By Narda Robinson, DO, DVM
Imagine you twisted your knee and your doctor diagnosed an injured anterior cruciate ligament. What if she offered you only surgery or euthanasia (hypothetically legalized for humans)? Would you explore alternatives or accept this false dilemma? Would it change your mind if you discovered that more enlightened surgeons are exhorting their colleagues to stop cutting cruciates at least until patients have undergone a month or more of conservative care?
In the same vein, why do some veterinary surgeons limit options for dogs, forcing clients to choose between breaking their hearts and breaking their banks? Yes, canine and human stifles differ, but the chronicity and persistence of canine cruciate disease argues in favor of a long-term, rehabilitative and integrative approach, not for bone saws.
Moreover, far from being a slam-dunk diagnosis and treatment, confusion lingers. Unknowns persist about whether a lameness is indeed due to cruciate injury and if so, what caused it. Furthermore, “The ideal treatment modality for cranial cruciate ligament (CrCL) injury has yet to be determined…”1
Consumers want options.2-6 Many in our profession insist that only surgery or euthanasia allows dogs to avoid a life of disabling pain, arthritis and poor quality of life.
What does the evidence say about their claims?
Claim No. 1
“A chance to cut is a chance to cure.”7,8 False.
Cutting does not cure cruciate disease. In fact, about half of Labradors rupture the contralateral CCL within six months after tibial plateau leveling osteotomy.9 Evidence indicates that TPLO does not halt the progression of osteoarthritis in dogs.10,11 TPLO outcomes vary widely and long-term clinical trials are lacking.12 In fact, three studies show that radiographic signs of OA significantly worsen after TPLO. This concurs with human evidence indicating higher OA morbidity following surgery as opposed to conservative care.13
Claim No. 2
“Studies with force plates demonstrate the superiority of the TPLO.” False again.
“There is little good scientific evidence that any one surgical procedure is better than any other,”14 even though many surgeons advertise or teach that TPLO is the “gold standard.”15-17 Also, force plate analyses paint an incomplete picture, especially for dogs with naturally occurring disease and multi-limb lameness. Kinematic parameters differ between breeds, arguing for the establishment of normative data in healthy dog populations before making inferences about injured clinic patients.18
Claim No. 3
“Pelvic limb lameness is cruciate injury until proven otherwise.” Untrue.
Who hasn’t stumbled off a curb or strained a muscle after a run? Dogs’ paws, too, may slip and injure soft tissue.19 However, most injuries do not require surgery for their successful resolution. Rest and wrap, massage, acupuncture, laser therapy and proprioceptive retraining may produce a full recovery for many problems whereas cruciate surgery never restores the limb to normal function.20 Who pays for the diagnostic error when the surgeon finds an intact ligament? The dog and the client.
Claim No. 4
“The canine stifle differs from the human stifle; therefore, comparisons cannot be made.” This statement merely reinforces the case for conservative care.
The chronic, unrelenting course of cruciate disease in dogs emphasizes the need to try a multifaceted non-operative strategy first. Even in humans who usually acutely rupture their cruciate, many advocate rehabilitation: “At present, there are no evidence-based arguments to recommend a systematic surgical reconstruction to any patient who tore his ACL.”21-23
Claim No. 5
“Don’t look for things that you don’t want to find (a surgeon’s aphorism).”
It is difficult to ignore the long list of complications from TPLO. Up to one-third of dogs experience complications, many require a second surgery to address them, amplifying post-operative pain that much more.24 TPLO risks include osteosarcoma (with Slocum or non-Slocum plates),25 soft tissue injuries (lacerated blood vessels, patellar tendon, medial collateral ligament, or long digital extensor tendon); severe intra-operative hemorrhage; tissue reactions to sponge retention; swelling; bruising; infection; and seroma formation. Surgeons may inadvertently fracture the tibia or fibula. Hardware can travel into a joint or break. Additional complications include osteomyelitis, internal tibial torsion, delayed union, ring sequestrum, screw loosening, Kirschner wire loosening, implant failure and draining tracts.26
Claim No. 6
“Your dog will be as good as new after TPLO.” No.
All surgical approaches for cranial cruciate ligament insufficiency result in some lameness and restricted limb use in the first two weeks. Four to six weeks after that, as the osteotomy heals, muscle mass and thigh circumference typically decrease. While some recovery of TC takes place over time, it likely will not recover fully, and stiffness in that stifle can last five or more years.27Alternatively, continued instability of the stifle following TPLO may result in persistent lameness.28
Claim No. 7
“There is no evidence that acupuncture benefits patients with OA of the stifle (or knee).” Untrue.
A systematic review and updated meta-analysis of acupuncture for patients with OA of the knee showed “significantly better relief from knee OA pain and a larger improvement in function than sham acupuncture, standard care treatment, or waiting for further treatment.”29 Thus, those dogs that do develop OA, with or without TPLO, may benefit from acupuncture, shown to be a safe and effective method to improve physical function, quality of life, range of motion and pain control.30,31
Claim No. 8
“Conservative options have no evidence; strict crate rest for six to eight weeks is the only other option.” False on both counts.
While research on non-surgical approaches to cruciate disease is growing for humans and for dogs, no evidence supports confining dogs in crates for weeks on end. Between dogs who did and did not have stifle surgery, research shows no differences in scores for lameness, stifle instability, OA, and/or force plate outcomes.32,33Conservative management consists of weight loss,34 omega-3 fatty acids,35,36 electrotherapy, cryotherapy,37 massage,38 acupuncture, laser therapy, 39,40 and more, and can be tailored to dogs’ specific diagnosis and athletic performance requirements.41
The integrative medicine credo “primum non nocere” (“firstly, do no harm”) compels us to consider why, given the facts, clients are forced to choose between surgery or euthanasia and not provided with alternatives. This problem exists in other areas as well, such as the treatment of disk disease, where the case for conservative care rivals or outcompetes that for surgery, for both humans and dogs. Now that 94 percent of Americans feel closer to their dogs than they may to their mothers (87 percent), cat (84 percent) or father (74 percent),42 let us honor this bond by providing clients options and answers, not just surgery or euthanasia.
1. Au KK, Gordon-Evans WJ, Dunning D, et al. Comparison of short- and long-term function and radiographic osteoarthrosis in dogs after postoperative physical rehabilitation and tibial leveling osteotomy or lateral fabellar suture stabilization. Veterinary Surgery. 2010;39:173-180.
2. Dog ACL/CCL Ligament Injury website. /redirect.aspx?location=http://tiggerpoz.com/ Accessed at 07-20-12.
3. DogKneeInjury website./redirect.aspx?location=http://dogkneeinjury.com/what-if-i-can-not-afford-ccl-surgery/. Accessed at 07-20-12.
4. DogChannel.com. Is surgery the answer for ACL injuries? http://www.dogchannel.com/dog-health/is-surgery-the-answer-for-acl-injuries.aspx on 07-20-12.
5. Brauns JM. Non-surgical options for canine CCL injuries. Mile High Dog. Dec 2011/Jan 2012. Pp. 16-17. Accessed at /redirect.aspx?location=http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=9&ved=0CHQQFjAI&url=http%3A%2F%2Fwww.milehighdog.com%2Fimages%2FMile_High_Dog_-_December_2011_-_CCL.pdf&ei=wZoKUMn0DY-G8QTPp-XTCg&usg=AFQjCNE6kyj1x8pXce8kXjI0EmCjzDQsng&sig2=lvNNthcBHQlrWoRRw5Dftw on 07-20-12.
6. Cooper N and Hooper G. Against anterior cruciate ligament reconstructions–and response by orthopaedic surgeon. Journal of the New Zealand Medical Association. 2011;124(1334). Accessed at /redirect.aspx?location=http://journal.nzma.org.nz/journal/124-1334/4650/ on 07-20-12.
7. Goldenberg D. Memorable medical quotations. Accessed at /redirect.aspx?location=http://www.technion.ac.il/medicine/Students/medical_quotes.html on 07-20-12.
8. Zeltzman P. Deciphering 13 surgeon phrases. Accessed at http://www.veterinarypracticenews.com/vet-practice-news-columns/surgical-insights/deciphering-13-surgeon-phrases.aspx on 07-21-12.
9. Buote N, Fusco J, and Radasch R. Age, tibial plateau angle, sex, and weight as risk factors for contralateral rupture of the cranial cruciate ligament in Labradors. Veterinary Surgery. 2009;38:481-489.
10. Lineberger JA, Allen DA, Wilson ER, et al. Comparison of radiographic arthritic changes associated with two variations of tibial plateau leveling osteotomy. A retrospective clinical study. Vet Comp Orthop Traumatol. 2005;18:13-17.
11. Hurley CR, Hammer DL, and Shott S. Progression of radiographic evidence of osteoarthritis following tibial plateau leveling osteotomy in dogs with cranial cruciate ligament rupture: 295 cases (2001-2005). J Am Vet Med Assoc. 2007;230:1674-1675.
12. Lee JY, Kim JH, Lee WG, et al. Scintigraphic evaluation of TPLO and CTWO in canine osteoarthritis. In Vivo. 2007;21(5):855-859.
13. Casteleyn PP. Management of anterior cruciate ligament lesions: surgical fashion, personal whim or scientific evidence? Study of medium- and long-term results. Acta Orthopaedica Belgica. 1998;64(3):327-337.
14. Atherton MJ and Arthurs G. Osteosarcoma of the tibia 6 years after tibial plateau leveling osteotomy. J Am Anim Hosp Assoc. 2012; 48:188-193.
15. Veterinary Orthopedic Sports Medicine Group website. Accessed at /redirect.aspx?location=http://www.vetsportsmedicine.com/surgery/TPLO.html n 07-20-12.
16. Au KK, Gordon-Evans WJ, Dunning D, et al. Comparison of short- and long-term function and radiographic osteoarthrosis in dogs after postoperative physical rehabilitation and tibial leveling osteotomy or lateral fabellar suture stabilization. Veterinary Surgery. 2010;39:173-180.
17. Cook JL, Luther JK, Beetem J, et al. Clinical comparison of a novel extracapsular stabilization procedure and tibial plateau leveling osteotomy for treatment of cranial cruciate ligament deficiency in dogs. Veterinary Surgery. 2010;29:315-323.
18. Agostinho FS, Rahal SC, Miqueleto NSML, et al. Kinematic analysis of Labrador Retrievers and Rottweilers trotting on a treadmill. Vet Comp Orthop Traumatol. 2011;24:185-191.
19. Angle TC, Gillette RL, and Weimar WH. Caudal paw displacement during movement initiation and its implications for possible injury mechanisms. Vet Comp Orthop Traumatol. 2012; 25. Epub ahead of print.
20. Robinson N. Pelvic limb lameness: palpate early and often. April 4, 2012. Veterinary Practice News. Accessed on 08-10-12 at http://www.veterinarypracticenews.com/vet-practice-news-columns/complementary-medicine/pelvic-limb-lameness-palpate-early-and-often.aspx.
21. Delince P and Ghafil D. Anterior cruciate ligament tears: conservative or surgical treatment? A critical review of the literature. Knee Surg Sports Traumatol Arthrosc. 2012;20:48-61.
22. Cimino F, Volk BS, and Setter D. Anterior cruciate ligament injury: diagnosis, management, and prevention. Am Fam Physician. 2010;82(8):917-922.
You May Also Like Nationwide study shows short-nosed dogs are less healthy23. Strehl A and Eggli S. The value of conservative treatment in ruptures of the anterior cruciate ligament (ACL). J Trauma. 2007;62:1159-1162.
24. Bergh MS and Peirone B. Complications of tibial plateau levelling osteotomy in dogs. Vet Comp Orthop Traumatol. 2012;25. [Epub ahead of print.]
25. Atherton MJ and Arthurs G. Osteosarcoma of the tibia 6 years after tibial plateau leveling osteotomy. J Am Anim Hosp Assoc. 2012; 48:188-193.
26. Bergh MS and Peirone B. Complications of tibial plateau levelling osteotomy in dogs. Vet Comp Orthop Traumatol. 2012;25. [Epub ahead of print.]
27. Moeller EM, Allen DA, Wilson ER, et al. Long-term outcomes of thigh circumference, stifle range-of-motion, and lameness after unilateral tibial plateau levelling osteotomy. Vet Comp Orthop Traumatol. 2010;23:37-42.
28. Bergh MS and Peirone B. Complications of tibial plateau levelling osteotomy in dogs. Vet Comp Orthop Traumatol. 2012;25. [Epub ahead of print.]
29. Cao L, Zhang X-L, Gao Y-S, et al. Needle acupuncture for osteoarthritis of the knee. Saudi Med J. 2012;33(5):526-532.
30. Mavrommatis CI, Argyra E, Vadalouka A, et al. Acupuncture as an adjunctive therapy to pharmacological treatment in patients with chronic pain due to osteoarthritis of the knee: a 3-armed, randomized, placebo-controlled trial. Pain. 2012;153:1720-1726.
31. Um S-W, Kim M-S, Lim J-H, et al. Thermographic evaluation for the efficacy of acupuncture on induced chronic arthritis in the dog. J Vet Med Sci. 2005;67(12):1283-1284.
32. Chauvet AE, Johnson AL, Pijanowski GJ, et al. Evaluation of fibular head transposition, lateral fabellar suture, and conservative treatment of cranial cruciate ligament rupture of cranial cruciate ligament rupture in large dogs: a retrospective study. J Am Anim Hosp Assoc. 1996;32:247-255.
33. Vasseur PB. Clinical results following nonoperative management for rupture of the cranial cruciate ligament in dogs. Veterinary Surgery. 1984;13(4):243-246.
34. Grierson J, Asher L, and Grainger K. An investigation into risk factors for bilateral canine cruciate ligament rupture. Vet Comp Orthop Traumatol. 2011;24:192-196.
35. Hansen RA, Harris MA, Pluhar GE, et al. Fish oil decreases matrix metalloproteinases in knee synovia of dogs with inflammatory joint disease. J Nutritional Biochemistry. 2008;19:101-108.
36. Tokuyama S and Nakamoto K. Unsaturated fatty acids and pain. Biol Pharm Bull. 2011;34(8):1174-1178.
37. Hart JM, Kuenze CM, Pietrosimone BG, et al. Quadriceps function in anterior cruciate ligament-deficient knees exercising with transcutaneous electrical nerve stimulation and cryotherapy: a randomized controlled study. Clinical Rehabilitation. 2012. [Epub ahead of print.]
38. Zalta J. Massage therapy protocol for post-anterior cruciate ligament reconstruction patellofemoral pain syndrome: a case report. International Journal of Therapeutic Massage and Bodywork. 2008; 1(2):11-21.
39. Guo H, Luo Q, Zhang J, et al. Comparing different physical factors on serum TNF-alpha levels, chondrocyte apoptosis, caspase-3 and caspase-8 expression in osteoarthritis of the knee in rabbits. Joint Bone Spine. 2011;78(6):604-610.
40. Jang H and Lee H. Meta-analysis of pain relief effects by laser irradiation on joint areas. Photomedicine and Laser Surgery. 2012;30(8):405-417.
41. Wilke V. Alternative therapies for managing mobility: nonsurgical management of cranial cruciate ligament rupture (sponsored by Iams). DVM360. Accessed on 080912 at /redirect.aspx?location=http://veterinarycalendar.dvm360.com/avhc/article/articleDetail.jsp?id=704202.
42. Taylor P, Funk C, and Craighill P. Gauging Family Intimacy. Dogs edge cats (Dads trail both). Pew Research Center. Accessed at /redirect.aspx?location=http://pewresearch.org/pubs/303/gauging-family-intimacy on 07-29-12.