So good afternoon everyone, and welcome to today's webinar. My name is Eric Valters. I'm a veterinarian and EVS boarded specialist in surgery and orthopaedics, and I'm a proud leader of EIA's medical interest group in surgery and orthopaedics.
I'm thrilled to see so many of you are here. Today's session focuses on something central to our mission early diagnosis of orthopaedic conditions in pets. This is a topic that is incredibly important, not only for us as veterinarians, but of course more importantly for the well-being of our patients.
At any cua, we believe that early detection and intervention are critical to ensure the best outcome for our patients. We can recognise orthopaedic issues in early stages, and it opens the door to more effective treatments, medically or surgical, of course, and finally helps our patients live pain free and healthier. As part of this commitment, Doctor Andreas Hermann will focus on the critical aspect of diagnosing and managing cruciate ligament disease in dogs.
Doctor Hermann will share effective first aid protocols for managing injuries before referral, explore various treatment options, and highlight the importance of accurate assessments in enhancing patient care. Doctor Hermann is a distinguished veterinary surgeon who brings extensive expertise in small animal surgery to the Eiguran network. He earned his veterinary degree from the University of Zurich, where he also completed his doctorate at the Institute of Veterinary pathology.
Doctor Hermann's specialised training includes comprehensive residency programmes at both the University of Zurich and the University of Bern, leading to his board certification as a specialist in small animal surgery. He also holds a certification in every age specialist in small animals, demonstrating his commitment to the highest standards of veterinary care. He has been an integral part of Eura's family serving in multiple locations, 2 locations in Norway, one in Oslo, and also in Tomso, where he contributed his advanced surgical expertise to the Norwegian veterinary community.
Currently, Doctor Hermann serves as a valued member of the surgical team at Enniura Terglingtoun in Switzerland, where he continues to provide exceptional surgical care for small animal patients. I hope today's webinar offers your new insight, practical knowledge, and of course the tools that you can apply in your practise. Together we can make a positive impact on the lives of our patients, ensuring they receive the care they receive the care that they need when it matters most.
Before we start, I would like to take a moment to thank Hills and Doctor Beckley Mullis for their support in making this webinar series possible and their dedication to raising awareness of the import in the importance of proper nutritional management in orthopaedic patients. Doctor Becky is a small animal veterinarian and a board veterinary nutritionist with the American College of Veterinary Internal Medicine. After graduating from the University of Tennessee.
Doctor Mullis completed a small animal internship and a clinical nutrition and residency. She is passionate about educating veterinarians worldwide on the impact nutrition can have on the health of pets, both healthy cats and dogs, and those with health concerns, of course. She is currently working at the Hills office in Switzerland, where she lives with her husband, two young children, and of course Luna the cat.
Thank you all for being here. We are going to make an amazing session again, and please, Doctor Andreas Herman, start with your presentation. Thanks, Eric, a lot for the nice introduction and welcome, everybody.
Good afternoon. We will speak today about cruciate ligament disease. So, we will see why this topic matters a lot.
What's the prevalence importance of cruciate ligament disease. The goals of the talk, as Eric said, are clear diagnostic treatment options, as well as practical tips. The question is, why is everybody talking so much about ruge ligament disease?
It's because it's so common. You see in the numbers here in the table, about 3 to 5% of dogs, they have bred ligament disease. If you look a bit more to the, to the numbers here, you see on the right table, if you get a lame dog, it's fifty-fifty to have a high lameness.
If it's lame in the hind limb, it's quite likely it has, it has a problem in the stifle joint, and there, of course, if you look to the stifle joint more in detail, the ligament disease is quite an often cause of, of lameness. So you, as you said, talk about a little bit aetiology, pathophysiology, imaging, of course, treatment options, what we can do surgically about also about postoperative care. Probably, you know, you all know, the anatomy of the stifle joint.
We have different anatomic structures, and it's important to have a stable joint, which is, which is tight. So the crucial ligaments there are stabiliser of the joint. They're in the middle of the joint, and they are twisting around and making this cruciate pattern.
If you look a little more to the detail, you see different, attachment or wrenching points. Where did the stifle joint, or the ligaments have the the, the course? So the cranial ligament, it's, it originates actually from, from the caudal part of the femur, the, the cale medial aspect of the lateral femoral condyle.
It's it it it hurts ron the inter intercondulate area of the tibia. . We come back again to the function of the crucial ligament.
The caudal one, it's also a stabiliser of the, of the stifle joint and it's more for caudal tibial movement. And usually it's intact if you have a rupture of the cranial crucial and it's, it's, there's no rupture or issue with the caudal one. Another reported stabilise of the diver joint or the menisci.
So, the medial one is more attached to the, to the tibia mostly. And this has an implication of, of getting also damages on the medial menisci and the meniscalia stabilises as well as low distributors like kind of a crushing effect. Another Important key anatomic structure.
Well, it's not a structure, but it's important. It's a TV plateau angle. So that's the angle which the tibia plateau is, is forming.
And the, the higher the angle is, the higher the chance or to have a more mechanical strain on the crucial ligament, which has also implication, regarding, aetiology. There are many ligamentous structures in the joint. So we have the meniscal ligaments which fix the menisci to the to the tibia, but there's also one ligament which fixes the lateral meniscus to the femur, which is also an implication because this makes the lateral meniscus moving along with the femur.
So if there is a quality with rust, it's less likely to have a damage because it moves with the femur. We have seldomly damaged or lesions to the lateral meniscus. The crucial ligaments, as you know, there's a cranial cord one, it prevents the cranial teal thrust, and there are actually two distinct bands.
One is the cranial medial and one is the quail lateral band. Which form in total the product we recommend. Of course, there are also some collateral ligaments which also serve as stabilisers.
And the meniscus as well, we don't go to in detail, but as I said, they're mostly for load distribution and shock absorption. So they also, they are important to have the test for the joint congruently. They convert all the auction load which is transferring to through the joint into the hoop stress and distribute the, the forces.
The crucial ligaments, specifically, they have, of course, different functions as stabilisers, the cranial one is a primary function. It, prevents cranial tibi thrust or cranial tibial translation and hyperextension. And secondary function, it also limits the internal rotation of the tibia.
It has also function for vagus virus, at the caudal one that also limits the internal rotation along with the crucial ligament. It also helps to prevent hyperextension and virus vagus movements. The question is what's actually wrong with the cry crucial ligament.
Is it just too weak? Is it not strong enough? Might be, but more likely is that it gets degenerative changes.
So there is again disorganisation, metaplasia, it loses the tensile strength, it loses its normal structure. So There's a partial tearing and the early phase, it can go also to complete rupture. Joint instability is also one component which we have to take into account because if the chronic ligament weakens or ruptures, it can't longer prevent the chronicivity thrust, the hyperextension or internal rotation.
So there is this leads to synoviti, meniscal damage, and of course, osteoarthritis. And we know nowadays as well that the the inflammation we have to synovial inflammation, it plays a central role in in the progression of, of the disease, and, yes. So from positive factors, of course.
There are some Predisposition, it's not the origin of immune disease. It's, it's just not just one factor. There are different factors, and we know there are some breeds which are predisposed.
We know that the conflammation of the leg or the joint has has an influence about the posture, the TPA, the angle of the TB blood is important, the age. Overweight dogs are also at higher risk, activity level has some influence. And as I said, the inflammation, it's important and, and some studies they even suggest that there is an autoimmunoinflammatory response, which are important in early crucial ligament disease.
So. You know, we now know there is a quite high likelihood to have. Crucial disease in a lame dog, which is just maybe high limb lameness.
So, before having seen the dog, we already know, or we can estimate if it's likely to have the talk of, disease. So might, we can maybe do some hands-off diagnosis just from the numbers and just from the breed, age, sex, duity level. But, still, the, the most important thing is, is not to have the crystal ball and look to it and maybe, see good things in the future.
The most important thing I think is always to do hands-on diagnostics. So, which means in the cranator ligament disease, finding the rupture. So finding the drawer sign, doing the drawer test.
So with the drawer test, we We demonstrate abnormal motion of the stifle joint. And it's not like this stop, it's doing, it's, it's like this. So we need to figure out if there is not, if there is increased motion or abnormal motion in the stifle joint.
If it's positive, then we can already say there is a rupture or there, there is at least a disease of the ligament. If it's negative, it's less likely, but still a partial tear might be still possible. Of course, that's quite black and white and sometimes it's not so easy to have to do a good blood test.
It depends also from, from the size of the dog. If it's a large breed dog and it's really tense in the muscle, it can be quite difficult sometimes to do a proper drawer test. Keep in mind that It's, it's also wise to repeat the draw test at different angles, so inflexion, extension, because mostly because the, the different bands of the peculal ligament, they are differently taught inflexion extension to the one is taught inflexion and extension and or the latter one it's taught extension, but lacks inflexion.
And of course, for me, The drawer test is one important test, but for myself as a, also as a teal surgeon, the TB compression test is the second test we need to do for a for assessment of the stifle the ligaments. So the key orthopaedic findings, if you do a proper orthopaedic examination is to draw test, the TB compression test, the CIT test. Also keep in mind that the CIT test itself, it's not completely indicative for ru ligament disease because for me it's an indicative for stifle joint pain, so.
The dog sit like this because they would like to release or relieve the joint, so they, they hold the leg in the front. Joint diffusion sometimes also be difficult to feel, those depends from the firm. So, for example, but you can, try to have a, have a feel that the patellar tendon or paraatellar region, then usually you, you can feel some increased synovial fluid.
Med blood transformation it's something I, I, also have a look. It's that's a firm swelling on the medial aspect of the sinal joint. And, and in more chronic ones, you can feel this hard swelling and that's, it's it's a sign of chronic instability because the in plen ligament disease, the, the loosey joint tries to stabilise and makes this.
Soft tissue build up at the middle aspect of the stifle needs to click. Sometimes you can hear it, sometimes you can feel it. It's for sure indicative for its injury, but it's, it also in mind sometimes osteoarthritic changes or new boneflammation can also lead to crepitation or kind of a click.
For, for diagnostics, . Often X-rays are a first diagnostic step. We cannot, we can't visualise the, the ligament, but it gives, gives us a clue because we might see joint diffusion bit better.
We can compare it, to the, to the contralateral side. Usually, it's seen when, when you see, more, more wooden joint when the fat pad is pushed to cranu. And also try to changes.
At the region of the patella, the femoral procle, you see some new bone formations, and you can compare with the other joint. And if the sty joint has these changes, there is something going on. So it might be negative for, for chronic ligament disease.
In severe cases, of course, then you have subluxation, it's quite clear, then you see. The femur is too much caudal or too much cranary and this it's indicative also for, of course, of rupture of the ligament. That's how it can look like in a dog with with a ruptured ligament.
You see on the crinocoal one, there is some more soft tissue swelling on the middle aspect of the tibia. You see some, new bone formations at the pel on the latter view. So this gives us also a clue about, what's going on in this type of joint.
For diagnostic, ultrasound possible. I do it sometimes for visualising the, the ligament, but also for the meniscite, but it's for sure not a standard procedure because it's, it, it needs some experience to have a look on the joint with the, with the ultrasound. Computer tomography or other advanced cross-sectional imaging, can give us some help in cases it's where it's not clear, so where you think there might be a crucial ligament disease, but it's not a standard case, but of course computergraphy it's not, always viable.
But that's how it can look like. You see on the, on the statutory, picture on the right, there is someization. This dog has had, a large ligament.
And that's what the same applies to MRI. That's the gold standard for, for non-invasive, imaging or soft tissue regulation. And it's a question you quite, we get quite often if you can do MRI, of course, we Probably can I see the crucial ligament as well as the meniscus like in humans, but I think usually there is no need for MRI because my my hands are enough to, to diagnose the, the rupture of the ligament.
Arthroscopy is a diagnostic tool as well as a therapeutic tool. We usually perform arthroscopy the same, in the same session like we do the TP or the TTA, and it's for me, kind of the gold standard because when I see the ligaments, I can evaluate if it's ruptured or not. I can have a look on the meniscus, I have a good visualisation, but of course, that's not commonly viable for, for all the people.
That's how it can look like you see you from cranial to the to the intercondulate area. The probe is kind of hooking into the ruptured fibres and then you see this . Sometimes these drumsticks formation when the fibre are already a little bit lump from the inflammation.
If you speak about diagnosis, there are many differential diagnosis specific to the, stifle or nearby. We won't go into details, but of course taloxation, OCD lesion, can be a differential, carnemus muscular tendipathy which can mimic the five limbs. There, there are some differential diagnosis, but still crucial ligament disease is still the.
The most common cause of of spinal pain. Management, treatment options. We have always the, the, the option of quantitative treatment.
A surgeon like to cut, but there are other ways. I mean, if you speak about quantitative management, you can do it in small breed dogs. There's a number of under 15 kg, but I think, it can also be tried in larger dogs, cats, as well.
If it's a partial tear or it's a, if it's a dog, it, it has not high activity level and the core components of positiveative treatment, it's pain management, it's physical therapy, weight management, of course, and also optosis can be tried. There are different supplies of optosis which gives some stability. Because the goal of consultative treatment, it's, it's improved the comfort and the function.
It's maybe to avoid, but I think mostly to delay surgery and to encourage the, the fibrous stabilisation of the joint, which, which will, will happen. There are limitations and it's, I think it's important to, to do, to do a good client communication because it has to be a realistic . The gold standard, I think it's to go for surgery, but it can be tried and if it's not working with quantitative treatment, there's still the option for, for, for surgery.
Treatment options It looks like a big table, and that's why there's a, it's a channel of different surgery techniques. So it's not so easy probably for, for non non surgical skilled vets to, to have an overview over all the techniques. I think that's not necessary.
I think it's important to, to keep in mind there are different techniques. Nowadays, the osteotomy technique, I think it's the Most reliable techniques, the TPR TTA as well as the CCWO, there is, there are the extra couple of techniques which is the last suture, which is still done quite often. It can work quite good and the intercoal techniques, that's a little bit different story and there are new, new systems coming up, but there is more, more data necessary.
So. Of course, I put Gillows first because I'm a GP surgeon. The goal of the tibial, so the tibial tibial plateau levelling osteotomy is to neutralise the cranno tibial thrust.
That's, what's happened in, in the rupture ligament. So we, we changed the tibial plateau angle to more or less 5 to 6 degrees. We do a radial cut of the proximal tibia, turn fragment and we fix it with a, with a plate.
So, The the, the ligament is still ruptured. So after the surgery, the drawer test is still positive because the ligament is ruptured. But the TB compression test, it has to be negative cause that's how the dog is walking.
It's, it's standing on the pole and the forces are transmitted with tier joints, so that gives us the stability, so that's neutralising the ronal tibial to us. There are. Potential complications like infections.
Sometimes we see the patellar ligament thickening, which might be a reason for, for a continuous, lameness or painless stifle, but usually the, the outcome is quite good to excellent. So over 90% of dogs, they're walking normally after, after a certain time, after the rehab. TGA, it's a little bit different technique.
We do, frontoplastectomy. We don't change the TB plot the angle. We change the patellar tendon angle to 90 degrees, which also, reduces or ates the, the vector force in the joint, so it makes it stable again.
And also the TTA it has a good to excellent outcome if most dogs walking good. The CCWO, that's a technique which is more reserved I think for excessive TPA. We want to go into detail, it's a little bit different osteotomy technique in the cranial aspect of the tibia.
I think the more common technique that's the, that's the latters. So it, it forces the joint from outside the capsule, the joint capsule to be stable. And of course this huge with, with thousands of steps, it, it will get loose, but in that time, the body has also the chance to build up all the fibrosis tissue which for long term gives the stabilisation at the end.
And the outcome, I think it's good. Most dogs do quite well, but I think it's still a little bit, I would go for T or the osteotomy techniques if I could choose, if I could really choose all the techniques. Meniscal treatment during such, I think it's, it's important.
We have to look on the menisca because they can be damaged at the same time and then if there is a damage, we won't treat it after, after the crucial ligament surgery, it will stay lame. So it's important to have a look and to exclude a meniscal damage or to treat it. So what if it's not standard, because not all the stifled joints, they all the textbook, nothing there is where it gets interesting.
So if you have a dog with a really excessive T to angle, we can't just do a tepilo because we need to turn a lot and we have a high forces on the implants, . So we have other options like the CCWO we can combine the T with with a core base collection, but it needs quite a careful preop preoperative planning in a good case selection. What if the dog has a combined ligamente disease and elation, which can arise sometimes in a small breed dogs, crucial ligamune disease can also make a pal luxation worse because if there is more internal rotation, it pulls the patella more to the medial limb.
So we can combine this, this, . These problems and then address both at the same time. And with Tlo it's quite easy because we can just at the level of just we can kind of translate the proximal fragment or the this one to to lateral.
What about if a dog has a bilateral crucial ligament disease? That's not that rare. Of course, usually they are chronic ones, so 11 staff is more affected clinically, but there are occasions.
A dog has really, severely, severely instability in both hind legs and both stifle joints, and they can't even walk anywhere, walk anymore. They're sometimes referred to as, as paraplegic neurotic cases. The thing is, if a dog is really bad, you usually we try to do stage surgery because it's a bit mean to go for both joints the same, same session.
But it's possible to do. So you can do simultaneously, address both types like see on these images, we did about half a year ago. So we, we did the TTA the same day, and, it was, was good to do.
What about in young dogs? So if you have, if you get a young dog, which has, which has, positive draw test, it's clearly unstable. Keep in mind that, there might be an avulsion fracture of the attachment or origin site, because the young bone is more soft and truly recommend this.
Still quite strong, so it's possible that you have an original fracture and you have the same findings in the, in the orthopaedic exam. So what you can do is you can try to fix the urgent site of the, the attachment site, which is usually quite difficult because These are small bony fragments and you can try to put a pin or a screw inside, but that's, that's not easy. I usually try to do the proximal tibi physodesis, which, which is still on the X-ray.
So you put a screw in the cranial part of, of the epiphysis in the growing dog, it's still growing in the caudal part. So it's kind of a tillo effect, so you're changing. To give you plateau angle because it's still growing in the causal respect and it gets it gets less.
What about in cats because cats, cats are different. They do what they want and also the stifle of cats. Usually, they have traumatic events.
And usually if a cat has, stifle disruption, there are multi-ligamentous injuries, including the cruise ligaments, collateral ligaments, as well as menisci. And it needs to stabilisation. And you can do this with prosthetic ligaments to replace it.
Sometimes that's not enough, and you also need to add some external stability for like the fixator or there's also a pin. I usually, I usually try to, to fix the joint temporarily with a pin going through the femur and the tibia because then I have my neutral position fixed and I can. Build up all the prosthetic ligaments.
What about the three leg patient? So if you have an amputee, of course, then you have less, compensation or option for compensation with the other leg. And, the leg which, which has, rupture has increased mechanical load.
I think that's the case. I would not go, for example, for, for extra caps repair. I would like to, to make it, really stable, and that's why I would go for a foster toy techniques.
So post-op, that's, I think even at least as important as the surgery because the rehabilitation, it's, it's, it's critical for the management. It should focus on pain, physiotherapy, mobilisation. And for me it's usually 3 months.
I say the owners, 3 months of rehab are realistic. So, it's important to try to avoid stairs at the beginning, at the beginning, slippery surfaces, walk the dogs on the leash. Exercise measurement is important, and of course, you need to recheck the removal of the stitches, doing X-rays to see if everything is OK.
From, from the long term outcomes, generally, with most of the search techniques, it's good to excellent. So, after one year, most of dogs, they are not lame anymore. They have, regardless of the technique.
The osteoarthritis usually it's still progressive and it's also regardless of the technique. But it might progress faster in the exoapsular repair because I think it's, it's, it's a different, method of stabilisation the joint. So there's maybe a little bit more progression of the osteoarthritis.
Poliminary meniscal tear, so that's when, when the meniscus is, is intact during the surgery, but it gets gets damaged afterwards, can occur usually within the 1st 6 months postoperatively, if an incidence of, between 3 and 25%. So if a dog gets lame, so it has a good course after the surgery, it's working fine, but all of a sudden it gets lame again. Think about meniscal tear.
And they also think about low grade infection because that's, that's the two main reasons why the dog is initially doing fine and he gets lame again. And also the recent studies that showed that the meniscular release, which tries to prevent a postliminary meniscal tear, is probably not the best thing to do regarding prevention, but it's still done quite a lot. So the key take home messages from, from this talk, I think.
There are things you probably already know that. Chronic diseases, it's progressive. It's a degenerative condition.
It's, it's not a traumatic event and that's, that's the main difference compared to the human field. Hands-on examination is the most important diagnostic tool. Your hands, my hands are the most important thing to diagnose ligament disease.
But still, the radiograph they can support it can't replace, but they can give us some indication and, and, and the clinical suspicion. Such stabilisation, even there is, there is the option for, for quantitative or medical treatment. I think it's a gold standard, so that's also the difference to the human field because of many reasons, the TPAO TA or other stabilisation techniques, I think that's the gold standard.
Consultative treatment is still positive for selective cases. It's very individual, but it can be tried. It's important to have a good communication with the clients because they need to know what they can expect with or without surgery.
And, and, and I think it's also good to, to speak a lot or a lot to speak good to the owner regarding the origin because most of the owner, they think it's a traumatic, but it's not. And then that's I think it's important to discuss with the clients. We have some special cases like, like a short like the amputees or the geriatrics, it's individual, but they still benefit from stabilisation, but that's the decision making process.
It's a matter of, of case selection and which we need to do. So thank you very much for your attention. I hope you enjoy it and that's just a picture from, from not in the phone now, but that's where we do, that's where we are doing surgery too.
Thank you very much. OK, so we're gonna expand on one of the kind of more medical management aspects of orthopaedic disease, and that is weight management. So there's a lot of things we can talk about when we talk about surgeries, what we do before and after, but weight management is something that I think is important to really understand what we need to do for these patients.
So many of them are gonna come in overweight or obese. With 50 to 30% of pets being overweight or obese globally, there's a good chance that orthopaedic patients you are diagnosing. Are going to have excess body weight.
And one problem is pet owners may may not be aware their pet is even overweight at that point, and they're probably not asking you about their pet's weight. So this is a great opportunity for us to start proactively talking about weight. We have a reason to talk about it, so it makes it a little bit of an easier conversation for us to have with the pet owners.
It's also important to remember that fat is biochemically active. While it doesn't take much in the way of energy to maintain body fat, it is producing pro-inflammatory cytokines, acute phase proteins, and can result in this low grade chronic infla inflammatory state in the body. So it's something that we really want to promote an ideal body weight.
In addition, we have many increased health risks associated with obesity. Osteoarthritis is more likely, I think in the last portion of this lecture, we mentioned courses on the cruciate ligament, potentially resulting or contributing to cruciate injuries. But depending on cat dog, there's lots of different concerns we can have associated with obesity.
Now, when we look at surgical evaluation, having these pets being obese or overweight can complicate that workup process and also add additional risk during surgery. So physical examination may be more difficult, that abdominal palpation, palpating lymph nodes, that can be more challenging. Diagnosis, Taking samples can be more challenging.
And then when you actually get to the surgery, drug dosing can be more challenging, or operating times can be longer. While we're talking more about dogs today, I think it's important to point out that anaesthetic risks may also increase. There was one study saying that heavier cats, many of them may be obese, or maybe some larger breeds in this population, but are 2.5 times more likely to die under anaesthesia.
So it's something even before surgery, we can think about getting these pets to a healthy weight. So, when we set up a healthy weight plan, it can be either before or after surgery, or maybe if you're doing conservative management for these conditions, it's important to think about what your goals are at each time point. So, the main steps are going to be the same whether you're starting before or after, and even if it's before surgery, you can also get some of this started to avoid excess weight gain in the immediate recovery period.
So the 3 things you're gonna look at dietary history, identifying their ideal body weight, or the optimal body weight for that pet. Creating an optimal or appropriate feeding plan, and then monitoring that weight loss. So we're gonna start with just the dietary history.
This is the first step. If you don't have a diet history form you're using in your clinic, the World Small Animal Veterinary Association has a great free download on their website you can use. It's something that pet owner can fill out, so you can determine how many calories that pet is eating.
Are they a pet with a very low metabolic rate? They need very few calories every day, or are they just being grossly overfed? And that may help that conversation and planning with the pet owner.
I love to send these home with pet owners to bring back because they can actually look at the bag of food and accurately write down what they're feeding. Now, once we have that, it's really great to look at what their ideal body weight is. My favourite tool is the Hill's Body Fat Index chart.
And the reason I really like this, it was developed with the University of Tennessee. So there's a lot of DEXA scans looking at body fat in these dogs. But it really helps for those very obese pets.
So it actually has pictures and descriptions at each% body fat interval, at 10% intervals. So you have characteristics, and once you figure out if it's 40% body fat, 50, 60 or 70, you can take the current weight, use the chart, and quickly identify what that pet's ideal body weight should be. It can be done in the exam room.
There's not lots of calculations, so it's really easy to identify that quickly. And in a busy day, that can be a huge time saver. But once you have that weight, you use that ideal weight in this calculation to determine its resting energy requirement.
So looking at those calories needed for basic biologic functions. So this is what I use for a starting point for weight loss. In dogs, I typically am starting around a resting energy requirement for weight loss.
In cats, they tend to hold on to excess body fat and eat a little less calories, so I start at 0.8 times the resting energy requirement. But having that dietary history can also influence this.
If they are grossly overfed, maybe we don't have to go so far down to get them to lose weight. But if you know they're already being fed around RER and we're a dog, maybe we need to drop down even further. The next part is looking at what kind of food should I feed.
Do we stick with what we were fed before, or do we switch to a weight loss dietetic or veterinary food? And so here's just an example, if you wanted 400 calories, you can see. From a maintenance food, just a wellness product versus a weight loss food, we're gonna be getting higher protein, higher levels of minerals, vitamins, other essential nutrients to maintain that pet.
So if you have 1 or 2 kilogrammes to lose in a larger breed dog, You probably don't need a dietetic or a therapeutic weight loss food, but if we have significant weight to lose, or what that pet has very low energy requirements, a dietetic food or therapeutic food is so crucial to maintain their nutritional. State. So there's actually been a publication, it was an abstract presented in nutrition conference several years, but they actually looked at what would happen if we used the maintenance food for weight loss.
And what they found was that several amino acids were frequently deficient. If you have deficiencies in amino acid, which are the building blocks of protein, we may have trouble maintaining muscle mass in these pets on a weight loss plan. So it's important to remember that.
And then you can also have different vitamin and mineral deficiencies show up. When we look at a dietetic weight loss food, there are several features we frequently recognise. They typically have higher protein, higher fibre levels, they have a higher caloric density.
They may have L carnitine to help shuttle, fatty acids into the mitochondria burn that fat, and then antioxidants and fish oil. The other thing you can also see in some of these dietetic foods, especially metabolic, we use a technology called Neutrogenomics. We actually looked at how different ingredients and nutrients affect gene expression, which you can see in this little bow tie shaped, image up top.
So there's different gene expression we see in obese pets versus lean pets, and that has to do with Cell function and metabolism in that pet. So overweight pets have more pathways being expressed associated with inflammation, insulin resistance, decreased appetite control, glucose metabolism, and healthy pets, it's the opposite. So by using neutrogenomic technology, we can actually start pushing.
The pet's metabolism from resembling an overweight pet towards a healthy pet metabolism. So it's a unique way to add additional support to these pets undergoing weight loss. The other thing I'll say about metabolic is we actually did a study where pets at home didn't even know they were going on a weight loss plan.
They were just given feeding amounts and 88% of the pets in that study lost weight at home. So it just shows you how effective the right food can be in supporting these patients on a weight loss programme. You wanna make sure that the pet owners feel like they are doing something and making a difference.
They don't see weight loss, they may stop that weight loss plan. In addition to weight loss, we want to make sure they maintain that ideal weight for as long as possible. So in some of our controlled studies, we actually saw that after they lost weight, their body conditions still continued to improve during the weight maintenance phase.
So they actually, the pets, cats and dogs continued to lose body fat and gain lean body mass during that maintenance phase. So there is a benefit of making sure they maintain that ideal weight and on an appropriate food. The other thing, when we're talking about orthopaedic issues, is weight loss has been shown to improve gait.
So as little as 6 to 10% weight loss can result in improvements in mobility. And for example, cruciate surgeries, having a food with high levels of fatty acids included in the food. That may also help improve weight bearing even sooner than dogs without that fish oil.
So a lot of great benefits nutrition can have for these patients. So just overall, overweight pets can have additional health risks or anaesthetic risks. Addressing food intake around the time of surgery can help avoid weight gain during periods of exercise restriction, and using those dietetic or veterinary design weight loss foods can really help them safely lose weight, and get them feeling better and more active again.
So thank you. Thank you, Becky. Thank you, Andreas.
Amazing, and thank you for your presentations and I received several interesting questions I would like to address. First of all, it's Andreas. On stem cell therapy and yes.
Could you, let us know what is known about stem, stem cell therapy in non-surgical, as a non-surgical option for cruciate disease. That's, it's a very interesting point. There are different, options for stem cell therapy.
What, what we usually, many people call us stem cell therapy is, it's not generally used in the veterinary field, but that's usually with mesenchymal stem cells. Of course, there is an increased demand for autobiologics like, autologous condition plasma, the, PRP. What you're using on a regular basis, .
There is, is different evidence if it's working also in the, in the human field, there are different studies, and there are different, of course, many, many different options to inject, PRP for example. But to come back to the question, stem cell therapies is, is used in very specialised, institutions. We don't do usually regularly do it, but it has some potential for the future.
Yeah. OK. Thank you very much.
Other question, was sent on conservative treatment. To what extent you would, rest. Your patient, would you recommend to create rest, and only, well, let the patient out there for toileting or just limit the amount of, activity, concerning jumping and running and also for how long?
Usually I think it's good also to go for a time period of 6 weeks. So we would keep the dog on the leash. I think it's still good they, they walk on the leg.
I think it's not necessary to do cage rest, but it also depends from, from the amount of instability. So if, if there is one which has of course, a really stable stifle joint. Well, I would probably not go for cogitive treatment, but if it's just for a partial tear, I think it's not necessary to go for chest.
I think it's OK to limit the activity for to leisure walk and to reduce, reduce the time or the distance to go for walks. Yeah. And you already mentioned it because Michelle was asking about partial tears and treatment on that, which you already recommend surgical treatment in a certain phase of partial tear, or would you say, well, recommend, a lot of treatment like conservative.
That's a very good question. I would go for surgical, surgical option. Cause it's a matter of time.
If the, the, the time we see or we diagnose the, the crucial ligament disease. There is already a time before. That's why we see the changes on the X-ray, the osteoarthritic changes.
There's a history. And if there is, if the ligament is diseased, it will get ruptured completely. So it's still more difficult to diagnose, but they will still go for surgery.
Yeah. Yeah, nowadays, I think what I also hear from other surgeons it's quite common to already treat common tears surgically. In the past, we, we did, yeah, just wait and, choose more often for conservative treatment.
I mean, the question is, the question is always, in a small dog with a partial tear if we benefit from a lot to suture, which also forces, . The joint, but if it's stable, if the dog, benefits from from the suture, but that's still controversial, I think, yeah, yeah. Thank you very much.
So partial TS and we go for surgery and then we have another question by David. If TPO does not eliminate raw or sign, then why is it considered superior to other treatment methods, LV Lhase and dro? I didn't get the question completely.
You asked, if TPO does not eliminate the drawer, the positive drawer, why is it considered superior to other surgical techniques? Because drawers, if the drawer sign, it's . It's diagnosis for having a ruptured ligament.
But the TV compression test, that's dynamically how the dog is walking. So by, by, all the forces acting from the tars or from the paw to the hip joint, the TV compression test is, it's more, natural, to test the, the stability of the joint. Yeah, so I don't expect after the, the, the draw test to be positive, to be negative because there is still no ligament, but we changed the stability, we changed the confirmation, we, we add some stability to the joint.
Yeah. Yeah, yeah, thank you very much. And then a question on PRP from Doty to ask.
Do you ever use PRP? Yes, we use it, for, for many joints, not not only for stifle. What I think it's a little bit controversial is if you do arthroscopy or articular, if you have opened up the joint.
I usually try not to inject directly because if there's some holes, I think it's just the PRP it's really something, valuable. So if I have photoroscopy holes, which which is huge, of course, which is close, but some of the PRP I think it's, it's running out of the joint I think. Sometimes it's, it's better to wait, some time and then inject it, when, when it has healed already.
Thank you very much. And maybe Rebecca would like also to add something on this question on PRP and if it can reduce osteoarthritis. I mean, I, I think also, I mean, having those fish oils are really nice.
I mean, when it's actually working in the joint, it's actually helping to down regulate enzymes that are breaking down cartilage. So I think it has some biochemical action, but it's also anti-inflammatory. So I think having that in the joint, and it's not an instant fix, I mean, having that long term in the joint at the right level is going to be important.
But I think based on all the analysis, fish oils are one of the, when it comes to supplements, are one of the leading ones to help with pain control and Function for those joints. Always more research coming out, but I think as of right now, that's the, the leading recommendation. It's nice food.
Some dogs take capsules better than others. So I think having it in the food makes it an easy way to ensure it happens every day. All right.
Thank you very much. And last and final question, also maybe for Andreas, but also for you. Any recommendation on preventing or decreasing osteoarthritis of the TPLO?
Well, difficult. I think it's a good question. I think.
I think still having the dog in a good condition, . It's, it's the best prevention we can do, so keeping good range of motion, keeping good muscles. Maybe trying still not to go for too much for high force motions or activity.
But by the fact that it's a degenerative disease, I think it's not something we can really avoid, but maybe we can delay or we can, having a dog in good condition also, during the time of surgery, I think it makes a healing process much quicker. Yeah. All right.
It was the last question. Thank you very much for your presentations. It was super amazing and thank you all for joining today's session.
We hope you find the insights valuable and the help, of course. With your day to day practise in the clinics and if you'd like to revisit any part of the presentation or share it with your colleagues, the full session will be available on demand in the next 24 hours. And as we conclude this final webinar in our orthopaedic series, I want to express our gratitude to the more than 2000 veterinarians from across Europe who have chosen these sessions for their continuing education.
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Wish you a great day. Bye. Thank you.
Bye bye. Bye bye.
