Is Surgery Really Necessary for Dogs with Ruptured Cruciate Ligaments

In a recent article concerning an herbal product used for treatment of a dog with a ruptured cranial cruciate ligament (the equivalent of the “ACL” in humans), I stated, “Surgery is the treatment of choice for a ruptured cruciate ligament. Weight loss, physical therapy, and possibly medications are all helpful and important, but without surgery a large dog will have permanent instability in the knee and will develop progressive arthritis.” One of my regular readers challenged this statement and referred to evidence in humans suggesting that surgical therapy was no better than non-surgical therapy in treating this disease. This stimulated me to look into my assumption that surgery was superior to medical management for large dogs and see whether or not the evidence supports this claim.

Following the usual approach I take in evaluating a proposed therapy, I will look at the plausibility of the intervention first. A great deal has been written about the biomechanics of the canine knee and all the factors that may play a role in cruciate ligament ruptures (e.g. 1, 2, 3, 4, 5, 6, 7, 8). The bottom line of all this is that ruptures of the ligament are caused by multiple interacting factors including breed (and hence genetic influences), size, the structure of the canine knee, and activity. The various surgical procedures recommended for this disease are all rational and plausible based on a detailed understanding of the basic biomechanics of the disease.

There have also been many studies looking at the effect of various surgical procedures in animal models of the disease, usually laboratory dogs with ligaments that have been deliberately damaged. While this sort of model does not replicate all the features of naturally occurring disease, it can provide some clue as to whether the surgical therapies are likely to be effective. These sorts of studies, often used as models for arthritis in general, show clearly that severe joint disease and marked dysfunction results over time without surgical treatment of a ruptured cruciate ligament (e.g. 9, 10, 11, 12, 13, 14, 15)

There is extensive clinical research in humans concerning whether surgical repair of cruciate ligament rupture is necessary. I am quite skeptical of the applicability of this research to the same question in dogs since the biomechanics of the canine knee are quite different from those of the human knee. Also, conservative management for humans includes exercise restriction, physical therapy, and often immobilization of the knee with a brace, all of which are challenging and not often used in dogs with ruptured cruciate ligaments. However, the basic anatomy and pathophysiology of arthritis are quite similar, so research in humans may have some value in answering the question for dogs.

The results of clinical trials in humans are mixed. One Cochrane Review examining older surgical techniques found they were generally superior to conservative management. Some studies have found no advantage to surgical management, but these are not large or methodologically robust trials. It appears that both conservative and surgical management can have good outcomes, but the differences depend on the patient population (age, nature of injury, activity level, compliance with treatment, etc) and the specific therapy employed, so not incontrovertible conclusion can be made as to whether surgery or conservative management is superior overall.

There are a many studies looking at the outcome of surgical treatment of cruciate ruptures in dogs. Overall, they find good outcomes in the range of 70-80% or more of patients returning to normal or near normal function (e.g. 16, 17, 18, 19). Comparisons of different methods of surgical repair do not support the clear superiority of one method. However, there are few studies directly comparing surgical and non-surgical treatment in dogs. The best of these, published in 1984, compared outcomes of non-surgical treatment in dogs weighing more or less than 15kg (about 30lbs). For the dogs over 15kg, only 19% were normal (7%) or improved (12%)  years after their injury, and all had clear evidence of severe arthritis in the affected knee. For dogs weighing less than 15kg, almost 86% were normal (75%) or improved (11), and while all of these had evidence of moderate arthritis, it did not seem to affect the function of most of these dogs. Other less rigorous studies have the same general findings (20, Paatsama S: Ligament Injuries of the Canine Stifle Joint: A Clinical and Experimental Study. Master’s thesis, Helsinki, 1952) 

Conclusion
As is almost always the case, the evidence is not of the highest possible quality or unequivocal, but this does not exempt us from having to draw conclusions and make recommendations to our clients. My interpretation of the available evidence is that overall, cruciate ligament disease causes significant arthritis and loss of function when untreated. For most dogs under 15kg, conservative management (primarily restricted activity for 3-6 weeks, achieving and maintaining and appropriate body weight, and possibly physical therapy and pain medication) can achieve acceptable comfort and function. In larger dogs, significant arthritis is inevitable and dysfunction is extremely likely without surgical treatment. No single surgical technique is clearly superior, so the choice of specific surgery should be determined by the judgment of the individual surgeon and the needs of the owner.

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215 Responses to Is Surgery Really Necessary for Dogs with Ruptured Cruciate Ligaments

  1. Erik says:

    I was wondering from your experience if the duration of time from injury to diagnosis matters. My 8 year old 76 lb aussie/blue healer injured his hind knee 13 months ago. Initially, we decided for conservative management and he improved over time. Also, we started him on joint supplements. Recently, a different vet at the practice convinced me to get an XR and now they are concerned that he could have a CCL tear with developing osteoarthritis. Typically, do they push for early surgical intervention? If not, it seems to me like my dog already passed his conservative management approach as he is fully ambulatory without pain. I recently took him to the dog park and he was more active than our 6 month puppy. Thanks for the great resource

  2. Fluxion says:

    SkeptVet;

    Thanks for what you do generally, and specifically for providing a clear and reasonable overview of the literature on this issue. Like you and many others, I find the lack of quality controlled research here unfortunate, particularly given the prevalence of cruciate ligament injuries.

    I have two questions I’m hoping you would be so kind as to share your thoughts on:

    First, do you have a clear sense of the extent to which post-operative complications are worse for very energetic dogs? To provide a bit more detail, my dog is a 9 year old, 90 lb lab-husky-rott mix with a left-leg ccl tear. We are considering surgical options, but a BIG worry for us is the possibility of post-operative re-injury. Our dog is very hyper. She bolts from place to place, runs back and forth around the house, and jumps up and down repeatedly at the smallest excitements. We’re having a hard time imagining how to enforce the level of inactivity that will be needed for recovery, short of keeping her crated the whole time. Are we right in assuming that even a few slip-ups where she is able to jump or run would potentially shift the overall outcome rates badly against her?

    Second, as we are about to navigate the rocky shoals of one or another surgery, do you know of anything we can do that would allow our experience to help inform others’ choices in the future? For example, do you know how we might go about enrolling in a randomized, blind study? The relative outcomes of the different surgeries seem close enough that I’d be willing to roll the dice if doing so would further the knowledge base.

    Thanks in advance for any response,
    Fluxion

  3. skeptvet says:

    Though I am not awware of any specific research on the subject, I think it very likley extremely energetic dogs are at greater risk for damaging their surgery sites. I sometimes prescribe sedatives for such dogs if it is critical they stay mellow for a while after surgery so I would ask your surgeon about that.

    I don’t know about any ongoing clinical studies you could enroll in. Unfortunately, it is up to the veterinary profession to establish mechanisms for tracking outcomes of various procedures to help us figure out how well they work, and there is little effort in that area right now. The regulatory authority in the UK has begun requiring practices to keep some outcome data, and that will definately help. Here in the US< every state regulates vets independantly, and there is little interest in adding any regulatory burden to anyone, so I doubt we'll have similar rules any time soon.

  4. Diann says:

    Thank you for this article.

    We have an 8 y.o. cat (indoors only) with an anterior cruciate rupture. It happened a little over three weeks ago and surgery is scheduled for next week. But he seems to be much better–walking with very little limp (almost not at all) and is back to jumping on the bed to sleep with us etc. I really don’t want the surgery. It’s extremely expensive, but beyond that, he seems better, and then I’m wondering if it becomes surgery (putting his life at risk) for no reason. Plus, I really have no idea how to keep him from jumping and being his regular self during the following the surgery and then reinjuring himself (even the surgeon has been little help there). All that said, the surgeon said the development of arthritis is inevitable without surgery. You mention in your post the development in large dogs, but what are your thoughts on a 12 lb cat? (Who, by the way, I have put on a scheduled feedings in an attempt to slim him down for the injury and other reasons.)

    Any thoughts are appreciated!

  5. skeptvet says:

    Cruciate disease is generally less common in cats, so we don’t know as much about it in that species. The limited evidence so far suggests that medical management may be ok for small dogs, so it is reasonable to expect it to be acceptable for cats, but I have no specific research evidence to prove that. Certainly, weight management is the most important part of that, so if your cat is overwieght I would dfinately encourage you to address that. Otherwise, I have no specific recommendations, but it might be worthwhile to seek other opinions for vets in your area.

    Good luck!

  6. Angie says:

    Hello, 3years ago our westhighland terrier millie developed a limp. After xrays and the draining of fluid we were advised to have cruciate surgery. After a lot of thought and tears. We declined not wanting to put 6yr old dog through such invasive surgery,3 yrs on with gentle excersise glucosamine + chondroitin we still have a very active happy little mute. Who is more than happy to go for a 40minute walk. We live in moment and enjoy everyday.

  7. Steve says:

    Skepvet, I’ve enjoyed the dialogue between yourself and dfg. I also appreciate your blog as source of information. Like dfg said, I also find myself “scratching my head” when it comes to finding useful information regarding the surgery/non-surgery debate. Here are a couple statements from dfg that I haven’t seen answered (assuming there is an answer) regarding ACL surgery.

    Dfg says:

    1) My main concern regarding my dog now isn’t so much if he can return to normal function. He appears to be well on the way to that given the default CM course I’ve taken… But what about 3-5-7-+ years out? Is surgery a superior fix in the long run?

    2) Agreed, the evidence is no better for CM. But its a far, far less invasive, painful or risky course which has a fair chance of working. I think tiggerpoz had a point earlier when he/she/they said it can’t hurt to try this non-surgical approach for all the reasons you stated (cost/risk/discomfort). If the results are good, then wouldn’t that be the preferred course? If not, then there’s always surgery, and the rest/rehab of CM wouldn’t be a bad thing to have done in the meantime. IOW, it’s not an either-or. It can be a “do one or both”.

    Skepvet, I have a thirteen pound, seven year old Havaneese with a torn ACL (right hind leg). Other then limiting the amount weight he places on the leg he seems fine, although the fact he sometime holds the leg off the ground indicates there is pain. At the same time he likes to motor around the house using all fours (he likes to play), and that has been difficult to control. I was with him when the injury occurred and he never made a peep. He continues to go about his luxurious dogs life (he’s spoiled with love) like nothings ever happened – although I’m sure he isn’t happy about having his walks limited. Bogey, my dog, is two weeks into this thing and currently taking anti-inflam‘s (PREVICOX – 57MG per tablet and takes ½ tablet per day).

    Regarding #1 above, does a lack of surgery increase the risk of future issues?

    Regarding #2, are there any drawback to attempting CM, and if that doesn’t work, or show improvement over the next three months, then pursing surgery? Is there any significant damage being done during the interim?

    Thanks in advance,

    Bogey’s Dad

  8. skeptvet says:

    Is surgery a superior fix in the long run?

    I’m not aware of any research to answer this question. Anecdotally, I have seen many patients treated with surgery (including my own dog), and a fair number not treated at all (which is not, of course, the same as treated with physical therapy, braces, or other non-surgical options). My impression is that all develop some arthritis but that the degenerative changes are significantly less and function better in those treated surgically, But as I often point out, even if we may rely on personal experience when there is no research to guide us, we must remember how unreliable it is.

    As to your second point, in the short term (months) I agree that trying medical therapy likely doesn’t make it impossible to proceed with surgery if the medical treatment isn’t working. I’m not sure, however, about how long one can persist with medical approaches without reducing the chances of a good outcome if they don’t work and surgery is eventually needed. As I mentioned, I see pretty impressive arthritic changes in the joints of dogs with CCL ruptures who do not have surgical treatment, and I wonder if this long-term damage doesn’t reduce the chances surgery will work if eventually chosen. Again, though, I am not aware of any research that answers this question.

    In the case of your dog, the limited existing evidence suggests you may very well get a good functional result without surgery due to his size. Unfortunately, I really can’t say whether surgery is better now, later, or never, since I think the jury is still out.

    Good luck!

  9. missy says:

    Hi All

    I have a 6yr old male beagle – he was diagnosed with a partial tear (very minor) about 4 months ago. The vet suggested first trying to just rest my beagle. After 7 weeks of resting and some pain killers… his leg was much better however 10mins at the park off lead and my poor little man was in terrible pain. (only lasts 1 day then he gets better and seems fine as long as we don’t walk off leash)

    Back to the vet the next day .. vet said it’s only minor but surgery is probably the next option.

    I made the choice to try rest again .. for another 8 weeks and there was huge improvements so last night we went to the park and my little beagle was sooooo excited to be free he ran his little heart out for around 15mins and spent the next 24hrs limping and in pain. He can stand on his back leg fine, just seems to be tender and he whimpers when pulls it the wrong way.

    Saying all that today – he is fine, leg seems fine and he is happy enough and playing / dancing around the house.

    I am not a big fan of the idea of putting him through any kind of surgery unless absolutely necessary but at the same time I do not want him to spent the rest of his life not being able to play at the huge park we have down the road.

    We have tried food supplements and joint medication – all of which helps however as soon as he goes off the leash we are always back to square one (although it’s never as bad as when he 1st did the injury)

    I am primarily worried that I will put him through surgery just to have little improvement in the future?

    The vet said this is a case where the decision is upto me … it does not seem so bad the vet can really give me a straight answer … so I look to you the people of the internet for any guidance / assistance or suggestions 🙂

  10. skeptvet says:

    Well, if he used to be able to run around off leash comfortably and now he cannot, that sounds like his disease is compromising his function. He may be getting used to the discomfort, shifting his weight to his other legs, and in general compensating for it, but your description suggests he still has regular noticeable pain and can’t do things he ought to be able to do. That seems like a less that acceptable outcome to conservative therapy and a reason to consider surgery. No guarantees, of course, but the evidence supports the claim that with surgery most dogs have near normal function. The debate is more about whether dogs not having surgery can also have near normal function, not whether surgery itself works, which it pretty clearly does. In a case like this, surgery seems a reasonable option.

    The decision is, of course, up to you, and no one can or should tell you what to do, including your vet. But if I had an injury that made it impossible to engage in a normal activity I had often enjoyed before, I would pretty seriously consider surgery if there was a good chance I would be able to resume that activity, and that sounds like the situation you friend is in.

    Good luck!

  11. Lisa says:

    My dog has a cyst on her front right paw that we were going to get xrays on in a few days and she blew out her back right knee last night. They think she has cancer in the paw and want a biopsy on it. She would also need surgery for the CCLD. But is there anyway that if she had to amputate the front paw that she could even get around with the back leg so bad?

  12. skeptvet says:

    I’m afraid I really can’t provide specific advice via the internet. I would have a detailed discussion with your vet about the two problems and the potential interactions between them. If you feel like you aren’t getting useful answers, perhaps consider seeking a second opinion.

    Good luck!

  13. Jodie says:

    I have a 12 year old beagle who is over weight and not at all active. He only gets up to eat and defecate. He just wants someone to rub his belly and let him sleep all day and night. He started limping on his front right leg and the next day he wasn’t putting any weight at all on his right hind leg. The emergency clinic said he had a suspect right cranial cruciate ligament rupture but didn’t do any x rays. I can’t afford surgery and I was just wondering how else I could help him and how did he get this injury when his activity level is nill.

  14. skeptvet says:

    Unfortunately, you can’t make any real decisions about how to help your dog without a good understanding of what is wrong with him, and it isn’t clear from your comment if you have one. I would suggest seeing your regular veterinarian and getting a thorough assessment.

  15. We have an 11 year old poodle australian shepherd (?) mystery mix rescue dog, that we love dearly, who took a freak tumble from the bed and had an acute rear leg ligament tear. Our vet did not recommend surgery (cost and age)and casted his leg to the hip (for approx. 2months). He is having some difficulty ambulating with this cast and we are concerned about his body mechanics over time as his gait is very abnormal. Milo has very short thick legs a longer torso and weighs about 45 lbs. He is not overweight but could lose a 2lbs. Our vet is guarded about prognosis but she did state that although he will not be normal or run there can be some quality of life left for him if scar tissue can help stabilize this joint. He is a highly intelligent “mind reading” dog who runs the show with our other two rescue dogs. We are trying hard to keep the level of stimulation down at mealtime, with visitors,etc. and keeping the dogs apart at transition times during this recuperation. Will it possible for our dear Milo to ambulate when this cast is removed, to move around in the house and get outside to the bathroom with supervision?We just don’t want the rest of his life to be misery. He loves us and I know our love and attention will compensate for his inability to run and lead the pack. Thank you for any comment you can make about our situation. Our family is devastated.

  16. Art Malernee says:

    I have never heard of a dog being cast for a ACL tear or recall any studies. Was the ligament was only partially torn? Once the ACL tears completely no treatment or time I know of will heal the tear.

  17. jac says:

    what is is the risk of surgery on 8 year lab cruiate ligament

  18. skeptvet says:

    It’s impossible to answer this question with certainty. For one thing, it depends on what you mean by risk. Risk of failure of the procedure, of wound infection, of death from anesthesia, of what? Also, risks for individuals depend on many factors and age is only one of these. Overall, age is not likely an important risk factor for anesthesia and surgery in otherwise healthy animals except at extreme ages, and 8 is not an extreme age for a Labrador.

    I would suggest having a detailed in-person conversation with your veterinarian about your concerns.

  19. I asked questions about our older dog Milo and a possible ligament tear on May 10th. The response I received from my comment led us to get a second opinion and it seems our dear Milo has dislocated his kneecap and that there wasn’t a ligament tear after all. His cast has been removed. He is limping at times but at other times seems almost normal.We are giving anti-inflammatory medication. The new vet who does orthopedic surgery wants to take a wait and see approach. We are monitoring him….using a leash when outdoors and using a crate at night (as we cannot risk another tumble from the bed which caused the original injury). Does anyone have experience with this type of injury and surgical outcome? Surgery will be a last resort, but we do not want to put the surgery off if it can improve quality of life. He limped and held the leg up last night after having his leg examined by the vet yesterday…it may have been sore from the manipulation and he had a sad tired look in his eyes like had when he first was injured. If anyone out there can give some feedback it will help us. His kneecap will not stay in place. He has arthritis in both knees and is very short legged…but is a wonderful 11 yr. old rescue mixed breed that we hope can have a few more quality years. THANK YOU.

  20. Art Malernee Dvm says:

    Does anyone have experience with this type of injury and surgical outcome? >>>
    If the diagnosis is medial or lateral patella luxations Most old vets have seen thousands of cases but i have never heard of it being treated with a cast. From memory when I did a online review years ago, the patella surgery is 90% successful, if success is measuring if the knee cap stays in place after surgery. Some of the 10% surgical failures come from over correction. The knee cap then pops off on the opposite side of the knee. I am not aware of any studies or controversy about this surgery not working. I have seen some dogs grow out of the luxation problem and no longer need surgery after I wanted to do it but those were young dogs not yet mature.

  21. Dawn Baddock says:

    My daughter’s 7 pound, 10 year old yorkie has suffered a cranial cruciate ligament rupture. We were told that he must have surgery to correct it. We were not even given the option of non-surgical therapy. Assuming we choose to opt for surgery, we need to decide between ligament replacement or the more expensive TPLO. Do you think that given the size of the dog, that the TPLO surgery is worth the extra cost?

  22. skeptvet says:

    Unfortunately, I can’t give you specific advice for your pet over the Internet. In general, it seems smaller dogs may achieve adequate function more often with more conservative care than larger dogs, so it is not unreasonable to think you might get as good a result with medical therapy or a surgical procedure other than TPLO as you would with a TPLO, but there is no definitive research to indicate exactly the best approach in every situation. I would have a frank discussion with your vet about your concerns and your options.

    Good luck!

  23. Dana says:

    We have an 8 year old lab mix who was just diagnosed with a complete CCL rupture. At his age and given the cost of surgery, this is not really an option for us. However the vet indicated that she has seen many dogs do well with conservative management – starting with strict rest, and a course of deramax and tramadol. He’s eating, happy, and just a little more tired than usual because of hoping on one three legs. He is about 65 pounds and very lean, although he does have existing arthritis. What is your opinion in this situation.

  24. skeptvet says:

    As you can see from the original post and the subsequent discussion, it isn’t possible to predict how well your dog will do without surgery, and since surgery isn’t an option it doesn’t really matter. If you can find someone to provide physical therapy support, that is a reasonable thing to try. I think it likely he will develop significant arthritis, and if he develops CCL disease on the other side, this may have a significant impact on his mobility, but only time will tell,

    Good luck!

  25. Reader says:

    My 3 year old great dane dog with 135 lbs is limping on her right leg since couple of days. I’m not sure how does that happen. She can still play with us like before, jump on the bed and stand on her back leg. But she avoids putting her full body weight on her right leg. I recently checked her paws to make sure its clear. Everything seems fine but she is limping and I came across this article. I think she have ACL or CCL. Does anybody have any suggestion to diagnose in home before I meet her vet?

  26. skeptvet says:

    My suggestion would be not to attempt self-diagnosis but simply to see your vet. People rarely feel like they should be able to fly the airplane themselves when travelling or fill their own teeth, but for some reason it seems more reasonable to diagnose and treat medical problems by yourself. Often, we get away with this because many things heal on their own. But I have seen enough unnecessary suffering from delayed diagnosis and treatment, or inappropriate treatment, that I really feel it is in your dog’s best interest to be seen by a vet.

  27. Reader says:

    I figured and I already setup appointment to see her vet today. I saw some redness on her right paws today. Hopefully it will turn out just a sprain or minor issues. Thanks for your reply though.

  28. Jeff Bryant says:

    Have a Golden Retreiver 7.5 years old who has a full tear of the CL. He has had the condition for almost a year and we have been treating with anti-inflamatory on a as needed basis. Last week it got bad where he could not get up, so we went back and got a surgical evaluation. The procedure they recommended is to shave the fibia bone to be flat and not slide on the knee cap. (Least that is what I think she said). This procedure cost estimate is $3000-$3500 and has a 8-10 week recovery which requires Kenneling and on leash for bathroom breaks etc.. No unsupervised out of the kennel basically. The doc also stated that the other knee looks to have a partial tear as well and that would need to consider doing that knee at a later date. Scout has been on a different medication for 2 days and is not getting around with no problems (still limping) but can get up. My real delimma is that this dog also has Golden Retreiver Uvitus along with this and his age and trying to see if there are other options to medicate for a dog up in years, but not towards the far end of his life. Very difficult to decide what to do. Any help/advise you can provide will help. Right now we are leaning on continuing the new medication for a few more weeks to see if he improves more, but just very torn on best option for us. Thanks in advance.

  29. skeptvet says:

    Only you can make the decision of what is right for your pet. However, I will say that 7.5 is not that old for a Golden, and I routinely see dogs of this breed in their early to mid teens. If the problem is fixable, and if it clearly has not gotten better on its own over such a long time, I would give serious consideration to your vet’s recommendations. I would also ask very clear and specific questions about risks and potential outcomes so you feel fully informed before making a decision.

    Good luck!

  30. Solena Hernandez says:

    I have a six year old yorkie…my little Chloe. She is overweight at 15lbs, and this past weekend she stood up on her hind legs or me to lift her up, I suspect that is when she injured herself. I immediately took her to the emergency hospital and they took xrays and told me she had a cranial cruciate rupture right stifle. I then followed up with my Vet on Monday and they confirmed that it was a complete tear. Her vet said the choice was mine on whether to have surgery or not, and I have read all the responses and am still unsure of what choice to make. I read on another blog that when it is a complete tear, as is the supposed case with my little one that surgery is a must, is this true? I just want to make the best decision for her, either way it is going to be tough as she has never, ever been in a crate, and although she isn’t very active, it will be hard to watch her being locked up. I guess I just want someone to tell me how to help my baby, and what is the best decision. She doesn’t seem to be in much pain, we are carrying her out to potty and try to keep her still for the most part, her appetite is good and she is taking Tramadol for the pain and Rimadyl for the inflammation.

  31. skeptvet says:

    Unfortunately, there isn’t an easy way to know for certain whether she will have a better outcome (better function, less pain and arthritis) with surgery or if physical therapy, weight control, and other forms of non-surgical management will work just as well. Until there is real research comparing these two approaches, no one really knows for certain. I personally chose surgery for my dog because I think it is reasonable to believe that stabilizing the joint is better than leaving it unstable, but that’s just based on general principles and my own experiences, not on objective research.

    While it isn’t certain that surgery is necessary for all or most dogs, I will say that most of the reasons people shy away from surgery aren’t more about cost and anxiety than anything else. We do have good evidence to show that the surgery is very safe in most cases and that outcomes with surgery are generally very good. So while I can’t say surgery is better than medical therapy without some research to demonstrate this, I can aay that surgery has been shown to work very well in most cases.

    Good luck!

  32. paula says:

    I have a 8.5yo Berner that just ruptured her ACL two days age. She already has some arthritis in the hips and some atrophy of muscles due to reduced exercise. The vet reommended surgery and I did nto even realize that they could return to normal without surgery.
    Just wanted to know your opinion about older dogs and how well they do post surgery? and is it worth getting the surgery if the hips and joints are already affected?
    Is there any sort of splinting that can be done to ease the pain?

  33. skeptvet says:

    As always, I can’t really give you specific advice about your pet since I’m not your vet. It is certainly important to consider the overall health of the patient, including other orthopedic problems, anesthetic risk, etc. Age itself is not a reason not to fix a fixable problem, but the specific decision in your case will have to be made with a detailed, open discussion with your vet.

    Splinting is almost never recommended as it can cause all kinds of problems. If in doubt, I would consider seeking a second opinion from a surgical specialist.

    Good luck!

  34. PJ says:

    I don’t think I can thank you enough for this post. We have a 1.5 y/o mix that was just diagnosed with CCL rupture after an acute injury. I am a lab tech (for humans) and as such I need studies, statistics and numbers to help make me feel like I am making the best possible decision. Yahoo answers and http://www.personwhoisntavet.blogspot.com just don’t cut it for me. I thank you for having an open mind and addressing the issue of surgical vs non-surgical methods in a way that is nonbiased and backed by science (regardless, of how little or error prone it may be). This post is exactly what I was looking for! I read through what you had to say and all studies and have decided that surgery is the way to go for my pup. He is still so young that I really wanted to mitigate his chances of early onset arthritis and all of the surgeries look so invasive that it seemed that by going that route he would surely suffer from arthritis pain from an earlier age. However, it appears that nonsurgical methods end up doing more harm than good. A million ‘Thank You’s’ for this post. It really set my mind at ease.

  35. skeptvet says:

    I’m glad you found the article useful. That’s why I write them! 🙂

  36. RottieMom says:

    Our 9 year old rottweiler has been diagnosed with CCL. We have a consult schedule with an orthopedic surgeon next week. However, given his age we are researching non-surgical alternatives. Is there any research about prolo therapy and its success as an alternative to surgery?

  37. skeptvet says:

    Here’s my review of prolotherapy

    And here’s the bottom line form that review:

    Bottom Line
    Prolotherapy is a purported treatment for connective tissue and joint pain and disability. It involves injecting substances which induce inflammation and other chemical and cellular reactions into affected tissues. These reactions are theorized to relieve pain and improve function. The logic of this theory is questionable, and no clear mechanism for beneficial effects from prolotherapy has been described, but it is possible that the theory could be valid.

    The clinical research on prolotherapy in humans is generally of low quality and results have been mixed. There is great variation in the techniques used by different investigators, so it is difficult to compare or generalize between studies.

    There is virtually no controlled research investigating prolotherapy in companion animals, and all claims made for safety and efficacy in these species are based solely on anecdotal evidence.

    The use of proltherapy in pets should be viewed as experimental with unknown risks and benefits. Such treatments should be reserved for patients that have significant symptoms that have failed to respond or cannot be treated by conventional means.

  38. Robb says:

    Hello,
    Have a 4 year old great dane that has been diagnosed with “Cranial (aka Anterior) Cruciate Disease” He also says she has bone spurs and signs of arthritic change secondary to the primary joint laxity problem. He is suggesting that we go with the TPLO surgery. She only holds her leg up for a short time after running at the off leash park or out on my parents acreage. After a day or 2 rest, she doesn’t favour the leg anymore. Is her diagnosis something we can have looked at down the road to see if it’s any worse or see if her discomfort improves or goes away? I can’t seem to find any info that tells me that the arthritis won’t continue regardless of surgery. So far she only limps after crazy activity.

  39. skeptvet says:

    Generally, there is some progression of arthritis after surgery, but it is less than without treatment. It is very unlikely that a dog this large will be comfortable and functional long-term without treatment. The question posed in this article is not whether dogs will do well with on treatment, but whether medical therapy is as good as surgical treatment. It is not unusual for them not to limp once the initial pain and swelling goes down. This doesn’t mean the leg is ok, only that they are able to shift weight to the others and still function.

    Most surgeons feel that delaying surgery for a few months probably doesn’t change the outcome, so it is possible to “wait and see,” but I don’t see any reason things would get better spontaneously without some kind of therapy.

    Good luck!

  40. Rod says:

    What a great site – thanks for all your advice and comments. We have a 10 year old Rottweiler who has just been diagnosed with CCL in her left hind leg. About 4 years ago, she had surgery on her right hind leg (TPLO or TTA, not quite sure) and has been fine ever since. The new injury slows her down and makes her limp – but she still wants to play with our other two, younger rotties. She is my very special ‘girl’ and I want to do anything to help – cost is irrelevant – but surgery at her age is not a good idea. Any suggestions about how we can make her more comfortable?
    Many thanks

  41. skeptvet says:

    Apart from surgery, it makes sense to focus on weight management, making sure she is as lean as possible, to ensure regular moderate exercise and try to limit intense, high-impact activity, and to treat any apparent discomfort with NSAIDs or other pain medications.

    Good luck!

  42. Sharon Lewis says:

    I have a 5 month old goldendoodle who has injured her left hind leg, she simply came up lame while running. She is tall, and weighs 44 lbs but looks thin. She was xrayed and manipulated while under sedation. The vets said to rest her and give vetprofen for 2 weeks then if she’s no better she will need surgery. I am reluctant to have knee surgery as her growth plates are still open. We will seek a second option (we are 1 hour from a vet school) but are wondering what you and your readers have to say.

  43. skeptvet says:

    I think a university consult is exactly the right approach. My impression is that surgeons disagree about which procedure is best in growing dogs, and I am not aware of any specific research evidence to help decide, so you will need to have a thorough discussion of options with an experienced orthopedic surgeon.

    Good luck!

  44. LS says:

    Thanks for this post, with a background in science it’s nice to have someone lay out the info on this in a less biased way than most of the internet!

    We had to take my 13 year old black labrador/mutt to the vet this morning after she hurt herself on a run at the beach. The vet (the only one in town, sadly) says she’s ruptured her hind right knee. She didn’t specify which ligaments, but she says its fairly serious. We’ve decided that we should probably opt for her to have the surgery to stabilise the joint, but I’ve got a couple of worries:

    The first is that she’s epileptic, and I’m not sure how that would be affected by the general anaesthesia? It’s not particularly severe (she has seisures perhaps every two to three weeks, and always recovers fully within the hour, with no real side effects that we know of). She’s not on any medication for it. But do you think that there’s a significant risk in her being put under/coming out of the anaesthetic?

    The second thing is that the vet seemed fairly resigned to the fact that it’s likely her other knee will rupture in the time it takes for the injured one to heal from the operation. We have a second dog, her litter mate, and the two of them are very active (though they are starting to slow a bit from age) and have always been very fit. It will be quite difficult to keep her immobile enough to give the knee time to heal, and in the mean time there’s a lot of extra pressure on that other leg.

    In the end, I figure the surgery is her best bet, even if she only gets another good year or two out of it. Are there any additional things we could do for her to help both the injured leg and the good one? Swimming, massage, stretches etc?

  45. skeptvet says:

    Epilepsy should not be a significant risk for anesthesia provided appropriate drugs are chosen. The most common ones used these days don’t trigger seizures. As for the other knee, the numbers suggest about a 50% chance of eventual rupture in the other leg, but of course she got to 13 without one, so really who knows. If she is properly managed during the roughly 8 weeks of recovery form a surgery, there is no reason a rupture should happen in her other leg during this time, and may dogs simply shift weight towards the knee that’s been fixed and protect the other once the surgery is healed.

    Good luck!

  46. Phil says:

    Dixie, my 10 year old lab was diagnosed by a vet with a cruciate ligament rupture in her rear left leg. She is 69 pounds, which is her ideal weight. She is limping, dragging foot, but able to get up and move. We are attempting to keep her inactive for two weeks and waiting to see her bodies response to rest and ability to heal. She also has been diagnosed with spondylosis, this was observed in xrays 1 year ago. In the vets opinion the spondylosis is quite severe, and put a 50% rate on the existing development. We are waiting for 2 weeks to see vet again and decide what route of care we will provide. The vet is not recommending surgery at this point. Is tplo surgery or another method of surgery a bad idea because of her spondylosis? Not expecting a definite answer just asking for advice and things that should be considered. Thank you for you willingness to share your knowledge, very selfless!

  47. skeptvet says:

    Spondylosis refers to production of new bone at the junctions between vertebrae in the spine. It doesn’t always mean there is pain or dysfunction, and it is commonly seen in normal older dogs. But whether or not this is associated with any pain in your dog, if the function in her legs is normal apart from the cruciate rupture, then spondylosis wouldn’t be a reason not to pursue surgery. Generally, the only reason not to consider surgery because of another orthopedic problem is if that problem is bad enough that the surgery isn’t likely to do anything to help the dog feel better or walk better. For example, we obviously wouldn’t recommend surgical treatment for cruciate rupture in a dog already paralyzed from an injury. But spondylosis shouldn’t have that kind of influence on how your dog gets around.

    Good luck!

  48. Eddie says:

    It is my experience that to choose the best course of action to take in the case of CCL damage you and your vet need to understand the relationship between your dog’s stifle bend and it’s tibial plateau angle as well as rear angulation. I believe the chances of healing an active, straight legged dog with conservative management is highly unlikely.

  49. G says:

    Just ran across this website while researching about my dog’s recommended TPLO surgery. Entertaining, I wish I could find something like this regarding dentistry…talk about lack of EBM. Anyway, still hard to swallow the price ($3-4k)…since this is roughly twice the charge you’d get from me to perform critical care to keep you from dying. (I know, I know, the final hospital tally will be much more, this is just my charge as an emergency physician.) Keep up the good work, look forward to learning more on this site.

  50. AES says:

    Our 12 year old boxer was just diagnosed with a torn CCL in her rear right leg. She is not weight bearing on it at all. The vet is recommending the tightrope surgery as it is noninvasive and better recovery for her age. She used to be a typical hyper boxer, but has really slowed down in the last 6 months and is happy to sleep for most of the day. We can’t decide whether to do the surgery or try and see if it will heal on its own. The vet is concerned that she is completely not weight bearing, she will tear the other leg’s CCL. I mentioned maybe waiting a week to see if it gets better but vet said scar tissue could form and then the surgery wouldn’t be possible. Thoughts?

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