All dogs suffer the occasional health problem, but some unfortunate pups end up suffering rather serious medical issues, which may even require surgery or other invasive procedures to correct.
We’ll discuss just such a situation today, as I’ll break down my personal experiences navigating my dog Remy’s double anterior cruciate ligament (ACL) surgery.
(Quick note: This ligament is often called an anterior cruciate ligament or ACL in humans, but the analogous structure in dogs is typically called the cranial cruciate ligament or CCL — ultimately, both terms refer to the same ligament).
I’ll detail some of the symptoms he displayed (i.e. the signs that made me suspect he needed a double ACL surgery), outline our vet’s diagnosis, and cover the actual surgery as well as his early recovery.
If you suspect your dog might need an ACL surgery, be sure to read this guide, as it’ll give you a better idea about what to expect.
How Did Remy Get Hurt?
People always want to know exactly how Remy ended up suffering an injury to both ACLs, but unfortunately, I don’t know for sure.
Ever since I adopted Remy he’s always had a bit of a weird, bow-legged gait, so it’s possible he had some pre-existing damage or there were some genetic issues at play.
However, there are a few incidents which I expect may have exacerbated his injuries (even if they weren’t the original cause of his problem).
The first? Improper play with the flirt pole!
Flirt poles are essentially long cords with a handle (usually just a fancy stick) at one end and a cute little “lure” (generally a stuffed or rubber toy) at the other end. You hold the handle, drag the lure around, and your dog chases it.
Flirt poles are excellent dog toys that provide physical exercise, mental stimulation, and plenty of training opportunities. And while any dog can enjoy playing with one, they’re especially well-suited for dogs with high prey drives, like my Remy.
When using a flirt pole, it’s important to play safely and keep the lure pretty close to the ground to prevent injuries (cue dramatic music here).
Unfortunately, there were a few incidents where friends and family members would wave the toy up in the air, encouraging Remy to jump up and grab the toy. This resulted in a couple of incidents where Remy jumped very high and twisted to get after the toy, before falling awkwardly and limping for several days after.
So, that certainly might have contributed to his ACL injury.
I also used to make Remy run up and down the stairs for exercise – and going down the stairs at full speed as Remy does might have made his injury worse.
Lastly, (and possibly the biggest mistake I made), there were several incidents in which Remy injured a leg and started limping for a while afterward. And despite my vet advising me to stop all exercise for several weeks while he recovered from these strains, I continued to walk Remy.
Pretty dumb, right?
Well, yes and no.
Exercise is a critical component of basic dog care, that helps keep pooches feeling and behaving their best. Dogs who don’t get regular exercise often exhibit behavioral problems, and some simply become very depressed.
And during this time, Remy’s behavior was really bad, with tons of arousal outbursts, nipping, and biting. It was a pretty rough period for us. I was terrified that if I stopped exercising Remy, his biting, barking, and other bad behaviors would escalate.
At the time, keeping him indoors with no exercise did not seem like a possibility if I wanted to protect the progress we’d made and ultimately keep Remy in my life.
In retrospect, I now realize I could have tried upping his mental enrichment while he was healing. Instead of continuing to go on long walks, I should have let him enjoy more time with puzzle toys, scavenger hunts, and other brain-occupying activities.
But at the time, I thought physical exercise was the only way to keep Remy’s arousal issues in check.
Remy’s Dog ACL Diagnosis
I started to realize something might be seriously wrong with Remy when he had another bad leg sprain that didn’t seem to go away for several weeks. In fact, he’d begun to walk with a hunch.
And it didn’t seem to be getting any better over time.
I tried to use a canine knee brace on him to prevent further damage. Knee braces work really well for many four-footers, but Remy was having none of it. He was constantly trying to bite and chew the brace to escape its clutches.
Some folks are able to make these types of braces work, but other owners, including myself, can’t really get them to function correctly with their dogs. Not only was Remy constantly trying to get the brace off, it also kept sliding down off his body and would never really stay in place.
Still, braces are something to consider trying if you’re looking for surgery alternatives and your own dog’s damage isn’t too severe.
I took Remy back to the vet, and she ordered a full set of leg X-rays, which required sedation.
Looking at the X-rays, my vet noticed some odd issues with Remy’s legs, but she didn’t see any damage that seemed to point to an ACL injury. She considered that there could be something wrong with his back or hips, but it was hard to say for sure.
Ultimately, she suggested I reach out to an orthopedic specialist to get a second opinion.
Getting Referred to a Canine Orthopedic Specialist
I ended up being referred to Dr. Stuart Bliss, an orthopedic specialist at Port City Referral Hospital in Portsmouth, NH. Dr. Bliss examined Remy and confirmed that he did indeed need a double ACL surgery.
In fact, he said that Remy could be the poster child for a dog needing ACL surgery, as his hunched posture and reluctance to put weight on his rear legs are both classic symptoms of ACL injuries.
Remy’s official diagnosis was: chronic bilateral cranial cruciate ligament insufficiency for which he would undergo a bilateral TPLO.
I was a bit surprised to hear that his need for a surgery was so obvious to the specialist, considering my vet seemed stumped. My veterinarian is lovely and very smart – I trust her completely.
But even the best vets miss things, and I’m so glad she referred me to an experienced specialist who could better illuminate what was going on with Remy’s injury.
And Dr. Bliss was great. Despite being unable to talk to him in person due to COVID, I sat in the parking lot and chatted on the phone with him for 40 minutes as he explained all the details of what he saw on Remy’s X-rays.
Dr. Bliss was very understanding of the tough situation many owners are placed in when a dog requires a surgery like this. With an $8,000 price tag, a dog double ACL surgery is one heck of a pricey procedure.
As I consulted with Dr. Bliss about Remy’s potential ACL surgery, I asked him what my options were. He patiently outlined my options (which weren’t awesome) and explained some of the details of what Remy’s surgery and recovery would look like.
When I asked if Remy was in pain, he noted that this is a bit of a problematic question because many owners have a lot of guilt around the idea of keeping a pet in pain.
He noted that mild to moderate discomfort is something many humans and animals live with, and that Remy could still live a pleasant life without undergoing surgery. Sure, he would be very limited in his activity, but he could still have a reasonable quality of life.
He explained that Remy would still be able to get around in his current state. His life would not be terrible, nor would I be cruel for expecting him to go without the surgery. But he definitely wouldn’t be able to be as mobile as he could be.
I was really touched by Dr. Bliss’s concession and his recognition that surgery might not be an option for all families.
I took a few days to reflect on the decision and decide whether or not to make Remy undergo a double ACL surgery (we shouldn’t forget that even though the surgery would make his life better in the long-term, it would force him to endure pretty significant hardships over the short-term).
I decided I wanted Remy to get the surgery because — at a mere 4 years of age — he is still a really young dog. There’s SO much more with Remy than what his current situation allows him to do.
So for me, the surgery was worth it.
And I knew undergoing this experience would allow me to share the process with our readers, so I was happy to undertake it.
Questions to Consider When Contemplating ACL Surgery: Things to Think About
When deciding whether or not a pet should undergo a surgery like this, there are a few factors you want to consider:
Your Dog’s Age
Older dogs will struggle a lot more than younger dogs when undergoing an ACL surgery. They can be less likely to enjoy a positive outcome, and they will usually have a longer recovery period than young dogs will.
If an older dog is well into his golden years, consider if it’s really worth putting him through such an invasive and traumatic procedure. Usually the benefits of surgery are well worth it for younger dogs who have many years ahead of them – especially if they are active, outdoor-loving dogs.
The Nature of the Recovery Process
Be sure to ask your vet about the length of the recovery process, and how intense it will be. Some dogs need to be kept on crate-rest nearly 24/7 following an intense surgery.
So, really consider whether it will be worthwhile for your dog, as well as whether or not it’s something you can realistically manage. If you can’t commit to the necessary recovery process, your dog’s entire surgery could be for nothing.
The Likelihood of Success
It’s worth doing some research into what a certain surgery’s chances of success are. Your vet can provide more details into the specifics of the surgery you are contemplating.
For such an intense procedure, I’d imagine you would want your chances of success to be fairly high.
Your Dog’s Personality
Some dogs have a very high baseline stress and anxiety level. While surgery may still be a worthwhile option for these doggos, it might not be worth putting a fearful four-footer through such a rough, potentially traumatizing ordeal.
Remy, however, is a very confident, self-assured dog, so I guessed he would take it all in stride.
Symptoms of Dog ACL Injury
As I waited for his surgery date, I noticed Remy displaying even more signs that he required ACL surgery, including:
- A slow, awkward, and uncomfortable posture when standing up and lying down.
- Swinging his back legs under his body to reposition himself and lie down (rather than using his back legs to maneuver).
- Hand-standing. It wasn’t uncommon to see Remy float his back legs completely off the ground, putting all his weight on his front legs. Once I even saw him lift both legs 6 inches off of the ground.
- A bulky body shape. Due to the unnatural way he was supporting his body weight, Remy acquired an odd shape, with a bulky front area and a thin hind area.
- Holding his head and neck down. Remy would constantly walk with his head and neck hunched down to keep his weight distributed over his front legs.
- He’d hesitate to jump up on the couch. I began to notice Remy would hesitate a lot before jumping up into the bed or couch and often move back and forth on his back legs prior to jumping up.
- Making tippy tappy movements with his back legs. In situations that did require Remy to lift his head, such as looking up at me for a treat or as I prepared his dinner, his back legs would tap back and forth as he tried to put as little weight as possible on them. He would also do a little poop dance where his back legs would lift back and forth.
Another weird issue that Remy has had basically since I adopted him are these back spasms, where his muscles would twitch a ton. I don’t think this is necessarily a known symptom of needing an ACL surgery, but I did always suspect that his twitching back muscles indicated some kind of strain or muscle problem.
Pre-Surgery Prep Work
Surgery is a big deal for dogs, so a little bit of prep work can pay huge dividends. I decided to implement some desensitization and associated training practices that would help Remy cope with his upcoming operation.
First, I began to practice using a sling with Remy so that he would be at least a little bit accustomed to the sensation.
Next, I bought some sod and put it out on my mom’s deck.
I decided to stay with my mom for the first week or so of Remy’s recovery so that I could have an extra set of eyes monitoring him. While the front of my mother’s house has three steps, the back deck has six, which would force him to endure twice as much wear and tear.
I thought the easiest option for Remy would be to put some sod on the back deck so that he wouldn’t have to go down any steps at all to relieve himself.
Despite my best efforts – from collecting Remy’s pee and sprinkling it over the sod, to standing on the deck with him leashed for several minutes while waiting for nature to call — Remy did not show any interest in using the sod to do his business.
So, as owners should always be ready to do, I adjusted and ended up just taking him down the three steps at the front of the house.
You might also want to consider getting your dog desensitized to wearing an e-collar or cone before his surgery too. I didn’t really need to do this with Remy, but it never hurts.
Surgery: The Big Day
The next step was scheduling Remy’s surgery.
I was concerned that Remy’s recovery might be put in jeopardy in the winter due to dangerous icy conditions, and the doctor confirmed that it wouldn’t be an issue to wait before performing the surgery. So, I booked it about 6 months down the line, during the summer.
On August 5th, I brought Remy to the Port City Veterinary Referral Hospital in Portsmouth, NH. I couldn’t give Remy any toys or clothing of mine for comfort due to COVID – I was only allowed to send him with a bag of food.
As the attendant came out and took Remy away, my brave, confident boy marched ahead, excited at the new smells, and didn’t look back once.
I was nervous about the whole procedure, but the staff at the Port City Veterinary Referral Hospital were incredible. Everyone I spoke to was kind, attentive, and patient, and they were willing to talk me through the details of the procedure and recovery multiple times.
Dr. Bliss kept me updated on Remy’s progress to an impressive degree, texting me right before they went into surgery as well as right after it concluded.
Remy stayed at the clinic for the next two nights, giving the hospital staff plenty of time to observe him post-surgery. I was told Remy was doing remarkably well and was already on his feet the day after surgery. Dr.Bliss observed that Remy was a very tough dog, and I must concur – he’s one brave guy!
When I went to pick up Remy on Saturday, he came out of the building limping and a bit wobbly, while accompanied by a veterinary technician. Remy marched over to me curiously, but not especially excited. But as soon as he got close to me, he gave me a big sniff and then burst into joyous cries and whining.
I was given instructions on Remy’s post-operative care (which had also been sent via email), and they loaded me up with three different medications for him, a wrap for supporting his rear end, and a plastic e-collar to stop him from licking the wounds.
The vet tech let me know that some of the drugs might make him feel pretty weird, and he might whine because of that.
On the car ride home poor Remy cried and whined incessantly, which broke my heart because that is very unusual for Remy – he never cries.
When we got home I unloaded him from the car, got him settled in his bed, and observed his wounds. The sutures were not wrapped, as this allows them to heal quickly.
While the 3-inch-long incisions looked gruesome to me post-surgery, I knew they could have been so much worse! I’d seen many horrific and gruesome-looking wounds when researching the surgery earlier.
In fact, I even asked Dr. Bliss why the incisions were so small, but he explained that some surgeons prefer to open up the entire leg to really see and examine all the ligaments clearly. But, Dr. Bliss had learned his method of ACL surgery — which involves making very small incisions — from a former human surgeon.
ACL Surgery Recovery Medications: Drugs for Doggos
Remy was sent home with the following medications and some dosing instructions in his discharge notes:
- Gabapentin 300mg (Per Capsule). Give one to two capsules by mouth every 8 to 12 hours as needed for pain. May cause sedation. Next due 4 PM for every 8 hour dosing. For the next 3 days it is recommended to give the gabapentin at a dose of 2 capsules every 8 hours. It can be decreased to 1 or 2 capsules every 12 hours thereafter.
- Carprofen 100mg (Per Caplet). Give 1/2 caplet by mouth every 12 hours as needed for pain. Give with food. Next due 8 PM this evening.
- Cephalexin 500mg (Per Cap). GIve one capsule by mouth every 12 hours until gone. Next due 8 PM this evening.
I’ll also be including Remy’s assessment in his discharge notes at the end of this post (check them out if you’re at all curious. Honestly, the language is fairly confusing, but I want to include it in case it’ll be helpful for others considering this surgery).
Dog ACL Recovery & Healing
With the surgery in the rearview mirror and Remy back at home, it was time to start the long and bumpy road to recovery.
Remy’s Recovery: Weeks One and Two
The first week of Remy’s recovery was entirely devoted to helping his wounds heal and keeping him comfortable while keeping his movements to a minimum.
Thankfully, the meds I gave him seemed to keep Remy very comfortable. In fact, I was shocked to witness that Remy didn’t need any of the e-collars or cones I had ordered, because he had little to no interest in licking his wounds.
Remy looked so pathetic in his beat-up state. The only thing that cheered us up was the fact that Remy had a cute little shaved square patch on his booty where they anesthetized him.
The first and second week consisted primarily of me taking Remy outside on a short lead for potty breaks (no proper walks) while delicately negotiating a few threshold stairs with the help of a sling.
Remy was pretty frustrated with this. In fact, after the first couple of days post-surgery, Remy began lying down in protest against the new no-walks mandate. I tried to make it up to him by allowing him plenty of time to relax outside and enjoy the sunshine while he was recuperating.
As the discharge notes stated, Remy’s bruising did worsen in the first few days, but he quickly began to heal after the first couple of days. Remy wasn’t very tolerant of cold compresses (which were recommended in the discharge notes), so we didn’t do much of that.
I kept Remy gated off from the couch and the stairs to eliminate the temptation of jumping and tried to limit his movement as much as possible.
Remy’s Recovery: Week Three
After the first two weeks, Remy began to recover much more quickly. In fact, after just two weeks, his wounds were completely healed over!
Remy was still doing some handstanding and navigating gingerly on his new legs, but friends observed that he seemed to be walking a lot better.
And, sure enough, as the weeks went on, I too noticed Remy standing with better posture and even playing and expressing some rambunctiousness that I thought he had long grew out of (although that stressed me out since he isn’t supposed to do a lot of running and leaping during recovery).
After the first two weeks, since Remy’s wounds had healed, we could focus on building up some of the back muscle strength he had lost.
This was done through:
- Short, slow walks. I was instructed to walk slowly with Remy and keep him by my side, as if teaching him to heel. This would prevent him from pulling forward and force him to put more weight on his back legs. We were allowed to do one 10 minute walk per day by week three, and then gradually increasing the duration to 15 minutes per day, and then we could start enjoying multiple 15 minute walks a day after three weeks. The doctor explained that it was really important to not push it, and keep progress slow and steady.
- Range of Motion Exercises. I was also instructed to do range-of-motion exercises. This entailed lettingRemy lie down comfortably, and then stretching one of his back hind legs so that it was in a relatively straight position. I’d hold him in that pose for 10 seconds, then fold the leg back to its original position. I was instructed to repeat that exercise every day, for about 10 repetitions on each leg. I wasn’t super diligent with this because I would just perform the exercise when Remy was relaxing, opting for whichever side was easy to use.
- Physical Therapy. Therapist-directed physical therapy was listed as another option I could pursue with Remy. We haven’t attempted this yet, but it’s something we might pursue in the future.
Our next follow-up appointment with Dr. Bliss is slated for early October. He and his staff will be taking another round of leg X-rays – let’s hope they have good news for Remy’s recovery!
We’d love to hear about YOUR experience with your own dog’s ACL surgery in the comments below! I’ll make sure to update new information about Remy’s recovery as he heals.
And for those who are curious, I’ve included Remy’s official discharge notes below:
Remy’s Discharge Notes: What to Do; What Not to Do
As mentioned, here are the discharge notes I was given from the hospital staff. I’ve just cut and pasted them from the original email.
Radiographs of the stifles showed moderate arthritic changes, and marked effusion/synovial thickening, bilaterally. Patellar tendon insertion was intermediate, and tibial plateau angle was 30 degrees. He was anesthetized, and epidural marcaine was given to control pain. Joint inspection on the right revealed partial rupture of the CCL. A large medial meniscal prolapse was found and was treated by removal of the caudal pole of the medial meniscus.
On the left, complete rupture and resorption of the CCL was found. A meniscal injury of similar configuration was debrided similarly. TPLO was performed bilaterally without complication. He was stable through the procedure and recovered well. He was treated over the next 2 days in hospital with IV fluids, IV analgesics, antibiotics, carprofen and gabapentin, and mild sedation.
On Saturday AM, he was alert and stable, with good pain control and intact appetite. He was discharged on that day.
Please monitor the incisions regularly for any excessive redness, swelling, or discomfort for Remy. Bruising is to be expected after this procedure. The bruising will probably become slightly more apparent over the next few days, but should show signs of resolution thereafter. If you notice substantial worsening of the bruising, please call us.
Remy may have some clear benign weeping of fluid from the incision. This occurs in a small proportion of dogs, and typically resolves spontaneously within a few days. It is recommended to clean the incision periodically with a warm moist cloth if you notice any mild drainage.
Also, excessive movement of the knees, such as with walking, tends to prolong and exacerbate this type of discharge. Therefore, keeping him as quiet as possible for the next few days will help minimize this. Otherwise, if you have any concerns about the appearance of either surgical site, please call.
Remy must not be allowed to lick or chew at the incisions. If he shows an interest in bothering the incision, a cone collar may be necessary. These can be obtained from Petco. The blue pillow-type buster collars available also from Petco are effective for some dogs.
Please give the medications as directed. If you feel that his discomfort is not adequately controlled, please call us and additional medications or pain management strategies can be discussed. There are no sutures to be removed. We encourage you to consider physical rehabilitation (physical therapy) for Remy.
Feel free to contact us with any questions about rehabilitation. An initial evaluation with a rehabilitation professional may be useful in developing an exercise program for Remy that will accelerate his recovery and improve his longer term function. Please refer to the accompanying instructions, suggestions, and recommendations for at-home exercise moderation and general aftercare, and call if you have any questions or if you encounter any difficulties with his aftercare during the next several weeks.
Recheck radiographs (Xrays) of the knee will need to be performed in approximately 8 weeks. Please call to make an appointment for radiographs. Mild sedation is likely to be required to obtain good quality radiographs; therefore, this visit will take a couple of hours. Remy may also be dropped off for the day for this appointment. This appointment is charged for separately.
He is a great dog, and we wish him the best during the next several weeks of recovery. Please stay in touch and do not hesitate to call with any questions or concerns.
Postoperative management and recommendations for home care rehabilitation after TPLO:
Remy underwent surgery for repair of bilateral cranial cruciate ligament rupture on 8/5/21. The repair that was performed is called the tibial plateau leveling osteotomy (TPLO) and involves a tibial corrective osteotomy (cutting of the bone of the tibia).
The bone is then repositioned appropriately, and stabilized in place with metal implants. This procedure is designed to change the geometry of the knees in such a way as to provide stability to the joints while the limb is bearing weight.
Careful supervision of Remy’s activity level by you during the 8-12 weeks following the procedure is critically important for a good functional outcome following this procedure. During the first 2 months after the procedure, the tissues in and around the knee will gradually heal, and new bone will form in the area where the bone was cut and repositioned.
It is important that the metal implants used to stabilize the bone not be excessively stressed during this healing process. Too much exercise may cause excessive wear and tear upon the implants and may lead to implant loosening, fracture of the portions of the tibial, or other damage to the joint. If this occurs, additional surgery may have to be considered for replacement of implants or restabilization of the joint.
Recommendations for at-home rehabilitation for Remy consist of the following 4 components:
1. Exercise restriction: Remy must be carefully exercise restricted for the next 8 weeks. Running, jumping, rough play with other dogs, unsupervised activity off the leash, and any other forms of vigorous activity should be strictly avoided. Activities that subject the joint to concussive forces, such as jumping and pulling hard against a leash, should particularly be avoided. Stairs are best avoided. Bathing and formal rehabilitation and water therapy are fine, once the incision has healed (14 days after surgery).
2. Cryotherapy (cold packing): For the first 5-7 days after surgery, application of ice packs to the incision may provide some pain relief and help reduce swelling. Ice packs may be prepared by mixing crushed ice with a small amount of cold water in a plastic leak-proof baggie, wrapping the baggie in a light towel, and holding the pack gently against the incision and around the front of the knee for 10 minutes. A bag of frozen peas wrapped in a light moist towel also works well. The ice should be removed if Remy indicates to you any sign of discomfort. Cold packing can be performed 2-3 times per day or more often if he is tolerant of it.
3. Range of motion exercises: Range of motion exercises consist of gentle flexion and extension of the knee while the leg is relaxed. These exercises may be started one to two weeks after surgery and continued for 8 weeks. To perform passive range of motion, Remy should be relaxed and lying on his side with the operated limb up. Gently tickle the underside of the right foot and gently encourage the knee toward a flexed position. Hold this for a few seconds and then allow the knee to relax into an extended position, and repeat this 15 – 20 times. The joint should be pushed toward, but not beyond the limit of what he will tolerate. If the exercises seem painful or Remy seems to resent the manipulations, stop, and try again later but more slowly and more gently. His tolerance for these manipulations, and the comfortable range of motion of the joint should improve over the first 4 weeks of exercises. These exercises may be performed a few times per day, or more frequently if he will tolerate it.
4. Active weight-bearing. Weight bearing is important for the health and function of the limb as it contributes to the maintenance of muscle tone, prevents atrophy of limb muscles due to disuse, and preserves health of the joint by circulation of joint fluid and compression of the cartilage surfaces within the joint. Active weight-bearing can be accomplished best with controlled walking as follows:
For the first 4 weeks, please limit Remy’s activity to short slow walks on a short lead. 5-10 minutes walks for exercise and for elimination purposes several times per day are acceptable during this time. Slow walking should be undertaken as if you are teaching him to heel, but on a very short lead. The pace should be sufficiently slow as to force him to walk but avoid trotting.
Slow walking will force Remy to place his feet appropriately and bear weight on the operated limbs, but will force him to load weight onto the limb in a gentle non-concussive manner. This type of gentle weight-bearing will help maintain muscle tone and muscle mass in the limb, and will contribute to the maintenance of cartilage health in the joint.
During the second 4 weeks, slow leash walks may be extended to 10-15 minutes at a time, 3-4 times per day. Bathing or aquatic therapy during formal rehabilitation are fine starting 2 weeks after surgery; however, vigorous exercise should be avoided as much as possible for the first full 8 weeks of the initial healing process. Followup Xrays of the knees are required at approximately 8 weeks after surgery. If the Xrays show appropriate signs of bone healing, then the amount and the pace of walking may subsequently be gradually increased back to his normal level, and slow trotting may be performed during walks; however, he should not be allowed unsupervised exercise, or be allowed to run off the lead until the end of the third postoperative month. After 3 months, if he is doing well, he may return to normal activity levels.