What to Expect 1: Leg Amputation

Osteosarcoma faces greyhound owners with an extremely difficult choice: Amputate the affected limb, or just manage the dog’s pain until it’s time to help him pass on. No one wants to make this choice, and every hound parent who has been through this has questioned their decision and agonized over it.

**PLEASE NOTE: I am NOT a vet. All medical advice given here should be discussed with a specialist and with your regular vet. This is based on my own experience with my boy Whitey (front-leg amputee at age 11), my boy Apollo (front-leg amputee at age 10), my other pups Crisco, Tanner and Annie (who had osteo but were not candidates for amputation), and extensive conversations with vets and parents of other osteo hounds. This is a work-in-progress, and I will revise/update as I gain new information.**

The information here is intended to help you make an informed decision, by telling you what to expect if you choose amputation, as far as surgery, recovery, medication, etc. Nothing, unfortunately, can predict the amount of time you will have with your hound whichever path you choose. But amputation may sound like a scary alternative, and we hope this information will help alleviate some fears.

Once you have an osteosarcoma diagnosis (your vet has seen the characteristic sunburst bone lysis on a radiograph), you need to do a couple things before you know whether amputation is an option for your dog:

First, get a high-resolution lung radiograph (xray). Osteo metastasizes extremely quickly, and if it is already in the lungs, amputation may not be a viable option except as temporary pain-relief. Unfortunately, osteo micrometastasizes so rapidly that once it is visible on a leg xray, it may already have invisibly spread to the lungs. However, if it is not visible on the lung films, it may be early enough that amputation/chemo can significantly prolong survival time.

Then, do a full blood workup to determine whether your dog is healthy enough to withstand surgery (and subsequent chemo, if you decide to do chemo). Make sure your vet understands the difference between greyhound blood numbers and those of other breeds. Check the alkaline phosphatase – if this number is elevated, the prognosis is worse. Make sure his kidney and liver values look good.

Once you have xrays and bloodwork, it’s time to get oncology opinions. With osteosarcoma, time is of the essence since it can spread so rapidly. Email, fax, or overnight all your materials to the Ohio State University (OSU) Greyhound Health and Wellness Program. This program is the world’s leading research center on osteosarcoma in greyhounds. The program head, Dr. Guillermo Couto, probably knows more about greyhound osteo than anyone on earth. OSU is extremely busy, so call and email until you get a response. (http://www.vet.ohio-state.edu/4366.htm)

If OSU believes that your hound has osteo and is a good candidate for amputation, they will send some handouts for your surgeon. As of this writing (March 2010), OSU will also send free Adriamycin chemo drugs for any ex-racing greyhound.

While you are waiting to hear back from OSU, find a surgeon. You want a specialist with overnight medical care. Meet with him/her, get their opinion on your dog’s case, get comfortable with them. You may even want to schedule a tentative surgery date to save time.  In Apollo’s case, we were able to have his surgery on the day of the consult, because we had already made our decision.

OSU does not recommend bone biopsies on greyhounds. This is a painful, invasive procedure that is intended to confirm that the hound actually has osteo. However, in most cases a diagnosis can be made on the basis of xrays (and at most, a fine needle biopsy which does not require anaesthesia). A bone biopsy also increases the chances of pathological bone fracture in the hound.

Once you’ve consulted with your regular vet, the specialist, and OSU, you can make your decision based on what you feel that you can handle, and what you feel your hound can handle. You know his personality better than anyone, and are the best person to make this decision for him out of love.

What to Expect with a Leg Amputation

Before Surgery:

It’s likely that you will not have a lot of time to prepare prior to surgery, but here are some things that you can do as soon as you know that your hound will be having an amputation…

…Supplies & Home Preparation

Order Aminocaproic Acid (a brand name is Amicar). This drug has been shown by Ohio State to minimize the post-op bleeding that greyhounds are prone to. Vets do not typically stock this, so you will need to order it. Begin giving it on the day of surgery, and give for 5-10 days after. 500mg three times per day.

Order an assistance harness (Here’s one we like at http://www.northcoastgreyhounds.net/ click on “Admirable Resources”). It may take some time to ship, and some are made to measurements, so order this in advance to have on-hand when your hound comes home. It will help you help him get up and about during the period when he is still finding his balance.

If you have slippery floors in your house, get some rugs. You don’t want your hound slipping and falling after surgery, while he is still learning balance. And many hounds will just flat-out refuse to walk on slippery floors.

If you have a lot of stairs, think about how you will negotiate these for the first few weeks post-op. You may want to set up a “recovery area” in the part of the house that has the fewest stairs, and prepare to keep the dog (and yourself) in that area most of the time post-surgery. If you have a few stairs to go outside, strongly consider purchasing (or constructing) a ramp with good traction.

Stock up on some things you may need when the dog first comes home. Pediasure is good for a dog who does not have much appetite, to get some calories into him. Chicken broth poured over food may stimulate eating. Gather some old t-shirts to cover the surgery site, some old blankets to put on top of the dog’s bed in case the wound is seeping. Maxi pads stuffed into the t-shirt can catch some seepage.

…Diet and Supplements

Get your hound on a low-carb diet. Carbs feed cancer cells, so it’s desirable to eliminate as many of these as possible while maintaining a healthy diet. Both Evo and Wellness make “very low carb” dogfoods. You can generally get the lowest carbs with canned, but there are some kibble options as well. Wellness also make some “jerkey-style” treats that are low carb. And Stella & Chewy’s makes a dried meat patty that can be fed as a treat (really intended as a complete meal for a small-breed dog).

(Locally, Chuck ‘n’ Don’s Petfood Outlets carry these brands. Whole Foods Market carries a small selection of the Wellness. Some Petcos and Petsmarts will also have a small selection.)

Get your hound on nutritional supplements. The strain on his joints is going to increase, so it’s a very good idea to get him on some glucosamine and chondroitin. Springtime makes a chewable “Joint Health” tablet. The same company also makes a “Longevity” supplement that can be used in conjunction with the “Joint Health” if desired. The Greyhound Gang sells powdered glucosamine and chondroitin that can be mixed into yogurt or food.

Order some Artemisinin. Studies have shown that Artemisinin (a holistic drug) kills cancer cells in the test tube. Ohio State has been doing clinical trials with it, and they use it with osteo dogs that they treat at their facility. You can order it from Hepalin.com. Give 100mg once a day. OSU recommends giving it first thing in the morning, when the dog has an empty stomach. Give it with a high-fat but low-iron treat, such as peanut butter or cheese. Refrain from feeding any high-iron foods for at least an hour afterward. If you are giving anti-oxidant supplements (such as the “Longevity”), give those at the opposite end of the day.

…Miscellaneous

Make sure the dog’s toenails are nice and trimmed, to minimize slipping.

Prepare yourself for what your dog will look like when he comes home. Join the Circle of Grey yahoo group, Greytalk.com, and Tripawds.com for personal stories of amputations, often accompanied by photos and sometimes video. All 3 of these groups are great about giving advice to newbies from been-there-done-thats, so ask questions!

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Day of Surgery

Make sure that your surgeon is familiar with the special needs of greyhounds under anaesthesia!! Also, make sure they are familiar with the greyhound’s sensitivity to certain drugs, and the differences between the greyhound’s bloodwork and that of other breeds. Most adoption groups will have info on these things that they can provide to your vet.

Make sure your surgeon has operated on greyhounds before, and is familiar with their post-op bleeding issues. Ohio State can provide your surgeon with information on aminocaproic acid, and on the anaesthesia and pain management protocols that they recommend.

You will need to fast the dog for around 12 hours pre-surgery.

Consider bringing your hound’s bed along, so that he will have a familiar place to recuperate in the ICU. Also bring one of your own recently-worn t-shirts (for your scent), some of your dog’s food, and some treats that he finds especially appealing.

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Post-Op

Choose a facility that has overnight medical care!

They will probably keep your hound overnight 1-3 nights, depending on how he is recovering. They typically like to see the dog both eating and able to get himself up and move around a little bit before going home.

If, when you see your dog, his level of mobility is not something you are comfortable handing, you can ask them to keep him another night. They will generally let you visit your dog in the ICU, but perhaps not on the day of the surgery itself, as the dog will be sedated and resting.

Be prepared when you see your hound for the first time. He can sense how you are feeling, and if you are upset and scared, he will be too. Act like everything is normal, and he will feel better. It is still the same dog!

If he is not bandaged, the sight of the incision may be a shock, so prepare yourself for a very large (10” or so) incision, with swelling and possibly substantial bruising. Also prepare for him still to be potentially a little “out of it” from the sedation.

Here are photos of Whitey’s bandage, and of his incision at one-week post-op.

…Meds

The hardest thing for the humans to handle may be if the dog seems afraid, anxious, uncertain, or painful. Remember that some of these things – especially the anxiety – can be caused by the very medications that are helping with his pain. He may still not be “with it.”

Pain medications such as Fentanyl (this is a patch that is applied to the dog’s skin for 3-5 days post-op), Tramadol, hydromorphone, etc. are called “opiates,” and some greyhounds may be extra sensitive to these. They can very often cause restlessness, panting, anxiety, whining, and dysphoria (hallucinations). However, they are also often the most effective method of pain control.

If the side effects are too much to handle, talk with your vet about possibilities for different pain meds. Your hound will probably also be on an NSAID (non-steroidal anti-inflammatory drug) such as Deramaxx or Metacam. These may cause a little stomach upset, but will not cause the dysphoria of the opiates. Another option to ask about is Gabapentin.

If the side effects of the drugs are keeping the dog from getting rest, you can ask your vet for some Valium (diazepam). This can “take the edge off” the anxiety from the opiates. Some vets may also use Acepromazine, which really can knock the dog out. If you use Ace, start with a VERY small amount (e.g., ¼ of a 25mg tablet), and if that has not had the desired effect after 90 minutes or so, give another ¼ tablet. This has a muscle relaxing effect, and will make it harder for the dog to walk. It can last 6-8 hours. It can also lower blood pressure, so ask your vet whether this is a concern for your dog.

It is very important that your hound be able to rest during the days after surgery, so it’s important to find a balance between pain relief and side effects of the pain medications.

Pepcid AC can help with tummy upset from the NSAIDs, too (although antacids should not be given with Gabapentin). He needs to feel well enough to eat something to keep his strength up. If need be, use the Pediasure or chicken broth to get some calories into him. And make sure he stays hydrated; offer him water often.

…Mobility

Your hound WILL require almost CONSTANT supervision during his first few days home from the hospital. The first night or two, you are unlikely to sleep much, so rest up before surgery and while your dog is in ICU. Make sure the schedule the surgery at a time when you will be able to take a few days off work when he comes home. Preferably someone who is physically able to lift the dog unassisted.

How mobile your hound will be when he comes home depends on the individual dog. Some dogs are getting around relatively well within a day or two. Others will take a week, 2 weeks, even a little longer to really figure it out. In the meantime, you can assist your dog with a harness (as mentioned above), or even with a long bathtowel looped under his ribcage. This can help you bear some of his weight and keep him on balance.

You will almost certainly need to assist him at first with pottying. Some dogs may find this type of help difficult to accept, especially those who are not used to doing their business while on-leash. Try to give him as much “space” as you can while still being there to support or catch him if he wobbles.

As he gets more confident, it’s up to you to keep him safe. He may forget and try to do things he did pre-amputation, like jump on/off the bed, run too soon, go down stairs without assistance, etc. It is very important that he not fall hard during his recovery period, or he can injure his surgery site (or one of his “good” legs).

Older dogs have a longer adjustment period in general. Also, paradoxically, the dogs who had the best use of their “bad” leg pre-amputation have longer recovery times. Dogs who were not bearing weight on the bad leg have already started to adjust to walking on 3 legs. The amputation is less of a change for those dogs, and actually eliminates the pain from that bad leg. However, those who had good use of their “bad” leg before surgery also probably had the cancer caught earlier, and will have the best prognosis.

Mobility generally improves as more of the sedation drugs and pain drugs leave his system, and as the swelling goes down.

He will learn it! He just needs rest, practice, and supervision and encouragement from you.

If you must leave your dog alone soon after surgery, put him in an area where he cannot hurt himself, and away from your other dogs. If possible, get someone to check on him if he is alone for a long period, or hire a dogsitter.

…The Surgical Site

The bandaging that your surgeon does will depend on his/her preferences. My vet recommends a compression bandage left on for the first 5-7 days after surgery. This prevents fluid buildup at the surgery site, which can cause pressure on the sutures and oozing of the wound. If this bandage gets wet, it will need to be changed.

After the bandage comes off, you can protect the area by putting a t-shirt on the dog. You can use a human t-shirt, tied up at the waist so not to trip the dog or get peed on. Or you can use a t-shirt made for dogs. (www.crittercozies.com has t-shirts made especially for front-leg amputees).

You can expect to see edema (swelling) around the compression bandage, down around the dogs chest and groin area. You will also see edema in the remaining leg. If this seems excessive or increases very rapidly, check with your doctor. It may remain for a week or so. As time goes on, everything moves “south”…The swelling in the chest will decrease but the swelling in the leg will increase. You can massage the leg gently, or use a heating pad on it to encourage circulation.

You will also see some redness and bruising. Again, if it seems excessive or increases very rapidly, check with the doctor. This should also dissipate over a few days to a week. It looks a lot worse than it is.

This is Apollo’s bruising and swelling a few days after surgery.  I panicked a little when I saw this, but my vet assured me that it was within the normal range for this surgery.  The edema was down into his abdomen and groin.  Over the next few days, it moved into his back leg so that both hocks were very puffy and swollen.

One more note on bruising — If your dog has had extensive bruising, you can expect to see some orange urine for a day or two as his body breaks down the extra blood.  You might immediately think “internal bleeding” but if he is otherwise okay (normal heart rate and respiration, not overly lethargic, normal temp) then this is unlikely.  For a quick test, check his gums.  If you press your thumb against it, the white spot you leave should turn pink again almost immediately.

You will need to watch for infection.  Your hound will probably either be on an oral antibiotic, or have been given a long-acting antibiotic injection during surgery, and infection is more likely to occur after those meds have finished.  Apollo developed an infection at the “Y” intersection of his incision at about 3 weeks post-op:

You can see that the top part of the incision is all nicely healed with no bruising; but just below the “Y” it has become extremely swollen.  The skin was taut and shiny, pulling on the staples and causing constant seepage from the wound.  The tissue in that area had become necrotic (died) and it was unable to heal up.  In Apollo’s case,  we gave him antibiotics for a couple weeks to get the swelling down and see how much tissue was ultimately going to necrose, and then we needed to put him back under anaesthesia, debride the wound and resuture it.  This was about a 20-minute procedure and he actually felt a lot better afterward.

The First Couple Weeks

Hound parents who have been through amputations with their hounds often report the “two weeks of hell,” during which the dog is recovering from surgery and taking lots of medications. Your hound is almost certain to behave oddly during this time, both as a result of the meds, and also of just adjusting to his new situation.

He may seem unable to get comfortable, or just not seem to know what he wants. He may stand up, lie down, stand up, lie down, wander aimlessly. He may pant a lot or seem anxious. He may cry out or whine even if it seems that nothing is touching his sore spot. He may refuse foods that he otherwise loved, and eat things you didn’t expect.

Unless any of these are extreme, they are probably within the normal range. Most of these do pass after a couple weeks, and your hound’s pre-surgery demeanor will gradually come back. Some people report that once the pain meds are gone, it’s like somebody turned the lights back on and the hound gets back to normal. DO NOT withhold pain meds, though, because he needs them!

Hounds can have phantom limb pain, just like human amputees do. This is *real pain* even though the limb is gone. It’s nerve pain. One of the best meds for this is Gabapentin. Ask your vet about it if you think your hound is having this type of pain.

You may also see what can only be called “depression” in your hound.  It is tiring, both mentally and physically, to feel “off” for days on end…whether that means painful, uncomfortable, drugged-up, nauseous, or just “not-quite-right.”  In most cases the depression doesn’t last long, and you can help your dog by getting him back into the normal swing of life.  Encourage him to do his favorite things.  We took Apollo for car rides, which he loved, even if it was just a half-mile to McDonalds for chicken nuggets and back home.  But try not to fuss over him too much, or he will sense your worry and reinforce the idea that something is very wrong.

Within 2-3 weeks, your hound should be moving around with near-normal confidence (although it is best not to allow him to run yet, if he feels up to it). Before that time, you might feel yourself questioning whether you’ve done the right thing for him. But remember, you made the decision out of love and the best information you had. He’ll get through it, and you’ve given him the best chance of pain-free life that you could.

Here are Apollo (one week post-op) and Whitey (2 months post-op) hopping around their yard:

Feel free to email me with questions! greyhoundmama @ earthlink.net