Critical decisions in cranial cruciate ligament repair

May 10, 2016
Jennifer L. Wardlaw, DVM, MS, DACVS
Jennifer L. Wardlaw, DVM, MS, DACVS

Dr. Jennifer L. Wardlaw, pictured with her bullmastiff Emma Corilata, is a concierge surgeon at Gateway Veterinary Surgery in St. Louis, Missouri.Little known fact: Dr. Wardlaw says she isn't afraid to binge watch cartoons, even when her kids aren't around.

Painful and debilitating for patients, expensive versus less effective repair options for clients, WAY too many recommended surgical approaches for you. Are you limping toward the best plan?

(Getty Images)The patient: A 6-year-old, 60-lb male castrated American bulldog with unilateral cranial cruciate ligament (CCL) rupture. The dog's body condition score is 8/9, and he has an estimated ideal weight of 54 lb. His hips and contralateral knee appear healthy on radiographs. Despite receiving a nonsteroidal anti-inflammatory drug (NSAID), the dog has a lameness grade 4 of 5. His heartworm status is negative, and preanesthetic blood work and urinalysis results are all normal. The dog is a house pet but plays in the yard and often goes on long walks to the park or occasionally jogs with the owners.

What is the ideal way to treat this patient? Don't forget you must also consider if your case has these potential confounding factors:

Owner-related: Small children at home, finances, flights of stairs in the house or to get into an apartment, travel or work schedule, emotional state toward the animal, resistance to referral, previous experience with a CCL rupture surgery, upcoming travel plans.

Patient-related: Separation anxiety or cage aggression, not leash-trained, skin infection, hypothyroidism, diabetes, Cushing's or Addison's disease, other house pets, bilateral CCL ruptures, hip dysplasia, age, chronicity, meniscal tear.

Surgeon-related: Do you have the right equipment or training?

Here's the order of treatment interventions you might recommend to the client for this particular patient:

Best: A tibial plateau leveling osteotomy (TPLO) is so highly recommended because it has been so well studied, and the results, in the hands of well-trained surgeon, are excellent. Depending on the chronicity or other joint issues, rehabilitation can be helpful to an even faster recovery.

Next: A braided suture and bone anchor technique. Most of these specially designed braided sutures are three times stronger than 80-pound nylon. So this technique will be mechanically stronger than a lateral suture, but has the potential downsides of more equipment, a possibly higher infection rate and critical isometric landmarks. Similar physical rehabilitation would be used for this and the next several options.

Next: A lateral fabellar suture procedure, also known as an extracapsular suture technique. While small- and medium-sized dogs can do well with this and A LOT of physical rehabilitation, larger dogs can loosen or break the suture and show more progressive arthritis because of the lateral joint restriction with range of motion.

Next: A custom brace to allow the owner some time to save up for more definitive repair, continued NSAID use and physical rehabilitation. Custom braces must be molded for the leg of each particular patient. Simply buying a medium or large brace on the Internet is a complete waste of money for this disease.

Last: Conservative management (rest, nutraceuticals, continued NSAID use, additional pain medications and physical rehabilitation)

To say this is complicated topic is an understatement, so head to Cranial cruciate ligament repair: One size does NOT fit all for more thoughts on selecting the best option for each patient.