Effective communication between general practitioners (GPs) and veterinary orthopedic surgeons is crucial for smooth case management and the best patient outcomes. However, miscommunication, incomplete referrals, and unclear follow-up responsibilities can lead to delays, frustration, and less effective care.

Take, for example, a dog with a CCL rupture. If referral notes lack high-quality imaging or joint stability test results, the surgeon may need additional diagnostics, which can delay surgery. Similarly, if post-op instructions are unclear, the GP may find it difficult to manage rehabilitation and pain.

By improving referral processes, information sharing, and follow-up protocols, veterinarians can collaborate more effectively, enhancing both surgical success and long-term patient care.

In this article, we will explore practical steps to improve collaboration, simplify workflows, and ensure better orthopedic outcomes for veterinary patients.

TL;DR

• Make referrals clear and complete – Provide a concise referral summary, attach high-quality imaging and lab results, and clearly state the reason for the referral to avoid delays.
• Perform essential pre-referral diagnostics – Take proper X-rays (multiple views, high quality) and run basic lab tests (CBC, chemistry, joint fluid analysis if needed) before sending the case.
• Communicate effectively with specialists – Use structured referral letters, make direct calls for urgent cases, and confirm that all records are received before the consultation.
• Clarify post-op responsibilities – Read and follow discharge instructions, ensure consistent messaging to the client, and know when to escalate concerns.
• Manage client expectations upfront – Discuss costs, timelines, recovery process, and potential complications before referral to prevent misunderstandings.

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Effective Referral Communication

Make referrals clear and simple to improve patient care.

Include a Clear Referral Summary

Don’t just forward a stack of medical records – write a concise referral letter or use a standardized form. Summarize the patient’s key history, physical exam findings, relevant test results, treatments given (with outcomes), and your diagnosis or differential diagnoses.

Also clearly state the reason for referral (what question or service you need from the specialist). This focused approach ensures the surgeon quickly grasps the case without sifting through unnecessary details.

Attach Relevant Documents

Provide copies of important lab results and diagnostic images (e.g., radiographs) with the referral letter. Ensure x-rays are high quality and properly labeled. Including this upfront prevents duplication and delays, allowing the specialist to plan the next steps without waiting for more information.

• Example (for TPLO cases): Include pre-operative radiographs (craniocaudal & mediolateral views), joint stability test results (cranial drawer and tibial thrust test), and CBC/biochemistry panel results to assess surgical readiness.
• Example (for Hip Dysplasia cases): Submit pelvic radiographs (VD extended view under sedation), PennHIP or OFA evaluation reports (if available), and any prior conservative management history (NSAID use, physical therapy, or weight management interventions).
• For Any Orthopedic Surgery: If a CT scan, MRI, or arthroscopy findings exist, sharing those with the referral will significantly improve pre-surgical planning.

Be Clear and Concise

Format the referral letter for easy reading—use headings or bullet points for sections like “History,” “Findings,” “Diagnostics,” “Treatments,” and “Referral Request.” Ideally, keep it to about 1–2 pages of focused information.

Avoid long narratives or illegible handwritten notes, which are common mistakes that frustrate specialists. Clear, well-organized information helps the receiving surgeon understand the case quickly and communicate effectively with the client about next steps.

For example, a GP once faxed over 15 pages of progress notes for a chronic limping case without a summary. The orthopedic surgeon nearly missed the detail that the dog had a prior ligament surgery on that leg, which was buried in the records.

Solution: Always include a summary letter highlighting crucial history (e.g., past surgeries, medications) and the specific question for the specialist. This ensures critical details aren’t overlooked in a sea of records.

Pre-Referral Workup & Diagnostics

Do basic tests before sending patients to specialists.

Complete Basic Imaging

Perform the necessary imaging before making a referral to streamline care. For orthopedic cases, this typically involves high-quality X-rays of the affected limb or joint, with at least two different views. Sedate the patient if needed to get clear images.

Sending these images to the surgeon ahead of time allows them to assess the injury and plan for possible surgery during the initial specialist visit, rather than just performing diagnostics then.

Run Relevant Lab Tests

Include recent blood work and other important tests in the referral package. For example, a CBC/chemistry panel (and urinalysis for older patients) is often recommended before orthopedic surgery. If there's a chance of infection, consider joint fluid analysis or culture and include those results. Providing this information ensures the specialist has everything needed and won't have to repeat tests, saving the client time and money.

• For routine orthopedic surgery (e.g., TPLO, hip replacement): A CBC/chemistry panel is essential to check for underlying conditions that may affect anesthesia or healing.
• For older patients or those with systemic disease: Include a urinalysis and thyroid panel (T4), especially in geriatric cases or breeds prone to hypothyroidism.
• If infection is suspected (e.g., septic arthritis, osteomyelitis): Submit a joint fluid analysis (cytology) and bacterial culture to confirm the presence of infection before surgery.
• Example (for a dog with suspected immune-mediated polyarthritis): Provide joint fluid cytology from at least three joints to help differentiate from infectious arthritis.

Avoid Unnecessary Delays

Don’t spend too long trying to perfect the workup if it's clear a specialist is needed. Perform the basic diagnostics you can, then refer promptly. Delaying a pre-referral workup too much (or referring without any workup) can both be issues.

Aim for a balance: address straightforward tests (like X-rays for a fracture or blood tests for surgical candidates) but know when to pass the case on.

Share Everything Pertinent

Make sure all diagnostic results are sent. Missing records or images can delay treatment—if the surgeon doesn’t have the radiographs or lab results at the consultation, they might need to repeat them. Double-check that the referral hospital received the files (many have an email for sending radiographs and labs).

For example, we have seen a dog with intermittent lameness referred to an orthopedic specialist without any X-rays. The specialist had to schedule the dog for imaging on a later day, frustrating the owner and delaying diagnosis.

Solution: Always take and send initial radiographs for orthopedic cases. Even if the images aren’t definitive, they provide the surgeon with a starting point. In this case, if the GP had provided X-rays, the surgeon could have assessed them and possibly proceeded with advanced imaging or treatment during the same visit, speeding up care.

Collaborative Case Discussions

Talk with specialists early to get the best advice.

Consult Early and Specifically

If you're unsure about an orthopedic case or need advice, contact the specialist for guidance. Many orthopedic surgeons are open to discussions with referring vets and may provide phone or email consultations as a courtesy.

When reaching out, prepare a brief case summary and specific questions to focus the conversation (e.g., "Given these X-ray findings, do you recommend referral for surgery, or can we manage conservatively for now?"). This focused approach respects the specialist's time and provides more helpful advice.

Use the Right Communication Channel

Choose your communication method based on the urgency of the case. For urgent or emergency orthopedic issues (like open fractures or sudden neurological problems), call the surgeon or specialty hospital directly and mention that the case is urgent.

For non-urgent questions or updates, an email with details or an online referral portal can be effective, allowing the specialist to respond between surgeries. If you don't receive a timely reply and the matter is urgent, follow up with a phone call.

Keep an Open Dialogue

Maintain open lines of communication throughout the case. After you refer the patient, you might have additional questions or new information (e.g., a lab result that came in later) – promptly update the surgeon.

Likewise, if the specialist notes something (like an incidental finding or a client concern) that you might help with, be available to discuss it. This teamwork approach ensures continuity of care. Remember, teleconsulting tools (even sending images digitally or having a quick virtual meeting) can facilitate veterinarian-to-specialist communication when distance or schedules are an issue.

Know When to Escalate

If a communication breakdown occurs – for example, you’re not hearing back about a critical case – don’t hesitate to escalate appropriately. You might contact an alternate specialist at the practice or even a practice manager if needed.

Timely, direct communication can prevent small misunderstandings from becoming big problems. As a referring vet, you are the advocate for your patient and client; it’s okay to politely push for information or clarity when the pet’s well-being is on the line.

Scenario (Specialist Consultation): A general practitioner suspects a cranial cruciate ligament tear in a dog but isn’t 100% sure. They email an orthopedic surgeon with the case details, asking if referral for a TPLO surgery is warranted. After two days with no response, the GP notices the dog’s condition worsening.

Solution: In cases where timely advice is needed, call the specialist’s office rather than waiting on email. In this scenario, a quick phone call identified that the email had gone to spam; once connected, the surgeon reviewed the case and advised immediate referral for surgery. The lesson is to choose the fastest communication method for urgent questions – a phone call can avert delays for a deteriorating patient.

On the flip side, for routine advice, scheduling a phone consult or sending a concise email (and confirming receipt) can get you valuable guidance on next steps without an actual referral, strengthening collaborative care.

Post-Surgical Coordination

Work together after surgery for a smooth recovery.

Obtain and Read Discharge Instructions

After the orthopedic surgeon treats the patient, such as performing surgery, make sure you receive a discharge summary or report. This should include details about the surgery, any findings during the operation, medications to continue, restrictions like exercise or bandage care, and the follow-up plan.

Review this information carefully as soon as you get it. If you haven't received a report by the time the pet returns to you, call the specialist to obtain it—never guess the plan. Clear documentation from the surgeon is essential for you to continue care properly.

Clarify Follow-up Responsibilities

Discuss with the surgeon and the pet owner who will handle different parts of the aftercare. Often, the general practitioner will manage tasks like suture removal, bandage changes, routine rehab exercises, or follow-up lab work, while the specialist might want to see the patient for recheck exams or follow-up X-rays at specific intervals. Make sure these roles are clearly defined.

For example, confirm if the surgeon will re-evaluate the pet 6–8 weeks after surgery for radiographic healing, or if you should take X-rays and send them over. Having this plan in writing prevents confusion for everyone involved.

Synchronize Messaging

It's important that you and the orthopedic surgeon provide consistent advice to the owner. Reinforce the surgeon's instructions when the pet returns to you. If the surgeon said "Crate rest for 4 weeks," emphasize that same message at each GP visit.

Any changes or concerns about the plan should be discussed between vets, not by giving the owner different instructions on your own. Consistency prevents the common issue of "but my regular vet said I could start walks earlier," which can undermine trust or the pet's recovery.

Stay in the Loop on Progress

Good communication goes both ways—the specialist should keep you updated on the patient's progress, and you should inform them if there are any complications or questions during recovery. For example, if the surgical site looks inflamed during a bandage change, let the surgeon know right away and perhaps send a photo.

Early communication about concerns allows the specialist to guide you on interventions, like adjusting medications or seeing the patient sooner. This teamwork ensures any post-op issues are handled efficiently.

Plan for Emergencies or Complications

Before the patient leaves the specialty hospital, make sure you know how to contact the surgeon or facility if an emergency happens (during or after hours). Share this plan with the client and ensure your clinic staff is aware of it.

For example, if the dog re-injures its leg or has a drug reaction, should the owner go directly to the ER at the specialty center, come to you, or call first? Discussing these options in advance prevents panic and wasted time if something goes wrong.

Scenario (Post-op Follow-up): A cat has a complex orthopedic surgery at a referral center. A week later, the owner visits their GP for a check-up and to ask some questions. However, the GP hasn’t received any discharge notes and doesn’t know that the cat has external pins that need weekly cleaning.

Solution: The GP’s office immediately contacts the orthopedic surgeon to get the discharge instructions, which include pin care and a schedule for pin removal. Moving forward, the GP now calls the specialty hospital on the day of surgery to get a briefing on the outcome and expected aftercare.

This scenario highlights the need for proactive communication: don’t assume you’ll automatically receive all the information—sometimes you must actively seek it to ensure smooth post-surgical care.

Client Communication & Expectation Management

Explain the referral process clearly to clients.

Introduce the Idea of Referral Properly

When you decide to refer, explain to the pet owner why a specialist is the best choice. Discuss the specific expertise or advanced procedures the orthopedic surgeon can offer (for example, “Tibial Plateau Leveling Osteotomy for your dog’s knee”).

Present it as teamwork: you're involving a colleague to provide the best care for the pet. This helps the client understand that you're not "handing off" their pet, but rather adding a specialist to the care team.

Set Realistic Expectations

Prepare the client for what will happen at the referral. Let them know the specialist may repeat some tests or take new images to get the most accurate information—this helps prevent frustration if diagnostics are redone.

Provide a general idea of the timeline: for instance, an initial consultation might take a few hours, and surgery (if needed) could be the same day or later. If the pet might stay overnight or longer, mention that.

Also, discuss recovery time and effort: for example, "After surgery, expect several weeks of restricted activity and possibly rehab exercises—it's not an instant fix." Setting these expectations helps prevent misunderstandings about the recovery process.

Discuss Costs and Logistics Upfront

Be honest about the potential costs of specialty care. While you might not have an exact amount, you can provide an estimate or range for advanced imaging or surgery based on past cases. Clients appreciate knowing the financial commitment so they aren’t surprised by the specialist’s estimate.

Additionally, assist with logistics: provide the referral hospital’s address, phone number, and any instructions (e.g., fasting before the appointment if sedation might be needed for imaging).

Whenever possible, your clinic can help make the appointment for them or at least advise on how to schedule it. Owners feel more comfortable when you guide them through the process (e.g., “We’ll send over all of Max’s records and X-rays, and the surgeon’s office will call you to set up a time. Here’s what you should bring with you…”).

Maintain Client Trust During the Handoff

Reassure the owner that you’ll stay involved and informed. Explain that after the specialist evaluation, you will communicate with the surgeon about the findings and plan. Clients often worry they’ll "lose" you once they go to a specialist, so let them know you’ll be there for follow-up and will receive updates.

Encourage them to ask questions during the specialist consultation, but also invite them to call you if they need help understanding any recommendations. This teamwork approach can greatly boost the client’s confidence in the referral process.

Avoid Over-promising

It’s natural for pet owners to ask, “Will my dog be 100% better after this surgery?” or “Is this going to fix the problem permanently?” Be honest that while the surgeon will do their best and most pets improve, no procedure is guaranteed. Discuss the prognosis in terms of probabilities or ranges (“There’s a very good chance of significant improvement, though minor lameness could persist”).

Also, discuss possible risks in a balanced way (not to scare them, but so they aren’t surprised if a complication occurs). By managing expectations, you prevent the scenario where an owner is unhappy despite a clinically good outcome, simply because they expected a miracle.

Scenario (Client Expectations): A GP referred a Labrador with elbow dysplasia to a surgeon, describing the procedure to the owner as a “routine arthroscopy” and assuring them the dog would be running normally soon. The owner expected a quick recovery. In reality, the dog needed more extensive surgery and months of rehab, leaving the client surprised and upset.

Solution: The GP should have prepared the client with a more cautious outlook. For example, they could explain that the specialist will determine the best course of action, which might be arthroscopy or another intervention, and that elbow problems often require significant rehab. Additionally, the GP could mention the range of recovery times, such as “some dogs heal in a few weeks, while others need a few months of therapy.”

By providing a realistic picture ahead of time, the client would have been mentally and financially prepared for the longer journey. The key is to inform without inflating expectations, so the client stays committed to the treatment plan rather than feeling misled.

Common Pitfalls & Solutions

Avoid common mistakes to make referrals better.

Incomplete or Unorganized Referral Info

Important case details can be lost when a GP sends only raw medical records or a brief note. This can leave the specialist unsure of why the pet was referred or what has been done so far.

Always include a structured referral letter that highlights the main points, such as history, findings, diagnostics, treatment, and the referral request. Many specialty centers provide referral templates to ensure nothing is missed; if not, a one-page summary is much better than 20 pages of records without context. Clear and concise communication from the start prevents confusion and helps the surgeon quickly understand the case.

Missing Diagnostics at Referral

The specialist may not have access to previous test results or imaging, leading to redundant testing or delays. For example, if a blood test or X-ray was done at the GP but those results were not forwarded, the specialist might have to repeat them or delay treatment.

Solution: Double-check that all relevant lab results, radiographs, and other test reports are sent to the referral hospital (and received) before the client’s appointment.

It’s a good idea to give the client copies as a backup. By providing a complete diagnostic workup in advance, you streamline the specialist’s process and avoid wasting time re-running tests the GP has already done.

Poor Indication of Case Urgency

Sometimes, a referral is made through routine channels for a case that actually needs immediate attention, causing a delay that harms the patient. The specialist might not realize a case is an emergency if it's not clearly communicated.

Solution: If a case is urgent (like a compound fracture or suspected septic joint), call the specialist right away and inform them of the situation. Mark any written referral or email as "URGENT" and provide context (e.g., "fracture – pain not controlled, please see ASAP").

Most surgeons will accommodate true emergencies, but they need to be informed. Quick, direct communication can prevent unnecessary deterioration while waiting.

Lack of Ongoing Communication

After a pet is referred, the GP might completely step back and not stay informed, or the specialist might fail to update the GP. This gap can leave the primary vet unaware of treatments given, or the client receiving mixed messages.

Solution: Keep a feedback loop open. The specialist should send a summary of findings and treatments promptly after the consultation or surgery. If you don't receive one, reach out and request an update.

Similarly, when the pet returns to your care, inform the specialist about the patient's status, especially if any complications arise. Continuous communication ensures everyone—GP, specialist, and client—stays informed about the pet's care.

Client Left in Confusion

The pet owner may not know who to contact for specific issues or might receive different information from the GP and the specialist. For example, the client might call the GP about a post-surgery issue when the surgeon actually wanted to handle those calls, or vice versa. This miscommunication can lead to frustration and even mistrust.

Solution: From the beginning of the referral, clarify the roles: The specialist will address the specific issue and inform both the client and you of the plan, while you will handle routine care and act as a liaison. Encourage clients to keep both your contact information and the specialist’s, and assure them they can reach out anytime.

Also, show a united front—when clients see their GP and surgeon communicating and co-managing smoothly, it boosts their confidence. Clients especially appreciate when their questions are answered and their veterinarians work together; simple follow-ups (even a quick call to the client after the specialist visit) can greatly enhance their perception of care.

Unaligned Expectations or Instructions

A common mistake occurs when a client expects something unrealistic, like an outcome, cost, or timeline, or when home-care instructions aren't clearly communicated, leading the owner to unintentionally stray from the plan (e.g., letting the dog exercise too soon).

Solution: Use preventative communication. Before the referral, align expectations by discussing likely costs and recovery scenarios. After the specialist visit, make sure the client has heard and understood the discharge instructions—have them repeat key points to you, or follow up in a day or two to check in. If you notice any confusion or if the plan is complex, provide a written summary or handouts.

By anticipating misunderstandings and addressing them proactively, you can avoid issues that might affect the pet’s outcome. If something does go wrong or not as expected, timely and honest communication among the GP, specialist, and client will help resolve the situation quickly.

Conclusion

In conclusion, improving communication between general practitioners and orthopedic surgeons is key to better patient care and efficient treatment. By ensuring clear and concise referral communication, conducting necessary pre-referral diagnostics, and having collaborative case discussions, healthcare providers can make the referral process smoother.

Moreover, effective post-surgical coordination and managing client expectations are important for a smooth recovery and maintaining trust. Avoiding common mistakes through proactive communication and organization strengthens the partnership between general practitioners and specialists, benefiting the patient and enhancing overall healthcare outcomes.

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Why Nutrition Matters in Orthopedic Recovery

Nutrition plays a key role in how well a dog recovers after orthopedic surgery or injury. Bones, joints, muscles, and soft tissues all need the right nutrients to heal properly. Without enough protein, vitamins, and minerals, healing slows down and the risk of complications goes up.

Inflammation is common after surgery. Some foods can help reduce it naturally, like those rich in omega-3 fatty acids. At the same time, proper nutrition supports tissue repair, keeps muscles strong, and helps rebuild cartilage around joints.

Supplements can help, but they don’t replace a balanced diet. For example, giving glucosamine is useful, but it won’t work if the dog is eating low-quality food that lacks protein or key vitamins. Recovery works best when supplements are part of a complete nutrition plan, not the only solution.

Start with the Basics: Weight and Diet First

Importance of Weight Management

Keeping a healthy weight is one of the most important parts of orthopedic care. Extra weight puts more stress on joints, especially the knees, hips, and spine. For dogs recovering from surgery, even a few extra pounds can slow healing and increase pain.

Obesity is strongly linked to many joint problems, including arthritis, cruciate ligament injuries, and hip dysplasia. The more weight a dog carries, the harder the joints must work, leading to faster wear and tear. In overweight dogs, surgeries like TPLO or joint replacement often have slower and more difficult recoveries.

Helping a dog reach or stay at a healthy weight reduces this stress and improves mobility. It also lowers inflammation, which supports healing. Even small weight loss—just 5–10% of body weight—can make a big difference in how a dog moves and feels after orthopedic treatment.

Key Nutrients in an Orthopedic Diet

A strong orthopedic recovery starts with a diet that supports healing tissues. Protein is the most important building block—it helps repair muscles, tendons, and bones. Dogs healing from surgery need more protein than usual, especially during the first few weeks post-op.

Calcium and phosphorus are key for bone strength. They must be given in the right ratio, especially in growing dogs, to avoid bone problems. Vitamins like C and D support collagen repair and calcium absorption. Omega-3 fatty acids from fish oil can reduce inflammation in joints and help with pain.

But more isn’t always better. Over-supplementing can throw off balance. For example, too much calcium can lead to bone disorders. It’s best to provide these nutrients through a balanced, high-quality orthopedic or joint-support formula unless your vet recommends extra supplements. Good food is the foundation; supplements should fill gaps, not replace meals.

Supplements That Work: Backed by Veterinary Use

When used with the right diet and weight control, certain supplements can support healing and reduce joint pain. Here are some of the most commonly used and well-researched options in veterinary orthopedic care.

1. Omega-3 Fatty Acids (Fish Oil)

Omega-3 fatty acids, especially EPA and DHA from fish oil, are powerful anti-inflammatory agents. They help reduce joint swelling and improve mobility in dogs with arthritis or post-surgery stiffness. Studies show they can lower the need for pain medications over time.

Common sources include salmon oil, sardine oil, and anchovy oil. Veterinary-grade products are more purified and properly dosed compared to grocery store options. The usual dose is based on body weight, and your vet can guide you to avoid over-supplementation. Fish oil is often the first supplement added to a recovery plan because of its safety, long-term benefits, and ability to work well with other treatments.

2. Green-Lipped Mussel (GLM)

Green-lipped mussel is a natural anti-inflammatory that comes from shellfish native to New Zealand. It contains omega-3s, amino acids, and antioxidants that work together to ease joint pain and stiffness, especially in dogs with osteoarthritis.

GLM is often found in vet-recommended joint products and is considered safe for long-term use. Research shows it can improve comfort and mobility in both older dogs and those recovering from orthopedic surgery.

Unlike synthetic drugs, GLM has fewer side effects and provides a gentle way to support joint health. It's not a cure, but when used consistently, it may lower the need for pain meds and improve quality of life over time.

3. Glucosamine and Chondroitin

Glucosamine and chondroitin are among the most widely studied supplements for joint care in dogs. They support cartilage health, reduce inflammation, and may slow the breakdown of joint tissues. Many vets include them in post-op recovery plans or for long-term management of arthritis.

However, results vary. Some dogs show clear improvement in stiffness and mobility, while others don’t respond as well. The biggest benefits are seen with consistent use over at least 6–8 weeks.

These compounds work best in early to moderate joint disease, not as much in advanced cases. While not a magic fix, they’re still a go-to part of many joint support protocols because of their long safety history.

4. MSM (Methylsulfonylmethane)

MSM is a sulfur-based compound found in plants and animals. In orthopedic patients, it's used for its anti-inflammatory and pain-relieving effects. MSM helps reduce joint swelling and may ease muscle soreness, which is useful after surgery or injury.

This supplement is often paired with glucosamine and chondroitin for added support. It also plays a role in building healthy collagen and connective tissue, which are key during the healing phase. MSM is generally well-tolerated and safe for long-term use.

While more research is still needed, many veterinarians recommend it as part of a combined joint supplement, especially when managing pain without heavy use of NSAIDs.

5. UC-II (Undenatured Collagen Type II)

UC-II is a unique form of collagen that works differently from other joint supplements. It targets the immune system and helps reduce the inflammation that causes cartilage breakdown. Instead of adding building blocks like glucosamine, UC-II trains the immune system to stop attacking joint tissues.

This can be especially helpful in dogs with immune-driven joint problems or chronic arthritis. Some studies suggest it may work better than glucosamine in certain cases, especially for dogs who haven’t responded well to standard supplements.

UC-II is usually taken in small doses and is often combined with other anti-inflammatory agents. It's a good option for dogs needing extra immune-based joint care.

6. Avocado/Soybean Unsaponifiables (ASUs)

ASUs are a mix of natural plant extracts made from avocados and soybeans. They work by slowing cartilage breakdown and blocking enzymes that damage joint tissue. Though not as common as other supplements, ASUs have shown promising results in both human and veterinary studies.

They’re often included in high-quality veterinary joint products along with glucosamine or chondroitin. ASUs are best used when the goal is to protect cartilage and delay further joint damage.

They may also reduce pain and improve mobility in long-term joint conditions. While not a first-line supplement, they offer extra support for dogs with ongoing joint stress or after major orthopedic surgery.

Natural Options Gaining Interest

Alongside traditional supplements, some natural compounds are gaining attention for their potential to support joint health. While the research is still developing, these options may offer gentle support when used carefully and under veterinary guidance.

1. Turmeric (Curcumin)

Turmeric contains curcumin, a natural compound known for its anti-inflammatory effects. Some studies and reports suggest it may help with joint pain and stiffness in dogs, especially those with arthritis. However, curcumin has poor absorption in the body unless combined with other ingredients like black pepper extract.

Many pet supplements use enhanced formulas to improve effectiveness. While it’s a promising option, the results are mixed and more research is needed. Still, turmeric can be a helpful addition to a complete joint care plan when properly formulated.

2. Microlactin

Microlactin is a dried milk protein from cows, known for its anti-inflammatory properties. It works by blocking white blood cells that contribute to joint inflammation and tissue damage. While it's newer compared to other joint supplements, early research and some clinical use suggest it may help reduce pain and improve mobility in dogs with chronic joint issues.

It’s often used as a secondary supplement for dogs who don’t fully respond to traditional options. So far, it appears safe and well-tolerated, but long-term studies are still limited.

3. CBD Oil for Joint Pain

CBD oil has gained popularity for managing pain and anxiety in pets, including dogs with joint problems. Some owners report better mobility and reduced stiffness. Early research also supports its potential anti-inflammatory and pain-relieving effects. However, there are concerns around safety, correct dosing, and product quality.

Veterinary-approved CBD products are best, and you should always speak with your vet before starting. While it shows promise, CBD should never replace proven treatments and should only be used as part of a supervised care plan.

4. Vitamins C & E for Joint Health

Vitamins C and E are antioxidants that help protect joints from damage caused by free radicals. They don’t rebuild cartilage or stop inflammation directly, but they support overall tissue health. In orthopedic recovery, these vitamins may help reduce oxidative stress around healing joints.

Most dogs get enough of these nutrients from balanced diets, so extra supplementation is usually not needed unless advised by a vet. When used, they serve more as add-ons rather than core treatments for joint disease or post-surgery care.

What Often Doesn’t Work (or Needs Caution)

Not all joint supplements are effective—or safe—when used without proper guidance. Many products on the market make big claims but offer little real benefit, especially when not chosen carefully.

Here are common mistakes to avoid:

• Generic or low-quality supplements: Many over-the-counter joint products lack proper testing or use low-grade ingredients. They may contain less active compound than listed or have poor absorption, making them ineffective.
• Overuse of single-ingredient products: Giving high doses of one supplement, like calcium or glucosamine, without balancing it with other nutrients can cause more harm than good. It may lead to imbalances or worsen certain conditions.
• Delaying supportive care: Waiting until a dog is in severe pain or has lost mobility can limit how well supplements and nutrition work. Early support gives the best long-term results.

Supplements are most helpful when started early, chosen with care, and combined with a full recovery plan. Always consult your vet before starting anything new—what works for one dog may not suit another.

How to Choose the Right Supplements

Choosing the right joint supplements for orthopedic care isn’t just about picking a popular brand. The quality, dosage, and how the supplement works with your dog’s overall plan all matter.

Here’s what to focus on:

• Vet-recommended or clinically tested brands: Look for supplements that have veterinary backing or are used in clinical studies. These are more likely to be safe, effective, and properly dosed.
• Absorption and dosage form: Some supplements work better in liquid or chew form because they’re easier to absorb. Powder-filled capsules may not break down well, especially in sick or older dogs.
• Purity and quality control: Choose products made by trusted companies that test for contaminants like heavy metals or fillers. Avoid supplements without clear labels or dosage guidelines.
• Part of a full plan: Supplements work best when used alongside proper diet, weight management, and physical therapy. They are not magic cures on their own.

Talk to your vet to make sure the supplement fits your dog’s condition and recovery stage. Personalized support is always better than one-size-fits-all.

When to Start and How to Monitor Progress

Starting nutritional support and supplements early in the recovery process gives the best chance for healing. The goal is to reduce inflammation, protect joints, and support tissue repair before damage becomes severe. In many cases, waiting too long can limit how well these therapies work.

Early intervention helps to:

• Reduce swelling and stiffness after surgery
• Support faster healing of bones and soft tissues
• Delay or prevent long-term joint damage

Once supplements are started, it’s important to track your dog’s progress over several weeks.

Watch for signs of improvement like:

• Better mobility or ease in getting up
• Less limping or stiffness after rest
• Reduced need for pain medication

Keep a simple journal or video log to track changes. If there’s no clear improvement after 6–8 weeks, or if your dog gets worse, it’s time to re-evaluate the plan. Your vet may recommend changing the supplement, adjusting the dose, or focusing more on diet and physical therapy.

Every dog is different—regular check-ins help keep the recovery on track.

Always Work With Your Veterinarian

Supplements and nutrition can play a big role in orthopedic recovery, but they should never be used without your veterinarian’s guidance. Every dog is different. Age, breed, diagnosis, weight, and other health issues all affect which supplements are safe and effective.

Your vet can build a personalized plan that fits your dog’s specific needs. For example, a dog recovering from TPLO surgery may need different support than one with chronic arthritis or hip dysplasia. Vets also help choose the right product, dosage, and timing for each stage of recovery.

Monitoring is just as important. Some supplements can interact with medications or cause mild side effects like stomach upset. Your vet can spot these early and make changes if needed.

Veterinarians also work closely with rehab professionals. Together, they balance nutrition, medication, and physical therapy to support healing. This team approach helps avoid delays, reduces pain, and improves long-term joint health.

In short, the best results come when supplements are used as part of a full veterinary-guided plan—not in place of one. Always keep your vet in the loop.

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FAQs

Do joint supplements really work for dogs with orthopedic issues?

Yes, joint supplements can help reduce inflammation, support cartilage, and improve mobility in dogs with orthopedic conditions. Results vary, but many dogs show benefits with consistent use. They work best when started early and combined with proper diet, weight control, and veterinary care.

Which supplements are best for arthritis in dogs?

The most commonly used supplements for arthritis include glucosamine, chondroitin, fish oil (omega-3s), and green-lipped mussel. UC-II and MSM are also helpful in many cases. Always choose vet-recommended products and use them as part of a complete management plan.

Can I give multiple supplements together for better results?

Yes, many joint formulas combine ingredients like glucosamine, MSM, and fish oil for a more complete effect. However, combining different products on your own may lead to overdosing. Always check with your vet before giving multiple supplements together.

When should I start my pet on joint supplements?

Start supplements at the first sign of joint issues or after orthopedic surgery. Early support can slow down joint damage, ease pain, and help your dog recover faster. Some vets even suggest starting in high-risk breeds before problems begin.

How do I know if a supplement is high quality and safe?

Look for veterinary-approved brands with clear ingredient labels and dosing instructions. Choose products that have undergone purity and safety testing. Avoid supplements without proper certification or those with vague claims. Your vet can recommend trusted options based on your dog’s needs.

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Early and accurate referrals are crucial for the best outcomes in veterinary orthopedic cases. Delayed or incorrect treatment can lead to chronic pain, joint instability, and reduced mobility, greatly affecting a patient's quality of life. General veterinarians need to know which conditions can be managed with non-surgical methods and which require surgery.

Some common orthopedic issues that need referral include:

• Cranial cruciate ligament (CCL) tears
• Hip dysplasia
• Patellar luxation
• Fractures
• Severe osteoarthritis

While some cases may improve with medical treatment, physical therapy, or weight management, others need surgery to restore function and prevent further joint damage.

In this guide, you will learn how to identify surgical versus non-surgical cases, helping veterinarians decide when to refer a patient to a board-certified orthopedic specialist.

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TL;DR

• Timely referral for orthopedic surgery improves outcomes. Delays can lead to chronic pain, joint instability, and reduced mobility.
• Know when to refer vs. manage conservatively. Surgical cases include CCL tears, hip dysplasia, severe fractures, and progressive neurological deficits, while mild conditions may respond to rehabilitation.
• Functional assessment matters more than imaging alone. Pain scoring, gait analysis, and range of motion tests help determine surgical need beyond X-rays or CT scans.
• Conservative management includes NSAIDs, weight control, physiotherapy, and PRP therapy. Some conditions improve with rehab, but worsening signs indicate the need for surgery.
• Financial transparency helps owners make informed decisions. Comparing surgical vs. non-surgical costs, explaining long-term benefits, and offering financing options can ease financial concerns.

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Recognizing Signs of Orthopedic Issues

The most common early signs include lameness, stiffness, pain when touched, and reluctance to jump or move. These symptoms may develop gradually or appear suddenly, depending on the underlying condition.

Acute vs. Chronic Signs

Acute orthopedic conditions, such as fractures or ligament tears, often show up with sudden, severe lameness, swelling, and pain. These cases usually need immediate intervention, often surgical.

On the other hand, chronic conditions like hip dysplasia or degenerative joint disease develop over time, with occasional stiffness, reduced activity, and increasing discomfort.

Knowing whether a condition is acute or chronic helps decide if conservative management or surgical correction is needed.

Breed-Specific Predispositions

Certain breeds are more prone to orthopedic issues. For example:

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• Labradors and Rottweilers often suffer from cranial cruciate ligament (CCL) tears.
• Dachshunds and French Bulldogs are at high risk for intervertebral disc disease (IVDD).

Large breeds like German Shepherds frequently develop hip and elbow dysplasia, which requires early assessment for intervention.

Behavioral Changes Indicating Pain

Dogs and cats often show subtle signs of discomfort before lameness becomes obvious. Restlessness, excessive licking of joints, difficulty rising, or a stiff, altered gait can indicate underlying orthopedic pain. Some animals may become withdrawn or irritable, avoiding play and interaction.

Recognizing these signs early allows veterinarians to start appropriate diagnostics and decide whether the case can be managed conservatively or needs surgical intervention.

Assessing Pain and Function: Objective vs. Subjective Measures

As a veterinarian, you need to use both objective tools and subjective clinical observations to assess pain levels, mobility, and joint function.

Pain Scoring Tools

Objective pain assessment scales help standardize evaluations and track a patient’s response to treatment over time. Two widely used tools include:

• Glasgow Composite Pain Scale (GCPS): A structured tool that assesses vocalization, mobility, response to touch, and demeanor to determine pain severity.
• Canine Brief Pain Inventory (CBPI): A validated owner-reported questionnaire that measures pain intensity and its impact on daily activities.

These tools enhance consistency in pain assessment, aiding in treatment decisions.

Functional Assessment

Assessing lameness, weight distribution, and joint mobility helps determine whether a case requires surgery or can be managed without it:

• Weight-bearing vs. Non-weight-bearing Lameness: Non-weight-bearing lameness usually indicates severe joint instability, fractures, or ligament tears, which often need surgical correction.
• Range of Motion (ROM) Evaluation: Limited ROM, crepitus, or pain during manipulation suggests joint degeneration or soft tissue injury.
• Observation on Different Surfaces: Walking on slick floors, stairs, or uneven ground can reveal subtle mobility issues that might not be noticeable on smooth clinic floors.

Pain Tolerance Variability

Pain perception differs based on breed, size, and individual factors. For instance, Labradors and Rottweilers might endure significant pain before showing signs, while toy breeds often show discomfort sooner. Larger breeds can also compensate for lameness longer due to their muscle structure, delaying detection.

By combining pain scoring with functional assessment, veterinarians can decide when to manage conservatively or refer for surgery.

Diagnostic Tools and Techniques: Functional vs. Structural Severity

While imaging provides critical structural information, functional assessments are equally important in evaluating clinical severity.

Choosing the Right Imaging Modality

• Radiographs (Standard & Stress Views) are the first-line imaging modality for diagnosing fractures, joint abnormalities, and degenerative conditions. They provide a quick and cost-effective assessment of bone structure. Stress radiographs are particularly useful for detecting ligamentous instability, such as cranial cruciate ligament (CCL) ruptures or medial shoulder instability, by revealing abnormal joint movement under applied force.
• CT Scans (Computed Tomography) offer detailed 3D imaging, making them essential for evaluating complex fractures, elbow dysplasia, and bony malformations. They are particularly valuable for surgical planning, especially in cases involving pelvic fractures and angular limb deformities, where precise anatomical reconstruction is necessary.
• MRI (Magnetic Resonance Imaging) is the preferred modality for diagnosing soft tissue injuries, spinal conditions such as intervertebral disc disease (IVDD), and subtle ligament or meniscal damage. It is especially useful when radiographs appear normal, but clinical signs persist, indicating potential soft tissue pathology that requires deeper evaluation.
• Arthroscopy is a minimally invasive technique that allows direct visualization of joint structures, aiding in the diagnosis of cartilage defects, meniscal tears, and synovial disorders. Beyond diagnostics, it also serves as a therapeutic tool, enabling surgeons to perform precise interventions with minimal tissue disruption.

Why Imaging Alone Isn’t Enough

Radiographic findings don't always match the clinical severity. A hip dysplasia case that looks mild on an X-ray might cause severe lameness, while some dogs with significant osteophytes on radiographs may still function well. That's why a functional assessment, including lameness grading, gait analysis, and pain evaluation, is essential for a complete diagnosis.

Lab Tests for Chronic Conditions

In chronic orthopedic cases, laboratory diagnostics help differentiate degenerative diseases from immune-mediated or infectious conditions, providing a more complete clinical picture:

• C-reactive protein (CRP): Elevated levels indicate active inflammation, commonly seen in immune-mediated arthritis and chronic joint disease.
• Synovial fluid analysis: Helps assess infection, immune-mediated polyarthritis, or degenerative joint disease, guiding treatment decisions.

Combining imaging, functional assessment, and laboratory diagnostics allows veterinarians to make precise decisions on whether a case requires medical management or surgical referral.

Criteria for Surgical Intervention

While imaging findings help guide decisions, the patient's clinical function and quality of life often determine how urgently surgery is needed. Surgery is recommended when pain, joint instability, or progressive deterioration significantly impact mobility and well-being.

Full-Thickness Ligament Tears Require Stability, Not Just Pain Management

Cranial cruciate ligament (CCL) ruptures cause severe joint instability, leading to secondary osteoarthritis. Surgical stabilization, such as tibial plateau leveling osteotomy (TPLO) or tibial tuberosity advancement (TTA), is recommended for long-term function.

Similarly, Achilles tendon ruptures often require surgical repair to restore weight-bearing ability and prevent permanent dysfunction.

Joint Instability and Severe Dysplasia Progress Over Time

Young Dogs with hip dysplasia might manage well with conservative treatment in the early stages, but those with severe joint looseness benefit from juvenile pubic symphysiodesis (JPS) or triple pelvic osteotomy (TPO).

For older dogs with arthritis, total hip replacement (THR) or femoral head ostectomy (FHO) might be the best options to restore mobility.

Patellar luxation (Grades III-IV) is similar—mild cases can be managed conservatively, but if lameness persists, surgical realignment helps prevent cartilage damage and long-term joint deterioration.

Neurological Decline Requires Urgent Decision-Making

Spinal conditions like intervertebral disc disease (IVDD) can rapidly progress from mild pain to complete paralysis.

In cases with progressive weakness, loss of deep pain sensation, or significant ataxia, surgery such as hemilaminectomy or ventral slot decompression should be performed as soon as possible to maximize recovery potential. Delaying intervention in severe IVDD cases significantly reduces the chance of regaining function.

Unstable Fractures Cannot Be Left to Heal Alone

Fractures vary in severity, but displaced long bone fractures require surgical fixation to ensure proper healing and prevent malalignment. Pelvic fractures, especially those involving the acetabulum or sacroiliac joint, often require stabilization to preserve weight-bearing function.

While some stable fractures in small breeds may heal with external coaptation, improper healing in weight-bearing bones can lead to chronic pain, limb shortening, or permanent lameness.

Functional Limitations vs. Anatomical Findings

Orthopedic conditions do not always present in predictable ways. A dog with severe hip dysplasia on radiographs may show little clinical discomfort, while another with mild radiographic changes may struggle to walk.

Decision-making should focus on functional limitations, pain assessment, and future prognosis rather than relying solely on imaging findings. If lameness significantly impacts the dog’s quality of life despite medical management, surgery should be strongly considered, even if radiographic changes seem minor.

Surgery is Sometimes Needed Even Without Severe Symptoms

Some orthopedic conditions require surgical intervention even before significant lameness is evident.

Hip luxation, for example, may not seem painful in the early stages, but chronic instability leads to joint degeneration and arthritis, making procedures like toggle pin fixation, FHO, or THR necessary.

Similarly, in elbow dysplasia with a fragmented coronoid process, early arthroscopic removal of loose fragments can slow the progression of arthritis, preserving function before severe pain develops.

Veterinarians must assess pain levels, joint stability, and long-term prognosis rather than relying solely on imaging.

Red Flags for Immediate Surgical Referral

Certain orthopedic emergencies need urgent surgery to prevent permanent damage, chronic pain, or disability. Delaying treatment in these situations can greatly worsen the outcome, so immediate referral to a specialist is crucial.

Open Fractures Need Immediate Stabilization

When a fracture exposes the bone, the risk of infection and bone inflammation rises sharply. Quick wound care, intravenous antibiotics, and surgical stabilization are vital to avoid complications. Untreated open fractures can lead to severe tissue damage, failure to heal, and long-term limb problems.

Severe Joint Luxations Must Be Addressed Quickly

Traumatic dislocations of the hip, elbow, or ankle need urgent realignment to prevent cartilage damage, ligament stretching, and joint wear. If untreated, ongoing instability can cause painful arthritis, requiring procedures like femoral head ostectomy (FHO) or total hip replacement (THR). Early surgical stabilization is crucial for maintaining joint function over time.

Non-Weight-Bearing Lameness with Acute Pain Signals Serious Injury

Sudden inability to bear weight, especially with severe swelling or deformity, indicates a fracture, ligament tear, or tendon detachment. These issues often need surgical repair to restore joint stability and function. Delaying treatment increases the risk of joint misalignment, arthritis, and other complications.

Neurological Signs Indicating Spinal Cord Compression Require Immediate Attention

Conditions like intervertebral disc extrusion (IVDD), vertebral fractures, or spinal instability can lead to ataxia, weakness, or loss of deep pain sensation. Early decompression surgery (such as hemilaminectomy or ventral slot) greatly increases the chances of neurological recovery. Delaying treatment in severe cases can result in permanent paralysis, bladder problems, and loss of mobility.

Why Delaying Surgery Can Worsen Outcomes

Putting off surgery in these situations can lead to more tissue damage, increased pain, and lower success rates. Joint instability speeds up cartilage wear, fractures may heal improperly, and spinal cord compression can cause lasting neurological issues. Prompt referral ensures the best possible recovery, helping patients heal faster with fewer long-term problems.

Early vs. Late Referral: How Timing Affects Outcomes

The timing of a surgical referral in orthopedic cases can significantly impact long-term prognosis. Early intervention often preserves joint function, prevents chronic pain and mobility loss, and improves surgical outcomes. Delays, on the other hand, can lead to irreversible damage, limited treatment options, and prolonged recovery times.

Conditions Where Early Referral is Key

Hip Dysplasia in Young Dogs

• Procedures like juvenile pubic symphysiodesis (JPS) or triple pelvic osteotomy (TPO) are most effective before skeletal maturity when joint remodeling potential is highest.
• Delayed intervention increases the risk of severe osteoarthritis, limiting surgical options to salvage procedures like total hip replacement (THR) or femoral head ostectomy (FHO).

Chronic Elbow Dysplasia

• Fragmented coronoid process (FCP) and medial compartment disease lead to progressive cartilage damage and osteoarthritis if untreated.
• Early arthroscopic removal of loose fragments helps reduce joint erosion and preserves function, avoiding long-term joint deterioration.

Partial Cranial Cruciate Ligament (CCL) Tears

• Many partial tears progress to full ruptures, resulting in joint instability, chronic pain, and meniscal damage.
• Early stabilization via TPLO or TTA prevents secondary degenerative joint disease and improves mobility.

Long-Term Consequences of Delayed Referral

• Progression of osteoarthritis, which lowers the success rate of surgeries.
• Muscle wasting, resulting in longer recovery times and decreased function after surgery.
• Permanent loss of mobility, particularly in severe hip dysplasia or chronic ligament instability.
• Need for more invasive surgeries as conditions worsen and fewer conservative options are available.

How to Counsel Pet Owners on Early Intervention

• Use visual aids like X-rays, gait analysis videos, and case studies to demonstrate the effects of early versus late intervention.
• Explain cost-effectiveness, highlighting that early surgery might be costly initially but can prevent ongoing medical expenses and more expensive procedures later.
• Discuss quality of life, helping owners see that delaying treatment can lead to chronic pain, limited activity, and long-term joint damage.
• Set realistic expectations, ensuring owners understand the benefits of early referral and the potential risks of delaying treatment.

By identifying surgical candidates early and educating owners on the benefits of timely intervention, veterinarians can improve patient outcomes, enhance mobility, and reduce long-term complications.

Non-Surgical Treatment Options

Not all orthopedic cases require surgical intervention.

Conservative management can be effective in certain conditions, particularly when the patient has mild to moderate symptoms and retains adequate function. However, careful case selection and close monitoring are essential to ensure that non-surgical management remains appropriate.

When to Attempt Conservative Management

1. Partial Ligament Tears: Early-stage cranial cruciate ligament (CCL) tears in small dogs and cats can sometimes be managed without surgery using strict rest, NSAIDs, and controlled rehabilitation. However, there is still a risk of the tear becoming complete.
2. Mild Osteoarthritis: Dogs with early joint degeneration might benefit from medical treatment, lifestyle changes, and physiotherapy before considering surgical options like total joint replacement.
3. Stable Fractures in Small Breeds: Minimally displaced fractures, especially in toy breeds, can sometimes heal with external support like splints or casts if strict rest is maintained.

Therapies Available for Conservative Management

1. Medical Management
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   • NSAIDs (Carprofen, Meloxicam) are used to control pain and inflammation.
   • Joint supplements like glucosamine, chondroitin, and omega-3 fatty acids help support cartilage health.
   • Platelet-Rich Plasma (PRP) Therapy aids in regenerative joint healing for early arthritis cases.
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2. Weight Management
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   • Obesity worsens orthopedic conditions by increasing joint stress and speeding up degeneration. Controlled weight loss greatly improves mobility and reduces pain.
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3. Physiotherapy and Rehabilitation
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   • Hydrotherapy (underwater treadmill, swimming) helps build muscle strength with minimal impact on joints.
   • Passive Range of Motion (PROM) exercises help maintain flexibility.
   • Laser therapy and therapeutic ultrasound are used to reduce inflammation and promote healing.
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Rehabilitation-First Approach: Cases Where Surgery Can Be Delayed

In certain orthopedic cases, targeted rehabilitation can delay or even prevent the need for surgery by strengthening supporting structures and improving joint stability. However, proper patient selection, structured rehab protocols, and regular reassessment are key to ensuring long-term success.

Conditions Where Targeted Rehab Helps

1. Grade I-II Patellar Luxation: Mild luxations with minimal discomfort can be managed with strengthening exercises, especially for the quadriceps and hip stabilizers. Weight control and joint supplements also help maintain joint health.
2. Mild Hip Dysplasia in Young Dogs: Controlled exercise, physiotherapy, and non-steroidal anti-inflammatory drugs (NSAIDs) can help young dogs with mild hip dysplasia stay mobile without needing immediate surgery. Hydrotherapy and core strengthening reduce stress on the hip joint and improve function.
3. Partial Ligament Injuries with Strong Compensation: Early-stage cranial cruciate ligament (CCL) injuries in small, well-muscled dogs may benefit from brace support, muscle conditioning, and controlled activity. Additionally, PRP therapy (Platelet-Rich Plasma) and regenerative medicine can aid tissue healing in select cases.

When to Reassess & Escalate to Surgery

• If the patient continues to limp despite structured rehabilitation.
• When joint instability worsens, causing more pain or secondary issues like osteoarthritis.
• If imaging reveals worsening cartilage damage, meniscal injury, or subluxation.

Success Rates of Rehabilitation vs. Surgery

• Mild Patellar Luxation: About 60-70% of Grade I-II cases can be managed long-term with rehabilitation alone.
• Hip Dysplasia: Physiotherapy can delay surgery for years, but dogs with severe hip pain will eventually need total hip replacement (THR) or femoral head ostectomy (FHO).
• Partial CCL Tears: Small-breed dogs (under 10 kg) may stay functional with rehab, but larger dogs often experience worsening ligament issues, requiring TPLO or TTA surgery.

A rehabilitation-first approach can offer pain relief and functional improvement, but veterinarians should be proactive in identifying cases where surgery is ultimately necessary.

Referral Process to Specialists

A smooth referral process improves patient outcomes, ensures continuity of care, and enhances owner confidence in the treatment plan.

When to Refer & Choosing the Right Specialist

Veterinarians should refer cases when:

• The surgical procedure is beyond their expertise or requires specialized equipment (e.g., TPLO, total hip replacement).
• The case is not responding to conservative management, and surgical correction is the best option.
• The patient has a complex fracture, joint instability, or progressive neurological deficits requiring advanced intervention.

What to Include in the Referral Letter

A well-documented referral ensures a smooth transition of care. The letter should include:

• Patient history (age, breed, medical conditions).
• Clinical findings (lameness grading, pain scores, joint instability).
• Diagnostic imaging results (X-rays, CT scans, MRI).
• Previous treatments & responses (NSAIDs, rehab, injections).
• Specific referral request (e.g., TPLO for complete CCL rupture)

Client Communication: Preparing Owners for Referral

Pet Owners should understand:

• Why referral is necessary and what outcomes to expect.
• The cost implications of specialist surgery.
• The timeline for diagnostics, surgery, and recovery.
• Post-operative care responsibilities (activity restriction, rehab, follow-ups).

Financial Considerations in Referral: How to Guide Clients

Discussing the financial aspects of orthopedic referrals is essential for ensuring that pet owners understand their options and can make informed decisions. While specialized surgical procedures can be costly, they often prevent long-term expenses related to chronic pain management and reduced mobility.

Estimating Costs: Surgical vs. Non-Surgical Treatments

Veterinarians should provide both surgical and non-surgical cost estimates to help owners understand the financial impact of each option.

Surgical costs include

• TPLO for CCL rupture, which ranges from $3,000 to $6,000 and covers surgery, hospitalization, and post-op care.
• Total hip replacement (THR) costs between $5,000 and $7,000 and offers long-term function restoration.
• Fracture repair with plates or pins costs $2,500 to $5,000, depending on the case's complexity.

Non-surgical costs add up over time.

• NSAIDs and pain management typically cost $500 to $1,500 annually.
• Joint supplements and rehabilitation therapy range from $1,000 to $3,000 per year, depending on how often treatments are needed.
• Frequent veterinary visits and disease progression can increase long-term costs, often surpassing the cost of surgery.

Explaining Cost vs. Long-Term Benefits

Owners often hesitate at the upfront cost of surgery, not realizing that delaying treatment can lead to higher overall expenses and a lower quality of life.

TPLO surgery prevents chronic joint instability that would otherwise cause severe osteoarthritis, requiring lifelong NSAIDs, physical therapy, and possibly more surgeries. With surgery, most dogs regain full function within months and need minimal long-term medication.

Early surgical intervention in hip dysplasia, like Juvenile Pubic Symphysiodesis (JPS) or Triple Pelvic Osteotomy (TPO), helps maintain hip function. If surgery is delayed, joint degeneration worsens, leading to expensive procedures like femoral head ostectomy (FHO), total hip replacement (THR), or lifelong pain management.

Helping Clients Make Informed Decisions Without Financial Strain

• Transparent Cost Estimates: Provide written estimates for both surgical and non-surgical expenses to help owners plan financially.
• Pet Insurance & Financing Options: Advise owners on pet insurance policies, CareCredit, or in-house payment plans to make treatment more affordable.
• Prioritizing Treatment: If full surgical correction isn't immediately possible, discuss temporary pain management options while planning for future surgery.

By presenting surgery as an investment in long-term mobility and quality of life, veterinarians can assist clients in making the best decisions for their pets while realistically addressing financial concerns.

Conclusion

Timely and accurate referrals for orthopedic surgery in veterinary cases are crucial for achieving the best outcomes for patients. By identifying which cases require surgery and which can be managed without it, veterinarians can provide the most suitable care, whether through conservative management or surgical intervention.

Early detection of orthopedic problems, thorough pain and function assessments, and the use of diagnostic tools are vital for making informed decisions.

Furthermore, understanding the financial aspects and clearly communicating treatment options to pet owners can improve the overall care process. Ultimately, a proactive approach to managing orthopedic conditions can greatly enhance the quality of life for veterinary patients.

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When a patient returns from specialist surgery, the referring practice resumes responsibility for day-to-day post-operative management. This is a routine part of veterinary practice, but it carries specific demands: interpreting discharge instructions from a procedure you didn't perform, monitoring for complications that may look unfamiliar, and knowing when to escalate back to the surgical team.

Getting this right matters as much as the surgery itself.

What this covers: The most common post-surgical complications in referred patients, how to recognize them at follow-up visits, management approaches for each, the follow-up communication structure with the surgical team, and owner support during the recovery period.Scope: Applies to soft tissue and orthopedic post-operative patients returning to primary care after specialist referral. MPL surgery recovery is used as a reference case throughout.Clinical principle: The referring veterinarian is often the first professional contact when a complication develops. Early recognition, appropriate triage, and clear communication with the surgical team are the core competencies this role requires.

Key takeaways

• The referring vet often sees complications first: owners contact their primary clinic before the specialist.
• Read the specialist's discharge instructions before the patient returns for follow-up.
• SSI, seroma, wound dehiscence, and persistent lameness are the most common post-surgical complications in referred orthopedic patients.
• Clear discharge presents normally in the first 48 hours; purulent or foul-smelling discharge warrants culture.
• Contact the surgical team for any major complication; don't manage implant or bone healing complications unilaterally.
• Owner communication within 24 to 48 hours of discharge improves compliance and early complication detection.

Your role as the referring veterinarian

The post-operative period is a shared responsibility. The specialist performed the procedure and wrote the discharge instructions. The referring vet and the owner implement them.

In practice, this means:

• Providing follow-up examinations at the intervals specified in the discharge summary
• Managing medications, dressing changes, and rehabilitation oversight locally
• Triaging complications and determining which require specialist re-evaluation
• Serving as the first contact for owner concerns and questions between scheduled rechecks

The ACVS notes that post-operative care is "a collaborative effort between the owner, primary care veterinarian, and ACVS board-certified veterinary surgeon." Your practice's contribution to that collaboration is the continuity of monitoring that the specialist can't provide at distance.

Pre-visit preparation

Before the first post-operative recheck:

Review the surgical summary:

• What procedure was performed, and are multiple procedures involved?
• What implants were placed, if any?
• What is the anticipated recovery timeline?
• Are there specific restrictions or monitoring parameters from the surgeon?

Confirm medications:

• What pain management was dispensed?
• Are there antibiotics, and for how long?
• Has the owner been administering correctly?

Prepare for the physical examination:

• Know what the operated site is expected to look like at this stage
• Have reference for normal post-operative appearance vs. expected complications
• For orthopedic cases: understand what the surgical correction involved before assessing function

Most common complications in referred patients

1. Surgical site infection (SSI)

SSI is the most frequently encountered complication in referred orthopedic patients and is particularly relevant following MPL surgery, TPLO, and other implant procedures.

Clinical signs:

• Redness extending beyond incision margins
• Local heat and swelling worsening after post-operative day 3
• Purulent (yellow, green, or creamy) discharge
• Incision odor
• Systemic signs: fever, lethargy, reduced appetite

Management:

• Culture and sensitivity testing of wound discharge before initiating antibiotics
• Empirical broad-spectrum antibiotics if culture results will be delayed and infection is clearly active
• Wound care as appropriate to the degree of involvement
• Contact the surgical team if the SSI is deep (involving fascial planes), involves implants, or is not responding to initial treatment within 48 to 72 hours

For implant-associated infection specifically, contact the surgical team promptly. Biofilm formation on implants may require implant removal, which is a specialist decision, not a primary care decision.

2. Seroma

A seroma is a sterile accumulation of serous fluid in a dead space beneath the incision. It is common after soft tissue and orthopedic surgery.

Clinical signs:

• Soft, fluctuant swelling beneath the incision
• Not hot or painful beyond mild pressure discomfort
• Typically appears in the first 1 to 2 weeks post-operatively
• No fever or systemic signs

Management:

• Conservative management first: strict rest to reduce fluid production, compression bandaging where anatomically appropriate
• Aspiration if the seroma is large, under significant tension, or causing discomfort; use sterile technique; ultrasound guidance if needed
• Aspiration does not prevent recurrence; re-accumulation is common without strict rest
• Placement of a Penrose drain only if the seroma is refractory and large; coordinate with the surgical team

When to escalate: If the seroma becomes infected (develops heat, discharge, systemic signs), or if it persists beyond 3 to 4 weeks without resolution, contact the surgical team.

3. Wound dehiscence

Wound dehiscence (partial or complete incision opening) requires prompt assessment and is sometimes a surgical emergency.

Classification:

• Superficial dehiscence: Skin only has opened; deeper layers are intact
• Full-thickness dehiscence: All wound layers have opened; tissue may be visible

Management:

• Superficial dehiscence: clean the wound, assess for infection, determine whether re-closure is needed or if second-intention healing is appropriate. Contact surgical team.
• Full-thickness dehiscence: cover exposed tissue with a clean, moist dressing immediately; contact the surgical team for guidance on re-closure approach; this may require specialist intervention
• Tissue protruding: emergency. Cover and refer immediately.

The primary cause of dehiscence in referred patients is owner non-compliance with rest restrictions or E-collar removal. Reinforce these at every interaction.

4. Persistent lameness beyond expected timeline

For orthopedic referred patients, particularly post-MPL surgery, lameness that persists beyond the expected improvement timeline warrants investigation.

Differential diagnoses:

• Re-luxation of the patella
• Implant failure (pin migration, tibial tuberosity displacement)
• Infection of the surgical site or joint
• Concurrent cruciate ligament injury
• Normal variance in healing pace

Approach:

• Radiographs of the operated limb to assess implant position and bone healing
• Orthopedic examination to assess patellar stability
• Compare to the post-operative baseline radiographs from the surgical report
• Contact the surgical team with your findings before making treatment decisions about the implant or bone healing

For reference on what normal MPL surgery recovery progression looks like and when lameness raises concern, see MPL surgery recovery as a reference case.

5. Post-operative pain beyond expected severity

Some patients experience more pain than anticipated. This is particularly relevant in bilateral cases or higher-grade corrections.

Assessment:

• Pain scoring at each visit using a standardized tool (Colorado State Pain Scale or similar)
• Distinguish surgical pain from position-related discomfort vs. complication-related pain
• Assess gait, willingness to bear weight, posture, and facial expression

Management:

• Step up analgesia within the discharge prescription parameters if available
• Contact the surgical team if pain is severe, not responding to current medications, or if you need guidance on additional agents
• NSAIDs, gabapentin, and opioid adjuncts are the most common options; the surgical team can advise on safe additions

The recheck examination for referred orthopedic patients

At each follow-up visit, perform and document:

1. Incision assessment: Appearance, closure status, discharge presence and character
2. Limb assessment: Weight-bearing status, gait quality, muscle mass comparison bilateral
3. Joint assessment: Patellar stability if MPL; range of motion; joint effusion
4. Systemic assessment: Temperature, appetite, energy level, pain score
5. Radiographs: At intervals specified by the surgical team; essential at the 8 to 10 week bone healing recheck for orthopedic cases

Document findings in a format the surgical team can access if needed. Many specialists appreciate a brief update email following major rechecks.

For an owner-facing reference on the signs they should be monitoring at home between your visits, see general signs of complications after soft tissue surgery.

Communicating with the surgical team

Knowing when to contact the specialist rather than managing independently is one of the most important skills in referred patient care.

Contact the surgical team for:

• Any major complication (deep infection, dehiscence, implant concern)
• Re-luxation or suspected surgical failure
• Pain that is not responding to standard management
• Any question about modifying the rehabilitation protocol
• A patient who is significantly worse than the discharge summary's expected trajectory

Manage locally without specialist consultation for:

• Superficial incision redness that is not progressing
• Small seromas under active rest restrictions
• Mild, expected post-operative lameness on expected timeline
• Medication refills within the existing prescription

A quick call or email to the specialist prevents the most common error: managing a complication beyond the scope of primary care while the problem worsens.

Owner support and communication

Owner compliance is the single most controllable variable in post-operative outcome. Your practice's communication structure directly affects compliance.

Check in within 24 to 48 hours of the patient's discharge from the specialist:A brief call or message asking how the dog is doing, whether medications are being given correctly, and whether the incision looks normal both supports the owner and catches early compliance failures.

Reinforce restrictions at every visit:Do not assume owners have retained all information from the specialist's discharge conversation. Re-explain E-collar use, activity restriction, and the specific signs to watch for at each contact.

Address financial anxiety directly:Complications can create anxiety about cost on top of the stress of a sick pet. Be clear about which complications are manageable at your practice level vs. which would require specialist re-referral, so owners can plan accordingly.

For guidance on rehabilitation protocols for referred post-surgical patients, including the phase-based exercise approach for MPL and other orthopedic patients returning to your care, see rehab protocols for referred post-surgical patients.

Frequently asked questions

The surgical team discharged the patient with only a brief summary. How do I fill the gaps?

Contact the specialist directly. A brief call clarifying the specific procedures performed, the expected recovery milestones, and any parameters that should trigger re-referral is entirely appropriate. Most specialists welcome this communication and will provide the context their written summary couldn't fully cover.

My patient has an implant issue on radiograph. Should I manage it or refer back?

Refer back. Implant adjustments, pin removal decisions, and assessment of failed fixation are specialist decisions. Your role is to identify the problem on radiograph, stabilize the patient, and coordinate with the surgical team promptly.

How soon should I see the patient after specialist surgery?

Follow the discharge instructions. For orthopedic patients, a 10 to 14 day post-operative recheck for suture removal and incision assessment is typical. Some specialists request an additional check at 4 to 6 weeks for gait assessment, and most schedule a formal radiographic recheck at 8 to 10 weeks for bone healing confirmation. Fit your visit schedule to these milestones.

The surgery happens once. The recovery happens over months, and it mostly happens at the primary clinic and at home. Referring veterinarians who take an active, structured approach to post-operative management, communicate proactively with the surgical team, and invest in owner education consistently produce better outcomes than those who take a passive "let the owner call if there's a problem" approach. The specialist finishes the surgery. You finish the recovery.

Resources

• American College of Veterinary Surgeons. Postoperative Care After Surgery: What Animal Owners Should Expect. acvs.org
• SustainableVet. Post-Surgical Follow-Up Guide for Referring Vets. sustainablevet.org
• Allied Veterinary. How Specialty Vets Monitor Pets After Surgery. alliedervet.com

What Is Arthroscopy in Veterinary Orthopedics?

Arthroscopy is a minimally invasive surgical technique used to look inside your pet’s joints. It involves making small incisions to insert a tiny camera (arthroscope) and special instruments. The camera sends real-time images to a screen, allowing the surgeon to see and treat joint problems without fully opening the joint.

Unlike traditional open joint surgery, arthroscopy causes less tissue damage, smaller scars, and quicker healing. It’s especially useful for diagnosing and treating conditions like ligament damage, joint inflammation, or loose cartilage. Because it offers better visibility with less pain and swelling, more vets are using it in modern orthopedic care.

Arthroscopy is commonly performed on the shoulder, elbow, stifle (knee), and hip joints. It allows precise treatment with fewer complications, making it a preferred option for both diagnosis and surgery in many orthopedic cases.

Diagnostic Benefits of Arthroscopy

Arthroscopy gives veterinarians a clear, direct view inside the joint, which is not possible with radiographs or even CT scans. This technique helps detect issues that might be missed with imaging alone, especially soft tissue problems. Because the camera goes directly into the joint, the surgeon can see the cartilage, ligaments, and joint surfaces in real time.

Here are some key diagnostic benefits of arthroscopy:

• Direct visualization of joint interiors helps identify problems right at the source.
• Cartilage damage, such as softening, thinning, or flaking, is seen clearly.
• Ligament injuries, including partial or early tears, are more accurately diagnosed.
• Subtle abnormalities, like joint inflammation or loose fragments, are easier to detect.
• Better than radiographs or CT scans for spotting soft tissue problems like meniscal tears.
• Synovial fluid or tissue samples can be collected during the procedure for lab testing.

Overall, arthroscopy improves the accuracy of diagnosis, allows early treatment planning, and reduces the need for exploratory surgery. It helps vets make more informed decisions and improves outcomes for dogs with joint issues.

Indications: When Is Arthroscopy Used in Veterinary Orthopedics?

Arthroscopy is commonly used in veterinary orthopedics to diagnose and treat joint problems with less pain and faster recovery. It is especially helpful in joints where precision matters and where early treatment improves long-term outcomes.

1. Elbow Joint Conditions

The elbow is one of the most common joints treated with arthroscopy in dogs, especially large breeds. Common conditions include:

• Fragmented Medial Coronoid Process (FMCP): Arthroscopy allows removal of small bone fragments and smoothing of rough surfaces.
• Osteochondritis Dissecans (OCD): Loose cartilage is removed with minimal joint trauma.
• Ununited Anconeal Process (UAP): Surgeons can evaluate the extent of separation and remove or reattach the piece.
• Elbow incongruity: Arthroscopy helps detect joint mismatch early, guiding further surgical decisions.

This joint benefits from arthroscopy because of its complexity and the difficulty of seeing problems on X-rays.

2. Shoulder Joint Conditions

Shoulder arthroscopy is often used to diagnose and treat soft tissue injuries that cause lameness. Key conditions include:

• OCD of the shoulder: Cartilage flaps are easily identified and removed with minimal damage.
• Biceps tendon pathology: Allows inspection and treatment of tendon inflammation or rupture.
• Medial shoulder instability: Helps confirm ligament stretching or damage and guide surgical repair.

Because shoulder injuries can be hard to detect with imaging, arthroscopy is a valuable diagnostic and treatment tool in active dogs.

3. Stifle (Knee) Joint Conditions

Arthroscopy is useful in diagnosing and treating stifle joint problems, especially when combined with surgical repair. Common indications:

• Cranial cruciate ligament rupture: Arthroscopy can confirm partial or complete tears and assess secondary damage.
• Meniscal tears: Allows clear visualization and precise removal of torn cartilage.
• OCD of the femoral condyle: Helps detect and treat cartilage defects in the knee joint.

In many cases, arthroscopy is done before or during surgery like TPLO to evaluate joint health and improve surgical outcomes.

4. Other Joints (Selective Use)

Though less common, arthroscopy can be used in other joints when imaging is unclear or precision is needed:

• Hip joint: Occasionally used to examine cartilage damage or joint laxity in young dogs.
• Tarsus (hock): Useful in complex cases with suspected OCD or instability.
• Carpus (wrist): Allows diagnosis of ligament injuries or chronic inflammation in small breeds.

These joints are smaller and harder to access, so arthroscopy is used selectively by experienced surgeons.

Therapeutic Uses of Arthroscopy

Arthroscopy is not only helpful for diagnosing joint problems but also plays an important role in treatment. Because it uses small incisions and specialized instruments, it causes less damage than traditional surgery and speeds up recovery.

Here are key therapeutic uses of arthroscopy in veterinary orthopedics:

• Removal of loose bone or cartilage fragments: Fragments from injuries or conditions like OCD can cause pain and joint damage. Arthroscopy allows precise removal without opening the whole joint.
• Debridement of damaged cartilage: Worn or injured cartilage can be trimmed or smoothed to reduce pain and slow joint degeneration.
• Lavage in septic joints: In infected joints, arthroscopy allows joint flushing (lavage) to remove pus, bacteria, and debris, helping the joint heal faster.
• Treatment of partial ligament tears: Minor tears, such as early cruciate ligament damage, can be cleaned and evaluated to guide future treatment.
• Joint flushing to reduce inflammation: In dogs with chronic joint inflammation or immune-mediated arthritis, flushing out the joint helps decrease swelling and improve comfort.

Arthroscopy offers a way to treat problems directly with minimal trauma, which leads to faster healing, less scarring, and better long-term joint function.

Benefits of Arthroscopy Compared to Traditional Surgery

Arthroscopy has become a preferred choice in veterinary orthopedics because it offers many benefits over traditional open joint surgery. By using small incisions and a camera, it reduces trauma and improves healing outcomes.

Key benefits include:

• Smaller incisions = reduced soft tissue trauma: The small entry points cause less damage to muscles and skin, which helps with faster healing and less scarring.
• Faster post-op recovery time: Dogs often return to gentle activity sooner than with traditional surgery. This can shorten the overall rehab period.
• Lower pain levels for the patient: Less tissue damage means less pain after surgery. Many dogs show improved comfort within a few days.
• Reduced risk of infection: Smaller wounds and shorter procedure times lower the chance of bacteria entering the joint.
• Shorter anesthesia and hospital stay durations: Arthroscopy usually takes less time, which means reduced anesthesia risk and shorter clinic stays.
• Improved precision due to magnified view: The camera gives a clear, enlarged view of the joint, helping the surgeon see tiny structures and treat the exact problem.

Overall, arthroscopy allows better care with fewer risks and a smoother recovery, making it a valuable tool in modern veterinary surgery.

Limitations and Considerations

While arthroscopy offers many benefits, it’s not the right choice for every case. There are certain limitations and factors to consider before choosing this technique for your dog.

Here are key points to keep in mind:

• Not suitable for very small joints or advanced joint disease: In very small dogs or cats, the joint space may be too tight for the instruments. Arthroscopy is also less effective when the joint has severe arthritis or bone deformity.
• Requires advanced training and specialized equipment: Not all veterinary clinics offer arthroscopy. It needs a skilled surgeon with special tools and experience, which may limit availability.
• In rare cases, may need to convert to open surgery: If the problem is too complex or the joint is hard to access, the surgeon may switch to a traditional open approach during the procedure.
• Cost considerations depending on setup and expertise: Arthroscopy can be more expensive than standard surgery due to the high cost of equipment and the advanced training required.

Despite these limitations, arthroscopy remains a valuable option for many joint conditions. Your veterinarian will help you decide if it’s the right choice based on your pet’s size, diagnosis, and overall health.

Prognosis and Expected Outcomes

Arthroscopy has a high success rate when used in the right cases and performed by an experienced surgeon. Most dogs recover well and show noticeable improvement in comfort and mobility.

Here’s what you can expect from arthroscopy:

• High success rate in properly selected cases: When done for the right joint condition—such as early ligament injury, cartilage damage, or OCD—arthroscopy provides excellent results with fewer complications.
• Faster return to function and normal activity: Because the procedure is minimally invasive, dogs often regain mobility sooner than with traditional surgery. Most pets can begin light activity within a few weeks.
• Early intervention improves long-term joint health: Treating joint problems early, before there is severe damage, helps protect the joint. This can delay or prevent long-term issues like chronic pain or joint deformity.
• May reduce progression to osteoarthritis if done early: By removing damaged tissue and flushing the joint early, arthroscopy can slow down the development of arthritis, especially in young or active dogs.

Overall, arthroscopy offers a strong long-term outcome with less pain, quicker healing, and better joint function—especially when performed before the disease becomes advanced. Regular follow-up and proper rehab are key to success.

Final Thoughts

Arthroscopy is a modern, minimally invasive technique that offers both diagnostic and therapeutic benefits in veterinary orthopedics. It allows for precise treatment of joint conditions like OCD, ligament injuries, and cartilage damage with smaller incisions, less pain, and faster recovery compared to traditional surgery.

It’s especially helpful for early-stage joint problems, where quick action can protect the joint and reduce long-term damage. However, not every case is a match for arthroscopy. Factors like joint size, disease severity, and available expertise must be considered.

Early diagnosis plays a major role in successful outcomes. If your dog shows signs of joint pain, lameness, or reduced activity, don’t wait. A timely exam can make all the difference. Always consult a board-certified veterinary surgeon to determine if arthroscopy is the right choice for your dog’s condition and recovery.

FAQs About Arthroscopy in Veterinary Orthopedics

Is arthroscopy painful for dogs or cats?

Arthroscopy is less painful than traditional open joint surgery because it uses small incisions and causes less tissue damage. Most pets experience mild discomfort, which is managed with pain medication. Many animals begin walking comfortably within a few days and show steady improvement as healing progresses.

How long does recovery take after arthroscopy?

Recovery time after arthroscopy is usually shorter than open surgery. Most pets start gentle activity within 2 to 3 weeks. Full recovery takes about 6 to 8 weeks, depending on the joint treated and overall health. A structured rehab plan, including rest and controlled exercise, helps ensure the best outcome.

How much does veterinary arthroscopy cost?

The cost of arthroscopy can range from $2,000 to $4,000 or more, depending on the joint treated, clinic location, surgeon experience, and whether therapeutic procedures are done. Additional fees for diagnostics, anesthesia, and follow-up care may apply. Always ask for a full estimate before scheduling the procedure.

Can small breed dogs undergo arthroscopy?

Yes, small breed dogs can have arthroscopy, especially for shoulder, elbow, or stifle issues. However, very tiny joints may be too small for the instruments. A skilled veterinary surgeon will evaluate your dog’s size and joint structure to decide if arthroscopy is a safe and effective option.

Is arthroscopy better than MRI or CT for joint problems?

Arthroscopy gives a real-time, direct view of the inside of the joint, making it better for diagnosing cartilage, ligament, or meniscus problems. MRI and CT scans are useful for imaging bones and deeper structures, but they can miss soft tissue issues that arthroscopy can clearly reveal and treat at the same time.

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