Surgical Correction of Traumatic Lateral Patellar Luxation Desrochers1, Ashley D. Sheen2, He le ne Larde 1, and Marie Babkine1 Emma Marchionatti1, Andre de Montre al, St-Hyacinthe, Que bec, Canada and 2Atlantic Veterinary Faculty of Veterinary Medicine, Department of Clinical Sciences, Universite College, University of Prince Edward Island, Charlottetown, Prince Edward Island, Canada
1
Corresponding Author Emma Marchionatti Faculty of Veterinary Medicine Department of Clinical Sciences de Montre al Universite CP 5000, St-Hyacinthe Canada QC J2S 7C6 [email protected] Submitted May 2015 Accepted September 2015 DOI:10.1111/vsu.12426
Objective: To report successful surgical repair of a grade IV lateral patellar luxation in a 437-kg heifer. Study Design: Case report. Animal: Seventeen-month-old Holstein heifer (437 kg). Methods: Diagnosis of traumatic lateral patellar luxation was made based on physical examination, and confirmed on radiographs. Arthroscopic examination of the stifle assessed joint changes. Lateral patellar luxation was surgically repaired using lateral release of the patella and medial imbrication of the joint capsule. Results: The heifer presented nonweight-bearing lameness of the left hind limb (5/5 lameness score). Unilateral grade IV lateral patellar luxation was diagnosed based on physical examination and radiography. Arthroscopic examination of the stifle showed synovitis and cartilage eburnation of the medial articular surface of the patella and of the lateral trochlear ridge of the femur. Lateral release of the patella and medial imbrication of the joint capsule was performed. The heifer remained lame (4.5/5 lameness score) and developed severe disuse muscle atrophy after surgery. By day 112, the heifer was walking easily and was completely weight bearing on the left hindlimb but did have a gait alteration (2/5 lameness score). On day 229, the heifer calved for the first time and lameness was no longer evident. Conclusion: This report documents successful surgical treatment of traumatic lateral patellar luxation in a large heifer but additional case evaluation is required to provide an accurate prognosis for this condition and treatment in large cattle.
Lateral patellar luxation in cattle is most commonly reported in newborn calves.1 It occurs during delivery with unilateral or bilateral involvement. The origin can be neurogenic (femoral nerve paresis) or traumatic.1–4 Congenital forms in calves because of femoral trochlear groove hypoplasia have also been described.1 Lateral patellar luxation in adult cattle is rarely reported, is generally acquired, and of traumatic origin.5 Various surgical techniques for correction of lateral patellar luxation in calves have been reported5–8 with a fair to good prognosis.1,5–8 There are no reports of successful surgical treatment of lateral patellar luxation in cattle older than 3 months. This case report describes the clinical and radiographic findings, surgical treatment, and long-term outcome of unilateral, traumatic lateral patellar luxation in a 17-month-old, 2-month-pregnant, 437-kg Holstein heifer.
CASE A 17-month-old, 2-month-pregnant, 437-kg Holstein show heifer was referred with a 7-day history of nonweight-bearing
lameness of the left hind limb. The owner reported the heifer fell in the claw-trimming chute during a preventive claw trimming and the left hind limb was held in complete extension. The heifer became immediately-nonweight-bearing in the left hind limb. The heifer was treated with two doses of flunixine meglumine at 2 mg/kg intravenously (IV), 24 hours apart, with no change in the lameness. The heifer showed reduced feed intake over the next few days and was progressively more unwilling to stand. At presentation, the heifer was alert and in good body condition (body score 3/5).9 The heifer was reluctant to stand or walk and would toe-touch only on the left hind limb with lameness graded as 5/5.10 Moderate swelling over the left stifle was noted. Palpation of the stifle revealed effusion of the femoropatellar joint and lateral patellar luxation. The stifle could not be manipulated into full extension and the patella could not be forced back into the trochlear groove. The right hind fetlock was hyperextended. A grade IV patellar luxation was diagnosed based on the physical examination findings.1 Radiographs of the stifle confirmed lateral luxation of the left patella (Fig 1). Recommendations for treatment included euthanasia or surgical intervention. The owner chose surgical
Veterinary Surgery 45 (2016) 121–124 © Copyright 2015 by The American College of Veterinary Surgeons
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Lateral Patella Luxation in a Heifer
Marchionatti et al.
Figure 1 Radiographs of the left stifle of a 17-month-old heifer diagnosed with traumatic lateral patella luxation ( ). (A) Caudocranial view. (B) Lateral view.
treatment given the high value of the heifer, despite the guarded prognosis. Hay was withheld for 36 hours, grain for 24 hours, and water for 12 hours before surgery. Meloxicam at 0.5 mg/kg subcutaneously and sodium ampicillin at 15 mg/kg IV were administered preoperative. After premedication with detomidine at 0.005 mg/kg IV and butorphanol at 0.05 mg/kg IV, anesthesia was induced with diazepam at 0.1 mg/kg IV, ketamine at 2.5 mg/kg IV, and guaifenesin (5%) at 0.5 mg/kg IV. Anesthesia was maintained with isoflurane in oxygen via an endotracheal tube using mechanical ventilation. The heifer was placed in dorsal recumbency with the left hind limb suspended in extension. An attempt at closed reduction of the luxation was unsuccessful. After aseptic preparation of the skin around the stifle, arthroscopic examination of the femoropatellar joint was performed11 to assess joint changes. A 1-cm skin incision was made midway between the femoral trochlear groove and the tibial crest, medial to the middle patellar ligament. The subcutaneous fascia was incised and a 5.5-mm arthroscopic sheath and its conical obturator were inserted angled 45° to the skin in a proximal direction. As synovial fluid flowed from the open stopcock of the arthroscopic sheath, the obturator was removed and replaced with a 4-mm diameter, 18-cm long arthroscope with a 25° viewing angle. After visualization of cartilage, the joint was distended with lactated Ringer’s solution. The patella was viewed lying outside the trochlear groove, lateral to the lateral trochlear ridge. Synovitis was evident as well as full thickness cartilage eburnation of the medial articular surface of the patella and of the abaxial aspect of the lateral trochlear ridge of the femur. Several free, small pieces of cartilage were visualized in the lateral recess (Fig 2).
122
No debridement of the articular cartilage eburnation was performed. The joint was irrigated with 3 L of lactated Ringer’s solution through a 4.5 mm open egress cannula to flush debris from the joint. After arthroscopic exploration, each portal site was closed with USP 0 monofilament polybutester in a cruciate fashion. A 10 cm lateral, parapatellar skin incision was made and the underlying tensor fascia lata muscle was exposed. The lateral femoropatellar ligament and gluteobiceps tendon were transected without invading the femoropatellar joint. The patella was replaced into the femoral trochlear groove with some difficulty. The subcutaneous tissues were sutured with USP 2-0 multifilament braided lactomer in a simple continuous pattern. The skin was closed with USP 0 monofilament synthetic polybutester with interrupted cruciate sutures. A second, 10 cm medial parapatellar skin incision was made and the underlying subcutaneous tissues were bluntly dissected to expose the joint capsule. No attempt was made to reconstruct the medial femoropatellar ligament. The medial joint capsule, the entire length of the patella, was imbricated with 10 interrupted Lembert sutures using USP 5 multifilament braided polyester without invading the femoropatellar joint. The joint capsule was not opened or resected. The subcutaneous tissue and the skin were then closed as described for the lateral incision. Intraoperative radiographs confirmed the patella was replaced in the femoral trochlear groove. The femoropatellar joint was infused with 20 mg of morphine in 10 mL of bupivacaine with an 18 gauge spinal needle at the end of the procedure. Surgical sites were protected with a dressing for the first 24 hours postoperative. Surgery and anesthesia times were 135 and 210 minutes, respectively. Uneventful and unassisted recovery to standing
Veterinary Surgery 45 (2016) 121–124 © Copyright 2015 by The American College of Veterinary Surgeons
Marchionatti et al.
Lateral Patella Luxation in a Heifer
Figure 2 Arthroscopic view of the femoropatellar joint. (A) There is cartilage eburnation over the medial articular surface of the patella (P) and over the lateral trochlear ridge (LTR) of the femur. IG, intertrochlear groove. (B) Several small cartilage fragments are present in the lateral recess of the joint.
occurred 20 minutes later. Sodium ampicillin at 15 mg/kg IV 3 times daily was continued for 3 days and meloxicam at 0.5 mg/kg subcutaneously was administered every 36 hours for 5 doses. Meloxicam was then administered every 48 hours for 6 doses, then every 72 hours for 6 additional doses. Ice packs were applied for 15 minutes, 6 times daily for the first 24 hours after surgery. The heifer was kept in an individual stall (3 3.5 m2) with straw bedding. Daily monitoring included physical examination and limb use at walk in the stall. The heifer was hospitalized for 23 days. The heifer would toe touch (lameness score 4.5/5) the affected limb during hospitalization and increasingly spent more time standing. A severe, disuse muscle atrophy of the affected limb developed during hospitalization and atrophy of the quadriceps femoris muscle allowed slight manual displacement of the patella laterally. Skin sutures were removed 12 days postoperative and the surgery sites healed without complications. Radiographs taken 14 days postoperative confirmed that the patella remained in the femoral trochlear groove. Lameness score at discharge was 4.5/5. The owner was instructed to keep the heifer confined in an individual stall for 3 more weeks, followed by restriction to a small pasture (60 square meters) to allow grazing, free walking, and rehabilitation. The referring veterinarian was asked to perform regular lameness and physical reevaluation of the heifer. At pasture turnout on day 47 postoperative, the heifer remained toe touching with slightly more weight-bearing on the left hindlimb (4/5) and had a body condition score of 2.25/ 5. The lameness improved by day 112 (2/5) and the heifer was completely weight-bearing on the affected limb but still had an abnormal gait. The hyperextension of the right hind fetlock and the disuse muscle atrophy had resolved and the body condition score was improved (3/5). The heifer was placed in a free stall barn with same age herd mates. The heifer calved for the first time on day 229 postoperative. At that time, lameness was almost resolved (1/5) but limited flexion of the stifle was noticed when the cow was lying down. The cow was sold at 184 days in milk, 413 days after surgery, for reasons unrelated to the patellar luxation. After evaluation of the Holstein Canada data sheet for milk production, it was determined that the mature equivalent lactation production of the animal was in
the average range for production for first lactation for Holstein breed.
DISCUSSION This report documents successful surgical treatment of lateral patellar luxation in a large, 437 kg, heifer. Surgical treatment of lateral patellar luxation has been previously reported in smaller cattle, successfully returning the animals to normal ambulation.1,2,5–8 Grade IV patellar luxation requires surgical treatment and untreated patellar luxation leads to degenerative osteoarthritis.1 Surgical treatment for traumatic patellar luxation requires thorough physical examination and radiographic evaluation as findings of femoral nerve paralysis1,2 and severe degenerative joint disease may contraindicate surgery.1,6 Surgical treatment of lateral patellar luxation in cattle includes lateral release of the patella followed by imbrication of the medial aspect of the joint capsule5,6 trochleoplasty,7 use of a prosthetic trochlear ridge,8 or tibial tuberosity medial transplantation.1,6 Trochleoplasty or the use of a prosthesis over the lateral trochlear ridge have been successful for treating congenital cases of shallow trochlear groove and lateral ridge hypoplasia in young calves.7,8 In the heifer reported here, as the luxation was traumatic, the trochlear groove was adequate and trochleoplasty was unnecessary. Tibial tuberosity transplantation is used in dogs to re-establish the quadriceps femoris line of tension and has been reported in a 3-month-old Ayrshire heifer.6 This procedure was not considered given the associated high risk of implant failure and non union reported in heavy cattle and dogs.1,12 The combined lateral release of the patella with medial joint capsule imbrication has been shown to produce a stable repair that preserves the integrity of the major muscles of stifle extension and good long-term success is reported for foals and young calves 1–3 months of age.5,6 The soft tissue release decreases the lateral pull forces on the patella, whereas the medial imbrication of the parapatellar structures helps to stabilize the patella in the femoral trochlear groove. This report shows its application in an older, heavier animal.
Veterinary Surgery 45 (2016) 121–124 © Copyright 2015 by The American College of Veterinary Surgeons
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Lateral Patella Luxation in a Heifer
Marchionatti et al.
Strict postoperative stall rest for 6–8 weeks was advised to allow strong fibrous tissue formation at the imbrication site and avoid risk of reinjury. Nevertheless, exercise is an important part of rehabilitation after orthopedic surgery to maintain joint function and improve muscle reconditioning. Controlled exercise via hand walking, gradually increasing in duration and intensity, is best combined with stall confinement. This, however, can be difficult in a farm animal setting. The heifer of this report had unrestrained movement in a small pasture starting 47 days postoperative. A more vigilant exercise program during the first 6–8 weeks may have been indicated, although the atrophy resolved within 9 weeks of pasture turnout, the minimum time required to re-establish musculoskeletal tissue strength following complete rest in the horse after orthopedic surgery.13 The heifer was at risk for development of degenerative joint disease, as a result of full thickness cartilage eburnation seen during arthroscopic examination. Pain and progressive joint degeneration may have contributed to the slow recovery. Pain management and control of inflammation with nonsteroidal anti-inflammatory medication are part of the overall management of osteoarthritis. Immediate postoperative pain was managed with the use of intra-articular morphine and parenteral administration of meloxicam. Opioid m-receptors have been identified in synovial membranes of horses and intra-articular morphine can produce effective and prolonged analgesia.14 Meloxicam is approved in the European Union and Canada for adjunct therapy for acute clinical mastitis, dehorning, and calf diarrhea. Meloxicam has preferential, but not specific, binding to cyclo-oxygenase-2 (COX-2) receptors, which makes it less likely to interfere with homeostasis of abomasal mucosa or renal perfusion than less selective COX-2 nonsteroidal anti-inflammatory drugs (NSAIDs). Meloxicam has preferential accumulation within the inflamed joints in dogs.15 Epidural administration of opioids such as morphine would have been another route to provide analgesia,16 although clinical results are varied and maximum effect is no more than 12 hours.16 Therefore, placement of an epidural catheter is necessary to provide continuous analgesia. Followup was restricted to telephone conversations with the owner and the referring veterinarian to assess outcome. Radiographic and ultrasound examination, and arthrocentesis would have provided information on joint function and range of motion, and progression of degenerative joint disease. Despite a prolonged rehabilitation, this heifer had a satisfactory outcome. The cooperative and calm temperament of the animal facilitated the recovery and contributed to the treatment success. The heifer went on to have a healthy calf and a normal milk production. Surgical treatment of lateral patellar luxation can be performed in large cattle but further case accrual is needed to verify the outcome.
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DISCLOSURE The authors declare no conflicts of interest related to this report.
REFERENCES 1. Ducharme NG: Patellar luxation, in Fubini SL, Ducharme NG (eds): Farm animal surgery. St. Louis, MO, Saunders, 2004, pp 497–501 2. Ferguson JG: Surgical conditions of the proximal limb, in Greenough PR, Weaver AD (eds): Lameness in cattle. Philadelphia, PA, Saunders, 1997, pp 270–271 3. Philip RG: Lateral luxation of the patella in a calf. Vet Rec 1970;86:190–191 4. Meagher DM: Bilateral patellar luxation in calves. Can Vet J 1974;15:201–202 5. Leitch M, Kotlikoff M: Surgical repair of congenital lateral luxation of the patella in the foal and calf. Vet Surg 1980; 9:1–4 6. Weaver AD, Campbell JR: Surgical correction of lateral and medial patellar luxation in calves. Vet Rec 1972;90:567–569 7. Kim NS, Alam MR, Lee JI, et al: Trochleoplasty in lateral patellar luxation in two calves. J Vet Med Sci 2005;67:723–725 8. Winstanley EW, Gleeson LN: Prosthetic trochlear ridge for treatment of patellar luxation in a calf. J Am Vet Med Assoc 1974;164:807–808 9. Edmonson AJ, Lean IJ, Weaver LD, et al: A body condition scoring chart for Holstein dairy cows. J Dairy Sci 1989;72: 68–78 10. Greenough PR, Weaver AD, Broom DM, et al: Basic concepts of bovine lameness, in Greenough PR, Weaver AD (eds): Lameness in cattle. Philadelphia, PA, Saunders, 1997, pp 3–13 11. Nichols S, Anderson DE: Determination of the normal arthroscopic anatomy of the femoropatellar and cranial femorotibial joints of cattle. Can Vet J 2014;55:232–239 12. Kowaleski MP, Boudrieau RJ, Pozzi A: Stifle joint, in Tobias KM, Johnston SA (eds): Small animal veterinary surgery. St. Louis, MO, Elsevier, 2012, pp 1361–1362 13. Kaneps AJ: Postoperative physiotherapy for the orthopedic patient, in Auer JA, Stick JA (eds): Equine surgery. St. Louis, MO, Saunders, 2012, pp 1483–1487 14. Sheehy JG, Hellyer PW, Sammonds GE, et al: Evaluation of opioids receptors in synovial membranes of horses. Am J Vet Res 2001;62:1408–1412 15. Johnston L, Narbe R: Preferential accumulation of meloxicam in inflamed synovial joints of dogs. Vet Rec 2012;170:207–208 16. Anderson DE, Edmondson MA: Prevention and management of surgical pain in cattle. Vet Clin North Am Food Anim Pract 2013;29:157–184
Veterinary Surgery 45 (2016) 121–124 © Copyright 2015 by The American College of Veterinary Surgeons
1
Corresponding Author Emma Marchionatti Faculty of Veterinary Medicine Department of Clinical Sciences de Montre al Universite CP 5000, St-Hyacinthe Canada QC J2S 7C6 [email protected] Submitted May 2015 Accepted September 2015 DOI:10.1111/vsu.12426
Objective: To report successful surgical repair of a grade IV lateral patellar luxation in a 437-kg heifer. Study Design: Case report. Animal: Seventeen-month-old Holstein heifer (437 kg). Methods: Diagnosis of traumatic lateral patellar luxation was made based on physical examination, and confirmed on radiographs. Arthroscopic examination of the stifle assessed joint changes. Lateral patellar luxation was surgically repaired using lateral release of the patella and medial imbrication of the joint capsule. Results: The heifer presented nonweight-bearing lameness of the left hind limb (5/5 lameness score). Unilateral grade IV lateral patellar luxation was diagnosed based on physical examination and radiography. Arthroscopic examination of the stifle showed synovitis and cartilage eburnation of the medial articular surface of the patella and of the lateral trochlear ridge of the femur. Lateral release of the patella and medial imbrication of the joint capsule was performed. The heifer remained lame (4.5/5 lameness score) and developed severe disuse muscle atrophy after surgery. By day 112, the heifer was walking easily and was completely weight bearing on the left hindlimb but did have a gait alteration (2/5 lameness score). On day 229, the heifer calved for the first time and lameness was no longer evident. Conclusion: This report documents successful surgical treatment of traumatic lateral patellar luxation in a large heifer but additional case evaluation is required to provide an accurate prognosis for this condition and treatment in large cattle.
Lateral patellar luxation in cattle is most commonly reported in newborn calves.1 It occurs during delivery with unilateral or bilateral involvement. The origin can be neurogenic (femoral nerve paresis) or traumatic.1–4 Congenital forms in calves because of femoral trochlear groove hypoplasia have also been described.1 Lateral patellar luxation in adult cattle is rarely reported, is generally acquired, and of traumatic origin.5 Various surgical techniques for correction of lateral patellar luxation in calves have been reported5–8 with a fair to good prognosis.1,5–8 There are no reports of successful surgical treatment of lateral patellar luxation in cattle older than 3 months. This case report describes the clinical and radiographic findings, surgical treatment, and long-term outcome of unilateral, traumatic lateral patellar luxation in a 17-month-old, 2-month-pregnant, 437-kg Holstein heifer.
CASE A 17-month-old, 2-month-pregnant, 437-kg Holstein show heifer was referred with a 7-day history of nonweight-bearing
lameness of the left hind limb. The owner reported the heifer fell in the claw-trimming chute during a preventive claw trimming and the left hind limb was held in complete extension. The heifer became immediately-nonweight-bearing in the left hind limb. The heifer was treated with two doses of flunixine meglumine at 2 mg/kg intravenously (IV), 24 hours apart, with no change in the lameness. The heifer showed reduced feed intake over the next few days and was progressively more unwilling to stand. At presentation, the heifer was alert and in good body condition (body score 3/5).9 The heifer was reluctant to stand or walk and would toe-touch only on the left hind limb with lameness graded as 5/5.10 Moderate swelling over the left stifle was noted. Palpation of the stifle revealed effusion of the femoropatellar joint and lateral patellar luxation. The stifle could not be manipulated into full extension and the patella could not be forced back into the trochlear groove. The right hind fetlock was hyperextended. A grade IV patellar luxation was diagnosed based on the physical examination findings.1 Radiographs of the stifle confirmed lateral luxation of the left patella (Fig 1). Recommendations for treatment included euthanasia or surgical intervention. The owner chose surgical
Veterinary Surgery 45 (2016) 121–124 © Copyright 2015 by The American College of Veterinary Surgeons
121
Lateral Patella Luxation in a Heifer
Marchionatti et al.
Figure 1 Radiographs of the left stifle of a 17-month-old heifer diagnosed with traumatic lateral patella luxation ( ). (A) Caudocranial view. (B) Lateral view.
treatment given the high value of the heifer, despite the guarded prognosis. Hay was withheld for 36 hours, grain for 24 hours, and water for 12 hours before surgery. Meloxicam at 0.5 mg/kg subcutaneously and sodium ampicillin at 15 mg/kg IV were administered preoperative. After premedication with detomidine at 0.005 mg/kg IV and butorphanol at 0.05 mg/kg IV, anesthesia was induced with diazepam at 0.1 mg/kg IV, ketamine at 2.5 mg/kg IV, and guaifenesin (5%) at 0.5 mg/kg IV. Anesthesia was maintained with isoflurane in oxygen via an endotracheal tube using mechanical ventilation. The heifer was placed in dorsal recumbency with the left hind limb suspended in extension. An attempt at closed reduction of the luxation was unsuccessful. After aseptic preparation of the skin around the stifle, arthroscopic examination of the femoropatellar joint was performed11 to assess joint changes. A 1-cm skin incision was made midway between the femoral trochlear groove and the tibial crest, medial to the middle patellar ligament. The subcutaneous fascia was incised and a 5.5-mm arthroscopic sheath and its conical obturator were inserted angled 45° to the skin in a proximal direction. As synovial fluid flowed from the open stopcock of the arthroscopic sheath, the obturator was removed and replaced with a 4-mm diameter, 18-cm long arthroscope with a 25° viewing angle. After visualization of cartilage, the joint was distended with lactated Ringer’s solution. The patella was viewed lying outside the trochlear groove, lateral to the lateral trochlear ridge. Synovitis was evident as well as full thickness cartilage eburnation of the medial articular surface of the patella and of the abaxial aspect of the lateral trochlear ridge of the femur. Several free, small pieces of cartilage were visualized in the lateral recess (Fig 2).
122
No debridement of the articular cartilage eburnation was performed. The joint was irrigated with 3 L of lactated Ringer’s solution through a 4.5 mm open egress cannula to flush debris from the joint. After arthroscopic exploration, each portal site was closed with USP 0 monofilament polybutester in a cruciate fashion. A 10 cm lateral, parapatellar skin incision was made and the underlying tensor fascia lata muscle was exposed. The lateral femoropatellar ligament and gluteobiceps tendon were transected without invading the femoropatellar joint. The patella was replaced into the femoral trochlear groove with some difficulty. The subcutaneous tissues were sutured with USP 2-0 multifilament braided lactomer in a simple continuous pattern. The skin was closed with USP 0 monofilament synthetic polybutester with interrupted cruciate sutures. A second, 10 cm medial parapatellar skin incision was made and the underlying subcutaneous tissues were bluntly dissected to expose the joint capsule. No attempt was made to reconstruct the medial femoropatellar ligament. The medial joint capsule, the entire length of the patella, was imbricated with 10 interrupted Lembert sutures using USP 5 multifilament braided polyester without invading the femoropatellar joint. The joint capsule was not opened or resected. The subcutaneous tissue and the skin were then closed as described for the lateral incision. Intraoperative radiographs confirmed the patella was replaced in the femoral trochlear groove. The femoropatellar joint was infused with 20 mg of morphine in 10 mL of bupivacaine with an 18 gauge spinal needle at the end of the procedure. Surgical sites were protected with a dressing for the first 24 hours postoperative. Surgery and anesthesia times were 135 and 210 minutes, respectively. Uneventful and unassisted recovery to standing
Veterinary Surgery 45 (2016) 121–124 © Copyright 2015 by The American College of Veterinary Surgeons
Marchionatti et al.
Lateral Patella Luxation in a Heifer
Figure 2 Arthroscopic view of the femoropatellar joint. (A) There is cartilage eburnation over the medial articular surface of the patella (P) and over the lateral trochlear ridge (LTR) of the femur. IG, intertrochlear groove. (B) Several small cartilage fragments are present in the lateral recess of the joint.
occurred 20 minutes later. Sodium ampicillin at 15 mg/kg IV 3 times daily was continued for 3 days and meloxicam at 0.5 mg/kg subcutaneously was administered every 36 hours for 5 doses. Meloxicam was then administered every 48 hours for 6 doses, then every 72 hours for 6 additional doses. Ice packs were applied for 15 minutes, 6 times daily for the first 24 hours after surgery. The heifer was kept in an individual stall (3 3.5 m2) with straw bedding. Daily monitoring included physical examination and limb use at walk in the stall. The heifer was hospitalized for 23 days. The heifer would toe touch (lameness score 4.5/5) the affected limb during hospitalization and increasingly spent more time standing. A severe, disuse muscle atrophy of the affected limb developed during hospitalization and atrophy of the quadriceps femoris muscle allowed slight manual displacement of the patella laterally. Skin sutures were removed 12 days postoperative and the surgery sites healed without complications. Radiographs taken 14 days postoperative confirmed that the patella remained in the femoral trochlear groove. Lameness score at discharge was 4.5/5. The owner was instructed to keep the heifer confined in an individual stall for 3 more weeks, followed by restriction to a small pasture (60 square meters) to allow grazing, free walking, and rehabilitation. The referring veterinarian was asked to perform regular lameness and physical reevaluation of the heifer. At pasture turnout on day 47 postoperative, the heifer remained toe touching with slightly more weight-bearing on the left hindlimb (4/5) and had a body condition score of 2.25/ 5. The lameness improved by day 112 (2/5) and the heifer was completely weight-bearing on the affected limb but still had an abnormal gait. The hyperextension of the right hind fetlock and the disuse muscle atrophy had resolved and the body condition score was improved (3/5). The heifer was placed in a free stall barn with same age herd mates. The heifer calved for the first time on day 229 postoperative. At that time, lameness was almost resolved (1/5) but limited flexion of the stifle was noticed when the cow was lying down. The cow was sold at 184 days in milk, 413 days after surgery, for reasons unrelated to the patellar luxation. After evaluation of the Holstein Canada data sheet for milk production, it was determined that the mature equivalent lactation production of the animal was in
the average range for production for first lactation for Holstein breed.
DISCUSSION This report documents successful surgical treatment of lateral patellar luxation in a large, 437 kg, heifer. Surgical treatment of lateral patellar luxation has been previously reported in smaller cattle, successfully returning the animals to normal ambulation.1,2,5–8 Grade IV patellar luxation requires surgical treatment and untreated patellar luxation leads to degenerative osteoarthritis.1 Surgical treatment for traumatic patellar luxation requires thorough physical examination and radiographic evaluation as findings of femoral nerve paralysis1,2 and severe degenerative joint disease may contraindicate surgery.1,6 Surgical treatment of lateral patellar luxation in cattle includes lateral release of the patella followed by imbrication of the medial aspect of the joint capsule5,6 trochleoplasty,7 use of a prosthetic trochlear ridge,8 or tibial tuberosity medial transplantation.1,6 Trochleoplasty or the use of a prosthesis over the lateral trochlear ridge have been successful for treating congenital cases of shallow trochlear groove and lateral ridge hypoplasia in young calves.7,8 In the heifer reported here, as the luxation was traumatic, the trochlear groove was adequate and trochleoplasty was unnecessary. Tibial tuberosity transplantation is used in dogs to re-establish the quadriceps femoris line of tension and has been reported in a 3-month-old Ayrshire heifer.6 This procedure was not considered given the associated high risk of implant failure and non union reported in heavy cattle and dogs.1,12 The combined lateral release of the patella with medial joint capsule imbrication has been shown to produce a stable repair that preserves the integrity of the major muscles of stifle extension and good long-term success is reported for foals and young calves 1–3 months of age.5,6 The soft tissue release decreases the lateral pull forces on the patella, whereas the medial imbrication of the parapatellar structures helps to stabilize the patella in the femoral trochlear groove. This report shows its application in an older, heavier animal.
Veterinary Surgery 45 (2016) 121–124 © Copyright 2015 by The American College of Veterinary Surgeons
123
Lateral Patella Luxation in a Heifer
Marchionatti et al.
Strict postoperative stall rest for 6–8 weeks was advised to allow strong fibrous tissue formation at the imbrication site and avoid risk of reinjury. Nevertheless, exercise is an important part of rehabilitation after orthopedic surgery to maintain joint function and improve muscle reconditioning. Controlled exercise via hand walking, gradually increasing in duration and intensity, is best combined with stall confinement. This, however, can be difficult in a farm animal setting. The heifer of this report had unrestrained movement in a small pasture starting 47 days postoperative. A more vigilant exercise program during the first 6–8 weeks may have been indicated, although the atrophy resolved within 9 weeks of pasture turnout, the minimum time required to re-establish musculoskeletal tissue strength following complete rest in the horse after orthopedic surgery.13 The heifer was at risk for development of degenerative joint disease, as a result of full thickness cartilage eburnation seen during arthroscopic examination. Pain and progressive joint degeneration may have contributed to the slow recovery. Pain management and control of inflammation with nonsteroidal anti-inflammatory medication are part of the overall management of osteoarthritis. Immediate postoperative pain was managed with the use of intra-articular morphine and parenteral administration of meloxicam. Opioid m-receptors have been identified in synovial membranes of horses and intra-articular morphine can produce effective and prolonged analgesia.14 Meloxicam is approved in the European Union and Canada for adjunct therapy for acute clinical mastitis, dehorning, and calf diarrhea. Meloxicam has preferential, but not specific, binding to cyclo-oxygenase-2 (COX-2) receptors, which makes it less likely to interfere with homeostasis of abomasal mucosa or renal perfusion than less selective COX-2 nonsteroidal anti-inflammatory drugs (NSAIDs). Meloxicam has preferential accumulation within the inflamed joints in dogs.15 Epidural administration of opioids such as morphine would have been another route to provide analgesia,16 although clinical results are varied and maximum effect is no more than 12 hours.16 Therefore, placement of an epidural catheter is necessary to provide continuous analgesia. Followup was restricted to telephone conversations with the owner and the referring veterinarian to assess outcome. Radiographic and ultrasound examination, and arthrocentesis would have provided information on joint function and range of motion, and progression of degenerative joint disease. Despite a prolonged rehabilitation, this heifer had a satisfactory outcome. The cooperative and calm temperament of the animal facilitated the recovery and contributed to the treatment success. The heifer went on to have a healthy calf and a normal milk production. Surgical treatment of lateral patellar luxation can be performed in large cattle but further case accrual is needed to verify the outcome.
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DISCLOSURE The authors declare no conflicts of interest related to this report.
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Veterinary Surgery 45 (2016) 121–124 © Copyright 2015 by The American College of Veterinary Surgeons
