Lucky's ACL Tear - A Case for Conservative Management (Part 1)

Things were a lot different in our home a year ago.  I had just graduated from my knee roller walker to partial weight bearing after breaking my ankle in December of 2009.  At the end of January (2011), Lucky suffered from a torn ACL in her left rear leg.  After a two-week period of pain management, inflammation reduction, and extremely restricted activity, Lucky was on her way to her first consultation with Dr. Kara Keesling, a veterinarian specialist in animal physical therapy and rehabilitation.  My husband was doing his best to cope with the daily requirements of life and work with both of his girls having severely limited mobility.  But first, some background about how we got to this place.

Lucky’s injury was a result of chasing a squirrel.  Squirrel chasing requires a lot of quick turns, stops and starts.  The squirrel zigged, Lucky zagged, and there went the knee ligament.  We didn’t see the exact moment that it happened as she had chased said squirrel from our front yard to the neighbor’s back yard (our neighborhood is pretty relaxed about Lucky roaming a bit).  She came back limping and within hours could not bear weight on the rear leg.  At first we thought it was a strain of some type but as the evening progressed it got worse.  Her morning walk was a struggle and a call to the vet was made.

Our vet confirmed an ACL tear.  An anatomical model of the dog knee (stifle) gave us a visual of how the dog knee works.  The stifle connects the femur (thigh bone) and tibia (leg bone) with a patella (kneecap) in front and fabella (a small bean-shaped bone) behind. Cartilage (the medial meniscus and lateral meniscus) cushions the bones and acts as a shock absorber when your pet runs and plays.  Two key ligaments hold everything in place.  The anterior or cranial cruciate ligament maintains knee stability and keeps the tibia from slipping out of place.

TPLO (Tibia Plateau Leveling Osteotomy) surgery was recommended.  Briefly, TPLO surgery involves cutting and leveling the tibia bone and screwing a plate into place so the bone will heal in its new location.  The surgery changes the slope of the tibia so the cruciate ligament is no longer needed to prevent the femur and tibia from rubbing against each other.  We were advised that if left untreated, complications included lameness, deterioration of the meniscus, bone spurs, and arthritis.  Our immediate concern was if our 12-year old dog was really a good candidate for surgery.  I had always heard about increased surgical complications in older dogs as well as additional risk of anesthesia.  Lucky had a bad experience coming out of anesthesia about two years prior to this incident.  Our vet indicated that while there were always unforeseen circumstances, Lucky’s overall good health made her a suitable surgical candidate.  

We were quoted $3,000 for the TPLO surgery and were advised that in many cases (no specific percentage given, the brief research I have done shows 35 - 50%) after a dog has TPLO on one knee, he will need the same surgery on the other knee within a 12-18 month period.  No particular reason was offered, it simply seemed to be a fact that we might need to prepare ourselves for.   Because the injury had just happened, Lucky was in too much pain and there was too much inflammation for a surgeon to thoroughly determine the exact procedure.  Anti-inflammatories, confinement, and pain meds were prescribed for a 10-day period.  After that, we were supposed to bring Lucky back for a more thorough evaluation and to confirm findings by the surgeon in preparation for the TPLO. 

We left the vet with many mixed feelings.  On one hand, I was relieved - there was a solution of some kind.  On the other hand, I was anxious and fearful - the TPLO was an invasive and somewhat complicated procedure and there were no guarantees it was totally effective.  We got Lucky home and created a “play pen” in the family room by moving furniture into place.  A sign went up on the door for people not to ring the bell (visitors with the best intentions as well as UPS drivers dropping off goodies always ring the bell, sending Lucky on a sprint to see who is here).  We put the trailer on the bike so we could roll her out to what we thought was the most desirable place to potty.  I used a towel sling to assist her in walking down the hall to go to bed each night.

And I got on the Internet with a mission to research options.  As any pet guardian knows, making decisions for your beloved companion’s care is a bit overwhelming.  I felt a great sense of responsibility to do right by Lucky.  I wanted to ensure her the best quality of life for her remaining years.  Here we were having to make a decision for a living, loving creature that could not tell us what she wanted.  

I found several good sites with plentiful information on dog knee injuries.  ACL tears are some of the most common orthopedic conditions vets see in dogs.  Besides factual information, there are several sites devoted to people sharing their experiences with various treatment options.  I read everything I could about alternative treatments and surgeries.  I quickly learned that surgical options other than TPLO were available.  A good friend of mine had a 13-year old mixed breed dog of similar size and breed make up as Lucky who had suffered an ACL injury eighteen months prior to Lucky’s injury.  She opted for non-surgical treatment and her dog was active, happy and doing well.  Our neighbor’s Lab had suffered a stroke a few years back, and they had done rehabilitative work with Dr. Kara and were very pleased with the results.  Armed with more knowledge, references and resources, we decided that TPLO was not the best option for Lucky. 

So that is how we arrived at Dr. Kara’s office that February afternoon.  Nearly two weeks of strict confinement and medications had helped to reduce Lucky's pain and inflammation allowing Dr. Kara the opportunity to do a complete and thorough evaluation.  Lucky was able to relax enough that Kara could palpitate the injured knee and feel the instability and irregular movement of the tibia in relation to the femur through the “drawer test”.  She thoroughly evaluated all of Lucky’s limbs, major joints, range of motion, overall body musculature, weight, and gait.  Lucky had some positive things going for her — she had no other orthopedic or arthritic conditions, a good level of overall fitness, and was not overweight (48 lbs at the time).  On the negative side, it appeared that she had a full tear.  

We agreed to a 6-8 week trial of conservative management (CM) which would include medications, supplements, weight management, (Lucky was not overweight, but we didn’t want the lack of activity to cause her to put on pounds), rest, icing, laser therapy, hydro therapy, range of motion and specific exercises to be incorporated as her treatment progressed.  Being that I wanted to fully understand what might happen, Dr. Kara and I discussed surgical options should CM not be effective.  Kara evaluated Lucky as she would her own dog and she indicated if surgery were needed, she would opt for a less invasive procedure over the TPLO.  She assured me that if it came to a surgical solution, qualified, capable and surgeons willing to do the best procedure for Lucky would be available.  After that first visit, I felt like we had a plan of action that best represented Lucky’s interests.  

Stay tuned for the next post where I share specifics about Lucky’s treatment as well as her results.