ACL Injury and Repair, part 1

"Every cloud has a silver lining." "When life gives you lemons, make lemonade." If Grace had to have knee surgery, at least I can get a few blog posts out of it, no? This way, she and I can help educate others about life after an ACL.

First, some anatomy:

I don't know who created the knee, but it is the worst designed joint in the body. Instead of a ball and socket joint, like the hip or shoulder, the knee joint is simply one bone sitting on top of another, held together by several ligaments.

In this first drawing of the knee (stifle) joint, we have the bottom of the thigh bone (femur) sitting on top of the shin bone (tibia.) In between the bones are the menisci (singular meniscus) - cushions that act as shock absorbers of the knee. The kneecap (patella) is at the very top of the drawing. On either side of the stifle joint are the collateral ligaments, those on the sides of the knee. In the middle are the two cruciate ligaments.


Cruciate comes from the Latin crux, meaning cross. You can see the crossed ligaments forming an "X" in the middle of the joint. The ligament in the front is the Anterior Cruciate Ligament, which vets call the Cranial Cruciate Ligament. I'll use the abbreviation ACL for short, since most people are familiar with that term. It is the one most prone to injury or failure.

These cut-away drawings show the ACL, highlighted in pink, in action. The first drawing shows the knee in extension (straight)


while the second drawing shows the joint flexed. In this second drawing, you can see the tension in the ACL as the knee bends. It is this action which puts the ACL at risk for trauma or failure.


If you watch any sports at all, you have surely heard the phrase "blew out his knee," or "ruptured his ACL." Traumatic ACL rupture occurs when the leg is suddenly rotated while the knee is bent at a 20-50 degree angle. This might happen if the dog made a sudden right turn while bearing weight on the right rear leg. The internal stresses cause the ligament itself to rupture, or cause it to tear loose from its attachment to the bone.

Ruptured ACL

How does your veterinarian diagnose a ruptured ACL? Or, better yet, how do I diagnose an ACL in every other dog that comes through the door except mine?

History is very important. "He was running in the back yard and suddenly, I heard him cry out. He came back carrying a back leg, and he won't put it down at all." Most people guess "broken leg" with these symptoms, but my first guess is always a knee injury. ACL is the most common cause of acute rear leg lameness in dogs.

Breed, age, and body type are important clues in making the diagnosis. Large breed dogs, like Labradors and Rottweilers, are predisposed to ACL rupture, although I have seen it in small breed dogs like Beagles and even in one cat. There are two basic types of dogs who present with ACL: middle aged, overweight, sedentary "couch potatoes," and young, athletic, active dogs. While the exact mechanics vary between the two types, the end result is the same.

On physical exam, there is usually some degree of pain on manipulation of the stifle joint, laxity (looseness) in the joint, called a "drawer sign," and occasionally effusion (fluid) in the knee joint.

demonstrating drawer movement

Radiographs (X-rays) are usually negative for any abnormalities, but are often taken to rule out other injuries.

Grace's right rear leg

and her (normal) X-ray
Sorry, I couldn't flip the picture to keep the orientation the same.

So, how did I miss the diagnosis of ACL in Grace's case? Well, first, I told you I wasn't always rational when it comes to my own pets. Secondly, Grace's history didn't fit the typical ACL presentation. Yes, she is an older Rott, but she is neither overweight and sedentary nor young and athletic. Also, she didn't present as an acute, non-weightbearing lameness, but as a slowly progressive condition. Finally, I was unable to demonatrate any laxity (lack of drawer sign) whenever I palpated her knee joint.

Dr. Shrader explained to me that Grace most likely had a degenerative failure of her ACL, rather than an acute trauma, which fit her clinical signs and the slow progression of her lameness. Also, he showed me how she was painful on hyperextension of the joint, something which he said was classic for ACL. When I asked about the lack of a drawer sign, he told me, "I think we rely too much on drawer sign for diagnosis," and gently reminded me that "Every stifle lameness is ACL until proven otherwise," something I knew, but blanked out.

Next post: Two surgical options for ACL repair, and I why chose the one I did.

The NAVC - The Gaylord Palms

A large part of the North American Veterinary Conference was held at the Gaylord Palms hotel. This is a pretty swanky place, and a little country mouse like me was easily overwhelmed by its opulence. Here is a shot of the exterior facade (taken from the flag pole):


And here is a view from the front of the Palms, looking back at where I had been. On my walk from the drive to the front door, I saw my first warbler of 2008 - a Palm Warbler. Very appropriate.


This dolphin statue filled the space between the first floor and the mezzanine as you walked from the convention rooms towards the hotel.


This was on the ceiling in one of the convention rooms. At first, I thought it was a light fixture, but I never saw it lit up. I guess it was just decorative.


Even the bathrooms at the Palms were snazzy. Each stall I was in had this lighted icon on the back wall.


While I was visiting one of the well-appointment ladies' loos, I happened across a harried employee making her rounds. I complimented her on her work - keeping three large public restrooms neat and clean when there are thousands of women using them all day long has to be a tough job. It's nice to be nice - say "Thanks" when you see people doing a thankless task.

The area between the convention center and the hotel is filled with a sort of indoor courtyard.


The inner hotel rooms look down onto this public square. Around the perimeter were bars and shops -


In the middle was this naturalized area, complete with waterfalls, trees and other plants, including orchids.

Oh, yes. And alligators.

Lynne, this BIRD's for You!

Lynne, at Hasty Brook, has an almost unnatural fondness for vultures. She is always begging Susan for pictures of RAPTOR's resident Turkey Vulture, Earl. I don't know why she is attracted to a bird most of us think of as smelly, ugly and disgusting, but I'm glad she is. Someone needs to love the poor unlovable vulture. So, when I ran into a flock of Black Vultures in Florida last month, my first thought was "Lynne will LOVE these photos!"

My cousin Nancy and I (yes, she of American Bittern fame) were walking around the impoundments at Lake Woodruff National Wildlife Preserve. We were surrounded by egrets, herons, and cranes. It was idyllic. Up ahead, I saw a flock of vultures on the ground.

I assumed they would fly away as we approached,
but they didn't.

We got closer. They didn't budge.

Black heads, white legs and short tails say Black Vulture.

I think the bird on the left is a juvenile, but I'm not sure.
Anybody want to weigh in with an opinion?

We got closer. One or two walked off, while the others casually strolled in front of us. This was weird.

Good grief! This is ridiculous.
Does nothing frighten these birds?

Finally, one flew. See the white wing tips? That is an important field mark when distinguishing between Black and Turkey Vultures.


Up ahead was an observation platform, and it, too had a resident population of Black Vultures.

One of them was bold enough to land on the railing two feet from me.

"I'm ready for my close-up, Mr. DeMille."

"Be sure to get my good side."

A face only a mother (and Lynne) could love.

Gracie's Home!

Grace came home last night, but we were both too exhausted from stress and pain (her leg, my tooth) to do much more than crash and sleep. Today, we both feel better.

Because a lot of people that I worked with at the EVC now work at the CARE Center, Grace saw some of her old friends, and met some new ones, too. Dr. Daniel and animal nurse Gloria were both there when I picked her up, and nurse Aimee ran her anesthesia the day before. Everybody commented on how good and sweet she was, naturally.

Depsite her many fans, Grace was eager to go home. Here she is, pulling the assistant across the waiting room, trying to get to me. I didn't have time to compose a photo, just aimed and shot, as you can tell.


It is always harder, seeing your own pet post-operatively than a patient. Grace whimpered as she climbed up into the back seat to leave, and again when she got out of the car. Back at the office, we loved on her and gave her treats, then put her in a cage up front for the rest of the afternoon. She ended up with her face in a back corner, and I had to turn her around so she could see out.


I don't know if you can tell, but she was a little distressed Friday afternoon. Her face, as well as her body position, shows her level of anxiety, especially compared to the more relaxed photos from Thursday's post. She wouldn't take her pills in Pill Pockets, so I had to force them into her. She wouldn't even eat a Trader Joe's chicken jerky strip, until I broke it into tiny pieces and hand-fed them to her, one by one. She just wasn't my Gracie, and it was breaking my heart.

When we got home, Holly had to sniff her all over, especially her leg, till Grace actually growled a little, totally out of character for her.

Today, she is not crying, is more interested in food, and is pulling me as I walk her around the yard on a leash. She made the rounds of the bird feeders with me when I filled them this afternoon. When we came back in, I had her lay down in the living room, in front of a space heater (which she loves) while I went to my computer room, but she wouldn't stay. She got up and followed me back here, and is laying in the sunbeam, keeping me company. That's more like her!

This is a typical posture for a dog 24 hours post-op cruciate surgery:


Actually, in Grace's case, I think it is a little better than average. Most dogs don't put the foot down for several days, and she is actually touching her toes to the ground, although not bearing any weight as yet. That's good. We don't want her to stress that healing joint just yet. In fact, we have 6 weeks of strict rest - leash walk for potty trips and that's all - before we can start any kind of rehab.

Wanna see my new digital SLR camera?

Grace's right rear leg after ACL surgery

Looks a lot like a Rottweiler leg, doesn't it? I had planned on using my income tax refund for a new and better camera, but instead I put it into Grace's surgery. Oh well, there's always next year for a new camera.

Here's a photo of a trip to Scotland:

Grace's left front leg after radiation therapy

How many legs does this dog have, and when will I be done paying for them?

Florida Trip List

Birds Seen in Central Florida

Jan. 18-26, 2008

1. Pied-billed Grebe
2. American White Pelican
3. Brown Pelican
4. Anhinga
5. Double-crested Cormorant

6. AMERICAN BITTERN*
7. Great Blue Heron
8. Great Egret
9. Snowy Egret
10. Cattle Egret

11. LITTLE BLUE HERON
12. TRICOLORED HERON
13. Black-crowned Night-Heron
14. GLOSSY IBIS
15. WHITE IBIS

16. ROSEATE SPOONBILL
17. Wood Stork
18. Mallard
19. MOTTLED DUCK
20. Blue-winged Teal

21. Lesser Scaup
22. Ring-necked Duck
23. Hooded Merganser
24. Red-breasted Merganser
25. Black Vulture

26. Turkey Vulture
27. Osprey
28. Sharp-shinned Hawk
29. Red-shouldered Hawk
30. Red-tailed Hawk

31. Bald Eagle
32. Wild Turkey
33. Common Moorhen
34. American Coot
35. Sandhill Crane

36. LAUGHING GULL
37. Ring-billed Gull
38. Great Black-backed Gull
39. ROYAL TERN
40. FORSTER'S TERN

41. Rock Pigeon
42. Mourning Dove
43. Belted Kingfisher
44. Downy Woodpecker
45. FLORIDA SCRUB-JAY

46. American Crow
47. Fish Crow
48. Tree Swallow
49. Carolina Chickadee
50. Carolina Wren

51. Blue-gray Gnatcatcher
52. Hermit Thrush
53. American Robin
54. Northern Mockingbird
55. European Starling

56. Yellow-rumped Warbler
57. Palm Warbler
58. Northern Cardinal
59. Eastern Towhee
60. Savannah Sparrow

61. Common Grackle
62. Boat-tailed Grackle
63. House Sparrow (1)


All told, I had a trip list of 63 species, with 11 Life Birds.

The Common Moorhen had been on my Life List as a "heard only" bird. This was the first time I saw one. I had seen the spoonbill and both ibises in a zoo, but this was the first time in the wild. The Red-breasted Merg and G. Black-backed Gull were my first USA sightings; I had previously seen both species in Scotland.

*LIFE BIRDS in CAPS
Featured birds in italics

What the Hell is This?

I got stuck behind this thing yesterday morning, on a narrow, winding, country road with no passing places.

It was moving slower than molasses, and of course, every time it had an opportunity to turn, it went the same way I was going.

Oh my God - now there are two of them!

Could we GO any slower?

No, no, no - Don't turn that way!

What IS this thing, any way?

Grace Goes to the Vet

Grace Ellen

I know, I know - I can hear you all saying, "Grace lives with a vet, why would she need to see go some place to see one?" Well, as much as this pains me to say, I don't know everything, and I can't diagnose everything I see. [I know - you are all stunned by this confession, aren't you?] Plus, when it comes to my own pets, I am not always objective.

Grace, my beloved 8 1/2 year old Rottweiller has been lame for over two months now. It started about mid-November, as an occasional and subtle little gimpy step, so mild that I said to myself, "Did she just limp?" At first, I wasn't even sure what leg it was on, but by Thanksgiving, I had narrowed it down to her right rear leg.

At first, I did what any good pet owner would do: I ignored it. "Maybe it will go away," I rationalized. "After all, it isn't too bad, and she and Holly do some crazy things as they run around the back yard. Maybe she just pulled something. Maybe it will go away."

As the lameness became more pronounced, I could no longer take the head-in-the-sand approach. She was definitely painful in her right stifle (knee.) I started her on Rimadyl, an NSAID (Non-Steroidal Anti-Inflamatory Drug) like Advil for people, but I delayed X-raying her.

You see, in veterinary medicine there is a saying: "Osteosarcoma (bone cancer) is found AWAY from the elbow and AROUND the knee." And, in my dogs, my first thought is never "muscle sprain," but "Cancer." I didn't want a diagnosis of cancer before Christmas, especially just after the 20th anniversary of my father's death from lung cancer.

Finally, finally, finally I X-rayed her knee, hips, pelvis, and lower back. Other than some arthritis in her lower back, a normal finding for an older large breed dog, I couldn't find anything wrong. I changed her pain meds and waited. And waited. And waited.

She didn't get any better. Drastic measures were called for. I needed help.

Right before I left for my trip to Florida, I couldn't stand it any more. I called the Cincinnati Animal Referral and Emergency (CARE) Center for an appointment with Dr. Steven Schrader, veterinary surgeon and orthopedist extraordinaire. I felt like telling the receptionist, "My dog has been lame for 2 months. I need to make an appointment this week," but I didn't.

The CARE Center is a 24 hour emergency service, and they also have specialists for surgery, cardiology, oncology, neurology and internal medicine who see patients on a referral basis.

Charlie Harper mural in the entry hall at the CARE Center

Our appointment was today. We arrived a little before 10am to check in. "Have you been here before?" "Yes." "Are your phone numbers and address correct?" "Yes." "Who is your regular vet?" "I am." "oh."

the waiting room at the CARE Center. They have 10 exam rooms!
See the guy in the blue shirt? That's who we're waiting for.

Dr. Schrader is the vet I took Grace to last year, when she had severe pain from a mass on her rib cage which I was certain was cancer. He touched her and miraculously healed her. I was hoping for another miracle today, but he told me he could only do one miracle per century.

His exam revealed a cruciate ligament rupture. I was: a) Relieved it wasn't cancer. b) Embarrassed to have missed the diagnosis, since it is the most common cause of stifle lameness in a dog, and c) Stunned to realize he was talking about taking her to surgery. As in today.

Grace waits patiently for her vet appointment.

So, I signed the forms and gave them my credit card and left the hospital without my dog. As I type, it is 5:30pm and I still haven't heard from the hospital. To say I'm nervous would be an understatement. I have every confidence in Dr. S., but still ....

Isn't that a face to inspire trust? And Gracie loves him, too.

Every vet should sit in the client's chair at least once, to experience what it is like from the other side of the table. With Grace, I have been in that chair three times. I think that's enough.

Updates later, with a discussion of cruciate ligament rupture and photos.

Pray for Grace.

> Update: 9pm. I decided to keep my plans to go to pottery tonight, instead of sitting around, worrying. Dr. S. called while I was on my way there. Grace is doing fine, despite having some heart irregularity during surgery. She was still pretty stoned on hydromorphone, a pain killer, when he called. (And the dentist told me to take ibuprofen for my aching tooth. How come dogs get all the good drugs?) She'll spend the night in the CARE Center's ICU, and I will pick her up some time tomorrow.

Thanks for all the good thoughts you sent our way. I can feel the love!