Monday, February 4, 2008

ACL Injury and Repair, part 2

So, now that you know what causes an ACL rupture, what are we going to do about it? Small, lightweight dogs with partial tears might heal with cage rest and pain meds, but most dogs require surgery. And if something needs orthopedic surgery, then I am going to refer you to a specialist. I don't do bones!

Dozens of surgical techniques have been tried over the years, but these days, we are down to two basic procedures - lateral imbrication and the TPLO.

The older procedure, lateral imbrication, involves passing a heavy-gauge suture from the lateral fabella (the little bone behind the knee joint ) to the crest of the tibia and tightening it down. This takes the place of the ACL, keeping the joint stable until scar tissue forms.

In this X-ray of Grace's knee, the fabellae are the three little bones behind the knee. There are two larger ones behind the end of the femur, and a tiny one behind the top of the tibia. The tibial crest is the ridge of bone that comes to a point at the front of the shin bone. The line between the fabella and the tibial crest follows the same angle as the old cruciate ligament did.

This is the procedure Grace had done, and this is what it looks like afterwards:

TPLO, Tibial Plateau Leveling Osteotomy, is a newer, more high-tech procedure. In this surgery, the tibia is cut and a piece of the bone is rotated and reattached with a specialized metal plate, thus changing the angle of the joint. The theory behind this surgery is that the angle of the joint is too steep, and thus the forces on the knee are too great. Those who advocate TPLO feels that the stifle needs "leveling" to eliminate those forces.

Many veterinarians feel that a lateral imbrication is only appropriate for smaller dogs, and that a TPLO is the only choice for large breed dogs. I don't have a three-dimensional brain, which is why I don't do orthopedic work, so I trusted Dr. Shrader. This is what he explained to me.

Because you don't open up the joint capsule in a TPLO, like you do in a lateral imbrication, the dogs are back on their feet faster, in two weeks instead of 1 to 2 months. From an owner's point of view, as well as a surgeon's, this is a Good Thing. We
all want our pets, our own as well as our patients, to be back to normal as soon as possible.

But, he continued, in both procedures, dogs must be leash walked only for 4 to 8 weeks, and then gradually returned to full use of the leg. After 6 months, he said, there is no difference in the use of the two legs. Both knees are at risk for arthritis, perhaps less so in the TPLO leg.

I chose the imbrication for several reasons. Number one, I wanted Dr. Shrader to operate on my dog, and he only does this procedure. A TPLO might get her on her feet faster, and would be my choice if she were a young, working dog, but given the fact that Grace is 8 1/2 years old and is slowing down, I don't need her to perform at a working level.
I doubt we would ever do any more agility work, anyway. The TPLO surgery also has a higher failure rate - infection, problems with the plates and screws, and nonunion of the osteotomy site are a few of the potential negative outcomes. Finally, a TPLO would cost about $1000 more than an imbrication. With a 30% chance that her other ACL will give out, I need to save my pennies for the next procedure!

There are many opinions on these two surgeries. Please go to the two links above for one surgeon's input. If your dog needs ACL surgery, discuss it with your vet and get at least one other opinion before you decide. What's right for Grace and I might not be right for you. If you choose a TPLO, the surgeon will have had specialized training in this procedure. Many vets, generalists like me as well as surgical specialists, can do lateral imbrications, but find out what that vet's track record is - how many surgeries s/he has done, and the success rate - before you commit your pet to his/her care.

Post-op instructions: Strict leash walking for 6 weeks, "necessary" trips outside and then right back in, that's all. Do you know what a hassle this is for somebody who is used to letting her dogs out three or four times a day unsupervised, knowing they will stick close to home? Still, we will follow doctor's orders, especially when he called it "protecting my investment."

Dr. Shrader is letting me manage Grace's medical care post-op. Other than wanting her on three days of antibiotics after surgery, he has given me freedom to choose her medications.

For our post-op antibiotics, 1000mg cephalexin (2 capsules) twice daily for 3 days.

For pain control, an NSAID (Non-Steroidal Anti-Inflammatory Drug) - 50mg Deramaxx once daily

combined with an opioid (morphine-like) drug, Tramadol. The two drugs work differently, and are a good combination. For the first 3 days, I had her on 200mg (4 pills) twice daily, but have cut her dose in half as of today.

Both dogs have been on Glycoflex II, a joint supplement, for some time, but during recovery, I have doubled Grace's dose to 1 tablet twice daily.

And, I added injections of Adequan, twice weekly for 3 weeks, to help stimulate healing of her joint cavity.

Well, that ought to be enough about knees to last you for a while. I will continue to update you on Grace's progress. Thanks for caring about my girl!


KGMom said...

Whew--I feel like I could go in for knee surgery now on my out-of-line joints.
Thanks for the in-depth explanation--very enjoyable.
And I will keep thinking good thoughts about Gracie.

Sara said...

I really appreciate your taking time to explain ACL repair. My little dog has had intermittant problems diagnosed as "stretched ACL" which will likely need surgery in the future. So, it is very helpful to learn about the procedure before that day comes, translation: while I am still calm and can think clearly !
Wishing an excellent recovery for Grace.
Sara in Michigan

Lisa at Greenbow said...

Just seeing those stitches makes me cringe. Ugh

Kathy said...

Thank you for sharing the information. I hope that my dogs won't need the surgery, but it is good to know about ACL repair, just in case.

Mary said...

Kathi, I really love this information you give. I'll count on it... Bookmarked it tonight. Hope Grace is feeling better each day.

Mary said...

And...I just sent your blog link to my daughter who owns a large Boxer-mix and a Bulldog. They're both under 3 years old. She'll enjoy your archives.

Eyes said...


Thanks for the information. I have a 30 pound American Eskimo mix who is 15. She is still very active, but lameness set in the past month. We found out yesterday it a severed ACL. My vet wants to do surgery. I'm torn and looking for insights. If you have any, I'd love to chat with you.