Cruciate ligament surgery in dogs or dog knee surgery

 

 

Commonly asked questions about cruciate ligament surgery

What is the likely success rate with your operation in your hands?

96% return to ‘normal’; ie : the walking/running capabilities the dog had before the rupture of the cruciate ligament. 2% chance of being slightly lame. 2% failure rate.

What are the treatment choices for my dog?

Extracapsular suture
Intracapsular techniques with use of grafts
Bone sawing/osteotomy techniques.

Why do you choose your skin graft technique?

It has a very long track record, the principles of the technique having been invented in Finland in 1952 with modifications since, and I have audited the results of my clinical cases in 100 dogs of many breeds and sizes and ages over a 15 year period (see vets section on this website)

I choose skin as my preferred graft because published papers in the 1960’s and 70’s showed it was better than nylon or fascia (Vaughan 1966 at the Royal Veterinary College).

No other technique replaces the ruptured cruciate ligament in the position in which it achieves re stabilisation of the stifle joint, which I believe is essential to the restoration of normal function in the long term.

Sawing the bone without replacing the ruptured ligament seems to me like an idea that no human patients would contemplate for themselves, so why would they think of doing it for their dogs?

Premiership footballers (humans) have their cruciate ligaments repaired using tunnel and graft techniques, and they can still be playing in the same League 10 years later.

Have a look at this website which illustrates how the surgeons approach the problem in humans:

http://www.biomet.com/patients/sportsMedicine/aclProcedure.cfm

What are the costs of each choice of procedure?

Using a skin graft with 2 bone tunnels in my chosen technique costs between £1000 and £2000,depending on size of dog and complexity of the particular case.   This is an all inclusive price including the x rays, anaesthetics, post operative medication.

Extracapsular suture is likely to cost about £1000.

Bone sawing/osteotomy techniques commonly cost in the region of £4000.

What is the potential for things to go wrong?

My results show that there is only a 2% chance of the operation ‘failing’ which has been judged by myself and my clients in that the operation has failed to restore the leg to normal function with the ability to play, walk and run. When the operation has failed, it is usually within the first 3 months after the operation when perhaps the skin graft has not healed properly or the graft itself failed, or the dog has exercised too violently before the end of the strict 3 months post op period of ‘strict lead exercise only’.

This compares to published results for bone sawing techniques where the quite serious complication rates can be in the range 8% to as high as 25%.

If the operation does fail, what can be done about it?

In the small number of cases where the operation has failed, one was a very old Yorkshire Terrier so it was decided that the old dog should have a choice and not go through another operation, and he was happy to potter around with a limp for his last year or so.

The procedure does not alter the alignment of the leg (bone osteotomy techniques do), and the situation in a failed operation using the tunnel and graft techniques is almost the same as it was before the operation was carried out.

It is a relatively uncomplicated procedure to repeat the operation and insert another skin graft, which is highly likely to succeed.

This compares to very serious potential complications with bone sawing techniques where there have been failures of the stainless steel plates and/or screws, and the potential for arthritis to develop seems to be much higher with the bone sawing which is a much more aggressive technique than using a skin graft.

The costs of attending to the 1% minor complications and 0% major complications with the skin graft technique in my hands is very small, perhaps a few hundred pounds if the need arises.  However, the costs of correcting complications from the bone sawing operations used elsewhere can amount to many thousands of pounds as I have discovered from telephone calls and meeting clients who have experienced this.

What are the chances that the opposite leg will need surgery?

My results with my technique show that there is about a 10% chance that the opposite leg will need surgery for the same problem.

This compares to most other published results where the chances range from a minimum of about 50% to 80% chance.

How long have you been using your technique?

Since I qualified in 1979 from Cambridge University where I was taught how to do it.

If you have a question that is not answered above, please contact me and I will try to answer it for you.

How do vets and clients ulimately make their decision to recommend or choose a particular surgical technique for a surgical correction of a ruptured cruciate ligament?

The late Professor Leslie Vaughan at the Royal Veterinary College told me he always got excellent results with the tunnel and skin graft technique, so before he died I was privileged to ask him 'why did you choose to change your technique?'  His reply was 'simply because of fashion.'

There is an increasing interest in evidence based medicine (EBM) whereby vets have tended to start looking more earnestly and critically at the evidence for choosing a particular technique or surgeon, and what facilities might be best for the patient.  There is little published evidence suitable for making comparisons between techniques, and a key reason why comparisons have not been made has been a lack of recognition of a research instrument or method that can consistently demonstrate the outcome evaluation.  I have been doing a piece of research looking into what the profession considers the best and most practical outcome measure to be, by using a questionnaire.  I am also interested in having dog owning clients fill in this questionnaire to get their views on how they evaluate the success or otherwise of the surgery for themselves.  If you would like to participate in this survey, please email your request for a questionnaire and one will be forwarded to you (email : admin@astonlee.co.uk  ref : cruciate questionnaire attention Paul Manning).  Alternatively you can copy and paste the questionnaire below.

 

By doing this research I hope to be able to produce what is called in the jargon a 'Health Related Quality of Life (HRQL) instrument which is widely accepted'.  With this development should come a greater critical awareness of the different surgical options available, which I hope will help to deliver better and better patient care for the future.

How quickly after the dog has suffered the cruciate ligament rupture should the surgery be done?

There are some conflicting thoughts on this because the aim of different surgical techniques varies in the degree of stability the choice of operation will achieve.  The results I have seen from my own surgeries include many dogs who have waited from 7 days to up to 2 years before having their operation.  Sometimes the reason for the delay has been a need to give a few days' notice to book the dog in for the surgery, to the reason that a client may have had to save up for the operation over a period in excess of 6 months, and some clients have eventually found their way to my surgery after hesitating from between 1 and 2 years under the care of a vet who may have been less positive about the potential outcome or may have had reservations about operating at a senior age of a dog for example.  In all of these cases, the outcome has been excellent and still within the 96% success rate reported in the vets section of this website.

So the answer to this question is that whilst surgery should not ideally be delayed more than 2-3 weeks because instability can cause early onset of arthritis, there does not appear to be any deleterious effect by delaying 2-3 weeks.  This is important because some clients have made arrangements to go on holiday or go to an event that has been planned a long way in advance, and it is useful to know that a short delay does not appear to affect the outcome.  It should be stressed that cruciate surgery is definitely not an emergency situation requiring immediate attention.

 Will my dog have to be in a plaster cast, cage rested, and any other constraints during the recovery after the operation?

With the technique I use (a skin graft and two bone tunnels) the main instruction for dog owners is to keep the dog on a lead for exercise for 3 months after the operation.  There is no need to keep the dog in a cage and I encourage owners to walk their dogs starting with a hundred yards in the first 2 days, and gradually increasing to 3 or miles a day towards the last month of the recovery period which is normally 3 months.  There is no plaster cast or bandage.

This contrasts to dogs which have the TPLO or some other bone sawing techniques where the advice frequently given is to cage rest the dog for 6 weeks after the operation to allow time for the elected osteotomy to heal with the plate and screws in place.

The other point here is that there ius evidence from my own work (see vets section on this website) that replacing the torn ligament with a graft can restore joint stability with a very high success rate as measured by the reduction and elimination or minimising of the cranial drawer and the restoration of limb function  In the technique chosen by many vets to use TPLO and/or other osteotomy procedures, there is no agreement on what the reconstruicted joint and bone alignement should look like.  This is a critically important point in my view because the aim of the surgery needs to be clear in order to maximise the chances of success.  The key questiuon for those advocating the TPLO is how many millimeters should the angle of the tibial plateau be in any given breed, age and weight of dog?  Secondly, how is it possiblt to know that the angle created immediately after surgery will remain the same over the passage of years when some bone remodelling and potentially some osteoarthritis develps?  These are very difficult questions to answer because it is argued that every dog is different, but then it should be possible to calculate the angle for any given dog from principles, but there is no wide agreement on this in the veterinary community.

On the other hand, using the graft technique that I use, the key question is what should the cranial drawer movement be when the surgery is completed?  That is easy to answer : it should and can be 0mm.  In some cases which have a huge cranial drawer movement before the surgery, I have found that the clinical outcome cvan be equally as good if the cranial drawer is reduced to within the range 0mm to 1mm. 

 

I have heard that grafts are not favoured by many vets in larger dogs because of a fear of failure of the graft, and that is why many vets recommend the TPLO or other bone sawing techniques?

 

The evidence from my results over the past 30 odd years (see vets' section on this website) is that the same technique of using 2 bone tunnels and a full thickness skin graft works equally well in a wide range of breeds, bodyweights and ages of dog from the tiny Yorkshire Terrier right up to the Giant brred such as the Great Dane.  The photo on this website of a skin graft which was placed in a large labrador 8 years before he reached the end of his natural life at age 15 years illustrates the survival and integrity of the graft many years after the surgery.  The science of transplantation medicine is a fascinating one, and there are many examples in human medicine where organs and tissues have been used to replace damaged or diseased structures.  One of the points that has attracted me to this skin graft technique is that it offers the patient the chance of a restoration of the original ligament with a natural graft which can restore and replace the torn ligament, and survive in the body without risk of any mechanical failure from insertions of metallic or other non biological materials.

Additional reading can be done by visiting our Vets section

 

Clinical decision making in canine cruciate surgery.

 

This website (www.tiggerpoz.com )  is a very interesting one, which very largely echoes my opinions and findings over 30 years of practice and reading the literature on the subject.  I find it heart warming to find people out there who actually agree with me on a few things at least!

 

There are two pieces from this website that particularly caught my eye.  The first is that a commercial form Arthrex in the USA with whom I am familiar are promoting the use of their ligament replacement material which they advocate as having the properties of durability, strength and longevity, properties which they assert are string reasons for choosing this technique for restabilising the stifle joint.  I have found this in my literature searches before, and have thought for many years that if there was a material that vets could agree would have those properties and be capable of replacing the ruptured ligament in restoring joint stability, vets would be persuaded that it would be the best method available to them.

 

The piece that interests me is that I believe that the best material for the purpose is the dog’s own skin.  Part of the evidence for the survival of the skin graft long term is on my website (vets section) in a picture of the microscopic appearance of the graft in a stifle joint of a 15 year old Labrador in which I placed the skin graft 8 years earlier.  The owner kindly agreed for me to do a post mortem because she was so pleased with the outcome for her dog and wanted to be able to share this information with other dog owners.

 

The evidence that is required to produce the high grade research papers that would be stronger evidence in the peer reviewed literature is prevented from becoming reality because there is no widely agreed method of evaluating the outcome of the cruciate surgery.  If this was agreed, as it is in human surgery (although still with lots of ongoing debate;eg: the IKDC system which you can Google), it would be possible to collect vastly more cases to pool together from around the world to produce an evaluation and comparison with much greater statistical power.  I attach a couple of questionnaires that I have designed and have been using to capture data from vets and clients evaluating the clinical outcomes.  I would be interested in your opinions and thoughts on these, especially if and when you choose to have surgery on your dog.  If you would fill in the questionnaire and forward it to me that would be much appreciated as I am gathering the opinions of dog owners.

 

Much of the website (www.tiggerpoz.com) questions the validity of the clinical decision making and the use of rigorous evidence based medicine in cruciate surgery, and I support that challenge.  My efforts to challenge the peer reviewers and orthopaedic surgeons in their clinical decision making have so far not met with acceptance, but there is a small but growing interest that I hope to be able to cultivate by encouraging dog owners and vets to contribute to the debate, research and discussion using the questionnaires and feedback.

 

The evidence that I have produced on my own website has been challenged.  However, the data is from real cases and 100 of them followed over 15 years.  The biggest problem I have is that most vets do not believe the results, but as clients have been involved in the evaluation as well as myself, many clients empathise with the results because they represent their peer group.  I also believe that ultimately the clients are the best judge of the outcome because they are observing their dogs for many hours each day in their daily activities, often for many years before and after the suergery, and clients can see if their dogs can return to the agility competitions, running 10 kilometers a day with the owner, and other activities, and that to me sounds like the best way of evaluating the outcomes.  Clients who have chosen me to operate on their dogs have testified to this return to normal activity after the surgery.

 

I appreciate the need in some dog owners wanting to wait and see if healing takes place without surgery.  I have seen many dogs over the years in which the decision to operate or not to operate has been taken very seriously.  If surgery is the choice made after a period of conservative management, it is good to have seen what level of activity can be achieved without surgery first.

 

References:

 

The Arthrex company, a maker of surgical equipment, developed a high-strength stifle stabilization procedure they call 'TightRope CCL'.  Arthrex sells a 'TightRope' kit for surgeons.

http://www.arthrexvetsystems.com/int/mediacenter/upload/TR-CCL-WHITE-PAPER-2007.pdf

http://www.innovativeanimalproducts.com/pdf/TightRope%20CCL%20MultiSite%20Data%20Aug%2009.pdf

'Securos' is another company which makes surgical equipment and supplies. They call their high-strength stabilization procedure "Securos XGEN CCR" and sell a kit for surgeons to use in performing it.  http://www.securos.com/downloads/XGEN%20CCR%20Manual.pdf

 

 

  

EVIDENCE BASED PRACTICE : QUESTIONNAIRE ON EVALUATION OF LAMENESS AND SURGICAL OUTCOMES

This should only take 10 minutes of your time, and I am very grateful for your opinions.  Hopefully this will help to contribute to the improvement of outcomes for dogs who find themselves in need of surgery for cruciate ligament problems in the future.

About you. 

Please circle all that apply to you.  If you normally own a specific breed of dog, please write the name of the breed in the box provided:

 

 

Owned a pedigree dog	Never owner a dog which had a problem with a cruciate ligament	Owned a dog which had surgery for cruciate ligament problems	Dog owner
Owned a cross breed dog	Owned a dog with a cruciate ligament problem but did not have surgery	Owned more than 1 dog which had to have surgery for cruciate ligament problems	Owned a dog(s) 0-5yrs
	Name of breed normally owned:		Owned a dog 5.1-10yrs
			Owned a dog more than 10 yrs

 

Evaluation of lameness.

 

How important are the following parts of your assessment of dogs preceding and following cruciate surgery regardless of the

 chosen surgical technique?  Please put a tick in the box which most closely matches your answer, or circle

‘Yes’ or ‘No’ answer where indicated.

 

 

Not used at all (0)

Nor very important (1)

Important  (2)

Very important (3)

 

 

	0	1	2	3
How important was your assessment as Dog Owner at the first consultation of your dog’s  lameness?
How important was your assessment as Dog Owner on the overall outcome/.lameness at the final post op examination?
I think I would have no doubt distinguishing between a) no lameness at the walk and run, b) slight lameness at walk and run; c) severe lameness at walk and run?	0	1	2	3
Clinical audit of the surgical results is carried out and made available to you;ie: track record of the surgery is made available to you.
The evaluation of the lameness of the dog before and after the surgery is based on a simple scale such as zero, slight, severe lameness.
Your own evaluation and opinion about the lameness based on your observations as the dog owner.
Force plate analysis of the outcome : ie: a computerised method of measuring lameness without human observation.
The final outcome is assessed more than 6 months after the surgery.
The assessment includes a minimum of 6 criteria that are evaluated subjectively or objectively and recorded for analysis.
In evaluating lameness before cruciate surgery, as a dog owner I use the following parameters: 1.ability to run
2.ability to walk
3.  Ability or inability to put weight on the affected leg.
4. .ability to climb stairs
5. .ability to sit with legs in the normal position
6. .ability to get up in the mornings without difficulty
7. .ability to jump over small fences/objects
8. .ability to play ball
9. .ability to walk more than 2 miles without a problem
10.other?  Either: Yes there is another method of assessment or No, there is no other method of assessment that I would expect to to be used in practice (Please circle your answer) 10a.  If there is another method of assessing the outcome not mentioned here, how important do you consider it is?	Yes	No	--------	........
In evaluating lameness after cruciate surgery, as a dog owner I use the following parameters: 1.ability to run
2.ability to walk
3. Ability or inability to put weight on the affected leg.
4..ability to climb stairs
5..ability to sit with legs in the normal position
6..ability to get up in the mornings without difficulty
7..ability to jump over small fences/objects
8..ability to play ball
9..ability to walk more than 2 miles without a problem
10..  Ability to return to all the activities enjoyed before the cruciate injury/disease occurred for more than 1 year after the surgical operation.			….	….
11.Other.  Either : Yes I would expect another method of evaluation not mentioned here, or No, I would not expect another method of evaluation to be used in practice. (Please circle your answer)	Yes	No
11a.  If your answer to question 10 is ‘YES’,  how important do you think it is?

Decision making in cranial cruciate problems in the dog.

 

This second part of the survey is about how decisions are made by vets and clients in choosing a surgical technique for a dog

 with a cruciate rupture or disease.      Please circle your answer using the guide below;eg: 0 = disagree strongly, 3=agree strongly.

 

 

Guide for your answers

Cruciate ligament surgery in dogs : questionnaire for all interested people. Question:

Disagree strongly (0) Or: Yes Or: Simple number choice

disagree (1)

Agree (2) Or: No Or: Simple  choice

agree strongly (3)

 

 

Cruciate ligament surgery in dogs : questionnaire for all interested people. Question:

0

1

2

3

1	I feel it is very important that the risk of complications that potentially could render the leg useless after the operation is considered.	0	1	2	3
2	I place a high importance on the complete return to normal;ie: to the level of activity the dog had before the injury or disease was diagnosed.	0	1	2	3
3   3a	I believe it is possible to achieve the level of success that returns the dog to ‘normal’;ie: whereby the dog can do all the activities enjoyed before the cruciate problem occurred, with a surgical technique. I have seen at least one case where the vet and the client both agreed that the dog had returned to ‘normal’ for more than 2 years after the surgery took place.	0     Yes	1	2     N0	3
4	I feel it is important for the vet to know the evidence base for the recommendation of the choice of cruciate surgery for the dog?  Ie: the vet has considered his/her own practice experience and studied published work	0	1	2	3
5	I feel it is important for me that the vet illustrates with diagrams and/or models the reason for his/her selection of the surgical procedure?	0	1	2	3
6 6b	The cost of an operation is one of the strong  influences on the choice of procedure. If the dog is insured, the cost of the operation has no influence on the choice of surgical technique.	0 0	1 1	2 2	3 3
7	I feel it is very  important for me to know the relative success rates and complication rates before choosing the method of surgery for the dog.	0	1	2	3
8	I feel it is important for me to know what will be able to be done in the event of a major complication, should one arise.	0	1	2	3

9

I feel it is important to consider the likelihood of needing an operation for the same problem in the opposite leg when deciding on the choice of operation for the first leg.  (This can vary between individual  dogs and choices of surgical procedure).

0

1

2

3

10   B C D   E F   G   H	I would  be prepared to share information between vet and client  about how the risk of infection will be minimised. Are you aware of RCVS (Royal College of Veterinary Surgeons) Standards for veterinary practice? Are you aware that there are different standards in veterinary practice? Are you aware of the use of clinical audit in any organisations outside of veterinary practice?   Are you aware of any clinical audit being done by your veterinary practice? Assuming checkups are included in the price, I feel very strongly that I need a minimum of 3 months checkups after the operation to ensure that the dog gets the best care. I feel that the minimum period of time needed for me to see whether or not the long term outcome of the operation was successful is more than 6 months. If the charges for checkups were extra, over and above the cost of the procedure, I think the post operative checkups would be discouraged	Yes   Yes Yes Yes   Yes 0   0   0	1   1   1	No   No No No   No 2 . 2   2	3   3   3
11	How many people in your circle of family and friends, including staff at the veterinary practice or specialist centre, would help you to evaluate the recovery from lameness after the operation? I feel that as the owner of the dog, my opinion contributes strongly to the evaluation of the outcome.	a) 0-2, 0	b) 3-5 1	c) 6-9, 2	d) >10 3
12 12.a.	I confirm that I am a dog owner. If the answer to question 13 was ‘Yes’ : How many hours in an average day would you, a family member or friend be with your dog?  A=0-6, b =6.1-12, c=12.1-18, d=18.1-24 hours.	Yes   a	b	No   c	d
13	Are there any questions that have not been asked that you would consider have a significant impact on your satisfaction with the operation?	Yes		No
14	If the answer to question 14 was ‘Yes’ how important to you was the question(s) that were not asked? 3.  Very important, 2 important, 1 not important, 0 of no consequence.	0	1	2	3
15	Name (optional)                                                             Email address (optional)

 

When completed, please post your questionnaire to : Dr Paul Manning, MA, VetMB, MSc(VetGP), DProf, MRCVS., Astonlee Veterinary Hospital, Tickford Street, Newport Pagnell, Bucks. MK16 9BA. 

 

 

 

 

 

 

 

 

  

 

Key question:

 

If cranial cruciate ligament surgery looks like the Howell philosophy incorporating the replacement of the torn ligament with a graft, why shouldn’t it look like this in the dog?

 

Reference:

 

 Kocher, M.S.,, Smith, J.T.,  Iversen,M.D.,  Brustowicz, K.,  Ogunwole, O.,  Andersen, J.,  Yoo, W.J.,  McFeeley, E.D.,  Andersen,A.F.,  Zurakowski, D.  (2011) Reliability, Validity, and Responsiveness of a Modified International Knee Documentation Committee Subjective Knee Form (Pedi-IKDC) in children with knee disorders.  American Journal of Sports Medicine 39 (5), 933-939.