Evidence Update: Is Surgery Necessary for Dogs with Cranial Cruciate Ligament Rupture?

Back in 2011, I first wrote about the issue of concerning whether dogs with cranial cruciate ligament (CCL) ruptures did better with surgery or with non-surgical management. My conclusion at that time was:

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. 

In 2013, I write an update looking at an additional study , and concluded:

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

Since that time, there has been some further research, but there has not been one single, definitive clinical study comparing surgery with other approaches for managing CCL disease. This is partly for ethical reasons. Since most vets believe surgery produces a better outcome, it is considered unethical to randomly assign dogs with CCL disease to getting surgery or getting a potentially inferior treatment. 

A new study has attempted to use existing data on a large number of dogs, and some complex analytic techniques, to mimic such a study.

Camilla Pegram, Karla Diaz-Ordaz, Dave C. Brodbelt, Yu-Mei Chang, Anna Frykfors von Hekkel, Chieh-Hsi Wu, David B. Church, Dan G. O’Neill. Target Trial Emulation: Does surgical versus non-surgical management of cranial cruciate ligament rupture in dogs cause different outcomes? Preventive Veterinary Medicine. 2024; 226;106165.

I don’t have the expertise to evaluate the analytic approach in this study. The authors acknowledge many of the usual limitations to large retrospective analyses, but despite these issues, such studies are valuable, especially I the evidence-poor environment of veterinary medicine. 

The results are pretty consistent in showing better outcomes in dogs treated surgically:

The current study shows that on average, surgical management leads to reduced lameness and analgesic prescription outcomes compared with non-surgical management. 

Interestingly, the study did not find any difference between large and small dogs. Both groups seemed to do better with surgery, which is a different finding than some previous research. The authors suggest this may be related to limited numbers of small dogs being treated, since they are less likely to develop CCL disease, so further work is needed to clarify the impact of size on the choice of treatment.

While there are always individual factors to integrate into any decision about the best management for a specific patient, this additional evidence tends to support the existing view that surgery probably produces better outcomes for dogs with CCL disease. While this is not the perfect definitive clinical trial, such a study is unlikely to occur. The evidence that we do have is pretty consistent, and it supports at least a moderate degree of confidence in recommending surgery for those patients in whom it is an option and who have no specific reasons to avoid surgical treatment.

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6 Responses to Evidence Update: Is Surgery Necessary for Dogs with Cranial Cruciate Ligament Rupture?

  1. I am relieved that last year we did have surgery for our Collie with a ruptured ligament. I was told that the great likelihood is that he will do the same to his other leg, and I read everything I can find about avoiding surgery. This makes me more comfortable about it. Though if he waits much longer he will be too old for the surgery. He is now 7.5 years.

  2. art william malernee says:

    was a force plate used to measure the recheck follow up lameness?

  3. skeptvet says:

    As described, this was a retrospective analysis of clinical records, not a prospective research study, so lameness was a clinical diagnosis. Lots of potential for bias and error there, ut no particular reason to think misclassification would be different between the surgery and non-surgery groups, so while the absolute prevalence of lameness might be different, the difference between the groups is likely accurate.

  4. art william malernee says:

    While this is not the perfect definitive clinical trial, such a study is unlikely to occur. >>> or occur and then put in a drawer somewhere unpublished. I am still looking for a human sham back surgery studies that was started and should have been published by now. One advantage in a prospective vs retrospective trial is that you can check to see if it was registered before started. If twenty prospective trials have been started and only one got published you can question if the one that got published was positive just by chance. Even with a human sham clean up knee surgery as good as the real one the human doctors still recommend it before knee replacement. At least you can show the surgeon the sham surgery study and watch him or her try to explain why he wants to do it.

  5. art william malernee says:

    Dr. Arthur Malernee

    can you tell me about the sham knee surgery done in humans? did the study find the knee surgery was better than the sham surgery?


    In the field of orthopedic surgery, sham surgery studies have been conducted to evaluate the effectiveness of certain surgical procedures. One such study is the “Arthroscopic Surgery for Osteoarthritis of the Knee” trial, which was published in the New England Journal of Medicine in 2002. In this study, researchers compared the outcomes of arthroscopic knee surgery with a sham surgery in patients with osteoarthritis of the knee.

    The study found that there was no significant difference in pain relief or functional improvement between the two groups at two-year follow-up. This suggests that the knee surgery was not more effective than the sham surgery in treating osteoarthritis of the knee.

    However, it is important to note that the results of this study have been debated and may not be applicable to all types of knee surgeries or all patient populations. Additionally, the study was conducted over a decade ago, and surgical techniques and technology have advanced since then.

    In summary, the “Arthroscopic Surgery for Osteoarthritis of the Knee” trial found that the knee surgery was not more effective than the sham surgery in treating osteoarthritis of the knee. However, the generalizability of these findings to other knee surgeries and patient populations may be limited.

  6. Geoff says:

    That’s a lot of data! I’ll confess that I didn’t read every word of it, but FWIW, I’ll share my experience and thoughts.
    I believe the condition of the meniscus post-CCL contributes significantly to arthritic changes, regardless of treatment. My Lab (American, field dog) fully ruptured her CCL at age 6. She was highly active and in excellent condition. Her meniscus was intact (not always the case with CCL rupture). She had a TPLO, with uneventful recovery. Swimming at 8 weeks, off least at 12 weeks. You wouldn’t have known she had ever had the injury. Year and a half later, she developed some mild lameness in the stifle. Arthroscopy revealed an effusion. The ostomy itself looked excellent. The effusion was drained, and the TPLO hardware was removed as well. The effusion was most likely due to weight gain and mild arthritic changes, but removing the hardware seemed a reasonable thing to do. She healed quickly and I started her on monthly Adequan injections, got her weight back to normal, and she had no further issues. Quite amazing, really.
    For an active and otherwise healthy dog, the TPLO was the best option, IMHO. For an older, smaller dog with a more sedentary lifestyle, perhaps other options would be suitable.

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