Cruciates: Less Cutting, More Self-Repair

The time has come for a methodical, evidence-informed alternative to the rush-to-surgery mentality.


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Veterinarians working on dog

What is it about the cruciate that makes so many want to intervene with blades and power tools? After all, the cruciate has feelings, too, and the limb has a vested interest in remaining intact.

With the lame dog, shouldn’t we investigate thoroughly to find out the facts before surgery?

We can’t uncut a tibia that has been refashioned after that of a human.

Ancillaries

Where there is a department of surgery, let us also assemble departments of wellness, rehabilitation and scientific integrative medicine.

Let us foster healthy debate and critique, so that forward-thinking orthopedic surgeons and like-minded individuals are no longer accused of “making waves” and performing “surgical (or professional) suicide.”1 I agree that, “In this era, it is important to re-evaluate and modify traditional treatment approaches with information gleaned from evidence-based medicine.”2

We now have evidence that the minimally invasive extracapsular repair approach known as the TightRope, far less traumatic than the tibial plateau leveling osteotomy (TPLO) and tibial tuberosity advancement (TTA), demonstrates the highest safety–to–efficacy ratio over the long term, allowing dogs to avoid catastrophic complications and the intensive trauma of revisionist methods.3

The time has come for a methodical, evidence-informed alternative to the rush-to-surgery mentality.4

First, confirm the diagnosis. Rule out trigger-point pathology as the cause of lameness. Rule out spinal cord or peripheral nerve disease, as thoracolumbar disk disease and other neurologic problems may resemble bilateral cranial cruciate ligament (CCL) injury.

When attention narrows to joint angles and shear forces in the black-and-white world of orthopedic radiography5, soft tissues fade to gray and are frequently forgotten.
 
Conversely, a pain medicine and rehabilitation practitioner evaluates joints in the context of the whole dog, often recognizing the source of the problem as also the key to the solution: namely, proprioception.6,7 Maneuvers that provide somatic afferent stimulation, such as massage, acupuncture and therapeutic exercise, improve postural stability and motor performance.8-10 In addition, physical medicine methods counter the immunopathological and inflammatory mechanisms associated with CCLD.11

Dealing with the Clients

Clients want options.12 While many can be convinced to schedule immediate surgery, they deserve to learn about the value of scientific integrative medicine and rehabilitation as an alternative or complement to surgery.

It is better that they know up front that up to one-third of dogs after TPLO experience one or more complications,13 including fractured bones, heavy blood loss, implant failure, continued instability, meniscal damage and infection. Some dogs will require additional surgery. Chronic pain afflicts approximately 30 percent of dogs after CCL repair,14 reducing quality of life and ability to exercise.15
The rule of “You break it, you own it,”16 does not apply to canine cruciate repair. Who will pay when the surgery fails? The client and, in many ways, the dog.

Since rehabilitation and pain control are usually necessary regardless of whether a dog needs surgery, why not start first with physical medicine and weight loss, which may make surgery unneeded?

Prevention Starts Early

Begin preventive measures early in a dog’s life by identifying modifiable risk factors and ways to prevent injury.17 Encourage activity that avoids straining the stifle with cutting and pivoting motions while fostering endurance.18 Inform clients that obese dogs have four times the likelihood of rupturing a cruciate as nonobese dogs.19 Don’t wait until the ligament ruptures in high-risk individuals and breeds.

Actively intervene with physical medicine to address their pain, lameness, stifle effusion and mild osteoarthritis.20

If the CCL does rupture, share information from recent research that their lame, overweight dog may not need surgery if s/he loses excess pounds.21,22

Review the anatomy of the stifle from a soft tissue enthusiast’s perspective. Functional stability of the knee or stifle results from competent active and passive stabilizers of the stifle. Nerves, whether sensory, motor, or autonomic, contribute to the health and security of the stifle joint.23,24

They coordinate activity in the stabilizers of the knee, including the quadriceps, hamstrings, gastrocnemius, and popliteus muscles. Injury to the stifle as well as longstanding muscular imbalance may result from altered neuromuscular activity.25,26

The meniscus participates in proprioception and serves to maintain and improve joint health far more than acting as a shock absorber.27

Perhaps we should focus on fostering its wellbeing instead of injuring or removing it in surgery. About one-third of dogs demonstrate persistent postoperative cranial tibial subluxation following TPLO; medial meniscectomy worsens the instability, by eliminating the ability of the meniscus to strengthen stifle mechanics.28

The CCL also contains mechanoreceptors that bolster endogenous repair mechanisms, including reinnervation; even as remnants of a ruptured structure.29 The pes anserine (or pes anserinus), a highly significant soft tissue structure, converges a multiplicity of nerve inputs, mechanoreceptors and tendons. It becomes tender in many dogs due to imbalance or overuse; it can mimic the pain of CCL disease.
 
Myofascial palpation of the pes anserine and all other relevant anatomy indicates which supportive approaches might effectively and quickly resolve lameness. In contrast, in surgery, the pes is stretched and lifted out of the way en route to access, and then sever, the tibia during a TPLO, possibly making matters worse.

Time for Change

While much is changing in medicine, more still needs to change. In the words of one physician, “All too easily patients become—like machines—identical, passive, and ‘fixable.’ Medicine, as has often been pointed out, has become dominated by a mechanistic hubris, which sees machines and engineered solutions to ill health as the favourite way forward. ... Finally, there is the fact that medicine has grown out of a science governed and dominated by men and masculine patterns of thought. …

With the rising awareness that an excessively masculine style of science has had considerable costs as well as benefits for humanity comes the possibility of other more complete ways of proceeding. … If we are to humanise medicine and encourage the full participation of patients, while offering them the best of traditional medicine, we need to incorporate new images into our thinking.”30 

These new images call for veterinarians to do less cutting and more cultivation of the self-healing impulses of the body. As gardeners and not just carpenters, we can partner with Nature, not just redesign her masterpieces after our own form (as in the case of the TPLO) or ideals.31

Dr. Robinson, Dipl. ABMA, FAAMA, oversees complementary veterinary education at Colorado State University.

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FOOTNOTES
1 Delince P and Ghafil D. Anterior cruciate ligament tears: conservative or surgical treatment?  Letter to the editor. Knee Surg Sports Traumatol Arthrosc. DOI: 10.1007/s00167-012-2123-2.
2 Vyas D, Semakula B, Elson LE, et al. Anterior cruciate ligament tear: surgical reconstruction versus nonsurgical management. PM R. 2012;4(12):1006-1014.
3 Cook SA, Beetem J, and Cook JL. Comparison of long-term outcomes associated with three surgical techniques for treatment of cranial cruciate ligament disease in dogs. Veterinary Surgery. 2013;42:329-334.
4 Personal communication with physical medicine colleagues and fellow pain practitioners.
5 Butler JR, Syrcle JA, McLaughlin RM, et al. The effect of tibial tuberosity advancement and meniscal release on kinematics of the cranial cruciate ligament-deficient stifle during early, middle, and late stance. Vet Comp ORthop Traumatol. 2011;24:342-349.
6 Lee H-M, Cheng C-K, and Liau J-J. Correlation between proprioception, muscle strength, knee laxity, and dynamic standing balance in patients with chronic anterior cruciate ligament deficiency. The Knee. 2009;16:387-391.
7 Reed-Jones RJ and Vallis LA. Proprioceptive deficits of the lower limb following anterior cruciate ligament deficiency affect whole body steering control. Exp Brain Res. 2007;182:249-260.
8 Bonfim TR, Grossi DB, Paccola CAJ, et al. Additional sensory information reduces body sway of individuals with anterior cruciate ligament injury. Neuroscience Letters. 2008;441:257-260.
9 Citations for acupuncture, massage, and laser therapy previously reviewed in earlier columns:"Questioning Canine Cruciate Ligament Surgery,"Treatment Options For Canine Cruciate Ligament Disease (CCLD)," and "Pelvic Limb Lameness: Palpate Early And Often."
10 Gworys K, Gasztych J, Puzder A, et al. Influence of various laser therapy methods on knee joint pain and function in patients with knee osteoarthritis. Ortopedia Traumatologia Rehabilitacja. 2012;3(6):14:269-277.
11 Doom M, de Bruin T, de Rooster H, et al. Immunopathological mechanisms in dogs with rupture of the cranial cruciate ligament. Veterinary Immunology and Immunopathology. 2008;125:143-161.
12 Personal communication, through email and in person, with dog caregivers wanting to avoid surgery for their lame dogs.
13 Bergh MS and Peirone B. Complications of tibial plateau leveling osteotomy in dogs. Vet Comp Orthop Traumatol. 2012;25:349-358.
14 Molsa SH, Hielm-Bjorkman AK, and Laitinen-Vapaavuori OM. Use of an owner questionnaire to evaluate long-term surgical outcome and chronic pain after cranial cruciate ligament repair in dogs: 253 cases (2004-2006). J Am Vet Med Assoc. 2013;243:689-695.
15 Brydges NM, Argyle DJ, Mosley JR, et al. Clinical assessments of increased sensory sensitivity in dogs with cranial cruciate ligament rupture. The Veterinary Journal. 2012;193:545-550.
16 Safire W. Language: you break it, you own it, you fix it. The New York Times. October 18, 2004. Accessed at: http://www.nytimes.com/2004/10/17/arts/17iht-saf18.html?_r=0.
17 Micheo W, Hernandez L, and Seda C. Evaluation, management, rehabilitation, and prevention of anterior cruciate ligament injury: current concepts. PM&R, 2010: 2:935-944.
18 Finnoff JT. Preventive exercise in sports. PM&R. 2012;4:862-866.
19 Adams P, Bolus R, Middleton S, et al. Influence of signalment on developing cranial cruciate rupture in dogs in the UK. Journal of Small Animal Practice. 2011;52:347-352.
20 Hayashi K, Manley PA, and Muir P. Cranial cruciate ligament pathophysiology in dogs with cruciate disease: a review. J Am Anim Hosp Assoc. 2004;40:385-390.
21 Wucherer KL, Conzemius MG, Evans R, et al. Short-term and long-term outcomes for overweight dogs with cranial cruciate ligament rupture treated surgically or nonsurgically. J Am Vet Med Assoc. 2013;242:1364-1372.
22 Baker SJ and Baker GJ. Surgical versus nonsurgical management for overweight dogs with cranial cruciate ligament rupture. Letter to the Editor. J Am Vet Med Assoc. 2013;243(4):479.
23 Dhillon MS, Bali K, Prabhakar S. Differences among mechanoreceptors in healthy and injured anterior cruciate ligaments and their clinical importance. Muscles, Ligaments, and Tendons Journal. 2012;2(1):38-43.
24 Owen JL, Campbell S, Falkner SJ, et al. Evidence in practice. Is there evidence that proprioception or balance training can prevent anterior cruciate ligament (ACL) injuries in athletes without previous ACL injury? Physical Therapy. 2006;86(10):1436-1440.
25 Hayes GM, Granger N, Langley-Hobbs SJ, et al. Abnormal reflex activation of hamstring muscles in dogs with cranial cruciate ligament rupture. The Veterinary Journal. 2013;196(3):345-350.
26 Kanno N, Amimoto H, Hara Y, et al. In vitro evaluation of the relationship between the semitendinosus muscle and cranial cruciate ligament in canine cadavers. Am J Vet Res. 2012;73:672-680.
27 Andrews S, Shrive N, and Ronsky J. The shocking truth about meniscus. Journal of Biomechanics. 2011;44:2737-2740.
28 Kim SE, Lewis DD, and Pozzi A. Effect of tibial plateau leveling osteotomy on femorotibial subluxation: in vivo analysis during standing. Veterinary Surgery. 2012;41:465-470.
29 Dhillon MS, Bali K, and Prabhakar S. Proprioception in anterior cruciate ligament deficient knees and its relevance in anterior cruciate ligament reconstruction. Indian J Orthop. 2011;45(4):294-300.
30 Hodgin P. Medicine is war: and other medical metaphors. British Medical Journal. 1985;291:1820-1821.

 

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