Step 6: TPLO Surgery Recovery

Step 6: Recovery Process

During the first eight weeks, we are completely relying on the implants (plate and screws) to stabilize the surgery site. It takes a minimum of eight weeks for bones to heal and good scar tissue to form. This process can take longer in geriatric pets or those with other systemic health conditions.

• Your pet should be confined to a kennel or small room until radiographs show good bone healing.
• Any running (inside or outside), jumping on or off furniture, or playing could lead to severe complications.

Recheck Appointments

• If a bandage or wound dressing was placed, a recheck may need to be scheduled to have this removed
• Your pet should be evaluated 10-14 days post-operatively to evaluate healing of the incision; if skin sutures were placed they will need to be removed at this time. Please schedule this appointment with your veterinarian.
• If lameness occurs or your pet fails to improve, X-rays may need to be taken to verify proper implant position and evidence of healing.
• At approximately eight weeks following surgery X-rays will need to be taken by your veterinarian to verify complete bone healing before returning to normal activity. The implants are designed to stay in for life. However, if pain, infection, or irritation occurs we can easily remove these implants.

Rehabilitation

Though physical rehabilitation protocols have been found to be beneficial in the recovery following TPLO, there is not an established rehabilitation protocol approved by all surgeons or rehabilitation specialists across the world. If you have elected to proceed with a TPLO on your pet, we strongly recommend that you follow the recovery protocol provided to you by your veterinary surgeon. However, this protocol may give you a general idea of the recovery period. Some pets may limp after surgery. If this occurs, please have your dog seen by your veterinarian so a treatment plan can be instituted. Finally, there is an arthritis protocol with helpful information about managing arthritis for the life of your pet.

Weeks 1 and 2

Controlled leash walks

• Walks are best performed on a short leash. Go slowly at first to help gradually improve strength. Walking slowly may help encourage use.
• Walks can be done three to five times per day for five minutes at a time for elimination purposes.
• Using a sling or folded bath towel under your dog’s belly can be used for support when walking on slick surfaces such as tile or wood floors, and even on other surfaces if they are unsteady on the surgical limb. The sling can also be used to help slow your pet’s pace down if they are pulling hard on the leash.
• No off-leash activity

Passive Range of Motion (PROM)

• Lay pet on their side with surgical limb up.
• Flex and extend the joints of the affected limb gently to resistance.
• Gently support the knee to prevent twisting or rotation of the limb.
• Repeat 2 – 3 times daily for 10 to 15 repetitions.
• PROM should not cause pain, discomfort or negative reaction.

Ice and Heat therapy

• Use of ice packs after walks and PROM for the first 3 to 4 days after surgery.
  • Drugstore packs, crushed ice in a Ziploc bag, or frozen peas or corn can be used.
  • Ice around as much of the circumference of the knee as possible.
  • While a paper or thin towel can be used to absorb moisture from the ice pack, a thick towel may prevent icing from being effective.
  • Ice for 15 minutes per session.
• Use heat packs prior to PROM after initial 3 to 4 days.
  • Drugstore packs or socks filled with uncooked rice heated in a microwave work well.
  • Test pack on your wrist first. If it is too hot for your skin, it is too hot for your dog.
  • Insulate the heat pack with a thin cloth.
  • Use for ten minutes per session.
• If your pet fails to begin using his leg during the first two weeks, please contact your veterinarian.
• A recheck should be performed at two weeks so the incision site can be evaluated. Sutures or staples are typically removed at the 10-14 day recheck.

Weeks 3 and 4

• PROM can be reduced to twice per week.
• Continue ice therapy as needed if your pet seems sore after walking/exercise.
• Increase leash walks to ~8 minutes in week 3 and ~10 minutes in week 4 as long as your pet is using the surgical limb.
• Incorporate the following exercises into leash walks as directed by your veterinarian, to build strength and body awareness:
  • Walk in large figure 8 pattern
  • Stepping slowly up onto and down off of a curb in an S pattern
  • Gentle inclines (a mild slope on a street or a driveway)
• The following exercises can also help build balance and core strength. Perform these exercises on a non-slip surface, with 5-10 repetitions each
  • Gently nudge the hind end from side to side while standing
  • Sit to Stand exercise – have your pet repeatedly sit down, then stand up
  • Three-Legged Standing Exercise – Have your dog in a standing position, then lift one leg off the ground at a time for 10 to 15 seconds (alternate with all but surgical leg)
• No off-leash activity

Weeks 5 through 8

• Icing and heat-packing can be discontinued
• Continue performing the previously mentioned exercises
• Week 5 increase length of walks up to ~12 minutes up to 3-5 times a day
• Week 6 increase length of walks up to ~15 minutes up to 3-5 times a day
• Week 7 increase length of walks up to ~18 minutes up to 3-5 times a day
• Week 8 increase length of walks up to ~20 minutes up to 3-5 times a day
• No off-leash activity

Weeks 8 through 12

Radiographs will be taken at about 8 weeks to confirm appropriate bone healing. Assuming the tibia is healing:

• Continue performing the previously mentioned exercises
• Continue to gradually increase the duration of the walks
• Gradually introduce off-leash activity, starting week 9 with about 5 minutes of off-leash activity 3-5 times a day, week 10 up to 10 minutes of off-leash activity 3-5 times a day, week 11 up to 15 minutes of off-leash activity 3-5 times a day, week 12 up to 20 minutes of off-leash activity 3-5 times per day.

Is your dog still limping?

There are multiple reasons why a patient may not want to bear weight on a limb following surgery. If your pet is not bearing weight within 2 weeks of surgery or develops an acute onset of lameness any time after surgery, please contact your veterinarian. Below are some of the more common reasons why a pet may limp following surgery.

• “Overdid it”– As with people, it is not uncommon for pets to “overdo it” leading to an acute onset of lameness. Sometimes during the post-operative recovery patients may be more active than is recommended (jump down from a sofa, chase the cat, etc.) or even just take a funny step, leading to a lameness of varying severity. If your pet develops a lameness during the recovery period, please contact your veterinarian so that we can determine if your pet needs to be evaluated to ensure there is not a serious injury.
• Infection– Approximately 5-7% of all patients undergoing a TPLO will develop a surgical site infection. Some infections may clear up after a short course of antibiotics. In approximately 3% of all TPLO cases, an infection may occur associated with the plate and screws. Patients may show signs of lameness or pain, swelling/redness at the surgery site, and discharge. In these cases, patients are placed on antibiotics until the bone is healed (based on x-rays) and the bone plate can be removed.
• Implant-associated pain– Until the bone has healed we are completely relying on the bone plate to stabilize the surgical site. In situations where a pet is allowed excessive high impact activity, the bone plate or screws can bend or break. Thankfully, this is a very rare complication (<1%). If this occurs, the surgical site may be unstable which in many instances may require further surgery. In other rare instances, patients may simply be uncomfortable with the presence of the plate. In these cases, removal of the plate after the bone has healed will typically resolve the lameness.
• Meniscal tear– Approximately 30-40% of all dogs undergoing surgery for a torn ACL will have a concurrent meniscal injury. In those cases, the torn portion of the meniscus will be removed at the time of surgery. However, approximately 5% of dogs with an intact meniscus at the time of surgery will develop a meniscal tear at some point in the future. When this occurs, patients may become acutely lame. In some cases, these patients may need a second surgery to remove the torn portion of the meniscus.

Arthritis Treatment

Cranial cruciate ligament (CCL or ACL) tears in dogs are typically a degenerative process and in most cases is associated with the development of osteoarthritis. Whether medical or surgical management is elected to treat the injury, a commitment to managing arthritis can help increase the odds of a successful long-term outcome. There are four important cornerstones of arthritis treatment (please see below for detailed explanations on each of these):

• Weight Management
• Exercise Modification/Physical Rehabilitation
• Joint Supplements
• Pain Medications

In dogs, the presence of arthritis is typically secondary to an underlying disease process (elbow dysplasia, hip dysplasia, cranial cruciate ligament tear, fracture, etc.). Frequently, treatment of the underlying cause will greatly increase a patient’s comfort level. However, arthritis can be a debilitating and painful disease in dogs and reverse the disease process is not possible. However, some interventions may slow the progression of arthritis. The following information gives an overview of the treatment of and prevention of further arthritis development. If at any point, you have questions about the potential therapies listed below, please contact your veterinarian.

• Weight Loss/Management: Keeping your pet thin is not just important, it is probably the most important aspect of minimizing the progression of arthritis and associated pain. A landmark study, referred to as the “lifetime study”, split dogs into 2 groups – one where dogs were fed as much as they wanted and another with restricted feeding. Those that had restricted caloric intake lived on average 2 years longer and developed arthritis 6 years later in life than those that were free fed. This study drives home the importance of weight management in dogs. We need to be able to feel the ribs easily. When looking at your pet from above, there should be an hour-glass shape present as opposed to a continuous “barrel” appearance.
• Exercise modification/Physical rehabilitation: Regular controlled physical activity, or rehabilitation, is very important in the treatment of arthritis in animals. These activities may include stretching and range of motion exercises, controlled walking, and swimming. More advanced techniques such as those used by physical rehabilitation specialists (balance boards, underwater treadmills, etc.) can also be utilized. The efficacy of physical rehabilitation in dogs with osteoarthritis has been proven in multiple scientific studies. In addition to the contribution physical activity can have on weight management, it can also help maintain range of motion, muscle mass, and comfort. Consistent, tolerable levels of activity are most beneficial. If a pet is able to increase their stamina by gradually increasing the duration of their activity, this is ideal. Multiple short walks may be better than one long walk. If high-impact activities such as fetch or playing with other pets are expected, a ‘warm-up’ period of walking may decrease the risk of injury. Avoiding excessive high impact activity is important, so try to avoid the ‘weekend-warrior’ type of exercise (i.e. really long hikes on an inconsistent basis).
• Joint supplements: Supplements have been shown in some cases to be effective at minimizing progressive damage to joint cartilage. Unfortunately, supplements and nutraceuticals are not regulated by the FDA. This means there can be a wide range of quality between products with some not containing a significant amount of an ingredient they claim to have. There is more evidence behind omega-3 fatty-acids and polysulfated glycosaminoglycans in dogs than there is for other supplements such as glucosamine and chondroitin.
  • Omega-3 Fatty Acids: Omega-3 fatty acids have been shown to decrease the inflammation of an arthritic joint. Fish derived Omega-3 fatty acids contain eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). In dogs, the specific fatty acid, EPA has been shown to have the most effect. This effect is in contrast to humans and horses. An easy way to calculate the dosage of Omega-3’s is to take your pet’s body weight in pounds and multiply that by 20. That is the amount of EPA we want to give. So if your pet is 20lb, then 20 x 20 = 400, so you want to ensure you are giving 400mg of the EPA component of the fish oil.
  • Polysulfated Glycosaminoglycans (PSGAGs): This drug, labeled in the US as Adequan, was originally designed to treat acute joint cartilage injuries and it is approved for use in dogs for arthritis. Though there is evidence of its beneficial effects from in-vivo studies, the mechanisms by which they are presumed to be effective are gathered from in-vitro studies. In-vitro PSGAG’s inhibit catabolic enzymes that degrade cartilage and inhibit the production of chemical factors that can lead to inflammation and pain. PSGAGs can also be effective in cats. The PSGAGs are naturally occurring in joints. A series of injections, twice weekly for 4 weeks to start, is implemented to determine if a patient is responding well. If a patient has a significant beneficial response, a plan is implemented to taper the injection to the longest effective interval.
• Pain management is an important aspect of treatment in the early stages of medical management and will likely be required intermittently throughout life. Multiple medications may be prescribed in an effort to keep your pet comfortable.
  • Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs block pathways that lead to inflammation and pain, and thus play a major role in the treatment of osteoarthritis and pain in dogs. It is very important that these medications be used judiciously, and only as prescribed by your veterinarian, as certain potential side effects and medical conditions may prohibit their use. Side effects may include vomiting, diarrhea, blood in the stool, not eating or drinking, lethargy, inactivity, or nausea. Simultaneous use of these medications with certain other medications (e.g. corticosteroids such as prednisone or other anti-inflammatories like ibuprofen) should be avoided as it increases the risk of complications. If you observe any side effects, please contact your veterinarian and discontinue the medication.
  • Amantadine: This medication controls pain by acting as an N-methyl-d-aspartate (NMDA) receptor antagonist. This drug has been found in the veterinary literature to be successful when used in conjunction with NSAIDs. Side effects may include agitation, loose stools or diarrhea.
  • Gabapentin: This medication has been found to have beneficial effects in treating neuropathic pain (pain associated with damaged nerves) in people. It has been used in dogs and cats for pain treatment. Unfortunately, of the multiple studies performed evaluating its efficacy in dogs, only one found any analgesic effects. It’s thought that this medication may be more appropriate for chronic, as opposed to acute, pain control. Along with pain-relieving effects, it may cause sedation.
  • Tramadol: Tramadol is a synthetic opioid that and can be used separately or in combination with NSAIDs and can also be used in cats. Side effects are rare but may include sedation.  Unfortunately, similar to gabapentin, there is little evidence to support the use of Tramadol for pain in dogs.