Treatment for ACL injury

So I still haven't mastered posting multiple photos to the blog, but fortunately I do know how I do this surgery. There are many ways to repair an injured ACL in a dog but this is the way I have been doing it for years with very good success. First the meniscus cartilage, which is not visible in this picture, needs to be inspected and removed if damaged. Then the remnant of the ACL is removed along with any cartilage buildup that will interfere with joint function. The joint is flushed, and closed. I then inject some local anesthetic into the joint before we go on to stabilize the knee.

The photo below shows the knee joint closed and the lateral stabilization suture in place. I use a large nylon suture and a crimp instead of a knot to hold it.

You can see the crimp on the suture. In this dog, a large dog, a second suture is place to insure stability. The skin is closed and we use ice and IV pain medication in the immediate post op period to reduce pain and swelling. We also treat the joint with a laser immediately post op and the next day to speed recovery.

There are many different techniques to repair cruciate injury. Many people will advocate one over another. I have found this approach to be straight forward and easy on the patient. It is also less expensive than some of the other repairs. I have tried to balance outcome and cost so that we can help as many dogs as possible. For clients that request it, we are fortunate enough to have many referral hospitals where surgeons can do the more technically difficult procedures such as tibial plateau leveling and tibial crest advancement if it is indicated.

In the next posts, I'll address post op care, rehab for stifle joints and long term treatment of the degenerative disease of the stifle joint.

Keith Niesenbaum, VMD

http://www.crawforddogandcathospital.com/

http://www.thevetschoice.com/

http://www.petsneedfood.com/

Why is my dog lame?

So I was out running the Long Island Half Marathon with a couple of members of Team Crawford, our unofficial hospital running team, and had plenty of time to reflect on knees. I saw old knees, young knees, normal knees, knees with braces, ... you get the idea. Runners have plenty of knee issues. I'm at the age where many of my friends have had surgery on their knees for either meniscus damage or cruciate ligament injuries. So this problem is common in active older people as well as in dogs. The thing is, the nature of the injury is different in dogs and people, although the clinical signs (pain, swelling, lameness) are the same.


In people, injury to the ACL (anterior cruciate ligament) is usually a traumatic injury. You know, the tennis ball goes one direction and your knee goes the other. In dogs, ACL injury is usually a degenerative injury. The difference is subtle but important. In people, the ligament is often normal and is injured by the trauma. In dogs, the ligament is abnormal, and although the lameness is often proceeded by a perceived trauma, most often this ligament was going to pop sooner or later. The implication of this distinction is that the other ligament is often bad as well. So dogs with an injury to one ACL are at a much higher risk of tearing the ligament in the other knee.


Once the knee is destabilized by a torn ACL, other horrible things can happen in the joint. If you remember from the last post (It's OK, take a second to look back at the beautiful pirated photo of the knee model) there are other structures in the joint. That soft cushion of cartilage, the meniscus, is often torn at the time that the ACL goes. (see the illustration below) This causes more pain than the torn ligament sometimes. Knees with chronic partial tears can cause intermittent lameness. These knees tend to develop pretty bad arthritis over time.





Next post we'll talk about some options for treatment and possibly things we can do to minimize the undesirable effects of this condition. Until then, you might want to check this out to help your pet's joint health. Many runners I know use similar supplements designed for people, why not use one designed for dogs. I also know dogs that use Omega 3 fatty acids for arthritis. It is the major active ingredient in many joint diets, but in far too small a quantity. Here is a great way to get enough of a really good thing for you and your pets.

Keith Niesenbaum, VMD

http://www.thevetschoice.com/
http://www.crawforddogandcathospital.com/

What the H_LL is the ACL

OK, things got out of hand at work and I slipped back into an old pattern and I haven't posted for a while. I guess that when I decided to write about cruciate ligament injury in the dog, I found the topic so overwhelming that I just avoided the entire project. So, I'm going to divide it up into several smaller posts and the task will be easier for me to tackle. This post will deal with the ligament itself, and an explanation of some of the anatomy of the knee.

The knee is a pretty remarkable joint. The photo shows a model looking at the knee from the front. The joint, is a hinge, designed to flex and extend in one plain of motion similar to the way a door hinge opens and closes. It also has some very amazing shock absorbing principles, that allow us to run and jump. The joint runs into real problems when we ask it to do things it isn't designed to do like rotate, or hyper extend beyond it's normal range of motion.

There are extra articular structures (outside of the joint) that keep the knee stable. The muscles of the thigh that cross the joint and several collateral ligaments that do the same. You can see these collateral ligaments on the outside of the model.

Inside the knee, there are two cushions of cartilage, called the menisci. The medial meniscus on the inside and the lateral meniscus on the outside. They are labeled in the photo above. Finally, making a cross in the center of the knee are the two cruciate (cross) ligaments. The anterior (ACL) and caudal (CCL) cruciate ligaments. These guys keep the knee from sliding forward and backward. In fact the instability caused by injury to the ACL is called anterior drawer sign because when the muscles are relaxed you can actually pull the tibia (shin bone) forward like a drawer in a desk.

So now we all know where everything is. Next post I'll talk about what can happen to these structures. Then finally, we'll get around to explaining how they can be fixed.

Until next time, check us out at:

www.TheVetsChoice.com

www.CrawfordDogandCatHospital.com where you can search our library for free information

Feline Stomatitis

I just watched my associate finish a dental procedure on a very painful mouth that looked a whole lot like this one. Since I missed Pet Dental Health Month, (not yet blogging regularly) I wanted to share this with everyone so that hopefully your pet will not have to go through such a prolonged, painful course of disease before you seek treatment.



Feline Stomatitis, is a painful, inflammatory condition of the mouth. We are not sure why some cats get this condition. Some veterinarians think that there is a chronic viral infection with Calici virus. Others think it is from chronic poor dental hygiene. Still others think that it is an over reaction to the tarter, plaque and bacteria, found in the cat's mouth. One thing most veterinarians agree on is that there is some sort of immune system over reaction in the oral cavity. If recognized early, stomatitis can sometimes be controlled with frequent dental cleanings, anti biotics and a stringent home oral care program. Once the cat's mouth looks like the one in this photograph, the only treatment is surgical..

In the case of our kitty today, he was admitted for blood tests, general anesthesia, a good dental cleaning above and below the gum line and dental radiographs to evaluate the extent of dental disease. Then all affected teeth (most of the uppers as well as a canine_ were extracted. He will be sent home on anti biotics and some oral rinses and we will recheck him in two weeks. If we are lucky, the mouth will heal well and we can control this disease just by having the owners take care of the mouth at home.



To have success, we must make sure that radiographs are taken and no roots are left behind under the gum line. In many cases, this treatment is not aggressive enough and we have to go back surgically and remove all of the teeth and diseased bone. Long term anti biotics follow the oral surgery. There have been many reports of cats doing very well once all of the teeth have been extracted and the diseased tissue removed.



The most common objection I get from clients is their fear that their pet won't be able to eat with no teeth. In fact the cats do better after treatment as their pain has been alleviated. Some will still eat dry food, but we try to get most onto a diet of canned cat food.



You should check your cat's mouth regularly and call your veterinarian if you see any signs of redness, swelling or bleeding from the gums. If the cat chatters it's teeth when you are looking in, then the mouth is painful and needs immediate attention. Your veterinarian should examine your pet's mouth as part of the regular physical examination and let you know if anything needs to be done to keep the oral cavity healthy,



Dental health is a team project. Good nutrition, regular dental care, and home care with observation will keep your pet's smile intact and breath fresh and clean.



Keith Niesenbaum, VMD

http://www.thevetschoice.com/

http://www.crawforddogandcathospital.com/

Heartworm Infections in Dogs and Cats

The diagram to the left (still working on images on my posts but I seem to be getting better at it) shows the life cycle of the heartworm parasite in the dog. There is an important distinction between dogs and cats but we'll get to that later.

Remember posts ago, I said that I like to have my pets on year round parasite prevention. It's not for the heartworm, because as you can see, the vector/intermediate host is the mosquito and there are none around in the cooler months here in NY. Those of you in the south need to talk to your vets about heartworm season. We keep our pets on parasite control all year round because of intestinal parasites.

The infected mosquito bites our pet, our us (although people are rarely infected as our immune systems take care of the problem) and the parasite goes through development and matures to an adult. Males and females live in the heart and the large vessels of the lungs. They mate and baby worms (microfilaria) are released into the blood stream to be picked up by the next mosquito and the cycle continues. The time from infection to microfilaria in the blood is about 7 months, so when your pet is tested this spring (and the American Heartworm Society recommends testing all dogs yearly even if they are on preventatives) we are really looking for last year's infections. In cats, the worms do not really mature as well and we often see single sex infections or no adults at all, but in a moment we'll discuss why this disease is still important in our cats.

In dogs, the most common clinical signs that we see are those associated with congestive heart failure. Large masses of worms are in the heart and obstruct blood flow. I thought I could post a photo of a heart with worms, but It seems that if I try to upload more than one image per post it just stacks them at the top of the post and it doesn't look right.

In cats, we see respiratory disease or sometimes just sudden death. The syndrome was recently identified and named Heartworm Associated Respiratory Disease or HARD. Many cats with chronic coughs have had previous infections with heartworms.

In both species it is easier to prevent disease than to treat them. We have already reviewed different medications and your veterinarian can recommend one that he or she feels is best for your pet.

There is no treatment for cats. We have to wait for the parasites to die and hope that they don't kill the cat first. Seems like a good reason to put them on prevention. We did a massive screening test on our feline patients about 5 years ago, sponsored by Pfizer (the manufacturers of Revolution) and found several cats that had heartworm exposure and one that had active adult infection. Interestingly enough, indoor and outdoor pets were equally affected. I guess those screens do have some holes in them.

In dogs the treatment involves hospitalization and treatment with several injections of an arsenic compound. Some dogs cannot withstand the treatment and some are left with permanent damage to their hearts and lungs. If caught early, most will respond OK and go on to live happy lives. But it seems given all we have talked about concerning our options, that prevention is the way to go.

I'm going to try to post some interesting cases that I've seen in the next couple of weeks. However, you all know that I can get distracted. Until then, follow me on twitter at www.twitter.com/knvet and check out our web sites.

Keith Niesenbaum, VMD

www.TheVetsChoice.com

www.crawforddogandcathospital.com

Great Opportunity

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Date: Monday, March 30, 2009
Time: 8:00 PM EST
Phone Number: 616-347-8200
Passcode 800479#
Contact: Keith Niesenbaum, VMD
Phone: 516 746 1566
http://www.thevetschoice.com/

FLEAS!! And what to do before you burn your house to the ground.

I know it is probably bad formatting to start with a picture, but I want some credit for being able to post an illustration at all. Now I'll explain it.

The adult fleas live on our pets, they take a blood meal (bite the pet) and then mate and the female lays eggs. These eggs may stick to the pet, or fall off into the environment. They hatch and molt and develop into larvae. These in turn make a cocoon and pupate. The pupae then mature into adults, hungry for a blood meal and the whole cycle starts again. How long does this cycle take? It depends on the environmental conditions, but if things are just right they can go from adult to adult in a couple of weeks. Even more ominous, the pupal stage can survive for months in the environment, hatching out when conditions are right.

This life cycle is important to understand because it will help you to prevent flea problems and aggressively treat infestations if you missed the opportunity to prevent the problem.

Prevention is easy. Monthly application of a topical flea product that not only kills adults but prevents the immature stages from developing will keep your pets and your home flea free. We recommend Frontline plus or Canine Advantix for our dog patients. These pets are on monthly parasite control (see previous post) so we don't need to worry about worms or heartworms (see next post). For cats we recommend Advantage Multi or Revolution. You can use a product that is only for fleas and ticks, but if you are going through the trouble to use a product for fleas, why not take care of internal parasites and heartworm disease at the same time. Yes, cats can get heartworm disease but that is for a future discussion.

Now if you were naive enough to think that your pets would never get fleas and your house is now infested with the pesky buggers, you have to deal with the fleas on the pets, and the fleas in the environment. I no longer recommend owners treating the surroundings themselves. Gone are the days of setting foggers off in the home and contaminating the environment with toxic pesticides. If you have a severe infestation, use a professional exterminator.

In moderate to severe infestations, you can still get by without dumping poisons into the living room. Use a quick kill product such as Capstar that you can get from your veterinarian. This will kill all of the adult fleas on the pet in less than 24 hours. Unfortunately it doesn't last so new adults will jump on. I have clients use it every 2 days while we are getting a problem under control. Then add a topical product to every pet. This will continue to kill fleas as they jump on the dog or cat. The growth inhibitors will also control fleas in the environment where the pet spends most of its time (the pet bed or corner of the run where they sleep.)

Vacuum the house well and throw out the bag when you are done. Wash all bedding in warm water. You can use an area spray for the highest traffic areas. If you are going to bath your pet, do so before you put the topical products on, no sense in washing them right off.

Now I know you are going to think, I can get a cheaper product from the pet shop. Fight the temptation as not all of these products are as safe or effective as those that your veterinarian will have on hand. In addition, the person advising you at the store may not be well trained and could possibly give you incorrect advice.

And why is it important to treat these fleas? Well besides the fact that they are gross and icky, they can cause disease in people and pets. I have seen dogs and cats actually die from anemia as these parasites suck the very blood from these poor animals. What a horrible way to die. They are also vectors for diseases that can infect both people and pets. If you follow this post, you already saw the link to Ted Nugent last week.

Next post I'll finish this series with a discussion of heart worm disease in dogs and cats. Hopefully by then I'll be able to put my graphics in the middle of my post.

Keith Niesenbaum, VMD
www.TheVetsChoice.com
www.CrawfordDogandCatHospital.com