Our dog Beau is a seven year old Golden Retriever and master of the household! He’s friendly, fun, energetic and spoiled! Unfortunately, we learned early in his first year that he also has hip dysplasia. Until now, this has not stopped him from having an active, doggy life. However, in late November we noticed some on again, off again limping and after a few days of this, we took him to the vet to check it out.
After an exam and x-rays (done under sedation) the bad news turned out to be a ruptured cranial cruciate ligament. Our vet said that this is a common injury in dogs, particularly large breeds and particularly dogs with hip dysplasia who tend to alter their gait and put added stress on the knee ligaments. While humans tend to tear these ligaments in sporting activities (the football player who misses the season due to a torn ACL), dogs put much more stress on their knees (stifles) and are more prone to rupturing these ligaments over time, without a significant trauma. We were presented with the following options for Beau:

1. No surgery. Treat with rest, physical therapy, pain and anti-inflammatory medications. Our vet did not feel that the ligament in a dog this size would heal on its own, however, and indicated that the likely outcome would be abnormal wear and tear leading to arthritis which would continue to worsen over time, becoming chronic and debilitating.

2. TPLO surgery (Tibial Plateau Leveling Osteotomy). This is a surgical procedure in which the head of the tibia is surgically altered and plated to create a new joint angle. A new angle is created in the stifle to prevent the femur from sliding off of the tibia. This surgery would need to be performed by an orthopedic veterinary surgeon and would be very expensive. We were never actually given an estimate for this surgery, but my research puts the cost in the $3,000 – $4,000 range. Our vet indicated that this procedure is considered by some to be the gold standard in treatment. However, due to it high cost and invasiveness, she did not recommend it for a seven year old dog.

3. Traditional Repair surgery (Extracapsular Imbrication). This procedure uses a strong leader line placed within the knee to provide stabilization. As it was explained to us, the downside of this procedure is that the line will eventually break and it is impossible to say when. It could be that the line lasts five years, or it might only last two months. With a large dog like Beau, our vet didn’t feel this was our best option.

4. Modified Traditional Repair surgery. This is the same procedure as in number 3 above, except that the dog’s own muscle is used to provide the stabilization, which is much stronger. As the area heals, it heals around this graft of muscle and further increases the knee stabilization. The cost of this surgery, as well as the surgery in 3 above, depended in part on whether or not the meniscus was damaged. The meniscus is the pad between the bones of the joint – a shock absorber. Estimates for this surgery were from $1,700-$1,900. Our vet recommended this option, which would be performed in their offices by a different veterinarian with extensive experience in this procedure.

To be honest, we didn’t give option 1 too much consideration. Neither my husband nor I could bear the thought of our middle aged (but not old), active dog declining early in such a painful manner. On the other hand, TPLO surgery was simply too expensive for us to consider and our veterinarian seemed to think this surgery would be warranted for a young dog, but not a seven year old dog. Option 3 seemed too risky and also was not recommended by our vet for a dog of Beau’s size. Thus, we elected for the Modified Traditional Repair using the dog’s own muscle to stabilize the knee. I was unable to find much information on this modified type of repair on-line, but it may be that there is a particular name for it which I was not searching under. I did see information on the Tightrope repair surgery, but our veterinarian felt that this was not in favor currently. One very sober fact: the vet told us that 40% of dogs that rupture the CCL eventually rupture the CCL in the other leg. Whatever choice we made, we best be prepared to make it again.
Unfortunately, we learned the next day that the veterinarian who was to perform the surgery was out of town for several weeks. The surgery was scheduled for December 8^th and our job was to keep Beau quiet and calm until then!

Our Dog Beau and His CCL Injury is a post from: Dog Knee Injury

How is Tightrope CCL Different from Extracapsular Imbrication or Traditional Repair?

The major difference between extracapsular imbrication/traditional repair methods and tightrope ccl is the way in which the knee joint is stabilized.  In a traditional CCL repair, a leader line (suture, or you can also think of this as a fishing line) is woven across the knee in a figure-eight pattern, connecting a bony protrusion on the femur to a small hole drilled in the top of the tibia.  The veterinary surgeon is able to access the knee through an incision on the knee a few inches long.   During the healing process, the leader line serves as a temporary way to stabilize the knee while scar tissue forms.  Eventually the leader line will break, and the scar tissue is solely responsible for providing knee joint stability.

In tightrope repair, a stronger material called Fiber Tape is used to connect bone to bone.  The FiberTape is held in place on the bone via metal anchors and small holes drilled through the bone.  The surgeon makes a few small incisions to access the points of attachment to the bone.  While the Fiber Tape will eventually degrade and possibly break over time, it is thought of as a superior material for larger dogs due to its greater durability and strength – buying your dog more recovery time.  While in place the Fiber Tape will act to control tibial thrust and prevents the cranial drawer sign, while allowing your dog to maintain full range of motion.

Both traditional repair and tightrope are considered to be minimally invasive procedures when compared to other surgical options like TTA and TPLO, which both involve cutting and changing of bone angles.

Tightrope Surgery vs. Extracapsular or Traditional Repair is a post from: Dog Knee Injury

Not surprisingly, surgery is almost always advocated by surgeons . It is likely that surgery does help reduce the amount of arthritis that occurs, but in a long term study of cruciate ligament surgery in dogs in Australia, about 50% still had detectable arthritis in surgically repaired joints and about 10% of dogs were persistently lame despite attempts to surgically stabilize the joint. Tibial plateau leveling osteotomy (TPLO) has become the top choice for surgical CCL repair among many orthopedic veterinarians, and it can be done in both large and small dogs. Supporters of TPLO will say its good choice for the situation in which there is a bilateral cruciate rupture since it seems to be a strong repair procedure, but there are many instances where dogs have done equally as well with either TTA or a traditional repair.

One benefit of doing a traditional extracapsular repair, in addition to saving a few thousand dollars, is that you still have other options for repair if for some reason the traditional repair fails. If you are choosing surgery for a dog with a double CCL rupture, make sure to research each procedure carefully before blindly going along with a procedure you know nothing about. TPLO, TTA and traditional repairs are all very different procedures, and each carry their own set of risks vs. rewards. The best way to find out what is right for your pet is to do as much research as you can and find a veterinarian that is willing to discuss your many options for surgical intervention.

If surgery absolutely isn’t an option, there is a very good chance that in a few weeks, to a few months, you will find that your dog is doing OK without any type of surgical intervention -especially if you can manage the weight loss. There are a number of great resources both on this website and the web with instructions on how to succeed with CM.

CCL Injury in Both Back Legs is a post from: Dog Knee Injury

Complications and risks associated with traditional repair techniques for cranial cruciate ligament surgery are as follows:

• Adverse reactions to anesthesia including nausea, vomiting, fatigue and in rare cases – death.
• Infection of the surgical site.
• Seroma – a build up of fluid at the surgical site which must be drained (aspirated).
• Allergic reaction to sutures or medications used.
• Allergic reaction to leader line, making re-operation for removal necessary.
• Patellar luxation – knee cap dislocation.
• Entrapment of the peroneal nerve – which can lead to paralysis and/or loss of the limb.
• Blow out of stifle joint, tearing of leader line. This requires surgical intervention and a TPLO is often used for repair.
• Tearing of mensicus.

Extracapsular CCL Repair Complications is a post from: Dog Knee Injury

During the extracapsular imbrication a large, non-absorbable suture is placed in a figure eight pattern within the structure of the knee. The leader line is placed around the lateral fabella through a hole in the tibial crest, mimicking the course of the CCL and preventing forward movement of the tibia, also known as the clinical drawer sign. The monofilament nylon leader line has a range of tensile strengths, and depending on the size of your dog, your veterinary surgeon will select a size between 40-100 pounds. Over time scar tissue will develop on the side of the knee joint where the large suture was placed, providing stifle stability in the absence of the canine cruciate ligament.

Extracapsular Imbrication Surgery, Traditional Repair Procedure is a post from: Dog Knee Injury

There are a few different surgical options for dogs with canine cruciate injuries, and not all veterinarians are trained in each procedure. It is important to find out from your vet what procedures they perform, and ask for referrals to specialists if you would like more information on a different type of procedure. There are vets the specialize in orthopedics and, if possible, it is preferable to choose a physician with this type of experience. Be sure to read up on each of the 4 surgical procedures before talking to your veterinarian about which one he/she recommends.

Surgical Repair Techniques for CCL Repairs:

1. Traditional Repair or Extracapsular Imbrication Technique – A leader line is woven in a figure-eight pattern through the joint beginning at the outer aspect of the femur to the tibial crest. The heavy suture will eventually be replaced by scar tissue providing support for the joint.
2. Tibial Plateau Leveling Osteotomy or TPLO – The head of the tibia is surgically altered and plated to create a new joint angle and prevent the femur from sliding off of the tibia. This procedure is an invasive on and involves cutting and plating of bone; it is associated with a higher rate of complications than the other surgical options.
3. Tibial Tuberosity Advancement or TTA – This is very similar to TPLO, yet considered to be less invasive, and involves stabilization of the stifle joint by cutting the bone and changing the angles of the knee.
4. Fibular Head Transposition – The head of the fibula is rotated and the lateral collateral ligament is moved in such a way that it mimics the cruciate ligament. The new positioning of the fibula is held in place using pins and wires. This procedure is not done very often and you may have a hard time finding a veterinarian that will actually perform it.
5. Tightrope Repair – An extracapsular technique using the lateral suture stabilization (LSS) procedure in conjunction with a material called FiberTape to provide bone to bone stabilization.   Similar to traditional repair, the joint will form scar tissue, but the Fibertape will also provide support for a greater length of time.
   

Surgical Repair Options for Cranial Cruciate Ligament Repair is a post from: Dog Knee Injury