Kenai’s Knee History

By Joy Whitehead, Loving Paws Client
February 2011 Kenai my 2 year old, 120 lb, Great Dane was running around our back yard enjoying a crisp winter day.  I had just adopted Kenai from a rescue group in Tennessee five months earlier and since she came into my family she has been one happy little girl.  She has a Great Dane sister named Akela, a nice fenced in back yard, more toys then she knows what to do with and a human Mommy that loves her dearly.   However, on this fateful winter day Kenai received an injury that would cause us much pain, suffering and heartache for a long time to come.

The ground was not icy and there was only a dusting of snow.  Kenai ran around the corner of the yard by herself and came back limping badly on her hind left leg.  I immediately thought she might have twisted her leg or stepped on something.  I took her in the house and went over her from top to bottom.  Nothing was in her foot and there was no heat or swelling.  I kept her quiet for a few days and took her outside only on a leash.  After two days she improved, but was still limping.

I took her to Dr. Rivera my holistic/chiropractic vet at The Healing Oasis a week after the injury; we had a previously scheduled appointment for a chiropractic adjustment.  He took several X-Rays of her foot, hip, Tibia, Femur and knee to rule out a break or any other skeletal injury.   At this time he did not know if there was any major soft tissue damage and wanted to wait to see how she progressed.  I personally feel that there was a tear in her CCL (Cranial Cruciate Ligament) at this time, but it was a very small tear and was not yet noticeable with a basic exam.

We went home and I continued to watch Kenai closely and did my best to not let her get too rambunctious, which is hard to do with a 120 lb puppy!  I started her on Knox Gelatin, Boswellia and Microlactin and increased her Glucosamine, Chondroitin and MSM supplements.  Knox Gelatin is 100% collagen and is found to help rebuild connective tissue; Boswellia is an herb which is beneficial for connective tissue and joint support, Microlactin is a natural anti-inflammatory; Glucosamine, Chondroitin and MSM have been shown to relieve pain associated with joint injury.  MSM also has anti-inflammatory effects.

I returned to Dr. Rivera after Kenai did not improve and on the second visit he was able to manipulate the knee enough to be able to tell the CCL was indeed torn, but not yet ruptured.

The ligament is much like a tightly wound rope.   A tear will start with just a few stands breaking and over time more and more will break until what is left of the ligament is not strong enough to support the stifle (knee) joint.  If you look at a picture of a torn ligament it looks like a bunch of spaghetti strands.  When the knee no longer has support the tibia will move forward with each step, this is called Tibial thrust.

Now that I knew Kenai had a torn CCL I had to decide what the best course of action would be for my young girl.  I read many web sites on CCL injuries in large dogs, I watched videos on actual     CCL surgeries (that was hard to do), and I talked to several General Medicine Vets and a few Orthopedic Surgeons.

Honestly, the more I learned the more confused I became.   Some devices they implant into the limb are there to prevent the tibial thrust and to keep the joint supported, until the body can build up enough scar tissue to support the knee on its own.  Other surgeries implant medal devices that change the angle of the leg where the CCL is no longer needed.  But which one is the right one for Kenai?  There are four techniques that are available for CCL tears:
  • The Lateral Suture technique is the oldest technique and from what I have read and been told it is the safest and least expensive way to go for smaller dogs.  This technique is done by suturing the joint.  Some vets suture only through the muscles, but some vets will drill a hole in the tibia to give more support to the joint and less strain on the soft tissues.  The suture material will break down over a few years and by then the body will have built up enough scar tissue to support the knee.  The problem with large dogs is that because the stifle has to withstand so much torque the sutures can tear through the soft tissues or can break.
  • The Tightrope technique is the newest technique, only a few doctors are performing this today.  This type of surgery is similar to the Lateral Suture but instead of a string type suture they use a fiber tape material and two small titanium anchors, making it much stronger to be able support large/giant breeds.   Small tunnels are drilled through the femur and the tibia in positions that closely mimic the anchors of the cruciate ligament itself.  The implant is passed through the bone tunnels and tied using the titanium anchors to hold it in place.  The implant stabilizes the joint and restores the function.  They say the tape will mostly likely break down over several years.  But like the Lateral Suture the joint will have built up enough scar tissue to support itself.
  • TPLO (Tibial Plateau Leveling Osteotomy) involve cutting into the bones and implanting a large metal device that changes the angle of the tibia.  The procedure levels the tibial plateau, thereby eliminating the need for the cranial cruciate ligament as a restraint against tibial thrust.
  • TTA (Tibial Tuberosity Advancement) is very similar to the TPLO but slightly less invasive.  However, it still involves cutting into the bone and placing a metal device into the leg that will change the angle of the joint.
  • And the one option never talked about by Orthopedic Surgeons:  Is Surgery Really Necessary for Your Dog’s Ligament Injury?   A good site to read is:  http://www.tiggerpoz.com

With so many choices I had to decide what I thought was best for Kenai; a large and young dog.  I felt that the TPLO & TTA were not good choices because of several reasons:   I don’t understand why you would want to risk cutting into a healthy bone.  By changing the angle of a leg how much damage are you doing to hips, backs, hocks, etc. because the dog no longer stands, walks, or runs the same way they used to?    I was told by two surgeons that these techniques also cut most of the nerves in the leg and in their opinions that is why dogs feel better fairly quick after they recover from surgery.  They also say because the nerves are cut the dog no longer feels the pain, but that does not mean the joint is still not deteriorating and building up arthritis that can cause issues later in life.  And my biggest fear with these techniques are that if there is any major complications they cannot normally go in and remove the device like they can with the Lateral Suture and Tightrope.  If the dog’s body rejects the device or there is a infection you are in a great deal of trouble and from the statistics I have read when things go wrong with these techniques a lot of the time the only way out is amputation or euthanasia.

The Lateral Suture is not an option for a giant breed, so that left me the two choices; Tightrope or no surgery at all.  After much deliberation I decided to go with the Tightrope even though doing no surgery at all made some sense to me, but I could not sit back and watch my baby girl limping around and in pain.  I felt that I had to do something!

I searched for vets that did the technique in our area.  I found that University of Madison Veterinary Hospital will do the Tightrope but will not do it on large breeds.   I then found a list of Vets that learned how to do the Tightrope from Dr. Jimi Cook (the inventor of this technique) and who worked on the initial case study for Tightrope procedures.   I also talked with my general vet to find out if they knew of any patients that had gone through this procedure.

One of my vet’s patients had a Tightrope done on their Mastiff and had wonderful success.  The doctor they used was Dr. Will Wright of Capital Illini Veterinary Services.  I called Dr. Wright and talked with him at length about the procedure, recovery and chance for complications.  Dr. Wright was very helpful and I wish I would have had him perform the surgery on Kenai.  But because he was about 5 hours away he suggested that I contact Dr. Robert Cook (not related to Dr. Jimi Cook) of Animal Medical Center of St. Charles, only 1.5 hours away.

The one thing I liked about Dr. Cook over Dr. Wright was that Dr. Cook did the part of the procedure via arthoscope, Dr. Wright did not use a scope and therefore the incisions would be much larger and recovery time would be longer.

I made an appointment with Dr. Robert Cook about five weeks after she injured her leg.  Dr. Cook examined Kenai and confirmed that her CCL was indeed torn.   Vet’s can tell if the CCL is torn by manipulating the joint, a expensive MRI is not needed.  However he would not be able to see if the meniscus was torn until they were in surgery.  Most vets say that often times when there is  a torn CCL there is also a torn meniscus.  Dr. Cook and I talked for about 45 minutes and at that point I agreed that he could perform the surgery on Kenai that day.

On March 17 Kenai underwent the Tightrope procedure for her torn CCL.  The surgery lasted about 2 hours and I was able to take Kenai home that evening.  When we left Animal Medical Center of St. Charles, Kenai was still very groggy and could barley walk on the three legs she was using.  I questioned why she was going home so soon in my head, but in reality was happy to get her home so I could watch over her and keep her very comfortable.   Total cost for surgery and medication was $2,814.

Kenai had three incisions.  One on the inside of her leg about 1.5 inches long, one on the outside of the knee about 2.5 inches long and one right at the front of the knee that was maybe a centimeter.  All the incisions were closed by staples.  The outside incision and the one on the front of the leg were open and not covered or bandaged.  The one on the inside of the leg was covered with a clear adhesive bandage.

I was not told that Kenai would receive an epidiral and was quite shocked when I saw her shaved back.  I feel this is something that I should have been informed of before the surgery.    This was my first red flag that told me I picked the wrong doctor.

The epidiral caused Kenai to not have control of her blader and bowels for about 24 hours.  No one told me that this could happen and I was quite concerned.  I contacted Animal Medical Center of St. Charles and asked them about her lack of control and they told me it was normal.  I sure wish they would have told me that before, so I could have prepared.  The inside incision also continued to bleed and ooze for about 3 days.  I do not feel this was normal but was constantly being told by Dr. Cook’s assistant that it was nothing to worry about.

On the second day after surgery Kenai started to walk on the leg but would only toe touch.  She started to put her foot down all the way within 3-4 days.  For about 5 days Kenai was doing very well and I was very happy with her progress.  Kenai was confined in a bedroom with a matress on the floor.  She was not allowed to go up stairs and could only go outside for potty breaks.  It was hard to keep her quiet but she tolerated the confinment well.  Then about day 6-7 the knee swelled and she started to show signs of pain.

March 25, 2011 I returned to Dr. Robert Cook’s office because of excessive swelling.  Dr. Cook said it was a seroma (a built up of blood and fluid under the skin) he took out a few staples that were pulled very tight due to the swelling and he told me that doing a combination of heat and ice could help with pain and inflammation.  I did as he instructed for 7 days and the swelling reduced, but did not go away completely.  No charge.

April 4, 2011 Returned to Dr. Cooks office to have the remaining staples removed.  The swelling was still there, but not as prominent.  However, the leg was still very sore and somewhat swollen, red and there was some heat.  He said it was normal and nothing was done.   No charge.

April 26, 2011 Returned to Dr. Cooks office because joint was still swollen and Kenai was in a lot of pain.   He did nothing but told me to watch to see if the swelling increases and prescribed more pain pills for $72.  I made several phone calls to Dr. Cook’s office for days after this visit and talked with his assistant.  I stressed my concern that something was not right with the joint and that Kenai was not healing as she should have been.

Saturday April 30 a bubble started to form on the inside of Kenai’s leg just below the knee joint.  By Sunday the bubble was about the size of a marble.  I called Dr. Cook first thing Monday and he told me to bring Kenai back in on Tuesday May 3.   When I came home from work on Monday I found that the bubble was now the size of a golf ball, then during the night the bubble burst.  The substance that came from the bubble was the consistancy of raw chicken fat mixed with blood and pus.  Frankly it was disgusting!  I called my general vet at home and asked her what to do and she advised me to leave the wound open and allow it to drain freely.  When I arrived Tuesday morning at Dr. Cook’s office the wound was still oozing all over the place.  Dr. Cook did some cultures of the ooze and took a sample from the joint fluid to test to see how far the infection spread and what type of infection we were dealing with.  He prescribed antibiotics and more pain pills.  Cost: $239.

On May 5, 2011 the cultures came back showing that Kenai had a MRSA infection.  Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterium responsible for several difficult-to-treat infections. It may also be called Multidrug-Resistant Staphylococcus Aureus.  MRSA is a bad infection!!  The only good news is that it had not yet spread to the inside of the joint.  We had to hit the infection hard and fast with a lot of drugs and pray it does not move into the joint.  The prognosis if it moves into the joint is amputation.    More antibiotic prescribed, cost: $133.

Because MRSA is such a drug resistant infection and the fiber tape used in the Tightrope procedure is a harbor of bacteria I was advised that Kenai would need to undergo another surgery to remove the Tightrope device.

May 10, 2011 Surgery was done to remove Tightrope device. Two more incisions were made on the inside of the leg, both about 1.5 – 2 inches in length.  No epidural this time.  Kenai came home the same day.  Cost:  $957.

May 20, 2011 Visit to my trusted general vet Dr. Susan Sallee of Grayslake Animal Hospital.  Dr. Sallee removed the staples from the upper incision because it had healed nicely and they were no longer needed.  The other incision was still open, swollen and oozing.  Dr. Sallee prescribed more antibiotics and pain meds.  Cost $202 (the antibiotics are costly).

May 27, 2011 Returned to Dr. Cook’s office.  The remaining incision is still unhealed, bleeding and oozing.  He trimmed the dead skin off the edge of the incision and put in more staples.  No charge.

At this point I was done with Dr. Cook and his uncaring attitude and decided I would never set foot in his office again.  I feel that if he would have taken all my concerns into account and done a culture in the first or second return visit, perhaps we could have avoided a lot of the pain and suffering Kenai had experienced.  And perhaps the device to fix her knee would not have had to be removed.  I also feel that I should have been more adamant with Dr. Cook to do something sooner. After all the research I did, the knowledge I gained and the hope that I was doing the right thing for my baby girl, it still all fell apart.    I expressed all of these concerns to Dr. Cook in a letter, but never received a response.

June 4, 2011 I returned to Dr. Sallee’s office because the one incision would still not heal.  She did a cold laser treatment to stimulate healing and gave me a topical collagen ointment.  Cost:  $32.

June 6, 2011 Dr. Sallee did a second cold laser treatment.  No charge.

June 17, 2011 Dr. Sallee was able to remove the remaining staples from the incision.  No charge.

At this point Kenai had gone through a lot of suffering for absolutely nothing!  And I have spent around $4,500 for my poor baby girl to go through torture.   The question is what do I do now??  Another surgery is not an option for various reasons.  At this point she still is limping on the leg, however showing signs of improvement each day.   Now I need to find some ‘non-surgery’ methods of treatment for a torn CCL.

I read that hydro therapy is very helpful in building up muscle tone without putting pressure or strain on the knee joint.  Kenai needs to build up her muscles; her thigh has atrophied so much.  But quite honestly the bank has been broken with all the medical expenses and professional hydro therapy is expensive.  So I decided to do Kenai’s water therapy on my own.

I purchased a 16 foot round portable pool from Wal-Mart.  The type of pool that has the inflatable ring on the top edge and the rest of the pool is just vinyl.  The great thing about these pools are they are inexpensive, flexible and you can fill the pool to just the right depth that you need.   Cost of pool was $200.   Since Kenai is a tall girl I knew I would not be able to have her swim so I filled the pool to 34’ which is the top of her back.   The plan was to get her into the pool and have her walk around the edge at a slow and steady pace.  Just like professional hydro therapy does with an underwater treadmill.

I am so happy to say that Kenai took to the pool right away and seemed to really enjoy her exercise sessions.  We started at three times a week – 3-5 minutes per session and slowly increased to every other day – 10 -15 minutes per sessions.  In about four weeks her thigh was showing vast improvements and after two months you could hardly tell the difference between the thigh that was atrophied and her healthy leg.

The pool was a great help in Kenai’s recovery however she still needed something that would support her stifle during her day to day activities.  I decided to look into purchasing a brace that would offer her the support she needed without limiting her range of motion.  I had found several sites that offer Stifle Braces but after talking to my general vet and the companies themselves I narrowed it down to two:  Animal OrthoCare (www.animalorthocare.com) and OrthoPets (www.orthopets.com).

Both companies custom make the braces to your pet’s specifications.  They both are designed to eliminate/reduce the tibial thrust, just like a Tightrope or Lateral Suture technique would do.  The brace should be used until the body can build up enough scar tissue to support the joint; this can take six months to two years or longer.  The two main differences in the companies were: OrthoPets hinge design is geared more for smaller dogs and they cost about $350 more.  OrthoPets uses a range of motion hinge which are much more like human ACL braces that can withstand large dogs. These hinges also provide more medial-lateral stability and prevent rotation. They also have a removable secondary suspension system that goes below the hock. This prevents any slippage or migration of the brace.

I decided to order my brace from Animal OrthoCare.  The order process started by OrthoCare sending me a ‘Casting Kit.’  This kit supplied everything I needed to make a cast of Kenai’s leg.  You can do the casting at home or with your vet.  Since Kenai is a big girl and there is a lot of leg to cast in less than 2 minutes, before the cast hardens, I felt it best to go to my vet for help.  Dr. Sallee and I did the casting and cut off the cast in about 5-10 minutes.  Kenai was a perfect angel during the whole process. Cost: $43.

I shipped OrthoCare Kenai’s cast, once it was received they used it as a mold to make a plaster replica of Kenai’s leg.  With the  replica of her leg they fabricate the brace to her exact measurements.   It took about two weeks to make the brace.  Cost of brace and casting kit $475.

When the brace arrived I put it on Kenai for about 15 minutes at a time.  She took to it OK, but she would ‘knuckle over’ on her foot.  I could not figure out why she kept doing this and was afraid that I had the brace on too tight or too loose or in the wrong place.  I took Kenai and the brace to Dr. Sallee and she said that everything looked great; the fit, the positioning and the brace itself.  So I called the director of OrthoCare and asked his opinion.  He stated that knuckling over is a very common issue and he suggested taking off the removable secondary suspension system that goes below the hock.  Once I removed it she walked with the brace perfectly fine.  The brace is molded precisely to her leg shape and I do not feel that the extra suspension was needed to prevent slippage.

However, after a week it was apparent that the brace needed to be adjusted so she could have more range of motion in her hock.  With OrthoCare all adjustments are free; you just need to pay the shipping to send the brace back.  It took about a week to get the brace fixed and returned.  Since then the brace has been working great.

Kenai wears the brace at all times when I am home, except at night.   I am not yet comfortable leaving the brace on while I am away from home, I am afraid that she could get tangled up in a blanket or something and cause herself more injury.  But I might try it soon, since she does not mind wearing the brace at all.

It is now late September and Kenai is doing better than expected.  We have had the brace now for over a month and it is working remarkably well.   She does not limp when wearing the brace, but her gait is slightly different.  She turns her hip out with each step, I don’t know if this has become a habit because she was in pain for so long.  Or, if this is how she will walk from now on to compensate for the weak knee.  Dr. Sallee feels she is doing very good and thinks the combination of water therapy and the brace is what has allowed Kenai’s knee to start to heal naturally.

We have also been walking daily and have worked up to just over a half mile.  Perhaps in a few months we can start joining the Hiking Club walks again.  I hope by mid next year we can ditch the brace and Kenai can go back to