsided, warm compresses and massage can help increase circulation.  Starting a few days from now you should initiate physical therapy of the knee daily to maintain range of motion of the knee.  Here's my dog Jefferson to show you how to flex and extend the joint.  You should start with conservative treatment initially, with as much motion as Bonnie is comfortable with, and then increasing the number of repetitions and extent of flexion as Bonnie heals and the pain of surgery subsides.   In addition, muscle electrical stimulation has been shown to aid in improving mobility and strength.  We can refer you to a facility capable of performing this therapy if you wish.  
	It is important for Bonnie to remain on a strict diet to reach her ideal weight.  The prognosis is improved if she loses weight, and there is a decreased chance of arthritis pain and dysfunction.  Because of the limited exercise she will receive in the next 12 weeks, it is going to be doubly important that you control her diet.  You should continue the r/d diet until she reaches her ideal weight.  We will monitor her progress by bringing her into the clinic to be weighed every two weeks starting 4 weeks from today.  We will observe her progress and assess her exercise regimen at those times as well.