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.
I believe cruciate treatment has about a 90 percent favorable result “regardless of the treatment modality” If you xray and find arthritis at the time of tear or have a practice with a lot of big spay and neutered dogs or people that want to play active sports i” believe” that percent favorable results would be lower.
art malernee dvm
see below
CRUCIATE DISEASE: PATHOPHYSIOLOGY AND EXPECTATIONS
Loïc M. Déjardin, DVM, MS, Diplomate ACVS, Michigan State University, East Lansing, Michigan
2002 ACVS Veterinary Symposium Equine and Small Animal Proceedings
Small Animal Seminar
Arthrology Track
Keywords: cruciate ligament, pathophysiology, therapeutic, canine
Cranial cruciate ligament (CCL) rupture is the most common injury to the stifle joint of dogs and is the primary cause of degenerative arthritic changes diagnosed in that joint. As such, CCL injuries constitute one of the preponderant activities of many small animal practices.
With careful treatment selection, management of CCL deficient stifles has yielded 85% to 90% of favorable results regardless of the treatment modality. Further improvement may require implementation of better medical and rehabilitation protocols
I believe this number refers to the outcome regardless of which surgical treatment is used. The only numbers I can find on non-surgical treatment are those referred to above, whcih are considerably poorer for large dogs.
We need to start two columns. One for the other against. What cochrane review did you find saying cruciate surgery helps? Does anyone know Loïc M. Déjardin, DVM, MS, Diplomate ACVS, Michigan State University, East Lansing, Michigan ? My read was any treatment not any surgical treatment gave about ninety percent sucess,
art malernee dvm
see
Operative treatment for anterior cruciate ligament ruptures in adults [protocol]
Linko E, Harilainen A, Malmivaara A, Seitsalo S
This protocol should be cited as: Linko E, Harilainen A, Malmivaara A, Seitsalo S. Operative treatment for anterior cruciate ligament ruptures in adults (Protocol for a Cochrane Review). In: The Cochrane Library, Issue 2, 2002. Oxford: Update Software.
Cover sheet – Background – Methods – References
Background
Each year around one in hundred people suffer a serious knee injury (Kannus 1989). Anterior cruciate ligament (ACL) rupture is the most common cause of acute, traumatic haemarthrosis (bleeding) of the knee, an isolated rupture being found in about 38% of patients with acute knee haemarthrosis (Harilainen 1990).
The ACL is the primary passive restraint to anterior translation of the tibia relative to the femur (Seitz 1996). A rupture of the ACL compromises the stability of the knee in active individuals resulting in chronic instability, recurrent injury, and associated intra-articular pathology (O’Neill 1996). ACL rupture may also lead to changes in lifestyle and disability. Both conservative and operative interventions are used in the treatment of ACL injuries. While operative treatment of ACL lesions in athletes is widely performed, conservative treatment has been considered to have a good outcome in the general population (Casteleyn 1996).
Hey Groves 1917 presented the first report of a procedure to reconstruct torn ACL by using a tethered fascia lata graft through anatomically placed drill holes in the femur and tibia. Surgical techniques include simple repair by suturing or suturing with augmentation, intra- or extra-articular reconstruction, open or arthroscopic operations, use of different kinds of grafts as well as various graft fixation methods. The materials used for ACL replacement can be broadly classified as follows:
1) autogenous (from the patient) or allogenous (for example cadaveric) grafts (for example fascia lata, hamstring tendons and patellar ligament);
2) heterogenous (from different species) grafts (for example lyophilized fascia lata and dura mater);
3) artificial ligaments (for example carbon fibres and dacron) (Franke 1985; Shino 1993).
Despite the growing and widespread use of ACL reconstruction and the many reports of different operative treatment options for the reconstruction of ruptured ACL, the benefit (both efficacy and cost-effectiveness) of ACL reconstruction surgery still needs to be established, as do the relative benefits of the different methods used. This review is being undertaken to look at the evidence from randomised trials for the various surgical options available in an attempt to address these issues. The benefit of ACL reconstruction versus conservative treatment also needs clarification.
Carlos L. Aragon, DVM and Steven C. Budsberg ACL study
Stifle stabilization is a 1 billion dollar per year industry, but yet no method has been carefully investigated!
surgeons are often passionate about the specific technique they use. The most common procedures are TPLO, extra-capsular or intra-capsular. There is a fairly large literature on the subject of surgical technique, but the interesting thing is that most of the papers have almost no evidentiary value! Many are not clinical (e.g.; they are bench science) so that there is no direct relationship between the research and patient outcomes. Other papers have no control groups, artificially induced lameness or very small sample sizes.
When I say critical evaluation I mean of the scientific methodology. For example: Are the reviews of only clinical papers or do they include in vitro work? Randomized blinded trial beat observational studies independent of the subject matter. In human EBM reviews cost about $70,000 and are done mostly by a team that may have only one subject matter expert. The focus of EBM is the patient. The original developers wanted to do better by their patients, so their work has been to develop EBM to bring clinical researcher into the clinics that makes sense.
The Aragon and Budsberg study (below) has a very explicit (and repeatable) search strategy for finding papers. Their initial search netted 240 information sources, and 28 were relevant to the stifle stabilization technique. They used a classification system different and more general than the ADA primary research instrument we described . They focused primarily on the study design to classify studies into evidence categories. That was a reasonable approach in this case, as most of the 28 studies didn’t warrant the more in-depth analysis of the ADA assessment. Their ranking, from best to worst is:
1. Evidence from multiple, RDBCT in the target species
2. Evidence from clinical trials with historical controls
3. Evidence form uncontrolled case series
4. Evidence from expert opinion or physiologic studies.
I suspect that the original intention of the paper was to do a meta analysis, that is, combine results from various studies to come to a conclusion about the best treatment method. However, the studies, by their scale didn’t have much evidence so the goal of the paper was to evaluate the literature to get a summary of what was out there.
There have been discussions by professional about why Stifle treatment research has not been randomized , blinded, large sample sizes, etc and there are those that believe that EBM is not possible due to lake of money to make these studies possible. I don’t think it is $$$. I think that it is an excuse. At least to some degree. There are grants and sources of money; also consumers are educating themselves and will soon demand scientific evidence behind recommendations for treating ACL.. I think the goal of most research in vet med has been “jumping hoops” – finishing a residency or academic advancement rather than quality answering of important clinical questions. It is easier to scan hospital records for a retrospective study than to obtain funding and do a randomized trial. Vets should stop using all the retrospective stuff for clinical decisions. It is really only good for designing larger, better studies. Getting back to the Aragon paper… Aragon and Budsberg found no level 1 or 2 studies in their literature search, and concluded that the use of evidence-based medicine in answering the current question yielded very little data to support any single ACL treatment. Although this doesn’t tell us which ACL treatment to choose; it does tell us there is no scientific support for much of the propaganda that 1 single treatment is far superior to all others. As evidence-based medicine gains in popularity, the level of research expectations will increase producing more studies with evidentiary value. Likely, as the demand increases, more reviews will be published with overall recommendations to help with treatment recommendations on a day to day basis.
*****
Applications of Evidence-Based Medicine: Cranial Cruciate Ligament Injury Repair in the Dog; Carlos L. Aragon, DVM and Steven C. Budsberg, DVM, MS, Diplomate ACVS
Objective: To evaluate the literature reporting surgical interventions pertaining to canine cranial cruciate ligament (CCL) injury using an evidence-based medicine paradigm.
Study Design: Systematic literature review.
Methods: An on-line bibliographic search through Medline, PubMed, Veterinary Information Network, and Commonwealth Agricultural Bureau Abstracts was performed during August 2004. Two hundred and forty resources of information were identified. Studies were compared and evaluated with regard to study design (retrospective, prospective, randomization), surgical technique, short- and long-term follow-up, and evidence classification.
Results: Twenty-eight resources qualified to assist with evidence classification. No class I or class II studies were present, 5 studies were categorized as a class III and 23 studies were categorized as a class IV. Seventeen studies were retrospectively designed and 11 studies were prospectively designed. Proposed results ranged from a wide variety of subjective findings including clinical impression, radiographic analysis, synovial fluid analysis, gross pathology, and histopathology. Objective results, although infrequent, included force plate analysis and cadaveric biomechanical
Conclusions: At this time, the application of evidence-based medicine in analyzing the current available evidence suggests that there is not a single surgical procedure that has enough data to recommend that it can consistently return dogs to normal function after CCL injury. The requirement for assessing and categorizing the available evidence becomes increasingly important as more data becomes available and the quality of research improves.
Clinical Relevance: An evidence-based medicine paradigm did not provide sufficient evidence favoring 1 surgical technique for management of canine CCL injury.
guest
Here is a wsj article promoting 20%.
art malernee dvm
fla lic 1820
“Without surgery, only 20 percent of dogs will regain normal function, says Dr. Michael Conzemius, an Iowa State University veterinary surgeon and a co-author of the November JAVMA article.”
Dogs face epidemic of knee-ligament injuries
Tuesday, April 11, 2006
By Kevin Helliker, The Wall Street Journal
A dog named Paddi was chasing a cat through a suburban Seattle neighborhood when suddenly she pulled up lame. So tender was Paddi’s hind leg that her owner, physician Kevin Bulley, had to carry her home.
The diagnosis turned out to be a ruptured cruciate ligament, an injury that Dr. Bulley, a family practitioner, had associated only with humans. Cruciate ligaments hold in place the parts of the knee, and wrong turns on the athletic field often injure these cords.
The cost of fixing Paddi’s knee was about $3,000. She had barely recovered from that surgery when the cruciate ligament in her other knee ruptured, prompting a second $3,000 procedure — all for a mutt that Dr. Bulley and his family had adopted and grown to love. “She’s the most expensive free dog I’ve ever heard of,” says the physician.
Being an athlete is a well-known risk factor for cruciate-ligament injury. A larger — but lesser-known — risk factor is being a dog. The number of dog knees undergoing cruciate-ligament repair each year in America is estimated to now exceed 1.2 million. That’s about five times the number of human procedures — even though humans outnumber dogs in the U.S. by nearly five to one. And it’s not as though dogs have more knees: The joint on their front legs are elbows that aren’t vulnerable to the problem.
Dog owners often have no idea that this danger exists. Pennsylvania engineer Martin Yester, for example, investigated the medical history of his yellow Labrador, Sarah, before purchasing her as a puppy. Knee risks didn’t come up — until her cruciate ligament ruptured in December. Even though certain larger breeds have been shown to be more susceptible, “nobody talks about knee problems,” says Mr. Yester.
The extraordinary rate of failure in dog knees is mystifying even to veterinarians. Is the prevalence of such canine injuries rising — or are people less willing to let their pets hobble on three legs? “It’s a bit of a mystery as to the cause,” says Steven Budsberg, a veterinary surgeon who is director of clinical research at the University of Georgia College of Veterinary Medicine.
Today, cruciate-ligament repairs are the most common surgical procedures for injured or diseased dogs. And inside veterinary medicine, controversy is raging over the best treatments.
A relatively new technique, called tibial plateau leveling osteotomy, or TPLO, involves breaking and resetting the tibia, the long bone below the knee, in such a way as to obviate the need for a cruciate ligament. The surgery costs from about $2,500 to $5,000 per knee. That’s about twice the cost of the conventional procedure, which like the human equivalent involves constructing a replacement ligament.
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.”
Still, TPLO now is used for an estimated 50 percent of cruciate-ligament procedures in the U.S., and by all accounts that percentage is growing.
Such treatments have helped fuel a doubling of the number of veterinary surgeons in the U.S. in the last decade to 1,219 from 660. It is also the largest factor in a near doubling of the average annual cost of veterinary surgery visits — to $574 in 2004 from $289 in 2000, says the American Pet Products Manufacturers Association.
Like Dr. Bulley, hundreds of thousands of Americans are digging deep into their pockets each year for a surgery most never realized a dog might need. A November article in the Journal of the American Veterinary Medical Association estimated that Americans spent $1.32 billion to fix dog knees in 2003.
Without surgery, only 20 percent of dogs will regain normal function, says Dr. Michael Conzemius, an Iowa State University veterinary surgeon and a co-author of the November JAVMA article.
Even if Americans increasingly consider dogs to be part of the family, health insurers don’t. According to the pet products industry and insurers, fewer than 3 percent of dog owners have purchased a medical policy for their pet.
A spokesman for the largest pet insurer, Veterinary Pet Insurance of Brea, Calif., says that cruciate-ligament problems in dogs accounted for nearly $4 million in claims in 2004, and that no other condition had a higher cost per claim.
One claimant was David Wright, a San Jose software engineer who several years ago bought two Labrador Retriever mixes for $80 each. The male, Sage, tore the cruciate ligaments in both of his knees in 2002. “The $80 dog became the $6,000 dog,” says Mr. Wright.
Then the female, Kenya, wrecked both of her knees. Of the $12,000 that Mr. Wright spent on those surgeries, he says Veterinary Pet Insurance reimbursed him about $5,000. “Thank God I had that insurance,” says Mr. Wright, adding that reimbursement for other, non-knee-related medical expenses already had exceeded the premiums he’d paid.
Unlike human knees, dog knees don’t lock — their back legs are always bent. That means the ligaments of the joint are tense whenever the animal is standing.
This helps explain why canine cruciate tears often occur over time in middle-aged dogs, while human ruptures can happen at any age, and almost always result from an acute twisting or turning of the joint. As in humans, the dog knee contains two cruciate ligaments, and the front-most ligament is likeliest to tear. In humans this is called the anterior ligament, in dogs the cranial ligament.
Few warnings exist for puppy purchasers or dog owners. The Web sites of breeding clubs typically make no mention of cruciate-ligament injuries while offering warnings and advice about screening for hip problems in dogs. The Web site of PetSmart Inc., the nation’s largest retailer of pet supplies and services, offers advice about problematic hips in dogs, but not knees.
Diane Dahm, an orthopedic surgeon at the Mayo Clinic renowned for her knowledge of cruciate-ligament troubles in humans, says she isn’t familiar with similar canine issues. “I’m aware of hip dysplasia in dogs,” she says.
In fact, hips troubles aren’t as common as canine knee problems. But hip problems have received attention in part because of a proven genetic component. Puppy buyers can demand certification of a family history free of hip dysplasia, a debilitating condition in which the ball and socket don’t fit well together.
Some research suggests that cruciate-ligament tears also bear a genetic component. There always had been anecdotal evidence: For instance, Mr. Wright’s two affected dogs are half siblings. An article in the January issue of the Journal of the American Veterinary Medical Association identified a gene that appears to predispose Newfoundlands to cruciate tears. Eventually, this discovery could lead to a test that would identify carriers of that gene, ideally enabling breeders to screen out problematic dogs.
Even now, some doctors say purchasers of puppies belonging to the larger, more at-risk breeds — Labrador Retrievers, German Shepherds and such — should ask about family history of cruciate-ligament disease. “Unfortunately, there’s little you can do at this point except ask about it,” says Dr. Conzemius.
For many pet owners, the thought of spending thousands of dollars on a dog knee remains laughable. “I’d never spend more than $300 on a dog, no matter how much I loved it,” says Roger Holwick, whose eastern Kansas farm is home to eight dogs.
The fastest, an Australian Shepherd, has a bum leg that Mr. Holwick never considered getting fixed. “She rules the roost, and she doesn’t even know she has a disability,” he says.
One more
When I was cutting them I told the owner we needed to stabilize the joint but according to this nyt quote that promotion is questionable.
But in practice, the importance of stability after A.C.L. treatment is “controversial,” The New England Journal study’s authors, Richard Frobell, Ph.D., and Stefan Lohmander, M.D., Ph.D., of Lund University, wrote in their e-mail. In an important 2009 study published in The British Journal of Sports Medicine, researchers retrospectively compared outcomes after 10 years in competitive athletes who had surgery or had opted for conservative treatment of their torn A.C.L.’s. The surgically repaired knees were notably more stable. But they weren’t fundamentally healthier. The surgically reconstructed knees and the conservatively treated joints experienced similar (and high) levels of early onset knee arthritis, a common occurrence after an A.C.L. tear. The treatments were almost identical, too, in terms of whether the athletes could return to sports and whether they reported subsequent knee problems.
Hi Skeptvet!
Well done for addressing Art’s assertions in the previous thread. (Even if he still is banging on about it). It’s one of the major things I like about this blog, you actually engage with readers in the comments.
max
Thanks, Max! I do try to respond since a dialogue is both more interesting and more likely to help me avoid getting lost in the echo chamber of my own opinions.
max, from my review of the literature I suspect suscess may be about the rain dance not the surgery or medical treatment. Here is a 90% non surgical promotion. When you find every thing works you need to question if the body is doing the curing not the surgery or medicine the doctor is charging for.
From: “Dr. Joel F. Spatt”
Date: May 2, 2011 12:02:16 PM EDT
To: “Art Malernee”
Subject: Re: Knee brace
There are no prospective or retrospective studies out yet. However, based on our surveys of veterinarians and people that have used our brace taken in a random but consistant fashion show that about 90% of the dogs do well with the brace meaning that they adapt to the brace and bear more weight on the affected leg. Of this 90% about 75 to 80 % go on to heal and do not require a brace.
Sincerely,
Dr. Joel F. Spatt
—– Original Message —– From: “Art Malernee”
To:
Sent: Sunday, May 01, 2011 7:27 AM
Subject: Knee brace
Can you send me price info and any retrospective or prospective canine studies? Wsj promotion says only 20 percent do ok without surgery. I think that’s bogus
Art Malernee dvm
Fla lic 1820
I have a 36kg labrador. Would a knee brace be suitable for her and where can these be purchased if this was the case
Knee braces have not been shown to be an effective way to manage cruciate ligament disease in dogs. There are problems having to do with the biomechanics of their joints, with keeping a brace on a dog, with avoiding the damage that a brace can do if improperly fitted given that the patient can’t tell us how it feels, and other such issues. I am not aweare of any such device that works for this problem.
Greetings from a concerned pet owner.
I have a 16 year-old female cat (alley cat) who has suffered what a veterinary orthopedist believes is a hind leg ACL rupture, possibly with damage to the other leg as well. X-rays revealed severe arthritis in both hind legs. While the arthritis has, it seems, been there for some time, until the acute injury occurred about two weeks ago, she appeared to be getting around pretty well (difficulty navagating stairs only intermittently, jumping ok, just at lower heights).
Local vet prescribed Buprinex + 1/2ML Prednisolone daily, with advice to keep her moving. Aside from the fact that the Prednilosone seems to irritate her delicate belly, I am leery about long-term steroid use, even at “anti-inflammatory doses.” I also am not at all a fan of the idea that she should spend her days half coherent on opioids. Fundamentally, I question this tack of “conservative medical management” alone.
So, I took her to see a Board Certified orthopedic surgeon, who believed that aside from immediate limitation on activity, surgery was a realistic possibility (unilateral Extracasular Fixation, I believe), notwithstanding her advanced age, boarderline kidney and liver function and bouts with pancreatitis… provided that a detailed Internal Medicine work-up be performed immediately before surgery. Ok, walking away from that consult I felt like surgery would be likely to yield a potentially bright outcome, which attracts me to this option. More than the anesthesia and/or surgery itself, however, after researching it more on the Web, I am quite concerned about the recovery, which I understand is intensive for 12 weeks. I worry that my old girl would have a very tough recovery road. Early in life she was an abandoned stray kitten and I imagine survived by being strong and independent. Of course, the flip side of those wonderful traits is that, even after 15+ years in a life of comfort, she remains strong and independent, has her own mind with no problems expressing it, and voluntary compliance on her part is an issue. She is very intelligent and not easily fooled into compliance either. Thinking about cage confinement, ice packs and hot packs, plus physical therapy, I cannot imagine her permitting such things for any length of time (at least without some sedative).
Alternatively, I have considered Stem Cell Therapy… primarily due to my kitty’s advanced age and apparently somewhat boarderline condition… the assumption being that Stem Cell Therapy would be somewhat less invasive, less recovery intensive, and quicker expected recovery time. Though there seems to be a lot of anecdotal evidence that this is great option, and seems to have had some success in people as well, I am aware that this therapy is considered experimental. Notwithstanding, this option is attractive to me given my kitty’s advanced age and state of being (i.e., “good for her age” but not optimal). So, I contacted the main stem cell company for information, and to see if the therapy is alternatively viable using subcutaneous fat (versus deeply harvested adipose tissue)… which I gather is a possibility for some patients; albeit it is unclear to me whether, assuming that Stem Cell Therapy is a viable option, growing cells from subcutaneous fat is expected to be equally effective vis-a-vis deeply harvested cells.
Otherwise, it is my understanding that “conservative management” (i.e., rest and medical management) is an option, but that given the severity of my kitty’s arthritis, ongoing pain medication would be required for life. Of course any conservative approach not yielding undue harm or pain would be my favorite option. However, it seems that my kitty has very limited options with respect to pain medications – Meloxicam being imprudent, Buprinex yielding a lifetime of half coherent existence, and no other choices except anti-depressant type drugs (which I would not consider given the lack of understanding as to whether and how they work on pain).
I would guess that each option is the best option under a specific set of facts, there being a spectrum of possible scenarios. Just not sure where my kitty lies on this spectrum. Really, I do not know what my best course of action is here.
I want to make sure I fully consider all sides of the options, and consult appropriate experts on both sides of the fence in each instance before making a decision. Most of all, I want to make the best decisions and right choices for my dearly beloved kitty. Time and money are not an issue.
Your thoughts on my options and best course of action would be much appreciated!
M. Elizabeth
Background Info:
Labs: Kitty’s kidney values (e.g., BUN, Creat., Spec. Gravity) are boarderline at the UL. Liver values (ALT) are slightly elevated (+/- 115). Pancreatitis Panel was just barely positive (5.5 with UL 5.4). Other laboratory values are generally normal.
Clinical: Vomiting of bile is not infrequent, and rarely may be punch colored. Vomiting of food occurs, but less frequently. Diarrhea occurs every so often. Appetite is curbed if not fed small meals frequently throughout the day. Stuffy nose is another symptom which results in mild wheezing after eating/drinking. Feline Triaditis may or may not be present, but the condition appears to be managable with frequent meals. Kitty is FIV negative, FeLV negative, and according to the local vet, there is no evidence of FIP. Over the years, one Corona Virus titer was mildly positive, however previous and subsequent titers have all been negative. Also over the years, one Herpes Virus titer (occular swab) was positive, however, all previous and subsequent titers (occular swabs & serology) have been negative. My guess is that some unidentified something is causing these symptoms, perhaps something less run of the mill that exists in a chronic nature. Would love to get to the bottom of it, but a myriad of fancy tests have yielded no answers, and anyway, of first order now is addressing the acute injury.
Naturally, I can’t give you specific advice for your pet without being directly involved in the case as her vet. However, I would point out that all choices come with a mixture of possible risks, possible benefits, and some uncertainty about the outcome. My feeling is that the risks and benefits are better characterized for surgery and conventional management than for stem cell therapy, and an experimental therapy is always more of a roll of the dice than an established one. I would also point out that such therapies in humans are still illegal in the U.S. and not recommended even by researchers trying to develop them because we don’t yet have enough information on safety and effectiveness. The standards for regulation of veterinary procedures are lower, so companies are allowed to sell these therapies for pets, but that itself may not be a good reason to use them.
Overall, I think it is wise to consider all sides, and I don’t think any of the options would be completely unreasonable. Myself, I would probably either elect surgery or conservative medical management depending on how severely affected I felt my cat’s quality of life was. I would probably only elect stem cell therapy if it were clear that other, better known options were not possible or not likley to help, but that is a personal decision.
Best of luck.
M. Elizabeth,
For what it’s worth, the buprenex dose may need to be lowered, by as much as half. Speaking from experience with many cats, the textbook dose may leave a cat mildly or severely sedated. Ask the vet if you can lower or half the dose, you might see much better results.
I would be cautious of any long term use of metacam, although some vets are comfortable with long term use in specific situations, if I recall, the manufacturer does not suggest it for senior cats, and especially for kidney or liver impaired cats.
Dealing with chronic pancreatitis can be tough, and each cat has different medical needs. The pred you’re currently using is probably helpful, but I agree, it’s a tough decision to continue long term – you have to weigh the benefits with the negatives. With the ligament problems now, the pred might be helping with inflammation in both cases, which in some aspect, helps to reduce the pain (but ultimately, an appropriate pain medication should be considered for long-term use if necessary).
I realize this may not be the answer you’re seeking (you have some tough decisions, for sure), but when I’m in a serious predicament, I ask my vets what they would do if this were their own cat, I am always confident in their response, and I take their opinions very seriously in my considerations, usually opting for their recommendations. It doesn’t hurt to ask, if you are confident in their abilities, experience, etc.
Here’s wishing you luck and I hope your kitty improves significantly. Please remember that cats generally self-limit their own activity after a major orthopedic surgery. With appropriate pain medication, following home care instructions, and having your vet monitor her progress (or answer your questions), you may have a bit less to worry about.
Thank you very much for your informative replies!
Skeptvet,
Your dismissal of the use of activity restriction in non-surgical recovery is unreasonable. “… 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. …” Activity restriction is absolutely necessary for recovery, whether or not surgery is done. Certainly activity restriction can be difficult with young active dogs, but it is very often successfully used, as are physical therapy and braces.
Do you take this same approach in your recommendations to clients for TPLO postop recovery? Do you tell them that exercise restriction is “…challenging and not often used …”? Of course not.
Many of your other statements also show a failure to be objective in looking into the effectiveness of non-surgical treatment. You are quick to accept any pro-surgery claims or evidence however clouded, and to dismiss any indications that non-surgical treatment is a viable option.
I believe that you are failing to be an objective judge of the question. In your blog entry you are an advocate for a near-universal surgical approach to dog CCL dysfunction while pretending to objectively consider the question of non-surgical treatment’s effectiveness.
Regards,
Max tiggerpoz.com
I think you have overinterpreted my statement. I said exercise restriction, along with physical therapy and some external support such as a brace, were challenging (which I believe is true) and not often used (which I also believe is the case as surgery is the most common treatment for this condition). This is not a “dismissal” of conservative treatment. My conclusion is simply that for small dogs conservative treatment may lead to adequate comfort and function but for large dogs are very likely to develop significant arthritis and dysfunction without surgery. You haven’t presented any evidence to the contrary.
As for objectivity, while everyone has potential bias I think it’s a bit silly to sy that I advocate surgery out of some kind of personal bias. Cases that are treted surgically I have to refer away to a specialist. If I were to recommend conservative medical treatment, I would keep those patients. So what bias is it that would lead me to recommend surgery depsite evidence (which, as I said, you haven’t offered) that it is isn’t necessary?
In discussing non-surgical recovery from dogs’ CCL dysfunction, an immediate problem arises in defining what is meant by “Conservative Management /Treatment”. In the literature, when CM is referred to at all the author almost invariably means an ill-defined brief period of lessened exercise which is followed by a return to normal pre-injury levels of activity after a few weeks. I agree that this is not an effective treatment method. Let me use an analogy here to make a point: What if we had never thought of using casting for broken bones. Someone comes up with the idea of putting a cast on a broken bone. He has had success with casting but he does not make the details of his method clear to the medical community in his reports. So docs try out casting using their own guesses about how it should be done. Many assume that 3-4 weeks in the cast should be sufficient, so they remove casts after 3-4 weeks. The bones easily re-break, and the docs conclude that casting just doesn’t work. Their reports and studies state that casting has been tried and it doesn’t work at all well. The problem is not that casting doesn’t work. The problem is that the method was not properly defined / implemented.
—- With dogs’ attempted CM recoveries, failure is very often the result of a similar mistake. The failures are not the result of an inability of the dogs’ bodies to restore stability if the right conditions were to be imposed for sufficient time periods. The vast majority of failures are the result of too short a period of activity restriction and too quick and sudden return to pre-injury activity levels. My website tiggerpoz.com has detailed suggestions for non-surgical recovery and recommendations for how and when to decide that surgical intervention is appropriate, so I will refer you there rather than go much further into detail about what I am confident constitutes proper CM treatment.
—– I think the Aragon review of the literature is convincing in its conclusion “…Conclusions: At this time, the application of evidence-based medicine in analyzing the current available evidence suggests that there is not a single surgical procedure that has enough data to recommend that it can consistently return dogs to normal function after CCL injury. …”and we can all agree there is no Class I or II research to indicate that any surgical treatment method is preferable. This leaves us with lower quality studies comparing surgical options and no studies including what I would consider properly done CM. However there are many reports of successful CM recoveries in dogs of all sizes from dog owners and vets who advocate CM. Is the correct decision in this situation that we should exclude CM as an option and that surgery should be preferred simply because the lower quality studies that exist do not include CM? Of course it would be preferable to have good research that included CM, but that is not available. But we can make a choice which I think provides a way to prevent further significant degradation of the joint while determining whether the patient has the capacity to re-stabilize the joint without surgical intervention. At the point in time where ACL dysfunction is diagnosed, why rush to the OR? All surgery has risk, and if you believe surgeons’ self-reported results for CCL procedure long-term results then I have a bridge I want to sell you. The flat truth is that there is no surgery which has great results overall and the objective studies confirm that. So when considering CM versus surgery we are not looking at a potential alternative to a group of wonderful highly successful procedures that bring dogs back to pre-injury condition. All the surgical alternatives leave much to be desired. If we can avoid surgery with CM and have good results with CM, we should do that. The best approach imo is to first try properly done CM. Careful activity control will prevent further damage to the joint so that if re-stabilization is not progressing after 8 weeks of properly done CM it will be possible to reconsider surgery with no significant degradation of the joint because of the delay.
—- As to reported greater arthritic changes when surgery is not part of treatment, this conclusion relies on incorrectly considering no-restriction of activity or inadequate restriction as being CM. When properly restricted with only the appropriate gradual increases in activity over an extended period, the joint is not repeatedly re-injured by excessive stresses before it has re-stabilized, and so the degree of future arthritic changes are similar to what should be expected when surgical stabilization was part of treatment.
—- I agree that there is no solid research showing CM to be effective or preferable. But this lack of proof is not proof of a lack of effectiveness. My recommendation is to first try CM as described at my website for 8 weeks (rather than the too-short period of activity reduction we all agree doesn’t work well). Use this 8 week restriction as a diagnostic tool to determine whether the dog begins to stabilize the joint in that time. If not, proceed to surgery. If the dog does begin to improve in that time, continue cautious restriction with gradual activity increases. And swimming as therapy if at all possible. In my experience most dogs do show that they are able to stabilize the joint without surgical intervention. Activity restriction protects the joints from further injury during the 8 weeks whether or not surgery ultimately turns out to be appropriate.
—– These injuries are not emergencies. Referring the dog for surgery when first diagnosed is generally not the best choice for the patient, especially if the ortho has a boat payment due. Restricting activity properly and reconsidering the situation in 8 weeks is a reasonable approach. Most dogs show clear improvement at 8 weeks and go on to have fine non-surgical recoveries.
You wrote “… As for objectivity, while everyone has potential bias I think it’s a bit silly to sy that I advocate surgery out of some kind of personal bias.…”
I did not say that. I said that in my opinion you were failing to be objective in your consideration of CM as a treatment option. I did not attribute that perceived lack of objectivity to personal bias. I did not presume to state a cause for what I judged to be a lack of objectivity. Imo your objectivity was flawed because you were not sufficiently skeptical in your examination of the literature. Too easily accepting of others’ stated conclusions and implied conclusions– surgery advocates’ conclusions/ implied conclusions– in their articles without considering their possible biases and the processes that led to their conclusions. Eg, you did not look at all deeply into the question of what constitutes CM although that should have been important to your blog’s subject. In the literature CM is commonly treated by surgeons in an offhand manner indicating it is of little interest to the authors who are often concerned with comparing surgeries against other surgeries. You came to their articles with CM as your subject, and imo should have been less accepting of their inclination to assume CM is basically non-treatment and undeserving of detailed examination.
Regards,
Max tiggerpoz.com
The possibility that conservative management has failed to be shown to be effective because it hasn’t been properly applied is certainly plausible. However, the problem is that the standard response when one is convinced a therapy works and clinical rials fail to support this belief is to look for a flaw in how the intervention was applied or tested. Such a flaw may very well exist, but this is only a hypothesis, and the burden is then on the person making it to support it with controlled research data. The same arguments are routinely made for all kinds of far less plausible therapies (homeopathy, psychic powers, etc), so while it is an appropriate possibility to raise, by itself it doesn’t settle anything. It simply provides a otential explanation for the data that then needs to be properly tested.
As for the decision to have surgery done or to try conservative management first, I agree that there is no ironclad high level evidence to justify one course over the other. We routinely have to make such decisions in an imperfect world with imperfect data. I find the limited data that exists, my own clinical experiences, and other factors lead me to believe that surgery is the more prudent course. I am perfectly open to being shown this is not true, but the basis on which you are arguing for the alternative is no stronger than the eveidence supporting my own position. It is an area in which reasonable people can disagree, and clearly we do (though I still think you are characterizing my preference for surgery and resistance to CM far more strongly than I have actually stated it. It is, like all beliefs in science, a provisional conclusion based on the information currently available and always subject to revision as better data are generated).
I also wonder about the practicaility of the approach you propose. The exercise restriction that follows a TPLO, for example, is by far the hardest part of the whole treatment process for clients, and compliance is variable at best, often poor. People who choose not to have surgery in my experience (which is thoroughly uncontrolled, as is everyone else’s) do so partly because they feel they can’t manage the severe activity restriction necessary in the post-op period. I wonder how likely people are to be able to comply with the aggressive CM you advocate? If a therapy is too difficult for most owners to employ, it matters little whether or not it works since it won’t get used.
Sorry if I overinterpreted you concern about my “objectivity.” I am routinely acused of a priori bias, and it’s difficult for me to see the distinction you are making between poor objectivity and bias. Perhaps what you mean is more that I was not adequately thorough in my research? Obviously, my inquiry was a pragmatic exercise in reading and interpreting the primary and secondary literature available to answer a specific clinical question as a practitioner. It was not an attempt to execute a systematic review or other formal evidence appraisal on my own. I don’t have the impression your conclusion is based on anything more objective than mine. You have reviewed the literature and come away with a sense that it does not effectively negate your hypothesis that CM is as good or better than surgery, a hypothesis that presumably has come from your clinical experience and the theoretical considerations and reading you have listed. Similarly, I have reviewed the literature and come to the conclusion that it does not effectively demonstrate CM as equal to or superior to surgical management. Again, I think reasonable people can disagree here, but I’m not sure it’s a question of objectivity so much as different interpretations of limited evidence informed by different perspectives and experiences.
Thanks for the interesting discussion!
From tiggerpoz’ website:
“The tiggerpoz website is provided anonymously, pro bono, as a source of information about dog stifle ACL / CCL ligament injuries. Remaining anonymous makes it possible to function more effectively in working toward a less profit-focused approach to medical treatment.”
And, you accuse veterinarians, and ortho surgeons of being profit-driven with huge expensive *unnecessary* surgeries. And people should believe your anecdotal reports and advice…because, why?
Granted, for every pet, there is an individual situation and individual medical need, whether surgery or conservative management. It’s more than just the surgery that has to be taken into account. I realize you addressed some of those things on your website, but might you also have some bias against vets and especially ortho surgeons?
skeptvet,
Your comment about clients’ failure to comply with activity restriction recommendations is a valid point. This is a problem with non-surgical recovery as well as post-op. A big problem. I think many vets fail to empathize the importance of activity restriction as strongly as they could. But regardless of how well this is explained there will doubtless be numbers of clients who fail to restrict properly.
v.t.,
You wrote: “… might you also have some bias against vets and especially ortho surgeons?…”
—- There are many honest, trustworthy, and highly competent vets including many ortho specialists. But not all vets are honest and competent. If our mission is to help animals rather than to defend all members of the profession whether right or wrong, then it is not appropriate to close our eyes to the possibility that docs could be influenced by greed or other common human failings.
Regards,
Max
tiggerpoz.com
Max, I would agree to that statement, depending on who you’re accusing of greed (or human failings, as you put it).
I’m hoping in your reading you might be able to point me to some information. I have a dog with a ruptured ACL, she weighs just over 40 pounds, she also has chrondrodysplasia, where her bones are bowed rather like a Cardigan Corgi without being nearly so short. She is a mixed breed dog, so I’ve no real idea how she came to this conformation. The ACL injury occurred when she was alone with another dog in the front yard, she may have had a tussle that injured it or she may have just moved wrong. I’m wondering if her funny conformation makes her likely to damage the other ACL, is there any data showing that dogs with chrondrodysplasia are more prone to these types of injuries? It seems to me that this may be the case, since the physics of the leg would be different with bowing of the bones, however so far I’ve not been able to turn up any actual data. The other question I have has to do with size, is there any reason that 30 pounds was the cutoff for dogs who do better without surgical treatment? This seems sort of arbitrary to me, did the authors of the study show any correlation between other size variance and outcome?
Breed is certainly a factor influencing the risk of CCL rupture, and chondrodysplasia has some implications for surgical repair, but I’m not sure the extent to which chondrodysplasia affects risk. A bit beyond my level of knowledge on the subject.
The 15kg cutoff is arbitrary in the sense that all cutoff values are when looking at a continuous distribution. I believe it was chosen because it seemd to most effectively predict outcome with or without surgical therapy, but of course it can only be a general guidelines, not a precise indicator of prognosis in a specific dog. Sorry that I couldnt’ be more help. You might consult with a surgical specialist or the nearest veterinary school orthopedics department.
Thank you for your response, I’m in contact with the right vets, I was just trying to educate myself a bit since I want the best possible outcome and I like your skeptical POV.
interesting debate.it must be as frustrating for people in vet work as to pet owners that there is very little data on success rates for different procedures. Im in the uk with a 6 year old lab. After walking him to vets, about half mile, for annual booster and check up he was a bit lame after several weeks took him back and she said it was pretty certain torn knee ligament because of the movement in the joint of which the test caused him to have extreme lack of use of the leg and suggested an operation to put a band arond the joint to stop the excessive movement. after a week of no walking and frantically searching the net as i dont have £ 1200 for the op I found a site advocating possible cm for bigger dogs and by then he was standing on it again so tried him on a small 130 yd walk 3 times a week then after a month every night. After 4 months the leg appears to walk normal and so add an extra 100 yds. After two more months add an extra 300 yds. Everything is fine then starts limping on other leg. Due to the evidence that the cat food bowls are on the floor hes strained his knees getting up to the table to get at the cat food. Previuosly he used to pull the tablecloth down to get it. Been to a different vet and she says it ligament damage to the knee. Trouble is they are both now kaput and the new vet said about £ 300 to 400 pound a knee then came back saying £ 900 each and should go for x ray too. So I’m back reading up . my conclusion is that the data is out there as hundreds , thousands of operations have been done and the records are sitting there in each vet surgery. Due to the world economic crisis its not about paying the yaught bill theres a strange undertone of paying just to keep the vet surgery going. My option is cant afford ops and they probably work well now but will have to find cheaper option and try braces.
Interesting information and debate.
I have a 7 yr old very active 60lb, yellow lab who has shown stifle instability contra-laterally now for almost 1 1/2 years. Xrays have not been done but tests have been performed to estimate the level of tear. One knee seems significantly more lame than the other but the “drawer” test has only shown partial movement – both are still fairly stable. I am only delaying surgery because of the lengthy recovery period. With having 2 active dogs in the house and this lab being on the higher energy scale (of labs), it will be a difficult time to restrict her activity post-surgery.
My question though really comes down to what surgery to go with. I’m not keen on TPLO, not because of the cost, but because of cutting bone. I have also heard that the potential for meniscus damage can increase post TPLO or TTA. That concerns me. I am looking more at some ‘older’ methods of repair that have shown good results (fish line etc). Any opinion on this? Is it still true that Univ of Penn Vet School/Hospital is still not performing TPLO and, if so, do you know which surgery they are performing?
Thanks for the great information!
I’m afraid I don’t have an answer to your questions. I know that folks in the orthopedic department at UPenn have stated, correctly as far as I can tell, that there is not clear evidence the TPLO procedure is superior to other surgical procedures, but I’m not sure if the TPLO is performed at Penn or not. As for the relatove merits of the various procedures, I think individual surgeons have preferences based on theoretical cnsiderations, personal experience, and limited research evidence, but a clear superiority of one technique over the others has not been demonstrated.
I don’t perform any of these procedures myself, so I can’t offer much personal perspective, which wouldn’t be worth a lot anyway. 🙂
After having the fishing line surgery done on my English pointer 7 years ago and observing my sister’s dog and a friends dog go through the same surgeries, the surgeries were preformed by 3 different vets. The dogs never regained “normal” range of motion and all three ended up with substantial arthritis in the joint. Don’t know if the dogs ended up with a closer to normal range of motion and put off debilitating arthritis for a year or two, but it seems like the dogs ended up with the conditions that were described if surgery wasn’t done. Makes me wonder what what the dogs gained. This is where I would like to see more scientific data, seems like simple research observe the dogs where owners opt not to have the surgery vs the ones that do.
Although the author evaluated the results of surgery vs no surgery I did not see any mention of the use of prolotherapy for treating dogs with torn cruciates. I would like pet owners to know that prolotherapy is a viable third alternative to surgery or no surgery and in my hands it has been extremely effective. I have been performing proliferative therapy (prolotherapy) on both small and large breeds of dogs with torn cruciates for 10 years and would estimate it to be at least 80% effective in significantly reducing lameness and enhancing the quality of the pets life. Cold laser therapy can be used with prolotherapy to hasten the formation of fibrosis and the relief of pain. For those who have never heard of prolotherapy it involves injecting a specially prepared solution around and into the affected joint. Repeated injections are given every three weeks for approximately 5 visits. The injections are given under either sedation or light anesthetic. What prolotherapy does is stimulate fibrosis and the thickening of the joint capsule and other supporting ligaments around the damaged joint. Over a period of time the newly formed fibrosis contracts and tightens the joint. The procedures is very safe in experienced hands. Prolotherapy was orginally developed for use on humans and was first introduced in the mid 1950’s. For more information on prolotherapy visit either of my websites: myholisticpetvet.com or doc4pets.com .
To find out about prolotherapy for humans visit “caringmedical.com”.
And I encourage readers to read about the lack of convicining evidence for prolotherapy here: http://skeptvet.com/Blog/2011/07/prolotherapy-for-dogs-and-cats/
Bottom Line
Prolotherapy is a purported treatment for connective tissue and joint pain and disability. It involves injecting substances which induce inflammation and other chemical and cellular reactions into affected tissues. These reactions are theorized to relieve pain and improve function. The logic of this theory is questionable, and no clear mechanism for beneficial effects from prolotherapy has been described, but it is possible that the theory could be valid.
The clinical research on prolotherapy in humans is generally of low quality and results have been mixed. There is great variation in the techniques used by different investigators, so it is difficult to compare or generalize between studies.
There is virtually no controlled research investigating prolotherapy in companion animals, and all claims made for safety and efficacy in these species are based solely on anecdotal evidence.
The use of proltherapy in pets should be viewed as experimental with unknown risks and benefits. Such treatments should be reserved for patients that have significant symptoms that have failed to respond or cannot be treated by conventional means.
Hmmm, looks like someone took an opportunity to spam your blog, Skeptvet.
About 3.5 years ago my then two year old female hound/bully breed (MAYA) weighing about 60lb came up lame after a wild romp at the beach. I had never heard of canine ACL disease before that day. About a month later I found a surgeon who would put Maya right again. However, as I was still far too undereducated on the subject and determined not to put her through the trauma of surgery I decided to try conservative management. So we spent the next year swimming, swimming, swimming to tire her out enough that she wouldn’t object to resting in her crate as much as possible when home. It was tiring and labor intensive. The year was full of 3 steps forward 2 steps back until finally she seemed what looked to me like good as new and boy was I relieved. But not for long. One day I noticed her standing at the top of the stairs with the familiar look of a dog in pain, holding her leg off the floor almost entirely so that the toes barely touched. it must have really hurt, poor girl. But there was an interesting surprise. The offending leg was the wrong one, the originally injured leg was now being used as the stabilizer and I was a little in shock.
During the year spent rehabbing maya’s leg I had been reading everything I could get my hands on regarding canine cruciate tears. Armed with a little knowledge I finally agreed to having her undergo TPLO surgery. Her surgeon is fabulous and about one year post op we’d built up maya’s ability to do some pretty big hikes, often ten miles and once we went 22 miles. My hiking buddy happens to be a vet which helped my anxiety over letting her put her leg to the test but now I call her a poster child for TPLO surgery.
As luck would have it, my second dog (COOKIE), an 80lb boxer/pitbull mix just two years old has recently been diagnosed with displaysia and osteoarthritis to varying degrees in her all four hips AND elbows, good grief. Though so far, she doesn’t seem to be experiencing pain other than in her front left elbow and as a starting point, she will undergo exploratory surgery later this month. I mention this because I am using the same surgeon who performed Maya’s TPLO surgery a few years earlier. He asked me if I’d had Maya’s other leg done, he had no way to know I would never use any other surgeon. Anyhow, he was frankly stymied to hear Maya continued sound in all four legs and I should not have been secretly proud about it.
One day, very shortly thereafter I’d just come home after an easy walk with both dogs. Maya came up lame for no apparent reason, holding her leg off the floor, this time the original leg apparently reinjured and I felt so guilty. I haven’t had the chance to tell her surgeon yet but he’ll hear about it soon enough.
As for me I will be spending a lot of time in 2013 doing everything possible to get my dogs on all fours and as pain free as possible. The moral to the story I guess would be that it seems conservative management has it’s place, but I now believe if a dog is at all active and has a long life yet to live, surgery gives the dog the best chance at being the happiest dog he can be for the rest of his/her life so back to Dr. Serdy we (all) go, oh boy!
Thanks for your blog and particularly this post. I am an emergency physician who tries to practice as much evidence based medicine as possible. I’ve got a Cocker-Havanese with both CCLs injured – apparently common with hypothyroidism?, though I haven’t seen much evidence of that. Nice to read your opinions on the surgery.
Glad the information was helpful. There are, unfortunately, a lot of areas of significant uncertainty or gaps in the evidence in veterinary medicine, but a least knowing that frees us a bit from dogma, even if it doesn’t always allow us to identify a single “right” answer to every clinical question.
I have a 9-year-old Aussie, male, tall, 70 lbs. He came up lame on his right leg recently, quite suddenly. I did not take him to the vet right off, preferring to see how it would go. I came home from work the next night and he was trembling all over, his entire body. I took him in to the vet. There was a substitute vet there; I’d never seen him before. He gave Figgy a cursory exam and pronounced it to be arthritis, the trembling was from pain. Prescribed tramidol, 2 a day. The next night he was trembling again. Vet increased to 3 a day.
Over that weekend, however, it occurred to me how unsatisfactory the vet’s exam was. I bring a dog in for trembling and he does not check his eyes, his heart, his temperature. So I called the vet back, the owner, the one we normally see, and he agreed to do a re-exam. This time a thorough check was done and the diagnosis was a partial tear of ACL, right leg. The first recommendation was conservative treatment and see how it goes. I asked about an x-ray and was told that since you can’t see the ligament on film, an x-ray isn’t needed. We went to a surgeon anyway, to confirm the diagnosis. This vet said, yes the right leg, and oh the left leg a bit now, too. (Alarm bells go off.) Again, no x-rays, not necessary. Right leg surgery, $5000. I put it off for now.
For the next 10 days, I put myself through the wringer as I tried to decide what to do. My heart said conservative, the information I read for the most part said surgery. I had not yet been able to visit Canine Wellness, a well-known reputed canine physio/rehab clinic here in Toronto. In the meantime, Figgy’s activity was severely curtailed and meds continued (we were now also taking meloxicam). The limp quickly disappeared but the drugs zapped him out, especially the painkiller.
Having finally decided on surgery — God knows how I got there, to be truthful — I went to see another surgeon at another hospital who also happened to be cheaper (even though I have insurance).
We’re scheduled for 11 a.m. We walk in and the vet, to whom I had already sent all existing medical reports, asked if x-rays were done. He wanted them. He called me, with Figgy there in the cage waiting. He tells me that if there was an ACL, yes, the ligament doesn’t show, but there would be evidence of inflammation around the joint. There wasn’t. In fact both knees showed fine. Both patellas, fine. All appear normal. In fact, virtually all is normal except for some possible problems in the lower back, of which he had also done an x-ray. His letter follows:
______
Figgy Vulpe was referred as a second opinion of a bilateral pelvic limb lameness previously diagnosed as bilateral cranial cruciate ligament injury on Nov. 22, 2012. On presentation the owner described Figgy’s symptoms as trembling, perhaps due to pain, and to intermittent hopping of carrying of one of the pelvic limbs. Figgy was treated with tramadol and meloxicam which seemed to eliminate the trembling and reduce the gait problems. On physical exam Figgy was short strided in both pelvic limbs but had no detectable limp. I could not elicit cranial drawer or cranial tibial thrust from either stifle. There may have been some periarticular fibrosis around the right stifle but it was minimal. Postural reflexes were normal and no pain was elicited on deep lumbosacral palpation.
Lateral radiographic views could be taken without sedation to investigate stifle and or obvious lumbosacral changes. The owner agreed to that strategy. The lateral views revealed no obvious effusion or osteoarthritic change in either stifle. There may be some endplate sclerosis in the lower lumbar spine but this study is not diagnostic for lumbosacral problems. The radiographic images were sent to a radiologist for additional interpretation.
I don’t believe there is sufficient evidence to pursue stifle surgery at this time. My recommendation to the owner is to discontinue medication and restrict exercise to 20-30 minute leash walks. I recommend a recheck evaluation in 2 weeks, sooner if Figgy’s symptoms worsen. Recommendations may change with the radiologist’s interpretation.
_____
So, Figgy, sitting there still in the cage is given a reprieve by the Governor. What a relief. But really, I remain unsettled. Four veterinarians, three diagnoses. Only one seemingly honest enough to say “I don’t think there’s a problem.” Does that mean I am going to have to go for multiple second opinions every time?
For now, we are going to Canine Wellness anyway, where we will do some hydrotherapy, weight loss and general conditioning. If there is a problem brewing, perhaps this will put us ahead of the game. But it certainly cannot do harm. Thankfully, my insurance covers a portion of this.
My conclusion(s)?
1. Buy pet insurance. You will never recoup your premiums but it’s nonetheless worthwhile. Its value, however, is limited by your commitment to making decisions that are right for the dog not just because you can now afford it. (e.g., I would never put my dog through chemotherapy).
2. Question the vet, again and again. And again.
3. Listen to your gut.
4. Question why so many of these surgeries are being done? Over-diagnosis? Profit? Owners wanting perfect dogs that live to 15? What?
I’m still not sure where I sit in all of that but I do know I will think twice before I throw my dog into the O.R. The dog will not develop debilitating arthritis in 8 weeks while I try the conservative approach.
As for Figgy’s possible back problem, lots of humans live with a pinched nerve in the back and lower back pain. If there is an issue, it will be managed with rest, meds, and physiotherapy as appropriate. If he gets to the point of losing use of his rear limbs or bowel control, his days may be numbered, no matter how hard that will be for both of us. I am not letting anyone with a scalpel near his spine. The idea of breaking a tibia to fix a knee was horrific enough.
In the end, while he was apparently wrong about an ACL tear, my regular vet was right on one thing: the first approach is conservative. I have told him I’m angry however, for putting me through the wringer.
<blockquote cite="Buy pet insurance. You will never recoup your premiums but it’s nonetheless worthwhile. Its value, however, is limited by your commitment to making decisions that are right for the dog not just because you can now afford it. (e.g., I would never put my dog through chemotherapy).”>
I certainly would put my dog through chemotherapy as it’s been shown to prolong survival in certain neoplastic diseases much longer than surgical excision or amputation procedures alone. Chemotherapy in dogs is not the big, bad wolf of treatments like it is in people. As part of my veterinary oncology courses, we had to read and discuss several articles related to these treatments and go through cases to assess outcomes.
Yes, I just put to sleep a dear patient last week whom I had treated for lymphoma. The dog was 14 when it became ill (golden retriever), and many people would not have elected to treat. But she handled the treatment with almost no side effects for 25 weeks and stayed healty and in remission for two years. That’s a lot of good quality living she would not have gotten to do if we hadn’t treated her.
Our, just turned three, Female Border Collie just had a TTA by a competent certified vet in our area. I have read so much written on cruciate ligament rupture and asked our vet but still have questions. First, does the repair procedure change a dog’s conformation in such a way it puts more stress on other joints, primarily the hip joints? Second, she is very active. We have not done agility with her but she loves to run with our other dog in a large yard and does Canine Freestyle in which we teach many behaviors and create a routine to music using some of those behaviors. Such behaviors include backing around me, weaving through my legs, backing away from me, moving facing me in a parallel fashion. We were going to teach her to crawl but have not started yet. All moves are done with ‘four on the floor’ meaning she does not stand on her back legs but at times, she does that when we don’t want her to probably due to excitement (she likes to stand on her back legs as she backs away from us). A big part of the routine is heeling mixed with some of these behaviors. My concern is how much can do without harming herself. We cannot get a clear answer from our vet and understand any answer from you will be a ‘standard’ answer since you do not know our dog, etc. She weighed 36 lbs at surgery which is a couple of pounds heavy for her as we kept her quiet several weeks prior to surgery. We worry that keeping her quiet will not be a quality life and, given our situation with the other dog and yard, nearly impossible to curtail. Her interaction with our other dog is much more active than freestyle but we do question the freestyle movements and if those will be harmful. She’s very stoic and lives to play. Any input you might give us will be appreciated, thanks in advance, Sandy
For what it’s worth, I think you’ve answered your own question in that severely restricting your dog’s activity will deny her an acceptable quality of life. The only purpose to treating CCL is to enable a good quality of life, so it seems to me not to make a lot of sense to dramatically restrict your pet’s lifestyle. Realistically, I don’t think anyone can predict the difference in risk of trouble with the knee if you do or do not allow your pet to engage in these activities, so no one can tell you whether restricting her activity is even necessary. But since it seems impossible to do so anyway, and since doing so would take a lot of the enjoyment out of her life, I can’t see a strong case for doing so. All just my personal opinion, of course.
Hope this helps.
I just found out friday that my chocolate lab has two ruptured ACLs on his hind legs with the start of arthritis and also bad arthritis in his hips. My vet is looking at refering me to a surgical center in Dallas because he really isn’t sure how to deal with a case like this. His right side is worse than the left side but not by much. He weighs 74 lbs and his muscle mass in his hind legs are not near what they should be for him. He is 6 years old and has always had a limp just never really knew why. Well, I guess now I do..he has probably been predisposed to this from a young age. He is active but a pretty chill dog and doesn’t do super crazy activity.
Not sure how you would go about deciding what to do for a dog that might have to have major surgery on his back half. We have 2 small kids and finances are tight. We def can’t spend the money that we would have to dish out for this…
Any suggestions???
Right now he is on Rymadil and Phycox…just need feedback. We will find out Wed what the surgery center suggests..
Obviously, I can’t offer specific advice without being there and being your dog’s vet. In general, it’s a tough situation for which there may not be a perfect solution. If he truly has ruptures of both cruciate ligaments and significant hip disease, it is unlikely there will be any solution that does not involve surgery, likely with significant expense. It may be something that can be delayed, if needed, for financial reasons, but not something you’re likely to be able to avoid and still have a good outcome. I appreciate how frustrating a position that puts you in, and I hope things work out for you and your pet.
I’m wondering if pet insurance companies cover surgeries like this, although I suspect it has to have been diagnosed earlier while already enrolled in a plan. Also, Cdios, if you qualify, perhaps try CareCredit, if your vet accepts it. It’s a payment plan with no interest applied as long as you pay the balance before the plan’s term is up (there are a few different options that may suit you). It is worth a look, click on the veterinary section on their website for more information.
Sometimes, due to costs, and depending on the vet’s assessment, an option might be surgery on one leg now, the other leg later, but this has to be a careful assessment, based on degree of degeneration, the dog’s ability to heal quickly, the owner’s diligence during the dog’s recovery (restricted activity, etc). Discuss your options carefully with your vet and/or vet surgeon.
Wylie is a rescued shepherd/pitt? mix now 11 and since puppyhood has had bad joints. Had rear hips removed at 1-2 years of age. Arthritis most everywhere, he limits his activity and he is a 2x daily Rimadyl and Tramadol pooch. Has been controlling the pain and he’s been happy. Now has a partial tear of his right rear ACL. Vet instructed limited freedom and more Tramadol. Surgery doesn’t look to be an option since his other rear leg could not bear his wieght ( he is 76 lbs) during recovery and big dog success is not a slam dunk. Appears we have very few positive options other than get a brace. I know their effectiveness is questioned, but he is certainly at risk for a complete tear or injuring the left side. Websites say their costs are $600-$850. We will spend the $$ if he gets a reasonable chance (50%)? of help. Any opinion whether or which type would be appreciated.
Thanks,
Bob
Thank you both for your comments. My vet really didnt know what to do because he said if he were to repair the worst one now, it could cause the other one that is in better shape to get extremely worse through the recovery of the bad one, so he had to send it off to get a second opinion on how to deal with a situation like this. Also, is there any knowledge on if they are fixed, what is their quality of life and it is something that lasts the rest of their life?? My brothers dog had both his dogs ACL’s fixed and the dog still has issues walking but might not be in pain anymore. My dog doesn’t seem to be in a lot of pain but then again, he can’t talk to me. He is still running and I am afraid that one day the tendons will pop or not be mobile anymore and he will become limp. I just hate to not be able to do anything for him since he is only 6 years old but a lot comes down to his quality of life to be honest. It might be that we just let him live his life giving him rimadyl until he can’t go anymore..it’s hard when you have a 3 and 5 year old at the house and its hard to spend that kind of money on a dog when you dont know what the long term is. Ughhhh, decisions, decisions…
Cdios, those are questions best asked of the vet and surgeon, again, based on the seriousness of the problem and your dog’s individual needs.
I think you’re right to be concerned about having the one leg done and the risk to the other leg, but this is where restriction, followups, and careful discussion with your vets come in. I’m of the understanding that the surgery can help slow the progression of degenerative disease but every case is different. I honestly don’t think the long-term use of Rimadyl would be helpful (it is not without risks).
Don’t assume anything without talking in detail with your vets, they are the only ones best qualified to give you your options.
Well, I know that dogs who have surgery very often have a perfectly normal quality of life, though there are cases certainly which do not for many different reasons. My own dog had a TPLO at 6 years old and was still fine on the leg when he passed at 16. Just an anecdote, but my sense is that such outcomes are not uncommon, though again there are undoubtedly cases that don’t do as well.
I’m afraid I don’t have any information about braces. I have never seen or heard of one being used and am a bit surprised to hear such a thing recommended since in general such devices are rife with problems and not very useful in veterinary medicine. I would look carefully at the evidence, ideally from actual clinical studies published in reputable journals if there are any, to understand the potential risks and benefits of such an approach.
Hopefully my vet will get back to me shortly on advice he has gotten from the experts in Dallas that deal with ACL’s daily. Just trying to gather as much info as I can to be prepared and know the correct things to ask.
Thanks again for taking the time to give me your 2 cents..its very much appreciated!
Thanks for the great article and all the response. We have a 16 month old, probably needless to say, very active chocolate lab. She is favoring one back leg somewhat but still puts alot of weight on it and has never come up “lame”. Our vet sedated her to do the exam and said upon manipulation of the joint he feels that she has a partial tear in her ccl. Neither of us like the idea of surgery, mostly because without kenneling her we do not see us able to get her through the rehab process. She isn’t really exhibiting any pain at the moment and our vet did not prescribe any kind of medications for her which makes me think it is a mild tear or perhaps a strain. Do you tink a dog of this age and activity level is a good candidate for nonsurgical treatment?