Cranial cruciate ligament (CCL) disease is analogous to an ACL tear in humans; however, the disease process is very different. It is uncommonly a result of trauma, but rather in >90% of dogs it is associated with a degeneration and weakening of the ligament. As the ligament weakens, fibers begin to tear causing inflammation in the joint. This inflammation is a source of pain and results in lameness. The lameness may improve initially or resolve, but ultimately will recur once more fibers tear. Eventually, enough fibers tear causing instability in the knee. Once instability is present, there is risk for a concurrent meniscal tear that is an additional source of lameness.

How are CCL tears treated?

The recommended treatment for a cranial cruciate ligament tear is a tibial plateau leveling osteotomy (TPLO) surgery.  A TPLO procedure consists of making a cut in the tibia (osteotomy) and rotating the bone to provide a more neutral surface for the femur to rest on (leveling). To stabilize the osteotomy site, a bone plate and screws are applied. While there is no surgery that can prevent arthritis from progressing, the TPLO is designed to stabilize the knee so that the patient can return to normal activity without a fully functioning cranial cruciate ligament. 

There are alternative procedures described, including an extracapsular suture (“lateral suture”) and other osteotomy procedures. Overall, the TPLO procedure had the most evidence-based support and consistency for successful outcomes at this time. It is recommended in patients for partial or complete tears of the CCL. Not all animals are candidates for a TPLO procedure and may require alternative procedures to be performed.

What should I expect post-operatively and during the healing period?

Regardless of management strategy used, the care YOU provide to your pet is CRITICAL to the successful management of a CCL tear. Our surgeon will provide you with detailed instructions at the time of discharge.

All animals will require a period of activity restriction, typically 8-12 weeks; however, the length of restriction will depend on the animal’s healing progress noted during recheck examinations. This means no running, jumping, or playing. Your pet will need to be taken outside on a leash to urinate and defecate; excessive climbing up and down stairs or on and off furniture should be avoided. When not directly supervised your pet needs to be placed in a crate, small laundry room or bathroom, or a small, sectioned-off portion of the house. Too much activity can result in delayed bone healing and necessitate prolonged activity restriction or result in implant breakage that may require revision surgery.

Surgically repaired CCL tears will create incisions in the skin. These incisions will need to be monitored daily for evidence of infection, and an e-collar will be placed on your pet until the skin incision is healed, typically for 10-14 days, to prevent your pet from licking or chewing at the incision.

At approximately 2 weeks after surgery, the incision will be evaluated, and staples/sutures will be removed if present. Radiographs will be needed at 8 weeks after surgery to evaluate healing, depending on the age of the animal. For certain high-risk patients, or if at any time there is an abrupt change in comfort or limb use, additional recheck examinations may be recommended.

 Most animals do not require removal of implants. However, if an infection develops, the implant breaks, or the implant is causing discomfort, the implant may be removed after the fracture is healed. 

Are there possible complications if surgery is performed?

As with any surgery there is always the possibility of complications. Complications to consider include infection after surgery. To ensure keeping infection rates low your pet will receive antibiotics before, during, and in some cases after surgery. Additionally, an e-collar will be placed after surgery to prevent your pet from introducing bacteria into the incision site. Second, there is a risk for the implant to fail and/or break before the bone has healed, which may result in revision surgery.  Our surgeon diligently evaluates each patient and makes recommendations for management that increase the likelihood of success while avoiding unnecessary procedures/risks. Third, there is always the possibility that the bone takes longer than expected to heal or does not heal at all. There are several factors that influence bone healing, including the patient’s age, their health status, concurrent systemic disease, and activity level post-operatively. There is also risk for bleeding or damage to soft tissues, often time which will resolve with no additional treatment. Finally, there is a risk involved in using general anesthesia for all animals. Up to date bloodwork and a general physical examination will be required prior to the procedure to ensure there are no concerns that would increase an animal’s risk for anesthetic-related complications. During surgery your pet will be continuously monitored to ensure the highest level of safety.

What is the prognosis for an animal with a CCL tear?

The overall prognosis will depend on treatment type; however, regardless of what treatment is performed, all animals will have osteoarthritis that will cause occasional discomfort of the knee. The overall severity of osteoarthritis is decreased in animals that receive surgery. Long term management will be an important part of the management strategy for CCL disease.

Following a TPLO, a majority of dogs return to normal weight bearing on the limb within 6 months of surgery, except for occasional discomfort noted from osteoarthritis. However, for athletes or other high-performance dogs, the rate to return to competitions/performance is approximately 65% with surgery.

Fractures can occur in any bone of an animal at any age. Though they are commonly caused by trauma, fractures can occur as a result of weakening of the bone from cancer or nutritional/metabolic derangements. The age of an animal, history of events, and the fracture’s appearance on radiographs (x-rays) will determine if a veterinarian suspects an underlying process. If your veterinarian or surgeon has any concerns, additional diagnostics may be recommended to ensure we make an accurate diagnosis and provide your pet with the best care.

When fractures occur from trauma, we can assume the trauma sustained by the animal was significant. Therefore, it is imperative that your pet receives a full examination to evaluate for concurrent problems that may be life-threatening, put your pet at a high risk for general anesthesia during fracture repair, or change your pet’s prognosis for a full recovery. This may include bloodwork, radiographs of the chest and abdomen, a full orthopedic and neurologic examination, and additional radiographs of other bones and joints. Occasionally advanced imaging, such as CT or MRI is needed for a full assessment. If these diagnostics show your pet is not stable enough to undergo fracture repair, other urgent medical care may be necessary before the fracture can be repaired.

How are fractures repaired?

The goal of fracture management is to regain function and comfort by providing the bone stability to allow it to heal in proper alignment. There are several options to achieve bone stability, including management in a splint/cast, surgical repair with implants (pins, wires, plates, screws, interlocking nails, external fixators), and, rarely, activity restriction alone. If there are concurrent neurologic deficits, significant soft tissue injury, high risk for unsuccessful repair, or financial constraints, amputation of a limb may be discussed to provide your pet comfort.

As each fracture is unique for every patient, evaluation of radiographs and an examination of your pet are needed for the surgeon to determine which management strategy is most appropriate. Factors that influence the method of repair and possible post-operative complications include which bone is involved, the presence of wounds near the fracture, the shape of the fracture, the number of bone fragments and their displacement from one another, and involvement of a joint surface or open growth plate. Often additional radiographs may be taken by the surgeon prior to surgery for the purpose of including a measuring device. This device ensures appropriately sized implants are used and are available at the time of the repair.

Can all fractures be successfully managed with a splint/cast?

No. Adequate stability of the bone cannot be achieved with a splint/cast for every bone and fracture type. For a splint/cast to be effective, immobilization of the joint above and below the fracture needs to be achieved. The geometry of the fracture line, the displacement of the bone fragments, and the location of the fracture also influence the effectiveness of a splint/cast.

What should I expect post-operatively and during the healing period?

Regardless of management strategy used, the care YOU provide to your pet is CRITICAL to the successful management of a fracture. Our surgeon will provide you with detailed instructions at the time of discharge.

All animals will require a period of activity restriction. The length of restriction will depend on the animal’s age and healing progress noted during recheck examinations. This means no running, jumping, or playing. Your pet will need to be taken outside on leash to urinate and defecate; excessive climbing up and down stairs or on and off furniture should be avoided. When not directly supervised your pet needs to be placed in a crate, small laundry room or bathroom, or a small, sectioned-off portion of the house. Too much activity can result in delayed bone healing and necessitate prolonged activity restriction or result in implant breakage that may require revision surgery.

Surgically repaired fractures will create incisions in the skin. These incisions will need to be monitored daily for evidence of infection, and an e-collar will be placed on your pet until the skin incision is healed, typically for 10-14 days, to prevent your pet from licking or chewing at it.

Some animals will be placed in a bandage after surgery or as a primary management strategy. Bandages must be monitored closely and typically require weekly changes by a veterinarian. Bandage sores and complications occur frequently, but most are minor and can be managed during bandage changes. If left untreated or go unnoticed, serious injuries can occur that require extensive medical or surgical management.

Depending on the fracture type, physical rehabilitation may be recommended during the post-operative period.

At approximately 2 weeks after surgery, the incision will be evaluated and staples/sutures will be removed if present. Radiographs will be needed at 4, 6 or 8 weeks after surgery to evaluate healing, depending on the age of the animal. For certain high-risk fractures, fractures with delayed healing, or if at any time there is an abrupt change in comfort or limb use, additional recheck examinations may be recommended.

Most animals do not require removal of implants. However, if an infection develops, the implant is causing discomfort, or for some fractures in juvenile animals, the implant may be removed after the fracture is healed.

Are there possible complications if surgery is performed?

As with any surgery there is always the possibility of complications. Complications to consider include infection after surgery. To ensure keeping infection rates low your pet will receive antibiotics before, during, and in some cases after surgery. Additionally, an e-collar will be placed after surgery to prevent your pet from introducing bacteria into the incision site. Second, there is a risk for the implant to fail before the bone has healed. Our surgeon diligently evaluate each fracture and make recommendations for management that increase the likelihood of success while avoiding unnecessary procedures. Third, there is always the possibility that the bone takes longer than expected to heal or does not heal at all. If conservate management with a splint is performed or the implant bends/breaks, it is possible the bone heals in an abnormal alignment. Malalignment of bones can result in a range of clinical signs from no detectable lameness to severe limb dysfunction. For this reason, the doctor will walk you through each of your options and the associated risks so that you can make an informed decision for you and your pet. Finally, there is risk for bleeding or damage to soft tissues, including nerves that are near the fracture site, and a risk involved in using general anesthesia. During surgery your pet will be continuously monitored by one of our trained staff members to ensure the highest level of safety.

What is the prognosis for a fracture?

With appropriate fracture management and diligent care during the healing period, most fractures have an excellent prognosis. Bone eventually regains 100% of its original strength when the fracture is completely healed. Our surgeon will inform you if your pet has a risk for developing osteoarthritis as a result of the fracture, bone growth abnormalities, or if your pet has an increased risk for infection or delayed/incomplete healing of the fracture.

Patellar luxation refers to the movement of the patella (kneecap) out of the groove within the femur that it normally sits in. There are 4 grades of patellar luxation. Grade 1 luxation refers to a patella that is in place, can be moved out of place but immediately returns to its natural position. There are no clinical signs associated with this and surgery is not recommended. Grade 2 luxation refers to a patella that is typically in its normal position but can be luxated out of place for a period of time. Clinical signs vary from minimal lameness to a regular skipping-leg or intermittent non-weight bearing lameness. Surgery is recommended only for some dogs with grade 2 luxations depending on the severity of the lameness.  A grade 3 luxations refers to a patella that is positioned outside the groove but can be manually reduced back into its normal position. A grade 4 luxations refers to a patella that is positioned out of the grove and cannot be reduced. Both grade 3 & 4 luxations consistently result in lameness and often can be associated with more severe deformities of the bone(s). Surgery is typically recommended for grade 3 and 4 luxations and may require advanced imaging for surgical planning.

How are patella luxations repaired?

For almost all dogs with grade 2 luxations, and most with grade 3 luxations, a combination of techniques involving the bones and soft tissues around the knee are performed to encourage the patella to sit in the normal anatomical position. The combination of techniques is determined by the surgeon at the time of surgery. For dogs with a higher grade of luxation, the standard techniques are performed in addition to correcting deformities in the shape of the femur and or tibia are needed.  

Young dogs with patella luxations may require a staged procedure- one while they are still growing, and a second procedure once their growth plates are fused.  

What should I expect post-operatively and during the healing period?

Regardless of management strategy used, the care YOU provide to your pet is CRITICAL to the successful management of a patella luxation. Our surgeon will provide you with detailed instructions at the time of discharge.

All animals will require a period of activity restriction, typically 6-12 weeks; however, the length of restriction will depend on the animal’s healing progress noted during recheck examinations. This means no running, jumping, or playing. Your pet will need to be taken outside on a leash to urinate and defecate; excessive climbing up and down stairs or on and off furniture should be avoided. When not directly supervised your pet needs to be placed in a crate, small laundry room or bathroom, or a small, sectioned-off portion of the house. Too much activity can result in delayed bone healing and necessitate prolonged activity restriction or result in implant breakage that may require revision surgery.

Surgically corrected patella luxations will create an incision in the skin. The incision will need to be monitored daily for evidence of infection, and an e-collar will be placed on your pet until the skin incision is healed, typically for 10-14 days, to prevent your pet from licking or chewing at the incision.

At approximately 2 weeks after surgery, the incision will be evaluated, and staples/sutures will be removed if present. Radiographs will be needed at 6-8 weeks after surgery to evaluate healing, depending on the age of the animal. For certain high-risk patients, or if at any time there is an abrupt change in comfort or limb use, additional recheck examinations may be recommended.

 Most animals do not require removal of implants. However, if an infection develops, the implant breaks, or the implant is causing discomfort, the implant may be removed after the bone is healed.

Are there possible complications if surgery is performed?

As with any surgery there is always the possibility of complications. Complications to consider include infection after surgery. To ensure keeping infection rates low your pet will receive antibiotics before, during, and in some cases after surgery. Additionally, an e-collar will be placed after surgery to prevent your pet from introducing bacteria into the incision site. Second, there is a risk for the implant to fail or break before the bone has healed, which may result in revision surgery. Reluxation after surgery is the most common complication noted. Approximately 8% of grade 2 or 3 luxations recur following surgery, but this is increased to around 21% with grade 4 luxations.  The implants may migrate or cause soft tissue irritation and require removal after the bone has healed. Finally, there is a risk involved in using general anesthesia for all animals. Up to date bloodwork and a general physical examination will be required prior to the procedure to ensure there are no concerns that would increase an animal’s risk for anesthetic-related complications. During surgery your pet will be continuously monitored to ensure the highest level of safety.

What is the prognosis for an animal with patella luxation?

The overall prognosis will depend on the degree of luxation and treatment type; however, regardless of what treatment is performed, all animals will have osteoarthritis that will cause occasional discomfort of the knee. The overall severity of osteoarthritis is decreased in animals that receive surgery. Long term management will be an important part of the management strategy for patella luxations.

Generally, there is a good prognosis with surgical correction for dogs with grade 2 and grade 3 luxations. There is a worse prognosis associated with grade 4 luxations due to increased risk for re-luxation of the patella, and overall persistent lameness post-operatively.

Platelet Rich Plasma (PRP) is extracted from blood and includes serum with a higher concentration of platelets and varying number of white blood cells, depending on the method of preparation. Platelets are a reservoir for growth factors that play a role in coagulation, immune response, and promote the formation of new blood supply and tissue repair.

The rational for using PRP is that the growth factors and signaling molecules in the platelet granules can modulate the immune system to reduce inflammation and encourage proliferation and differentiation of resident cells to enhance the natural healing process of tissues.

What is the process?

 Your pet is placed under heavy sedation and blood collected from your pet into a specialized device that is centrifuged. Serum is then extracted that contains beneficial platelets, growth factors, and some white blood cells. The serum is then injected into the site of interest, which may include a joint, tendon, ligament, or in the surgical site. Your pet will have a small area along the neck that was shaved and sterilely prepped for the blood collection as well as a location over the site of injection. Your pet will be discharged the same day once recovered from sedation.  

What should I expect post-injection and during the healing period?

All animals will require a period of activity restriction. The length of restriction will depend on the underlying disease and may range from 2-6 weeks, or potentially more. This means no running, jumping, or playing. Your pet will need to be taken outside on leash to urinate and defecate; excessive climbing up and down stairs or on and off furniture should be avoided. When not directly supervised your pet needs to be placed in a crate, small laundry room or bathroom, or a small, sectioned-off portion of the house. Some animals will develop a greater lame for a few days after the injection, which is normal.

The response to PRP is variable. A recheck examination is often discussed 4 weeks after injection. If improvement is noted, additional injections may be discussed. Some animals require repeat injections to help manage their disease process long term. The interval between injections is highly variable and typically based on recurrence of clinical signs.

Are there possible complications with injection?

The injection is safe with few complications reported as the serum is created from the animal’s own blood.  However, this is contraindicated with infection or cancerous processes.

What is the prognosis?

The prognosis is variable depending on the underlying disease and an individual animal. Unfortunately, there is little scientific research using PRP and other regenerative medicine practices in dogs and cats.  PRP has been used in humans for a variety of orthopedic conditions and most of the veterinary medicine reports are in the use of PRP in horses. While this field is growing in small animal medicine, and the literature that is published is promising, in my experience, the expected outcome is variable between each individual animal, ranging from no improvement to significant improvement. If no improvement is noted, subsequent injections are not typically performed. The role of PRP in treatment of orthopedic disease is still being understood, but PRP potentially provides a cost-effective, simple, procedure that enhances a natural healing process to treat many diseases that often do not have a cure, with little to no harmful side effects. The decision to use PRP in a patient will be made after discussion between us, your veterinarian, and you about costs, risks, limited evidence, and other traditional treatments.