29 Jun 2019
Usually, I try to find blog inspiration from those that I assume are smarter than me. However, this week, I want to pass along a little story of a very interesting case, and an off the wall thought I had about it.
So, this case was a typical cruciate tear. Trauma induced (owner slipped on ice and fell on the poor dog). Young female dog. No other known issues. The owner opted for an extracapsular method for repair.
All was fine. She took the dog to the veterinarian, had the surgery done and came for physio and underwater treadmill therapy. She had a home program. And let me assure you that this owner is the kind of owner that would DO the exercises.
However, at 4 weeks, there was still puffy swelling along the line of the incision. No oozing, no pain, no redness… just a thick puffy line that seemed to be just under the incision. So, back to the vet. He drained it, and the fluid looked normal (Serous fluid. No blood. No goop, pus, or stanky manky gunk). But the swelling came back. So, the vet drained it again. But again, it came back. This time the vet said, “It should just go away on its own.”
Fast forward to the 9-week mark. Still swelling! And the swelling was just localized to the line of the incision. Not the joint itself. But with this swelling, the dog was still significantly partial weight bearing in stance, and had a mild limp, and we were stagnate with increasing thigh circumference. She had a 4cm difference between the two thighs (proximal thigh circumference).
I recommended going back to the vet, but this time coached the owner to ask about some sort of a medication that could treat the dog for a potential allergic reaction to the suture material. (Nothing else made sense in my head!) However, at her vet visit, the vet said he was happy with the surgery and to just ‘push the dog harder and allow off-leash time’, stop any NSAIDS, and ‘no’ to any other medications.
Okay, so I just about hit the floor with the ‘off leash and push the dog’ comment. That was NOT going to be the answer in this case! We had reduced activity. We had increased activity. We had pushed. (BTW, pushing simply resulted in more swelling.) And under no circumstances was this dog ready for ‘off leash’! Fortunately, the owner was more amenable to my suggestions than the vet’s ‘all clear’… for a case that was most definitely not ‘all clear!’
So, here’s where I stepped a little outside of my scope... but just a little. The owner agreed with me that it was odd that the swelling was so localized to the incisional area, and was in agreement with the possibility of it being a reaction to the suture material. I asked her if she had any anti-histamines in the house, that she kept for the dogs. She had Benadryl (diphenhydramine). I asked her to phone her regular vet clinic (different than the surgical clinic) to ask if she could give Benadryl to her dog (for the purpose of reducing a suspected suture reaction), and if yes, what dose would be appropriate.
She did so. Permission granted. Dose obtained. Now to phase one of our experiment. I asked her to measure her dog’s stifle circumference. She measured the dog’s stifle after their evening walk (20 minutes). It was 12 ¼ inches. She gave her a Benadryl that night. By morning the stifle was down to 11 ¼ inches. She gave her another Benadryl in the morning, and went for another walk. That evening the stifle circumference was down to 11 inches. Two days later, the stifle circumference remained at 11 inches.
Clinically, when I saw the dog again the following week, it was like looking at an entirely different leg. The incisional puffiness was totally gone!!! A week later yet again, the other therapist that shares management of the case with me told me that the dog was finally starting to put on muscle!!! Finally, we were making gains!
I checked in with the owner recently. She kept the dog on a twice a day (morning and night) protocol of Benadryl for two weeks, then down to once a day after that. The dog is still primarily on leash for walks… but the swelling / puffiness has not returned!
Finally, we can make some headway... but she's behind! Fortunately, the owner can understand the chain of events and is willing to put in the extra time to get her dog back to full healing before removing that leash and saying, "Now run!"
Okay, so the moral of the story is to think outside the box to help problem solve and advocate for what your patient might truly need.
Tags: Suture reaction , TPLO , post-operative , stifle , novel treatment , allergic reaction
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