January 31, 2023

Originally Whiskey was supposed to have her consult and surgery on Monday, January 30th. However, we decided to use a different hospital for Whiskey’s surgery. On January 31st Whiskey had a consult with Dr. Kate Morris, the Surgery Department Head at Mount Laurel Animal Hospital. A great friend of ours, Amanda, is the Nursing Supervisor for Specialty Surgery at Mount Laurel Animal Hospital, so we know Whiskey will be in good hands, and the clinic is much closer to home.

Exam

Dr. Morris examined Whiskey and confirmed that there is a suspected cranial cruciate ligament injury (bilateral, right worse than left). It was decided that Tibial Plateau Leveling Osteotomy (TPLO) surgery will be performed on Whiskey’s right knee first. Four to eight weeks later, Whiskey will need a second surgery on her left knee in addition medical management.

Tibial Plateau Leveling Osteotomy (TPLO) Surgery

In surgery, the first step will be to look in the knee joint in order to confirm that the cruciate ligament is torn, and to assess the meniscus. If the meniscus is damaged, the damaged portion will be removed in order to provide pain relief.

Dr. Morris explained that during the TPLO procedure, a cut is made in the top of tibia, allowing her to rotate the top of the tibia to remove the slope. By altering the biomechanics of the joint, Dr. Morris will be able to negate the need for the cruciate ligament and provide a stable surface for the femur to rest on. The two parts of the tibia will be held in the new position with a plate and screws. Though the plate and screws are no longer needed once the bone has healed, most patients keep their implants for the rest of their lives unless infection or irritation occur.

Following surgery, most patients begin toe-touching within the first few days. By the two week recheck, most patients are consistently placing their leg though lameness will still be noted. This should steadily improve over the following weeks. Strict rest is required until the bone has healed, at approximately 8-12 weeks following surgery.

Potential complications associated with this procedure include infection, need for implant removal, future meniscal injury, patellar luxation, incisional complications, pivot shift, persistent lameness, and fracture.

Pending Whiskey’s progress with her right knee, surgery will be performed on her left knee as soon as 4 weeks after surgery on her right knee.

Medical Management

• Weight management
  • Keeping Whiskey lean will decrease the load going through her injured knee, and will
    also decrease systemic inflammation.
• Activity modification
  • Limiting Whiskey to controlled exercise such as walks and swimming as opposed to
    high impact activities like jumping and running may help maintain her comfort.
• Physical rehabilitation
  • Whiskey may benefit from enrolling in a formal rehabilitation program where her
    muscle mass and range of motion can be maintained while she is also mentally stimulated.
• Joint supplements
  • Glucosamine and chondroitin supplements are thought to support cartilage health. A
    recommended veterinary brand is Dasuquin.
• Omega 3
  • These fatty acids work as anti-inflammatory medications and can be particularly effective in
    treating joint pain. Recommended veterinary brands include Welactin, Nordic Naturals and Canine
    Omega Benefits.
• Non-steroidal anti-inflammatory medications
  • These medications are used to decrease inflammation and
    keep Whiskey comfortable. Examples of NSAIDs include Rimadyl/Carprofen and
    Metacam/Meloxicam.
• Pain control
  • As Whiskey’s arthritis progresses, other medications such asGabapentin, Amantadine or an
    opioid may become necessary to keep her comfortable, especially after periods of activity.

Procedure

Whiskey is scheduled for tomorrow morning, February 1st, for the first of her two surgeries. Dr. Morris said that the decision to have Whiskey spend the night at the hospital following surgery will be determined once Whiskey is awake and assessed.

Below is a journaled account of how we discovered Whiskey’s bilateral CCL tear. As with just about everything else our pack members acquire, it is never presented in textbook fashion, and always a puzzle to figure out!

January 8th 

Whiskey took a walk with Jägermeister. Nothing out of the ordinary was noted during the walk, and she was completely fine afterwards. About an hour later her hind end collapsed and she could not stand back up. This lasted only a few seconds and then she was walking normally…well…normally for Whiskey… Those of you who have been following along for a while now or who have met her in person know that she has a “wonky” gait due to a broken shoulder and broken growth plate – both acquired before she was rescued by Pointer Rescue Organization as our foster dog, “Wish.” We thought maybe she just tripped or lost her balance but to be sure, we put her on crate rest into the next day. She seemed fine and resumed normal activity…playing, walking, running, jumping up/down on the couch, etc. She continued to show absolutely no symptoms for the next week. 

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January 16

Whiskey and I took a walk with a friend and her dog. Whiskey was absolutely fine throughout the entire walk. It was a nice day so after the walk was over, I sat down to eat lunch with my friend and Whiskey remained her usual busy self for approximately 40 minutes, walking around and keeping an eye on the geese in the nearby lake – and then all of the sudden once again – her hind end collapsed. She got right back up and seemed fine – absolutely no limping. We had a 25 minute ride home. When we arrived to our house,  Whiskey could not support her hind end at all, and was not recovering. Luckily, our primary vet, Dr. Campbell, got us right in for an appointment.  When we arrived, Whiskey still could not support her hind end. An exam was performed and an X-ray of her spine was taken. No significant findings were observed. Dr. Campbell gave Whiskey a steroid shot and sent her home with Prednisone. Dr. Campbell suggested that we see a neurologist.

Radiographs:

Lateral TL spine (T4-Sacrum): Spondylosis at LS. No other significant findings.

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January 17

Whiskey was able to walk and was not limping.

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Jan 19: Neurological Exam

Whiskey was still displaying no symptoms at this time. Porter and Whiskey’s neurologist, Dr. Eagleson at BluePearl Pet Hospital, performed a neurological exam on Whiskey.

Physical Exam:

• General – BAR, appropriate, ambulatory
• ENT – No significant findings
• H/L – No murmur ausculted, lungs clear, strong synchronous pulses
• ABD – Soft non-painful, no masses palpated
• lUG – WNL
• PLN – WNL
• INTEG – Clean hair coat
• MS – BCS ~ 6/9, thickened right shoulder joint

Neurologic Exam:

• Mentation – Alert and appropriate
• Gait – Normal
• Reflexes – Normal withdrawal in all limbs; normal patella bilaterally; normal perineal reflex
• Postural Reactions – Normal
• Cutaneous trunci – Normal
• Cranial nerves – Normal
• Sensory – No pain on CTL palpation or neck ROM
• (NEUROANATOMIC LOCALIZATION – Normal exam

Diagnostics:

• Bloodwork
  • CBC: NSF
  • Vetscreen: NSF

Release Notes from Dr. Eagleson:

Whiskey’s neurologic exam was normal. In the video, it appears that she is having trouble/difficulty supporting weight in her back legs. This is causing her to shift her weight forward onto her thoracic limbs and she walks with her back arched. She would be taking on this posture either due to weakness or discomfort when bearing weight. I did not find any source of pain on her exam and her stifles and hips palpated normally. We performed bloodwork which was normal (including her muscle enzymes). A lack of blood flow to the back legs could cause weakness; however, she has no evidence of this (she has great femoral pulses). To further rule out a spinal cord problem an MRI is recommended. This is scheduled for next Tuesday (1/24/23). In the meantime, we are going to wean her off of the prednisone. If she has another episode, I would like you to try to evaluate her reflexes if possible.

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January 20

Whiskey began limping again, but this time only what appeared to be on her right side. 

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January 24: MRI appointment 

Whiskey was still limping predominately on her right side. Prior to our appointment, I had sent all videos I had taken to Dr. Eagleson. I took Whiskey to her MRI appointment and when Dr. Eagleson examined her upon her arrival, he suggested that we hold off on the MRI when he saw that she was now presenting in a different fashion.  He suspected that Whiskey torn her right CCL. Dr. Eagleson had the Surgical Team look at Whiskey and noted that if Whiskey were to continue to have episodes of hindlimb weakness after correcting her knee(s), we will pursue the originally planned MRI.

Dr. Deahl, a surgeon at Blue Pearl viewed all the videos and examined Whiskey. Dr. Deahl determined that Whiskey has a bilateral CCL tear after palpating her knees….a complete tear on the right, and a partial on the left. It was suggested to surgically repair the right side and then reevaluate the left side once the right is healed. It is suspected that the left will have to be repaired as well. An appointment to sit down and speak with Dr. Deahl has been set for January 30th. It is also quite possible that Dr. Deahl will perform surgery on Whiskey’s right CCL that same day.

Release Notes from Dr. Eagleson:

On exam today Whiskey had a consistent right pelvic limb lameness. On physical exam it was found that he had a torn right cruciate ligament. An orthopedic consult was performed which confirmed the right cruciate ligament tear as well as evidence of a partial tear/chronic remodeling in the left knee. I showed the videos to the surgery service who agreed that the way Whiskey was holding the right leg up is peculiar for a CCL tear. It’s also a bit strange that she wouldn’t bear weight in both limbs as episodes and then recovered. However, since there is evidence of the left knee not being completely normal, then it’s possible that she was just sore in both knees on those days (since it happened after longer walks). Although it’s possible two issues could be going on, I feel it’s more likely the cruciate tears presenting in a slightly atypical fashion. We discussed either performing MRI first to rule out a possible neurologic issue versus correcting the knee first. I feel that a 5 year old Pointer will need to have the knee fixed in order to remain highly active. The only reason not to correct the knee would be if there was something seriously bad going on in the nervous system (e.g. tumor), which I do not feel there is a high likelihood of. If Whiskey were to continue have episodes of hindlimb weakness after correcting the knee, we would always pursue MRI at a later date. At this time you have decided to follow up with the surgery service.

CCL Tears and How a TPLO Surgery Works:

More Great Resources That Were Shared With Me to Help Explain CCL Injuries and TPLO Surgery:

• VCA Animal Hospitals
• Colorado State University
• American College of Veterinary Surgeons
• Upstate Veterinary Specialties
• Fetch by WebMD
• Tibial Plateau Leveling Osteotomy – TPLO

FaceBook Groups:

• Canine Cruciate Recovery FB Group
• FB Group for Conservative Management (CM) Support