Today, clients have access to seemingly unlimited information about veterinary medicine. With the availability of internet search engines, social media groups, and now AI, clients have many resources beyond their veterinarian. By the time I consult with pet owners as a specialist, they often have a diagnosis or partial diagnosis from their primary care veterinarian. For elective cases, there is often time between the initial information provided by their primary care veterinarian and the consultation with me, allowing the client to research the diagnosis and potential treatment. When a client has researched a diagnosis and/or treatment prior to a consultation, this can allow for a more comprehensive discussion, as the client already has some knowledge about the condition. If the client has obtained information from less reliable sources, their understanding of the diagnosis and treatment recommendations may be unrealistic. Diagnosis and prognosis Sometimes, a diagnosis requiring surgery is reasonably straightforward—a single large cystolith. Other times, a seemingly straightforward diagnosis is more complicated. Cranial cruciate ligament (CCL) injury is a very common condition seen in a surgical referral practice. Sometimes the diagnosis is relatively easy to make, especially when a complete rupture of the ligament is present. Partial or incomplete tears can be trickier to diagnose. When a patient has concurrent conditions, these should be taken into consideration when formulating a treatment plan and discussing a diagnosis with the client. Consider the prognosis for a five-year-old Labrador retriever with a recent, partial CCL injury. The prognosis for this patient will likely be different from that of a 10-year-old Labrador retriever with bilateral chronic cruciate ligament injuries and radiographic evidence of osteoarthritis. These concurrent conditions are important to recognize as they will play a role in surgical recommendations, expectations, and possibly the recovery from the procedure (Figure 1). When discussing a diagnosis and prognosis with a client, this information needs to be acknowledged and discussed. These are the intricacies and nuances about complex surgical cases that cannot be learned in a weekend course, wet lab, or lecture, but are critical to recognize. It is important to have conversations with the client about the pet’s history, complete a thorough physical examination, and not allow tunnel vision when making recommendations. Figure 1. Preoperative radiograph demonstrating multiple orthopedic abnormalities requiring comprehensive evaluation and surgical planning. Photo courtesy Dr. Kendra Freeman Surgical options Sometimes there is a single surgical option for a given diagnosis, and sometimes multiple options are available. As the veterinarian recommending a procedure, it is important to do your best to provide the client with the most reasonable options for their pet. The client needs to understand the potential advantages, disadvantages, and limitations of the options. In general practice, this may be a conversation about traditional ovariohysterectomy vs. ovariectomy vs. ovarian-sparing spay. If you are a nonspecialist in a general practice offering orthopedic procedures, the client should be informed of procedures you offer in your clinic (extracapsular stabilization for CCL injury) vs. what options may be available from a traveling specialist or referral to a specialty hospital (tibial plateau leveling osteotomy [TPLO], tibial tuberosity advancement). The clients should be informed about potential advantages and limitations of each option, not just differences in cost and travel times. For more advanced procedures, detailed discussions about surgical options may be left to the specialist performing the procedure. Clients who are informed about reasonable options can make decisions that best fit their pets. I urge everyone not to pass judgment or make assumptions about which surgical option a client will select. I’m often surprised by which clients are interested in a total hip arthroplasty for hip dysplasia and which clients elect femoral head and neck excision. Again, with options reasonably explained, the clients will ultimately make the decision that best fits their family. Anesthesia A common concern expressed by clients is about general anesthesia. They may have had a previous bad experience, or the patient has a tricky diagnosis or comorbidities that may increase the risk of anesthetic complications. Overall complication rates related to anesthesia are reported to be 10 to12 percent in dogs and cats, with anesthetic deaths much lower and reported to be <1 percent.1 Perianesthetic complications for brachycephalic breeds have been recorded in up to 49 percent of these patients.2 Acknowledgment of individual patient’s needs, ability to tailor an anesthetic plan for an individual patient, and diligent monitoring in the perioperative period are key to minimizing potential complications. Setting client expectations for anesthetic recovery is also important. After an orthopedic surgery, how quickly is the pet expected to be able to walk? What is their appetite likely to be? How long until a bowel movement is expected? These are common questions from clients and are best addressed prior to the surgical procedure to help set expectations in recovery. A question often asked during our surgical consultations concerns the patient’s age. It is easy to say that age is not a disease but a consideration, but what does that really mean? Instead of using the patient’s chronological age, we may better serve our patients and clients by considering their frailty. Frailty is a state where the body has a limited reserve and increased vulnerability to external stressors.3 We can evaluate this in our patients by looking at tolerance for activity, body condition, mobility, and muscle mass. An older (geriatric) patient that maintains a healthy weight, reasonable mobility, and minimal comorbidities can be a good candidate for anesthesia and surgery. A geriatric patient with recent, unintentional weight loss, poor muscle mass, and decreased energy requires a different conversation and client expectations for surgery. It does not mean the latter patient cannot successfully undergo an anesthetic event. It means additional treatments, diagnostics, medication selection, and perioperative care may be beneficial. Recovery The length of recovery after a surgery varies with the type of procedure performed. An uncomplicated soft tissue surgery, such as a cystotomy, has a much shorter recovery time than a TPLO surgery. Ensuring the client understands the length of recovery is important. The clients should understand how the pet’s activity needs to be regulated, whether bandages are involved, and how the incision should be protected (Figure 2). Figure 2. Example of a post-operative bandage with poor owner and patient compliance. Photo courtesy Dr. Kendra Freeman In our practice, the two consistent points of contention are the use of an Elizabethan collar and activity restriction. After a TPLO procedure, I ask for eight weeks of strict activity restriction with leash walks starting two weeks after surgery. The activity restriction plan is discussed in detail, and expected challenges are discussed and troubleshooted ahead of surgery. Despite this previous conversation during the consultation, a written expectation, and detailed review of discharge instructions with the client at the time of post-operative discharge, we recently had a client call two days after a TPLO surgery to report their dog was feeling great and wondered if they could let the dog have free access to the house and yard. Incisional complications Complications of incisional healing may include inflammation, infection, seroma formation, and dehiscence. Perioperative factors can help mitigate some of these risks–ensuring incision is made into healthy tissue, when possible, appropriate tissue handling, and suture selection. The client also has a responsibility in helping the incision heal. Most incisions need protection–either from the environment in the form of a bandage, or from the patient in the form of licking prevention. While the Elizabethan collar is likely the most reliable, alternatives can be effective and help increase client compliance. In our hospital, providing clients with at-home alternatives, such as surgical suits and inflatable collars, has increased client compliance (Figure 3). Figure 3. Inflatable collars are good alternative to a rigid plastic Elizabethan collar and can help improve client compliance and patient recovery. Photo courtesy Dr. Kendra Freeman. Clients often seek information about their pet from a variety of sources, some of which are more reliable than others. During the consultation, it is important to set aside adequate time to perform a thorough physical examination, review diagnostic findings, and answer the client’s reasonable questions. This dedicated one-on-one time before the procedure helps build trust, reinforces the veterinarian-client relationship, and encourages the client to become an active participant in their pet’s care and recovery. Ensuring both the veterinary team and the client share a clear understanding of the diagnosis, treatment plan, expected recovery, and potential complications helps establish realistic expectations and promotes better communication throughout the surgical process. Well-informed clients are often better prepared to recognize normal postoperative changes, identify potential concerns early, and adhere to discharge instructions, ultimately improving patient outcomes. Kendra Freeman, DVM, MS, DACVS (Large Animal/Small Animal), is a graduate of Colorado State University and maintains dual certification with the American College of Veterinary Surgeons. Dr. Freeman is an associate surgeon in Albuquerque, N.Mex. Her caseload consists of orthopedics, general soft tissue, and sports medicine cases, with occasional returns to her roots in large-animal lameness and surgery. References Gaynor, J. S., Dunlop, C. I., Wagner, A. E., Wertz, E. M., Golden, A. E., & Demme, W. C. (1999). Complications and mortality associated with anesthesia in dogs and cats. Journal of the American Animal Hospital Association, 35(1), 13-17. Gruenheid, M., Aarnes, T. K., McLoughlin, M. A., Simpson, E. M., Mathys, D. A., Mollenkopf, D. F., & Wittum, T. E. (2018). Risk of anesthesia-related complications in brachycephalic dogs. Journal of the American Veterinary Medical Association, 253(3), 301-306. Peron, Frank and Hoummady, Sara. (2020, November 25) Canine Aging and Frailty. Royal Canine Academy. https://academy.royalcanin.com/en/veterinary/canine-aging-and-frailty
