Treatment for Cranial Cruciate Ligament (CCL) Injury
In-House Surgery, Referrals, and Other Options
High Desert Veterinary specializes in Extra Capsular surgery for animals with a partially torn or ruptured CCL. We can also refer you to qualified surgeons for other types of CCL surgeries.
Will my Pet Need Surgery?
Not every CCL injury requires surgery. After a physical exam, all animals with suspected CCL injury are candidates for a radiographic evaluation. Radiographs allow us to detect any additional problems, such as arthritis of the knees and/or hips. Additionally, they allow measurement of the Tibial Plateau Angles to determine which surgical procedure(s) has the best likelihood of success. Radiographs also help us to predict future CCL problems with the unaffected knee. Sedation is necessary for us to obtain good radiograph images; sedation also provides the opportunity to perform Drawer and CTT tests.
Small dogs and cats with CCL injuries may heal with medication and eight to twelve weeks of restricted activity. If the animal is overweight, weight loss is crucial to success. Some may regain near complete mobility, although ongoing anti-arthritis medication may be needed. Others may require surgery.
For larger pets with a ruptured CCL or substantial evidence of a partial tear, surgery offers the best chance at full rehabilitation. (The good news: surgical procedures for CCL injuries are not as expensive as you might think!)
Before recommending surgery, we’ll need to determine if your pet is a good candidate. In addition to taking radiographs, we’ll also draw blood and order labs. Labs assess blood and metabolic parameters to detect problems that might affect our choice of anesthetic agents and medications (both immediate and long-term). Heart health is a key concern for procedures requiring anesthesia; any red flags on the exam or labs may direct us to do a more thorough heart evaluation.
Once our pre-op evaluation is complete, we’ll discuss options for surgical repair. We’ll explain the chance for success, the degree of invasiveness, the possibility for complications, and the cost.
Surgical Approaches
There are many different surgical approaches to choose from, and this presents a frustrating and confusing situation for many pet owners. From a surgeon’s perspective, factors influencing procedure recommendation are: patient’s size, age, predisposing conformation, activity expectations, feasibility of post-op care, and technical requirements of the procedure. From a clients perspective, influencing factors are: chance for successful outcome vs risk of failure, feasibility of post-op care and cost.
The three basic categories of CCL surgery are: Extra Capsular, Osteotomy, and Intra-articular.
Extra-capsular (EC) procedures essentially create a “brace” outside of the joint, under the skin, that prohibits cranial tibial thrust. There are many variations of this procedure. EC procedures are minimally invasive and typically less costly, but they may not be suitable for certain animals.
Osteotomy procedures such as the Tibial Plateau Leveling Osteotomy (TPLO) and the Tibial Tuberosity Advancement (TTA) involve cutting the Tibia and implanting appliances that permanently improve conformation of the joint. This redirects weight-bearing forces through the joint to stabilize it under load. A A TPLO reduces the tibial plateau angle, thereby eliminating the forces that drive the tibia to slide forward under load. A TTA repositions the Patellar Ligament to redirect load-bearing forces for a similar effect. Both the TPLO and the TTA improve the bio mechanical function of the joint. They are both more invasive, technically demanding, and expensive. Because these procedures use implants, they have an increased risk of failure and require more careful post-op care. With an experienced surgeon, a compliant pet, and a diligent pet parent, the TPLO and TTA are good options for many pets.
Intra-articulate procedures utilize various approaches to simulate the structure and function of the CCL within the joint. With the development of advanced Extra-Capsular and Osteotomy procedures, Intra-Articulate procedures are not widely used any more.
Weighing the Options
Studies have shown that EC, TPLO, and TTA procedures are successful in most, but not all, patients. They’ve been shown to be equally effective in restoring lameness-free mobility, but also prone to result in arthritic deterioration of the joint if comprehensive anti-arthritis measures are not taken.
The field of veterinary prosthetics has made serious advancements in the past few years, and customized external braces are currently available. These come with their own set of functional assets and liabilities, and could be entertained as a non-surgical option. Patients that are not good surgical candidates might benefit from such support.
Our Approach
At High Desert Veterinary, we are capable of evaluating any animals for CCL injury, and we can make recommendations based upon what is most appropriate for both the patient and the pet parent. We refer patients for Osteotomy procedures but perform EC procedures in house. Specifically, we perform the Lateral Fabella Stabilisation Suture (LFSS) procedure. We have a great deal of confidence in this procedure, and we have a great deal of experience and expertise with the LFSS. We have restored mobility for hundreds of pets patients. We certainly appreciate the advantages of Osteotomy procedures for some animals, but we have achieved excellent results in pets who were clearly candidates for TPLO or TTA. We’ve performed this procedure on everything from small cats and dogs to 160lb + pound giant dog breeds, from couch potatoes to field-trial athletes.
Aftercare
Once surgery is complete, your pet’s leg is bandaged from the toe to as high on the thigh as possible.
Patients go home on pain relievers, anti-inflammatory medications and an anti-arthritis medication. We may also recommend a short course of antibiotics.
The leg bandage stays in place seven to ten days. The knee joint is stable immediately after the procedure, but your pet will need to restrict activity for eight weeks to support surgical healing. Skin sutures are usually removed in 10 to 14 days. As surgical healing progresses, your pet can resume reasonable, low impact activity in gradually increasing amounts. Surgical scar tissue will remodel and strengthen over the ensuing four months, so by six months post-op the stabilization will be as strong as it will get. Atrophied muscles will recover as the leg becomes increasingly weight bearing.
We credit much of our long term success with this procedure to the benefits of anti-inflammatory and anti arthritis medications that we advise as ongoing measures. We find Non-steroid Anti Inflammatory meds (NSAIDS) and Adequan to be very beneficial to long term, pain-free mobility. Adequan begins as a four to eight dose series, administered by injection sub-cutaneously, then once monthly. We instruct clients on administration and most find it easy, convenient and economical. An additional advantage to this approach is that it benefits all joints of the body, and may prevent deterioration of the unaffected CCL.