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What is Cruciate Disease?

Cruciate Disease in cats and dogs is a very common orthopaedic condition, where the cranial cruciate ligament (CCL) frays or ruptures.   This ligament sits as an "x" within the stifle (knee) joint, crossing the caudal cruciate ligament, and its job is to prevent forwards and backwards movement of the tibia against the femur when weight is put through the leg.

 

When the CCL is torn or frayed, the tibia (shin bone) slides forward in relation to the femur (thigh bone), which is known as a positive drawer sign. Most animals with this injury cannot walk normally and experience pain. The resulting instability damages the cartilage and surrounding bones and leads to osteoarthritis (OA).

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Top 5 Symptoms of Cruciate Disease

Lameness

  • This can come on without warning when the weakened ligament gives way as the animal is running or playing. They can suddenly experience severe discomfort, to the point that they will not put the foot down at all.

  • Alternatively, some dogs show a gradually worsening, on-and-off lameness over weeks or months. They might seem to get better with rest, but then become lame again as they become more active. 

​Sitting abnormally​

  • They may sit or lie with their leg sticking out to the side rather than tucked in like normal, as it hurts to bend the knee.​

Stiffness in both back legs

  • Although it’s usually noticed as a lameness on one leg first, approximately 50% of patients that have a CCL injury will go on to get one in the other knee within 12 months. If the two injuries happen at the same time and both knees are affected at once, the dog may appear to be “stiff” in the hind end, be reluctant to go for their normal walks or even be able to get up at all. ​

Knee thickening/swelling

  • CCL injuries cause inflammation and swelling in the knee, causing scar tissue over time. This makes the injured side look bigger than the normal knee.​

Clicking

  • Walking on the unstable knee puts more stress on other structures in the joint. The meniscus, a shock-absorbing pad of cartilage, can easily become torn or injured due to the knee moving in an abnormal way. Sometimes, this may result in an audible “click” in the knee which can be heard whilst the dog is walking. A meniscus injury is quite uncomfortable so there is typically a significant lameness as well as the clicking.​

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Diagnosis and Management

If cruciate disease is suspected, your pet may require sedation or anaesthesia to have a thorough examination of their joint to assess it for instability.   It is often a good idea to perform imaging such as an x-ray at the same time, to help confirm your pet’s diagnosis and to fully understand the pathology in the knee.  With our modern digital x-ray unit, we are now often able to see early signs of cruciate disease (before the ligament ruptures) by x-raying the joint, since the advanced imaging shows the soft tissue structures in the joint in more detail.

In nearly all cases of cruciate disease, surgery is generally recommended as soon as possible to reduce permanent, irreversible joint damage and relieve pain.  In most cases for dogs over 15kg, vets will recommend a procedure where the bone conformation to the tibia is altered, so the impact on the knee changes and the cranial cruciate ligament is no longer required.


Several surgical techniques are currently used to correct CCL rupture. Each procedure has unique advantages and potential drawbacks. Our friendly vets will guide you through the decision-making process and advise you on the best surgical option for your pet. We will cover two types of CCL surgery here: extra capsular repair and TPLO (Tibial Plateau Leveling Osteotomy).

Extracapsular Cruciate Repair

This traditional technique is the oldest surgical correction for cruciate ligament injury in dogs and can be very effective for cats and dogs up to 15kg in body weight. The name of the procedure originates from the fact that the joint stabilization occurs outside the joint capsule (externally).

In simple terms, a loop of a special type of suture material (an artificial nylon ligament) is placed external to the joint in the same orientation as the CCL, stabilizing the knee to prevent forwards and backwards movement (cranial drawer) of the tibia against the femur.  This suture is placed after a full examination of the joint itself, where any damaged or torn portions of the CCL and/or meniscus are removed.   After the joint capsule has been examined and any cartilage or ligament fragments are removed, the joint capsule is sutured closed and then the external stabilizing suture is installed.

 

TPLO Surgery

In dogs weighing more than 15-20kg, an extracapsular repair is not usually recommended, since the extra weight makes repeat tears of the artificial ligament and the need for repeat surgery more likely. 

The TPLO procedure involves making a curved cut into the top of the shin bone to create a more level angle between the tibia (shin bone) and the femur (thigh bone).  A locking plate and screws are then installed to stabilize the bone. The purpose is to neutralise the shearing forces that occur on the knee joint in dogs, without the need for replacing the CCL itself.  

 

Careful pre-operative planning specialized equipment and expertise is required to perform the TPLO surgery and predict a successful outcome. Many veterinary hospitals are thus unable to offer this procedure, however at Vogue Vets & Wellness Centre, we are able to offer this procedure.

There are many factors that may influence which surgical procedure is best for your pet and these include breed, weight/ size, activity, experience of the surgeon, ability to properly restrict the patient post-operatively, slope of the tibial plateau, and other concurrent medical conditions.  Once a diagnosis has been made, our friendly vets will guide you through the choices and assist you in making the best decision for your pet.

Non-Surgical Options

Sometimes surgery simply isn't an option.  This may be due to concurrent health issues, or financial constraints.  What ever the reason, Vogue Vets & Wellness Centre is well placed to assist you in helping your pet regain their mobility through our physio/rehab and hydrotherapy programs.  

Knee Bracing - Custom knee bracing is relatively new to canine orthopaedics.  Braces can be purchased both “off the shelf” or custom made to assist with stabilization of the knee in a non surgical fashion and a satisfactory accomplishment of the management goals in selected patients is possible.

 

Using a brace as the only treatment option may not benefit sufficiently for a long term resolution and often merely prolongs the time until surgery is necessary, thus causing more joint deterioration as well as meniscal tear injury.  We therefore would not recommend bracing as the sole treatment option where surgery is an option.  For non-surgical candidates, a rehab assessment would firstly be recommended, and our rehab therapist can then advise whether or not a brace is suitable for your pet.

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TPLO Surgery & Post Op Care

Preparing Your Home

Prior to your pet’s surgery, speak to us about how to best confine your dog during their recovery. Making your dog as comfortable as possible is just as important as a good rehabilitation plan.

Since your dog’s mobility will be restricted following an extensive orthopaedic surgery such as the TPLO, we recommend taking the following steps:

  • If your dog is crate trained, find a crate that’s large enough for him/her to stand up in & turn around.

  • Create a gated off area in your home, such as the kitchen or living room to restrict them to certain areas.

  • Rooms with hardwood floors, tile, or linoleum can be particularly difficult for dogs to walk on, especially after surgery. If the room you’ve chosen has slippery surfaces like these, be sure to place some throw rugs with rubber backing on the floor to help your dog walk around more easily during the post-op period

At Vogue Vets & Wellness Centre, we use several different methods and modalities for pain management.

Anesthesia protocols commonly include the following:

  • Injectable analgesics and anti-inflammatories – Given before, during, and after surgery as needed to prevent or minimize pain. These are used either as intermittent injections or constant rate infusions.

  • Cold Compression Therapy – Provides post-operative control of swelling and pain using cold packs and compression.

  • Post-operative oral pain medication combinations to be sent home for the first 1-2 weeks after surgery

 

We also offer post operative rehabilitation which includes pain relieving modalities such as laser therapy, pulsed magnetic field therapy, therapeutic exercises and hydrotherapy to assist your pet in recovering as quickly as possible.  Rehab can be commenced as early as the day following surgery, whilst hydrotherapy cannot be safely instigated until 4-6 weeks post op

Will my Pet Experience any Pain?

What is the Success Rate of TPLO Surgery?

The success rate of TPLO surgery is extremely high, with as many as 90-95% of dogs returning to near-normal function. Compared to any other procedure, dogs who undergo TPLO surgery recover more quickly and get back on all four feet sooner. With TPLO surgery and proper rehabilitation, your dog will most likely be able to recover completely from a CCL tear and regain full mobility. The vast majority of patients return to normal or nearly-normal activity within six months.

In comparison, dogs with extracapsular repairs are often walking much sooner after surgery, but tend to plateau after 6 months and often only reach 80% normal capacity post operatively.

It is also important to understand that a high percentage of dogs who develop cruciate disease in one leg will go on to rupture the cruciate in the second leg, within 12 months.  Statistically, 85% of dogs with no surgical intervention will go on to rupture the second leg within 3 years, compared with 25% of dogs who have early surgical intervention.  Whilst rehab cannot guarantee that the second leg won't rupture, post operative rehab does significantly reduce the odds of the second cruciate being torn.

What are the Possible Complications of TPLO Surgery?

It is very important to note that whilst every attempt is made to treat or repair cruciate injury, none of the above treatments or surgery will bring the knee joint back to 100%. Thus, over time, the onset of arthritis in the joint is inevitable. How rapidly this sets in and advances is variable, however, in most cases, a surgical approach to treatment, lessens this onset but does not negate it all together.

 

Before making any decision to proceed with surgery in any pet, it is important that you, the pet owner, are aware of the possible complications of surgery in these cases. Whilst complications are rare, they do happen and in some cases, may result in subsequent surgery being needed.

 

Please feel free to discuss any concerns or questions you may have with one of our veterinarians at any time.

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After Your Surgery: What Happens Next?

We feel it is important to remain available for your questions and concerns before and after surgery. Routine rechecks following TPLO are therefore scheduled at 24 hours, 2 weeks postoperatively, and with recheck radiographs (x-rays) obtained at the 8-week point.  Additional rechecks may be scheduled as needed.

Recovery & Rehabilitation

Following a TPLO surgery your dog’s activity level must be restricted to short leash walks only (preventing running/jumping activities) for a full 10-12 weeks.

This means no jumping on or off the bed, on/off the couch, or on people. We recommend starting with very short walks to urinate/defecate only and then gradually increase the duration of those walks through the rehabilitation period.

Access to stairs should be limited as much as possible, especially for the first 2-4 weeks after surgery. You can help, by guiding your pet up and downstairs with a short leash, harness, or sling. If you have stairs in your home, limit your dog’s access with a baby gate to prevent unsupervised use.

When your pet is alone, they should be restricted to a small area or a crate. Adequate restriction of your pet’s activity level plays a major role in successful outcomes post-surgery.

We recommend refraining from active play until your veterinarian or rehab therapist tells you otherwise (likely until after the 8-week post-op radiographs to confirm bone healing).

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