AI-Generated Veterinary Surgery

Kenny

Friday, September 6, 2024 at 8:41 AM

Surgery Note

Description

Kenny, a 4-year-old neutered male mixed-breed dog, was presented for a surgical repair of a ruptured cranial cruciate ligament (CCL) in the left stifle. After confirming the diagnosis through orthopedic examination and radiographs, a lateral fabellar suture (extracapsular stabilization) was elected. Kenny was fasted overnight and admitted the morning of surgery. A pre-anesthetic examination was unremarkable. Anesthesia was induced with propofol and maintained with isoflurane inhalant gas. The affected limb was clipped and aseptically prepared. The procedure was completed without complication. Postoperative radiographs confirmed appropriate implant placement. Kenny recovered uneventfully and was placed on appropriate analgesia. An e-collar was applied, and postoperative instructions were reviewed with the owner at discharge.

Anatomy

Pre-surgical physical exam revealed moderate muscle atrophy and joint effusion in the left stifle. Positive cranial drawer and tibial thrust were present. No abnormalities were noted in the contralateral limb. Cardiothoracic auscultation was normal; mucous membranes were pink with CRT <2 seconds. Abdominal palpation and general neurologic function were within normal limits.

Diagnostic Finding

• Orthopedic exam consistent with cranial cruciate ligament rupture.
• Radiographs showed periarticular osteophytosis and joint effusion in the left stifle, no bony abnormalities.
• CBC/Chemistry panel: within normal limits.
• ECG: Sinus rhythm, no arrhythmias.

Follow-Up

• Kenny was discharged the following day with carprofen (75 mg BID for 7 days), gabapentin (300 mg BID for 5 days), and trazodone (100 mg as needed for sedation during activity restriction).
• The owner was instructed to enforce strict activity restriction for 8 weeks. Short leash walks only; no stairs, running, or jumping.
• Cold compresses advised for the first 3 days, followed by warm compresses. Passive range of motion exercises were demonstrated and encouraged beginning day 3 post-op.
• Recheck appointment scheduled in 10–14 days for incision assessment and suture removal (if non-absorbable).
• A follow-up orthopedic evaluation and radiographs are recommended at 8 weeks to assess healing and return-to-activity planning.
• The owner was advised to monitor for signs of swelling, discharge, decreased appetite, or changes in behavior, and to contact the clinic if concerns arise.