OK, so now you’ve got your diagnosis: It’s a cruciate ligament tear or rupture with possible injury to the meniscal cartilage of the knee, too. Ouch! What you really need right about now is an expert opinion on the optimal treatment for this injury given your budget (OK, so maybe you need a tissue, too). To that end, here’s the skinny I promised…
Common cruciate options
1-Surgery (one of the so-called “leveling osteotomies” is recommended for medium and large breed dogs, the most common of which is called a TPLO).
2-Surgery (a procedure called an “extra-capsular repair”—increasingly considered a good option only for smaller breeds)
…and when funds are scarce:
3-Rest, anti-inflammatory (pain) medication, weight loss and nutraceuticals (all of which are also crucial to the success of options 1 and 2).
TPLO
Though some board-certified veterinary surgeons may quibble with this statistic, the most commonly reported rule of thumb is that cruciate injury patients weighing over 25-30 pounds are best served by the surgical procedure called TPLO (tibial plateau leveling osteotomy), which employs cutting the bone, leveling it, and holding it with a metal plate to help stabilize the joint. (My local surgeons routinely recommend TPLO for patients as small as 12 to 15 pounds and find they do much better as well.)
This surgical procedure is typically accomplished by boarded vet surgeons (who have completed three-year residencies and passed a grueling examination along with specific training for this technique). Non-boarded surgeons (regular vets like me) who take a special interest in orthopedics may take a course and gain sufficient knowledge and proficiency, too. There’s no law that says boarded surgeons need be your only option.
The price of this repair typically ranges from $1,500 to $4,000.
Extra-capsular repair
The next most common surgical approach is called an extra-capsular repair. Though dogs may appear to gain some immediate relief with it (and some vets swear by its efficacy), in the long run it doesn’t statistically compare to the success of the TPLO approach in the larger breeds most commonly afflicted.
This repair is generally less expensive, however, since fancy hardware isn’t required. And dogs under 25-30 pounds may be sufficiently well served by this simpler extra-capsular repair.
The price of this procedure runs as low as $500 and as high as $2,500.
Why the range?
As with many medical procedures, the frequency with which the practitioner performs either of these surgeries is an excellent indicator of proficiency. Most vets would agree that docs doing one or more a week are typically considered experts. All others may be great, even more proficient in some cases, but the stats are not so much in their favor.
In fact, cruciate repairs are one area in surgical vet medicine where skill is considered especially critical to success. That’s because no knee surgery will return your dog to 100% pre-cruciate injury normalcy. The earlier it’s undertaken after the ligamentous insult the more likely you are to see a dramatic improvement and less future arthritis, but an experienced surgeon can make all the difference, even when chronic tears have already allowed for significant accumulation of arthritis in the joint.
Good surgeons like to say that these surgeries are easy to do, but difficult to do well.
The prices for this procedure usually reflect this—but not always, as some less experienced practitioners may look to the average price of the procedure in an area and govern their own prices accordingly. (I’ve certainly seen that happen in my vicinity.) I’ve also seen some pretty competent vets undercut the high-priced competition and manage a high number of these procedures every month as a result. Ultimately, it’s up to the individual buyer to beware of the competency of their chosen surgeon—and it’s not an easy task.
Then there’s the standard issue of hospital policies and procedures and the cost of these oft-unseen variables. Some hospitals will spare no expense when it comes to materials and staff and other safety nets designed to provide the best surgical experience possible. Others will cut corners to get at a more affordable price point for their clients. Both are absolutely valid approaches as long as you know what you’re getting. It’s up to you to decide what fits you best.
Unfortunately, the fact that these variables are unseen means you don’t always have access to the information you need to make the most educated choice when it comes to these issues. Asking around (your regular vet is a gold mine here) is your best bet.
Consider, also, that larger dogs will require more medication, and larger, more expensive TPLO plates. Their repair is invariably going to cost 10 to 50% more than for the same kind of surgery in a smaller dog.
What if I can’t afford any surgery?
While not all owners can afford the expensive surgery this condition typically requires, weight loss, arthritis medications and nutraceuticals (glucosamine and chondroitin sulfate, typically) can impact dogs’ comfort levels markedly.
Though in general this “conservative” approach is considered much less effective than a TPLO, it does provide owners who can’t afford this surgery the opportunity to take responsible action.
In fact for most bigger patients, it seems that weight loss is far more effective than choosing the extra-capsular repair option. In other words, if you can’t go for the recommended kind of surgery, no surgery might be your best option. (Of course, this determination depends heavily on the skill of the practitioner and the size of the dog.)
One final point
And finally, beware, great surgeons often don’t have stellar bedside manners. Try your best to overlook this and concentrate instead on their experience level and other objective concerns, especially if this is a vet not well known to you (as is typically the case with excellent quality cruciate repairs).
But ultimately, it doesn’t have to come down to the nickels and dimes. In the end, trust alone is often worth whatever premium you feel you might be paying for sticking with a vet and a hospital that answers all the right questions and treats your pet just right.
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PS: A hearty thanks to the vets from coast to coast who helped me confirm these dollar amounts and, most of all, to my consultant and proofreader, Dr. Marc Wosar (vet surgeon extraoirdinaire).
Dr. Patty Khuly February 22nd, 2008 09:29:00 AM
Thank you for the useful post. My 10 year old Lab ruptured his CCL a few months ago and we have opted for conservative management. I am considering hydrotherapy as well as weight loss and supplements. I think we will put up an article regarding CCL repair on our Labrador retriever web site.
Daniel
webmaster@justlabradors.com
Daniel February 22nd, 2008 10:58:00 AM
I went with the TPLO for my small dog (11 pounds) because he's so absurdly active and is hard on his joints in general. Slowing down is not on this terrier's list of options. He didn't even want to stop playing fetch just because he only had three legs left working. A three legged dog hobble was fine with him if I'd just keep flinging the toy!
It's now three years since the surgery and he's nearly back to full strength. I never imagined he'd be this healthy and strong again. It was well worth the money and living nightmare involved in making him rest for those first months. I also can't speak highly enough of the supplements. They really do make a huge difference.
Anna February 22nd, 2008 11:30:00 AM
I opted for the suture type repair for my 45 pound pit bull bitch. The vet I trust most felt that TPLO was unnecessary, and she referred me to the surgeon she'd want fixing her own dog's knees, and he felt that suture type repair was a reasonable choice. She's a little better than six months post-op and she'd definitely not as good as she was before injury, but I'm happy enough with the results. I will go back to him when she blows the other knee, even though he was expensive ($2000 including bloodwork and radiographs - which had been done at my regular vet but several months previously - and hers was only a partial tear and we weren't certain that surgery was the right course to take, so I hadn't re-done them).
I have a coworker with an 8 year old, 90 pound German Shepherd who had suture type repairs on both of his knees by the age of two. He has no trouble at all with them now, so I am keeping my fingers crossed and double crossed that my dog will do as well.
katie February 22nd, 2008 05:42:00 PM
I'm leery of TPLO surgery. While it works well for some dogs, I've heard of others where the joint doesn't heal properly and the dog is worse off than before. The skill of the surgeon may be a factor, but how do you determine that? I have also heard a number of reports, both directly and indirectly, of dogs developing bone cancer following this surgery, as well as other long-term complications. Removal of all implants six months to a year following the surgery may help to reduce this risk, but it seems this is rarely done.
As far as I know, no one tracks of the results of these surgeries, so that one might have a better idea of the odds of problems developing, and the long-term cancer risk.
If I had a large, active dog, the risk might be worthwhile since the traditional repair is less likely to work, but I've been satisfied with the results of the two traditional repairs I've had done for my 35-lb dog at ages 3 and 10 (she's now 16).
Mary February 22nd, 2008 06:38:00 PM
OK, regrettably I have had lots of first hand experience with cruciates, both my own dogs (5 over 17 years) and alot of rescue dogs.
All I have to say is YAY!!! for TPLO surgery. Before, the old graft method worked, but recovery was slow and arthritis down the road a real possibility, external sutures were OK for partial tears but there was always the caveat that the dogs real work days were over. Often no matter what you could always tell something was not quite right, and any favoring of one leg puts strain on the opposite knee, especially in an active young dog.
And if the injury was long standing, then neither surgery seemed to get them back to decent function.
The first experience I had with TPLO was on an older girl who had been virtually three legged lame for at least two years. She actually walked out already toe touching. The TPLO leg ended up as her good leg. My most recent experience was with my own 65 lb dog who got a little too ambitious on the ice and snow and came in in obvious pain and on three legs. #@*&# He is two weeks post op and feeling way too good, only 8-10 weeks more to go. I am 3200.00 lighter but I have a fantastic surgeon and worth every penny
As for cancer. Well, like microchips, any foreign body can cause that reaction, rarely. Several of the breeds prone to TPLO are also prone to osteosarcoma, so maybe it's coincidence, or the implant acted as the trigger? I've been an oncologists wife for 13 years and he has no concerns over this type of surgery. Having seen the results of not fixing the joint after cruciate failure, I don't hesitate.
JenniferJ February 22nd, 2008 07:00:00 PM
I believe that TPLO performed by a qualified and experienced orthopedic surgeon is the gold standard for cruciate rupture. I think it has withstood the test of time.
Jules February 22nd, 2008 08:32:00 PM
I have an 85-lb. doberman/lab mix and a 50-lb. mixed breed...the real possibility of cruciate repair in either is one of the many reasons why I have a CareCredit card.
anna February 22nd, 2008 09:39:00 PM
Thanks for this informative series.
One thing I've never been clear on is whether this is an injury that is restricted to the rear legs? Or can it happen on the fronts & is the treatment the same?
hornblower February 22nd, 2008 10:44:00 PM
hornblower: Nope. Cruciates are only in the knees. Ligamentous damage can occur at any joint, but cruciates are special. They are incredibly common.
Dr. Patty Khuly February 23rd, 2008 07:45:00 AM
Another option is the TTA surgery (tibial tuberosity advancement). From what I have seen in the past two years, the overall success and recovery rates are good with a lower complication rate than TPLOs. Cost seems to be relatively lower as well ($1600-2000 here in the Midwest).
For non-surgical candidates, try going to www.orthopets.com and seeing how their braces can help support injured legs.
Tomcat1765 February 23rd, 2008 12:14:00 PM
I agree that TPLO is currently considered the "gold standard" for cruciate ligament repair, but would still very much like to know the percentage of cases with serious complications.
When I tried unsuccessfully to find statistics on complications with TPLO, I did find one recent paper from a veterinary conference that talked about complications with TTO (Triple Tibial Osteotomy, which they describe as "a new technique designed to combine the features of both the TTA and TWO techniques to achieve the same outcome, but with less radicle angular changes"):
http://www.ivis.org/proceedings/wsava/2007/pdf/73_...
"Seven [out of 64] post-operative complications were encountered (11%). There were two fractures through the tibial tuberosity, one joint infection, one plate infection, one case of suspect bone neoplasia [cancer], and two meniscal injuries."
They still concluded that "Analysis of the outcomes in this prospective study, in which a significant number of the patients completed the long-term follow-up, reveals an outstanding result in a very high percentage of cases."
Those are serious complications, especially since from what I can find osteosarcoma is most likely to occur when there is infection following surgery, so there may eventually be 3 cases of bone cancer rather than 1, out of 64 dogs. 11% is a pretty high rate for serious complications, especially if this may be lower than with other forms of tibial plateau alterations.
Again, my concern is not just hypothetical, I have heard directly from several people who have had this happen to their dogs. If complications were rare, I doubt that would be true.
If you have a working dog or a large, very active dog, then I still think the risk is probably worth it because the outcome is definitely better when the surgery works, but I'm not so sure for the older dog, couch potato, or even typical pet. It would be nice to be able to make an informed decision based on statistics rather than just being told that "complications are rare."
Mary February 23rd, 2008 01:43:00 PM
Great post to refer back to. Helps the owner to understand the injury & surgery, and be able to ask questions.Still, unless you have been around the block on a particular problem, you are most dependent on the "primary" vet and advice given. Sometimes, time is an element and certain presentations can cause hasty decisions & not much background research.
We were very lucky to have an excellent referral surgeon suggested for Pearl's spinal surgery, and, surprisingly,we were steered away from a couple of well-known places. I am thankful for this every single day! It was also helpful that my boyfriend had undergone a spinal fusion & disk replacement a few years earlier. He knew a couple questions to ask. But his best one was "How many of these surgerys do you do a year, Doc?" And we fixated carefully upon the answer and body language.
Pearl's surgeon (earned specialty at Penn) was nice but not really a warm & fuzzy type----who cares??! It was the results that counted!
Long afterwards, I found out about "Dodger's List"---with IVDD focus.
Barbara A. Albright February 23rd, 2008 08:13:00 PM
Mary: One of the reasons the multiple-Billion dollar study was conducted (the one I referenced in the first post on cruciates) was to push the vet industry to fund more studies like the one you're requesting. When a problem is so common (and so expensive!) it's crucial (no pun intended) to safeguard the pets and those who pay for these procedures. I second your concern and I happen to know there is work currently being done in this area at multiple universities.
Dr. Patty Khuly February 24th, 2008 10:08:00 AM
Infection with knee replacement surgery is a major risk with humans as well and while I haven't been in a speciality practice OR, the surgical procedures done in the regular clinics I have been in are far from what one would consider a strict sterile techinque. Infections can get under appliances and cause problems for years but I don't really consider that a failure of the procedure as much as a complication. Home care and preventing the animal from licking the site is crucial in preventing infection also. I will be interested in more study results.
Jules February 24th, 2008 01:21:00 PM
Our English Springer just had this surgery last week. We were told to keep him inactive - no running, jumping, steps... My concern is when we let him out he does touch his foot down when pooping. I'm just hoping this is not a big deal and will not cause any damage this soon. Another concern is that he is having some bloody stool which I will share with my vet tomorrow. Any of your dogs have any bad reactions to the pain meds? Riley is on Rimadyl. Thanks!
Maureen March 23rd, 2008 08:28:00 PM
My first child with fur will be having a TPLO surgery on her right leg with Dr. Marc Wosar in Miami tomorrow morning. I’m a nervous wreck as I suppose can be expected…Marlee needs TPLO on both legs, but we’re starting with the right leg. It became suddenly unstable last night. Marlee is a 5 year old Rottweiller and really the little love bug of my life. I searched, researched, called, e-mailed so many doctors around the country and was convinced at first meeting that Dr. Wosar is the exact person I was looking for…the only person I would trust Marlee too. I do have to say Dr. Sarah Evans at Hollywood Animal Hospital made #2 of the many I spoke with. Anyway, if there is anyone out there that has been through this and has any tips on the dreaded recovery period…especially considering we will do the second leg as soon as possible…I’d love to hear from you. I’ve cancelled vacations, meeting my first nephew to be born next week to make Marlee my priority. Saying a little prayer her brother won’t need the same treatment…and will behave while I do my best to keep her calm and stationary for months and months to come. : ( If you have lived through this, please share at stacy_happy1@hotmail.com. Say a little prayer for Marlee tomorrow. Thank GOD for Dr. Wosar – I have a peace in my mind knowing she’ll be in his hands….literally.
Stacy C April 17th, 2008 10:06:00 PM
My precious canine child had two TPLO procedures. He had a reaction to the metal implant in his right leg, so as soon as the bone had healed, the implant and screws were surgically removed. However, the implant and screws were NOT removed from his left leg..... and he developed osteosarcoma (bone cancer tumor) directly at the site of the implant.
Amputation and thousands of dollars later could not stop the cancer from metastasizing. The medical profession offered NO HOPE NOR TREATMENTS WHEN MY PRECIOUS BOY WAS SUFFERING.... ONLY EUTHANASIA! I am in touch with others whose dogs had developed osteosarcoma at the surgery site of the TPLO procedure. We are grieving the losses of our animal angels.
Trouble's Mom July 16th, 2008 03:23:00 AM
I'm wondering if you can point me to any journal citations saying that large-breed dogs do better with TPLO surgery than with other types of surgical repair. There is only one, five-year-old, study I've found suggesting this; however, it was based on the level of osteoarthritis from looking at X-rays. This disturbs me on two fronts: 1) Numerous clinical studies in humans show that X-ray assessment is NOT a good predictor of the actual pain felt by arthritic patients, and 2) Since TPLO involves major alterations to bone geometry and the insertion of metal pins into the bone, there is no way that this study could be blind; therefore, it is possible that the study may not be objective.
Furthermore, I just read the following review:
Kim SE, Pozzi A, Kowaleski MP, Lewis DD. Tibial osteotomies for cranial cruciate ligament insufficiency in dogs.
Vet Surg. 2008 Feb;37(2):111-25. Review.
These authors suggest that the poverty of objective and useful data in clinical follow-up studies ofTPLO make it, in fact, impossible to make any kind of determination about whether TPLO or the less-expensive, traditional methods of CCL repair are superior.
Aragon CL, Budsberg SC.
Applications of evidence-based medicine: cranial cruciate ligament injury repair in the dog.
Vet Surg. 2005 Mar-Apr;34(2):93-8. Review.
Jerram RM, Walker AM.
Cranial cruciate ligament injury in the dog: pathophysiology, diagnosis and treatment.
N Z Vet J. 2003 Aug;51(4):149-58.
These are older articles, and my university doesn't have access to the full text, but the abstracts appear to say similar things, namely, that at this point it is difficult to determine whether TPLO is in fact superior to extracapsular repair.
All the articles agree that TPLO does have a positive outcome in most dogs. However, conventional surgery also has a positive outcome in the majority of cases. Conventional surgery has several merits in comparison with TPLO, as well: 1) It is a less-invasive procedure, requiring a shorter overall recovery time since there is no sawing of bone (unless for some reason a surgeon is still using FHT). 2) TPLO has several nasty and specific complcations (sarcoma from the plates inserted, tibial tuberosity fracture, bone infection). 3) Conventional surgery is much cheaper, on the order of 1/3 to 1/2 the cost -- going with conventional surgery instead of TPLO can therefore lessen the economic burden on families with CCL-deficient dogs, and if TPLO is presented as the only option, many dog owners who could afford conventional surgery will be unable to afford the TPLO, and their dogs will go untreated.
I thought that you might be interested in these citations, as a practicing veterinarian who is not a surgeon. TPLO might be better-thought of by many orthopedic surgeons because of the immense profit generated by the surgery: TPLO used to be a proprietary surgery of Slocum Enterprises, Inc., and the high price point of the surgery reflected this. The patent has since (I believe) lapsed, but the price of TPLO remains equally high; the higher cost of this surgery is not fully justified by either the time spent in surgery or the additional hardware used. I am not saying that those vets who use TPLO are unethically pushing a more-invasive procedure on owners and primary-care vets, but I do believe that these vets may be unconsciously predisposed towards TPLO surgery, and that there is a definite conflict of interest present.
Kat S. September 5th, 2008 03:41:00 PM
It is interesting to read various comments here regarding cruciate disease in dogs and the owner's perspective. Yes I am a veterinary surgeon. It is indeed an area of great confusion with respect to diagnosis and treatment options for owners and veterinarians alike. We try our best to provide the most favourable outcome for the companion animals we treat often under very trying circumstances. Now without going into all the pros and cons of each treatment protocol (it would fill a book!) I will briefly list the options (most preferable to least preferable) that I would choose for my own much loved large dog (Rhodesian Ridgeback cross, 45 kg or 100lb in weight).
Surgery to stabilize the knee to control anterior drawer (looseness in forward to backward plane): either TPLO, TTO or TTA (all of which have similar results and complication rates when performed by experienced surgeons)
Extracapsular repair using nylon suture to initially help limit looseness
Conservative treatments: weight control, minimize high impact exercise, physiotherapy, injections of pentosan polysuphate, nutraceuticals (greenlipped mussel extract combined with glucosamine and chondroitin is the best combination I know of). Note that these conservative treatments should also be used after surgical treatment.
As far as cancers forming after surgery; this is related to chronic inflammation and is in fact quite rare (I have seen one case only after performing orthopaedics for 24 years). If you consider this an issue simply have your surgeon remove the implants after healing is complete (and yes this will cost extra and is the leading reason owners decide not to have the implants removed).
I hope this helps
Regards
Adrian Scipione
Adrian Scipione November 27th, 2008 10:23:45 PM
Costs are the same in Europe. For instance, caudal TPLO on large breed dog (surgery, xrays and medications) performed by certified and experienced orthopedic vet in Italy gets up to $3,000. This if you do post op rehab by yourself...
gianmario March 12th, 2009 12:55:54 AM
The biggest question on this subject that I cannot find anywhere is what if I take the conservative approach and it doesn't get better? Is surgery down the road an option?
I have a 10 year old much loved "mutt". She is 55lbs (slightly overweight) and just torn her CCL. I am in the process of going to another vet for a second opinion but I just don't know what to do. I can't really afford a $1000+ surgery. Will she be able to live for several more years with this injury? Any advice would be appreciated.
Dave Linn March 16th, 2009 06:05:36 PM
My vet told me when diagnosing my 50lb staffordshire terrier's partial CCL tear about the options that would work for her: TPLO and "conservative management". I asked him the same question, "What if conservative management doesn't work?" He said that TPLO is still an option later but the longer I wait, the higher the risk of advanced arthritis in the joint down the road. I asked about the cost of conservative management vice TPLO and he said that, in his experience, people end up spending a lot of money on pain meds and end having to have the surgery anyway. He's one of two specialists in the area here and is not hurting for work, so I don't think he was pushing the surgery for his own gain.
In the end, we went with the TPLO right away for two reasons: I know how painful knee problems are firsthand and with our work schedules, the time investment in the conservative approach would be difficult (and if we know we will have trouble giving her everything she needs to recover, then why even go that way)
We are now 3-weeks post TPLO and she's managing fine. I, too, was worried about her putting any weight on the knee (including when going "out" and getting in/out of the crate) and the doctor assured me that those incidental times can't be avoided but those times need to be a very small percentage in balance to the time she puts no weight on it.
A point of learning: I would note to budget for the interim appointment charges - the surgery cost was one thing, but her incision isn't healing quickly, so we've had two post-op appointments requiring new stitches - and no one even mentioned this possibility (or cost) at any point earlier on, so I'm a bit frustrated. Overall, this will be costing close to $5k when looking at everything involved.
I can't WAIT for 16 weeks to arrive when she can be allowed to be back to her "normal" self without restriction. Only 13-weeks to go!
Kelly March 28th, 2009 07:38:23 AM
My 13 year old terrier mix came in on three legs yesterday morning. I took her to our vet and he said he thought she had completely torn the CCL (he based this on the movement in her leg). He is sending us to a surgeon next week. The vet feels surgery is the only option. I am concerned because she is already on Deramaxx for arthritis in her hip. She is 22 pounds and a very timid little girl. I do not want to see her in pain but am unsure how to proceed. Any recommendation would be greatly appreciated.
Lindylee May 24th, 2009 05:58:14 PM
My two dogs had TPLO surgeries. They both developed osteosarcoma, as have many other dogs who had the sub standard metal implants used a few years ago. Sadly to say, they both died as a result. When my dogs both developed lameness, they were x-rayed. I was repeatedly told my dogs had arthritis... until either an honest vet or one who knows how to read an x-ray (because the tumors were visible on both of my dogs' x-rays) confirmed the correct diagnosis of bone tumors. Veterinarian surgeons still state that the percentage of dogs who developed cancer after having the TPLO are very small. How many dogs, like both of mine, become painfully lame, and are taken to vets for x-rays, only to be told their dogs have "arthritis" when it's really cancer? I know for a fact there's more than my two. I wonder how these so called "specialists" sleep at night.
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My 14 year old terrier mix, 35 pounds, has a complete tear of the cruciate ligament right hind leg - vet has recommended we see a surgeon next week. I am unsure what to do - the costs are extensive and I'm not sure that putting him through this at this age is the right thing to do, especially given the apparent very long recovery process. He's slowed down quite a bit over the last six months, but is stll reasonably healthy. Any advice or similar experience?
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