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

  1. skeptvet says:

    I don’t have a lot to add to what is already in the article and discussion here. The ligament will certainly not heal on its own, of course, but your pet may be able to compensate and function adequately without surgery. My own sense is that these dogs probably are more comfortable and functional with surgery than without, but as the article indicates that has by no means been objectively proven.

    Good luck!

  2. Kelly says:

    Surgery was never an option for my doggy and I because of her age. Depending on how bad the injury…maybeeee it will heal on its own but when my dog tore her ACL she was in a lot of pain so I knew I had to do something. After researching non-surgical methods I came across Woundware and got her a brace. It took some time for her to get use to it but awhile she was walking without a wobble. I was so happy! And it was great not seeing her in pain anymore. A brace might not be an option for some people but it worked for my dog so I thought I would share 🙂

  3. Kathleen says:

    I am so relieved to have found your site. My 1 1/2 year old male 95 lbs yellow lab has a CCL tear and is scheduled for surgery on Thurs. Oct. 9th. The vet, an orthopedic surgeon suggested the TTA vs the TPLO. My dog has since stopped limping, it is his L hind leg and it was damaged I believe by getting tangled up in his cable wrestling with the other dog when he was outside. Since he is not in pain any longer I was concerned if I should still go through with the surgery as thinking it might not be necessary. Well, after reading your article and getting more information on this I’ve decided to continue with surgery as planned so I don’t take the risk of more harm to him later down the road since he will have a long life ahead of him. Thank you for your very informative article.

  4. skeptvet says:

    I’m glad you found the site helpful. Good luck!

  5. Kimber's Mom says:

    Two of my beloved dogs died after having TPLO surgeries. The implants had corroded in them. They had eveloped osteosarcoma. Their vet even had a name for it…..”plate related cancer”. With both of my dogs, the cancer had metastasized to the vertebrae in their spines. My male had to have his leg amputated and died for months after the amputation. My female was repeatedly misdiagnosed. ..i had insisted that she had osteosarcoma because she had the same NON MEDICAL GRADE METAL IMPLANT in her as my male had. Finally, through much determination, doctor number 5 could see the tumor already in her vertebrae as shown on the original x ray!!!!!!!!! So being that holistic medicine gave my boy four months to live, i went with Western medicine as the facility i had driven out of state to go to told me that with chemo and radiation, my dog would live 6 to 8 months. So i handed over my charge card (more than $3,000.00 for one month of treatment)…. my precious angel died 35 days into treatment!!!!! When i had called this facility the night before she had to be euthanized, an oncologist viewed her ultrasound images that were taken on her first visit. He told me that with the size of the tumor in her vertebrae, nothing would have helped….. the best treatment for her would have been to just keep her comfortable…. she probably would have lived longer and more comfortably had she not been subjected to the needless treatments she had. Had the institution been honest on our first visit, my dog would have not suffered how she did. Ex: multiple holes in her vertebrae for her FNA… all these needle injections probably caused the vertebrae to fracture! Was this not an example of greed ? At my dog’s expense? Shame on them!!!!
    Needless to say, when my third dog tore her ACL, over my dead body was she going to have a TPLO. Conservative management was the route we went… and she had braces made from Orthopets…. my 105 pond dog recuperated completely. And yes…. years later she had developed arthritis. …. but so did my TPLO dogs as was seen on their x-rays. I know their are ethical and honest veterinarians who are not driven by financial gain and truly honor the Hippocratic oath they took. … wish i could find one. Three TPLOs and cancer care cost me more than $17,000.00….and two dead canine children leaving me with a heart that cannot be repaired.

  6. skeptvet says:

    As tragic as your experience with this procedure has been, it is not consistent with the experiences of many thousands of other people, myself included, who have had TLO surgery done for their dogs and had excellent results. And while your anger is understandable, not every tragedy is someone’s fault or a sign of greed and bad behavior. I still believe people will make the best decisions for their pets if they trust science more than personal stories, good or bad.

  7. Kimber's Mom says:

    Do you mean the “science” that does not support annual or triennial rabies vaccinations? I DO trust that science…… sadly, it’s most mainstream veterinarians who don’t trust it and subject our animal companions with needless revaccinations that cause health problems, cancer, etc for the almighty dollar…. cha-ching!!!!!!!!

  8. skeptvet says:

    1. There is little objective data on how commonly veterinarians adhere to vaccination guidelines. A recent poll on a veterinary internet site found about 70% gave core non-rabies vaccines every 3 years as recommended. However, a 2 year-old study from the UK found over 84-96% of veterinarians gave vaccines in cats more often than recommended. In my area, I don’t know a single veterinarian who gives rabies annually, but I don’t doubt that far too many do in other areas. the point is that when you say “most mainstream veterinarians” give annual rabies vaccines, you are making that up, and it seems unlikely to be true.

    2. As for whether the annual use of rabies vaccines leads to more health problems, including cancers, than the recommended three-year vaccination protocol, this too is not something science has demonstrated, just something you choose to believe. I happen to agree with the guidelines that we should not vaccinate more than the best scientific evidence suggests is necessary to generate appropriate individual and herd immunity, but I also think you and others who claim the “holistic” view exaggerate the dangers of vaccines for your own purposes, to generate suspicion and distrust against veterinarians who don’t buy into you alternative claims.

    So while I, an advocate of science-based medicine, tend to follow a pretty limited vaccination protocol similar to that advocated by some alternative vets, I doubt you will see that as reason to question your own angry narrative about money-grubbing vets who don’t care about the health of their patients. It is childish and not productive to demonize people just because you disagree with them, and it does nothing to help us get to the truth about how best to care for our animal companions.

  9. Mel says:

    Back in 2004, I had a german shepherd/husky mix that I rescued from CVHS in 1998. It was spring and the mud was horrible in the back field. Storm tried to run and skidded to a stop with a yelp. I thought her leg had been broken. Now I called in for an emergency appointment. The vet diagnosed a torn cruciate ligament and told me the only place that could do the surgery was 4 hours away in Rutland and it would cost me close to $3 grand in fees.
    Storm was already 13 at this time and I asked my own vet what might be best forher, not just any dog. She was a very hard headed animal and always thought she knew better than we did. My vet told me to give her aspirin, support the leg, give her 3 days of non-weight bearing rest and then start home physicaltherapy. Moving the leg to mirror natural motion. It took us 5 months of this but my vet had also said, since she was 13 there was a good chance she wouldn’t survive surgery.

    8 months after the initial accident she was free of any limp, weight bearing, and able to get on both hind legs at the door to bark at people. She did develope some arthritis but the physical therapy to strengthen the muscles and joints allowed it only minimally. She was back racing and raising hell with our rescued wolf hybrid by the 10th month. She stopped for nothing and was about 80 pounds or so. She lived 4 more good, enjoyable years before she died in 2008. She was 17 at the time and her heart just stopped one night. We were just happy we hadn’t needed to put her through surgery, not due to cost but due to stress on her. She wasn’t a “people”or “car ride” sort of dog. She loved her family but not strangers or children. The work we put into her therapy was the best choice for both her and the rest of the family.

  10. Claudia Methvin says:

    Thank you for the brief review of the scant evidence-based research available on this topic. As a human doctor, I try to practice the “standard of care” recommended by peer-reviewed research–so it’s frustrating to see how poorly veterinarian science funds important studies, to the extent that you are having to reference human research on ACL tears to dogs!

    Our 8-y.o. mixed-breed rescue, Lulu (REALLY mixed! we did a doggie DNA on her, and it was astonishing–but she is mostly American Eskie), loves to chase her beloved Blue Football, and after an exceptionally vigorous session of catch last weekend, began to not bear weight on the left hind leg. Vet says likely ACL on the basis of laxity on examination–unfortunately, I sent my husband with the dog because I was working late, and I was not present to ask questions. She weighs 24.5 lbs, but she is really a DENSE dog, stocky in a way that our other Eskies are not. I admit that a major deterrent against surgery is that this dog is deaf and I’m not sure she would fare surgery well.

    Do you have any opinions on non-operative rehab options? Passive manipulation of the limb? Bracing, as someone else mentioned woundwear.com?

    Thanks again for your site. I really appreciate it.

  11. skeptvet says:

    In terms of objective data, there isn’t much I am aware of beyond what I discuss in the article. In terms of personal opinion and experience, with all it’s inherent randomness and unreliability, I still think the TPLO is a very consistently effective surgery, and it’s what I chose to have done for my own dog. I did, however, have a boarded surgeon perform the procedure, so this is not something I would have a regular GP do even if they have some training in it.

    As for PT, braces, etc., I honestly don’t know if they work as well or better than surgery because the evidence isn’t there and you can find anecdotes in both directions. Sorry there isn’t anything more definitive at this point.

    Good luck!

  12. Art says:

    Do you have any opinions on non-operative rehab options? Passive manipulation of the limb? Bracing, as someone else mentioned woundwear.com?>>>>

    Before you get excited about the before and after videos using the bracing I would like to tell you that medically treated patients will sometimes use the leg walking in grass and then hold it up on hard surfaces. So the videos fom wound wear may not be bogus but maybe just gives the dog confidence to use the leg.

  13. Danni says:

    Surgery is not always the only option. My dog had some what of the same injury and I ended up getting her an A-trac brace from Woundwear. Although the brace took a little while for her to get used too, she is doing much better! I really didn’t want to put my dog through surgery and for others out there looking for a Plan B, getting a brace is the way to go 🙂

  14. Art says:

    Anyone know what the human non surgical rehab standard of care is and if it’s evidenced based. My own dog just tore her ACL last week. The knee swelled the day before the Acl broke all the way. The last dog I owned that tore both acls I did surgery on both of them. I can understand why posters want to do something. 🙂

  15. Jay says:

    My 6 yr old 60 lb german short hair pointer blew her knee out with severe ruptured CCL 6 months ago. 5 different vets recommended her for immediate surgery TPLO etc….I disregarded their advise opting to wait for something better then the surgeries offered and to see how she would do. She recovered slowly and at times I questioned if I knew what I was doing….here we are 6 months latter and she is running and playing as if it never happened! Only getting sore at times but less and less every week. I am so happy I didn’t put through the surgery and trama not to mention expense. Wait! Avoid the surgery! Vets are obviously not doing these surgeries with your pets best interest in mind, if they were they would be taking a conservative approach prior to making instant surgery recommendations.

  16. skeptvet says:

    Vets are obviously not doing these surgeries with your pets best interest in mind

    Sorry, but this is insulting and deeply unfair. After all the review of the evidence for and against surgery reviewed in this article, do you really think your personal experience means all vets who recommend surgery are wrong or lying? How do you explain, then, that I had a TPLO done on my own dog? What possible reason could I have for that other than the best interests of my pet? And my dog functioned great for another 10 years after his surgery. So if we are just going to decide on the basis of dueling anecdotes, then we get nowhere when different people have different experiences. That’s why real data is so important.

  17. Art says:

    What possible reason>>>
    too much prior plausibility consideration from teachers, experts, employers and employees.
    Sometimes you need to get away from standard of care practice until the real data becomes comfortable in your brain. My best conversations along this line are with retired veterinarians who stop vaccinating their own pets every 1-3 years after they retire but did it for their own pets ever since vet school while practicing.

  18. skeptvet says:

    My point was simply that the motive for this choice was a desire to do what was best for my dog. Whether or not the belief that TPLO was the best therapy was accurate is, of course, open to debate. But I was responding to the assertion that vets recommend TPLOs with motivation other than the best interests of their patients, presumably to make money. This clearly wouldn’t apply to a decision made for my own pet which cost me money.

  19. Art Malernee Dvm says:

    My point was simply that the motive for this choice was a desire to do what was best for my dog>>>> i suspect the way the human mind works wouldn’t studies show the primary motive really is not what’s best for patients even pets of our own or even whats best for ourselves but what we as the doctor are most comfortable doing? I have read about how we lie to ourself and when we do it it’s because we can’t handle the truth. Sort of like in the star track episode where captain Picard was tortured when he said to his captures said he saw two lights rather than three which was the answer they wanted and reflecting back on the torture the captain said even though there was only two lights there was a time during the torture he really thought he could see three lights.

  20. Art says:

    I got my light numbers wrong from the Cardassion episode. I think Even the best of humans can torture even when everyone knows it does no good if it makes us comfortable doing it. It’s the way our minds work.
    See
    https://m.youtube.com/watch?v=F5rsxXRoD5U

  21. skeptvet says:

    Certainly, cognitive dissonance and all manner of cognitive biases distort our perceptions and judgment, but I’m not aware of any research that suggests doctors are motivated more by comfort that what is best for their patients. I think we are often wrong about what is best, especially if we don’t pay attention to the evidence, but I think your speculating about motives.

    And such speculation is itself very prone to bias. Proponents of alternative medicine often believe conventional doctors are motivated by greed or are simply brainwashed by industry. Skeptics often claim that CAM advocates are also motivated by greed or are simply stupid. How is such speculation about motives productive? It seems just a convenient type of ad hominem for dismissing any claim or argument one doesn’t like.

    In any case, my perception is that I sent my dog to a surgeon for a TPLO because of a combination of explicit reviews of the evidence (which suggests the procedure is generally very effective) and less tangible motives (such as my own experience of cases that had surgery and cases that did not, which subjectively seem to me to show an advantage to surgical treatment). If that is not the “real” motivation and I am acting on some sort of unconscious motive, I don’t see how we are likely to figure out what that is objectively or how trying to do so furthers our understanding of what is best to recommend for our patients.

  22. TJ says:

    Hi. I’m just starting to go through this with my dog – a 10 year old very active beagle x springer spaniel. He’s just had xrays and I was told he had totally ruptured the ligament of his left hind leg and that there was ‘nothing left’. Would that seem to indicate that surgery is the only option? Just reading Jay’s comment above it seems that his/her dog also had a complete rupture and yet was able to heal. I was under the impression that this could possibly happen with a partial tear if you can keep the dog well restrained, but not if it was fully ruptured? I’m looking at all options at this stage and very worried!!

  23. skeptvet says:

    As you can see from the article and all the discussion, there isn’t a clear, one-size-fits-all answer. Personally, I suspect dogs with treated with surgery will have better comfort and function long-term, especially if they are fairly young and active. But there’s no proof of this, and obviously some people feel their dogs do ok without surgery.

    Good luck!

  24. Kim Economos says:

    Hi
    My sisters dog has ruptured both her cruciate ligaments over Christmas. One on Christmas Eve and the other on Boxing day. She is a Rottweiler who weighs 35 kilos (2.2 pounds to the kilo is the conversion). They have had her assessed by 2 different vets who have advised euthanasia due to the damage done, her size and costs involved. She is so loved by her family that this decision is tearing them all apart. The dog is on a high level of medication for pain relief and is still happy and loving even though she needs help with toileting etc. My question is.. has anyone had any results with CM on a large dog that has done both cruciates. This poor dog has already had surgery on her front legs for Elbow Dysplasia that cost in excess of $4000 Australian dollars. One ortho vet has said they maybe up for $12000 AUD if they went ahead with surgery but is worried about post op quality of life. Just need all the info we can before this beautiful dog is PTS> Thanks everyone.

  25. Renee says:

    Kim-I am no expert on the subject nor do I claim to be and I do not usually post anywhere on the web, but I wanted to share my experience yesterday as well as pass along a few links that you might find helpful.

    As a background my 115lb dog tore his CCL just before Christmas and I have been trying to figure out the best way to proceed with treatment and management. Obviously TPLO for a large breed is the preferred method of veterinarians and I have been encouraged to go that route. Needless to say I was, and am still, apprehensive about breaking a bone to fix a ligament. Also, the time to get into my preferred surgical center is 2 months away raising new concerns about the onset of arthritis in the joint.

    Yesterday I decided to go into the ER of the vet school at Texas A&M University for imaging and second opinion consult (3.5 hrs away). While waiting on my dog to wake up from anesthesia, a huge boxer (~90-100lbs) who appeared to be in good health came in to sit next to me in the waiting room. Oh how I longed for my dog to be in such good condition. It made me curious about the reason for their visit. Since the vet school only accepts referrals I knew it must have been a serious case. Was the dog sick with some rare genetic disorder? Cancer? There were no signs of injury. I asked the owner why their dog was had an appointment. They said he had ruptured both his CCLs in his back legs! No joke, this dog looked amazing!!! TPLO had been performed on both legs and the recovery was long (this was their 6 month visit). They said following post-op procedure to the ‘T’ was critical but they are so happy they hung in there. They did not have much time to talk as they were soon rushed to their appointment by a resident with their beautiful dog trotting happily at their side.

    This made me feel much better about my options. This was not some dog who had a one in a million recovery and so they used him as an example on the internet. I know no one can promise me results like this dog had but my greatest concern was doing the procedure and spending the money for very little improvement or outcome.

    Yes, money is always a factor, I know, and I don’t recommend people spend money they do not have. These are hard decisions. I would sell everything I owned to keep my dogs quality of life and independence as long as I can. My dog is 11yo giant breed who’s max lifespan was 9 at best so this investment is a serious decision (6 month confinement/restrictment in recovery is a long time in dog years). Conservative management without surgery is estimated be about double that confinement/activity restrictment requirement.

    Rehabilitation and bracing appears to be a somewhat new and untested option. The vet school staff do not think is a reliable option at this time. However, Orthopets appear to be working on clinical trial research to improve bracing options so they do not appear to just be trying to sell crap to desperate people. I will be keeping an eye on them for future options for my dog’s other leg or my other dog should degeneration become apparent.

    Regenerative medicine holds great promise based on other species including humans however this is a long way off, years not months, from addressing full ruptures in a dog. I will cross my fingers for evidence based treatments of partial tear or degeneration in other joints hopefully coming in the coming year or two.

    TPLO, which was recommended for my dog, is estimated to be about $3500-$4000 for my giant breed. As it turns out there is also a partial tear in my dogs other leg which if it doesn’t tear may be second less invasive and less costly procedure called ex-cap suture.

    Links worth a read:
    http://csu-cvmbs.colostate.edu/vth/small-animal/sports-medicine-rehabilitation/Pages/typical-recovery-rehabilitation-schedule.aspx

    http://csu-cvmbs.colostate.edu/vth/small-animal/sports-medicine-rehabilitation/Pages/canine-cruciate-ligament-injury.aspx

    http://www.akcchf.org/canine-health/your-dogs-health/stabilizing-the-stabilizer.html

    There are many other good articles on akcchf.org. This site worth a search

    I hope that whatever decisions your family makes, results in the best outcome possible for their, and their dog’s, situation.

  26. Jane Zollinger says:

    Our older mixed breed dog(heeler mix) has a ruptured cruciate ligament. We think she is 12 -13 years old and she is currently just under 50 lbs. She is scheduled for TPLO surgery in a couple of weeks but I don’t know if this is really the right thing to do. I’ve had broken bones and a variety of surgeries and they are extremely painful. Her knee already has major arthritis so we aren’t going to be preventing the condition in her case. I don’t want her to be in pain and lame for the rest of her life but that could just as easily describe just leaving her alone maybe trying a brace or the long haul of recovering from surgery. If she was young the decision would be a lot easier. How do you make this decision? Other than the knee problem, she is in good health.

  27. skeptvet says:

    I wish there were a simple way to make this decision, but of course we can’t be certain how things will work out whichever way you go. Age itself is not really much of a factor in how they respond to surgery, though of course it can be if they have other medical problems. I would encourage you to raise your concerns with your vet, and even to seek a second opinion so you are comfortable that at least you know as much as you can about the options before you make a final decision.

    Good luck!

  28. jodie says:

    Hi,

    I found this article after we had our dog X-rayed today after over a year of trips to the vets concerned there was something wrong with her back leg, though symptoms were intermittant. She is a toughie and did not respond as though in pain but to us we could see something wasn’t right and there was muscle degeneration in her leg as well. We requested an X-ray as we felt we were getting no where and were concerned we were adding to any problems she may have. She is a rescue and approx 4-5 years old. The Vet today believes she had ruptured this ligament and as it had gone undiagnosed for a year it had healed itself, badly. He has advised us we can now leave it as it wont get worse but she will continue to have lame periods, will need hydrotherapy and muscle specific massages to try to build the muscle up again or operate but there is no rush as the damage is there. We are thinking surgery will be best, she is still young and this surgery will clean up the ligaments making it less painful overall. She also has nodules of Arthritis in the bone as well (though my guilt is alleviated slightly by the fact this probably would have happened anyway with this injury). She is 24kg approximately and a very bouncy dog so this wont have helped!

    Anyway, I just wanted to post this as a sad owner whose dog is now suffering as we didn’t get a diagnosis and it was left to heal by itself. Perhaps if we had known using a brace may have helped though I suspect we would have had it operated on.

    Best of luck to all you other doggies and owners and thanks for this article which attempts to find the evidence base!

  29. Rue says:

    “Conservative management without surgery is estimated be about double that confinement/activity restrictment requirement. ”

    Renee, this is incorrect. Exercise restriction is about the same length of time regardless of whether or not they have had surgery.

    Kim, I have seen double TLPO that all is well and heals fine. But on the flip side, I have also seen a double TLPO where years later the dog can still barely walk despite his owners best efforts. If I’m being honest, I’ve seen more of the latter (dogs that seem to not heal well despite surgery). I’ve also seen a large dog (80 or so pounds) do conservative treatment and make about as full of a recovery as you can get, surgery or otherwise. He currently competes in agility. However, the blog owner here is correct in saying there is no one correct answer. I believe a lot has to do with owner compliance and commitment to treatment, whichever route they choose to go.

  30. skeptvet says:

    And all of this, unfortunately, is haphazard observation, not controlled studies, so we have to be cautious in using it to guide our decision making. How, exactly, do we know how long to exercise restrict dogs managed conservatively or with surgery? In the case of surgery, the recommendations are based on the healing time of bone, which is at least reasonable, but there is not research specifically comparing different post-surgical protocols to determine which is best.

    For dogs treated medically, I’m not aware of any research identifying the best type or duration of activity limitation, so how do we know?

    And as far as anecdotes comparing surgical and non-surgical treatment, my own are quite different. I have seen the vast majority of surgically treated patients who are very comfortable and functional after surgery. I have seen a fair number of non-surgically treated small dogs with good apparent comfort and function, though also with significant arthritis in the affected legs. And I have rarely seen a large dog with a confirmed CCL tear using that leg normally without surgery. But that just illustrates the problem with anecdotes: you can find some to support any point of view, so they really don’t help much in figuring out the truth.

  31. emilie says:

    my Australian shepherd has completely torn both cruciate ligaments. she was in pain, had an extremely difficult time getting up, walking pretty much anything. the vet said our only option was surgery. I got a second opinion and a third and a fourth all whom said the only option is surgery otherwise she will be in pain the rest of her life and will not have a good life. surgery for both knees would cost about $10,000.00 which I could not afford. long story short, I decided against the surgery and my dog is doing AMAZING!!!! I am writing this because I felt hopeless and felt I had no options other than surgery. their bodies has an amazing way of healing themselves. I put her on strict bed rest (which you would have to do anyway if you had the surgery) I did this for about 6 months, then I gradually increased her activity over time. she got 6 sessions of laser therapy and walking on a treadmill in water. this was only $500 (compared to the 10grand) it was very important that she regained muscle in her legs as they were beginning to shrink. I messaged her legs and did hot and cold compresses on her knees. today she can go for long walks, run around in the backyard with the other dogs, get up and do stairs easily and she is pain free. her therapist is amazed beyond words and said she cant even tell she has the injury. she walks normally. keep in mind I do not do any strenuous activity with her anymore the way I used to but she is doing great and im so glad we decided against the surgery. its very upsetting that all these vets say the only option is surgery when that’s clearly not the case. my dog is 60lbs and its possible. perhaps for extremely large breeds surgery would be necessary but my dog is proof that they can recover naturally from this injury!! heck one day my husband brought her in the field with his 3 wheeler and she ran around like crazy I thought forsure that would set her back again, but she was fine! my advice is don’t listen to the vets and put your dogs through this intense surgery and recovery and spend all that money. its not necessary in most cases!

  32. skeptvet says:

    my advice is don’t listen to the vets and put your dogs through this intense surgery and recovery and spend all that money. its not necessary in most cases!

    Sorry, but I was with you up to this point. As has been explained many times in this article and the subsequent discussion, most dogs do well with surgery, and some dogs do well without surgery. Whether overall surgical or medical therapy is better isn’t known because there has been no research comparing the two. You can’t simply say “Here’s what happened to my dog” and then claim that the veterinary profession is all wrong and you’ve figured out the answer for everyone else’s dog. Anecdotes simply aren’t reliable predictors of what will happen to other pets, so while it is great your dog is doing well, it is not evidence that other dogs don’t need surgery. If your dog didn’t do well, it wouldn’t be evidence that other dogs should have surgery. It’s just one more uncontrolled anecdote.

  33. Judy Dunn says:

    I am very interested in the articles that I have read equating early spay/ castration with ACL problems.

    Another thought and not scientific at all but an observation. I have had GSDs since 1960 – bred them and none of MY dogs have had an ACL problem. But at least 4 of my puppy buyers have had ACL problems. None of these puppies have been exercised stressed, all have been spayed neutered under a year. I do not know the food fed.

    I do not rec neutering until maturity but many vets really harp/ pressure for neutering at 6 mos. or younger. I feel this is wrong!

  34. Stephanie says:

    Judy, I agree with you 100%! I work at a Health and wellness center for dogs. I see this so much with dogs neutered of spayed before maturity having ACL/ Cruciate tears, and other customers that have waited to have procedure done that have dogs middle age and beyond, that have never had those problems. Coincidence…I don’t think so. The body needs to finish developing for it to work properly…like a car it needs all its parts to run properly, so does the body need all its parts strong and developed to work properly. Over vaccination is another thing and over medicated is another, but that’s for another blog. I agree with many..sometimes the easy fix is not always the answer. When I got my beautiful yellow lab he had already been neutered and he was only 7 months. He loves to run as all labs do and he now has a cruciate tear in his left hind leg. I’ve got two opinions. One by a holistic vet and one by a regular vet. The regular vet said surgery before he even seen the X-ray and my holistic vet said rest 6 weeks, laser therapy and water therapy. Which I will do. Also light walking, short distances. I also apply essentials oils dilute to his knee for inflammation and give him massages to keep circulation flowing well in the area. He also winds up with full body massages because he gets so relaxed! Lol
    So all I am trying to get across here is sometimes if we do the work, as in doing strict therapy, it may be worth the time and effort before doing such extensive surgery. Why not try therapy before jumping into surgery with all the side effects medications ect. can cause. You can always have the surgery later if it doesn’t work. if you decide you must do the surgery, I would make sure who you have do it is highly recommended, and make sure he has some great credentials. I rather pay a little more for a great job then pay less and have a botched up job done. As for for me I am 59 and have gone through losing many dogs to believing in western medicine. The pain and ache of feeling I made wrong choices over the years took much from me. I choose the holistic world now, and my results have been emmense and my dogs are happy and very healthy now. I feed a balanced raw diet, we titer our vaccines and I do no chemicals on my dogs. My lab is 6 now, and our vet says his blood work is impeccable, his teeth so healthy, his bones strong (except for this cruciate tear…grrrr) again I believe due to the early neutering. Another lesson learned.
    I will continue with physical therapy for Major Renegade (my beautiful boy). I think if he had a choice and could talk he’d tell me that’s what he wants. Give me some time and I will come back and tell you how it’s going.
    We all have to do what we feel is best for us and our pet. Always go with your gut.

  35. art malernee Dvm says:

    We all have to do what we feel is best for us and our pet. Always go with your gut.>>>
    My holistic gut feelings stink.

  36. ellen hine says:

    I have a 12+year old dog who has been recommended for TPOL surgery. I am still torn as to what to do. She has a bit of arthritis in her hips but loves long walks, even with her current situation. We try to only take her on walks around town, and not to places she will have rocky or uneven terrain. I think the surgery would kill her spirit. She will have such a long recovery. She doesn’t show any signs of pain, just a bit lame in her back left knee. Can physical therapy and limited exercise work? Acupuncture?

  37. Terry says:

    Dr. How do you prevent a dog from possibly tearing the ACL again after surgery? What do you recommend in an effort to try to limit a dog’s activity? This seems like the difficult part. Crating a dog who has been uncrated for several years doesn’t seem like the answer. We have a 5 year old very active pit bull and just trying to limit her activity while we make a decision, has been challenging.

  38. skeptvet says:

    There isn’t much to add to what is already discussed in this article and the comments. Surgery definitely works well for most dogs. Some dogs do fine without surgery, but there is not evidence comparing specific non-surgical treatments (rest, physical therapy of various kinds, etc.) to surgery, so we don’t know if they do as well, better, or worse than dogs who have surgery. There is also no evidence that acupuncture has any effect on this problem. In the face of this uncertainty, the best any of us can do is try and balance the current comfort and function of the dog against the potential improvement with surgery and the cost/challenges of surgery. There isn’t a single right answer for everyone.

    Good luck!

  39. skeptvet says:

    Surgery is only performed if the CCL is completely ruptured, so there is no issue of reinjuring it again afterwards. Most dpgs need to be restricted pretty severely for 6-8 weeks after surgery (again depending on the specific procedure), but after that they should be able to engage in normal activities, since that’s the whole point of doing the surgery.

    About 50% of dogs who rupture the CCL on one side will eventually rupture the other. One might be able to prevent this by restricting their activity, but again this gets into quality of life since the goal of treatment is to allow normal activity. I generally warn owners about this possibility, but I don’t recommend major lifestyle change for most dogs even if there is a chance we may need to treat the other knee someday.

  40. Terry says:

    The CCL (what is the difference in the CCL and ACL?) is completely ruptured. I have heard horror stories of dog owners having difficulty limiting their dog’s activity after surgery and the surgical leg ruptures again.

  41. skeptvet says:

    CCL is just the usual name in dogs. ACL stands for “anterior” cruciate ligament, which refers to something on the front of the body. CCL stands for “cranial” cruciate ligament, meaning something towards the head. The nomenclature is different because humans are bipedal and dogs are quadrupeds, but the ligament is the same.

    Sure, it is possible for a dog to damage the surgical site if they run on it too soon after surgery, but this is the case for any kind of surgery and isn’t necessarily a reason not to do the procedure. We can usually mange even crazy young dogs with confinement and even some sedation if absolutely necessary.

  42. Lea says:

    Hi all,

    I think a very important question you must ask yourselves while considering what course of action to take is what your goals are for your pet’s quality of life.

    I have an 80lb 7 yr Old English Bulldogge. She tore her crucial ligament in her back right leg 4 yrs ago. it was a year and a half of vet visits and mis diagnosis to finally get to an ortho vet who recommended TPLO surgery. We went through a cycle of her over using the leg and then being lame for a day or two. When she felt better we would let her run free again And be right back in the same situation. So we opted to do the surgery. I thought at the time that a good quality of life for her meant running free at the dog park or cottage.

    Things were ok after surgery physically but mentally she was never the same. Our vet warned us that 50% of dogs end up rupturing the ligament in the other leg. We let her once again run free and she would get stiff from time to time but overall we were happy with the results. Last summer she started biting the leg at the incision site. Chewing it until it bled. It turns out her body was rejecting the hardware so she had to have another surgery to remove the plate and screws. this was three years or so after the surgery.

    Last Thursday she came in from the back yard lame on her left side. I have an appointment this week with the ortho vet but I can already guess she’s ruptured the ligament in the other side. She’s been resting for four days and is no better.

    I won’t do another TPLO. I am looking into conservative therapy this time because I realize now that my quality of life goals for her were misguided. Right now she is completely lame and it’s my own fault. I was reckless in letting her run around after knowing the stats of injury to the other leg.

    My only goal for her quality of life now is to get her to be able to walk pain free. I would be over the moon if we only had short leash walks in our future. Fingers crossed.

  43. Maya says:

    I think it’s really important to stress that your dog’s possibility of healing itself and living happily and pain free without surgery is going to be dependent on many factors, including age, their weight, previous injuries, physical condition, and the SEVERITY OF THE TEAR! No 2 dogs are alike.

    We were successful with the conservative treatment. My dog tore her ACL about a year ago when she was 10 years old. We wanted to exhaust all of the possibilities before thinking about resorting to surgery. To help stabilize her knee while it repaired itself, we found the Ortocanis dog knee brace online from a company called Ortocanis. While the support it provided was moderate, my dog was on complete bed rest so it was enough support for her. Another important thing was that she didn’t seem bothered by the knee brace or try and take it off. A year later of more or less consistent use and the Ortocanis knee brace is as good as new. And it cost less than $50!!

    There are so many different treatment alternatives out there for when things like this happen and it can be overwhelming. Obviously your vet is the first person you should go and listen to.. but hopefully my experience can serve as guidance for someone out there in the same situation!

  44. Alison says:

    Maya, is this the Ortocanis dog knee brace you used? http://www.ortocanis.com/en/technical-helps-for-dogs/90-knee-brace.html

    I had read some really great things about it and was considering using it to treat my dog’s torn ACL. Other companies online sell similar products but for much more money. This seems reasonable and the quality seems pretty great. I think I’m going to give it a go!

  45. art malernee dvm says:

    my dog broke her acl about two years ago and I treated it with nothing.

  46. Maya says:

    Yes Alison that’s the Ortocanis knee brace we used. If you have any questions or want to know more about my experience.. just send me an email at maya10delmar@gmail.com

    I’d be happy to help!

  47. Jenny says:

    Hi! I’m heartbroken and confused… Koda 1 year old cattle dog who is the love of our lives blew her acl three days ago! We are face with surgery or no surgery! I’ve read a lot and still just do not know what to do. We are creating her and limiting activity … her mood seems better but still no weight on her leg! We have money saved and would spend it on her. She’s our child and money isn’t the issue. We are just scared of making a wrong choice. We have an appointment with a surgeon in three weeks. We got her glucosamine painkillers and anti-inflammatory Meds to help with the pain. I’m happy your dog recovered and I pray my dog does the same

  48. skeptvet says:

    Just to be clear, there is no question surgery works, so it is still the safest choice. The question is whether other treatments can work as well if surgery is not an option for medical or financial reasons, and that’s what we don’t yet know. But if you can choose surgery, that is very likely to help your companion.

  49. art malernee dvm says:

    Just to be clear, there is no question surgery works,>>>>>
    When is surgery a placebo? Do you consider Acupuncture for ruptured cruciate ligaments a placebo but not cruciate surgery? Do you think the published prospective randomized cruciate surgery trials we have now with links on the internet show a benefit beyond placebo? Narda Robinson just published a article titled “when is surgery a placebo” in veterinary practice news. Sorry could not find online link yet. She mentions tplo cruciate surgery. My take reading the article is she thinks its unfair to attack needling when you promote knee surgery that if the FDA regulated like Apoquel would be little more than a scar that denotes an unproven remedy.

  50. skeptvet says:

    Surgery can certainly be a placebo. Internal mammary artery ligation and other procedures have been tested against sham surgery in humans and found to be no better than a skin incision alone. Obviously, this test is not used often, however, because it is considered unethical to anesthetize and cut open a patient as a placebo control with no intention of doing anything that might benefit the patient. So we’re not likely to see a trial comparing TPLO to fake surgery.

    So we have to find other ways to evaluate the effects of surgical procedures. These can include comparisons with non-surgical therapies and non-clinical trial forms of evidence, such as pathophysiologic rationale. Nothing is as strong as a placebo comparison study properly designed and conducted, but that doesn’t mean we have to throw up our hands and give up on making rational decisions if we don’t have one.

    In the case of TPLO surgery, there is a lot of evidence, from basic biomechanical studies to clinical trials, suggesting improved function compared with other surgical procedures or no treatment. There is not robust evidence comparing TPLO to a specifically defined medical management protocol, which is why I agree that we still don’t know if surgery is better than any particular medical therapy or combination of therapies. But to suggest that we don’t have any evidence that TPLO is effective is to dramatically overstate the case. The evidence is limited in many ways and imperfect, but it’s pretty good.

    Narda strongly recommends acupuncture, laser, massage, and various kinds of physical therapy approaches. Virtually none of these have been tested as extensively in CCL Dz patients as TPLO has been. I have written about several such methods and reviewed the evidence concerning them. I consider laser promising but the evidence is still limited and, in my opinion, weaker than that for TPLO. Acupuncture is most likely a placebo or perhaps a counterirritant with mild non-specific effects on pain. There is no reason to think any of these methods repair or replace the function of the CCL, whereas there is some reason to think TPLO may do so.

    The lack of perfect evidence for TPLO is an issue, but it doesn’t translate into evidence that these other therapies are effective or that we have absolutely no evidence to support surgical treatment. The argument that evidence for conventional treatments is flawed so we can consider alternative therapies just as good is logically unsound. It appeals to a sense of “fairness,” but ultimately the limitations in the evidence for TPLO doesn’t mean acupuncture works; these are separate issues. Overall, the evidence is imperfect for both (and for almost everything in veterinary medicine), but I think it is stronger for TPLO than for acupuncture. Lots of gray, not so much black and white.

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