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

  1. zbr says:

    While a financial bias may be present, it is offensive to claim that all vets care about is money.

    I’m not in the field, I do live with dogs. Lucy, maybe you need to find a new Vet. I have had the privilege of knowing wonderful Vets in my lifetime. Are they infallible? I think that is only reserved for the Pope :). I have had and seen worse in the human medical field!

    Skepvet, because the extracapsular procedure “loosens” over time on larger dogs (over 50lbs). What about that procedure and a brace? They use this in human acl procedures. What would your thoughts be on this?

  2. skeptvet says:

    I don’t have any specific opinion on the idea of extracapsular repair+brace other than that it needs to be evaluated in clinical trials, ideally in direct comparison with TPLO and other methods. It seems plausible, bu many things do that don’t actually work in reality.

  3. zbr says:

    Ah, reality, stickler. Thank you for quick the answer.

  4. Sandi Centoni says:

    I have a 9 yr. old female boxer with a right rear TPLO. She was diagnosed about with this condition about a year ago.
    She’s had 2 Cancer Surgery’s in the past year on her right front ankle area for this reason and due to her age I really don’t want to put her out again so soon.
    My question is, **Will a fitted brace help her out instead of the Surgery??
    I’ve taken weight off of her and do walk her twice a day for about 20 minutes for each walk so as not to overdue the strain on the rear leg.
    I’d appreciate your advice.

  5. skeptvet says:

    Unfortunately, the bottom line is no one knows because no research has been done comparing various types on non-surgical treatment and surgery. Extrapolation from human medicine is particularly difficulty in this area because the anatomy is so very different, so we really can’t predict outcomes on non-surgical treatment. I would just keep a close eye on your dog’s comfort and function. If she is clearly avoiding putting weight on the leg, that probably indicates it is uncomfortable or unstable, and at some point I would consider surgery. If she seems to be supporting her weight normally on the affected leg, then there’s probably no urgent reason to have surgery done.

    Good luck!

  6. Pat Carden says:

    My 14 year old Border Collie (26kg/57lb) has just been diagnosed with cruciate ligament disease in the right back leg and possibly developing in the left back leg. I am trying to make the decision re surgery considering his age and other age related problems i.e arthritis, failing sight and hearing. He would be happy if he could enjoy his walks, as a result of surgery, but taking 2-3 months of rehab to achieve this when life has become so short is making the decision very difficult. Is conservative management the better option? Or is surgery always the better option regardless?

  7. skeptvet says:

    As you can see from this article, there really is no simple answer to your question. We know surgery is effective for most dogs. We don’t know if some kind of medical management (and there are many different non-surgical treatments offered) works as well or better or does not work at all. And, as you point out, each individual patient has circumstances that affect the decision and the balancing of risks and benefits. I would try to have a detailed discussion with your vet about your options, and unfortunately you will have o make the best choice you can without perfect information.

    Good luck!

  8. Brette says:

    We agonized (and I stress the agonized) over whether to have the procedure done as recommended by our vet (who we believe is an excellent veterinarian) for our 8 year old husky, who would have required 2 separate procedures (bilateral). Part of the difficulty in making a decision was wading through the mountain of anecdotal and clinically unsupported material that turns up in search results. Ultimately we were able to find a published study indicating (at least at that time) there was no clinical evidence supporting a finding that surgery provided a better outcome vs. conservative management, and decided that the recovery time (which with two procedures would have meant a year of significant limitation) weighed in favor of conservative management providing a better quality of life for our pet given her anticipated lifespan. Did we make the right decision? Unfortunately there’s no real way to know on an individualized basis since you you only get to make that decision one way or the other, but I can say that it would have been extremely helpful to have had the benefit of this blog at the time we were weighing our options. Thank you for this site, which does an excellent job of providing fact based information to assist in making critical choices about the care and well being of cherished members of our family.

  9. skeptvet says:

    Thanks for the comment. I hope the site will be useful to you now that you’ve found it!

  10. Emanuela Leabu says:

    I need help ! My dog is a 7 years old Maltese and she weights 5.4 lb . She s not an eater so she s pretty skinny . .She was diagnosed with ccl and surgery was recommended. She has good days and bad days. She was limping for a few days and then she was back to normal Most of the articles reffer to big dogs and the weight being a problem. We definitely don t have that problem 🙂 my question is : how soon should she get the surgery ? What’s the downside of not doing the surgery ? She already had knee surgery in both legs ( pattela) and i m really not looking forward in putting her through that pain again but in the same time I want the best for her

  11. skeptvet says:

    As always, these are really questions you should be asking your vet. If you feel like you can’t get clear, adequate answers, then a second opinion is a good idea. In general, surgery isn’t always necessary for small dogs, but every individual is unique and the circumstances of the case make a big difference, so no one can give you reliable advice online.

    Good luck!

  12. Merrill Fox says:

    Hi Skeptvet
    I Have a very fit active working(sheep) border collie who is nearly 10. He briefly caught his hind leg whilst jumping from the sheep pens. He was carrying the leg and I put him away. He seemed sound the next day but I kept him on the lead as a precaution. After a couple more days I decided he looked fine and let him collect a few sheep in a tiny paddock, but that was a mistake. He was carrying the leg again. The vet has ex-rayed and examined the leg and diagnosed a damaged cruciate ligament. The joint is free of arthritic change and there is only a small amount of unwanted movement. The treatment recommended is the tta. He was examined a week ago. I have done some online research and question whether surgery is necessary. With or without surgery I realise that his return to full recovery might be months rather than weeks and am well aware that very careful lead exercise and cage confinement is the way to go. So far anyway he is fine with this. At the moment he is walking on the injured leg without being lame other than the first few strides after coming out of his cage. He is having 3 short walks a day, just ambling and sniffing. As a consequence his food ration is also drastically reduced to avoid him becoming overweight but he has graciously accepted his lot poor lad! Later on I intend to take him to hydrotherapy. Now my question, is he able to make a full recovery with this conservative management or is the proposed surgery the only way?

  13. skeptvet says:

    Obviously, I can’t give advice about specific pets online since they are not under my care. Dogs with cruciate injuries have been reported to recover with no treatment, various medical treatments, and various surgical treatments. The problem is we can’t yet predict how any individual dogs is going to do with each of these options. It is not unreasonable to try medical rather than surgical treatment in some cases, depending on the details of that case, but the answer to the general question of “Is surgery necessary?” is still uncertain.

    Good luck!

  14. Merrill Fox says:

    Thanks, will post back in 6 months or so to update you

  15. Madison says:

    My dog had the TPLO surgery this past week. I read everything I could find on cruciate surgery, had two medical consultations, and in the end decided I would trust the veterinary surgical specialist. Sometimes you just have to trust your instincts.

  16. art malernee dvm says:

    Sometimes you just have to trust your instincts.>>>>
    the problem with surgeon trust is when you are a hammer everything looks like a nail. Even after surgeons saw this randomized study (below) a head of a surgery association has stood up and said to the press the joint surgery should still be done. I wonder if the ocd shoulder joint surgeries I have done on dogs the last 40 years did any good.

  17. Debra Hope says:

    I have a 21 mo. f. Newfoundland who ruptured her ccl. Her vet has recommended TPLO, she is 111lbs and is good for her frame. Her breader is suggesting the surgery that uses the cord, I don’t remember the name, and is saying this has nothing to do with genetics. My girl did slip when running but the vet said it just helped what was already happening and the TPLO is the best way to go. Any ideas?

  18. skeptvet says:

    Sorry you’re having to deal with this. I’m not surprised that your breeder doesn’t want to believe there is a genetic component to CCL disease, but unfortunately, that’s just not correct. There are other risk factors as well, but it happens in certain breeds more than others partially because of genetic differences between breeds.

    As for which procedure to use, there isn’t very good data comparing the TPLO and the tightrope procedure. One low-quality study was done by the owner of the patent on the tightrope procedure, but otherwise there isn’t much research to compare them. Subjectively, most surgeons I have talked to who do CCL procedures (I don’t), feel like the tightrope is less reliable, and it seems to have gone somewhat out of fashion. As always, I would find a surgeon you trust and get their opinion, and I wouldn’t take the breeder’s opinion very seriously since breeders often have very strong opinions about medical subjects without the training or expertise to really have informed opinions. I would give the surgeon’s opinion more weight.

    Good luck!

  19. Debby Newton says:

    Our lab 5 years old had the TPLO on her left leg 4 months ago. Her recovery went well with 8 weeks of PT and water therapy. A very expensive surgery and rehab. However today while running in the backyard she came back limping and putting no weight on her other leg. Needless to say we are heart broken, that this has repeated itself in the unaffected leg. Do we do this again with surgical intervention or try a conservative approach?
    Any insight would be helpful.

  20. skeptvet says:

    I’m sorry this has happened to your friend, but unfortunately it’s quite common. About 50% of dogs who have a cruciate rupture in one leg will eventually have a rupture in the other leg since the predisposing factors are the same for both legs. Personally, I think it makes sense to repair both legs since that likely will get the best comfort and function in the long term, and she’s a pretty young dog. However, as you can see from this article, it is not certain whether physical therapy and other conservative treatments could work just as well. From a cost perspective, though, conservative therapy isn’t likely to be a lot cheaper since, done properly, it involves a lot of physical therapy.

    Good luck!

  21. Gene says:

    Any comments on TPLO vs TTA procedure? Is one better than the other?

  22. skeptvet says:

    TPLO is certainly the preferred procedure among surgical specialists, and there is some evidence to suggest it is more effective than TTA. Here’s another review with similar conclusions.

  23. Tay says:

    Would be interested in knowing what you ended up doing?

  24. Anne Onymous says:

    Thanks for posting a ‘no axe to grind’ review of options. Vet was pushing for an immediate decision to choose TPLO in the consultation on the basis of a drawer diagnosis without any consideration of other options or other kind of surgerys.

    It’s a real comfort to have a breath of fresh air on it.

  25. Terri Daly says:

    Diane wondering what you ended up doing we have an overweight kuvasz with torn ligaments in both back legs, her quality of life currently is poor, so we are considering surgery…

  26. Judy says:

    I am in shrewsbury Pennsylvania and can not come to Florida can you recommend someone in my area for a torn dog ccl

  27. skeptvet says:

    Sorry, I can’t provide specific referrals except for patients I see in my practice (which is in CA). I would contact your local vet or look for a board-certified veterinary surgical specialist in your area.

  28. Siska Kooi says:

    Hello Skepvet, I have an 11 year old female labrador that has chronic kidney failure (diagnosed october 2018) and is somewhat overweight. She is on a strict kidney diet and wasn’t supposed to losse weight becauce of her kidney failure. Around Christmas 2018 she ruptured her left ACL. The vet immediately told us she needed a TTA or TPLO and that it had to be done as soon as possible. Due to the holidays, surgery was sceduled on januari 7th. In the mean time we asked a lot and read a lot about ACL ruptures, surgery and non-surgical treatments. Because of her kidney failure (I am an pharmacist, so I know there are anaestetic options that are possible with kidney failure and include post-op IV to cleans the body from the anaestetics) and the fact that with a TPLO or TTA she actually needs to rehabilitate from a broken bone with her conditions, made us decide to go for a custom made brace. She is wearing it only when she goes for walks in the garden or outside in de woods and after 6 weeks she is able to walk at least 3 times 30 minutes. She even can run with it, but isn’t allowed by us. Inside without the brace we see that she can stand on that leg en put pressure in it. So everything is going well for that leg en we were very hopeful, until last weekend. She startend limping with her right leg and after X-Rays the ver concludeert that the right ACL was also ruptured. So now we have tot decide whether we go for a second custom Made brace or for surgery, but How can she rehabilitate with 2 ruptured ACL, presumming that they will do one leg at a time. So we are asking a lot and eading a lot again and like to hear your opion about this.

  29. skeptvet says:

    Sorry you are in this position,. It’s a complicated one, and I don’t think there are any absolutely right or wrong choices. Most surgeons do stage bilateral TPLO surgeries since it is very difficult to rehabilitate a dog after having both knees operated on at the same time. This, of course, does increaser the anesthetic time and risk. Some dogs can also function well with only one knee repaired, especially if the brace or other treatments seem to be helping with the other leg. I would just encourage you to seek multiple opinions from different surgeons, and remember that there are multiple ways to approach this that are reasonable and appropriate.

    Good luck!

  30. Siska Kooi says:

    Thank you for your quick response. I talked to the vet today and she is consulting another surgeon about surgery (TTA versus TPLO and other options) and we will go there for a second opion too. It is good to hear that doing surgery on only one leg cóuld also be a possebility. Thanks again!

  31. Diane M says:

    @ Terri Daly, sorry I did not see your post sooner; I hope that whatever you decided worked for your Kuvasz. What I did with my Pyr (Teddy)–this was back in 2013-14:

    First I saw several DVMs including a rehab specialist; Teddy was put on a high dose of Rimadyl (if I remember it was 100mg twice a day), did some hydrotherapy sessions, did some cold laser sessions, didn’t seem to have much effect. All DVMs told me Teddy was in a lot of pain, his other knee was bound to rupture soon, and strongly implied that it was neglect/abuse to not get TPLO surgery done, and done immediately.

    Then I had a consult with a (veterinary) orthopedic surgeon who has a reputation for being one of the best on the West coast. This was my best decision. I gained invaluable insights:
    1) Actual confirmation of the diagnosis (which other vets suspected, but even under anesthesia the drawer sign wasn’t really clear)–he was able to elicit a drawer sign so obvious and severe that I could see it from where I was sitting about 10 feet away, made me feel ill!
    2) A CCL tear is NOT an emergency; no need to rush into surgery, you can take time to decide.
    3) Tightrope surgery (which I hoped would be an option) is a bad idea on a large dog because the “tape” (kind of like an artificial ligament) stretches out over time.
    4) For a large dog, if you don’t want to do TPLO, it’s better to do no surgery at all. (Per a surgeon!) Lots of people don’t do surgery, for various reasons, and it works out fine for most dogs; perhaps not as well as TPLO, it’s hard to say–but not doing surgery is a legitimate option.
    5) A dog’s knee is going to develop arthritis in the injured knee whether you do surgery or not.
    6) My dog was not in pain. He said the first few days after the injury are painful, after that most dogs are limping due to the instability of the joint, not pain. Not necessarily true for every dog’s situation, but he thought true for my dog. Suggested discontinuing Rimadyl since it can have negative side effects and he didn’t think it was needed. When I expressed doubts, he asked, “Did you notice any change when he started the Rimadyl?” and honestly I had not. “Then try discontinuing it and see if you notice any change from that.” (So I did discontinue it, and no, I did not notice any change.)

    I decided to do conservative management instead of surgery, pretty much following the protocol from tiggerpoz.com, which mainly involves very strict rest, gradually getting less strict, over about 8 weeks. (Similar to what you would have to go through after a TPLO.) Also I did use a brace. My logic for the brace was that stabilizing the tibia from sliding around would help prevent accidents, possibly also mitigating development of arthritis; allow him to offload some weight from the healthy knee and hopefully reduce the risk of blowing that one out; and allow him to be more active sooner. He had a setback at home while I’d taken off the to give his leg a rest from it–heard something outside that caused him to jump up, and he slipped on the laminate floor between throw rugs. So discouraging; we started over and the second time I could definitely see his gait was not quite normal, but functionally he did improve. He compensates (I think) when running by using both rear legs together sort of like a gallop, but when climbing stairs he uses his legs individually rather than bunny hopping.

    A lot of people recommend glucosamine and other supplements, but I did not use any because as I’ve learned from skeptvet’s blog, there’s not much evidence that any of them help. 🙂

    So that was Winter of 2013. I was over-cautious and limited his activity til well into the Spring. In Summer I put the brace on him only when he was going to be engaging in riskier activities such as going to the beach or doing slight climbing over rocks, etc. By Fall I didn’t use the brace anymore or limit his activities.

    I am a dog walker and he usually comes along, so he has done lots of hikes, trips to the beach, dog parks, climbing up and down embankments to get into creeks, and/or just plain long walks almost every day since then.

    He’s 12 now and sleeps a lot more and takes a lot more “personal days” as I call it, but both his knees are doing OK. About 6 months ago developed a problem in his spine that requires his activities to be limited in certain ways. He’s on Rimadyl for the inflammation in his spine, and for whatever arthritis he has, and it has made a huge difference. He is like a new dog. I have to hold him back a lot to protect his spine from getting injured (for example if he tries to wrestle with another dog, or tries to jump down from something). We were at the vet yesterday and it took all my strength to hold him back from escaping every time someone opened the lobby door. LOL

    So that is just an anecdote. A dog walker friend tried a different version of conservative therapy on her large Akbash (prolotherapy, no brace, various supplements, and less restriction), with limited success. Another dog walker friend had bilateral TPLOs on her small (maybe 15 lb) terrier mix with great success.

    All anecdotes. However, the insights from the surgeon are based on a long career full of anecdotes, a lot more information than most vets have access to, so I weight his opinions most heavily.

    Sorry for the extremely long post! But hopefully it will be useful to people looking for info for their dogs with torn CCLs. It can be so hard to find information and so agonizing trying to decide what to do.

  32. avi gold says:

    our 75 pound 9 year old Husky Pyrenees cross tore her ACL and now the vet after a 5 minute examination says she needs surgery.TPLO is the one she is calling in an orthopedic vet to perform.Our dog is very active and difficult to keep quiet so I’m dreading the surgery and really starting to question whether its the way to go.I’m also feeling pressured by my vet in a subtle “if you love your dog you ll go ahead with the surgery”I’m so torn.we love our crazy wild dog and if the surgery will give her back total mobility and reduce the pain Ill do it.the question I keep asking myself…will it?

  33. skeptvet says:

    No procedure is perfect, but there is strong evidence that TPLO is very effective for most dogs. There may be alternatives that could also work well, the problem is none have been studies, so any other treatment is a bit of a roll of the dice compared to surgery.

    Good luck!

  34. J.B. says:

    My 2 year old boxer started limping after we came back from hiking trips last summer. We had xrays and his drawer test didn’t produce any real movement. He was diagnosed with a partial tear but without an expensive MRI who the heck really knows, it’s more of an educated guess. I opted for conservative management. 10 weeks of highly restricted movement. After that I slowly rehabbed the leg and never let him off leash. It worked well for about a year and then one day he came up fully lame after running in circles while on the leash. It’s been a week & he’s still on 3 legs. I’m going with the TPLO, given his young age and how hyper he is, that’s the decision I am making. I know everyone can’t afford expensive surgery and I’m not judging anyone who opts for conservative managment, but the people who act like it’s some magic bullet and all surgery is bad live on another planet. Every dog is different and every surgeon is different. Could I rehab is leg? Sure its possible, but I wouldn’t feel comfortable having that same leg hold up his whole body if the other knee goes. I’m hoping my TPLO goes well, he is very hyper and the chance something goes wrong is certainly there. Im going to do my best and I hope anyone reading this has success with whatever they choose.

  35. Lori says:

    Hi Diane, my GSP had TPLO surgery 4 yrs ago on her left leg, surgery was a success , long and painful recovery but has been good since. She has been limping on and off on the right leg now. Unfortunately we do not have the resources to have surgery on the 2nd leg ,have not had her assessed by her vet yet but am suspecting it is her cruciate ligament.
    I am interested I’m looking into a brace for her. Where did you get yours? What brand is it? I am also researching cannabis oil to help with the pain and inflammation. Any advice you can provide would be much appreciated! Thanks Lori

  36. art malernee says:

    If a doctor has success promoting or has paid for something they are more likely to think it works. Here is a doctor that wants to treat cruciates with needles. https://www.veterinarypracticenews.com/questioning-canine-cruciate-ligament-surgery/

  37. art malernee dvm says:

    makes you think cruciate surgery is proven medical care.

  38. skeptvet says:

    Not sure what your point is. The conclusion was, “There is no evidence comparing functional outcomes of TTA and LFS for unilateral cranial cruciate ligament disease in dogs weighing less than 15 kg.In view of this absence of evidence, it is recommended that practitioners use their personal experiences and preferences to advise clients and decide on which of the procedures to perform in small dogs.”

    This doesn’t apply to dogs over 15kg, for which there is some evidence. As always, in the absence of better quality evidence, we make decisions based on low-quality information, such as pathophysiologic reasoning, clinical experience, etc. It’s very frustrating we don’t have better evidence so much of the time!

  39. art malernee dvm says:

    Is TTA better than lateral suture in small dogs with cruciate disease?
    Is x homeopathic better than 2x homeopathic medicine in small dogs with cruciate disease?
    Is x acupuncture needle site better than Y acupunture needle site in small dogs with cruciate disease?
    see where I’m going with this?
    we seem to be using evidence based labeling to dance around the question which should be.
    Is surgery better than medical treatment in small dogs with cruciate disease?
    I know its only been about 10 years since a human prospective randomized trial was published showing cruciate surgery was not better than medical treatment but I fear that all this talk about which surgical techniques to use is little more than dancing on the head of a needle with out a prospective randomized trial showing efficacy for the two surgical treatments we are comparing.

  40. skeptvet says:

    Ah, I see. Yes, a standardized comparison study between surgical and medical management would be useful. Of course, this is a lot more complicated than it sounds because we have to account for baseline differences in breed, weight, meniscal involvement, neuter status, and a bunch of other variables that could affect outcome. We would also need to define medical treatment, and anyone who has a pet treatment they like that isn’t included would simply ignore negative results. If exercises was, for example, not as effective as surgery, anyone doing laser, supplements, acupuncture, stem cells, etc. would just claim that the results were meaningless because the “wrong” medical treatment was tested. If the goal is to reduce unnecessary surgeries, then this is a real problem.

    Of course, it is also possible that surgery really is more effective than some or all kinds of medical management. If so, I suspect people convinced surgery isn’t necessary (such as you?) would find a reason to dismiss the findings as well. I would still like to see a study like this, but surgeons who already believe surgery is superior will object that it is unethical to deny patients surgical treatment for such a trial. Lots of problems getting this kind of evidence.

    That said, comparisons of different surgical treatments aren’t meaningless in the way comparison of different quack therapies like homeopathy are. Surgery is a plausible intervention with low-level evidence of benefit, and comparing various techniques is still useful info. If you can show that lateral suture is just as good as TPLO, for example, you will save a lot of pets a very invasive procedure and owners a lot of money!

  41. art malernee dvm says:

    If you can show that lateral suture is just as good as TPLO, for example, you will save a lot of pets a very invasive procedure and owners a lot of money!>>>>>

    do you think that’s true if neither surgeries are efficacious?

    I couldn’t wait to read the FDA approved back surgery study approving a artificial disk. The FDA only made them show the artificial disk worked as well as standard back surgery. If neither back surgeries were efficacious would you think the FDA study helpful? I worry comparing two unproven treatments can cause more harm than good.

  42. Sydney says:

    FWIW, our 45lb staffordshire terrier ended up getting TPLO surgery on both sides (about a year apart) when she was pretty young (2 or 3). She was active and healthy until we lost her at nearly 15 years.

    We are now facing this in our 8 year old staffie and will probably again go with TPLO. Even knowing that the outcome was so good previously, it’s nice to have some data to evaluate the options.

    Thank you for the information.

  43. art malernee dvm says:

    bmj.com just posted a review of 10 common orthpedic proceedures . two randomized controlled trials for cruciate surgery concluded.
    “A total of two randomised controlled trials were included in the three reviews, and each reported no differences in patient reported outcome measures between surgical treatment and non-surgical treatment.” if your doctor wants to remove a meniscus better check out that review also.
    see https://www.bmj.com/content/374/bmj.n1511?utm_source=twitter&utm_medium=social&utm_term=hootsuite&utm_content=sme&utm_campaign=usage

  44. art malernee dvm says:

    here is the surgeons cannot fix joints thats why we replace them take home message [below] from the link above. Since these surgeries are still done i guess doctors will continue to say the rcts do not apply to their patients who are different than the ones in the trial or they have a better surgery than the one used in the trial or they are better surgeons than the ones in the trial.

    . “Randomised controlled trials have shown that arthroscopic anterior cruciate ligament reconstruction, arthroscopic partial meniscectomy, arthroscopic repair for acute rotator cuff tears, arthroscopic subacromial decompression, lumbar spinal decompression for spinal canal stenosis, and spinal fusion for degenerative disc disease have similar outcomes to non-operative care.”

  45. skeptvet says:

    Still, can’t extrapolate confidently from humans, especially with significant anatomic differences like the stifle joint in a biped and a quadruped.

  46. art malernee dvm says:

    been getting facebook sales pitches for dog braces for cruciate treatment. No boarded surgeons yet in the adds but that may change if enough money can be made selling braces. TPLO surgery was developed and sold by a non boarded vet surgeon so we have a history of this. Dr Poll on tv had a episode where a cruciate case came in and he told the client ligaments take months to heal but prognosis was good. I do not think dr poll really thinks the ligament heals but knows its the support structure of the kneee that need time to adapt and change. I wonder if putting a brace on the knee delays the knees own natural ability to rehab the knee. Should be easy question to answer. At the flip of the coin one dog gets tplo surgery one dog a knee brace and one dog gets dr Poll tincture of time treatment.
    here is the knee brace link .https://www.aocpet.com/

  47. art william malernee says:

    chatgpt can now pass true false law school test. Im betting it could pass true false vetschool and medical school test. I ask chatgpt some cruciate surgery vs medical treatment questions see below

    is surgery usually needed for people who tear their anterior cruciate ligament?
    Surgery is often recommended for individuals who have torn their anterior cruciate ligament (ACL) in order to restore stability to the knee and prevent further injury. However, the decision to undergo surgery will depend on the individual’s specific situation and will be made on a case-by-case basis in consultation with a doctor or orthopedic surgeon. Physical therapy, braces, and other non-surgical options may also be considered before deciding on surgery.

    what about dogs that have torn their anterior cruciate ligament?
    Dogs that have torn their anterior cruciate ligament (ACL) may also require surgery to restore stability to the knee and prevent further injury. The decision to perform surgery will depend on the specific situation and will be made on a case-by-case basis in consultation with a veterinarian or a veterinary orthopedic surgeon. Factors such as the dog’s size, activity level, and overall health will be considered when making this decision. In some cases, non-surgical options such as weight management, physical therapy, and controlled exercise may also be considered. In any case, it is important to get a proper diagnosis and follow the veterinarian’s advice.

    what about cats that have torn their anterior cruciate ligament
    Cats that have torn their anterior cruciate ligament (ACL) may also require surgery to restore stability to the knee and prevent further injury. Cats are generally less active than dogs, and some cats may not require surgery, but this is a decision that should be made on a case-by-case basis in consultation with a veterinarian or a veterinary orthopedic surgeon. Factors such as the cat’s size, activity level, and overall health will be considered when making this decision. In some cases, non-surgical options such as weight management, physical therapy, and controlled exercise may also be considered. In any case, it is important to get a proper diagnosis and follow the veterinarian’s advice.

    Are there any prospective randomized controlled trials in any person or pet that prove surgery for torn anterior cruciate ligament provides better long term results than those treated medically?
    There have been multiple randomized controlled trials (RCTs) conducted in both human and veterinary patients that have evaluated the long-term outcomes of surgery versus non-surgical treatment for torn anterior cruciate ligament (ACL).

    In humans, several RCTs have shown that surgery provides better long-term outcomes in terms of knee stability and function compared to non-surgical treatment. These studies have found that surgery results in a lower rate of knee osteoarthritis and a higher rate of return to sport.

    In veterinary medicine, there are several studies that show that surgery provides better long-term outcomes in terms of knee stability and function compared to non-surgical treatment. These studies have found that surgery results in a lower rate of osteoarthritis and a higher rate of return to normal activity.

    It is important to note that the decision to undergo surgery or not should be made on a case-by-case basis, in consultation with a doctor, orthopedic surgeon or veterinarian, taking into account the individual’s specific situation and other factors such as overall health, age and lifestyle.

    Are the trials you say show better outcomes for surgery vs medical treatment available online in places not behind a paywall?
    I apologize for any confusion – as a language model AI, I cannot access specific articles or studies. However, in general, many scientific studies are published in peer-reviewed journals that may be behind a paywall. However, some journals provide free access to certain articles or allow access to abstracts or summaries of articles without a subscription. Additionally, many universities and medical institutions have online databases that provide access to journal articles for their students and faculty.

    Alternatively, some systematic reviews and meta-analyses that evaluate the literature on a particular topic, such as surgery vs non-surgical treatment for torn anterior cruciate ligament (ACL), may be available online without a paywall. These reviews may provide a summary of the available research on a topic and can be found through a search of the PubMed database or other scientific databases.

    It is also possible to contact the authors of the study and ask for a copy of the study, some of them may provide you a copy.

  48. Sue says:

    My 8yr old Alaskan malamute recently tore the CCL in his left hind leg and I am trying to decide what to do. He’s a lean 82 lb male. The shelter he came from neutered him before he was a year old. Since this blog post was published in 2013, I would like to know if there has been any more recent research published comparing conservative management vs surgery since then.

  49. skeptvet says:

    Unfortunately, recent reviews of the evidence find very little comparing the most common procedure (TPLO) and conservative management (which is, of course, a vague term for many quite different non-surgical options). In general, studies of specific treatments find variable success rates, but it is still impossible to say with confidence when and in which dogs one approach is better than another.

  50. art william malernee says:

    https://knowledge.rcvs.org.uk/quality-improvement/canine-cruciate-registry/ here is the vet cruciate registry. if cruciate surgery in dogs is no better than those treated medically like the prospective randomized controlled trials show is true in humans i would guess either the surgical technique that’s most expensive or the technique that does not involve moving bone will be the best one. A lot of people think their doctor or treatment is good because he or it is expensive. Surgery is a great placebo but moving bone around with screws and plates has considerable side effects also.

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