Evidence Update–Is Surgery Really Necessary for Dogs with Cruciate Ligament Ruptures?

A couple of years ago, I wrote about the question of whether or not surgery was better than medical management for dogs with cranial cruciate ligament (CCL) disease. Here was my conclusion at that time:

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.

A recent research article has added an important piece of evidence concerning this subject, and while supporting the value of surgery it does weaken somewhat the case against medical treatment for large dogs.

Wucherer, KL. Conzemius, MG. Evans, R. Wilke, VL. Short-term and long-term outcomes for overweight dogs with cranial cruciate ligament rupture treated surgically or nonsurgically. Journal of the American Veterinary Medical Association 2013;242(10):1364-72.

The authors interpretation of the results supports the argument that both surgical and nonsurgical treatment can be successful, even in overweight large-breed or giant-breed dogs, but that surgery appears to provide a better outcome.

Overweight dogs with CCLR treated via surgical and nonsurgical methods had better outcomes than dogs treated via nonsurgical methods alone. However, almost two-thirds of the dogs in the nonsurgical treatment group had a successful outcome…

Overall, I agree with their conclusion, though I would probably place less confidence in it than the authors do.

The Study
Forty overweight large-breed or giant-breed dogs with unilateral rupture of a CCL were recruited and randomized to either medical therapy alone (a weight loss program, individualized physical therapy, and daily use of a nonsteroidal anti-inflammatory medication) or medical therapy plus surgical therapy (TPLO). Outcomes were assessed at 6 weeks, 12 weeks, 24 weeks, and 52 weeks after the beginning of the study.

There was a high rate of drop out (5 digs by 6 weeks, 11 dogs by 24 weeks, and 17 dogs by 52 weeks). The majority of these dogs (11/17) dropped out due to CCL rupture in the opposite leg, and there was no overall difference in dropouts between the two groups (9 in surgical group and 8 in non-surgical group).

Both subjective outcome measures (surveys of owner perception of their dogs’ pain and lameness and pain scores generated by the investigators) and objective outcome measures (body weight, body fat, body condition scores, and several measures generated by force-plate analysis) were evaluated at the beginning of the study and in the dogs still participating at each follow-up point.

The Results
No adverse effects were reported for the weight loss diet, the NSAID therapy, or the physical therapy. A few minor complications associated with TPLO surgery were reported at rates consistent with those reported in other studies.

The weight loss program did result in decreases in body condition score and percent body fat for both groups, and there were no significant differences between the two groups. Interestingly, while total body weight did decline slightly for both groups, the decrease was not statistically significant for either, and there was no difference between the groups.

Subjective measures, both owner and investigator assessed, improved significantly for both groups. There were no differences between the groups in the subjective outcomes assessed by the investigators. The surgery group had significantly lower scores for pain severity and interference than the non-surgical group only at the 52-week evaluation. Some differences between the groups in visual analog pain scale assessment by owners were reported, but how many measures were assessed and which ones differed were not reported, and no statistical analysis of these differences was reported, so it is difficult to assess this outcome measure.

Of the several force-plate measures assessed (5 or 6 measures; it isn’t clear from the paper), only one differed between the groups, and this difference was significant only at two of the four assessment points (24 weeks and 52 weeks).

The investigators also created a composite measure of “successful outcome,” defined as achieving both a specific force-plate measure that was >85% that of a normal dog and a subjective, owner-assessed improvement in lameness and quality of life >/= 10%. The dogs in the surgical group had higher “successful outcome” scores at all assessment points, but this only reached statistical significance at 24-week evaluation.

Strengths of the Study
Overall, this was a well-designed study. The use of both subjective and objective outcome measures, random assignment of treatment, an aggressive and consistent medical therapy program, and partial standardization of surgical treatment all reduce the risk of bias, confounding, and other error in the study. The consistency of several reported variables (such as surgical complication rate) with those reported in other studies increases the confidence one can have in the results. And the attempt to verify compliance with the weight loss aspect of medical therapy is an important part of any study employing this therapeutic approach.

Limitations and Caveats
A significant limitation is the lack of blinding of owners or investigators to treatment group. While blinding would be difficult, and possibly unethical due to the need for a sham surgery component, the lack of blinding introduces significant risk of information bias, particularly in the subjective outcome measures.

There was some individualization of surgical procedure and physical therapy treatments employed, which means not all subjects had the same treatment. If some techniques used work better than others, or if the selection of technique to be used is associated with the likelihood of a good or bad outcome, this could generate an erroneous impression of the differences between the surgical and non-surgical treatment groups.

The biggest limitation of the study was probably the high dropout rate. In general, dropout rates greater than about 20% are considered to severely compromise the data, and the overall dropout rate was 42.5% in this study. Though the number of dropouts were evenly distributed between the two groups, this does not mean the dropouts did not introduce bias into the results. If those patients who dropped out, most because they developed a second CCL rupture in their other leg, differed in terms of their underlying disease or response to treatment from the subjects who stayed in the study, this could have significantly altered the findings.

Also, as the authors themselves point out, the dropouts caused a significant loss of power in the study (though no power analysis is presented in the report), and this could lead to a failure to detect a difference between the groups. Overall, the dropouts significantly weaken the confidence we can place in these results.

Bottom Line
This study does provide some support for the contention that overweight, large-breed or giant-breed dogs have better long-term outcomes when treated with both surgery and non-surgical therapy rather than with non-surgical therapy alone. However, the limitations in these data are great enough that the case for preferring surgical intervention is not strong. The non-surgically treated patients had overall very good outcomes that, at most time points and by most measures, did not differ significantly from the patients who received surgical treatment. Additional evidence would be required to make a strong statement that overall surgery is superior to aggressive medical therapy.

While it is reasonable to tell dog owners that there is some evidence their pets will benefit more from having surgery than not having it, we must also inform them that most dogs will have a good long-term outcome even without surgery. And it is important to emphasize that even with surgery, aggressive management of weight and physical therapy are important elements of  comprehensive and successful treatment. For those owners who cannot afford surgery, or those patients who are not good candidates, there are still effective therapies that can be offered.

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64 Responses to Evidence Update–Is Surgery Really Necessary for Dogs with Cruciate Ligament Ruptures?

  1. Dennis Stanford says:

    Thank you thank you thank you ! The Dr. Dean Edell of veterinary medicine

  2. skeptvet says:

    Awww, shucks! 🙂

  3. Art says:

    Article Abstract

    OBJECTIVE: To compare the long-term outcome of tibial plateau leveling osteotomy (TPLO) and extracapsular repair (ECR) for treatment of a ruptured cranial cruciate ligament (RCCL).

    STUDY DESIGN: Prospective clinical trial.

    ANIMALS: Normal adult dogs (control, n = 79); dogs with unilateral CCL disease (n = 38).

    METHODS: Dogs had TPLO (n = 15) or ECR (n = 23) for treatment of RCCL. Force plate gait analysis was performed for the control group at one time point and for treatment groups at serial points: preoperatively, 2 weeks, 8 weeks, 6 and 12 months postoperatively. Symmetry indices (SIs) were calculated between operated and unoperated pelvic limb for ground reaction forces (GRFs), including peak vertical force (PVF), contact time (CT), and vertical impulse (VI). GRFs of the treatment groups and control group were compared using a general linear model and Kaplan-Meier survival analysis.

    RESULTS: At 8 weeks, for PVF and VI, the TPLO group had more symmetric limb loading than the ECR group at the walk and trot. SIs of the TPLO group were not different from the control group by 6 months to 1 year postoperatively. SIs for the ECR group were less symmetrical than the control group at all time periods. Using survival analysis, median time to normal function was no different at the walk between groups, but was shorter for the TPLO group for VI and PVF.

    CONCLUSIONS: Dogs achieved normal limb loading faster after TPLO than ECR. TPLO resulted in operated limb function that was indistinguishable from the control population by 1 year postoperatively.

  4. Diane says:

    So I find myself with a large (Pyrenees) dog who is at least 5 pounds overweight (despite a lot of work trying to get it off) and who has a torn CCL and very likely a meniscal tear.

    I’ve been told by several vets that dogs over 50 pounds can’t recover from CCL tears without surgery and it would be a bad idea to choose anything but a TPLO. This JAVMA article suggests that’s an overstatement. I saw another article that concluded that TP angle was irrelevant in regaining function; but it’s hard to know if I’m understanding it correctly or how sound that research was.

    Meanwhile, all the vets also tell me that the only option for a dog of any size with a torn meniscus is surgery, and one claims that it’s best to remove the entire meniscus rather than simply the damaged part, and that the current thinking is that even if the meniscus is not torn, when you have a dog on the table for CCL sx you should release the meniscus to help prevent it from tearing later. He claims this is the prevailing wisdom at UC Davis currently.

    I’ve been searching but haven’t found any information to speak of about torn menisci and whether research has been done on the best way to manage tears, whether there are factors that make a difference such as the length of the tear, the extent of damage, dog’s lifestyle, etc.

    Is there research on this issue? The only thing I’ve found is that removal of the meniscus apparently leads unavoidably to DJD. The vet I saw today told me dogs don’t live long enough for that to be an issue; it’s only an issue in humans, and removal is the standard of care now. OK, my dog is almost 7, and large breeds don’t live terribly long, and so far he has only a hint of arthritis in that knee, but really? Taking out his entire meniscus would be the best thing for him? It seems so counter-intuitive. I’ve been told that in addition to its mechanical function in the knee, it is involved in proprioception, so wouldn’t there be consequences to losing that?

    I’m having trouble reconciling myself to getting a TPLO done; not just because of the expense (which is a significant problem), but it just seems barbarically invasive, and I fear complications, including links between corrosion of the plates and osteosarcoma. So I would definitely try conservative management of the CCL, but the meniscus issue throws another wrench in. At the same time I’m having difficulty understanding why it’s so important to intervene surgically on the meniscus. I partially tore my own ACL and my meniscus many years ago and the surgeon did nothing but debride the edges of the meniscus and sent me on my way. It did hurt for 15 or 20 years, but it certainly wasn’t painful enough to do something invasive about it. Maybe the human meniscus is not as rich in pain receptors, maybe the tear wasn’t long enough to require real intervention, maybe anecdotes are irrelevant? 🙂 I don’t know…

    It’s very difficult to know whether advice I’m getting is based on research or just “common wisdom”–many vets just get condescending when you ask what their recommendations are based on exactly. I’m also finding it very difficult to separate emotional concerns from factual concerns. I don’t want to fail to give my dog the best care simply because I’m squeamish and anxious.

    I made an appointment with an orthopedic specialist who’s supposedly on the bleeding edge so I’ll see what he says, but in the meantime, Skeptvet, do you know of research on the meniscus issue?

    Sorry for the long, rambling post. I’m just kind of discouraged about this situation.

  5. skeptvet says:

    Sorry, I’m not specifically aware of a research study that looks at the effects of removing or leaving a torn meiscus. In the absence of good quality scientific evidence, we all too often have to rely on uncontrolled experience. It’s not as ttrustworthy, but decisions have to be made, and we have to make them based on the evidence we have, not the evidence we wish we had.

    I hope things work out for your big guy!

  6. Art says:

    Sorry, I’m not specifically aware of a research study that looks at the effects of removing or leaving a torn meiscus.>>>
    I did a meniscus review about ten years ago and I think a systematic review out of the bmj found surgery did not produce better long term outcomes. Will post the review if I saved it. A lot of the bmj is no longer free to those of us in the USA . If you are watching nba basketball, dwane wade, the last few weeks is blaming his knee problems on a torn meniscus he says should not have been removed in college.

  7. Art says:

    http://www.cochranelibrary.com/CLIB/CLIBINET.EXE?S=0&Q=1022611153&U=ART&A=3&B=0&E=0&R=0&F=&H=&D=1&L=1&N=8&M=8&C=1240&T=CRUCIATE

    Reviewers’ conclusions

    Implications for practice

    The lack of randomised trials means that no conclusions can be drawn on the issue of surgical versus non-surgical treatment of meniscal injuries, nor meniscal tear
    repair versus excision.Compared with total meniscectomy, partial meniscectomy is associated with shorter operating times, a faster recovery, superior post-operative
    functional scores, and better subjective assessment of outcome. No reduction in the incidence of post-operative osteoarthritis has been demonstrated in the short term.
    Though the long term superiority of partial meniscectomy is not established from the results of randomised studies, it is probably appropriate that partial meniscectomy
    remains the more favoured option of the two.There is insufficient evidence available from randomised trials to establish whether arthroscopic surgery is better than open
    surgery. The choice of method depends on a surgeon’s experience and patient preferences with the two methods, but the potential of a skilled application of arthroscopy
    to limit the damage to knee structures and enhance the rate of recovery makes arthroscopy an attractive option.

    *

    Asymptomatic meniscal tears as common as symptomatic onesClinical question

    What is the significance of finding meniscal tears in the evaluation of patients with osteoarthritis of the knee?

    Setting: Outpatient (specialty)

    Study design: Case-control

    Synopsis

    Cool study. The authors recruited 154 patients with symptomatic osteoarthritis and 49 asymptomatic age-matched control patients. All had weight-bearing plain x-rays
    and magnetic resonance imaging. Those with symptomatic osteoarthritis filled out the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index (that
    assesses pain, stiffness and function) and graded their pain on a 100-mm visual analog scale. Unfortunately, the authors don’t tell us if the folks reading the films knew
    whether the films came from symptomatic or asymptomatic patients. Among the control patients, 33 (67%) had fewer tears of the medial meniscus compared with 132
    (86%) of the symptomatic patients (P = .004). However, among symptomatic patients, there was no significant difference in function and pain between those with tears
    (WOMAC score 29 of 96; pain score 34/100) and those without tears (WOMAC score 29 of 96; pain score 31/100).

    Bottom line

    I have been EXTREMELY critical of the research methods used by orthopedic surgeons, so I feel compelled to give kudos to this group; they paid a great deal of
    attention to the principals and rigors of good research design and evidence-based medicine. Meniscal tears are common in patients with symptomatic osteoarthritis of
    the knee AND asymptomatic patients of the same age. In those patients with symptomatic osteoarthritis, the presence of tears is NOT associated with more pain or
    impairment. Unless these patients are complaining of mechanical symptoms or joint line tenderness, magnetic resonance imaging to evaluate for meniscal tears is not
    warranted.

    Level of Evidence

    3b

    Reviewed By

    HB

    Reference

    Bhattacharyya T, Gale D, Dewire P, et al. The clinical importance of meniscal tears demonstrated by magnetic resonance imaging in osteoarthritis of the knee. J Bone
    Joint Surgery (Am) 2003; 85-A:4-9.

    *

    Surgical treatment for meniscal injuries of the knee in adults

    Background and Objectives:

    Injuries to the knee menisci are common and operations to treat them are among the most common procedures performed by orthopaedic surgeons.

    To evaluate the effects of common surgical interventions in the treatment of meniscal injuries of the knee. The four comparisons under test were: a) surgery versus
    conservative treatment, b) partial versus total meniscectomy, c) excision versus repair of meniscal tears, d) surgical access, in particular arthroscopic versus open.

    Source:

    We searched the Cochrane Musculoskeletal Injuries Group specialised register (March 2001), MEDLINE (1966 -1998) and bibliographies of published papers.

    Study Selection: (LOE = 1a)

    All randomised and quasi-randomised trials which involved the above four comparisons or which compared other surgical interventions for the treatment of meniscal
    injury.

    Data Synthesis:

    Three trials, involving 260 patients, which addressed two (partial versus total meniscectomy; surgical access) comparisons were included. Partial meniscectomy may
    allow a slightly enhanced recovery rate as well as a potentially improved overall functional outcome including better knee stability in the long term. It is probably
    associated with a shorter operating time with no apparent difference in early complications or re-operation between partial and total meniscectomy. The long term
    advantage of partial meniscectomy indicated by the absence of symptoms (symptoms or further operation at six years or over: 14/98 versus 22/94; Peto odds ratio 0.55,
    95% confidence interval 0.27 to 1.14) or radiographical outcome was not established. The results available from the only trial comparing arthroscopic with open
    meniscectomy were very limited in terms of patient numbers and length of follow-up. However it is likely that partial meniscectomy via arthroscopy is associated with
    shorter operating times and a quicker recovery.

    Reviewer Conclusion:

    The lack of randomised trials means that no conclusions can be drawn on the issue of surgical versus non-surgical treatment of meniscal injuries, nor meniscal tear
    repair versus excision. In randomised trials so far reported, there is no evidence of difference in radiological or long term clinical outcomes between arthroscopic and
    open meniscal surgery, or between total and partial meniscectomy. Partial meniscectomy seems preferable to the total removal of the meniscus in terms of recovery
    and overall functional outcome in the short term.

    Citation:

    Howell JR, Handoll HHG. Surgical treatment for meniscal injuries of the knee in adults (Cochrane Review). In: The Cochrane Library, Issue 1, 2003. Oxford: Update
    Software.

  8. Diane says:

    Thanks for responding, skeptvet, and thank you, Art, for the journal article info; it is helpful to know about the lack of vet research on the subject and also really helpful to know about the human research to at least give me a clue. I appreciate that you pasted it here because I could not get the link to work.

    I don’t follow basketball but that’s interesting about Dwane Wade. I’m a little shocked that his surgeon was so aggressive as to remove his entire meniscus; intuitively it seems crazy, especially a high-level athlete.

  9. Art says:

    I wish i could read the surgery reports on just what these surgeons are doing when they cut open the knees of our top athletes. I suspect the day will come when all surgery in human medicine is video recorded.

  10. Dog with Torn CCL ACL says:

    My large dog was limping badly so went to the vet, it was a torn acl ccl knee tendon and was told by my vet that the only solution was tplo surgery, tta surgery or tightrope surgery and or removal of the entire meniscus joint padding. I called numerous vets all said surgery only. I researched online to find alternatives to surgery and learned that a dog knee brace does basically the same as surgery for a torn CCL or ACL. Support the knee from the outside without painful complications from surgery. I also learned that there is newer evidence to leave the meniscus pad and not to remove it as it will heal if the knee is supported. Online there are several companies that make several different types of dog knee braces. I ended up trying several, as each one seemed to fit differently. The braces all worked to a point after finally figuring out how to make it fit but had to keep readjusting as the braces kept slipping down or the brace used a tube shaped strap wrapped too tightly on the hock to hold the brace up. Next I tried the posh dog knee brace which had an added lower extension to prevent slipping and an improved anti slipping system that also helped with the slipping problem. The straps worked better too. I have used it for several months and was relieved to see that it works as with the brace on my dog could take longer and longer dog walks, my dog was healing without any complications that can happen from surgery. It was http://www.poshdogkneebrace.com Fortunately I found a safer alternative. I use the dog knee brace with conservative management and supplements like glucosamine, shark cartilage, crushed flax seed, and salmon oil. I use the dog brace for dog walks and activities but take it when laying around. I hate to see other dogs go thru unnecessary surgery when there is a safer way. The healing takes many months whether you go with surgery or a brace. But the brace doesn’t have horrible side effects like infections, bone cancer, corrosion of the implant, amputation of the leg or even worse I read. I would tell anyone try a brace. Surgery is not guaranteed and if it goes badly your dog will suffer in severe pain. Go the safer softer way and try a dog knee brace. If you opt for surgery months later, you can use the brace to protect the knee after surgery. Glad to report my dog has healed well and is happy again.

  11. skeptvet says:

    As you can see from the article and discussion, it is not clear if surgery in general is better than medical management in general. Certainly, it is impossible to predict the specific outcome for any particular dog. That said, the fact that your dog did well without surgery doesn’t prove surgery is unecessary for other dogs or that braces are “basically the same as surgery.” Without controlled research, we have no idea whether your dog got better because of or despite what you did or whether he would be better or worse off had you chosen a TPLO. I can tell you with near certainty that the glucosamine and shark did absolutely nothing. There is some evidence for fish oil, though it is limited, and none for flax seed.

    The porblem with relying on anecdotes like this is that everyone has one, and none of them are really proof of anything. My dog had a TPLO and did great for 10 more years. Does that mean TPLOs are better than medical maangement or that you made the wrong choice? No. But the fact that your dog did well without surgery also doesn’t mean surgery isn’t necessary or that you made the right choice.

  12. Art Malernee Dvm says:

    Do knee braces even work? 800 dollars for “maybe” is a lot of money
    See
    http://familydoctor.org/familydoctor/en/prevention-wellness/exercise-fitness/injury-rehab/knee-bracing-what-works.html

    I noticed knee bandages for dogs compete with the knee braces. We need a vohc for more than dental products.

  13. Toad says:

    Art,
    The studies you quote are human based studies. One must be careful in translating human results to the veterinary field since the biomechanics are very different (ie 4 legs vs 2 legs). There is a good veterinary study looking at meniscal release and removal. It is an area of question within the surgical field and they are not sure of the right answer. Right now I would lean on your surgeon to explain/perform what he/she is most comfortable with. The one real area of agreement is the same as that now seen on the human side >> total meniscal removal ONLY if absolutely necessary

  14. JR Random says:

    My dog a 67lb GSD partially tore her right hind CCL and was diagnosed a week ago, she also has mild hip dysplasia in that hip. My vet talked to me about a TPLO, there is no sign of degradation or remodeling in either joint as of yet. Currently I can’t afford surgery and after seeing pictures am uncomfortable with that surgery. I am considering a brace for support , a custom fitted one. I’m wondering if you have any thoughts on bracing, soft vs hard etc. My goal is to try and prevent arthritis as well as allowing her to be active. She currently does not limp on the leg.

  15. skeptvet says:

    I am skeptical of braces. I’m not aware of any research data on their safety and efficacy, but I do see splints, casts and other kinds of limb appartus as really problematic in dogs. We have to be very aggressive about preventing trauma, skin infectons, and other complications.

    If you have to pursue medical therapy, weight reduction (if your dog is overweight), NSAIDs for pain control, and physical therapy are probably better options.

    Good luck!

  16. Ryan says:

    I was skeptic of braces, too. But I was also skeptical of my vet demanding that surgery for my senior dog was my only option. Is it really? I researched the heck out of my options and thought a brace would be a less expensive, and more importantly a less invasive option for my dog. People also need to remember that surgery isn’t guaranteed. It’s also not a “quick fix”. So long story short, I bought a Wound Wear brace. For my dog, it was a great choice. He didn’t mind wearing it and he started walking normally in a matter of days. It was pretty awesome, if you ask me. Of course, I followed the protocols to a T, and believe me—it’s not a walk in the park and does require lots of patience. However, in the end it was worth it. That’s my two cents 🙂

  17. Art Malernee Dvm says:

    I was skeptic of braces, too.>>>
    Why did you go with a brace over just rehab? If you are skeptical of surgery why aren’t you also skeptical that your dog would have had the same positive outcome without the brace?

  18. Art Malernee Dvm says:

    There is a new cruciate surgery for dogs called Simitri. It looks like a hinge applied surgically to the knee. I have no pictures or non password protected links to post but is another different surgical approach. Word on the street papers have been written but not published. Anyone with a vin.com subscription can find pictures and promotions by the maker of this new surgical technique.

  19. Art says:

    Anyone know why they choose to use only big fat dogs and why they added meniscus surgery to the Cruciate surgery in this study? Isn’t the study really randomizing no surgery to Cruciate and meniscus surgery?
    See
    “Cranial cruciate ligament rupture was confirmed by stifle arthrotomy (n=10) or arthroscopy (n=10). The medial meniscus was found to be intact in thirteen stifles and torn in seven stifles. All torn menisci were treated with a partial medial meniscectomy. Five of the 13 intact menisci were released at the time of surgery. A standard TPLO was performed on the affected limb.”

  20. tom says:

    Many white papers are written to mislead the public for profit. Many scientific studies are paid huge profits to mislead the public. Here is a link to an article about how to turn any lie like tplo surgery, etc into a scientific fact for profit. Pay those researchers and they will write anything on a white paper and then repeat it on the media. Researchers will write whatever they have to to get paid.
    Natural News

    There doesn’t need to be a white paper for an acl ccl posh dog knee brace. I just use common sense, just like most everything you hear and see on TV is a lie to sell chemical prescriptions with white papers that disguise the truth for profit. There are hundreds of knee braces for humans that support the knee so the knee can heal and they avoid surgery.

    The dog knee brace isn’t a maybe. Common sense that if a knee is supported, it can and will heal.

    Surgery is a maybe.

    After reading many comments of those that put their poor dog thru surgery and the vet didn’t warn them about the high risk of failure, severe infections that may cause death, nsaids that can kill without warning, and on and on. Common sense is to select the safest non invasive treatment. The safest with a guarantee of no infection was a acl ccl dog knee brace.
    My very large lab was diagnosed with a torn meniscus with a fully totally torn ccl acl. The vet wanted to sell tplo or tta surgery asap.
    I asked about dog knee braces, and the vet became angry and did not want me to buy a dog knee brace. I told the vet I would research it first and make my own decision. I don’t need a vet to make a decision for me based on his profit. I make a decision based on common sense and what is best for my dog.
    My 14 year old big lab healed in just a few months wearing a acl ccl posh dog kneebrace.
    My vet has seen my dog again and won’t say anything about how well my dog’s knee healed from wearing a dog knee brace but I can see in my vet’s face how amazed he is that my dog has healed so well. But of course he doesn’t want to admit it. I have fired this vet, I just stopped by to show him how well my dog healed but because my vet was dishonest in not telling me about dog knee braces and was not supportive of the safer alternative that I selected, he is obviously not a veterinarian that I can trust.

    The best part of a dog knee brace is getting your dog out walking right away. Dogs that get painful surgery are down for a long time. But with a brace, you start walking your dog with the support of the brace right from the start. With the exercise and the knee supported, the knee starts healing and as the weeks and months go by the knee is healing and is stronger and the dog walks are longer.

    I did not give the nsaids to my dog after research, as nsaids can slow healing, cause severe arthritis, and kill a dog without warning with internal bleeding and severe bleeding ulcers.

    I used numerous natural supplements in articles by real holistic veterinarians that helped better than any dangerous toxic chemical nsaid.

    After this experience I am learning more about holistic care after learning that both the medical industry and the veterinary industry are based totally on profit and covering up safer alternative treatments that really work and are more affordable.

    An honest caring veterinarian tells the patient about all the treatments available including all safer more affordable treatments like an acl ccl dog knee brace for any dog with a torn acl ccl knee. And an honest veterinarian is helpful and supportive if this is the treatment the patient prefers.

  21. skeptvet says:

    You are mistaken about so many things here, it’s hard to easily address them all.

    1. People will say anything for money: To begin with, this is just as true of the people selling knee braces or homeopathy or whatever other “alternative” to conventional treatment is out there, yet people seem to trust one source of information more than another despite both having a financial interest. In any case, you have just blithely dismissed the whole enterprise of scientific research by saying it is unnecessary if we just use common sense and unreliable because of money. If this is true, then all the progress in health and well-being in the last two centuries is an illusion, and I find that ridiculous. Sure, financial bias is a real phenomenon, but it isn’t an excuse o ignore evidence or say it is unnecessary and we can all simply believe whatever seems sensible to us personally.

    2. Braces make sense so they must work: Completely ridiculous. People have been doing what common sense dictates for all of recorded history, with disastrous results in healthcare and many other areas. Just because it feels right to you doesn’t make it true, and that, again, is why we actually do need scientific evidence to help us. And such “common sense” is even less protected against financial and other kinds of bias, so if you reject “white papers” on the basis of such bias, how can you accept mere opinion as if it were somehow more reliable?

    3. ” the vet didn’t warn them about the high risk of failure, severe infections that may cause death, nsaids that can kill without warning, and on and on. ” You are just making this up. You don’t know what vets said or didn’t say to other people about risks, you don’t know that surgical therapy is overwhelmingly successful with serious side effects in less than 5% of cases for the TPLO, you don’t know that NSAIDs are well-established to have far more benefit than harm when properly used, and on and on. You are simply giving your opinion and ideology and labeling it as fact.

    4/ “I did not give the nsaids to my dog after research, as nsaids can slow healing, cause severe arthritis, and kill a dog without warning with internal bleeding and severe bleeding ulcers.” Then you have denied your pet effective pain control on the basis of risks you don’t understand and have overestimated. Fatal ulcers are incredibly rare, there is no evidence that the effect of NSAIDs on healing changes the outcome for dogs with surgically treated cruciate diseases, and NSAIDs DO NOT cause arthritis. I would suggest you make a greater effort to get your facts straight, but again it is clear that you value belief far more than facts.

    5. “I used numerous natural supplements in articles by real holistic veterinarians that helped better than any dangerous toxic chemical nsaid.”
    The you’ve ignored the robust evidence for potential harm from so-called natural products and the widespread lack of evidence of any real benefit for most.

    6. “After this experience I am learning more about holistic care after learning that both the medical industry and the veterinary industry are based totally on profit and covering up safer alternative treatments that really work and are more affordable.” For one thing, those holistic vets make their living by selling the remedies they use, and rely heavily for advertising on telling lies about conventional healthcare, so it’s bizarre to imagine they are somehow purer in their motives or less financially motivated than anyone else.

    All-in-all, your comments simply present your own beliefs and opinions as if they were incontrovertible facts regardless of the absence of evidence or even the strong evidence against them. You are free to believe what you like, but if all you have to offer in support of your belief is “common sense,” and slander against those who disagree with you, there is no reason anyone else needs to take your claims seriously

  22. v.t. says:

    *cough* Natural News *cough* – Conspiracy-laden, factless drivel by a supplement seller.

  23. Myra says:

    My overweight sheltie, weighs 65 pounds but has always weighed that he is really more the size of a border collie, tore his ACL. Have looked at so many sites that I don’t know what to do. Vet suggests surgery. He’s 10 years old and is already having problems getting up-and-down ,had given him a dose of steroids the day before he tore the ACL. X-rays showed minimal hip arthritis. Surgery seems so severe. What would you do if he were your dog.

  24. skeptvet says:

    I would (and did) choose surgery for my dog, but of course that doesn’t mean it’s the right solution for you. I will say that cruciate surgery is a pretty routine procedure with a high success rate, so while it is expensive and there are never any guarantees, it still seems a reasonable choice.

  25. Myra says:

    Which of the surgeries did you have done on your dog?

  26. Art Malernee dvm says:

    SkeptVet’s dog had tplo.A surgery invented and its tools patented by dr slocum, a non boarded veterinarian. Does anyone know how to use the online language translators to see if the vets in Sweden usually cut them?
    See
    http://www.medpagetoday.com/Surgery/Orthopedics/11995

  27. skeptvet says:

    Yes, I had a TPLO done on my dog at age 6, and he functioned well until 16. This is not, of course, evidence for the overall safety and efficacy of the procedure, just an anecdote. However, there is research evidence showing the procedure to be effective and to have minimal complications. The open question is whether dogs managed with non-surgical therapies (physical therapy, braces, rest, etc.) can do as well overall as those managed with surgery, not whether dogs managed with surgery generally do well since this has already been shown.

  28. Art Malernee Dvm says:

    Many respected academic veterinary experts believe that TPLO offers a faster and fuller return of function. But published proof of that theory is lacking, prompting some to avoid the procedure. For instance, surgeons don’t perform it at the University of Pennsylvania School of Veterinary Medicine, says Gail Smith, chairman of the department of clinical research. He calls TPLO “a fashionable procedure.”
    If anyone reading this can review the Swedish literature I would love to know how dog cruciates are treated there.

  29. Mary Margaret Taborek says:

    Interesting reading! It is so difficult to know what to do when before this happens to your pet, you have no prior knowledge whatsoever. We have a 4 yr old, 70 lb lab mix who just tore her CCL. There is a $2000 difference btw the extra capsular repair and the TPLO repair (Ontario, Canada) — this is including the follow up x-rays for TPLO repair. I have read that for an active large breed dog the TPLO is recommended, but also read elsewhere that there is no definitive evidence to recommend one or the other. As for “doing nothing”, I take it arthritis can be a factor in all cases but would be more progressive if you do nothing?

  30. Art Malernee dvm says:

    There is a 1994 human study showing more arthritis in those operated vs treated medically. If that is true or just the opposite in animal I have not seen the study

  31. Mary Margaret says:

    Bad news gets worse…found out other knee does not look good, has inflammation and will likely go. She has also been diagnosed with degenerative bone disease…so if you like, I will give you anecdotal evidence of whether or not “conservative treatment” works as we cannot afford to do both knees to the tune of $10 000, nor does it make sense as she will likely be prone to other injuries and further degeneration down the road. Question though… people are telling me to try glucosamine, fish oil, etc for “stronger bones”. Any truth? So far we are managing with metacam once daily “until finished” and strict activity restriction– leash only, even to pee!

  32. skeptvet says:

    You can look through my previous articles on glucosamine and fish oil. Glucosamine is almost certainly useless. Fish oil may has some small benefit for arthritis, but of course it is not a substitute for NSAIDs, which are the most effective pain relievers for this disease.

    Good luck!

  33. Petrana Nikolov says:

    My 45kg Maremma, yes she is still overweight, we are working on it, tore both cruciate ligaments last April/May or thereabouts. Our vet gave us anti-inflammatories, a monthly cartrophen injection, immediate weight loss measures, (she was 50kg) and we were to have only VERY short slow walks. Along with some nutraceuticals, namely cosequin and liprinol, my girl is now much better. Our vet said given her age (9 yrs) and her size he was uncomfortable with the surgery option due to the failure rates in large dogs.She still has some minor soreness after a longer walk but so far our vet is happy with the outcome and so are we.I hope this more simple approach helps, regards

  34. John says:

    Indianapolis – Thank you SkeptVet for your blog and bringing some rational discourse to the world of old wives tales and urban legends that pet owners encounter when they seek out answers on the animals they love and cherish.

    I have a 100-pound, Lab mix, neutered male, age 5, who blew out his right rear CCL making one of his routine circus catches of a frisbee. He was diagnosed by his vet. He recommended TightRope surgery from another vet 200-miles away.

    Seeking options closer to home, I soon found almost all Indiana vets were extremely dismissive of TightRope, insisting that “evidence showed” TPLO was the ONLY way to go for a Big Dog. And in any event, TPLO was the only technique they offered.

    Seriously confused and hoping to find a less biased, research-based opinion, I crated my dog off to Purdue University’s veterinary facility. Once again, the vet/faculty concurred on the diagnosis, but seemed both dismissive AND even more disheartening, quite unfamiliar with TightRope as a CCL alternative.

    Given little other choice in central Indiana, I plan to hold my breath and go with TPLO followed by ice, heat, restricted activity, followed by short walks, followed by underwater treadmill if I can find one, followed by some balancing exercises and some mild hill or stair climibing. I will pass, however, on all supplements except the same Costco fish oil that I use daily. And I will pass on laser treatments, acupuncture and prolotherapy.

    But assuming that course of action works, I am unsure whether it will be safe to resume our long walks, trail runs (hills galore), his beloved extreme frisbee, jumping into and swimming in anything that remotely resembles water and general dog park rowdiness.

    I would “consult my vet” as owners are always advised, but in my experience, while vets (much like human physicians) know a great deal about injury and disease, they are sadly behind the curve about dog conditioning. What are your thoughts?

    In addition, I would like your opinion on a few other observations I have made in the course of the past few weeks.

    One, as far as I can find there is almost no serious science for the superiority of any CCL technique. And that is what it is. But what is it with all the veterinary attitude I have encountered when I ask for sourced evidence for their own contradictory opinions?

    Two, if neutering leads to CCL, as what little research there is surely seems to indicate, why are pet owners so often bullied – as I was – into just that surgery as a canine variation of political correctness for a dog that is mild tempered and home-loving by nature and not allowed to roam on his own in any case?

    Three, if conventional wisdom, however counterintuitive, is correct and CCL is degenerative rather than traumatic, where then is the research on whatever the root cause may be? And why, just like humans, are the athletes of the dog world (labs, chesapeake bays and golden retrievers, Bernies, german shepherds, ridgebacks, rottweilers and staffordshire terriers) the breeds that are prone to CCL while the athletically challenged (bassets, dachshunds) are “said” (as always, there is a LOT of breed-specific disagreement from “experts”) to be less prone to CCL?

    Four, what should any dog weigh? Really? Why are the fitness standards so subjective? Are the latest beauty standards so anorexic that Newfie’s and Labs must look like Whippets? And if so, won’t Newfie’s and Labs soon swim no better than Whippets? Why don’t vet schools develop some serious breed-specific body fat standards to replace that ancient and childish Purina-sponsored wall chart in their offices?

    Five, follow-up rehab for CCL is preached as gospel in the literature. Yet, in my experience, the surgeons themselves disagree (laser, acupuncture, supplements, special diet, massage, PT, stairs, no stairs, yadda, yadda, yadda) on almost every exercise beyond ice, heat, ROM and 15-minute walks three times a day whatever $1000-plus “rehab packages” they offer over and above the $4000 surgery.

    If rehab IS so important (and instinctively that would seem intuitive) why then is there so little professional knowledge regarding what rehab works, what rehab is risky, and where can pet owners find it? For example, my dog swam like a champion – rivers, creeks, marshes, lakes – but that was rough terrain. Unfortunately, the closest sandy beach that allows dogs is 150 miles away – near Chicago. Worse there are only two underwater treadmills – at $50 per ½ hour and no – zero – swimming pools for pets in central Indiana.

    When I am done, I will have invested enough on my beloved mutt to start a kennel of show dogs. And even then, no matter what course I choose, I will have licensed “professionals” who then insist that I did it all wrong.

    For the sake of owners simply trying to do the right thing, why can’t the veterinary profession get its act together and give us some peace of mind? Please discuss.

    Thank you again for trying to light a few candles to light the darkness.

    Sign me,

    SkeptClient

  35. skeptvet says:

    Lots of good questions. To begin with, thee are lots of studies comparing different surgical techniques. A systematic review published last year evaluated this literature and found some decent evidence for preferring TLO over lateral capsular suturing techniques (including the tightrope), but didn’t find strong evidence to evaluate some other techniques:

    Bergh MS, Sullivan C, Ferrell CL, Troy J, Budsberg SC. Systematic review of surgical treatments for cranial cruciate ligament disease in dogs. J Am Anim Hosp Assoc. 2014 Sep-Oct;50(5):315-21. doi: 10.5326/JAAHA-MS-6356. Epub 2014 Jul 15.

    Surgery for cranial cruciate ligament disease is often recommended; however, it is unclear if one procedure is superior. The aim of this systematic review was to answer the a priori question, “Is there a surgical procedure that will allow a consistent return to normal clinical function in dogs with cranial cruciate ligament disease and is that procedure superior to others?” A systematic literature search was performed through September 2013. Peer reviewed publication in the English language and 6 mo of postoperative follow-up were required. In total, 444 manuscripts were identified and reviewed, and 34 met the inclusion criteria. Two studies provided level 1, 6 provided level 2, 6 provided level 3, and 20 provided level 4 evidence relative to the study question. The most common surgical procedures included tibial plateau leveling osteotomy (TPLO, n = 14), lateral extracapsular suture (n = 13), tibial tuberosity advancement (n = 6). The strength of the evaluated evidence most strongly supports the ability of the TPLO in the ability to return dogs to normal function. It also provided strong support that functional recovery in the intermediate postoperative time period was superior following TPLO compared with lateral extracapsular suture. There was insufficient data to adequately evaluate other surgical procedures.

    What’s missing is good research comparing surgery to specific non-surgical protocols.

    As for post-surgical activity, most studies evaluate lameness and owner satisfaction with function, so I’m not aware of any that specifically look at the risk of failure at the surgical site after full normal healing. My own experience, and the subjective impression I have, is that once healing is complete there is no real reason to restrict activity, and failure of TPLO surgeries long after the procedure are rare. About half of dogs will have an eventual rupture of the opposite CCL, but as I mentioned previously I still think activity restriction to prevent this is not justified. Of course, this is just an opinion, with all the usual limitations.

    As for getting attitude when asking for evidence, this is really shame. I think vets simply aren’t yet adequately familiar with evidence-based medicine and the practical and ethical imperative to have a clear and explicit rationale for their recommendations. We often have only our opinion to offer, in the absence of high-quality evidence, but when that is the case we should simply declare that and accept the uncertainties that come with it. My hope would be that if more owners start asking for evidence, vets will get in the habit of knowing what evidence exists for a specific question and will see it as normal to explain the strengths and weaknesses of this evidence to their clients as part of the consultation. We’re not there yet, but I try to remain hopeful.

    Next, there is some evidence that neutering increases the risk of CCL rupture, at least in some large breeds. I have discussed the risks and benefits of neutering and the associated scientific literature in great detail, and the bottom line is that we have to balance these risks and benefits in individual dogs, considering breed, context temperament, and lots of other factors as well as the evidentiary uncertainty. Neutering is never a simple and easy question with one clear answer, so there is no basis for “bullying” owners into any particular decision. This includes both acting as if neutering were a moral imperative every owner should automatically embrace AND the opposite of acting as if neutering were a crime or death sentence that should never be employed. Reality doesn’t fit such simplistic narratives, even if they are easier to share than the nuanced and uncertain reality. Increased CCL risk is one of many factors that I consider when talking with owners about the pros and cons of neutering their dogs.

    The most consistent risk factor for CCL rupture seems to be size, with larger breeds more commonly represented than smaller breeds. I’m not sure it’s accurate to say “athletic” breeds or “athletically challenged” since that implies something about what differences are relevant that I don’t think has been demonstrated. There are genetic factors involved, since some larger breeds almost never show CCL rupture (e.g. most sighthounds), but size itself appears to be a factor.

    As for optimal weight, the evidence has not yet reached the level seen in humans where specific BMI, body fat scores, etc. can be associated with quantitative differences in disease risk. That said, caloric restriction has been proven to reduce disease and prolong life in every single species studies so far, and it seems very likely that leaner is almost always better barring outright malnutrition.

    Rehab- There is no question physical therapy is an important and effective collection of practices in human medicine. There is also virtually no research on what kind of PT is useful for which conditions in companion animals. The disagreement about specific procedure stems from the near total lack of good evidence on the subject. And as usual, when people have only opinions, they tend to hold to those opinions with far more vehemence than is justified.

  36. Carole says:

    Great info, thanks… I’ve been looking into this very thing (how I stumbled across your blog). Our now 9 yr old Golden had CCL surgery on her left knee 3 years ago (Extracapsular) and did great. Now it’s her right. I’m not as keen on doing surgery if not needed, and certainly would have trouble with the cost.

    Fortunately, I’ve always kept her on the light side. Working as a vet tech for years I didn’t want to have yet another overweight Golden, and as her breeding/breeder were questionable, I’ve erred on the side of caution from the get go. Not that she wouldn’t love the opportunity to become the fattest dog in town, haha.

    She’s about 48 lbs and quite mellow for a Golden, so restricting activity isn’t a big challenge. She’s a very good patient and her recovery from surgery the first time went very well as did the surgery itself and the results. I also work at home, so am around all the time and have a flexible schedule -not to mention with almost 10 years as a vet tech this isn’t my first rodeo, so to speak.

    I’m leaning towards trying conservative treatment, see how it goes. She’s on carprophen and cosequin (which I agree studies point to being pretty much useless, but since it appears harmless and I’ve seen enough dogs in the clinic do better after being on it for months – why not).

    I’m looking for good information because my vet (and former boss) is a very good surgeon with her favorite area being orthopedic surgery, including a love of CCL surgeries in particular. For that reason she’s not really keen on or up to speed with non-surgical treatment, and I want to find a more balanced source of info to compliment hers.

  37. skeptvet says:

    As you can see from the original post, there isn’t much research available to help determine how well non-surgical treatment works and what kind works best. So you likely won’t find too much hard information, just opinion. There are more and more vets working in physical therapy/rehabilitation lately, and if you can find a boarded specialist in this area, they might have some useful suggestions.

    Good luck!

  38. Carole says:

    Yeah, I guess I’m looking more for the “how”, the nuts and bolts, and a vet that has the experience to advise on the best non-surgical protocol going forward. Thanks for the link, I’ll look for a specialist around here!

  39. Art Malernee dvm says:

    I am skeptical of braces. I’m not aware of any research data on their safety and efficacy>>>

    The brace sellers have one rct now on the Internet. Remember the first study showing a positive effect is usually a false positive.

  40. Art Malernee dvm says:

    My bad, it’s retrospective. That really does not add much to the debate.
    The Use of Canine Stifle Orthotics for Cranial Cruciate Ligament Insufficiency
    Brittany Jean Carr, Sherman O Canapp, Stephanie Meilleur, Scott A Christopher, Jeffery Collins, Catherine Cox

    Published: 22/01/2016 in: Articles
    Views 288 HTML: 83 PDF: 59

    Objective: To assess weight bearing of dogs treated for unilateral cranial cruciate ligament insufficiency with a custom stifle orthotic.

    Background: Cranial cruciate ligament (CCL) insufficiency is the most common cause of hind limb lameness in dogs. While there are numerous options for surgical management, surgery is not always an option. Recently, the use of canine stifle orthotics has also emerged as a means to non-surgically manage patients with cranial cruciate ligament insufficiency.

    Evidentiary value: This is a retrospective study of ten dogs treated for unilateral cranial cruciate ligament rupture with a stifle orthotic.

    Methods: Medical records (January 2005- December 2012) of ten dogs treated for unilateral cranial cruciate ligament rupture with a stifle orthotic were reviewed. Temporospatial gait analysis was performed using a pressure sensing walkway at baseline and 90 days or greater post orthotic placement to identify weight bearing with total pressure index % (TPI%).

    Results: TPI% improved significantly by 5.1% in the affected limb when compared to baseline (p = 0.0020). At final gait analysis, TPI% significantly improved by 3% in the affected limb with the orthotic off when compared to the unaffected limb (p = 0.0020).

    Conclusion: Custom canine stifle orthotics allow for improved weight bearing in the affected limb.

    Application: Custom canine stifle orthotics should be considered for cases with concurrent medical conditions or financial constraints that do not allow for surgical intervention.

  41. Marv H says:

    Last year about this time our dog was diagnosed with CCL & TPLO in his left knee. Our vet told us the only option was surgery, so we did it. All in ~ $5000.00. The dog suffered for 6 months and finally healed. Now he’s been diagnosed with the same in his right knee. This time I did some of my own research and found there are alternatives. I’m going to try a knee brace and see how he does. Looks like that will cost ~ $900.00.
    Now I’m researching which is the most promising brace.

  42. art malernee dvm says:

    Gina rocks,
    check out all the letters to the editors with their knee and spine surgery testimonials. I like the patient and doctor testimonials that say they believe in evidence based medicine but know the surgery works because it worked for them. When I did cruciate surgery I removed the meniscus about 20% of the time.
    http://www.nytimes.com/2016/08/04/upshot/the-right-to-know-that-an-operation-is-next-to-useless.html?mabReward=A6&moduleDetail=recommendations-0&action=click&contentCollection=DealBook&region=Footer&module=WhatsNext&version=WhatsNext&contentID=WhatsNext&src=recg&pgtype=article

  43. Tyler Jenne says:

    I still have yet to find anything convincing, for or against regarding extracapsular suture stabilization using “tightrope”. All my correspondence with vets in my city have said it is ineffective with larger dogs over 50lbs but when questioned why Arthrex website contradicts this information, I am told by every one of them, “I am really not familiar with the results of ‘tightrope’ specifically”, but they are quick to dismiss its proposed value as stated by the developers. I am in a position where I am not keen on a TPLO for my dog for various reasons but in the end it may be the only choice. What is bothering me the most is the lack of solid conclusions that ‘tightrope’ using extracapsular suture stabilization will not work for my 85 lb dog when the developers say it will be very sufficient for a dog weighing 113kg (250lbs). Even this page speaks against it yet still no educated evidence of study has stated specifically against it that I have found. Why is ESS being generalized in a way where the product seems to be night and day along with the fact that how the ESS is performed also makes a huge difference. (where holes are drilled as an example stated by a BSO Surgeon)
    *Angle of bone does not play into my case of my dog apparently

    We are going way of brace until I am 100% confident I am being informed without bias.

  44. skeptvet says:

    The challenge, of course, is in finding and critically evaluating the research evidence. While it is not my specialty area, I have looked at the evidence regarding the various surgical procedures available for CCL. TPLO has the most robust evidence showing a high success rate. Extracapsular repairs, including the tightrope, have less evidence to support them, though there is some. Only a couple of studies have compared the procedures, and they are quite problematic. One comparison of TPLO and lateral fabellar suture stabilization showed TPLO to be superior. This was a pretty good quality study with objective outcome measures (force-plate analysis):

    Gordon-Evans WJ, Griffon DJ, Bubb C, Knap KM, et al. Comparison of lateral fabellar suture and tibial plateau leveling osteotomy techniques for treatment of dogs with cranial cruciate ligament disease. J Am Vet Med Assoc. 2013 Sep 1;243(5):675-80. doi: 10.2460/javma.243.5.675.

    There is also a paper comparing TPLO to tightrope specifically, but it was done by the owner of the patent for the tightrope and was a lot less methodologically rigorous.

    In terms of individual surgeon experience, which of course is less reliable than controlled research, most surgeons I have spoken with over the years feel extracapsular repairs, including the tightrope, are less reliable than TPLO, though there are exceptions.

    So I don’t think 100% confidence is going to be possible given the lack of large, high-quality, replicated and conclusive clinical trials comparing the two techniques. This is not unusual in veterinary medicine, and at some point you have to decide whether or not to trust the perspective of a surgeon you are paying for his or her knowledge and skills. If you haven’t consulted a boarded surgical specialist, I would consider doing so.

    Good luck!

  45. Lucy says:

    “As you can see from the original post, there isn’t much research available to help determine how well non-surgical treatment works and what kind works best. ”

    HERE’S ONE:
    Please check in youtube video from Wesley J. Roach, DVM from Nashville Veterinary Specialists giving a talk to students and obviously selling TPLO.

    He mentions (inadvertently I guess…) Wucherer JAVMA 2013 study which gave the following results of the success rate: After 6 months there was a big difference in favour of TPLO but after 12 months:
    TPLO = 75%
    Conservative Management = 65%

    For any half intelligent person the results are a non-brainer, yet this vet (a Professor, I guess….) unbelievably goes on to say that the real benefit is that TPLO “gets them ‘there’ faster” and that in his opinion it is ‘unnaceptable’ for a dog to have to wait 12 months to get better. I find that shocking!!! You can all make your own conclusions as to why he makes no references to the serious risks of TPLO while CM has NONE…

    Well Dr. Wesley J. Roach DVM, I personally prefer to get there at a slower pace and not submit my beloved dog to any potentially fatal procedure.

    After 6 months of CM my 4 y/o Doberman is recuperating very well with no brace and no medication as she’s not in pain. I recently got her a brace, as extra insurance for long hiking walks which she has started to do again. She’s not yet 100% but she’s not in a crate and gets plenty of walks and socialization. The only thing she’s still not allowed to do is chase deer, squirrels and go bonkers. I don’t know when she will be able to do that.

    I recently let her free without a leash in a secured fenced paddock. She went crazy, not having been off lead for six months, and I was bracing myself to see her limping or hopping on three legs next morning and was kicking myself for having been so silly but I was delighted to see only a very minor, hardly noticeable setback. But it’s only been six months and I’m really looking forward to the next six months encouraged by the results of Wucherer JAVMA 2013.

    CM is a leap of faith, it requires a lot of patience and in my dogs’ case she will probably need a life time of carefully managed activities but she’s alive and well and specially happy and I’m happy with my decision not to operate going against ALL the eight vets that saw her . No infections, no drugs, no failed implants, no amputations, no second or third procedures, no death.
    These are not anecdotes I’ve read. My dog lost a best 3 y/o friend to TPLO and I’ve known multiple cases of pain and nasty infections while my dog is sailing away slowly but surely, so I’m very sensitive about this issue.

    In my friend’s case the vet never explained the risks, said surgery was the only way and that if it didn’t get done quickly arthritis would set in… and all the balavah that all of you in this conversation are now familiar with….

    Vets are definitely making a lot of money with TPLO and in my opinion this has clouded their ethics….

    I only say that if a vet doesn’t explain fully all the risks and true success rates based on medical class 1 or class 2 studies and the result is not what was indicated definitely it’s time to call in a solicitor.

    My two cents would be a recommendation for full 6 to 12 months of CM depending on dog’s size and lifestyle. You can always choose to have surgery later. CCL is not an emergency.

    Good luck to you all.

  46. Lucy says:

    Surely the fact that there are not hundreds of studies comparing a) an extremely invasive technique which is providing vast amounts of profit to vets with b) a non invasive technique which makes no money to anybody ie: David vs Goliath speaks volumes in itself. The lack of class 1 / class 2 studies actually answers all the questions.

  47. skeptvet says:

    While I don’t think the evidence is strong enough to make a definitive case that either approach is superior, your interpretation of the Wucherer study as a “no-brainer” for “any half-intelligent person” is a bit of an exaggeration.

    The study evaluated both owners’ subjective assessment of how things went (which, we know from studies of arthritis medications, is subjective to a significant caregiver placebo effect) and an objective measure using a force plate device.

    The subjective measures showed very little difference between groups, with the only statistically significant difference being a very slightly higher rating for the TPLO group at 52 weeks. In this study, it didn’t appear that owners could tell much difference between TPLO and conservative management.

    The objective outcome, while still fairly close, did show more of a difference. From the abstract:

    Surgical treatment group dogs had a higher probability of a successful outcome (67.7%, 92.6%, and 75.0% for 12-, 24-, and 52-week evaluations, respectively) versus nonsurgical treatment group dogs (47.1%, 33.3%, and 63.6% for 12-, 24-, and 52-week evaluations, respectively).

    The TPLO group always had higher scores, and the difference ranged from about 11.4% at 52 weeks to as high as 59% at 24 weeks in favor of the TPLO procedure. From 33-63% of dogs had a successful outcome measure objectively with conservative management, meaning from 1/3 to 2/3 did not have this good a result at any given time. For TPLO, scores ranged from 2/3 of the dogs to nearly all having a successful outcome, depending on the time frame, which does suggest TPLO provided a better result for a fair number of patients.

    So overall, there was not a convincing, consistent difference that would support a strong claim that one method was better, but there was some evidence that TPLO provided a better outcome when evaluated objectively, even though owners didn’t seem to see the difference. And despite your understandable concern about complications from surgery, this study does not support your grim characterization of the safety of the TPLO procedure. Of 20 dogs treated surgically, there were only minor complications in 3 dogs, and no serious or life-threatening problems at all.

    So again, this paper is not a slam dunk for either side of the debate, as you seem to characterize.

  48. skeptvet says:

    Nonsense.

    1. While a financial bias may be present, it is is facile and offensive to claim that all vets care about is money and nobody bothers to study anything unless there’s a buck in it for them.

    2. Conservative management, including braces, physical therapy, supplements, laser treatments, stem cell therapy, and all the rest are at least as profitable as TPLO surgery, so any financial incentive could easily be shifted to conservative management if that were all anyone cared about. I don’t actually do cruciate surgeries, I refer them out. That means I generate more revenue by not recommending the procedure. But if the evidence suggests surgery provides a better result for the patient, you bet I’m going to recommend it because I’m a doctor, not a car salesman, and I care about my patients. Insinuations to the contrary are insulting and vapid.

    3. There are never hundreds of large clinical trials for any intervention in veterinary medicine because we’re the poor cousin of human medicine and such high-level evidence is almost always too expensive to produce. The exception is usually pharmacologic therapies, which of course then leads people to reject that kind of evidence anyway because of the same superficial claim of financial bias you’re making here.

    4. Even if it were as simply and purely greed-driven a situation as you suggest, that doesn’t change the fact that without good evidence, no one has any business making strong claims for or against the treatments we are discussing. You can’t say TPLO is better, conservative management is better, or they are equivalent until you have the evidence to back it up, and whatever the reason for not having this evidence might be, it doesn’t make such claims any more legitimate.

  49. Lucy says:

    Dear Skepvet,

    You respect the Wucherer JAVMA 2013 study sufficiently to mention it in your blog. You describe it as an important piece of evidence but I strongly disagree with your interpretation of said study to your readers.

    “A recent research article has added an important piece of evidence concerning this subject, and while supporting the value of surgery it does weaken somewhat the case against medical treatment for large dogs.” Weaken? Really?

    The results of the study show that after 52 weeks there is an 11% advantage to TPLO over Conservative Management. This makes perfect sense as the scar tissue has to form first and then it has to harden, so we have to allow sufficient time for this to happen. But this 11% advantage to TPLO has not factored- in the risks of TPLO. I am not a statistician but I would have thought that once the risks of TPLO (minor and major) are taken into account at the very minimum this 11% advantage would be wiped out. You did not mention to your readers the risks were not factored-in. You kind of dismissed it by saying “A few minor complications associated with TPLO surgery were reported at rates consistent with those reported in other studies”… “Of 20 dogs treated surgically there were only minor complications in 3 dogs”.
    That represents 15% of dogs.

    Another point you dismissed as “no overall difference” was the difference of 1 dog with damage to the ‘good leg’; but 1dog in 11 is nearly 10%. This means that nearly 10% extra of dogs that had surgery were more likely to have damage in their good leg! That is not “no overall difference”.

    You praise the high score results of TPLO without explaining to your readers a) that scar tissue takes time to form and harden b) that the risks of TPLO were not factored in and c) that in 25% of the cases TPLO failed . For these reasons I do not think you were as clear in your explanation of the study as you could have been.

    I maintain my position that according to this study the choice of treatment is a no-brainer and I do not agree my statement is an exaggeration. What I think is an exaggeration is to cut the bones of the leg to repair a ligament when it is a well-known fact that if left alone, with the correct ratio of restriction, exercise and sufficient time MOST dogs have a very good chance to make a very good recovery. Yet you have to search high and low, at least in the UK, to find a vet that would prescribe, PROPERLY EXPLAIN and monitor Conservative Management or even prescribe a brace so that the insurance could pay for it… not here…

    Dogs die and end up maimed as a result of these surgeries and the public is hungry for clear honest answers that vets (generally speaking) are not giving. I saw no less than EIGHT vets and all eight strongly pushed towards surgery. My Dobberman dog is healing beautifully after seven months of conservative management. I am immensely grateful to Max of Tiggerpoz.com whoever he happens to be.

    Please do not let my words offend you Skepvet. This is a highly controversial subject. We must be able to speak freely without intimidation and your conscience is there to protect you from taking my words personally.

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