Saturday, December 26, 2009

Talk To Me About ACL Injuries

I truly hope that you will never have to find out what the acronym ACL means. But if your dog develops sudden lameness in a hind leg, and particularly if he is a large breed, you might hear your vet say these letters...

Image from Dog Health Handbook
So what does an ACL injury mean, besides not being good news? 

ACL is short for anterior cruciate ligament. Sometimes it's also referred to as CCL, which stands for cranial cruciate ligament. Same thing.

So what is it? The ACL is one of two little ligaments that cross each other inside the knee and hold the large bones that form  the joint in place.
Ruptured Anterior (Cranial) Cruciate Ligament

If the ACL ruptures, the tibia/shinbone can slide forward and away from its normal orientation with the femur/thighbone.. That causes pain, joint instability and in the long term it leads to arthritis. If your dog has injured his ACL, he will be hesitant to bear weight on the affected leg or he may not put that foot down at all.

The tear can be full or partial. A complete rupture causes the most joint instability but even a partial tear means that the ligament cannot function properly.

ACL ruptures can happen as an acute or sudden injury. This is actually the better of the two scenarios. It means that some dramatic trauma to the joint has caused an otherwise normal ACL to tear. The upside is that only one leg is likely to be affected.

More often though, the rupture is a result of chronic weakening of the ligaments, where they become more and more frail until they finally let go. If this is the case, sadly, sooner or later the other ligament will often fail as well. There are number of reasons why this happens. Among others, there seems to be a connection between hypothyroidism and ACL failure.

So now that it has happened, what do you do? You have to do something. The thing about ligaments is that they don't heal very well. It is possible for knee with a mild, partially ruptured ACL to heal with rest and physical therapy, but more severe injuries are unlikely to repair themselves on their own. The longer the knee is unstable, the more severe is the arthritis that will develop, and now you have two problems instead of just one. So it is best to deal with is as soon as possible.

First, get a good diagnosis, ideally from an orthopedic surgeon, to make sure you know what you're dealing with. Then you have choices to make among several different treatment options.

Some people take a minimalists approach. The knee CAN stabilize on its own with very controlled exercise only, by the means of scar tissue forming around the joint and stabilizing it that way. I have seen posts by people who have done this successfully. But seriously, how well do you think you can control every movement your dog makes?

When Jasmine injured her ACL, we did a lot of research, looked into all the options and considered this one as well. But we didn't feel convinced that the odds of this being successful were that great.

Your decision should depend on your dog’s age, size, overall health and activity level.

Stifle Braces

If your dog is quite old or cannot undergo surgery, then your best choice might be a knee brace. There are number of products out there and I encourage you to check them all out. There are unilateral and bilateral brace products available. Look at all of them before picking the one that will work best for your dog.

During our research, the product I liked the best and would have gone with if we didn't decide on surgery is OrthoPets brace http://www.orthopets.com/ACLStifleDevice.htm. The guy who runs the place used to make braces for athletes and has it really figured out. In my opinion this is a superior product.

For more information about non-surgical options please read  ACL Injuries in Dogs: Non-Surgical Alternatives?

Surgery

If your dog is still young and is otherwise healthy, surgery might be the best option. We've been through this with Jasmine twice. It is heartbreaking, but I do believe it's the best thing to do.

Which surgery to chose is a different question all together. In the past, surgeons often attempted  to reconstruct the ligament. But that didn't seem very successful. Just as the once damaged ligament cannot heal, it seems it cannot really be replaced either. So that leaves us with joint stabilization surgeries.http://www.veterinarypartner.com/Content.plx?P=A&S=0&C=0&A=1975

TPLO (Tibial Plateau Leveling Osteotomy) and TTA (Tibial Tuberosity Advancement)

Presently the most popular and most commonly used modern surgeries are TPLO and TTA, the TPLO being more common. Both TPLO and TTA stabilize the stifle by altering the joint anatomy.

Which one is better - the answer will depend mainly on who you ask. The best way to make the optimal decision would be to talk to a surgeon who is certified and has experience with both and get a recommendation best suited for your dog.

Most often though you'll run into a surgeon who does and believes in one of them. In any case, make sure that whichever surgery you pick, you have a surgeon who is comfortable doing it and has the experience and skill needed to do it well.

TPLO (Tibial Plateau Leveling Osteotomy)

It is easier to understand what this surgery does by translating it into English. The two bones meeting in the knee joint are the tibia (i.e., shinbone) and femur (i.e., thighbone). The tibial plateau is the top, relatively level surface of the shinbone, on which the thighbone sits within the knee joint. I say relatively level, because there is actually a slant to it. Without the support of an intact cruciate ligament there is nothing to prevent the thighbone from sliding out of place.

In a TPLO, the top portion of the shinbone is cut and rotated in order to change the slant of the tibial plateau which stabilizes the joint. The bone is secured in its new place by metal plates.

Because this surgery is done to a weight-bearing part of the bone, it often takes longer for the dog to bear weight on the leg. While I find it quite invasive, I do believe that it provides good stability when it's done well. I do feel that there is quite a bit of room for error, so make sure you pick a good, experienced surgeon.

Tibial Plateau Leveling Osteotomy

TTA (Tibial Tuberosity Advancement)

Another way to increase the stability of the stifle joint is to modify the relationship between the slope of the top of the shinbone and the patellar tendon. The patellar tendon attaches the kneecap to the front part of the shinbone.

In a TTA, a wedge is cut in the the top of the shinbone and the piece of bone pushed forward. This also pulls the patellar tendon forward, which helps prevent abnormal movement within the knee.

The bone is secured in place by titanium implants and the open area is filled with a bone graft.

Because the surgery is done to a non-weight-bearing part of the bone, your dog will start bearing weight sooner. In comparison to a TPLO, a TTA does look somewhat less invasive to me, but, they both involve chopping and repositioning of bone. If done right and with nothing going wrong during the post-op period, both surgeries seem to be quite successful though. Their objective is to stabilize the knee in such a way so that the cruciate ligament isn't needed anymore. I recommend you look them up in detail to have a good idea how each of them is done and how they work.

Tibial Tuberosity Advancement (TTA): How TTA works

TTO (Triple Tibial Osteotomy)

This is a new technique that originated in New Zealand and it is presently available in New Zealand, Australia and England. It combines elements of both the TPLO and TTA and it actually looks quite cool. I describe it in more detail in my article Newest Surgery for Ruptured ACL in Dogs.

Extracapsular Repair

This is an older type of surgery, largely abandoned particularly for larger breeds. However this is the one we opted for. One of the reasons was that it is the least invasive. It involves drilling small holes in the bones and stabilizing the joint by use of surgical cord. The great vet we found has done quite a number of them on both small and large dogs with great success. There seems to be evidence that there is virtually no difference between TPLO and extracapsular repair 18 months post surgery.

For larger dogs our vet uses two sutures for better stability. Whether or not this could be an option for you depends largely on three things. Whether you have a great vet who you trust and know he has the necessary expertise, your dog's tibial plateau angle, and your ability to follow through with a strict post-op protocol, which is crucial for proper healing.

The stabilizing sutures are meant to hold the joint in place only long enough for fibrous/scar tissue to develop, and it is the scar tissue that stabilizes the knee at the end.

Jasmine had it done on both knees, three months apart and with great results.

Cranial Cruciate Ligament Rupture - Lateral Imbrication Technique (Extracapsular)

TightRope

http://www.warrenanimalclinic.com/tightrope.html
http://dogkneeinjury.com/2009/tightrope-surgery-vs-extracapsular-or-traditional-repair/
The above links have good information on this relatively new technique. It does seem to be a good option. Our vet was a bit skeptical about this one. But it is also minimally invasive.

Summary

So you see there are choices. Each of them has its pro's and con's. My main points here are, know your options, and do your homework. Always. One cannot make a good decision without information. Understand all your options, discuss them with your veterinarian or surgeon and then make a decision.

Don't wait too long though, this is one of those problems that will not go away by being ignored,.delay will only cause additional problems down the line.

Jana

Related articles:

ACL Injuries in Dogs: Non-Surgical Alternatives?
ACL Injuries in Dogs and Stem Cell Regenerative Therapy
Newest Surgery For Ruptured ACL In Dogs
Preventing ACL Injuries In Dogs
ACL Injuries In Dogs: Xena's Story 
ACL Injury Conservative Management: Sandy's Story
Surviving The Post-Op: After Your Dog's ACL Surgery
Talk to Me About Arthritis
Don't Forget the Physical Therapy

26 comments

  1. Thank you so much for this data. We have tried acupuncture and chiropractic. Both helped but....... I feel like we have options now. Hope is a wonderful thing.

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  2. Hi! Thank you for reading. I am glad our experiences can be helpful.

    Dealing with an ACL injury is tricky. What is the best option depends on the degree of the injury, reason why it got injured, tibial plateau angle, age of your dog ...

    Non-surgical approach can help in some cases, whether it's prolotherapy, stem cell regenerative therapy or others.

    However, for a young active dog, surgical solution us often the best thing to do.

    I'd love it if you shared your story with me, you can email me to grade3699@rogers.com. Please include "Jasmine" in the subject, so it doesn't get eaten up by spam filter.

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  3. Thank you! My best friend is going for acl surgery tomorrow. After reading Jasmine's story I am a little more confident that we will be able to get through this. I will let you know how things go through our recovery process.

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  4. Dear Suzanne

    I am glad my info was helpful to you! There is also an article about the post-op Surviving The Post-Op: After Your Dog's ACL Surgery that you might find helpful.

    Which surgery did you choose? Probably TPLO?

    Yes please, definitely keep me updated.

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  5. Hey Jana, great article. My name is Dr.james St.Clair the director of vet rehab at www.topdoghealth.com. I just wanted to make you aware of the FREE post-surgery home rehab guides that we have for pet owners whose dogs are about to have, or had ACL surgery. Below is a list of all the different sites where they can download the Free information:
    www.cruciatesurgery.com
    www.tploguide.com
    www.tplosurgery.com
    www.fhoguide.com

    thanks for the great article

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  6. Dear Dr. James

    That's wonderful, thank you!
    Would you like a guest post?

    Jana

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  7. Wow, what a thorough article! I see a lot of dogs that have had the extracapsular, lateral suture repair and do well with it. Low risk of complications. There are also some new stem cell transplant procedures, but the long term effects are not yet known. I'm glad you sited the correct term for the ligament, as "CCL" in canines. Thank you Susan Davis, PT

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  8. Hi! Glad you enjoyed my article.

    Yes, studies seem to confirm that once healed there is no difference in the stability of the knee that had extracapsular repair and one that had the TPLO surgery.

    Jasmine is going to be 18 months post-op after her second knee repair and she's doing great!

    Jasmine actually also had stem cells injected, primarily in an attempt to save her second knee and also to help with arthritis and assist with healing. Success of the stem cell procedure in ACL injury depends on the type and degree of the tear.

    While this therapy couldn't save Jasmine's other knee, it was of great benefit during healing process and she has no effects of arthritis and is not on any pain or arthritis medication.

    Yeah, I realize that CCL is the correct term, but it does seem to be mostly referred to as ACL, that's why I used the more common term and included the other for clarification.

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  9. Scout, a German Shorthair Pointer, had TTA surgery on his right back knee when he was only a year old. He is now 2.5 years old and rips around the yard as nothing has happened. At times though, he still favors that knee a bit.

    He was just so young, I couldn't think of him living his entire life with a lame leg.

    Our vet/surgeon does quite a bit of these surgeries and has great outcomes. I felt completely comfortable with his abilities and am thankful Scout has done so well following the surgery.

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  10. Dear Cindy

    Wow, so young, poor Scout. Glad the surgery worked so well for him. I think there might be some arthritis in that knee now which you might need to address.

    I would love if you shared your story here, let me know if you'd like to.

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  11. Great article, Jana!

    I see so many clients whose dogs have blown out their ACL. Mostly large breed dogs, but I've noticed an influx in small dog knee injuries (Bichon Frise is the first breed that comes to mind).

    It's such a shame to witness a dog - recovering from ACL surgery - blow out his/her other knee due to over compensation.

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  12. Dear Brandon. Thank you :-)

    Yes, seems to happen to small breeds too. I am wondering what some of the factors might be. Wondering about the role lifestyle and nutrition plays in this for example, as well as an increase in allergies and immune related conditions such as digestive issues, hypothyroid etc.

    So often the other knee goes also (Jasmine's did).

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  13. this is without question the best and most thorough article that I have read on this subject. Two days ago I accidentally hit our 4 yr old Tibetan with my car! an absolutely horrible moment. the vet says he has a completely torn ACL and recommends the surgery. o I have spent the best part of the last days looking for answers, suggestions, ideas and options. Based on your piece I think we have no option but the surgery.

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  14. Dear Jonathan. Thank you, I am glad you found my article helpful!

    So sorry about your dog!

    Yes, I think that considering the amount of trauma and his age surgery is your best option.

    There are 4 surgeries available. The extracapsular repair (which is quite great, minimally invasive and worked great for us - but it is more demanding on the post-op rehabilitation); TPLO; TTA; and TTO. TPLO is the most common. Personally, from these three I like the TTO the most
    http://dawgbusiness.blogspot.com/2010/03/newest-surgery-for-ruptured-acl-in-dogs.html

    I think it already did make it to US.

    An important criteria besides the type of surgery itself is how comfortable your surgeon would be doing it and how much experience he/she has with it. That can also make a lot of difference.

    An either way, regardless on which surgery you choose, post-op rehabilitation is very important to a success of any surgery.

    http://dawgbusiness.blogspot.com/2010/04/surviving-post-op-after-your-dogs-acl.html

    http://dawgbusiness.blogspot.com/2010/05/dont-forget-physical-therapy.html

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  15. Hello! Thank you for a very comprehensive discussion about ACL injuries and the various options that we have.

    Our 12-year old Lab, Missy, underwent TPLO for a torn ACL early this year.

    The vet surgeon who conducted the TPLO has done the procedure many times and is considered one of the best TPLO surgeons. The surgery went well.

    Our vet told us that the surgery was just half of the work if we really want Suzy to regain full use of her limb. He said post-surgery care and rehab therapy is equally important to help in the proper healing of the limb. We went home with a long list of discharge instructions and lots of painkillers.

    Since we decided to do the rehab ourselves, our vet gave us some instructions which we really did not understand completely. So we took it upon ourselves to read up on the procedure and scoured online. We came across this TPLO home rehab guide which was made by Dr. James St. Clair, a veterinarian who is an expert in canine rehabilitation. The instructions were very easy to follow and we slowly progressed through the rehab regimen one week at a time until we completely finished the program without going to a rehab facility.

    Today, Suzy has regained full use of her limb and she doesn't look her age. She's back to playing with our kids and living a full and happy life :)

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  16. Hi Sheryl, yes, that's right, rehab therapy can make or break the success of any surgery. It IS very important and I'm glad you're surgeon stressed it enough for you (some don't).

    It is good that your vet gave you instructions, should have explained or even demonstrate too, though.

    Glad you found a good program and was able to follow successfully. Happy that Suzy is doing great!

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  17. Popping over from My Brown Newfies...my Gracie was just diagnosed with ACL injury and DJD in both knees. Looking for all the info I can find so we can make a decision concerning possible surgery. Thanks for the info.
    val

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    1. Sorry to hear. Yeah, the DJD comes with the cruciate injuries. How is the front and the lungs?

      I can SO commiserate; we just got hammered by another incident today; front left this time ... again. :-(

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    2. Wait a minute, Gracie, not Sherman. Got the Newfies confused; thought the name didn't match. Sorry; had a hard day here too.

      With both knees bad, the TPLO type surgery (TPLO or TTO) is probably the best bet.

      Delete
  18. Jana,

    Thank you for your articles about Jasmine's surgery - they've been a big help in weighing my options in treating my dog's own injury. I wanted to ask: was the "less invasive" part the primary reason why you opted for the extracapsular over the other techniques? Were there other factors in the mix as well?

    I ask because I'm facing the same choice you did (extracapsular vs. TPLO, in my case) for a 8-year-old, 115-lb. Great Swiss Mountain Dog (giant breed). Different vets are offering different techniques, and I'm getting different stories on what would be best for my dog. Extracap vet offers a thorough rehab program and says that experience with a given technique, not really the technique itself, is what determines the outcome. TPLO vet says that extracap will not work for a dog this size or with a 30-degree tibial plateau angle. He does not offer a rehab program, though. (TPLO vet also mentions that surgery "might not be the best option" for my dog but is vague on the specifics; she is healthy otherwise.) I trust and have had good experiences with both vets, and deciding which way to go is driving me nuts; I don't want to leave my dog worse off than she was pre-surgery (she's a little slow to get up, but that's pretty much it).

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    1. Glad that Jasmine's story could help you.

      Yes, being less invasive was the primary reason we opted for the extracapsular repair. As well as if something went wrong, we'd be where we started, rather than in bigger trouble. As it turned out during the surgery, Jasmine's bones would likely not be able to take the TPLO but we didn't know that at the time of the decision (her bones were very soft because of poor nutrient absorption due to her IBD).

      The other consideration was that we were reasonably confident we'd be able to make it through the post-op. If she was younger and wilder, we might have gone with the TPLO because it is sturdier, has somewhat shorter recovery and is more "forgiving." Though when things do go wrong they usually go quite wrong.

      Other consideration is the tibial plateau angle. If the angle was too steep, than TPLO would have been the best option.

      If your vets are suggesting different techniques, please ask for their reasoning behind it.

      Thorough rehab is a must regardless of the chosen technique.

      Yes, how experienced the surgeon is does play a big role also.

      Also get reasoning behind the surgeon thinking that surgery isn't the best option - the surgeon must be able to explain why they feel that way.

      Another option is to get a third opinion to see which option a different vet would lean towards.

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  19. Thank you for the opinion. I *am* concerned about things going wrong with a TPLO, honestly, but it's sounding more and more like it's the best option for her. The issue is that each of the two possible vets offers the technique in which he specializes only - one won't do the other's surgical method - and while I'm looking for a vet qualified to give a third opinion in my area, I'm not having much luck. (I searched the webpage of the American College of Veterinary Surgeons, but the pickings are pretty scant.) I'm currently in the process of asking other owners in the breed about their experiences, so we'll see how that goes.

    (BTW, if I may ask: do you recall what Jasmine's tibial plateau angle was?)

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    1. I actually don't know what Jasmine's angle was. It was at the beginning of me becoming a health advocate for my dogs. I know we discussed it and the vet was happy with the angle. But I don't remember what the actual angle was, sorry.

      Seems like your dog is just about borderline according to some sources:
      " Dogs with excessively steep tibial plateau angles of greater than 32 degrees tend to do somewhat better with bone cutting techniques"
      http://web-dvm.net/cranialcruciateligamentrupture.html

      Though other sources seem to favor even less of an angle.

      As for third opinion, I don't think it needs to be a vet in your area. Some specialists do online consultations when provided with records etc. Though an orthopedic specialist is likely to lean towards the TPLO.

      Studies are showing that once the knee is healed, there is no real difference between the methods. The time when it does make a difference is during the recovery.

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  20. My Rottweiler Diesel has recently had an extracapsular repair of his left stifle, and he's now two weeks in. Like you, I opted for the surgery I felt most comfortable with, the least invasive, despite my vet's reservations. He was persuaded to do the surgery, and like yours used two lines in an attempt to stabilise the joint under the heavier weight it was expected to bear.

    Two weeks post surgery Diesel is doing brilliantly. I'm tempted to be over cautious though, which my vet is delighted with. Apparently most people are ready for walks at this point (Diesel is bearing a lot of weight now, actually standing on it to per and lifting the other leg, which my bet did not expect so soon), but I'm tempted to keep him restricted for another couple of weeks...
    He's asked that I take him swimming if I can; there are no hydrotherapy pools anywhere near me, but I live in an area of Scotland surrounded on three sides by sea. Chest waders for me it is - let's go swimming!

    Unfortunately though, I can't find any posts about long term recovery. How was Jasmine after, say, 4 or 6 months? A year? How much of her original strength did she recover? Could she go long walks? Runs? Hill walking? Or was she only able to do half hour walks? On or off lead? Playing with other dogs in the park? I can find nothing of my boy's long term prognosis!

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    Replies
    1. I'm glad to hear he's baring weight and recovering so well. Your vet should have given you a post-op recovery plan, where the steps threw time should be outlined, such as in this example:
      Cruciate Ligament Surgery Post-Op Care: Example Plan


      It does take time before the scar tissue, which eventually will hold the joint together instead of the ligament, develop. It is important to give it the time it needs and avoid any mishaps which could lead to stretching of the sutures and instability of the joint.

      The plan isn't written in stone; going through it should be a cooperation between you and your vet as he evaluates your dog's process. They can agree that you can jump further in the process, or they might tell you need to step back.

      Hydrotherapy is awesome and you can definitely start that. It keeps the joint from taking on too much weight while keeping it moving and making the muscles stronger which also helps stability of the joint. It would be definitely yes for swimming or underwater treadmill.

      It takes about six month for the knee to fully "heal"/the scar tissue develop fully in order to hold things together fully. After that, nothing should be able to go wrong - didn't for Jasmine. Once it's fully healed, if proper rehabilitation was done, the knee will function pretty much as a normal healthy knee would.

      After her post-op, Jasmine's knees were as good as new. She could walk, run, jump, whatever she wanted to do.

      There were some studies done comparing the suture technique to TPLO after the knee fully healed; no differences were found.

      The only thing to keep in mind is that if one knee ligament ruptured, it is quite likely the other one might too. So while the recovered leg might be fully functional and strong, the other one might not be.

      Jasmine had both ligaments go and surgery on both legs. Once all that healed, there was nothing else to get busted and we could have stopped worrying about it.

      Once fully healed, nothing should go wrong.

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  21. My 4 year old amstaff tore her ACL and we're treating her naturally. We're using a knee brace with her but it's not a stifle brace, it offers less support and more flexibility but still stabilizes her knee and keeps the area nice and warm.. and seems to reduce her pain.

    I think it's important that the level of immobilization of a knee brace doesn't complete prohibit movement, otherwise muscle atrophy can be a negative consequence that appears later on.

    We bought the Ortocanis dog knee brace from the online store www.ortocanis.com and I think the whole thing cost us under $60 if I remember correctly. The brace has held up after some time and my dog isn't bothered by it all.. she adapted to it the same day. I'm hopeful that we'll be able to avoid surgery.

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