This is the total cost of the surgical procedure. It includes pre-op and post-op x-rays the day of surgery, IV catheter, blood work, the completed surgery, antibiotics, pain medicines, a post op sleeve for the affected leg and an Elizabethan collar.  Not included are any fees for follow-up visits.

Cranial cruciate ligament (CCL) - equivalent to the ACL in people - rupture is the most common cause of hindlimb lameness in the dog and one of the leading causes of arthritis too. There are actually two cruciate ligaments inside the knee: the cranial cruciate ligament and caudal cruciate ligament. They are called cruciate because they cross over each other inside the middle of the knee.

This can be a traumatic injury but more commonly it is a degenerative process, hence the term cruciate ligament “disease”.

The ligament is genetically weak from the start and over time they suffer micro tears that lead to mild episodes of lameness that seem to get better with rest until the next micro tear occurs. Eventually the ligament ruptures completely and those tend to be the dogs that are acutely painful and holding their leg up. 

When the CCL is torn or injured, the shin bone (tibia) slides forward with respect to the thigh bone (femur). This movement is known as a positive drawer sign. The resulting instability damages the cartilage and surrounding bones, leading to pain and osteoarthritis.

Diagnosis:

• Exam: This is the most useful part of diagnosis.  Our veterinarian will do a series of tests in the exam room that are very helpful in making a diagnosis.  Documenting a “cranial drawer” sign which often requires sedation as this can be uncomfortable and the dog’s strong muscles around the knee can prevent us from feeling this instability when they are wide awake. Additionally thickening of the knee due to inflammation and scar tissue. Sometimes a “click” can be heard if the meniscus is damaged.
• X-rays: Even though the ligament itself cannot be visualized on a x-ray we see changes on x-ray that confirm the diagnosis and help rule out other potential causes as well as surgical planning.

Treatment:

In some cases medical management may be attempted or recommended. Surgery is recommended often due to the size of your dog, the amount of instability in the knee, presence of a likely meniscal injury, the desire for optimum recovery and athleticism or based on other health issues related to your dog.

Non-surgical management

1. Weight management
2. Exercise modification
3. Joint supplements/adjunctive therapies
4. Pain management with anti-inflammatories and/or pain medications
5. Rest and professional rehabilitation

It is important to understand that after a full cruciate ligament tear. The ligament cannot heal. The body is attempting to cause long-term scar tissue or fibrosis of the joint to allow improved function.

Our biggest concern with medical management of cruciate disease is lower success rates and the potential for more muscle loss and arthritis.

It should be considered an ‘apples to oranges’ outcome, but one that can be suitable depending on age and expected outcome. Initially a six-week period of strict rest in a crate with leash walks only and dedicated professional rehabilitation is required. Planning to treat the inevitable arthritis and changing lifestyle should be part of the plan from the start.

There is no evidence that external supports or braces have beneficial value over that of rest and rehabilitation. Custom braces can cost upwards of $1000 and can themselves cause problems.

Weight management:

Reducing the weight of your pet is one of the most important ways to deal with the consequences of a torn cruciate ligament.

Exercise modification:

Regardless of whether surgeries are performed, regular and controlled activity or at-home rehabilitation are all important in the treatment of arthritis. This can include stretching, passive range of motion, swimming or leash walking and more advanced techniques are used by physical rehabilitation specialists. Consistent and regular low intensity exercise is much more favorable than high intensity exercise to reduce the onset of arthritis and flare ups of arthritic pain. The worst type of exercise is the ‘weekend warrior’ that sits on the couch all week and has a very long hike on the weekend. We want pets to be slim and well-muscled but avoiding high intensity.

Joint supplements/adjunctive therapies:

There is not a lot of evidence of a positive effect here, but we do know omega-3 fatty acids (dog specific) can slow arthritis.  Poly sulfated glycosaminoglycan (Adequan) is an injectable medication to lubricate joints, delay degradation of cartilage and is administered in a series of injections.

Pain management with anti-inflammatories and/or pain medications:

These are required in the initial stages and often again during flare-ups or as arthritis progresses.

Please consult your veterinarian for information regarding anti-inflammatories or pain medications.

Surgical Management of Canine Cruciate Disease

The decision to recommend surgery is based on a number of different factors. These can include the size of your dog, the amount of instability that is felt in the knee, the athleticism expected and the presence of other concurrent medical conditions. Surgical treatment provides the most predictable and best outcome for dogs over 30 pounds.

Osteotomy techniques are directed at the root cause of ligament tearing. Technically speaking they ensure the dog no longer needs an ACL and results in a dynamically stable knee. Unlike the human knee where the top of the tibia or lower leg bone has a flat surface, canine patients have on average a 25° angle on the top of the tibia. This means that putting weight down on the tibia results in a slide forward. This results in progressive weakening of the ligament and ultimately results in tearing of the ligament. After a ligament is torn, weight bearing is painful for the same reasons and can result in tearing of the meniscus, a shock absorbing disc in the knee. By changing the angle of the bones, we provide a long-term option that cannot be undone after it is healed.

The most commonly performed osteotomies are the tibial plateau leveling osteotomy (TPLO), Cora-based leveling osteotomy (CBLO), triple tibial osteotomy (TTO), closing wedge osteotomy (CWO) and the Tibial tuberosity advancement (TTA).

Our surgeons utilize the TPLO which has been performed for well over 20 years. 

A quarter circle cut (osteotomy) is made into the top of the tibia, and the bone is rotated to flatten the tibial plateau slope from the average of 25° to approximately 5°. A bone plate and screws are then used to keep the bone in the right place until it heals. This leveling turns the top of the tibia into a flat surface and prevents any sliding caused by weight-bearing. Your pet will bear weight on the limb within a few days of surgery and significantly faster than other procedures. Usually they are toe-touching on their way out of the clinic! There is generally no bandaging required either.

The metal plate and screws are holding the bone in place until the bone heals, which is generally the first 6-8 weeks after surgery.

Approximately 3% of patients will need to have the plate removed after healing has occurred due to infection or irritation.

With TPLO, 90% to 95% of dogs will have a good to excellent outcome where they are able to run, jump and play without noticeable lameness. 

Approximately 5% to 10% of patients will not reach the level of function that we hoped for. Even if your pet suffers a complication such as an infection or a late injury to the meniscus, they can still have a good long-term outcome with further treatments.

Long-Term Outcomes:

There is a 98% chance that you’ll be happy with your pet’s long-term healing after the surgery at our office.

Surgery success depends on a few factors:

1.  How long has the leg been injured?  The longer the injury, the worse the long-term outcome.  Arthritis sets in quickly after a torn ACL, causing meniscus and cartilage damage that we can’t reverse.
2. Older animals and overweight animals heal slower and have more complications.
3.  Pets that are hyper or hard to confine heal slower and have more complications.  These complications include delayed bone healing, incision infection, or stitches that pop out too early.