Dr. Phil Zeltzman’s Blog

Pet owners regularly question why we take X-rays to diagnose an ACL tear. After all, an ACL is “soft tissue”, and you can’t see it on X-rays. This is actually a very valid point. So why bother? Is it a waste of money? Are we taking loving pet owners for a ride?

The story of Zeus, a 3 year old pit bull, is a perfect way to explain why it is so important to take X-rays before ACL surgery.

Reasons include:

. An experienced family vet or a surgeon can actually diagnose an ACL tear on X-rays. Sure, we can’t see the ACL, but we can see the consequences of the tear: too much fluid in the joint, arthritis, displacement (or dislocation) of the thigh bone and the shin bone etc.

. In order to do a TPLO or a TTA, we need to take measurements to plan the entire surgery, so X-rays are mandatory. By the way, the X-rays must be in a very specific position, and require sedation. If the leg it crooked before the patient is awake or struggling, the measurements will be off, and the outcome of the surgery may be affected.

. Before any type of repair, we need to make sure that there isn’t something else going on. It could be something benign, like a fracture. This was recently the case of Ellie, a 6 month old English Bulldog, who was thought to have a torn ACL. A simple X-ray clearly showed that she had in fact a fracture of the shin bone (tibial crest avulsion). Note how the fracture piece (red arrow) is lifted off its normal position (green arrow).

Or it could be something much worse, as in the case of Zeus.

In December of 2018, the 3 year old pit bull was limping on the left back leg. X-rays showed subtle changed. A board-certified radiologist thought it could be a partially healed fracture of the shin bone and/or a torn ACL.

Zeus’ owner, wishing to pursue surgery, found me on my website, and asked me to do a TPLO. I referred him to a clinic where I frequently do TPLO surgeries. Surgery was delayed for various reasons.

On March 6, 2019, the day of surgery, the knee appeared unusually swollen. We repeated X-rays to be safe. Surprise… this was not at all an ACL tear. The shin bone had been literally eaten away by, most likely, bone cancer.

I called the owner and explained the findings. Unfortunately, the best option was amputation. Initially shocked, the owner accepted. Surgery went well and Zeus went home.

On March 7, 2019, the day after surgery, the phone update was good: “Zeus is doing well. He is getting around well three-legged. In fact, he had been only using 3 legs for a couple of months. He is eating and drinking small amounts. He has gone outside and urinated.”

Here is a video showing what a trooper Zeus was during his recovery (yes, he should have been on a leash…). He still has the Band-Aid over the incision. And he’s able to climb a few steps.

On March 13, biopsy results were back. Rather than the most common bone cancer (osteosarcoma), the cancer was hemangiosarcoma. This is an aggressive cancer of the blood vessels – in Zeus’ case, of the bone.

A few months went by, and Zeus enjoyed a happy life. Eventually, he started to limp on the right front leg. Initially, it was suspected that shifting weight to the front legs may have been responsible. Pain medications were started in August. “Zeus seems to be feeling much better since starting pain meds daily.”

Sadly, things progressed. Zeus’ family vet wrote in the medical record dated September 3, 2019: “Large visible swelling over right shoulder. Zeus is obviously in a lot of pain.”

X-rays showed that bone cancer, most likely, had spread to the arm bone (humerus). Notice how the bone looks moth-eaten.

That day, Zeus was humanely euthanized.

He survived for 6 months after the amputation.

This could be the end of this blog. But I decided to call Zeus’ owner to see how he felt about this whole experience.

His comments: “Sure it was rough at times, but Zeus was happy until the end. I feel that I did everything I could for my dog. I probably did more than most people would have. But Zeus was happy and comfortable. We went to the park every day. He loved people watching. I have no regrets.”

As I always say, when we deal with a cancer patient, I’d rather have 6 months of happiness than 6 years of misery.

Zeus is a perfect illustration of that concept. Sure, amputation is an invasive surgery, but dogs bounce back very well from the surgery. They don’t care about having 3 legs. They care about being comfortable.

Zeus lived happily for 6 months after his surgery. To his owner, these 6 extra months were priceless.

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified

Dr. Phil Zeltzman is a traveling veterinary surgeon in Pennsylvania & New Jersey. An award-winning author, he loves to share his adventures in practice along with information about vet medicine and surgery that can really help your pets. Dr. Zeltzman specializes in orthopedic, neurologic, cancer, and soft tissue surgeries for dogs, cats, and small exotics. By working with local family vets, he offers the best surgical care, safest anesthesia, and utmost pain management to all his patients. Sign up to get an email when he updates his blog, and follow him on Facebook, too!

Simone, a 1 year old Chihuahua, was relinquished to a rescue organization in New Jersey (www.facebook.com/SecondChancePetAdoptionLeague). Her story was nebulous, but it sounds like she sustained a 10 foot “fall” through a window. The story doesn’t say how…

That’s a pretty big fall for a 5 pound dog… Luckily, Simone’s only injury was a broken forearm (radius and ulna), just above the wrist.

The Animal Clinic of Morris Plains in NJ reached out to me to fix Simone.

Because there was so little space below the fracture, we “cheated” and used a special plate called a T- plate and 5 tiny screws. The T part allowed us to fit more screws below the fracture.

To reinforce the repair even more, a splint was placed on the leg after surgery. Simone recovered smoothly from anesthesia and went to recover in her foster home.

After 2 months of strict confinement and TLC, Simone’s bone looked healed on X-rays.

It is now time to start to rehab Simone. This simply means that she will need to be walked longer and longer to rebuild muscle. Then she can start to live a happier life with her new family.

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified

Dr. Phil Zeltzman is a traveling veterinary surgeon in Pennsylvania & New Jersey. An award-winning author, he loves to share his adventures in practice along with information about vet medicine and surgery that can really help your pets. Dr. Zeltzman specializes in orthopedic, neurologic, cancer, and soft tissue surgeries for dogs, cats, and small exotics. By working with local family vets, he offers the best surgical care, safest anesthesia, and utmost pain management to all his patients. Sign up to get an email when he updates his blog, and follow him on Facebook, too!

Kali, a 15 year old Australian cattle dog, was drinking and peeing more than usual. These are very vague signs, and thankfully her owner acted on them. Then Kali had vomiting and diarrhea.

Since these signs can be seen in multiple conditions, Kali had a physical exam. Blood work showed high liver numbers, so she had X-rays, which showed a liver mass.

An ultrasound revealed that the mass was the size of a pear.

Statistics tell us that most liver masses are cancerous. Kali’s owner didn’t know what to do. “Friends and family” told her that it was not reasonable to do surgery on an ancient dog with cancer.

Yet amazingly, this loving pet owner decided to give her 15 year old dog a chance. She chose to have the liver mass removed at Harmony Animal Hospital in NJ.

Kali was given IV fluids. Pain medications and anesthesia drugs were chosen to minimize the impact on her liver.

BEWARE, the next picture is graphic. You have been warned!!!

In surgery, the mass turned out to be much larger than anticipated. Instead of being the size of a pear, it was the size of a cantaloupe!

Because the risk was much higher than anticipated, I decided to call Kali’s owner in the middle of surgery to brainstorm and to make a decision together. Removing a mass this large greatly increased the risk of bleeding.

Of course, leaving a mass this large had its own risks. Left alone, the mass would continue to grow and would likely rupture, which would lead to internal bleeding. After careful consideration, the owner decided to continue with surgery.

So we finished the surgery, which was not exactly an easy task… We did have some significant bleeding. But overall surgery went well.

Here is the mass postop. The coin next to it is an American quarter… (a bit under 1 inch or 2.5 cm in diameter).

Kali stayed overnight on IV fluids, pain medications and antibiotics. Her red blood count stayed surprisingly high.

I stopped by the clinic the next day. Kali looked pretty good.

Two days later, Kali was bright and alert. She was ready to go home to heal and rest.

A week later, the biopsy results came back as… benign! Unbelievably, this enormous mass, that everybody was convinced was cancer, turned out to be a benign tumor (hepatocellular adenoma).

Twelve days after surgery, the update was very positive: “She is doing wonderful! Feeling a lot better, more like herself. She has a good appetite and good energy.”

One month later, her owner said that she “couldn’t be happier. Kali is doing phenomenal. She’s happy and back to her old self.”

And the best part: “Choosing to do surgery in spite of the odds and in spite of her age was totally worth it.”

Then something unusual happened at home:

“We recently found her on the couch sleeping upside down… and it dawned on us that it has been almost a year or so since she stopped jumping on furniture. We thought it was because of her arthritis in her elbows… but now we believe the tumor was making her uncomfortable to jump and lay on her back.”

So what’s the morale of this story?

. Just because your pet is old, doesn’t mean that you should give up.

. Don’t (always) listen to friends and family. They have good intentions, but ultimately you should make a decision you are comfortable with. You have to live with your decision. They don’t.

. Never assume. Just because everybody “knows” a mass is cancer, doesn’t mean that anybody is right. The only test I trust is a biopsy read by a board-certified pathologist.

. As I have said many times before, “Age is not a disease.”

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified

Dr. Phil Zeltzman is a traveling veterinary surgeon in Pennsylvania & New Jersey. An award-winning author, he loves to share his adventures in practice along with information about vet medicine and surgery that can really help your pets. Dr. Zeltzman specializes in orthopedic, neurologic, cancer, and soft tissue surgeries for dogs, cats, and small exotics. By working with local family vets, he offers the best surgical care, safest anesthesia, and utmost pain management to all his patients. Sign up to get an email when he updates his blog, and follow him on Facebook, too!

“I am absolutely terrified of surgery”

I probably hear this statement from loving pet owners once or twice a week. Since I am a surgeon, this statement obviously hurts my feelings.

Surgeons have feelings too, you know!

I typically ask questions to try to understand where my client is coming from. The story usually involves fear of the unknown, or the loss of an older or sick pet under anesthesia years and years ago.

Then I help the client realize that their fear is not really about surgery, but about the anesthesia. Even though surgeons hate that quote, in our profession we say that “there are routine surgeries, but there is no routine anesthesia.”

So we take anesthesia extremely seriously. And you should make sure that the veterinary team about to treat your pet takes it seriously as well.

What does that mean? It means doing blood work to ensure your pet is a good candidate for anesthesia. If there are abnormalities, it gives us a chance to correct them. If the bloodwork is normal, then this is wonderful news.

I feel strongly that every pet should have a trained, dedicated nurse monitoring them throughout anesthesia. This allows the doctor to focus on your pet and the surgery, while the nurse focuses on the anesthesia. This is similar to what happen in human medicine.

Years ago, a huge scientific study (almost 100,000 dogs and 80,000 cats) found out that the death rate around anesthesia time is 0.17% in dogs and 0.24% in cats. I said “around anesthesia time” and not “under anesthesia” because the researchers looked into pets who died up to 48 hours after the end of anesthesia.

Even better: these numbers are actually the average death rate. It’s the average between perfectly healthy patients, extremely sick patients and everything in between. And the study included puppies and kittens, adults as well as seniors.

So if you have a healthy pet, you’d think that going under anesthesia for a planned (ie non-emergency) surgery, the risk of death under anesthesia is even lower.

Sure enough: in healthy dogs, the death rate around anesthesia time is 0.05%. In healthy cats, it’s 0.1%.

Numbers are a bit worse for sick patients. In sick dogs, the death rate around anesthesia time is 1.3%. In sick cats, it’s 1.4%

These numbers are incredibly small, which means that anesthesia is incredibly safe in our cats and dogs.

That said, the risk is sadly never zero. And that is why we take it so seriously – and you should too.

Now… there is something else you should know.

Anesthesia is not the riskiest thing for your pet. The biggest risk, believe it or not, is the period right after anesthesia, when they wake up.

This is not the time to be complacent and walk away from a patient. This is the time to continue to monitor and make sure the pet is comfortable and warm and breathing well.

Monitoring after anesthesia should be taken very seriously.

So how do you ensure that your veterinary team takes your pet’s anesthesia seriously? As your pet’s best advocate, you have the right to ask questions.

Here are 10 suggestions to discuss openly with your vet:

. Will someone monitor my pet during anesthesia?

. How qualified is this person?

. Will you monitor my pet after surgery?

. Will you monitor my pet’s blood pressure?

. Will you monitor my pet’s CO2 level?

. How will you ensure my pet remains warm during and after surgery?

. What kind of pain medications will my pet receive?

. Will my pet have an IV catheter and receive IV fluids?

. Does my pet have specific risks under anesthesia?

. What will you do if my pet gets in trouble?

If you’re not happy with the explanations you receive, then you have the right to investigate another option you’re more comfortable with.

If you’re happy with the answers you hear, then rest assured that your veterinary team will do the absolute best to ensure your pet’s safety.

This is not about ego or offending someone.

We’re talking about your pet’s safety after all.

And you have a right to take it very seriously.

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified

Dr. Phil Zeltzman is a traveling veterinary surgeon in Pennsylvania & New Jersey. An award-winning author, he loves to share his adventures in practice along with information about vet medicine and surgery that can really help your pets. Dr. Zeltzman specializes in orthopedic, neurologic, cancer, and soft tissue surgeries for dogs, cats, and small exotics. By working with local family vets, he offers the best surgical care, safest anesthesia, and utmost pain management to all his patients. Sign up to get an email when he updates his blog, and follow him on Facebook, too!

As promised last time  (How to Find a Veterinary Surgeon Part 1), we share 5 more ways to find a surgeon for your cat or your dog.

6. Visit the clinic’s web site

The web site of the clinic where your prospective surgeon works will also give you some valuable information. You can get a feel for the clinic in general and the surgery service in particular.

7. Visit the surgeon’s page

Within the clinic website, there should be a page or a section dedicated to your surgeon. You can look at their biography and learn more. You can verify the surgeon’s credentials (do they have the letter DACVS after their name?). You can tell where your surgeon studied, where he or she specialized and how long they have been in practice. You can read about professional and personal accomplishments.

8. Does the surgeon understand your needs?

When you talk to the surgeon, feel free to explain your particular situation. Do you have any special requirements? Does your surgeon understand your goals with your pet? Do you and your surgeon have the same expectations? Expectations may or may not be realistic, but can always be discussed.

9. Does the surgeon answer the tough questions?

Ask about your surgeon’s success, failure and complication rates. Nobody likes to talk about failure or complications, but it should be discussed honestly. Do you truly understand exactly what your pet will go through? Do you understand what you will need to do after surgery? How generous is your surgeon with pain medications? Who will monitor your pet during and after anesthesia?

10. Trust your intuition

During the consultation, ask questions, and decide if you feel comfortable with the surgeon. Did the surgeon explain things well? Did the surgeon use simple words? Has the surgeon performed the surgery your pet needs multiple times before?

Keep in mind that some conditions are rare, and therefore that particular surgery may be performed rarely.

11. Bonus: a traveling surgeon

There is one more solution you may find convenient. Your family vet may work with a traveling surgeon. In this case, the surgeon comes to your vet’s hospital to perform specialty surgery. You don’t need to travel anywhere. This instantly fulfills several of the criteria above. Clearly, your vet would trust the surgeon they work with!

Called me biased since I am a traveling surgeon, but there are many benefits to staying local.

Ultimately, your choice of surgeon has a lot to do with trust. You need to find a surgeon you trust to operate on your beloved pet. Once that happens, you can in turn help other pet owners and their pets by referring them to someone you trust.

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified

Dr. Phil Zeltzman is a traveling veterinary surgeon in Pennsylvania & New Jersey. An award-winning author, he loves to share his adventures in practice along with information about vet medicine and surgery that can really help your pets. Dr. Zeltzman specializes in orthopedic, neurologic, cancer, and soft tissue surgeries for dogs, cats, and small exotics. By working with local family vets, he offers the best surgical care, safest anesthesia, and utmost pain management to all his patients. Sign up to get an email when he updates his blog, and follow him on Facebook, too!