Cruciate Ligament Disease: A Comparison of Surgical and Nonsurgical Treatment Outcomes
I was intrigued by the results of a recently published study in which the researchers focused on cranial cruciate ligament disease (CCLD) in dogs. Specifically, they evaluated owner satisfaction with outcomes of two very different treatment options, one involving surgery and the other using a custom fitted brace (orthosis).
An all too common injury
The cranial cruciate ligament is vital for maintaining stability within the knee joint (stifle). Tearing of this ligament is ridiculously common, particularly in medium and large sized dogs.
In most cases, the tear occurs abruptly, often in association with exercise or activity. It results in a sudden onset of lameness with the dog often unwilling to bear any weight on the affected leg. More and more, we are learning that neutering before one year of age predisposes to cruciate ligament disease, at least in some breeds. This association has been clearly documented in Labradors, Golden Retrievers, Vizslas, and German Shepherds.
Traditional treatment recommendations
As far back as I can remember, surgical repair has been the primary recommendation veterinarians make for treatment of CCLD in medium and large sized dogs.
The recommendation for nonsurgical management (restricted activity, a knee brace, anti-inflammatory drugs, pain medications, the tincture of time) is usually reserved for smaller dogs with the thinking that, the lighter the load carried by the knee, the less there is a need to restore “perfect” function. For medium and larger sized dogs nonsurgical management is typically the “go to” when there are extenuating circumstances such as financial constraints, anesthesia risks, advanced age, concurrent diseases, opposition to surgery, or an inability to successfully manage post-operative care. And, these extenuating circumstances commonly arise.
Study design
The researchers distributed online surveys to people whose dogs were treated for CCLD. The questions were developed to evaluate their overall satisfaction with treatment outcomes. All the dogs were medium to large sized dogs and all were treated via one of the following two methods:
- Surgical treatment with tibial plateau leveling osteotomy (TPLO) procedure
Of the many types of surgeries used to repair torn cruciate ligaments, the TPLO has long been regarded as a gold standard. This surgery has an excellent track record for restoring normal function and minimizing development of arthritic changes within the knee.
TPLO surgery is performed almost exclusively by veterinarians who specialize in surgery. The operation is quite pricey, particularly for dogs who end up tearing ligaments in both knees (happens approximately 50% of the time). TPLO post-operative care is laborious involving a lengthy period of confinement and controlled activity for the dog. (I know this to be true from much personal experience!) The TPLO complication rate is reported to be less than 7%, and most of the complications resolve with appropriate treatment.
- Nonsurgical treatment with a custom made knee joint orthosis (brace)
With the recent rise in access to canine rehabilitation therapy (the equivalent of physical therapy in the world of human medicine), the use of custom fit orthoses (braces) to treat dogs with CCLD has grown in popularity.
Study results
Of the 1,022 surveys distributed, 309 were completed- 203 from the orthosis group and 76 from the TPLO group. There were no significant differences between body weight, size, and age of dogs between the two groups.
Factors influencing treatment decisions
The factors that most influenced the decision to treat with an orthosis rather than surgery were cost, convenience, and personal preference. Amongst the TPLO respondents, veterinarian recommendation was stated to be the most influential factor.
Treatment outcomes
The proportion of respondents who reported that their dog’s treatment outcome was excellent, very good, or good was higher (98%) within the TPLO group compared to the orthosis group (86%). The percentage of respondents who reported that their dogs had either mild or no lameness following treatment was also higher in the TPLO group (98%) than in the orthosis group (88%).
Complications
Forty-six percent of respondents in the orthosis group reported that medical attention was required for skin problems caused by the brace. The need for multiple orthosis adjustments was commonly reported. By comparison, only 4% of respondents from the TPLO group reported complications requiring medical attention.
Customer satisfaction
Overall satisfaction ratings were pretty much identical with 85-90% of respondents from both groups reporting that, given the chance, they would choose the same treatment again.
Conclusions
Plenty of prior studies have evaluated CCLD surgical outcomes. This study is one of the first providing well-researched data pertaining to a nonsurgical treatment option.
The results are thought provoking for me on a few different levels:
- I was surprised that, despite the fact that reports of a normal gait (no lameness) and ratings of outcomes were significantly lower in the orthosis treated group, these respondents reported a high level of satisfaction and willingness to make the same choice all over again.
- I was surprised that, in spite of the very high complication rate associated with orthosis treatment (46%), respondents reported a high level of satisfaction with this treatment plan and a willingness to make the same choice again.
- Prior to reading this study, I would have assumed that nonsurgical treatment for CCLD would have resulted in lower customer satisfaction. I would have been wrong. My notion is that the high level of satisfaction within the orthosis group was related to good communication between veterinarians and clients about realistic expectations.
So, how is all of this information relevant to dog lovers and the veterinarians who advise them? It makes a strong case for veterinarians spending time in the exam room discussing all CCLD treatment options with their clients rather than focusing solely on surgery.
Despite the sentiment that surgery is the best treatment choice for CCLD, in many cases, this option simply isn’t feasible. Kudos to the researchers involved in this study for choosing to evaluate a nonsurgical alternative.
Has your dog ever torn a cruciate ligament? If so, what did you opt to do and what was the outcome?
Best wishes,
Nancy Kay, DVM
Diplomate, American College of Veterinary Internal Medicine
Author of Speaking for Spot: Be the Advocate Your Dog Needs to Live a Happy, Healthy, Longer Life
Author of Your Dog’s Best Health: A Dozen Reasonable Things to Expect From Your Vet
Recipient, Leo K. Bustad Companion Animal Veterinarian of the Year Award
Recipient, American Animal Hospital Association Animal Welfare and Humane Ethics Award
Recipient, Dog Writers Association of America Award for Best Blog
Recipient, Eukanuba Canine Health Award
Recipient, AKC Club Publication Excellence Award
Become a Fan of Speaking for Spot on Facebook
Please visit http://www.speakingforspot.com to read excerpts from Speaking for Spot and Your Dog’s Best Health. There you will also find “Advocacy Aids”- helpful health forms you can download and use for your own dog, and a collection of published articles on advocating for your pet’s health. Speaking for Spot and Your Dog’s Best Health are available at http://www.speakingforspot.com, Amazon.com, local bookstores, and your favorite online book seller.
Thanks for taking the time to provide this amazing information! It is truly helpful.
Hi Nancy-
Thanks for posting this well written piece featuring the first real published information about the use of Stifle Orthosis (Knee Brace) for conservative treatment of the ruptured Cranial Cruciate Ligament in dogs.
I am a veterinarian certified in canine rehabilitation and I work very closely with OrthoPets and together as a team- we select who would be a good candidate for a stifle orthosis, and make very careful measurements to design custom stifle orthotics (as well as many other types of veterinary orthotic and prosthetics).
If the Orthotic measurements and fitting are done by a more experienced and trained rehabilitation professional the outcome is usually better. Also- in my experience- the level of skill and knowledge of the manufacturer of the orthotics vary widely. This too will greatly affect the outcome for both fit and function.
A custom medical device usually does require acclimation and adjustment for both the dog and the caregiver who must learn to don the device correctly. But once the fit and function is good- the patients do really well!
Here are some more considerations from OrthoPets- for individuals thinking about a stifle orthotic solution as an alternative to surgery for the dog:
Is a stifle orthosis the right solution
for you and your dog?
Injury to the cranial cruciate ligament (CCL, also called the ACL) is the most common orthopedic injury in the dog. This injury is due to a partial or complete tear of a ligament inside the stifle (knee). The resulting instability leads to pain and arthritis.
Stabilization is recommended for best short and long-term function, quality of life, and comfort. Stabilization is traditionally done surgically either with a joint realignment surgery (TPLO or TTA) or with a pseudo-ligament surgically placed outside the joint (tight rope or lateral suture). These procedures are considered the standard of care, in general. In the past 10 years, the use of custom orthosis (brace) has become available as an alternative to surgery when surgery is not appropriate for any reason. These reasons may include other health issues, unacceptable surgical or anesthesia risk, advanced age, and financial constraints, among others.
Because an orthosis is not the correct therapy for all patients, before choosing an orthosis the following points are important to keep in mind:
1). The device MUST be put on every morning and removed every night. The device is to be used all day everyday, but must be removed at night. . It is NOT like human knee brace, worn only for sport. The orthosis stabilizes the stifle from the outside only when ON, while surgery does so from the inside permanently. Because of this it must be used whenever your dog will be standing and/or moving about. The device is not used at night and your dog must not be allowed to move about at night (jump on or off bed, wander the house, go outside through a dog door, etc.).
2). Adjustments are expected and are a normal part of the custom orthosis process. The device is custom-made for your dog. Every effort is made to accurately fit the device and 2 complimentary adjustments are included in order to meet the requirements for an appropriate fit; your veterinarian will coordinate these adjustments. Importantly, your dog is much more active at home than at the veterinary clinic. Increased activity and activity intensity can expose fit issues requiring further adjustment. Additional adjustments if needed are most commonly required in the first few months and as time goes on (see importance of follow-up #4). Please follow all instructions with regard to monitoring the leg and contact your rehabilitation veterinarian promptly if you have concerns.
3). Follow-up is critical to success. An orthosis is considered a “durable medical device.” This means that proper use is necessary to meet therapeutic goals and to ensure its safe application over the lifetime of your dog. In the first few months of fitting your rehabilitation veterinary team with the help of your OrthoPets trained veterinary case manager will work with you coaching with regard to device use and rehabilitation. Annual to twice annual appointments are advised depending on age and activity of your dog. At these appointments your doctor will thoroughly assess your dog’s orthopedic condition and evaluate the condition and fit of the device. Recommendations will be made for continued success in the device. If adjustments are required, it will be necessary to ship the device to OrthoPets with a turnaround time of 1-3 business days excluding shipping time.
4). Even with an orthosis, surgery may be required. When the cranial cruciate ligament is torn sometimes the meniscus is also torn. The meniscus is a comma shaped cushion on the inside of the stifle. There are 2, one on the middle and one on the outer side of the stifle. The middle or medial meniscus is most commonly injured and this may occur at the time of the initial cranial cruciate injury or any time later due to too much activity on an unstable joint. A torn meniscus is very painful and if not treated it will cause continued lameness despite stabilizing the joint with surgery or an orthosis. If this occurs, a surgical procedure called a partial medial menisectomy is required. It can be done by itself or with a surgical stabilization (see first paragraph). A torn medial meniscus is diagnosed either at surgery, by MRI (rarely), ultrasound where available, or based on clinical judgment with or without use of an orthosis. If your veterinarian suspects a meniscus tear please see our handout on options available for your dog.
5). The Role of Rehabilitation. Whether your dog undergoes surgical or orthosis stabilization for a torn cranial cruciate ligament and whether or not surgery is required for a torn medial meniscus, it will take time to recover full, comfortable function. If an orthosis is part of therapy most dogs adapt quickly to wearing an orthosis. Behavioral techniques can facilitate this. Also your dog will need to learn basic skills while wearing the device. These include: transitions (sitting, lying down, and getting up), stairs, getting into vehicles safely, managing on different types of surfaces (ground, carpet, hardwood floor, etc.). Finally, orthopedic injury leads to compensatory abnormal movement and associated muscle strain and weakness. The best way to ensure the highest level of success is to follow recommended rehabilitation schedule and techniques. Each patient’s condition and abilities are unique and as such an individualized rehabilitation program is needed. It is important to work with a certified canine rehabilitation therapist (CCRT) who will custom design your dog’s physical therapy program.
A proactive approach to arthritis management is the second key to long-term success. Just as rehabilitation is important whether your dog undergoes surgical or orthosis stabilization, arthritis management is key as well. All dogs will develop arthritis after injury to the CCL regardless of the stabilization techniques chosen. The difference is the severity and speed of development of that arthritis. Steps taken early on and continued throughout your dog’s lifetime will make a difference in terms of regaining and maintaining comfort and an active lifestyle well into the senior years. Seek a certified veterinary pain and mobility specialist who can create an individualized, integrative arthritis management plan for your animal.
Remember:
Orthotics (braces) for dogs is a new solution to an old problem. Modern medicine moves forward at a rapid pace. It takes a lot of time and many tens of thousands of dollars to perform a controlled clinical trial to compare a new therapy to the standard therapies in common use. As such, there is no (limited) published data directly comparing use of a stifle orthosis to surgical stabilization for CCL injury in the dog. As the industry leader using our unique, anatomically aligned, and mechanically sound custom design, OrthoPets provides stifle orthoses for nearly 1,000 dogs per year. This level of experience allows us to carefully select the patients best suited for a stifle orthosis; design appropriate rehabilitation protocols for best success; and troubleshoot interesting individual patient challenges. This is not a substitute for clinical data, but is referred to as empirical (or experiential) data. This is the current state of orthotics for animals. OrthoPets continues to work closely with university professionals at Colorado State University College of Veterinary Medicine to develop studies to prove and improve the use of orthotic devices in animals.
We routinely work with the OrthoPedics Department at Colorado State University and have also participated in research studies with both CSU and the University of Louisville. The research papers are currently not yet published, but have been presented at the Symposium on Therapeutic Advances in Animal Rehabilitation (STAAR) and Veterinary Orthopaedic Society (VOS) conferences. Additional information can be found in the conference abstracts. Please refer to information below:
Information from the Symposium on Therapeutic Advances in Animal Rehabilitation (STAAR) conference can be found on their website:
http://www.staarconference.com/STAAR_CONFERENCE/CONFERENCE_NOTES.html
The article is titled: Updates on Canine CCL Research Using Computer-Based Simulation
Speaker: Gina Bertocci, PhD PE, Professor, Bioengineering, Endowed Chair, Biomechanics
Information from the Veterinary Orthopaedic Society (VOS) conference can also be found on their website:
http://s421629680.onlinehome.us/wp-content/uploads/2015/05/VCOT-VOS-2015-Abstracts-Part-II.pdf
The article is titled: Comparison of Pet-Owner Satisfaction with Stifle Orthoses or Tibial Plateau Leveling Osteotomy for the Treatment of Cranial Cruciate Ligament Disease in Dogs Hart JL1; May KD2; Goh CS1; Palmer RH1; Kieves NR1; Mich P3; Duerr FM1 (1)Department of Clinical Sciences, Colorado State University, Fort Collins, CO,
Hi Nancy. Thanks for your question. A surgical specialist would be the best person to answer it. I suspect that the partially torn tendon will likely never have its full strength restored. Depending on how much of the ligament is damaged, there may never be a longterm problem with it.
This is the EXCELLENT article Elaine Garley referred to- http://animalbridges.com/9-lessons-learned-from-dogs-acl-surgery-and-recovery/#more-2318. I strongly encourage reading it!
I had a yellow Lab who fits the classic model: spayed at 6-8 months, torn her cruciate at about a year old chasing a ball. This was in 1987. She had surgery at Cornell vet hospital. She ended up frustrated because she could not run as fast as other dogs chasing a ball, but ended up scamming other dogs by dropping the ball halfway back to the thrower, then staying there while all the other dogs ran to the thrower. That way, she was quite able to be the first to get the next thrown ball.
How timely are your blogs…
My Rudy, 99.6 pounds of tree climbing, cliff jumping, German Shepherd cross dog is in his eleventh week of post-operative recovery.
He is doing wonderfully, without any sort of limp or favoring his affected knee. Our super, super surgeon implanted some awesome titanium hardware into Rudy’s knee.
But let me tell you this!
Dr. did a wonderful job but I told him that I take 91.6% of the credit for his successful recovery. (sounds like a reasonable number) Keeping a 99.6 pound, very active, very healthy six year old dog, calm, confined and quiet for the past 11 weeks has been a full-time, monumental task. We live on five, fully fenced acres in the redwoods of Northern California. Rudy is accustomed to running free and isn’t smart enough to realize that he had a BIG, boo boo. He has not been off leash this entire time. He is now allowed to go on 1/4 mile walks. We go twice daily. And there are the many potty walks around the property throughout each day. In about another two weeks or maybe another month or two more months, Dr. might say, Okay, Rudy, you’re all better…go run and play. Then I’ll have a beer.
My 10 month old Lab had bilateral partial ACL tears. He was not able to walk without pain and unable to trot at all. After exploring all the options, I chose stem cell treatment. He recovered quickly with no need for restricted activity. He has such good movement that he finished his conformation championship, with several judges noting his good movement. The cost was much less than surgical reconstruction, and he needed no rehabilitation.
Great question Mary. The company is OrthoPets in Denver, Colorado.
Do you know who the maker of the “custom-made stifle joint orthosis” was? Seems like the construction of the brace might influence results.
Dr. Nancy – A few years ago by dearest Titus, Shepard Cross, had Cruciate Ligament Disease. My vet suggested 3 different surgeries that could be done and referred me to a specialist 2 hours away. I scheduled the surgery, but then started researching. The surgeries seemed horrible with a long period of being crated and rehab. Having three other dogs, it would be so hard for her to stay crated, plus she had many other health problems, including Addisions Disease. I cancelled the surgery, researched some more and ordered an “A-Trac Brace” from http://www.woundwear.com. I called the Doctor, which is required, to give him her exact measurements. I had the brace in three days and as soon as I got it on her, she put foot down and walked with her normal weight on that leg. She never once tried pick at or get the brace off. She wore it 24 hours a day for almost 2 months and she was fine. She never had a problem with that leg again. I am so thankful I found that option and that website.
Thank you for all the interesting information you provide!
Hobbes, a Wheaten Terrier, tore his CCL and had surgery last summer. He is now 10. We worked for several months with the Twin Cities Animal Rehab and Sports Medicine to build up Hobbes hoping not to have surgery. He twisted his knee again and I decided to go for surgery. Turns out he also had a torn meniscus. Yes, the few weeks after surgery was rough on all of us. With rehab, he started with cold laser treatment almost immediately. His recover is excellent.
I realize after the surgery, he had started having problems with his leg the previous fall. He was slower to sit down and get up. Now he is doing great and loving life.
Although it was costly and time intensive for me, I would do it again with the same team of vets. I wrote a blog on 9 Lessons Learned from Dog ACL Surgery. It includes tips for the caretakers.
My late Siberian, Pomo, had 2 TPLO surgeries. He was not neutered until 9 years of age, when he developed testicular cancer (I’ll never leave a dog un-neutered again!). After recovering from cancer, he tore his ACL and had the surgery ($3,000 back then…2005?). He recovered with no lameness, but that knee always wobbled a bit. A few years later, he tore the other ACL, had the surgery (same surgeon, this time $6,000!!!!) on a Friday, developed an infection and had to be treated at emergency for it (no more late week surgeries when non-emergency…experience is a great teacher, but she sends terrific bills!). I was fairly satisfied, but was really given to believe that there was no other reasonable alternative to surgery. I have heard enough positive stories on non-surgical treatment, that I would go that route if I ever have the same issue again. Pomo lived a long healthy life of 15 years.
My 14 year old Shep/Lab mix had her knee surgically repaired and did very well with the rehab (we did 4 15 minute walks daily). I have a question…if the ligament is partly torn, will it ever repair itself with restricted activity? I am a retired vet tech and forgot to ask this when I was still working. Thanks in advance for your time.
Our previous Giant breed Leonberger began limping with his front leg at around two years of age. We took him to his Vet clinic that specializes in treating Giant breed dogs.
The clinic has several well known Vets on staff.
Our vet that day suggested x rays as a starting point. After they were completed his vet came in the room and told us I have good and bad news. The good news, our boy didn’t have cancer, the bad news was he did have the start of OCD.
I asked what he suggested to help eliminate the problem. He then told me something that I could not believe. He suggested I run the hell ( his words ) out of him basically to make the problem worse, then to bring him back and they then could operate on him to repair his problem !
His suggestion did not make one bit of cense to me. So I took him home and restricted his exercise along with multiple daily massages to the sore area for a few weeks.
He recovered 100% and did not show any limping for the rest of his long, healthy life. He lived to almost 12 years old.
My Border Collie had a partial tear. My main vet recommended surgery which I was considering until the holistic vet suggested trying going with restricted activity. The non surgical route ended up working fine. He has had no problems in the 2 1/2 years since (knock wood). However, it was a partial tear.
Hi Linda and thank you for your comments. You have put a unique spin on the bond that develops during rehab! Consider avoiding neutering your next Lab puppy until after one year of age. This will lessen the likelihood of torn cruciate ligaments.
Dr. Nancy, my late great Lab, Gracie, had bilateral CCD with surgery on both knees as a puppy. This was just as TPLO was becoming the standard, but on the advice of our vet and ortho surgeon, we opted for the “fishing line and eye hook” repair.
The side effects included the deepest bond I have had with any of my Labs, bc she had to rely on me for everything from potty breaks to cone removal so Gracie could eat. She became an awesome therapy dog, and about 3 years after her sx, the vet called and said there was enough science behind the procedure that he could safely recommend increasing activity without worrying about rein jury.
Gracie went on to have a very successful and happy job as my partner in the obedience and rally rings.
Yes, the post-surgical therapy was very strict, but so is the brace therapy. Weight management for the dog’s life is crucial! For a young athletic dog I would make the same decisions I made for Grace.
Researchers at Wisconsin (I think-it’s been a while), have Gracie’s DNA along w vertical and horizontal pedigrees, and complete health records, for a continuing study on the DNA of CCD in Labs. My hope is that she continues to improve the outcomes, even this long after she has crossed The Bridge.
Best,
Linda Rehkopf
Thank you for your question Dora. Here is how I mentioned using a board certified surgeon within the article:
1. Surgical treatment with tibial plateau leveling osteotomy (TPLO) procedure
Of the many types of surgeries used to repair torn cruciate ligaments, the TPLO has long been regarded as a gold standard. This surgery has an excellent track record for restoring normal function and minimizing development of arthritic changes within the knee.
TPLO surgery is performed almost exclusively by veterinarians who specialize in surgery. The operation is quite pricey, particularly for dogs who end up tearing ligaments in both knees (happens approximately 50% of the time). TPLO post-operative care is laborious involving a lengthy period of confinement and controlled activity for the dog. (I know this to be true from much personal experience!) The TPLO complication rate is reported to be less than 7%, and most of the complications resolve with appropriate treatment.
You don’t say if a person’s day-to-day vet is the one who would do the non-surgical treatment or who a person should see if that was an option they were looking to use. Could you make a comment about this. I assume it would not be the surgeon?