Hi. I had a question. We have chatted before. I’m a physio in BC. My lab has been limping and my vet thinks she has a partial ACL tear on her right hind leg. He has recommended surgery (TPLO) which I feel is a big extreme. What are your thoughts on surgery for partial tears? Is there any research to support this vs conservative management? Thank you for your time.
A.
Conservative Cruciate
Re: Conservative Cruciate
Hi A.
So, it conservative management can work in some dogs... but it depends on how much is torn. If it's a full tear of the craniomedial band of the CCL, then a surgery is likely the best way to go with a young / active dog. I tend to recommend extracapsular surgeries for those however. Then the biomechanics of the leg isn't altered. However, not many vets are doing them anymore... which might be why your vet recommended a TPLO. This can work as well in this situation, but I also think it's 'overkill'.
From my experience, if it's a partial CCL (with most or all of the craniomedial band torn), then it will tear fully within 1 - 2 years.) So, if you can do surgery now, that would be better than waiting for it to tear fully.
Conservative management is not only dependent on the degree of tearing (and of which bands), but also on the dog. Like people, you will have copers, compensators & non-copers. So it can be trial and error. Canine Research on conservative management? NONE.
Laurie
So, it conservative management can work in some dogs... but it depends on how much is torn. If it's a full tear of the craniomedial band of the CCL, then a surgery is likely the best way to go with a young / active dog. I tend to recommend extracapsular surgeries for those however. Then the biomechanics of the leg isn't altered. However, not many vets are doing them anymore... which might be why your vet recommended a TPLO. This can work as well in this situation, but I also think it's 'overkill'.
From my experience, if it's a partial CCL (with most or all of the craniomedial band torn), then it will tear fully within 1 - 2 years.) So, if you can do surgery now, that would be better than waiting for it to tear fully.
Conservative management is not only dependent on the degree of tearing (and of which bands), but also on the dog. Like people, you will have copers, compensators & non-copers. So it can be trial and error. Canine Research on conservative management? NONE.
Laurie
LAURIE EDGE-HUGHES
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David Lane
- Posts: 164
- Joined: Mon Oct 24, 2016 10:51 pm
Re: Conservative Cruciate
Hello,
Apologies if I’m the vet you talked to earlier, and this is a repeat conversation (I remember recommending a TPLO to a physio last week, but I believe that knee was already unstable enough to no longer be considered a partial tear).
85% of partial tears become surgical within 3 years, with most of them going that way in the first year. The dogs in that study were not treated with rehab so it remains unknown if rehab would make a difference or not.
The advantages of going to surgery on a partial tear is to a) just get it over with because 85% chance you will end up there anyway, b) reduce the rate of OA progression, and c) to preserve the remaining ligament as much as possible.
The only surgery that has been shown to preserve the remaining ligament in a partial tear is a TPLO. For either the ex-cap or TTA, the remaining ligament needs to be transected or risk ongoing pain and surgery failure. Second look arthroscopy found that in TPLO dogs, most of the ligaments stop degenerating and remain viable. Not so with the other procedures. I used to be a big ex-cap advocate as well, but the advent of locking plates for TPLOs has dropped the major complication rate significantly. Also, the recent fluoroscopic studies made it pretty clear that TPLO is superior to both ex-caps and TTAs for returning normal kinematics (with a nod that it looks like combining a TPLO with an ex-cap antirotational suture might be better still)
For unilateral stable partial tears with a history suggestive of a true sports injury (rather than poorly built knees), I recommend stem cells and PRP to repair the ligament. The one study we have on that took the above 85% chance of needing surgery in 3 years stat, and reduced it to under 20% in 2 years that went on to need surgery. My oldest case is 4 years out and doing great.
If clients want to pursue rehab in partial tears (with no stem cells), then we take that on a month by month basis to see how the dog is progressing. Eg, if we are 1 month out and dog is still limping, we pull the plug then. If not, we progress for another month and monitor for ongoing issues… pulling or not pulling the plug depending on the clinical response. As long as they are being diligent on exercise restriction, then I don’t see the harm in trying… its just not what I would do for my dog.
I hope this helps.
Apologies if I’m the vet you talked to earlier, and this is a repeat conversation (I remember recommending a TPLO to a physio last week, but I believe that knee was already unstable enough to no longer be considered a partial tear).
85% of partial tears become surgical within 3 years, with most of them going that way in the first year. The dogs in that study were not treated with rehab so it remains unknown if rehab would make a difference or not.
The advantages of going to surgery on a partial tear is to a) just get it over with because 85% chance you will end up there anyway, b) reduce the rate of OA progression, and c) to preserve the remaining ligament as much as possible.
The only surgery that has been shown to preserve the remaining ligament in a partial tear is a TPLO. For either the ex-cap or TTA, the remaining ligament needs to be transected or risk ongoing pain and surgery failure. Second look arthroscopy found that in TPLO dogs, most of the ligaments stop degenerating and remain viable. Not so with the other procedures. I used to be a big ex-cap advocate as well, but the advent of locking plates for TPLOs has dropped the major complication rate significantly. Also, the recent fluoroscopic studies made it pretty clear that TPLO is superior to both ex-caps and TTAs for returning normal kinematics (with a nod that it looks like combining a TPLO with an ex-cap antirotational suture might be better still)
For unilateral stable partial tears with a history suggestive of a true sports injury (rather than poorly built knees), I recommend stem cells and PRP to repair the ligament. The one study we have on that took the above 85% chance of needing surgery in 3 years stat, and reduced it to under 20% in 2 years that went on to need surgery. My oldest case is 4 years out and doing great.
If clients want to pursue rehab in partial tears (with no stem cells), then we take that on a month by month basis to see how the dog is progressing. Eg, if we are 1 month out and dog is still limping, we pull the plug then. If not, we progress for another month and monitor for ongoing issues… pulling or not pulling the plug depending on the clinical response. As long as they are being diligent on exercise restriction, then I don’t see the harm in trying… its just not what I would do for my dog.
I hope this helps.
David Lane DVM
ACVSMR, CVA, CVSMT, CCRP
ACVSMR, CVA, CVSMT, CCRP
Re: Conservative Cruciate
Thanks David!
Good thoughts.
I have one right now. Full tear of the craniomedial band and intact caudolateral. The owner opted for an extracap. So far so good. I'm anxious to see how the dog does.
I think it's also important to note that not all partials are the same. One needs to define how much or if any of the craniomedial band is intact... If the craniomedial band has enough fibres intact, then I think it can heal. If it's fully torn, then absolutely surgery will make the difference and likely result in the best outcome. Just my soapbox, I don't think it's fair to say that all 'partial tears' are the same. Which is why I don't think we can take the current body of research at face value. Okay... off the soap box!
Thanks for your input David. (I don't know if you were the vet she spoke with either!)
Cheers,
Laurie
Good thoughts.
I have one right now. Full tear of the craniomedial band and intact caudolateral. The owner opted for an extracap. So far so good. I'm anxious to see how the dog does.
I think it's also important to note that not all partials are the same. One needs to define how much or if any of the craniomedial band is intact... If the craniomedial band has enough fibres intact, then I think it can heal. If it's fully torn, then absolutely surgery will make the difference and likely result in the best outcome. Just my soapbox, I don't think it's fair to say that all 'partial tears' are the same. Which is why I don't think we can take the current body of research at face value. Okay... off the soap box!
Thanks for your input David. (I don't know if you were the vet she spoke with either!)
Cheers,
Laurie
LAURIE EDGE-HUGHES