Is Surgery the only option for my dog with cruciate disease?
What is the best way to treat a dog with cruciate rupture in dogs? Like all things in medicine you will get varied responses to this question. There are some medical and musculoskeletal conditions where we can say with a large degree of certainty, based on the current research, that the treatment or treatments that the large majority of vets are currently using is the best way to go. There are other conditions where the popular treatment(s) being offered need more research and may not be the best way to go. I think it would be fair to say that cruciate disease is more in the latter category of treatments currently recommended which require more research and less in the category of “we are very certain this treatment will get the best results for your pet.” I’m a fence sitter – I really think most things are not black and white. The cruciate treatment debate is also not cut and dry.
I think there is a good argument for conservative non-surgical management of cruciate disease in canines at least as an Initial treatment option. I’ll put forward my reasons for this below.
I first need to qualify what I mean by a “conservative non-surgical” option. This should involve appropriate pain control which needs monitoring by your vet. This usually involves anti-inflammatories in the short term. Some dogs may also require long term management of pain and some may not. This longterm management may involve using supplements regularly (once or twice daily) to treat the “background” pain and then have stronger medication to use intermittently as needed for treating “breakthrough” pain. We can also use other modalaties for pain including laser therapy and pulsed electromagnetic field therapy to reduce inflammation.
Appropriate conservative management of this disease should include rehabilitation. This involves activities to improve strength and balance prescribed by a qualified rehabilitation practitioner. This part of conservative therapy involves at least some commitment and participation by the owner – we will not get the desired results if we throw our dog in a cage or the backyard and hope for the best.
When looking at whether we should implement surgical or non-surgical therapies for cruciate disease I think we have to firstly look at what treatment is likely to get the best outcomes.
Success rates of surgical treatments vary, in both their definition and the parameters measured. It is generally accepted that the success rate is about 85% for all types of surgical techniques.
There are few studies comparing longterm outcomes of surgical therapies vs non-surgical therapies . We do have this study from 2013 comparing surgical vs non-surgical treatment: Short-term and long-term outcomes for overweight dogs with cranial cruciate ligament rupture treated surgically or nonsurgically. Wucherer et al. There were two groups in the study – the first group received surgery (TPLO) and rehabiliatation and the second group received rehabilitation only. TPLO surgery with rehab resulted in 76% “success” (using force plate and owner survey analysis) after 12 months and in the rehab only group there was 66% “success” after 12 months. So this small study suggests that we may get an extra 10% of dogs do better with surgery compared with conservative therapy.
Of note, there was a large group of dogs that dropped out of the study due to cruciate rupture in the other leg. This was more or less equal for both groups : 5 dogs in the surgery group/ 6 dogs in the non-surgical group – so it seems surgery and rehab may make no difference to the risk of rupturing the remaining cruciate.
This was only a small study so clearly we need more data to determine with more certainty if non-surgical management of cruciate disease is a viable option. Nonetheless we have some suggestions that conservative therapy can be of benefit in some patients.
The more convincing argument for non-surgical management arises when we consider the downsides and risks associated with both therapies.
The downsides of conservative treatment are few. The short term risks are zero. The possible longterm risk is that it seems that a percentage of dogs may have had better results if we treated surgically. So it is the lost potential benefit of surgery that could be considered a disadvantage. But as stated above we don’t have the longterm data to assess this. Other than the possible lost potential benefit it seems there are no long term risks associated with rehabilitation of these dogs.
In comparison there are short term and long term risks associated with cruciate surgery. There are several studies which look at the complications of cruciate surgery and of note, these studies only look at problems with surgeries performed by very experienced specialists. Complication rates are very likely to be higher in surgeries performed by general practitioners.
The first study we will consider is from 2014: Complications associated with tibial plateau leveling osteotomy: A retrospective of 1519 procedures Thomas J. Coletti et al 2014. This study looked at 943 dogs which had surgery on one knee and 288 dogs that had staged surgery done on both knees. The amount of complications considered “major” was 3.1% and complications considered minor was 8.3%. Major complications were listed as medial patella luxation (that required additional surgery), joint infection, tibial fracture, plate removal, fractured fibula, bone graft required for slow healing, persistent valgus, medial collateral ligament rupture, continued instability and requirement for lateral suture placement, oesophageal stricture and renal failure. Minor complications included: incisonal, tibial crest or patella fracture, pin removal/ migration, patellar tendon tendonitis, and medial patellar luxation (resolved without surgery).
Another study performed by Fitzpatrick et al : Predictive variables for complications after TPLO with stifle inspection by arthrotomy in 1000 consecutive dogs et al looked at complications from a single specialist surgeon on 1000 TPLO surgeries. They reported a complication rate of 14.8% with 6.6% being major complications.
It is quite clear TPLO surgery (which is the current procedure preferred by most orthopaedic specilaists) is not a benign procedure. There are complications that can be disastrous and result in very poor longterm outlook for some dogs that go through this procedure. There is also a percentage of dogs that may need a second surgery to correct a major or minor complication. I appreciate that every medical and surgical treatment has its risks and benefits. The question is do the potential benefits of surgery outweigh the complications and possible negative outcomes.
So until we have more data I am going to continue to sit on the fence when deciding if we proceed with surgery or non-surgical options when it comes to cruciate disease in dogs. There are many pets where surgery may not be an option because of the pet’s age, concurrent disease or cost of the procedure. For these guys the non-surgical option is no doubt the way to go. But this approach, as mentioned previously, should include pain management and appropriate rehabilitation prescribed by a qualified practitioner. But when it comes to deciding if surgery or conservative therapy will get the best results then we have to consider the benefits and complications associated with both treatments. It seems the jury is still out but I think it is apparent that a non-surgical conservative approach is a worthy consideration.