Treatment options for my dog with a CCL Injury
There are both medical and surgical treatment options for patients suffering from CCL injury.
Medical or non-surgical management can be performed and your pet may even improve. The improvement seen is often due to fibrosis of the joint providing stability or stabilization of the joint. That means the improvement seen can be at the expense of osteoarthritis changes within and around the joint. Dogs that fail to improve or improve only in the short term usually succumb to complete CCL tear (as opposed to a partial tear) or have additional trauma and disease within the joint, such as meniscal injury.
1.) Pain management with anti-inflammatories and/or pain medications
2.) Weight management
3.) Exercise modification
4.) Joint supplements
Please note: Weight management and exercise modification are likely the most important things you can do to medically manage a patient with a CCL injury. They should always be a part of any surgical regime. In other words, weight loss, controlled activity, and anti-inflammatory pain medicine should still be a strong factor going into surgical management for CCL disease. Obesity has been found to drastically increase the risk of CCL injury. Patients with a good body condition score have fewer forces applied to joints and decreased systemic inflammation. Along with weight management, maintaining a baseline level of fitness is paramount in the treatment of osteoarthritis. It is best to avoid ‘weekend-warrior’ type of exercise (ie. going for a 3-hour hike once a month or free access to large acreage). Multiple short controlled leash walks are better than one long one. Taking your pet on controlled daily walks is ideal, starting with short durations and then slightly increasing as they become tolerated. In addition to regular controlled activity, rehabilitation activities such as stretching and range of motion exercises, controlled walking through or around obstacles, swimming, and underwater treadmill work may be of benefit for many pets.
The choice to pursue surgical management is typically based on patient age, breed and size, the degree of clinical signs, your pet’s activity level/quality of life, and the presence of any other concurrent medical conditions (i.e. severe heart disease, uncontrolled hormonal disease, cancer, etc).
Surgical treatment for rupture of the cranial cruciate ligament carries the most predictable outcome.
Many surgical treatment options have been described for CCL injury. Some of these originally focused on trying to recreate the ligament within the joint, similar to how ACL ruptures are repaired in humans. Unfortunately, grafts used to recreate the ligament in dogs often break down and they have not been found to have as high a success rate as some of the more current procedures. Accepted surgical treatment options are divided into “extracapsular” and “osteotomy” techniques.
Extra-capsular techniques focus on using a synthetic material (varying types of sterile suture or fishing line), which are placed in an effort to mimic the CCL and stabilize the joint. Some of these options include the traditional lateral extracapsular suture and the Tightrope® technique.
The lateral extracapsular suture technique is a classic technique with several modifications. It utilizes a nylon line to mimic the ligament and improve stability. Due to the low cost of the implant, the surgery is relatively inexpensive. Unfortunately, this nylon line can stretch, loosen, or break early in the post-operative recovery leading to less success particularly in larger active breed dogs. Failure of the implant leads to continued instability within the joint and potential need for revision or alternative surgical techniques. Success rates for this procedure are reported around 85%, but there is more and more evidence to suggest it is not the best procedure, especially in large breed dogs. It is, however, a very successful and common technique used in smaller breed dogs.
Osteotomy techniques involve changing the biomechanics of the knee joint by cutting the bone (osteotomy). There are a large number of osteotomy procedures performed in veterinary medicine. Osteotomy techniques include (but not limited to) the tibial plateau leveling osteotomy (TPLO), CORA based leveling osteotomy (CBLO), and tibial tuberosity advancement (TTA). DVSC focuses specifically on the TPLO and CBLO procedures. The TPLO procedure is the procedure most widely studied procedure and more and more evidence shows improved outcomes with TPLO over other commonly performed procedures.