15.2 Gait Evaluation

The evaluation of gait is an important aspect of recovery. Most patients recover in predictable fashion after CCL surgery but the rate of increase in limb use varies based on signalment, chronicity, and type of surgical intervention. Patients undergoing extracapsular stabilization often are nonweight bearing for the first few days after surgery. They tend to remain nonweight bearing for a longer period of time and take longer to regain full limb usage than patients undergoing TPLO or other osteotomies. After 3–5 days, they often are toe‐touching and slowly progress to a weight‐bearing lameness by the second week after surgery. Patients undergoing osteotomy‐based procedures tend to be toe‐touching at a slow speed the morning following surgery. Three to 5 days later, they bear weight consistently at a walk but still display a moderate lameness during weight bearing. By the second week, their lameness is commonly mild.

It is important that the rehabilitation practitioner and the veterinarian have an appreciation for the recovery of gait following any surgical procedure. The appreciation of differences in recovery rate and the regular observation of patients facilitate early detection of complications. Any deviation from anticipated limb use and setbacks in limb use during recovery should raise suspicion of a potential complication and trigger patient reevaluation. In some situations, delays in recovery or limb use setbacks represent a minor complication that requires no further intervention, beyond rest. In other situations, delays in recovery may represent early signs of a major complication where an intervention is warranted.

Several subjective scales and objective parameters can be used for gait evaluation. Various subjective numerical scales ranging from 1 to 4, 1 to 5 (Table 15.2), or 1 to 6 or a visual analog scale (VAS) can be used [13]. For both subjective numerical scales and VAS, the same examiner should evaluate the gait of the patient at each visit and document it in the medical record. The same scale should be used for all evaluations. Objective gait evaluation provides more precise information related to patient recovery and is more reliable than subjective gait evaluation, particularly when the lameness is mild. The agreement between numerical scales, VAS, and objective force plate analysis is low, suggesting that numeric scales and VAS are flawed for the assessment of lameness in dogs [14].

Kinematic gait analysis objectively describes gait by quantifying joint motion, limb segment velocity, acceleration, and deceleration, and angles of structures in space and time. Patients are often fitted with reflective markers and high‐speed cameras are used to capture motion. Kinetic gait analysis involves the use of a force plate to measure ground reaction forces, in particular the peak vertical force (pVF, the largest vertical forced resisted by each limb) and vertical impulse (VI, the product of force and time during each stride for each limb). Both kinematic and kinetic gait analysis are mostly used in research settings and are uncommonly used for clinical evaluation. However, smartphone applications with 2D analysis are becoming more available to calculate joint angles passively (Figure 15.1) and during gait [15].

Pressure‐sensing walkways and weight distribution platforms are emerging as objective tools for patient assessment (Figure 15.2). Pressure‐sensing walkways have been studied to determine normal and abnormal gaits in dogs of various dog breeds [16–20]. Walkways use sensors to calculate velocity, stance time, swing time, stride length, step length, and the total pressure index (TPI). Pressure‐sensitive walkways along with kinematic and kinetic evaluations rely on dynamic weight distribution to detect abnormalities during the gait. More recently, weight distribution platforms have been used to evaluate gait abnormalities in a static manner, when dogs are standing in place. Patients alter their static weight distribution as a result of pain. Even less is known about the shifts in weight distribution that result from limb pain in standing dogs compared to walking or trotting dogs. Weight distribution platforms collect measurements that are as accurate and repeatable as static standing on a pressure‐sensitive walkway [21]. The sensitivity and specificity of weight distribution platforms for the detection of orthopedic lameness have been evaluated in clinical patients, making this method of objective evaluation an emerging consideration during postoperative recovery [22].

The use of objective measures of gait can be incorporated into the postoperative evaluations to confirm continued improvement. While little information is known regarding the range in gains in pressure‐sensitive walkway or weight distribution platforms after various CCL surgeries, rehabilitation clinicians who examine gait and limb use regularly are well prepared to detect a lack of progress in limb use or delayed progress during the recovery period. For dogs enrolled in a formal rehabilitation program, abnormal progress is often suggestive of the presence of a complication.

15.3 Surgical Limb Evaluation

Palpation of the surgical limb is also critical to the detection of potential complications. In the early postoperative period, particular attention is paid to the surgical incision to ensure appropriate healing with no evidence of excessive inflammation, infection, or seroma formation. Variations in surgical technique and intraoperative tissue trauma lead to differences in surgical wound inflammation. Any incision that appears inconsistent with common standards is reported to the group that performed the surgery. A conversation between the rehabilitation practitioner and the veterinarian who did the surgery optimizes subsequent management.

15.4 Range of Motion Evaluation

The rehabilitation clinician should evaluate the range of motion of the stifle joint, the presence of a pain response to flexion and extension, and the craniocaudal and torsional stability of the joint. For example, extracapsular stabilization of a CCL‐deficient stifle joint can fail, resulting in the reoccurrence of stifle instability, detected through a decrease in limb use and the presence of a cranial drawer sign. In contrast, a decrease in limb use in a patient after an osteotomy can result from a failure of plate fixation and tibial plateau rollback. For a patient recovering from an osteotomy, the presence of cranial drawer is expected during the recovery period.

Joint motion is critical to limb use. Therefore, monitoring the motion of the stifle joint throughout recovery provides valuation information. Rehabilitation clinicians should monitor joint motion quantitatively by measuring maximal motion using goniometry and qualitatively by evaluating the pain response to joint motion and the feel at the end of motion (the end feel). Goniometry has been validated in several dog breeds (Table 15.3

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