Fat Sam and his terrible joints

My orthopedic surgery patient yesterday was a middle-aged golden retriever mix named Sam. Typical of most goldens (and golden mixes), Sam is about the sweetest, gentlest, most angelic dog you'll ever meet. If you stop petting him too soon, he'll ever-so-delicately offer you a raised forepaw and gently brush it on your leg to remind you he's still there.

Sam's mom adopted him from a rescue a year and a half ago. At that time she was told that he had recently been treated for heartworm infection, but was otherwise healthy. Sam's mom got him on regular heartworm prevention, made sure all of his subsequent heartworm tests were negative, and settled into a happy life, just her and Sam with occasional visits from her grown kids.

Sam's mom says that he was in rough shape when she adopted him -- his hair coat was in poor condition, he was "skin and bones," a number of his teeth were broken (possibly from chewing on rocks), and he just seemed neglected.

Several months after his adoption, Sam started limping in his hind end. His mom didn't think much of it until about two months ago, when Sam's limping became severe.

By the time Sam visited his regular vet 3 weeks ago, he was bearing almost no weight on his left hindlimb, with his right hindlimb also obviously painful on his rDVM's exam. Sam's rDVM took radiographs of Sam's hips and knees, and diagnosed him with hip dysplasia, cranial cruciate ligament (CCL, the equivalent of the ACL in people) disease, and luxating patellas. Sam left that visit with prescriptions for 3 different pain meds to help make him more comfortable.

Fast forward to two days ago, when Sam arrived at the VTH for an orthopedics consult. Sam hadn't improved much with the last few weeks of pain meds. He would bear some amount of weight on his left hindlimb but had an obviously limp, was reluctant to bend his left leg, and was more comfortable lying on his right side.

Sam's mom brought his radiographs from his rDVM for us to review. They revealed severe dysplasia of both of his hips, with moderate to severe arthritis. He also had evidence of CCL ruptures in both stifles, already with mild arthritis. Orthopedic exam showed a grade 1/4 medial luxating patella on the right side (insignificant relative to his other issues).

What Sam ideally needed to be ambulatory with minimal pain for the remaining 8-10 years of his life was a CCL repair on his left side, followed by treatment of his hips on both sides (total hip replacements or FHOs), and then probably treatment of his right CCL.

After Sam's orthopedic exam and reviewing his radiographs, we sat down with Sam's mom to discuss his joint diseases and his options. She was shocked to hear our diagnosis of "severe" hip dysplasia after reviewing his radiographs, having been told by her rDVM that he had "some" hip dysplasia but that fixing his knee should basically take care of his pain.

What Sam's mom could afford was a single surgery. So we planned to fix the most obvious source of Sam's current pain, his left knee.

I should mention at this point the other confounding factor: Sam weighs 72 pounds and should weigh 50-55. He is what we call a "body condition score" of 9 out of 9, with 4 to 5 out of 9 being ideal, 1/9 being completely emaciated, and 9/9 being, as the surgery resident put it in Sam's case, "shaped like a coffee table, with buttcheeks on his shoulders."

We proceeded to surgery with Sam yesterday, performing a TTA (tibial tuberosity advancement) which should eliminate Sam's need for a CCL (which was doing nothing it was supposed to in his left knee anyway) and will slow the progression of arthritis in this knee such that it will be almost unnoticeable.

And though Sam went home this morning with adequate pain control, a happy owner, and a bill that was less than her estimate, I can't help but feel that Sam has been failed in many ways in his 5 years of life:

(1) In this case, since Sam is a mutt, at least I can't blame a greedy, conscience-free, bad bad breeder for his joint disease.

(2) With the severity of Sam's joint disease at 1.5 years post-adoption, there is no way that a thorough physical exam performed by a competent veterinarian through the rescue group prior to Sam's adoption would not have identified at least some of Sam's joint issues (most notably his hip dysplasia). This would have allowed the rescue group to do something about it, or at least to better educate Sam's adopter about his likely need for costly medical and surgical care down the road, and the importance of keeping him at a healthy weight and on joint supplements. Whether the rescue group did not consult a vet, did not consult a competent vet, or had the information and chose not to relay it to Sam's mom is unclear.

(3) Sam's rDVM, who took his radiographs earlier this month, either mis-diagnosed the severity of his hip dysplasia, or was not upfront with his owner about how bad it was. Sam's poor mom was taken completely aback when we told her that Sam would ideally have surgery on both of his hips as well. Though there's not much that Sam's rDVM and his mom could have done differently in the last 3 weeks with a honest diagnosis of severe dysplasia, at least she would not have come to the VTH thinking that one surgery would make Sam all better.

(4) Sam's mom, though she loves him dearly, has allowed him to gain weight nearly to the point of literally loving him to death. Sam has pretty long hair, which makes him look like some amount of his bulk is due to fluff and not to fat, but it was a struggle to identify any of his bones underneath his deep fat pads during our orthopedic exams. If I hadn't seen Sam's hip joints on his radiographs, I truly couldn't have told you if he actually had bones there or not, based on palpation. Similarly, his ribs are nowhere to be found, no matter how deeply you dig your fingers into his chest. When we shaved Sam's left hindlimb for surgery, he had wads of fat sagging off his thighs.

It's the obesity that really gets to me in Sam's case.

Yes, there was probably no breeder at fault for Sam's joint disease (other than the owners of his parents who obviously didn't alter their dogs despite probable joint disease in those dogs). So no, Sam's probable inherent genetic tendency toward joint disease is not his current owner's fault.

Yes, the rescue group and Sam's rDVM could have been more thorough or more upfront about Sam's severity of disease.

But despite his "skin and bones" condition at adoption, Sam's mom did not have to allow him to become grotesquely obese, thus putting an enormous amount of unnecessary strain on his already painful hips and knees. This is the one thing that was truly preventible in Sam's case. Would Sam still be painful today and need surgery even if he weighed 50 pounds? I can't say with certainty that he wouldn't, but I'm quite sure he'd be more comfortable, more active, and could have made it longer before requiring the surgical treatment(s) he now needs.

You can give me all the excuses you want about living for months in a rainy climate, Sam not getting enough exercise from the rain, Sam getting "depressed" because he didn't get walked much and you "having to" feed him to make him "happy," and you being depressed from the weather and not caring about Sam's health.

Those excuses mean nothing to me after seeing how much Sam struggles to be a happy dog while combating an extreme amount of pain even while he's on three different pain meds.

Think about a person: Sam is the equivalent of a person having torn ACLs in both knees, and hip arthritis that makes it excruciating to take even a single step. Now take that poor person and make him wear a backpack, 24 hours a day, everywhere he goes (sleeping, getting up from the couch, walking to his car, sitting in a chair, trying to do any kind of exercise or mobile activity), with about 65 pounds of extra weight shoved into the backpack. Think they'd be as cheerful and loving as Sam is?

I find almost no excuses acceptable for an obese dog. You are the human. You can choose the type of dog food. You can choose the exercise plan. You can choose to feed measured amounts as meals rather than filling up the bowl once a day. In 95% of cases, you can make a decision not to have an obese dog.

Anyway, we had a heart-to-heart with Sam's mom about his obesity. I think (and hope) that she has a better understanding now of how important it is for Sam to lose weight. At his consult on Thursday, we recommended putting him on a hard-core weight loss diet (Science Diet prescription r/d), which Sam's mom picked up from her rDVM that same day and switched Sam to on Thursday night. She realizes that treats are now forbidden, and that she'll have to find Sam a new favorite treat from among her options of green beans, carrots, celery, unflavored rice cakes, and ice cubes.

If everything goes as planned at home, Sam won't be back for another 10-14 days, when he'll have his stitches out. At that point I'll be on vacation(!) and another group of ortho students will see Sam for his recheck. I sure hope he's doing well and has lost about 5 pounds!