Followup on an earlier question on ACL repair
Question: We are trying to decide whether or not to do an ACL repair on our 5 yr old 70 lb Newf-Chow mix. He apparently did some sort of injury to his left rear ACL last spring. At that time he was consistently limping and the diagnosis (after xrays and an exam under anesthesia by a Tufts orthopod) was 99% ACL injury. I have read about TPLO and been to the TPLO sites.
The situation now is that he does not limp as long as we do not exercise him. But a half hour of chasing a ball or a nice long walk at a moderate pace and he is limping again for the next couple of days and then he goes back to a more normal gait.
So he clearly isn't normal. 5 seems young to condemn a dog to a genteel lifestyle. And I don't know if we increase the risk of arthritis by not doing anything. But on the other hand it's very easy to keep him from limping (just don't take him on those nice long walks). And it seems like pretty major surgery. So I'm not sure the benefit is worth the risk.
Any thoughts welcome. And THANK YOU for your wonderful site!!
THANKS,--Mai-Lan
Answer: Mai-Lan
It is often hard for me to decide with certainty when it is best to attempt to repair a cranial (anterior) cruciate ligament injury and when not to. I feel pretty confident that dogs under 35 pounds really do about as well without repair of the knee as with it. I feel pretty confident that dogs over 90 to 100 lbs. do better with repair than without it. It is the dogs between 35 lbs and 90 lbs that are hard for me to decide about.
I really think that I would probably only consider the tibial plateau leveling osteotomy (TPLO) procedure at this time in a situation like yours. This repair procedure seems to work better in situations in which there are already degenerative changes in the joint, which is very likely with the duration of the injury (since last spring) at this time. Many veterinary orthopedic surgeons disagree with this advice, though. They feel that stabilization of the stifle is almost always better, using any of the currently popular techniques. I base my opinion on observation of the patients in our practice and a small number of studies that have followed dogs after cruciate ligament repair long term. The only problem with the TPLO surgery is that there are no long term studies that I have been able to find, so I am basing my opinion on shorter term studies and on the dogs who have had TPLO surgery in our practice. So far, they seem to be doing much better than I can remember dogs doing with any of the previous repair procedures but all of them have been operated on within the last two years, so I don't have long term results to report, either. We do not do any cruciate ligament repairs. We send all our patients who need this to surgical specialists in our area. I think if I did the surgeries I might believe in them a little more -- it is just human nature.
With that preamble in mind, I think that I would probably be comfortable advising a client of mine to consider TPLO surgery for a dog in your dog's age range and size, even after a delay in going for surgery. I have heard that this surgery is a little harder to do on really straight legged dogs, which chows often are, so you might want to ask the orthopedic specialist about this if you do go for a consultation visit prior to making a decision. On the other hand, it wouldn't upset me too much if a client of ours opted not to have surgery because I would think that over time their dog would do almost as well as the dog that had surgery.
I would probably recommend trying glucosamine and chondroitin supplementation, because studies in people seem to support a role for these compounds in stifle injury repair. I would recommend using aspirin or other pain relief medication on the days my patient was likely to become sore or was sore and would recommend moderate exercise on a regular basis.
I hope that this helps some. I know it is a little frustrating that I have such a wishy-washy opinion about this particular surgery but it is unfortunately a real reflection of how I feel about it.
Mike Richards, DVM 12/1/2001
Question: DearDr. Richards I have a 55lb boxer mix, just now 3 yrs, who loves to run, hop, jump and have fun. 1 year ago he hurt his left rear leg. To me it seemed to be due to an injury (I remember the day). However, he was diagnosed 2 weeks later with a torn ACL. After ~3 months of on and off rest (2-4 weeks at a time) he still became lame after any off-leash exercise. Every time he seemed heeled but then he would be in a great deal of pain for 2-6 days followed by recovery again. I finally decided on surgical stabilization (extra-capsular I think) even though they never got a significant "draw" on the knee. The surgeon did find a tear and removed 1/4 of the meniscal cartilage said to be damaged. The recovery was very slow and painful. He remained lame on this leg in that he never would bear his full weight on it nor would he sit on it or use it when going down stairs. Well now he does bear weight on it because he must. Several weeks ago the other (right) leg went lame! Again it seemed due to trauma. He is not using the leg at all yet.
My questins for you are: 1) How can this be degenerative when it seems to be due to trauma and he is so young? 2) Since you seem to be an advocate of medical treatment over surgical tell me how such a degenerative rupture can heel thyself? Does time just allow compensation? Why aren't other ligaments in the area degenerative? Does trauma make it worse? Why did he become lame every time he ran even with so much rest in between? 3) What does meniscal cartilage damage entail? Is this also degenerative or just due to the weakening of the leg? Is there any way to know if this has occured in the second leg before commiting to surgery? 4) Why do you think TPLO is a stronger repair? Would you wait till this technique is more established before going for it? I doubt I can afford it nor have I found a surgeon locally who performs it. 5) Without surgical repair, how long would you suggest for a better recovery - completely???? Even if it seems all better how long should I wait till he can be given some freedom? Or do I have to break his spirit (no off leash fun) in order to prevent him from experiencing such pain again?
Thank you so much for any advise you can give me.
Stacy
Answer: Stacy-
1) Not all cruciate ligament injuries in dogs are due to degeneration of the ligaments, that is just the most common cause in dogs. Traumatic injuries can occur in dogs just like in humans and are probably more common in very active, athletic dogs. This may be a more likely scenario given your dog's age, although it is a bummer to have traumatic injuries to both legs.
2) The ligament does not heal with surgical repair and it doesn't repair itself when surgery is not performed, either. Surgery has one of two goals, to stabilize the joint (most intra-capsular and extra-capsular repair techniques) or to change the angle of the tibial plateau to correct the tendency for the drawer movement to occur (tibial plateau leveling osteotom procedure). If surgery is not performed the joint capsule and tissues surrounding the knee will eventually scar enough to provide stability to the joint. I do not know with certainty whether it is better to try to stabilize the knee or just to wait. In searching for studies on this I have not found any studies that followed dogs their whole lives, or even for several years, to see if surgery makes a difference long term. I know that many of my clients opt not to have surgery and that I can not detect much difference between patients who have cruciate ligament surgery and those that don't over time but that is must one vet's subjective opinion. We have had several dogs have TPLO surgeries now and they do seem to do better than non-operated dogs, to me.
The cranial cruciate ligament is the most susceptible ligament to injury but all the ligaments in the knee can be injured. We see collateral ligament injuries on an occasional basis.
When the cartilage is injured along with the ligament there is a tendency for there to be more pain than when the cartilage is not injured. If it is necessary to remove a large portion of the cartilage the likelihood of long term pain increases, as well. Even when the stifle is surgically repaired most dogs still have arthritis formation and this is more painful for some dogs than for other dogs. Finally, there is a chance that another joint has weakness, especially the hips, or that there is also neurologic pain, such as might occur with lumbosacral instability or disc disease that might be present along with the cruciate ligament injury. Over time the signs of lameness may change enough to make it possible to diagnose one of these problems or it they may be found in further diagnostic efforts in a dog who doesn't recover well from the cruciate ligament injury.
3) Meniscal cartilage damage occurs because the cartilage is not firmly fixed to the bones and sort of floats between the bones (to a certain degree). So when the cruciate ligament is damaged and there is more movement between the bones the cartilage can be pinched or torn in the excess movement. When the cartilage is injured the subsequent arthritis in the joint is usually worse. It is possible to see cartilage damage with MRI scans in most cases and arthroscopy is also possible, although this is still a surgical procedure. Regular X-rays don't show cartilage damage at all and dye infusion wasn't too reliable in enhancing the X-rays enough to see the damage when that was the only other option. One of the best reasons to have surgery is the ability of the surgeon to look for cartilage damage prior to doing the surgical repair.
4) A small number of our patients (I think three, but that is just from memory) have had TPLO surgery. Subjectively, they seemed to have a much quicker return to function and they seem to have better long term function, so far, as well. I am susceptible to the placebo effect and have thought that a couple of other cruciate ligament repair techniques were really going to be better before finally resolving that I didn't see a lot of difference over the long term, so I can't say this won't happen with the TPLO procedures. I also don't know whether really long term consequences will occur because I think that about two years ago was the first time one of our patients had this procedure so there hasn't been much long term time to evaluate the procedure. However, the opinion among the surgeons who I know is that this procedure is working better, requires less after care ( probably a big factor in its success rate) and is particularly good for big or very active dogs.
5) For my clients who opt not to have surgery I recommend not engaging in things like Frisbee (tm) chasing for a couple of months, but do not try to restrict exercise other than that, except for the reduction the dog imposes on itself. I think that continuing moderate exercise is helpful but have not seen any studies to back up that opinion, either.
It is important that you understand that my opinion that dogs who do not have surgical repair of cruciate ligaments do about as well as those that have surgery, with the possible exception of TPLO surgery, is NOT the majority opinion among veterinarians. It is just one of my quirks and I could easily be wrong.
If this information raises more questions, please feel free to ask them.
Mike Richards, DVM 9/28/2001
Cruciate ligament ruptures in both back legs
Question: My 8 yr old mixed breed female dog was diagnosed 2 weeks ago with a torn cruciate ligament in her right back leg. Bed rest for 4 weeks was prescribed with Rimadyl. Last night I came home to find her not walking on her back legs at all; basically dragging herself around. I went back to my vet who said that she now definitely need surger for the right leg as the left one was also starting to shows signs of a tear. I am scheduling her for 5 days from now. She had a consult with an Ortho. surgeon who is the one that said surgery. He said the the success rate is 80-90% for these things. Is this correct? If not, at this point, do I have any other alternatives? Shes been on 50mg of Rimadyl along with glucosamine/MSM and Vitamin C. She currently weights 55 lbs and should be around 40 so she's on a diet. I just very worried about her as the total lameness came suddenly and we've ruled out any neuro problems.
Thank you Kathy
Answer: Kathy-
It is not unusual for dogs who have a cruciate ligament rupture in one leg to develop one in the other leg. It is a little unusual to have two severe ruptures at the same time but when it does occur, the signs are similar to what you describe. It is not unusual for veterinarians and pet owners to think that partial paralysis is present or that the severe lameness is due to spinal disc disease. It is good that your vet recognized this problem.
Surgical stabilization of the stifle (knee joint) is advocated by most veterinary surgeons when cruciate ligament rupture has occurred. Despite this, I can not find any studies that compare surgical repair to conservative treatment over the lifetime of dogs to show that surgery is actually beneficial when compared to long term comparison with medical treatment alone.
Three years ago we had a large German shepherd in our practice who ruptured both cruciate ligaments at the same time. Her owners were not able to afford surgery and so they just cared for her by supporting her rear with a sling so she could go outside with them and helping her up later when she needed help. After several weeks she could get around on her own and she shows no significant sign of lameness on yearly physical examination since that time, although I believe that I can palpate arthritis in the stifles and expect that eventually that is going to cause problems.
So this is the best way I can sum this up; surgery is almost always advocated by surgeons. It is likely that it 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. A new surgical technique is currently being used for cruciate ligament repair. It is called a tibial plateau leveling osteotomy (TPLO) and it can be done in both large and small dogs. It may be a good choice for the situation in which there is a bilateral cruciate rupture since it seems to be a strong repair procedure. On the other hand, if surgery 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, anyway. Especially if you can manage the weight loss --- it helps a great deal.
Good luck with this.
Mike Richards, DVM 8/3/2001
ACL surgery in large dog - arthritis risks
Question: Dr Mike, THANKS
He's still lame although better and has been examined under anesthesia by an orthopod. They still think "99% this is an ACL tear." I am hoping that the osteosarcoma question is less likely, as that X-ray was clear and it's now getting better rather than worse with time. Dog favors the leg when first getting up and while standing still, sits holding it straight out rather than tucked under him and gets up and down carefully but otherwise looks pretty normal and can take his weight on it to pee. We are pursuing "watchful waiting" until the fall because it's mild and it would be very difficult for us to do the necessary severe exercise restriction post surgery during the summer. Orthopod feels we are OK re not developing arthritis for this time. Arthroscopic surgery has not been presented as an option so we are talking open knee surgery.
Our questions at this point
- Other than the usual risks of surgery ie (anesthesia, infection) what are the risks of knee surgery itself vs leaving it alone (given that it's mild) with regard to long-term prognosis ie arthritis? What is done for an ACL - do they suture it?
- Should we be more aggressive with regard to investigating arthroscopic rather than open surgery? (the person who saw him is an orthopod at Tufts so this isn't exactly a backwater)
- Should we be more aggressive with ruling out injury to the other joints you suggest before agreeing to have his knee opened given that the orthopod seems pretty convinced that's where the problem is?
- Isn't 5 y/o in a 70 lb dog a bit young to have degenerative problems?
AARGH - this was supposed to be my exercise dog and we were doing GREAT until this happened!
THANK YOU AGAIN
Answer: Mai-Lan-
There is not a clear answer to the question about the risks of arthritis with surgery and without it. To the best of my ability to tell, no one has actually studied dogs that do not have surgery, long term, to determine the percentage of dogs that develop arthritis or that develop permanent disability. However, based on observing the patients in our practice over the last 22 years, I think that the differences between dogs who have had surgery and those that haven't have been relatively small differences in arthritis formation and in future use of the leg. I think that at least 50% of dogs who have surgery still have significant arthritis and that about 70% of dogs that don't have surgery have significant arthritis later. I can't recall a dog in our practice who had surgery, or who did not have surgery, that refused to use the leg later. I know that some patients in both categories developed very significant arthritis later in life, leading to great difficulty getting around, but I do not have a good feel for how much surgery improved the odds of avoiding this outcome -- or even if it did. I wish that I could find some sort of really long term follow-up for dogs with and without cruciate ligament repair but if this data exists I am currently unaware of it.
The ligament is rarely sutured. In almost all cases the remnants of the ligament are removed and then some sort of stabilization procedure performed which attempts to reproduce the effect of the ligament on the joint. In the past these have generally fallen into two groups of procedures, ones that attempted to duplicate the path of the ligament in the knee joint (intra-articular repairs) and ones that stabilized it externally, usually by using wire or large suture passed through holes drilled in the bone to provide stability. More recently, a new procedure, the tibial plateau leveling osteoplasty (TPLO) surgery has been developed. This procedure attempts to provide stability by changing the angle the angle of the tibial plateau (the top of the lower leg bone) to provide stability. This procedure seems to work better than the older procedures, especially for big dogs. It also has less follow-up care. It is a more complex procedure due to the need to remodel bone. At the present time I think that if my large breed dog needed cruciate ligament surgery this would be the option that I would chose. This is not a surgery that can be done arthroscopically.
Even though I think that it is always a good idea to rule out injuries to other joints, from a practical standpoint the odds that an injury causing decreased weight bearing without obvious fracture or luxation in a rear leg is a cruciate ligament injury is very high. If the surgeon finds evidence of laxity in the joint and didn't find anything obvious in any other joints that is sufficient for most veterinarians to focus on the stifle injury without worrying about the other joints.
We see cruciate ligament injuries that seem to be due to degeneration of the ligament rather than a sudden traumatic event in dogs as young as two to three years of age but it is much more common as dogs get to the six to eight year old range. So five years is a little young but not out of the possible range for this sort of injury at all.
It does not bother me when clients opt not to seek surgery for cranial cruciate ligament injuries, even in large dogs. My feelings on this might change if the TPLO surgery proves to be as good as it seems like it might be right now. Over time, it will become clear if this surgery really provides a major life-long benefit. The intra-articular and extra-capsular surgeries do not provide enough advantage, in my opinion, to make me feel like not doing them is a serious mistake. Lots of veterinarians disagree with me so it is important that you understand that this is just my opinion.
I do not know if the TPLO surgery is an available option but it is becoming a more widely available procedure and it might be worth asking your orthopedic surgeon, or your regular veterinarian, about this.
Mike Richards, DVM 7/24/2001
Cruciate ligament damage plus arthritis
Question: Hi, Dr. Richards,
My 14 yr. old English Springer Spaniel was diagnosed yesterday (via an X-ray) with a ruptured cruciate ligament in her right rear leg after limping around for the last 2 weeks. The X-ray also showed significant arthritis in the knee. She seems very uncomfortable. She cries a lot and is not eating very well. My vet advised me that surgery is the only way to fix it, and that due to the arthritis already present in the knee, he did not think it would help much.
Since the dog is already being treated for liver disease (CAH), he had me increase the her dosage of prednisone from 10 mg. every other day to 10 mg. every day, which hasn't helped much. He is reluctant to use NSAIDs due to the liver disease, even though she may be in remission (her liver values have been normal for the last couple of years, although the SAP is elevated, possibly due to the prednisone).
Given this scenario, would you consider surgery? Trying NSAIDs? Money is no object; I just want the dog to be as comfortable as possible for whatever time she has left.
Carol
Answer: Carol-
I wouldn't be pushing for surgery to repair the cruciate ligament in this situation, either, except if the pain persists. In that case, I would worry that the meniscal cartilage may be damaged in addition to the ruptured cruciate ligament. Damage to the cartilage probably occurs in about a fourth of cruciate ligament ruptures. Exploring the stifle and removing the damaged areas of the cartilage can alleviate pain and it is worth considering exploratory surgery for this reason if pain persists. After the stifle is examined it is relatively easy to go ahead and stabilize the knee to some degree at the same time.
If surgery is done it is best to try to cut back on the dosage of prednisone at least during the recovery period, to allow healing to occur without the interference of the corticosteroids. That may not be possible since she has the chronic active hepatitis problem, though. So that has to be factored into the decision making, too.
If the pain hasn't resolved or if pain relief is necessary post-operatively, it is possible to use narcotic pain relievers in dogs. Hydrocodone, codeine and morphine can all be used in dogs, when necessary.
Hopefully, the pain has mostly resolved and you are just dealing with the residual arthritic pain. In that case, the prednisone should help. We are willing to use carprofen (Rimadyl Rx), when it seems necessary, even with some pre-existing liver disease, but I can understand the reluctance to do this, since it causes liver problems in some patients. I rate the risk of using carprofen in patients with known liver disease as less than or equal to the use of prednisone on a daily basis, though. Of course, that's just an opinion and your vet is absolutely entitled to have a different one!
Mike Richards, DVM 6/5/2001
Question: Hi Sorry to hear that you have been ill; hope by now you're feeling much better.
I am a relatively new subscriber but I have been enjoying your material very much. I wrote to you a while ago about my lab/shephard mix who had developed a cough; well now he's developed another problem, I can not reach my vet until next week and I'm so worried about him I don't know what to do. He woke up last Sunday morning screaming in pain, when he walked his right hind leg just dragged behind him. At first my vet thought it might be a spinal injury but after x-rays and an examination he said my dog had torn the ligaments around his knee. He prescribed metacam and cosequin and told me to give him lots of rest. What sounded simple has turned into a nightmare. I began the medication on Tues.. On thursday my dog started barking excessively. On Friday he barked all morning and now on Saturday he has literally barked and howeled all day. He is exhausted, he has been wondering around on his sore leg all day and by now he is so tired and in such pain he can hardly walk. My dog is a very nervous animal who does not do well with anything new. Its quite normal for him to become a little disoriendted at times and wonder around the house whinning for a short time. But we've never seen anything like this. W're tried everything we can think of. I'm afraid he's going to die of exhaustion if I can't make him rest but he won't even put his head down. He's on so many medications I was wondering if this behavior could possible be some sort of drug reaction.
Medication taken: insulin phenobarbital ( he takes seizures) imodium ( he has IBD) salazopyrine cosequin metacam
If its not from the medication do you have any idea of what could be going on. Any info would be really appreciated.
Answer: R- There should not be this much pain associated with a cranial cruciate ligament rupture which is the most common ligamental knee injury, but there might be this much pain with injury to more than one ligament in the knee or with disruption of the collateral ligaments, although this sort of injury normally is associated with known trauma, like being hit by a car.
I really think that you should have him re-examined by your veterinarian. If that is not possible for more than a day or so, I would strongly suggest seeing another vet or looking for an emergency veterinary clinic if that is a service available in your area.
It may be necessary to re-take X-rays or to consider referral for more sophisticated testing such as a CT or MRI scan of the back if more signs of back problems have developed since the last exam. Many times, our initial diagnosis is based on mild or moderate clinical signs that get a lot worse -- and when they are worse, it is easier to tell what is going on sometimes. If that is the case, it may be possible to reach some conclusions without more sophisticated testing. In any case, you need to have a re-examination, as a minimum.
With the medications you mentioned, there are possible interactions. These probably aren't the current problem, though.
Sulfasalazine (I think this is the US name for the medication salazopyrine ) causes lots of other medications to have stronger effects because it competes for protein binding sites that carry the medication. When the binding sites are occupied by sulfasalazine, there is more of the active ingredient of the other medication in the blood stream. There are no specific recommendations to avoid any of the other medications on your list, though.
Meloxicam (Metacam Rx), is a non-steroidal anti-inflammatory medication. This group of medications can cause gastric irritation, although I have not heard of this degree of pain associated with that problem. Usually they just cause dogs to stop eating and perhaps vomit. They can cause ulcers, but even this is usually not painful enough to produce the type of vocalization you are describing. I do not know of an interaction with the other medications but meloxicam is not approved in the United States, so I can't check a package insert to see if these types of reactions have been reported.
Insulin dosage is affected by some of the other medications and if the sugar levels have changed as a result of new meds, that might be causing some of the problem. If salazopyrine is sulfasalazine, then it can cause insulin to be less active, as can phenobarbital and possibly the non-steroidal anti-inflammatory medications such as meloxicam (although I do not if it does this specifically, it is just in the right class). So perhaps the combination of all these effects has produced a problem with the maintenance of normal glucose levels --- but this is just another reason to get a re-exam by your vet so it doesn't change the advice.
I really think that the problem is that the knee injury is more severe than your vet thought or that another problem is present at the same time. Cartilage damage can occur when the ligaments rupture and it can be very painful. So that is worth considering. On the other hand, cruciate ligament injuries in pets come on gradually and it is possible for these to worsen quickly if the dog is walking abnormally due to another problem or even to occur coincidentally with another problem.
We are currently working with a patient who came in with a crouched walk and severe pain. We through bilateral rupture of the cruciate ligaments was very likely but it turned out this dog's knees seemed to be OK. Regular X-rays of his back failed to show a problem so we referred him to a neurologist who did an MRI exam and found that there was a significant problem with pressure on his spinal cord from inflammation around one disc space. It just didn't show up on normal X-rays. This is the sort of problem that can make diagnosis of pain difficult, so it may take several tries to find the source. Hang in there until you know what is wrong or the pain subsides.
Good luck with this.
Mike Richards, DVM 12/4/2000
Cranial cruciate ligament injuries
Question: I must ask about my dog who's had surgery on his knee. Again, please write just when you can. I can't imagine the amount of emails you must get, and I, of course, get lots of info from my own vet, and just appreciate your second opinion. I have a shepherd/husky -- 5 years old, active, active dog. He's torn both ligaments in his back knees. He had an operation a year ago on the left knee that never healed properly, and his right knee was just operated on 3 months ago. The right knee has healed beautifully. The left knee was operated on again, and the surgeon reported, "there was an area on the weight bearing surface of the lateral condyle where the cartilage is sclerotic and unattached to the subchondral bone." She said, she curetted this cartilage away. She also told me that often she sees cartilage problem in the left condyle in young dogs, but not in a 5 year old, and she couldn't explain why there would be this problem. I have my dog on a pet insurance plan, and so he was operated on by a specialist. What does this all mean? I have a hard time understanding all of this. From what my vet tells me, there may be permanent damage to the left knee, and he told me to see how the next 2 months go. What is the long term prognosis for him? I think with all of these operations, I've maybe prolonged his life a bit -- i.e., a pain-free kind of life longer than without the surgery, but I assume he'll have painful knees as he gets older? Should I be more careful about throwing a ball for him etc? Again, this is just another opinion I'm asking for, and I know it's difficult when you haven't seen the dog, but any information you can offer is so helpful to me. I feel much better when I know everything I possibly can on my dog's health. Thanks again for your time! Lori
Answer: Lori-
I can not find much information relating specifically to the area of sclerotic cartilage that is described, but I can give you some information regarding the general prognosis for dogs that have cranial cruciate ligament injuries, which I am surmising is the case with your shepherd/husky mix.
There have been several long term follow-up studies done on dogs with cruciate ligament injuries. Most dogs with this problem will have arthritis after surgical repair of the cruciate ligament but most of the time this will not be so severe that it interferes with a fairly normal lifestyle. These dogs won't be Frisbee (tm) catching champions, but they can get around well enough that almost all owners are content with the progress in follow-up studies. Late onset (older dogs) cruciate ligament injuries and cartilage damage are the two prognostic indicators most likely to produce an unsatisfactory outcome, though. In our experience, even dogs with cartilage damage are usually able to be mobile well into old age with the use of medications such as glucosamine/chondroitin combinations, non-steroidal anti-inflammatories (aspirin, carprofen (Rimadyl Rx), etodolac (Etogesic Rx)), by keeping weight under control and through moderate exercise on a regular basis.
Weight control is very important in pets that have arthritis or for which it is reasonable to expect that they will develop it, such as a dog that has had stifle surgery. Keeping a dog thin (at or just below ideal weight) can make a huge difference in the dog's ability to get around. If weight is a problem, start working on weight control now, for the best long term results.
The exercise maxim "use it or lose it" is true when it comes to arthritic joints. Regular moderate exercise, avoiding high stress on the stifle through activities such as jumping or sudden stops and turns, is beneficial. It is much better to encourage fifteen minutes of exercise every day than two hours of exercise one day a week, for instance. Swimming is probably the best exercise for dogs with damaged stifles but a swift walk or slow run is probably fine, too.
There is evidence that early use of glucosamine and chondroitin in people with cruciate ligament injuries is helpful in lessening the long term complications. There is no reason to believe those benefits wouldn't occur in dogs. If it is necessary to use non-steroidal anti-inflammatory medications to facilitate exercise (make it possible?) then I would advocate starting them early on, too. In general we start with aspirin and use the other medications as time goes on and they seem more necessary but your vet may have different advice for this situation based on his or her assessment of how your dog is doing.
Good luck with this. It would be better if there had not been cartilage damage but there is still a good chance for mobility well into old age, despite the presence of this problem, if you can control the other contributing factors to loss of mobility, such as weight gain and loss of strength from too little exercise.
Mike Richards, DVM 12/4/2000
Torn cruciate ligament in Sheltie
Question: Dr. Richards,
I have an 11 year old Sheltie with an approximately 4 year history of arthritis. He has recently been diagnosed with a torn cruciate ligament of the right hind leg. He was examined by his vet who recommended rest and Rimadyl to see if the leg would improve. It has improved somewhat, however, he is still limping quite a bit. He was further examined by an orthopedic vet who recommended surgery.
To further complicate the matter my Sheltie has recently been diagnosed with Cushing's syndrome. He is currently taking Anipryl and Cosequin DS and has shown a reduction in his liver enzymes. And is actually doing quite well at this time except for a decrease in his activity level.
My question is, in your opinion, do you feel the benefits of surgery would be worth the side effects and recovery time for him. We were told by the orthopedic specialist that the leg could improve on its own without surgery, however, arthritis might be a later concern. This is already a problem for Casey, which has been helped tremendously by Rimidyl. My main concern is his being sedated for the surgery with anesthesia and his seeming long recovery time.
He is a beloved member of our family and we want only the best for him. His quality of life is very important to us. The Cushing's diagnosis is a definite consideration as to his life expectancy.
Thank you for your time and consideration.
Thank you, Sandra
Answer: Sandra-
I think that the June issue of the VetInfo Digest, which is in the subscriber area, had information on cruciate ligament injuries.
Most dogs under 35 lbs. in weight will do just as well with surgery as without it, based on at least two studies of cruciate ligament injuries. Most shelties are under this weight. Obese dogs may benefit more from surgery than dogs who are closer to their ideal weight, though.
Hyperadrenocorticism interferes some with wound healing and would make aftercare of a surgery more difficult. It is important to understand the post surgical care prior to deciding to do surgery for cruciate ligament injuries, as it is difficult for some people to manage. If good aftercare is not possible it may be best not to do surgery.
Every veterinary orthopedic surgeon that I know recommends cruciate ligament surgery for any cruciate ligament injury. I think they are sincere in their belief that it provides a quicker recovery and less long term degeneration in the joint. Some general practitioners feel this strongly about surgery, as well. I think that many general practitioners are more ambivalent, though. Many dogs who develop cruciate ligament injuries already have significant arthritis, making the outcome of a surgery less important. In addition, most dogs do well enough that their owners are content with the progress within two to three months. We see lots of dogs whose owners can not afford surgery or will not consider it as an option. Almost all of these dogs eventually become comfortable enough, although arthritis is sometimes a problem later.
In the end, you still have to do what you think is best. I would really carefully consider whether surgery is necessary if your sheltie is less than 35 lbs. in weight and not obese, especially given the other problems present. If your vet does not feel strongly that surgery is necessary, or feels strongly that it is, that should be factored into your decision making, too.
Hope this helps some.
Mike Richards, DVM 8/4/2000
Anterior cruciate ligament (cranial cruciate ligament, ACL, CCL) repair
Question: Dear Dr. Mike
Our Aussie Sheppard mix who will be five in September had her ACL replaced in Mid January. She has always been very active. My wife took her out riding with her horse 2 or 3 times per week and I am a hiker so she usually went a couple of times per week with me in the mountains of Northern New Mexico for 4-5 hours. We do spend six months in Florida where she had the surgery. After the surgery we followed the instructions religiously and she made an excellent recovery up to a week or so ago when she injured her bad leg again (left rear) I have been careful to watch her closely on all walks and it seems that she only gets in trouble at full cantor or gallop. When walking or trotting she is fine. After she hurt the leg we confined her pretty much for 3 days and have now started exercising her each day with short walks 10-15 minutes twice per day. Prior to this occurrence we were up to 30-45 minutes. Also try to take her for short swims a couple of times per week. My question is could she have just strained the tendon by over stretching or what? Also what should our therapy program be to regain her strength. It is now over a week and she is vastly improved limping only occasionally and usually if I remind her to walk walk she uses the leg. I want to get her back in shape to hike but in no way wish to rush it. Any advise would be appreciated
Thanks Steve
Answer: Steve-
In most instances of anterior cruciate ligament (cranial cruciate ligament, ACL, CCL) repair, the ligament is not repaired. Instead, some sort of stabilization of the joint is accomplished using natural tissue from the stifle, large suture material, surgical wire or realignment of the bony structures (tibial plateau or fibular head) so that the joint is stable until the joint tissues become strong enough to compensate for the loss of the ligament. Often, this "repair" will break down after several months to several years and this may result in temporary lameness for a few days to a few weeks while the joint responds to the new laxity. It is not possible to be sure this is what happened, but it is a possibility. Other possibilities include a sprain or strain unrelated to the cruciate ligament or meniscus (cartilage) damage that sometimes occurs in stifle joints secondary to cruciate ligament problems. There is also a reasonable chance that this the increase in exercise time was a little too quick and she has muscular, joint or tendon soreness in another area.
As long as you continue to see progress towards more normal motion of the limb, this is probably not a major setback. It is usually best to rest an injury like this for a few days. Usually it does not take more than 5 to 10 days of rest. Then start back to about 50% of the exercise level you were at when the injury re-occurred. Then add about 10% per week to the exercise level until you are up to the level you need to be at. It is hard to go this slow and sometimes it isn't necessary, but I find from personal experience that my knees do a lot better if I stick as closely as I can stand to this sort of recovery period.
Hope this helps.
Mike Richards, DVM 6/12/2000
Question: Dear Doctor Richards, My four year old beagle, Hershey, was diagnosed with hip dysplasia about three years ago. Immediately following the diagnosis, I took him to Cornell Vet School; they said he that although he was limping, he was "compensating nicely" for his dysplasia and "was not a candidate for hip replacement". They advised me to put him on a diet (he weighed 45 pounds) and to give him rimadyl. He was limping pretty badly at that time despite the pills, so I took him to a new vet who was licensed to do acupuncture. That vet told me the real cause of Hershey's limp wasn't his hip dysplasia at all, but a torn cruciate on the opposite knee, probably injured because of his weight and the irregular gate he had developed due to his hip. About three months into the acupuncture, he ruptured the ligament entirely and had surgery. He seemed to recover completely from the surgery. Currently, he does not limp and is quite active, despite the hip dysplasia. My question is: what else can I do for him to help him have the longest and best quality of life? Most specifically, would some type of canine chiropractics help? He is currently on Cosequin, vitamin E, C and selenium, gets regular, moderate exercise and has lost over ten pounds . I never resumed the acupuncture after his recovery as he showed no outward signs of pain or limping; I also took him off rimadyl for the same reason; yet, I often wonder if he's in pain, and I can't tell. My vet thinks I am over-reacting and says to just keep on doing what I'm doing. In short, I love this little guy, and want to give him the best care for his condition and the best possible future. Everytime I see an old dog with arthritis, I get so nervous, wondering what old age will bring Hershey with his joint problems. Is early or severe arthritis inevitable with this his condition, or can I be doing something else now to prevent it? Is it likely that he will tear the other cruciate as he is very bowlegged? I'd hate to have him go through that experience again. Any advice you could offer would be greatly appreciated. Thank you, Laurie
Answer: Laurie-
Cranial cruciate ligament rupture is a common problem in dogs. Most of the time it occurs as a long term degeneration of the ligament, similar to the history that you describe. Approximately 40% of dogs with cranial cruciate ligament rupture in one leg will experience a rupture of the cranial cruciate ligament in the other leg, usually within a couple of years of the first one. Since this is a degenerative disease, it is hard to prevent the rupture of the ligament in the other leg.
At the present time, a limited amount of research supports using chondroitin and/or glucosamine to help prevent degeneration of the opposite joint. I am not sure whether this will be supported over time by other research but it seems to be a safe combination of medications, so continuing the Cosequin (tm) is a good idea, since it contains these ingredients.
Weight control helps a great deal with almost all orthopedic problems so it is very good that you have been able to get Hershey to lose weight. Moderate exercise is also a very good idea.
I don't think that anyone promotes acupuncture as a preventative for further joint disease, so I don't think that stopping once pain is no longer evident is wrong.
I am not aware of any studies supporting or refuting chiropractic care for this type of injury.
I think that your vet is probably right. You are doing very good things to help Hershey to have a better chance of not rupturing the other cruciate ligament. You seem to be very in tune with Hershey, which makes me think that you will be able to tell when he is in pain, since subtle things like eating less, not wanting to be touched, hiding from you, decreasing exercise voluntarily and poor sleep would all probably be noticed. So not using pain relief medications chronically is probably OK. Since you are doing all the right things at this time, you are doing what you can to prevent future problems. This is a common enough problem that if any new information comes out, I will try to get it into the VetInfo Digest quickly.
Keep in touch with your vet and have Hershey checked out when you are worried. That really is probably enough for now.
Mike Richards, DVM 5/30/2000
Cranial cruciate ligament (CCL)surgery
Question: Dear Dr. Mike,
Thank you for your response to my request for a subscription as I have an immediate concern about a torn cruciate ligament in my lab mix four year old dog, Sadie. She weighs 70 lbs. The history is as follows. In Oct.,99 she began favoring her right rear leg and would hold it up about half the time she was up and around. My vet tried anti-inflammotory medication, I believe Rimadyl, on two occasions with no noticeable results. In mid Nov. 99, she had x-rays with a diagnosis of a torn ACL. He performed surgery that same day, and she came home the next day. I followed all post op instructions, but the improvement was very slow. She returned twice for staple removal and to have a fluid pocket drained. After several more post op checks from then until the present, he said everything felt solid and it would take time. However he did want to recheck the x-rays. She was put back on medications for pain and inflammation. This past week, after the x-yas he thought the sutures had come loose and wants to do more surgery to put in a stronger type af suture he described as a fish line type. I am not totally sure but I believe the original surgery involved an artificial ligament. I am very reluctant to have her undergo more surgery without more information or a second opinion. She walks about two or three blocks weather permitting on a leash daily, has some stretching of the leg exercises, but still holds it up more than I would think she should after three months. My vet has said repeatedly that this is a long rehab and will not be 100%. I would appreciate any advice, sources of information, that you could provide me with. Sincerely, Sue
Answer: Sue-
I have very ambivalent feelings about cranial cruciate ligament (CCL)surgery, based on a couple of problems that I perceive with it. These have been tempered somewhat by the introduction of a newer surgical procedure for repair of these injuries that seems to work better than the older ones in large dogs, which I will describe later.
Cranial cruciate ligament repair works better in the hands of some surgeons than in others. Part of the difference is probably in selection of cases and in the method of repair chosen. There are probably fifty different surgical procedures for CCL repair. This almost always means that none of them work well --- or there would only be one repair method. My guess is the 10 to 20% of the patients we see with cranial cruciate ligament injuries have surgical repairs. These dogs appear to regain use of the leg more quickly than dogs that do not have repairs, most of the time. At least two of our patients have actually taken much longer than average after surgical repair to recover, but surgeries always pose some risk, so this is probably to be expected. Over the long term, though, I see very little difference between patients whose CCLs are repaired and those that are not. Patients still develop degenerative joint disease over time and there is about an equal need to use medications to control pain and inflammation in patients who have had CCL repairs and those that have not, if you look only at the long term picture. Due to this, I have been reluctant to push hard for surgical repair of CCL injuries. There are some other advantages of surgery, such as the ability to repair cartilage defects and other injuries to the joint that might occur in conjunction with the CCL rupture. Disadvantages of surgery primarily involve cost and the necessity for aftercare that can be difficult for some pet owners.
The other side of this coin is that I don't recall ever meeting a veterinary orthopedic surgeon who wasn't convinced that CCL repair made a big difference, at least when they did the surgery. I don't say that to be sarcastic. I think that these vets are sincere in this evaluation. So I have always felt that my personal experience may vary somewhat from the norm in veterinary medicine.
Recently, a new procedure has been developed for repair of these injuries called a tibial plateau leveling osteotomy. It seems to work better for big dogs and it requires less difficult aftercare, making it even more likely to succeed. Dogs must still be restricted from exercise for several months, though. I can not be sure that the long term effect of this surgery will be any better but right at this point I would consider it for a dog of my own that had a CCL injury, based on the reports of success, so far. This procedure requires special equipment and training and it is probably going to be necessary for your vet to refer you to an orthopedic surgeon if you would like to consider having it done.
I can't evaluate your dog's condition, obviously. In my practice, I tend to advise either going to an orthopedic surgeon to have CCL repair done or to skip the procedure and hope for the best. That advice is based partly on my reluctance to do surgeries that I feel I won't ever do enough of to get really comfortable with, though. CCL surgery fits in that category given my practice area. Most of the time dogs adjust reasonably well, over several months (three to four) and will use the leg fairly comfortably after that, even without surgery. As I said at the beginning of this note, I am very ambivalent on this subject. I really do think I would consider TPLO surgery for one of my dogs, at this time, though. If someone is doing this procedure in your area it might be worth checking into.
Mike Richards, DVM 2/14/2000
Q: I have determined that the problem is in the dog's shoulder area. The top portion of her leg, approximately @ the shoulder joint is very sensitive. There also seems to be knotted or swollen portion. Are we still talking arthritis? My vet basically gave me the same advice as you did, although I have considered seeing an orthopedic specialist if nothing changes by Monday. Would that be pemature? Thanks for your previous reply.
A: It is possible that your dog may have bicepital tendon bursitis. That would cause lameness and pain in the shoulder region. This tendon is normally pretty painful when directly palpated if that is the problem. Your vet will know how to locate this tendon and see if it may be the problem. It is also possible that there is an arthritic problem in the shoulder joint or referred pain from somewhere else. If you are concerned and wish to seek a second opinion, I see no reason not to do that, especially since you are going to a specialist. It would make sense to call your vet and discuss where you think the pain is and consider a recheck with your usual vet since you feel you can localize the pain. That helps a lot in narrowing down the diagnostic workup necessary to confirm what is going on. It is often a lot easier to make a diagnosis on a second visit when the problem has had time to develop a little Mike Richards, DVM
Partial rupture of the cruciate ligament - Dalmatian
Q: Dear Dr. Mike- I wanted to give you an update about "Storm". We took her to the U. of Illinois and had her seen by a neurologist who then sent her to an orthopedic surgeon. A new set of x-rays were taken of the left knee and all came to the same conclusion-partial rupture of the cruciate ligament. We took her last Wednesday, she had surgery Thursday and we got to pick her up today at 10 AM. She is not bearing weight on that leg very much to not at all. She is in quite a bit of pain as I suspected she would. There is some arthritis in the joint from the irritation. The synovial fluid in the joint was a bit thickened and the doctor ordered a C/S plus the synovial membrane was thick and he sent that for histology. The area was debrided and I hope that this helps her. I got a call every day with an update about how she was doing. I am very glad to have her back home. She was very much missed. I am very glad we took her there to be evaluated. It definitely was missed by the specialist in December. How did this happen? Is it because she is so active? She runs alot!! I wanted to let you know how things went. Thank you for all of your help and concern. It was greatly appreciated. Take good care. Debbie
A: Debbie-
I am glad to hear that this was a problem that there is a good chance of success for the surgical repair. Unlike people, most cruciate ligament ruptures in dogs are thought to arise from degenerative joint disease, although I am not aware of a known cause for that to start. The ligament weakens gradually over time and then eventually develops tears. In a partial tear there may not be enough joint laxity to allow for the typical diagnostic signs but the dog may still be very aware of a problem. Even in complete tears it sometimes takes more than one visit to really confirm that there is excessive laxity in the joint (a drawer movement). An exam under anesthesia is often necessary to confirm this problem and many vets are reluctant to anesthetize a patient at the first sign of problems.
I hope all goes well from here on out.
Mike Richards, DVM
Cranial cruciate ligaments and fleas
Q: Dear Dr.Mike; I rescued an abandoned male Staffordshire Terrier mix (Pit and Boxer mix, we think)about 8 years ago. He has been quite healthy until recently, developing lameness in his right rear leg with no apparent signs of infection or tramua. His hip joints appear normal, although he seems have lost some weight as well as his overall muscle tone. Normally , at his last Vet visit Buck's weght was 90 lbs and solid as a rock. I would guess that he has lost 10lb. I have looked through your pages which have given me great information, but far reaching for an uneducated guess to my pets ailment. which onset of the lameness occured after having fleas. Currently I am making an appointment for him to see the Vet, although your opnion on-line would be appreciated to help with my concern. Thank you.
A: Although it is impossible to tell you what might be wrong without an examination, the most common cause of persistent lameness in one rear leg in middle aged and geriatric dogs in my practice is degeneration of the cranial cruciate ligaments. This is more common in overweight dogs and the weight loss would be helpful if it isn't from a dire illness. Curiously, there is a connection between flea infestation and the incidence of cruciate ligament injury, in my opinion -- just based on the histories clients give me. I really wonder if the persistent scratching while standing on just one leg contributes to this problem. It could just be my imagination, though. We have not kept careful statistics on this. Mike Richards, DVM
Q: Hello Dr. Mike, My mother is in her 70's and the doctor told her that her dog is going to have to have surgery for "CRUCIJTE", she doesn't understand what it is and could you explain it to me so I can explain it to her. I feel the doctor didn't explain it so she would understand. Thank you,
A: Rita or Roy- I think you are referring to surgery for a cruciate ligament injury in the stifle (knee) joint. The cruciate ligaments are a pair of ligaments that help to stabilize the knee as it moves. They cross the joint from in a sort of "X" pattern, leading to the name "cruciate". Usually the anterior (cranial) ligament ruptures -- the names just mean the ligament located more towards to front of the joint. In dogs this is most often a degenerative disease in which the ligament gradually weakens and finally breaks. This gives the impression of a suddenly occurring injury. Often, the ligament in the other leg is weakening at the same time and will rupture at some time in the future. With the ligament damaged, the joint is unstable and degeneration of the entire joint (arthritis) develops. Surgery helps to stabilize the joint and stop this process.
The major difficulty facing your mother is aftercare. Depending on the surgery done (there are a lot of ways to stabilize the joint), it may be necessary to confine the dog to a cage or small confined area for several weeks and it is necessary to avoid stairs and to walk the dog on a leash only. For an older person the aftercare can be very difficult. I realize that this may come to late to help much in this regard but if surgery has not been done, please contact your mother's vet and make sure that proper arrangements are made for post-operative care. It may be necessary to find someone who can help your mother care for her dog or to consider boarding it for the first few weeks after surgery. Mike Richards, DVM
Q: Dear Dr. Mike, My Lab sustained a bad cut on his foot (what I would call his wrist area) that severed two tendon almost completely and cut an Artery completely through. This happened 11 weeks ago and he immediately had surgery where they completely repaired the tendon injury. We kept him quiet for eight weeks and he was given a clean bill of health and was considered fully recovered. However he continues to favor the good leg and in the last week has regressed to where he doesn't want to walk at times and holds the leg up at his side at times. I have gotten conflicting stories from the vets in my office, one says he is just sore and will experience good and bad weeks but is no longer in danger, the other says that he can re-injure the tendon even at this point and is still very much in danger. Who am I to believe. As a footnote, my dog will let me poke and prod at the area without pain and no discomfort what so ever. I had hoped to have some piece of mind at this point but find myself constantly concerned and protective of what he does. Thank you very much for reading my question. ... Brad
A: B- It is not uncommon for it to take several weeks for dogs to heal after injuries to tendons or joints. It is important to check for swellings, heat in the injured area or other signs of infection, since this is the most worrisome complicatio
Michael Richards, D.V.M. co-owns a small animal general veterinary practice in rural tidewater Virginia. Dr. Richards graduated from Iowa State University's College of Veterinary Medicine in 1979, and has been in private practice ever since. Dr. Richards has been the director of the PetCare Forum...