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Ouch! Cranial Cruciate Ligament (CCL) Tear & Repair

Jul 6, 2020

I promised I’d write about the knee surgeries Izzy had this year, so here we go! It’s a long story (that’s still unfolding), so I’m breaking it into parts. In this first part, I’ll talk about how Izzy originally injured her cranial cruciate ligament, which is similar to an ACL in humans, and how we chose the TPLO surgery rather than one of the others. In part two, I’ll write about the surgery itself and our recovery so far, as well as some things that helped us. After that, I’ll just give periodic updates when we hit milestones, such as six months after surgery, and probably a year after. I’m also planning a post on behaviors I wish I’d trained before surgery. Here we go!

The Ouch!

It had been pouring the rain for days, but with two active dogs, we were still going out for walks every day. On the day I believe Izzy first injured her left knee, we were headed out for our last walk of the day. Off-leash since she and her brother love to run circles around me and check in as we climb the rest of the hill that our house is on.

wet wood

I can actually still see it happening in my head. As we came outside, both dogs got excited about squirrels at the bird feeders and charged down the stairs.

Izzy slipped on the last stair and went down hard on her side with a yelp.

But then she bounced right back up and thundered after her brother as if nothing had happened.

I didn’t think anything else about it until we returned from our walk that evening. After a short pre-dinner rest, Izzy started holding her left foot up and hopping around instead of walking.

It was too late to make an appointment at the vet that day (I’m pretty sure it was a weekend and they closed at noon). We actually didn’t make it to the vet until Tuesday or Wednesday after the accident, because the morning after she fell and was limping, she was using it fine again.

It was very confusing for me since I’d never had a dog injured like this before. However, a day or so later, she was holding her left leg up every evening. I switched to shorter walks by the house and made an appointment.

stethoscope

At my vet’s office, we have a team of vets that rotate through during the week, so who you see really depends on what day you come in. I remember our first visit for this being with a male vet. He did a physical exam, declared a bad strain (I think. The first visit is a bit foggy these days.), and sent us home with painkillers and instructions to take it easy for two weeks.

After a week of painkillers, and two weeks of leash walks (without her brother around because the two of them get very energetic together!), Izzy seemed okay. There was no more limping, and it didn’t come back as we increased our exercise.

The Confusion

Six months later after a long Saturday hike, Izzy started holding her leg up again. This time when we went to the vet, they took x-rays in addition to the physical exam. Same diagnosis. Just a strain.

After another round of painkillers and rest, Izzy seemed okay. I decided not to let her run with her brother anymore since they kept overdoing it. I took them out one at a time, and that seemed to work. It was actually really nice because we really got to build a closer bond, just the two of us together.

Everything seemed fine.

And then Izzy started growling at us in the evenings.

It was a very subtle change, actually.

First, it was only late in the evening, and only when I was petting her, but it slowly escalated, starting earlier and earlier in the evening and spreading to growling when anyone touched her any place other than her head. She was particularly defensive when my niece would approach her (even without touching), and eventually started growling any time I moved in bed where she slept with me.

If I hadn’t noticed how warm her knee felt, I would have mistaken the growling for something else. The warmth I felt in her knee and down the front of her leg reminded me of the shin splints I’d had playing sports in high school, so I took her in for another exam.

This time, I was instructed to add baby aspirin as needed in the evenings, and that seemed to help quite well.

And then she started throwing it up on my bed.

Yikes!

During her recovery this time, she began limping on her other leg as well. One day, it would be the left. Two days later, it might be the right, and so on.

The Second Opinion

Dr. Google mentioned that it could be Lyme disease, which can cause “shifting leg lameness” or, essentially, limping on a random leg every once in a while. (Of course, Google also told me it could be a whole host of other things, including cancer.) I took notes on things to ask the vet, and then I called to schedule a visit.

But I couldn’t get in. They were booked up for several weeks.

So I decided it was time for a second opinion anyway, and scheduled with another area vet.

It was a brand new office, no closer to home, but no further away either. They were very nice and thought it sounded perfectly reasonable to check for Lyme. They did the blood draw, and then we sat in the floor with Izzy in the exam room, and the vet did a physical exam after listening to her history.

He did a test that I’d never heard of before, called the “Drawer test.” If I had known what it was, I honestly wouldn’t have let him do it. Izzy yelped in pain, and hid behind me the rest of the visit. She was so tensed up that he couldn’t repeat the test on the opposite knee. I will note though, that the vet that did this initially did it much more forcefully than our vet later and the one in the video below.

The diagnosis based on our history and this test?

A partially torn cranial cruciate ligament or CCL.

This tiny ligament basically keeps the top part of the leg from sliding too far forward over the lower part at the knee.

I called my vet’s office to let them know what we’d found, and they scheduled me with the vet who does knee surgeries.

He was very nice. We had only had him once before when Izzy was a puppy. I remember him being very grouchy-looking then, but so kind and gentle with Izzy, that I was pleased to see him when we arrived. He confirmed the diagnosis (being much more gentle with the Drawer test), and then told me our options—surgery or “conservative management.”

I was relieved to finally have a diagnosis and a plan in hand.

The Denial

I was not happy that surgery could be involved.

The expense had nothing to do with it. I would pay anything to have my babies be healthy and happy again.

Instead, and this is probably where I messed up, I remembered how my own surgery had gone. How it had fixed one set of problems, but created a whole new set. How much it still bothered me.

Basically, I remembered all the bad things about what had happened to me, and mixed that in with “why couldn’t they get this diagnosis the first time?” and suddenly I was very against surgery.

To be clear, while I blamed them then, I don’t anymore. Looking back, I realize that our local veterinarians are basically like our general practitioner people doctors. They see lots of stuff every day, so they don’t specialize in any particular field. It’s probably pure luck that the vet I went to for a second opinion thought to do a Drawer test at all. That luck led us to getting a semi-specialized general vet who could confirm it. Things happen in funny ways sometimes.

When my vet confirmed the diagnosis and then heard about the trouble we were having with baby aspirin, he offered to prescribe a new anti-arthritis pain medication for Izzy called Galliprant. A bottle for a dog her size for 30 days was $100, but I accepted it anyway. 

I didn’t expect the new medicine to help much. I did expect to clean more vomit off my bed.

Wee Beasties' dog Izzy, a black lab and Brittany mix

However, after only a week on the medication, Izzy began acting like a puppy again (she was four and half years old by then). She wanted to play, not just when we were outside, but also inside…even later in the evening.

It was so wonderful, I cried. This side of her was something I hadn’t realized was missing, honestly. We’d been in this slow boil of pain for so long, that I hadn’t noticed when the playfulness disappeared.

But it didn’t last.

We (Izzy included) only got to enjoy a few months of the “New Izzy,” before her activity slowly waned again until she barely wanted to “play school” (what I call our training sessions).

I had signed us up for several different online dog exercise classes during those months (basically any FDSA course from Lori Stevens or Dr. Leslie Eide), including one especially for dogs with cranial cruciate ligament injuries. Through them, I kind of fell into a community of people who had musculoskeletal injuries to help their dogs with. I didn’t post much myself, but after reading their experiences, I decided to start putting away money for surgery (I didn’t know about other payment options at that time. We’ll talk about them next time.). We were managing okay (and I was still scared of all the things I’d read like bone cancer and such), so I planned to do the surgery that fall during hunting season when we don’t get as many walks in anyway. It felt much less scary so far away at that point.

The Specialist

About that time, my friend started working for an orthopedic veterinarian—Veterinary Orthopedic Sports Medicine Group in Maryland—and she encouraged us to come in for a consult, which I’m still grateful for. I was wary of doing such an invasive surgery with the folks who had failed to find the problem until someone else did (I was still angry with them at that time!).

I was extremely impressed with the specialists’ office. The floor was a sort of rubbery surface that wasn’t slick like the tile at our regular vet (wonderful for dogs with leg injuries, let me tell you!). The scale for weighing pets was even built into the floor so the dogs didn’t have to step up or be lifted onto it. The seating was angled and had sides so that you weren’t staring directly at another dog, and mostly couldn’t see them if they were beside you either. If I were building my dream vet’s office, it had a lot of the features I would make sure I had!

Our consult did not take long, though they did their tests and took the time to answer all my questions.

The vet techs x-rayed Izzy, and the vet watched her as I walked her up and down a short hallway. Even I had been noticing the wobble in both her back legs during our walks, so it was a cakewalk for him!

He did not do a Drawer test and looked rather upset when I mentioned it. He said there are other ways to diagnose this now (though he didn’t tell me what they were), so be sure to ask about your options.

Both TPLO and TTA are done on the tibia, which is the larger of the two lower leg bones.

The TPLO or Tibial Plateau Leveling Osteotomy involves cutting and rotating the tibia until the part of the bone where the femur meets it is at less of an angle. This basically makes the torn ligament unnecessary.

The Beginning of the End (Hopefully)

Our treatment options again boiled down to surgery or continued management, though this time, I could opt to do a TPLO, whereas my vet back home only did the TTA procedure (or Tightrope, which Izzy was too big for). I thanked him and my friend and we made the long drive back home.

I did more research when I got home. Both vets had told me that my main concern—cancer—was rare, and that the only reason there were so many reports of it was that there had been an impure batch of surgical implants some years back. My additional research confirmed that, and I finally decided to book with the specialist. I needed more time to save for it, so I eventually booked our procedure for February 2020, a few months before Izzy would turn six.

The Tibial Tuberosity Advancement or TTA also cuts the tibia, but this time, the cut is vertical, and a metal “spacer” is inserted into the cut to push the front part forward (ie, to advance it). This also makes the torn ligament unnecessary.

The other procedure I mentioned, the “Tightrope” procedure is less invasive and involves inserting a device that imitates the healthy ligament. It is not recommended for larger or very active dogs because it can be easily ruptured just like the real ligament.

Phew! Told you it was a long story! Next time I’ll talk about how the surgery went and our recovery so far.

If you have any questions, please don’t hesitate to reach out!

PS—I found this excellent video showing the anatomy of the knee and talking about the different procedures. It was produced by The Royal (Dick) School of Veterinary Studies at the University of Edinburgh, Scotland via a grant (read more about it in the video description on YouTube).

Ouch! Cranial Cruciate Ligament (CCL) Tear & Repair, Part 2

Annnd, we’re back! Sorry for the delay. I’ve been struggling with some technical issues this past...
Dog laying on couch with shaved leg and ice pack; Words "Cranial Cruciate Ligament (CCL) tear and repair part two

Ouch! Cranial Cruciate Ligament (CCL) Tear & Repair

I promised I’d write about the knee surgeries Izzy had this year, so here we go! It’s a long story...
Black dog laying on couch with ice pack on shaved leg

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About Wee Beasties

Wee Beasties provides pet training and behavior consulting for multiple species in southern West Virginia.

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