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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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Daniel
webmaster@justlabradors.com
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.
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.
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).
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.
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?
For non-surgical candidates, try going to www.orthopets.com and seeing how their braces can help support injured legs.
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."
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.
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.