An ACL tear and TPLO journal

[Sue R]

So, what is the verdict? Celt is ready to resume any and all of his normal activities - cleared for stockwork, play activities, and whatever else is part of his routine or even what might be new to his routine.

 

His recovery took a longer than usual for several reasons. He was older, halfway through his tenth year, when he had surgery. This was a long-standing, deteriorating condition, not a traumatic event to an otherwise sound dog, so there was a lot of time to mask the injury and develop imbalances, improper muscle memory, and bad motion habits. He had been essentially laid up for almost three months prior to surgery, and so had lost a great deal of fitness, strength, and muscle integrity. We had a setback fairly early on, when I fell and Celt's movement to avoid being fallen upon (or my fall itself) resulted in straining his ileopsoas muscle, and setting his progress back by over a month - and also causing us to slow down on his recovery plan to avoid another potential setback if we should overdo things.

 

We discussed his exercise plan. Shari felt that, considering the results we saw today, I could reduce the in-house exercises to 2-3 times a week if I wanted but she would rather I did not dispense with them entirely at this point. The reason for them (along with the outside exercises) is to build and maintain muscling, strength, and stamina - all of which will contribute to continued soundness, support his joints, and reduce the likelihood of his blowing the other knee.

 

I am going to try and plan on doing them once a day on most days because I fear that, if I get too casual about them, I will tend to slack off and I don't want to undo the good we have done. Plus, I have the time and ability to do them but I know now that if I miss a day for one reason or another, it's not going to be a big deal (not like it would have been earlier on in his recovery).

 

Our outside walks and exercise will stay the same - making sure to get a minimum of an hour of walking, etc., a day with playtime either added on or as part of the walk, as we have been doing, dependent on time and other circumstances.

 

And as for stockwork, "Away to me, Celt!"

 

[WildFlower]

That's great news Sue! I'm sure you and Celt are both very happy!

 

And thanks again for posting this journal.

[Gloria Atwater]

Sue, I am so happy for you and Celt! What a long and difficult journey it has been, but here you are, triumphantly at the end! Thank you so much for sharing your experiences, the good and the bad, the setbacks and the solutions. It's an encouragement to the rest of us who may one day face potentially life-altering situations with our dogs. Help IS out there. Good things DO happen. And your dedication and diligence throughout have been an inspiration.

 

My very best wishes to you and to Celt, and may he live out his days as the happy, healthy, hard-working boy he loves to be.

 

Congratulations!

 

~ Gloria

[2 Devils]

That is great news.

[ness_bc]

Great news and I to have enjoyed the journal and following along with Celt's recovery.

[Sue R]

Thank you, friends!

 

It's been a journey and a real learning experience. But like many other aspects of life, it's not over. Maintaining Celt's soundness will be an ongoing process; watching for signs of any damage to the other ACL will be something I'll always be doing; and being grateful that we could help him with surgery and rehab/therapy is something is something I should always be feeling.

 

Best wishes with you and your dogs in all your endeavors!

[ness_bc]

Lame dogs are certainly a journey - fingers crossed he remains fit and sound (I am still hoping I can get a dog to that point ).

[Sue R]

2 March 2013 - over eight months post-op and about seven months of rehab/therapy

 

Celt is doing really well. He seems to be very sound although we know that because of the change in joint angle, his stride is not actually symmetrical. However, his gait seems very functional and is causing no visible problems.

 

I'm taking him to Shari about once a month for a cold laser and just so she can evaluate his condition. So far, so good!

 

Meanwhile, Megan has had an occasionally-recurring, usually minor, limp on her left front leg. So I got her an appointment with Shari just to have it checked and, if indicated, get her cold-lasered. To my surprise, the problem seemed located in her left wrist - it has significantly-reduced mobility both in flexing and extending than the right wrist. And her right hind leg, which is the diagonal hind leg, shows a bit less passive range of motion, which is not unusual as the diagonal limb often is "off" as the animal compensates for an injury in a limb. And she also seemed to show a little bit of mid to lower back discomfort, which also is not unusual as a result of an uneven gait.

 

The diagnosis (and we did not do any xrays to confirm) appears to be that Megan probably injured that joint some years ago. When it first happened, she was quite lame for several weeks, and rest restored it to apparent soundness. At widely-spaced intervals, particularly when overdoing things, she's been a bit gimpy on it but nothing that didn't resolve within a very few days, sometimes with a little rest and sometimes with normal activity. She has probably developed some arthritic changes in that joint at this point - that and/or just irritating an old injury has resulted in her being painful in that joint and less flexible. But this time, it's just not "going away" like it has in the past.

 

So we did a cold laser treatment - once Megan realized it was all about *her* and it felt good, she was all for it. Shari also gave me a couple of exercises, which are pretty minor and will only take a few minutes twice a day. One is the normal ROM exercise protocol for the hind leg, to help stretch and improve its range of motion.

 

The other is a bending and extending exercise for the affected front leg joint. Since Meg demonstrated excellent ROM for the other hind leg and both shoulders and front legs (she was more flexble than Celt, who has full ROM for his limbs now), Shari felt those didn't need additional effort.

 

So, we'll go back in one to two weeks, depending on how she progresses this week. I am becoming a fan of cold laser as I see my dogs, and others, who certainly seem to have greatly benefitted from it.

[Sue R]

After being wonderfully sound and able to work well, this winter took its toll on Celt. Heavy, wet snow that then packed and froze hard; layers of ice; and nasty spring mud and rough fields, resulted in some intermittent discomfort and lameness. Each time, a couple of days and he would be good as new apparently. And then about four or five weeks ago, he turned up very lame during one of our hike/bike ride outings up the road, something we have been doing daily for a while.

 

This time, it looked very painful and not just like a bit of overexertion on the part of a dog who's 11 1/2. I took him to Shari that evening and his ileopsoas and quad muscle on his non-surgical (left) side were both in spasm and hard. For a week, we used Rimadyl and gentle exercises which seemed to have a good effect, and then several more weeks of the same, and then a week of muscle relaxant and the exercises, all along with a reduced walking time of only about 10 minutes twice a day.

 

Shari was not happy with his slow progress but he was still showing progress. Last week, she suggested I get a second opinion and some xrays to make sure there wasn't anything else going on. So far, he was not showing evidence of an ACL tear on this second side, which is always a concern with a dog that has had one already.

 

I had him to the vet today as I could not take him to the ortho specialist without a referral. Since this was not the leg they had treated before, I had to take him to one of our regular vets. The one who saw him today, who has not seen him before, felt that it was an ACL tear and I was pretty upset.

 

Then tonight, when we walked into Shari's, the first thing she said was, "That is not the same limp." She confirmed what I was thinking earlier today, that the limp I was seeing today was not the same limp we'd been seeing for the past month or so. While he hadn't been exhibiting the typical toe-touching of an ACL tear, he was doing a flat-footed "hover" with that leg - not the same but not that different, either.

 

He is now, within the last two days, showing the classic symptoms of an ACL tear. Apparently, the ileopsoas injury had healed to the point where it is essentially non-influential and no longer masking the problem with the stifle. And, probably, the significant degradation of the ACL has been happening over the last four or five weeks while we've been treating the symptoms of the ileopsoas problem.

 

The ACL has probably been losing integrity since the winter when he began to hurt sporadically after exertion in the nasty snow/ice conditions, and then in spring work, and also more challenging spring exercise. He was probably losing some strands which would result in discomfort of a few days, and then he'd seem fine again as he still had enough ligament to keep things pretty normal.

 

Tonight, we were also able to see a difference in the wear pattern on his hind foot pads, very subtle but visible. That was not there a week or two ago because we looked. And his thigh measurements were another indicator - last fall, the thighs were symmetrical. In the winter, the right (surgical) thigh was 40 cm and the left (the "good" leg) was 39 cm. It wasn't a cause for concern with such a small difference but tonight we found the right thigh to be 39 cm (with his reduced activity, that was no surprise) but the left thigh to be only 37 cm, a significant difference and a good indicator (along with everything else) that he's probably got a complete ACL tear.

 

So I'm waiting to hear back from the ortho specialist about a consult and scheduling surgery. He warned me back after the first surgery that he felt the chance of Celt tearing the second ACL was about 79%, based on the angle measurements of his leg bones. Not what I wanted to hear but at least we should be able to be on top of this shortly. Plus, unlike the first time, I will keep him reasonably but gently exercised so that he doesn't go into surgery with the great deal of muscle loss that he did last time, which really set his recovery back as he had to regain strength so much.

 

I feel so bad for Celt and I also want to say, "Not again, please." At least we know what we are in for if the diagnosis is confirmed.

[Tilly's Handler]

I am really sorry to hear about Celt

 

Dan & Tilly

[Tommy Coyote]

Oh, shoot. Poor Celt and poor you.

 

Do those tears ever really heal up? Do you know of any that were really back to normal and stayed that way?

 

It seems like I just hear over and over that they re-tear. Or the other leg gives out, too.

[NCStarkey]

Hi Sue,

So sorry that Celt now has injured the cruciate in his other stifle. But, as the orthopedic surgeon mentioned after Celt's surgery, it was highly probable that this would happen. That, of course, doesn't make the news any easier to take. It is truly disheartening to have put a dog through the surgery, the healing and rehab after surgery, and then be faced with it again (not to mention the expense!). It's the pits.

Best wishes,

nancy

[Sue R]

I know you have been through this with Rye, Nancy. This time we are making a concerted effort to keep Celt better fit and muscled, which should aid with recovery. Meanwhile, I am anxiously awaiting a call from the specialist to find out when his consult/surgery will be.

 

Working the whole herd today for vaccinations and castrations has helped me not think about this hardly at all for the day.

[alligande]

Sorry to hear the bad news, I hope all goes well.

[Covelo Dogs]

Sue,

I am so sorry to read about Celt.

Hope consult with vet is positive.

As Nancy stated, "it is the pits".

Suki

[Sue R]

Oh, shoot. Poor Celt and poor you.

 

Do those tears ever really heal up? Do you know of any that were really back to normal and stayed that way?

 

It seems like I just hear over and over that they re-tear. Or the other leg gives out, too.

The way I understand it, the ligaments are composed of a number of fibers so, like rope, they are strong because of the numbers of the fibers. A dog can have an injury that involves the tearing of a few fibers and conservative treatment can result in a pretty good outcome. In a dog like Celt, whose joint angles predispose him to potential degradation of the ligament, a rather minor injury that tears a few fibers weakens the ligament and makes it easier for more and more fibers to break (or for damage in the first place, whether through trauma or wear-and-tear).

 

Torn fibers do not mend although for dogs (with partial tears in particular) conservative treatment (maybe using a brace) can allow scar tissue to build up in the joint and the dog can live a pretty comfortable, normal life - but that's not really an option for active dogs like these. It's an option for more sedentary dogs.

 

The surgeon showed me a photo of what a torn ACL looked like - when fresh, it looks rather like a shredded rope or string (or a fiber optic decoration) with fibers splayed out. As time passes, the ends "retreat" and it looks more like you've taken a nylon rope and used a match to melt and seal the ends, like blunt stubs. That's what Celt's was like when he had his surgery on the right leg, not a fresh, new tear but an older tear.

 

I am grateful to have access to a good facility, a good rehab, and a bank account that will reel from the shock but recover...

[Sue R]

Here is the link to a good page about ACL tears and repair alternatives from the UK -

 

http://www.fitzpatrickreferrals.co.uk/our-services/surgery/conditions/hind-limb/cranial-cruciate-ligament-injury

 

It explains things very clearly. It also uses the proper term, CrCL (cranial cruciate ligament) while we commonly in the US call it ACL (anterior cruciate ligament and its partner, CCL or caudal crucial ligament).

[Gloria Atwater]

Aw, heck, Sue. I'm so sorry to hear this. Poor you and poor, poor Celt. I hope the road ahead will go smoothly for you both. You're such a good caregiver for your dogs.

[Sue R]

Fortunately for Celt, he's not the worrier that I am. He wants to be his bouncy self even though I know there's pain involved. He's getting accustomed to walking a short distance with the rest of us and then coming home with Ed (or me walking him home and then setting out again with the other dogs). He was miserable the other day when he knew Dan and we were moving cattle and he was stuck in the house. It's a matter right now of keeping him gently active so he doesn't lose too much muscle mass and tone and gently inactive so he doesn't put stress on the joint and encourage inflammation.

 

Thank you, all, for your kind words and concern.

[Camden's Mom]

Hey Sue, I was just checking the thread for updates. I know you'd said you were waiting for a consult with the ortho specialist and I was wondering if it had happened yet and, if so, how it went.

 

I feel so bad for you and Celt. I'm starting to worry that I've got one of those dogs who will struggle to be sound his whole life and it just feels like such a daunting task. Celt is lucky to have an owner as devoted to his recovery as your are. I'm keeping my fingers crossed for you two that the consultation went (or goes) well...

[Smalahundur]

Another one who sorry to hear about Celt, I really hoped for you two he would have been sound after his first operation.

Also wanted to thank you Sue, for this very informative first hand experience topic. You obviously put a lot of effort in it.

[Sue R]

Thank you, all, for your concern!

 

It's been interesting. Because the place where his previous surgery was done is by referral only for specialty cases (other than emergency visits), I took Celt to a vet at our local practice last Friday. This is the first time I have used this particular vet and I really liked her (she also did the surgery on Megan's eyelid two days ago, removal of a papilloma from the inner eyelid surface that has been small for years but began to get quite larger in recent months).

 

She examined Celt, took xrays, and had her tech fax the referral to the specialist (and she told me this week that she watched as it was faxed, so it was faxed). I waited for that to be done and (as according to their website) called to schedule an appointment. Contrary to all my other dealings with this facility, I was treated (I felt) rather bluntly and rudely by the person to whom I was talking. She said that she could not check to see if the faxed referral had arrived; she didn't know why vets were always telling their clients to call to schedule (duh, maybe because your website lists that as the right protocol); and essentially said, "Don't call us, we'll call you." She would only say that should happen within 12-24 hours (of what, I might wonder) and that she could not even give me an idea of how far out we might be talking for an appointment.

 

So I waited until Thursday when I dropped Megan off and asked our vet office to check with this specialty office. They did call and the person who helped them was appalled that I had been treated as I had been, and also said that they could find no record of the referral ever being received. So my vet office re-faxed it and they said they would call back if they did not receive it within two or three hours.

 

It obviously got there this time but more than 24 hours later, I was still waiting for a call. Finally I called my vet again and they called the specialty facility again, and I did get a call - this time to my home phone number, which is *not* the number I give for contacting me (but which my vet sometimes uses in spite of my asking them to use my cell - mistakes happen). Fortunately, my vet had told me to go ahead and call the specialty back and I did get through to someone who was helpful, which is what I was previously used to expecting.

 

So, here's the news - Celt is scheduled for the consultation three weeks from yesterday (if things hadn't been screwed up in the first place, as in if that person I spoke to had been willing to work with me rather than just tell me what she couldn't or wouldn't do, we'd be talking two weeks at this point). Because that's a Friday and there will be no surgeries until the Monday, I'll have to bring him home (or pay boarding for the weekend, which I won't do) and then take him back, hopefully that Monday for the surgery.

 

I did ask for the same vet as last time but the person helping me pointed out that Celt would be seen and get the surgery about a week earlier with this board-certified vet, and that using a different vet for the same procedure should yield the same results, I went ahead with her advice.

 

Meanwhile, I walk him twice a day for about 10 minutes at a time, up the road/hill and back down again, so he can keep as much muscle tone as possible without stressing his joint any more than necessary. I'm also taking him for laser treatment once weekly, to which we added (this week) an underwater treadmill session, another way to help maintain his muscle tone while minimizing impact on his legs and joints.

 

Last time, a huge reason why it took him about six months to recover versus the expected normal three months or so is because he was so debilitated by crate rest (almost three months of very limited exercise as we tried to treat conservatively and then avoid over-exertion) that it took a long time to build up any strength, muscle tone, and balance in his legs. We are hoping to avoid this and "prep" him for surgery and recovery by keeping him moderately fit. Plus I do his range-of-motion exercises twice a day, to help him stay flexible and monitor his muscle tone and pain.

 

So, that's the news. He's happy but sometimes a bit sore and has a noticeable limp, particularly if he breaks into anything faster than a gentle walk. He's getting some Rimadyl twice a day primarily to combat inflammation, and it also helps in pain moderation. He's loose in the house when we are here, and confined (with Little Miss Conehead) to an enlarged xpen when we can't monitor him. That lets him move about and be less stiff than if he was crated but prevents him from being too active. He'd be more active if he could be.

[Sue R]

It's been nine days since I had Celt to Shari but today I forgot to do two things - I normally don't give him his Rimadyl at the feeding before a visit so she can more easily see if he's hurting and I don't normally walk him before his visit unless it's a half-day beforehand, so he's fresh for his visit. I forgot both...

 

Shari did his laser and stretches, and he did okay. She felt his joint and could not detect any swelling so the Rimadyl should be doing its job. Actually, noticeable swelling (or heat) has not been an issue this time, another reason why we think this time (as before with the othe leg) the ligament may have been deteriorating a bit at a time rather than suffering a major disruption.

 

He did three sessions in the underwater treadmill, with the water depth and Shari both supporting a lot of his weight. She had hoped to make each go for two minutes but he tired a little fast for that, which was probably due to having had his 10 minute walk only an hour-and-a-half beforehand. With each session, we could see him placing his feet closer to the midline under his body as he tired, and also really favoring his (new) bad leg, holding the leg so that the hock was in towards his midline and the toes facing a bit out. That was a position that was putting less stress on the joint.

 

She measured his thighs - when he was fully sound after his first surgery, they both measured at 40 cm. Several months ago, we noticed that the right was still at 40 but the left was at 39. At the time, we both thought that might be simply be due to the way he was working each hind leg, just a little differently because of the surgery having changed the angles of the joint. Now, in retrospect with what we know now, we realize that that was probably the first indication that there was some deterioration in the left knee joint and he was beginning to favor that leg, but not to any extent that could be noticed. However, the minor and transient episodes of mild limping after over-exertion were probably also a symptom rather than just a bit of old age and overdoing things.

 

Today's measurements were 38.5 cm and 36.5 cm but the measurement on the left leg (the smaller measurement) was not very accurate - he was certainly favoring that leg and not putting weight on it when he stood, which would skew the measurement to a smaller apparent size. So, basically, while he has still lost some muscle mass and tone with reduced activity (and, on the left leg, with favoring that leg), he still is retaining much of the muscle and tone. So we'll continue with his twice-a-day 10 minute walks, an occasional extra walk, and being loose in the house when I am home and confined to a larger xpen area when I am gone. This is an effort to maintain his muscling and strength as much as possible while minimizing the effect on his joint, to help reduce the time it takes him to recover from the expected surgery this time.

 

Hopefully, this approach (plus, also hopefully, not having me fall down on him and hurting his ileopsoas muscle during his early recover time) will help to shorten the rehab period, maybe as much as two months, for a more normal recovery (last time, it was about six months, or two to three months longer than is often the case). We'll see!

[Sue R]

One week later, and I managed to remember to both not walk him before his 9 am visit and not give him the Rimadyl so Shari could really see how he moved without it and feel for inflammation in the joint. I am trainable, it just takes a while to get the point across to me.

 

She did the laser and measured his thighs. We were fortunate in that someone made a loud noise in the laundry room next door to Shari's rehab room, and it startled Celt (a big stainless dog-bathing tub was bumped and made a rather thunder-like sound) so that he stood squarely on his hind legs for a few moments, enabling her to get a good measurement on both. To our surprise and pleasure, he measured 38 cm on each side.

 

So, while he had lost 0.5 cm on the right side since last week (and that may not have been that accurate as he was putting all his weight on that leg last week), his thighs were even and so he is using both hind legs reasonably well, and both are in much better condition than they were going into the first surgery two years ago. This is the aim of our program with him, to keep him as reasonably fit and his muscling as reasonably good as possible under the situation, to help enable a better, faster recovery after surgery.

 

He did the treadmill well, doing three sessions of two minutes each, without any real tiring. I wish I'd remembered the camera because the first session was notable because he leaned very much into the right hind leg and Shari as she supported him in the deeper (for buoyancy) water; then she adjusted how she supported him so he could not lean on her and his second session went well; the third session saw him trying to lean as he tired a bit but she didn't let him lean on her and so he was dependent on his own legs. It was easy to see the difference as I watched but without the camera, I missed the chance to document the differences.

 

She checked his weight and he was 42.5#, just about where we'd like to see him as extra weight will just add stress. His "optimal" weight is about 42-43#.

 

This coming Friday is the consult with the surgeon and, should the diagnosis be what it obviously seems it should be, the surgery should happen the next week. We've been through this all before but are experienced now and know what to expect, and Celt is in much better condition than he was last time.

 

Shari felt that it was about right to expect a recovery/rehab period of four months (maybe a little less) this time versus the six months it took last time. Part of that was his lack of condition prior to surgery; part was a small accident that hurt his ileopsoas and set him back about a month in his progress; and part was my not being aware enough of when enough was enough and too much was too much, and sometimes overdoing things and impeding progress.

 

Wish us luck this week and Friday at our appointment!

[gcv-border]

Good Luck. It sounds like Dan is well-prepared for surgery.