Canine Cruciate Ruptures: to Cut or Not to Cut

In a fascinating interview on cranial cruciate disease, Narda Robinson from CuraCore Vet examined the pros and cons of surgery for this condition, and in particular, the highly invasive TPLO procedure. She discussed the financial benefits of TPLO surgery, the implications of post-op complications, the research published on cruciate ligament healing without surgical intervention, the compensatory structures that can provide dynamic support to the stifle … and so much more.

 

Listen to the full interview here.

While I agreed with a great deal of what Narda said, I remained uncertain about what the best treatment approach for CCLR was. And, of course, we do need to consider patients as individuals – a single approach may not be correct for every patient with stifle pathology. Like Narda, I began to wonder if we are not leaning too heavily on surgery for this condition.
My own training and current knowledge of the literature tells me that a TPLO is generally the best approach, but Narda’s stories about clients coming to her desperate for a non-surgical solution sparked something in me. Honestly, I don’t want to put my own dogs through surgery. I don’t. It’s painful, invasive, hectic. And I have clients who feel just the same way. So, is there an ethical alternative that can be just as positive – or even more so?

In this article, I dive into the research that Narda mentioned, and some studies I dug up myself. Let’s see if we come to the same conclusion she did about the viability of non-surgical management for canine cruciate ligament ruptures/disease.

 

Conservative vs Surgical Management of Canine Cruciate Ruptures

 

Short-term and long-term outcomes for overweight dogs with cranial cruciate ligament rupture treated surgically or nonsurgically,

Katja L Wucherer, Michael G Conzemius, Richard Evans, Vicki L Wilke

This was a prospective, randomised clinical trial including 40 medium- to large-breed dogs with a unilateral CCLR. Dogs received either physical therapy only, or surgery and physical therapy, for a 12-week period. They were evaluated before their respective interventions and at 6, 12, 24 and 52 weeks.

Contralateral CCLR was the most common cause of exclusion from the study.

Table 1: The number of dogs that developed a contralateral CCLR injury at specific time points, and were subsequently excluded from the study

Time point	Surgical group	Non-surgical group
6 weeks	3	1
24 weeks	2	3
52 weeks	1	1
Total number of dogs	6	5

Surgical complications occurred in three dogs and included patellar tendonitis, tibial tuberosity fracture, a broken screw, and infection.

Pain severity and pain interference scores significantly improved in both groups of dogs at 6, 12, 24 and 52 weeks. Although the surgical group had better pain scores at 52 weeks, the difference between groups was small (measured with CBPI assessments).

No significant differences were found between treatment groups in limb length, velocity or acceleration. Peak vertical forces increased during the study period for both groups, with the surgical group showing higher average peak vertical forces.

GRF increased for dogs in both treatment groups, with no difference between the groups.

Table 2: The percentage of dogs with a successful outcome at different timepoints  

Time point	Surgical group	Non-surgical group
12 weeks	67.7%	47.1%
24 weeks	92.6%	33.3%
52 weeks	75%	63.3%

 

While both treatment approaches yielded positive outcomes, the surgical group had slightly better outcomes overall. While the risk of surgical complications is low, some complications are serious and have significant financial implications, as well as delaying healing. Overall, the non-surgically treated dogs recovered far better than I initially would have guessed (based on beliefs about CCLR), especially for medium- and large-breed dogs.

 

Short-term outcomes of cranial cruciate ligament rupture treated surgically with tibial plateau leveling osteotomy or non-surgically in small-breed dogs weighing less than 10 kg

Irin Kwananocha, Ekkapol Akaraphutiporn, Rutaitip Upariputti, Chalermpol Lekchareonsuk, Chalika Wangdee

 

This was a prospective, non-randomised clinical trial including 17 small-breed dogs under 10 kg. Concurrent MPL occurred in 11 affected stifles.

Nonsurgical management included NSAIDs, a joint supplement, and a rehabilitation program. Surgical intervention included a TPLO, adjusting to an mTPLO if concurrent MPL was present, with or without a meniscectomy, as indicated. NSAIDs, supplements and rehabilitation was performed as for the non-surgical group.

Rehabilitation included laser and underwater treadmill. Home programs included hot packs, PROM, and progressive leash walking.

There were no significant differences between the average orthopedic assessment scores, CBPI scores, or thigh muscle circumferences between the two groups in the short term. CBPI pain scores continued to decrease in the surgical group to almost 0 at Day 84, while they remained at a level of 6–9 in the non-surgical patients after Day 56. This could indicate the continuation of chronic pain in the non-surgical treatment group.

Overall, the non-surgical patients recovered well. While the continuation of chronic pain is definitely a concern in this patient group, alternative pain management methods may be pursued for a percentage of these cases.

From these two articles, I would feel more comfortable discussing non-surgical management with owners of either a large- or small-breed dog, depending on their beliefs and recovery needs. I would still not feel comfortable pursuing non-surgical treatment options in working dogs or athletes. 

 

Stifle Orthosis for Canine Cruciate Ruptures

 

Comparison of owner satisfaction between stifle joint orthoses and tibial plateau leveling osteotomy for the management of cranial cruciate ligament disease in dogs

Juliette L Hart, Kimberly D May, Nina R Kieves, Patrice M Mich, Clara S S Goh, Ross H Palmer, Felix M Duerr

This study was a survey-based assessment of owner-perceived outcomes of large- and medium-breed dogs treated with a TPLO, and dogs treated conservatively with a custom brace. The survey included responses from 203 orthosis owners and 76 TPLO owners.

Owner satisfaction scores were revealing: 98% of the TPLO group and 86% of the orthosis group reported good to excellent outcomes.

In total, 85% of owners in the orthosis group and 90% of owners in the TPLO group would choose the same treatment path again in the future.

Interestingly, 63% of the TPLO group and 56% of the orthosis group did not receive any physical therapy, and reported that they were not advised that it was necessary.

When it comes to complications, 46% of the orthosis group reported that their dogs developed skin problems, and 32% required medical attention for complications or for multiple adjustments of the orthosis. Only 5% of the TPLO group reported complications, which included tendinopathy, a draining fistula, and acute NSAID toxicosis.

In addition, 11% of the orthosis group went on to receive surgical intervention to stabilise the stifle or remove a damaged meniscus.

A great deal of valuable information is reported in the paper about the use of the orthosis, adjustment periods and wearing frequency.

 

Pelvic limb kinematics in the dog with and without a stifle orthosis

Bryan T. Torres, Yang-Chieh Fu, Gabriella S. Sandberg, Steven C. Budsberg

This study looked at stifle kinematics with and without an orthosis in six healthy dogs, and found that there were few differences between the braced and unbraced conditions of the stifle, with the majority of changes occurring during the stance phase. Adaptations were also measured at the hip and tarsus.

 

The use of canine stifle orthotics for cranial cruciate ligament insufficiency

Brittany Jean Carr, Sherman O Canapp, Stephanie Meilleur,  Scott A Christopher, Jeffery Collins, Catherine Cox 

In a retrospective study involving 10 dogs with a unilateral CCLR treated with a stifle orthosis, an improvement in weight-bearing capacity could be seen over the study period. The clinical recommendation was that custom orthotics be considered as a treatment option for patients with concurrent pathology or financial limitations that prohibit surgical intervention.

 

Why owners choose an orthosis over stifle surgery for canine cranial cruciate ligament deficiency

Gina E. Bertocci, Nathan P. Brown, Patrice M. Mich

A sample of 215 dogs were prescribed a custom orthosis at a veterinary pain management and mobility clinic. Of these, 19% had previously undergone surgical stabilisation of a stifle, with a high percentage of this group having experienced complications. In total, 96.3% of the dogs were referred for physical therapy, with the majority of owners opting not to pursue it. Orthotic stabilisation was pursued because owners disliked the idea of surgery, advances in the age of dogs, and the cost of surgery.

 

Publications focused on intra-articular therapies in canine cruciate ruptures

1. Partial cranial cruciate ligament tears treated with stem cell and platelet-rich plasma combination therapy in 36 dogs: A retrospective study, Canapp et al., 2016
2. assessment of a single intra-articular stifle injection of pure platelet rich plasma on symmetry indices in dogs with unilateral or bilateral stifle osteoarthritis from long-term medically managed cranial cruciate ligament disease, Venator et al., 2020

 

The development of Osteosarcoma following TPLO

1. Osteosarcoma following tibial plateau leveling osteotomy in dogs: 29 cases (1997-2011), Selmic et al., 2014
2. Association of tibial plateau leveling osteotomy with proximal tibial osteosarcoma in dogs, Selmic et al., 2018
3. Osteosarcoma of the proximal tibia in a dog 6 years after tibial tuberosity advancement, Sharma et al., 2020
4. Retrospective analysis of corrosion and ion release from retrieved cast stainless steel tibia plateau leveling osteotomy plates in dogs with and without peri-implant osteosarcoma, Specher et al., 2018

 

Comparative Literature on Anterior Cruciate Ligament Ruptures

 

Spontaneous healing of a ruptured anterior cruciate ligament: A case series and literature review

Leonardo Previ, Edoardo Monaco, Alessandro Carrozzo, Gianluca Fedeli, Alessandro Annibaldi, Matteo Romano Cantagalli, Giorgio Rossi, Andrea Ferretti, 2023

This literature review highlights that spontaneous healing can occur in patients that cannot undergo surgical stabilisation, but that evidence is still not clear on the predictors of healing, clinical outcomes or the most successful rehabilitation protocols.

 

Healing of acute anterior cruciate ligament rupture on MRI and outcomes following non-surgical management with the Cross Bracing Protocol

Stephanie R Filbay, Matthew Dowsett, Mohammad Chaker Jomaa, Jane Rooney, Rohan Sabharwal, Phil Lucas, Andrew Van Den Heever, James Kazaglis, Justin Merlino, Mick Moran, Maggie Allwright, Donald E K Kuah, Ra Durie, Greg Roger, Mervyn Cross, Tom Cross

A sample of 80 ACL rupture patients were managed with a cross-bracing protocol, including joint immobilisation at 90 degrees of flexion for four weeks, then progressively increasing ROM until brace removal at 12 weeks. At three months, 90% of the patients showed evidence of ACL healing. The majority of patients with a Grade 1 tear (92%) returned to sport, while 64% of patients with a Grade 2–3 ACL returned to sport.

The authors highlight that longer-term studies are needed to inform clinical practice.

 

Ligament healing after anterior cruciate ligament rupture: an important new patient pathway?

Florian Forelli, Jérôme Riera, Jean Mazeas, Claire Coulondre, Sven Putnis, Thomas Neri, Alexandre Rambaud

This review of the literature concludes that while spontaneous ACL healing can occur, non-surgical treatment options are not appropriate for every patient. Conservative management should be discussed and approached with caution, especially in the case of athletes.

 

From Dr Narda Robinson: Wait, Don’t Cut

 

Conclusion

After reviewing these research articles, has your perspective on surgical vs non-surgical management of CCLR changed or adjusted?

I feel greatly encouraged and excited about the literature coming out that supports non-surgical treatment approaches for CCLR, as there is a large patient demographic that are not ideal surgical candidates. From the outcome assessments in these articles, I feel confident that we can ethically offer a group of patients conservative management. However, this approach should be accompanied by an increase in physical therapy, a more intentional educational approach, and a long-term pain management strategy.

For athletes, I would still recommend surgical intervention.

In young dogs with a high risk of cancer, we also want to consider the association between TPLO and osteosarcoma. An alternative surgical approach or conservative approach may be more appropriate in such cases.

 

I would love to hear your thoughts and what you will be taking forward from this article into your clinical practice!