I don't remember exactly when I noticed a problem with Journey's hind leg. It doesn't really matter, because as it turned out, the trouble started way before I saw it. I took him to our regular veterinarian, at Timberland. Of course I was dreading the possible diagnosis of it being a Cruciate Cranial Ligament tear, (CCL). He was no longer limping when I took him in, but his knee was swollen and sore. The veterinarian said to rest him and give him Meloxicam, (anti-inflammatory) Tramadol for pain, and Ligaplex I, a dietary supplement. I did this for several weeks, but as I observed occasional limping, I knew I needed to take him to the specialist.
Dr. Lozier had done a TPLO operation on Quest, when he was 7 years old. Dr. Lozier was so highly referred, I never considered anyone else. Quest never limped again, nor did his other leg ever have any problem, which is a common occurrence after surgery on one side. As often happens, or so it seems to me, Journey woke up on the day of our appointment, with out any sign of injury to his knee. We kept our appointment and Journey's exam lasted a couple hours. He was x-rayed, and handled to explore every area of both knees. He was diagnosed with an early partial tear of the right cranial cruciate ligament with bilateral stifle effusion and mild right sided stifle DJD.
The good news was that the tear was caught early, at a 5-10% partial tear. So we discussed every possible procedure for his problem. Dr. Lozier has seemingly endless patience and I could not believe how many questions I was able to come up with, that he patiently explained to me. Together, we made the mutual decision of what the procedure would be in reference to the proposed surgery. Dr. Lozier anticipated that in Journey's case, it was very likely that the other leg was in similar condition. We could not know exactly what we were dealing with, without the knee being scoped. I chose for him to plan to do both knees if, after scoping it seemed merited, and if the surgery on the right knee went well. Dr. Lozier told me he would call me as soon as he had all the information on it. We scheduled the surgery for August 19, 2016. Both of Journey's hind legs were shaved and prepared for scoping and surgery.
Part 1 Technical Description
Arthroscopic examination of the right stifle revealed moderate synovitis and synovial proliferation. There were mild osteophytes. A 5-10% tear of the cranial cruciate ligament was noted at the insertion in the caudolateral part. The radiofrequency and motorized shaver units were used to ablate portions of the fat pads to improve visualization of the cruciate ligament and menisci. The radiofrequency thermal shrinkage probe was used to remove some of the visible damaged portions of the cranial cruciate ligament. The remainder of the CCL was left intact. The medial meniscus was assumed to be normal but could not be visualized with the intact cruciate. The caudal medial miniscotibial ligament was not treated. Visualization of the medial aspect of the stifle caudal to the collateral ligament revealed a normal SMT and joint capsule. The medial meniscus was not treated. The caudal aspect of the lateral meniscus could not be visualized but was assumed to be normal. The lateral meniscus was not treated.
The articular cartilage appeared to have suffered an area ofgrade III(advanced partial thickness wear) damage on the craniomedial aspect of the lateral femoral condyle where it appeared that external rotation of the tibia resulted in impingement against the lateral aspect of the lateral intercondylar eminence. The insertion of the caudal lateral component of the damaged CCL appeared to be trapped between these two structures as well. Internal rotation of the stifle (tibia) appeared to relieve this area of impingement. Finally, radiographically the proximal tibia was in mild valgus and there was a mild external tibial torsion. For these reasons the tibial osteotomy was also internally torsed simultaneously with the TPLO The cranial aspect of the caudal cruciate ligament was moderately frayed.
While attempting to rotate the proximal tibia following the osteotomy no motion could be achieved. This confirmed the complete synostosis at the tibiofibular joint that was suspected from preoperative radiographs. A lateral approach was made over the tip/fib joint and an osteotome was used to separate the synostosis. Rotation was easily accomplished after this. A right tibial plateau leveling osteotomy was performed. The surgical separation at the synostosis was kept to a minimum and no attempt to stabilize this was made. Mild internal tibial torsion alignment was performed simultaneously with the TPLO and attempts were made to reduce the valgus by several degrees. The sites were lavaged. Closure was accomplished with 2-0 Vicryl Plus.
Arthroscopic examination of the left stifle revealed mild synovitis and synovial proliferation. There were no osteophytes. No tearing of the cranial cruciate ligament, was noted in the craniomedial band. A drainage canula was not made. The portion of the medial and lateral menisi that could be visualized appeared normal. Neither menisci were treated. In the same area were the cartilage damage noted grade I fibrillation was occurring on the left side. However, no cruciate fiber tearing had occurred. The cranial aspect of the caudal cruciate ligament was normal.
Comments: It's my impression that external rotation of the stifle +/- genu valgum is an important factor causing the impingement noted and the cartilage and cruciate damage and even potentially the synostosis. I am not 100% confident that the outcome can be expected as good with a typical cranial cruciate ligament tear which I believe is due largely to hyperextension. Furthermore the breakdown of the synostosis will somewhat compromise the stability of the TPLO. Finally there was less damage in the left stifle then expected based on radiographs. All these reasons contributed to our electing to stop after one side as opposed to continuing on with our original plan of a bilateral procedure. The owner had been for-warned with the possibility of stopping at side one and was satisfied with our decision making process.
Note: I omitted some of the technical description of the materials used in surgery: plates, screws, blades used, templates, etc.
The above is as technical as I am going to get on the description of Journey's surgery. I am also not going to post close up gory pictures of his leg, so you can breathe a sigh of relief. It is pretty serious stuff as they must cut the bone and reposition it. That is probably about as much as anyone wants to know anyway. But the description above explains why his TPLO was not as easy as the one Quest had, and why there are more worries associated with his recovery.
PART 2 The Long Recovery begins
Dr. Lozier called me a couple times during the operation, to report findings and double check on choices when he felt it important. I trust him and his judgement more than I can say. He is not only a wonderful surgeon, he is a wonderfully kind and considerate person. When the operation was finished he called me with a full description. Journey was still under sedation, so he said his tech would call me as soon as Journey was conscious. He said that there was a 95% chance that Journey could come home the next day (Saturday). He did.
I knew it would be scary. It was scary with Quest, but this one is worse. Possibly in good part because I know more and also because there are more troublesome areas.
I arrived 15 minutes early, at 12:15. First I went into an exam room and one of Dr. Lozier's team members came in and went over everything with me. She answered questions, discussed medications, and directions. When I felt fully informed she went to get Dr. Lozier. He came in with models, and diagrams and explained everything to me. I saw each bone that he was discussing and he showed me radiographs of the problem areas. It was all very interesting, if a little overwhelming. I was glad everything was also typed out so I could read it again. He instructed me to call with anything at all that I might want to ask. If something did not look right he asked that I photo it and email it to him. (He requested that if I did, to also please phone and leave message so that he would for sure check his email right away.) He said if the people I talked to when I called could not answer my questions to ask to be put through to his extension and leave a message directly to him. He said to call with any problems whatsoever, any time of the night or day. He said to ask for the tech in charge of taking care of Journey, and that I could call for a status report on him at any time I needed reassurance. I have never had to leave one of my children at a hospital, but I seriously wonder if I would have received such care and attention if I had.
Then Heidi brought my boy in to me. He was a little spacey on his medication, but he was actually moving pretty well in his sling. Heidi walked out with me and we loaded Journey in the back of my Subaru wagon. I cross-tied him on his comfortable quilt so that he could reach the water and was not at risk for falling if he stood up. I got in the car and we were on our way home. I talked to him while I drove. Not sure he was following me, but he seemed okay with whatever I mentioned. We had to stop for gas, and I got some colder water for us both. When we got home I opened the gate and drove in. When I got to the house I left Journey in the shade while I went in and put the other dogs outside in their yard. I then unloaded Journey and walked him a little before taking him in to his gazebo. He settled in and I opened the door for the other dogs to come inside. They fussed over him and sniffed and kissed through the gazebo wire sides. They were so happy to see each other and Andiamo just kept whimpering and sniffing him. Pirate was equally happy to see Journey, but he wanted to get in the gazebo with Journey. It was kind of a confused evening. We walked but he did not seem to need to go. I fixed his dinner, but could not get him to eat anything except some cottage cheese. He seemed to enjoy that.
I slept on the couch where I could see and talk to Journey if he needed reassurance. The other dogs also slept beside the gazebo. Journey may have been hurting and a little out of it with his drugs, but i know he felt loved. He went to sleep. I cannot tell you how many times I had to wake up and study his tummy to be certain it was rising and falling rhythmically.
Everyone woke up early and I put the other dogs in their yard so I could sling-walk Journey out by the apple trees. He was not placing his foot very well and he was not interested in anything except maybe going in the pool, which of course he was unable to do. He was very distracted by the barking of the other dogs. We went back inside and started on pills, after which I worked out a way of keeping track of them. i had some roast which I sliced thin and in small pieces. I hand fed him alternately with the other dogs and he really seemed to enjoy that.
Sunday afternoon Journey was sleeping comfortably and I decided I could go shower and wash my hair. I hurried. When I came out he was awake and had been licking his incisions. Ekkk! I checked everything. It looked to me like there was a gap in the stitches, (maybe a half to 3/4's of an inch). It looked deeper pink and it looked open. I got on the phone to the ER immediately and explained. They said to bring him right in. I loaded him, using the sling to lift his rear. Not easy, but amazing how you can do things when you have no choice and no one to help. Off we went to Clackamas, Oregon. About 59 miles. I went in and they put us in an exam room. By this time the sedative I had given to Journey had kicked in and he was pretty mellow.
Following is an email I wrote to a friend, describing our ER run:
"Journey, please, please, please drink some water".
