Thursday, May 26, 2011

How The Oddysey Started: Jasmine's ACL Injury

Morpheus: What happened, happened and couldn't have happened any other way.
Neo: How do you know?
Morpheus: We are still alive. 


When Jasmine started limping in the summer of 2008 we didn't think too much of it. It wasn't the first time it happened.

Jasmine had injured her hind leg three times before that.

After an exam and x-rays, we were always told it was probably just soft tissue injury and sent home with recommendation of restricted exercise. Each time it did seem to have resolved on its own eventually.

This time it was different.

With passing weeks I started to feel that perhaps we should take her to the vet again after all. Things weren't getting worse, but they weren't improving either, and Jasmine was showing less enthusiasm for exercise. This hasn't happened before and wasn't like her at all--we always had a hard time holding her back.

At the beginning of September we took her to her vet at the time. He couldn't elicit the drawer sign but suggested an appointment with an orthopedic specialist just to be sure.

He mentioned the words ACL injury and that was the first time we ever heard about such thing.

After I researched what an ACL tear was I really wished it was something else!

Jasmine was putting some weight on the leg even though she was limping heavily, particularly after rest following exercise. She wasn't holding her knee up as would be typical either.

However, after a visit with the specialist, and a set of x-rays, the diagnosis was in and it was breaking my heart.

Yes, Jasmine did indeed have a partial ACL tear in her left leg, and if that wasn't enough, her right knee didn't look so great either. 

The recommendation was to do a TPLO surgery on the left knee immediately, with a prospect of another surgery once that heals. When I've learned what TPLO was I didn't like it the least bit.

To Jasmine, her legs were the most important part of her body! They took her places! 

Such an invasive surgery and the recovery ... taking almost a whole year out of her life ... I really didn't want to do that if I could help it.

I spent endless hours researching and looking high and low for other options. We considered conservative management with a knee brace. But Jasmine was only 5 years at the time and she was a very active dog.

Brace didn't sound like a good solution for her.

I was talking to many people and one vet from Australia mentioned that prolotherapy might be a solution for a partial ACL tear.

It sounded hopeful, and certainly better than a surgery. I found a vet in our region and discussed that with her. She said that it could be an option.

Before we booked a consulation with her I brought it up to Jasmine's vet. He didn't know much about it—looked it up quickly and figured it was a terrible idea, saying things such as bone infection and amputation scared the living daylights out of me.

I did talk to a number of vets who successfully uses this technique but the word amputation eclipsed all the positive things I read and heard. 


I called the consulting vet immediately and told her what Jasmine's vet thought. She was trying to explain that while there is some degree of risk they take precautions and it is very safe.

As she noticed I wasn't really hearing her, she said there was a new treatment out there which we could consider—stem cell regenerative therapy. It really is a shortcut to what the prolotherapy is designed to achieve."

Stem cell therapy? Ok, a new idea that didn't have the word amputation tied to it. 

I asked her how it worked—this certainly sounded interesting!

So back to research. The more I was reading about what the stem cells were, the more exciting the whole idea sounded. We discussed it with my husband and he also felt good about it.

So back on the phone with Jasmine's vet.

"Stem cells? From bone marrow?" he asked. "And what about rejection issues?"
"No," I said, "stem cells from Jasmine's own fat tissue".

This time he didn't even bother looking it up. "Sounds like a scam," he said.

Well, it didn't sound like a scam to us. 

I went back online to see if i could find any testimonials about this treatment in dogs. Didn't find many, but found some. And more importantly, this felt right.

I made a list of vets in our area certified for the procedure and starting calling them.

Ideally we wanted to find one who already had experience with this. 

It turned out that nobody in Canada—or in Ontario anyway—had actually done it yet. As we really wanted somebody who did, we decided to call around south of the border. Couldn't find anybody either.

Ok, this was pretty new stuff, huh?

Still though, it did feel right. So back to calling vets near by. One of them spent at least fourty minutes discussing things with me on the phone. He did feel that surgery might be the best option, but was open to the stem cell idea. "Knees love being operated on," he said.

Well, knees might ... but what about the dog?

We discussed it all again with my husband and figured that we do want to see where the stem cell route might take us. So we booked a consultation with this new vet.

When we brought Jasmine in, he started examining her head to toes.

"Hey, doc, the knees are over here in case you can't find them," we thought. But he explained how the bad knees would affect other things.
"I want to treat the whole dog," he said.
Our jaws dropped. "Wow, now there is a novel concept!"

Skipping through a series of events that stemmed from an additional abdominal exam the vet did while he had Jasmine under to take his own x-rays, a cancer scare, an exploratory surgery, several weeks later we were all set to go ahead with the treatment.

As destiny would have it though, a week before the planned treatment, Jasmine came home limping really badly, not using her left leg at all. 

We took her in immediately and our fear was confirmed, her ligament was now totally gone.

So there we were, back to the drawing board. 

Do we have to do the TPLO after all? (Personally I'd liked the TTA better, but there was no surgeon in Ontario doing that.)

Her new vet brought up the option of an extracapsular repair as less invasive. 

That confused things further, because we have already discarded this option at the beginning, after reading many articles on how bad this option is for large breed dogs.

However, this new vet already got a lot of our trust in the meantime and he has done this surgery successfuly on large dogs many times in the past.

I asked him the main question: "Is this what you would do if it was your dog?" 

He said that all things considered yes, he would. I was still a bit uneasy about potential failure of the repair, but it was substantially less invasive...

With that decided we didn't feel like abandoning the stem cell therapy idea though. Perhaps it could save her other knee? And while at it, it could maybe help the operated knee heal better?

And so it was all set. 

The first day her vet did the extracapsular repair and extracted a bit of Jasmine's fat tissue and sent it to VetStem to be processed.

Two days later he injected the stem cells into both of her knees, shoulders (which developed arthritis as she was compensating for her bad hind legs) and gave her one IV dose of stem cells also to help our areas that couldn't be injected).

The first month post treatment he seemed rather disappointed, as he couldn't see any difference the stem cell treatment would have been making.

By the second month though, he started to get really excited. 

We couldn't really tell, because we had nothing to compare it with. All along we were just praying that her right leg would hold up through all that.

At the end of the second month Jasmine was hardly limping at all, and the third month she had the bounce back into her gait. Now it started to get really exciting!

So of course, as a number of times before, just when we were so happy how well things were going, three months after the first surgery, Jasmine's right knee just went

She didn't do anything crazy or out of the ordinary. Just boom and there it was. That was really disappointing.

So back on the operating table. 

Looking back, I believe that the treatments we chose were the best option for Jasmine. She is living her life as if none of that ever happened and I wouldn't have done anything differently.

As much as I hate that she had to have gone through all that, it seems that it had to happen and couldn't have happened any other way. Look at Jasmine go today!

If it wasn't for her injured knee and our reluctance to put her through an invasive surgery, we wouldn't have found her new vet and her other health issues might have never been diagnosed and treated.

All that also taught me the importance of being involved in my dog's health care decisions, research and second opinions.

It's your dog's health!
Jana

Related articles:

Stem Cells for Dogs? Oh yeah, baby!
Interview with Dr. Robert J. Harman, D.V.M., M.P.V.M. - CEO and founder of Vet-Stem
Digging Deeper: The Science Behind Adipose Derived Stem Cell Therapy
Jasmine is Vet-Stem's poster child! 
Zeus Gets Stem Cell Treatment 
Jasmine Is Headed For Her Next Stem Cell Treatment 
Jasmine's Stem Cells Are In 
Running With The Wind: Trago's Elbow Dysplasia Surgery And Stem Cell Treatment
In The Beginning There Was Fat: From Vanity To Revolutionary Therapy

Talk To Me About ACL Injuries
ACL Injuries in Dogs: Non-Surgical Alternatives?
ACL Injuries in Dogs and Stem Cell Regenerative Therapy
Newest Surgery For Ruptured ACL In Dogs
Preventing ACL Injuries In Dogs
ACL Injuries In Dogs: Xena's Story 
ACL Injury Conservative Management: Sandy's Story
Surviving The Post-Op: After Your Dog's ACL Surgery
Talk to Me About Arthritis
Don't Forget the Physical Therapy 
My Love Is Sleeping At My Feet: ACL Surgery Complications 
Coco's TPLO Post-Op Diary 
Small Breeds Can Hurt Their ACL Too: Star's Naughty Knee 
One Thing Leads To Another: Why The Second ACL Often Goes Too

11 comments

  1. This really hit home for me on so many levels. Finding a vet you can trust is hard enough but dealing with a pet in pain is even tougher. Sadly, many vets I've met are like mechanics that want to keep doing trial-by-fire to stay billable. The fact that your old vet was so dismissive and selfish says a lot. Sadly, some service professionals feel that their way is the only way, the "right" way. That's a shame but your journey ended in a happy place so YAY to that! =oD

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  2. Hi Yogizilla, I agree, finding a great vet is not easy. We are very thankful that through Jasmine's ordeals we found one.

    Sounds like there is an important story behind your comment, would you care sharing it on this blog?

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  3. Hi Jana!

    Thanks for the warm welcome. Here is my pet story...

    Buddy was a wonderful cat. He was the kind of cat that dog lovers would appreciate. In fact, he sometimes thought he was a dog. I suppose he had an identity crisis but, whatever the case was, he was a charmer.

    Anyone that met him fell for him. He was affectionate, loved to play, and did the silliest of things. Quite often, you forgot he was an animal. He was a member of our family. Mind you, my mother was never big on pets but she adored Buddy.

    Buddy lived a long life that was ended rather abruptly. The tragic downward spiral started with an overlooked issue he had. We started to notice that Buddy's eye swelled up. I consulted some friends and did some research online. All the indicators pointed to the fact that he had a form of conjuctivitis. Fairly common amidst cats so we gave him some aide and basically waited it out, as we were advised.

    A week or two later, his eye was still swollen. We started to get worried. Then he started to sneeze repeatedly. This was more than an irritated/scratched eye.

    With great hesitation, we took Buddy to the only vet we could find. We had bad experiences with her before. She was a nice enough person but always had a way of trying to upsell us and stick us with extra charges when we tried to check our pets out. I didn't like it at all but we were beginning to get desperate.

    In her usual manner, our vet made assumptions without asking us key questions and running basic tests. She went straight to the most expensive battery of tests and procedures. After this initial approach, and over $1000 later (just for tests), she gave us the bad news: Buddy had cancer.

    What was worse is that Buddy had cancer for a long time but the symptoms were only just showing. Up until that point, his behavior had not changed. He was as playful, sweet, and silly as ever. This was a severe blow to us.

    Of course, she had to run more tests "to be sure". Every test and procedure she did beforehand was a total waste. I consulted other vets and they said her prognosis and approach were all wrong. I knew this much but, during such an emotional time, we just wanted to help our long-time friend.

    It was a back-and-forth process. Several days of doing different stuff and having no real direction, only to find out there was nothing that could be done for him. The cancer had spread more rapidly after his initial visit to the vet. It was almost as if they accelerated the process but that is purely speculation.

    Can you believe she still did some deep dental cleaning and other cosmetic stuff even though we did not request it? We came in for the issue at hand, not to get billed left and right. I had the money but that was not the problem.

    ( To Be Continued... )

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  4. Hi Yogizilla, that is quite a story. So sorry about Buddy and your misgivings :-( Thank you for sharing this!

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  5. I still remember taking Buddy to the local ASPCA to have him humanely put down. Anyone that says domesticated animals have no real intelligence or emotional range know nothing. Honestly, I'm choking back the tears as I write this, as silly as they may sound to some.. Buddy knew his final days were coming. He had gone into some solitude when his sinuses started to get bad. He was so smart that he kept all discharged concentrated where we could easily clean it and away from prying eyes, as if he did not want us to worry.

    New Year's came. I spent time with my closest family and loved ones. It was a somber coming of a new year. Only a few days left before we had to do something difficult and I was the one appointed to do what no one else wanted to do.

    Buddy knew what was coming. He made it a point to spend those last days with us, as if to let us know everything would be okay. Buddy was very special and it kills me that our vet was essentially only concerned with money.

    The ASPCA vet asked me if I wanted to watch but I could not bare to watch it. He was extra sweet and looked at me as if to say, "I guess this is good bye then." It truly broke my heart, as a "war-torn" male, and I have pretty thick skin. To think that I would not be going back with my dear friend was a hard reality to deal with.

    I would never recommend that vet to anyone. Can you believe that, during our extensive grieving period, their office sent us an automated letter to remind us to bring in Buddy for a routine check-up. They knew we were going to put him down. Really? I understand some things fall through the cracks but you would think they would be a little more proactive in lieu of our highly-emotional state. Simply terrible.

    The experience created more urgency for me to be more self-sufficient than ever before. I've done my own research and learned how to be more preventative with pet issues because, quite frankly, vets tend to be too caught-up with the money side of things, rather than the human elements. I did not expect empathy, but sympathy is not that difficult, is it?

    Maybe that was not the proper take-away but it feels too much like the mechanic that sees a desperate person and thinks, "Upsell and cross-selling opportunities!" It's truly a shame but I feel I am a better person for it. I make sure, these days, that I am extra mindful of the human touch process (call it warmth): relate/empathize and manange expectations. In other words, show you really care.

    The whole vet interaction was mostly cold. On the surface, she was "nice" and professional but there were many missed opportunities. We still miss Buddy to this day but the whole experience made my mother dislike pets and vets alike even more. In her mind, the lesson was, "Never get attached to a pet."

    Buddy's sister, Molly, is still alive and spunky as evil. She likes with my mom and my mom has warmed up to her. Buddy can't be replaced but Molly reminds us that he is still with us in some way. She's a sweet girl but no rockstar like her "big bro".

    Fun Little Fact: Buddy was a mixed tuxedo cat. He was always dressed to impress. He was a ham and always did something new to liven things up. He'd play fetch and even chase you around randomly, just because he could. I've met lots of cats but never a cat with his level of personality. He'd even sit back on the recliner, with his front paws on his hind legs, as if he was waiting for a drink and a sandwich. LOL... Again, you'd think he was human at times.

    Pardon my rant/diatribe. I'm not saying all vets are scum but definitely be careful. It's important to arm yourself with knowledge so no one can take advantage of you during moments of desperation and great urgency.

    Again, thanks for the warm welcome and allowing me to share this tear-jerker story with you. =o)

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  6. Thank you so much for your "rant". It truly is a tear-jerker story. Thank you so much for sharing! While I normally don't write about cats, I might make this a feature story. Thank you, Jana.

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  7. Awesome!

    I'd be excited to see that, Jana. It may help to state that my cat thought he was a dog at times. He'd play fetch, "bark", and even chase things/us around. He was truly a remarkable kitty.

    I'll susbscribe via my RSS reader and keep an eye out for updates! 8)

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  8. Hi Jana,

    I came across your site after hours (and hours) researching the pros & cons of the different surgeries for CCL injuries. I'm wondering if (and hoping) you'd possibly be willing to let me further 'pick your brain' & get an HONEST opinion. My poor baby is in, what seems like, a very similar situation as Jasmine was, his right knee went about 6 months ago & now the left knee has gone as well. If you're willing/available I'd love to share his whole story & get your feedback.

    Surgery is scheduled for Monday, but I'm not 100% or even 50% sure it's what I actually want to do.

    Hoping to hear from you soon,
    Amber

    PS. SO sorry to have read of your baby Jasmine's passing!

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    1. Hi Amber, sorry about your baby. The fortunate thing with Jasmine was that she only had partial tears initially. When the left knee got blown fully, we did the traditional surgery combined with stem cells. Three months post-op the other knee went but the first one was already strong enough to get her through the second post-op safely.

      I understand your baby now have both ligaments blown? I figure he's scheduled for TPLO on Monday?

      With both blown ligaments you don't have too many options nor you can take your time or wait and see or anything like that. You do need to do something.

      Traditional repair wouldn't not be likely to make it with both legs being out of commission.

      Now, the new surgery out there, Simitri Stable in Stride would work for bilateral tear but time is of the essence too.

      The long and the short of it - yes, I'd go ahead with surgery. For myself, I'd prefer the Simitri Stable in Stride. But you'd need to research it to see whether that feels like the optimal choice to you and find out whether and how quickly you could have that done.

      TPLO has been the option of choice for a long time and while there are reasons I don't like it it does work well for most dogs.

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  9. Thank you for your quick reply. Cash's left knee was a partial tear about 6 months ago, we're not sure exactly what happened as the limping/lameness was off & on (mostly off) for about 2 months. When he was first diagnosed, we decided on conservative management with the help of a stifle orthosis brace from OrthoPets, physical therapy, including underwater treadmill & laser therapy. He was doing very well, almost full weight-bearing, no (visible) pain & the knee itself was looking good. 3 weeks ago we were outside on a leash potty break, and 'boom', he just wouldn't put any weight on the right, completely toe-touching & you could see he was in pain. Our Rehab Vet recommended I schedule a consultation with an orthopedic surgeon, as she believed there was also meniscus damage. She knows how apprehensive I am about the TPLO surgery and thought maybe if I spoke with the surgeon, it would put my mind at ease. Well, that didn't happen. I'm still, for multiple reasons, not 100% comfortable with TPLO. He also seems to think that the original injury on the left knee should have TPLO, which kind of surprised me given Cash has done so well and 3 other vets have said the left looks very stable. It doesn't, however, surprise me that $7,000 (estimate) is recommended versus $3,500. Sadly. I asked for a 2-for-1 type deal, no surgeons thought that was funny..lol money really is not the issue for us, I just can't help but think that the TPLO is pushed more often than not due to cost. I do know it can be very effective & is most often the surgery of choice, the invasiveness of it just terrifies me. Cash is a black lab, 75lbs. he'll be 10 in March and not super active. He kind of goes with the flow, if we have an active day, he's active, however he's also known as 'the comfort king' lol i.e. anything that looks like a bed, is a bed, for deep relaxation, of course. We will, of course, do whatever is the best surgery/treatment for him. There's so much information out there, as you know, of varying opinions, both good & bad, horrible & terrific. I'll do some research today on the newer procedure you mentioned and see if it's available anywhere in Michigan. So, I guess, in short (long lol) my few questions for you are, were you guys fully satisfied with the traditional repair on both Jasmine's knees? Any complications from the sutures either stretching or breaking? Is it even possible to do traditional repair on a 75lb. dog and it be completely successful or am I chasing my tail on this one? My thoughts on Cash are to do the surgery on the right knee, hoping to go the least invasive route possible (fingers crossed) and see how the left holds up with continuing therapy & brace stabilization. While I was writing this, a vet in my area who does traditional repair on large breed dogs with (what they say) great success, called to schedule a consultation for Cash tomorrow morning. Sorry if my post is a little all over the place, it's refreshing to get an opinion from someone who has personally gone through it. I thank you so much for your time, as well as your blog, this CCL nightmare in dogs is so confusing, especially the more research you do!

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    1. Yes, with partial tear you can end up with lameness that comes and goes. Often, the way things happen, the ligaments gradually deteriorate, in which case no major trauma is needed for it to tear.

      When you were using the brace, was it on at all times? Here is the thing. With conservative management the knee (not the ligament) can heal but it does so by forming scar tissue to stabilize the joint that way. For this tissue to be effective, the knee needs to be stable during the entire process. If the brace isn't on at all times, this is not likely to happen.

      During the lameness, the other knee bears most of the weight, making it more susceptible to tear as well.

      At this point I'd address the knee that needs help most; they can also evaluate the other knee better while under anesthesia.

      TPLO is being pushed quite hard, yes, I think for the belief it's the right choice, not because of the $. After all, long-term physical therapy brings home the $ as well.

      I don't like it either but if Cookie's ligament went, and if the Simitri wasn't available for her size yet, I'd likely go with it.

      We were fully satisfied with the traditional repair for Jasmine. However, she was a good patient. Cookie would be a different story, as she is way more energetic than Jasmine was. The post-op with traditional repair is sensitive to mishaps and needs high level of cooperation on the part of the dog. Though, since you say Cash is very laid back, you might be able to get that cooperation from him.

      We had no complications with Jasmine's repairs. It can, happen, though.

      Jasmine weighted 90 pounds. It is possible to successfully do the traditional repair with any size of dog (actual size, not a dog who is overweight, though)

      Jasmine's vet has done traditional repair on many large dogs successfully. He uses modified technique, though, doubling the sutures.

      One criteria that affects the probability of success of the traditional repair is the tibial plateau slope. You might want to talk about that with during your consultation.

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