Canine Cranial Cruciate Ligament (CCL) Rupture Repair
We perform this orthopedic surgical procedure on a regular basis at Chuckanut Valley Veterinary Clinic. We have several highly skilled doctors who perform orthopedic surgery at our practice.
The dog’s stifle (similar to our knee) is stabilized by many ligaments. The two bands of fibrous tissue that comprise the cruciate ligaments join the femur and tibia (bones above and below the knee) to allow the knee to work like a hinged joint. The cruciate ligaments prevent abnormal forward and backward motion of the bones in the knee.
Some of the larger, more active breeds are thought to be pre-disposed to cruciate ligament rupture. Most often, symptoms of a ruptured or torn cruciate ligament develop when your pet is playing ball, running, or jumping and suddenly changes direction. This places an extreme amount of force on the cruciate ligament, and causes it to completely rupture. The stifle is now unstable, and moves, which causes significant pain and inflammation within the joint. This pain causes the slight, intermittent, or obvious lameness you may have noticed. Cruciate ligament disease in dogs is rarely an acute or sudden injury. It is now known that the ligaments in the knee, primarily the cranial one, weaken over time from chronic use and stress, and may be stretched or partially torn before rupturing completely.
A physical exam should be scheduled so that we can properly diagnose the cause of your pet’s lameness. After CCL Rupture has been diagnosed by manual manipulation and possibly radiographs, surgical repair is needed. Rapid surgical intervention and proper rehabilitation can greatly slow the onset of arthritis, degeneration of the joint, and allow your pet to regain nearly normal function of the limb. Repair should be done within several weeks of the diagnosis. There are other concerns from waiting between injury and repair, including damaging the cartilage in the knee (or meniscus), as well as muscle wasting or loss. For every day that there is muscle loss (starting from time of injury) it takes 3 days to regain it. Studies show that dogs continue to lose muscle mass in their thigh for 5 weeks after surgery. The most serious secondary problem is damage to the other knee, due to the increased weight put on it. It is possible that 40-50% of dogs will rupture the cranial cruciate ligament in the other knee within 1-2 years of the first surgery. Again, keep in mind that we know this is a degenerative disease that can occur in both knees over time.
When it is time to schedule surgery, we will ask you to drop off your pet the night before or before 8 a.m. on the day of the scheduled surgery. This is necessary, as it is very important for us to perform thorough pre-surgical exams, to help detect any abnormalities that may complicate surgery. This includes auscultating (listening) to the heart for any murmurs or irregular beats, and listening to the lungs for any wheezing, obvious congestion, or respiratory conditions. A veterinarian will evaluate the condition of the eyes, mouth, abdomen, ears, skin and haircoat, as well as the musculoskeletal system to determine any other conditions such as arthritis. Pre-surgical bloodwork is always completed for our patients. This evaluates the function of the liver, kidneys and other internal organs, to ensure that they are healthy enough to metabolize the anesthetic agents used. It also helps us determine if there is an underlying infection, anemia, or dehydration that needs to be addressed before undergoing anesthesia.
With the information gathered so far, the veterinarian and technician will decide on the proper pre-anesthetic protocol used before surgery. This is a calculated amount of various types of drugs that help your pet to stay calm and comfortable before the procedure. We can also incorporate a drug that keeps the heart beating at a regular rate and helps reduce excess salivation, which can cause complications. An injectable non-steroidal anti-inflammatory (NSAID) is administered pre-operatively as well, to help reduce pain and inflammation during, and primarily after the surgery. An epidural will be performed prior to surgery to provide complete pain relief for your pet as well. We have several options available to induce anesthesia. Again, careful consideration will be taken to choose the appropriate combination of injectable agents, and/or inhalant gas for your pet.
Intravenous (IV) fluids are always administered to our orthopedic surgical patients. An intravenous catheter is placed in one of the front legs, usually, before inducing anesthesia. In rare cases, we can place them in other veins throughout the body if needed. Intravenous catheters are very important to have placed while your pet is in any surgery. This provides an emergency port for a technician to administer any necessary drugs should the need arise. The IV fluids help keep the liver, kidneys, and internal organs supported, perfused, and functioning while under anesthesia. A drug can also be added to the fluids to provide long lasting pain relief after surgery. The IV catheter and fluids will remain running to your pet throughout the day and overnite after surgery.
Your pet will have the injured leg shaved down to the skin to provide a cleaner surface for the doctor to do surgery. A technician will carefully surgically scrub the leg to remove surface dirt, bacteria, and any other debris that would contaminate the surgical field. An Ioban drape is used to provide a sterile operating surface. Careful sterile technique is always used with our surgeries. The surgeon will wear a sterile gown and gloves, and both technician and surgeon wear a cap and mask to reduce contamination in the surgical suite.
Close anesthetic monitoring is always done by one of our licensed veterinary technicians throughout the entire surgical procedure, and well after recovery. We have the ability to monitor several vital signs, including pulse, heart rate and rhythm, respiratory rate, blood pressure, temperature, and oxygen saturation with anesthetic monitoring equipment and esophageal stethoscopes. Anesthesia is adjusted as needed throughout the surgery, always making certain that your pet is not feeling any pain, but will wake up as quickly as possible.
There are several surgical techniques available to repair a ruptured cranial cruciate ligament. The appropriate surgical technique will be decided upon at the time of your visit with us. Our veterinarians prefer to use the Tightrope CCL technique, an extracapsular repair, which provides immediate stability to the joint and has very few complications. The stifle joint will be explored and checked for any pieces of torn ligament that need to be removed. The menisci in the knee will also be examined, and removed if they are damaged. The advanced technique that our surgeons use involves the placement of a specially designed synthetic implant. This FiberTape is placed through the femur, crossing the joint and into the tibia. A tightening device is used to ensure proper tension is achieved. The FiberTape material is extremely strong and does not stretch. The placement of the synthetic ligament takes over the function of the torn CCL, preventing the forward drawer motion (instability) of the knee, allowing your pet to regain pain-free function of the limb. The incision is carefully closed, and suture may be placed on the outer most layer of skin, which will need to be removed in the clinic in 10-14 days.
Post-operatively, your pet will be moved to a recovery area where the entire staff of doctors and technicians will keep a close watch throughout the day. Injectable antibiotics will be administered to help prevent infection within the joint or incision region, and further pain medication may be given to allow your pet to stay comfortable. Ice is immediately placed on the stifle after surgery, to decrease the amount of swelling and pain in that area. A warm, comfortable run or cage will be where your pet stays for the night, and is allowed to recover from surgery in a quiet environment. The first laser therapy treatment is provided post-operatively to immediately start helping with pain, inflammation and healing. Laser therapy will continue after each physical rehabilitation visit to help accelerate healing and decrease pain.
The post-operative period is as important as the surgery itself. Proper care and early physical rehabilitation will speed up weight bearing, reduce muscle atrophy, and promote early return to function. The proper type of rehabilitation may also help prevent or slow the occurrence of a rupture in the opposite limb, as your pet will be regaining use of the leg that had surgery at a quicker rate, and placing less force on the opposite limb for a shorter amount of time. One of the biggest factors of how well a patient does post-operatively and long term is managing a very lean body weight. An appropriate weight loss program is almost always implemented for our orthopedic patients. It is important to remember that the healthy, lean dog is also going to gain weight during the recovery period because activity will be greatly restricted and reduced, so diet adjustments are necessary. We have several tools available to help you with your pet’s weight loss efforts, including developing a personalized weight loss plan, physical rehabilitation and exercise programs, regular weight checks and follow-up care long after your pet has reached their ideal weight. A glucosamine/chondroitin/MSM supplement should also be started, and your pet will be kept on this for life. Dasuquin chews or tablets are made with high quality ingredients and are a trusted source for these nutraceuticals. These nutraceuticals help keep the tissue and fluid in the joint healthy and elastic, repair damage to the joint easier, and also help reduce some of the inflammation present within the joint. These changes will occur, even with surgical repair, as osteoarthritis development will continue as your pet ages.
Physical rehabilitation begins immediately after surgery is completed, with the placement of ice packs on the knee. The very next morning, ice and passive range of motion exercises begin, to help encourage your pet to be bearing weight on the limb. Complete cage confinement and bandaging to restrict all motion are no longer the standards of care! Early weight bearing, and gentle, very short, controlled leash walks will be part of the rehabilitation plan. Throughout the recovery period, pain and inflammation control is very important to us. A non-steroidal anti-inflammatory will be sent home with your pet to use for up to 4 weeks. Most of the rehabilitation exercises are performed by you, at home. To help improve the rate of recovery and minimize loss of muscle and function, rehabilitation appointments in the clinic are important, as well. At your discharge appointment, a technician will go over the passive range of motion techniques, massage, stretching, icing and heating. It will take time and commitment to complete the exercises with your pet, but they are necessary for complete recovery, and return to normal function. Sutures that were placed need to be removed in 10-14 days after the surgery. At this visit, a doctor will evaluate weight bearing, limb use, and condition of the surgical site. If you have any questions regarding activity, rehabilitation exercises, or care, they can be answered for you at this time. A recheck appointment with the doctor is scheduled for 4-6 weeks after surgery. At this time, as physical rehabilitation progresses, new exercises will be implemented and activity increased to help strengthen the joint and muscles of the leg, and also to retrain proper balance and coordination. Many dogs are fully functional and exercising regularly by 5 months post-operatively. During the rehabilitation period, some pain and discomfort may happen if too much activity occurs. Properly managing the level of exercise will be important, following the guidelines that were set for you by your veterinarian and technician. It is crucial that your pet is never allowed to perform sporadic, quick jolting exercises, such as chasing a tennis ball, or jumping out of a truck or from other high places.
Cruciate Ligament Repair is an expensive and significant orthopedic procedure. With a proper and timely diagnosis, examination, correction, pain management, physical rehabilitation and lifestyle management, we know that near complete return to a functional life can be expected. We are committed to helping you achieve these goals, to provide many more years of a healthy, happy, and active life for your pet. We are available for your questions and concerns, and would be happy to schedule a consultation appointment to discuss these with you.
Rehabilitation Plan for Postoperative Cranial Cruciate Ligament Repair
Brandi Knapp, LVT, CCRP, Certified Canine Rehabilitation Practitioner
Your dog has had an extracapsular repair to correct the ruptured cranial cruciate ligament in the knee. Physical rehabilitation and postoperative care at home is now in your hands. With our instructions, we will develop a complete physical rehabilitation program for you to follow at home that covers dietary adjustments, pain management, and passive range of motion (PROM) and other exercises. Weekly rehabilitation sessions in the clinic with our Physical Rehabilitation Practitioner will help obtain the best possible outcome after surgery, and promote a faster recovery and return to using the leg. Please schedule your pet’s initial evaluation 4-7 days after surgery, with Brandi. As progress continues, new exercises will be implemented and adjusted for your pet’s specific needs. It is important to remember that every dog is different and some may not tolerate some of the suggested therapies. The exercises should always be performed slowly and should not cause pain. Be persistent, however, as some dogs will resist the new activities and exercises though they are not causing any pain. Please call at anytime during the rehabilitation period if you have any concerns.
- Non-Steroidal Anti-inflammatory Drugs (NSAIDS): Give all medications as directed. Use of these drugs will help with pain and inflammation and aid in early use of the leg.
- Massage: Helps to reduce swelling, pain and encourages muscle relaxation. Using long firm strokes in the direction from the toes towards the hip, for 5 minutes 3 times a day before doing exercises. This can be done on the affected leg, as well as the opposite leg.
- Passive Range of Motion (PROM): 3 times daily. Early movement of the knee is very important to aid in healing and prevent scar tissue from inhibiting range of motion. Place your dog on it’s side with the affected leg up. Support the knee joint, using both hands, placed above and below the joint. Slowly flex (bend), and then extend (straighten) the knee for one cycle. Each cycle should take 20 seconds, do not rush this exercise as it may become painful for your pet. Flexion and extension should be performed to the point of slight resistance from your pet, but a painful response should not be caused. Pain might be shown as a sharp turn of the head, vocalizing, biting, or pulling the limb away.
- Icing: 3 times daily, after exercises, for 15 minutes. We will provide you with a re-usable gel ice pack. Always place a thin towel between the ice pack and your dog’s skin. Icing should be done after each exercise session or walk.
- Walks & Activity: Exercise restriction is going to be needed. Your dog should not be outside off of a leash for at least 6 weeks after surgery. 5 minute walks on even terrain 3-4 times throughout the day for bathroom breaks, on leash ONLY, will increase circulation, encourage early use of the leg, and help prevent boredom.
If your dog is unable to bear weight on the leg, it is important to use a towel sling, around the abdomen held from above, to help prevent slips or falls, and prevent excessive pressure on the opposite limb during walks. Be sure to always walk slowly to help encourage weight bearing. Increased speed allows them to hop on 3 legs easier.
Running and jumping must be prohibited for the first 4-6 weeks. This includes getting in and out of a vehicle, on or off of furniture, or playing in the house or with other animals. When you have to leave your dog unattended, the area he/she stays in should be restricted to avoid any over-activity or injury. A large crate or smaller room can be an effective area, depending on the size and activity level of your dog. They should be able to get up and move or walk around comfortably. Complete confinement is not recommended.
- Passive Range of Motion (PROM): The stifle (knee) should be starting to flex and extend to a greater degree. Continue with PROM 3 times daily.
- Icing: Continue to ice after exercises for 15 minutes
- Heat: On day 7 begin using a soaked towel in hot water (moist heat), place it over the knee and surrounding muscle for 10 minutes, before exercises each day, to help warm up tissues, increase flexibility, and provide comfort and general relaxation of the muscles. Reheat if it gets cool. Be sure the towel is not too hot to the touch, and do not use heat if inflammation is still present. Do not begin using heat if a seroma (see below) has developed- continue to use ice only, several times a day.
- Seroma: Occasionally we can see a fluid pocket develop over the stifle, which may form from excessive motion or inflammation from surgery. If you start to notice a small swelling, apply ice to the area 3-4 times during the day to help reduce the inflammation. Ensure your pet is not being too active. If the seroma does not resolve over the next 3 to 5 days, please call and we may discuss other options.
- Walks & Activity: Your dog should at least begin toe touching by day 7 after surgery. The shorter the length of the leash and slower paced the walk, the more likely they will begin to do this. If they are not toe touching by day 7, please contact the clinic.
- Physical Rehabilitation: Physical rehabilitation should begin in the clinic once a week to help prevent muscle atrophy, reduce pain, and promote early regular use of the limb. An at home plan will be designed specifically for your pet based on the initial evaluation. Each physical rehabilitation session will consist of manual therapies and different modalities, as well as high power laser therapy to aid in the success of your pet’s complete recovery. Call to schedule an appointment with our Physical Rehabilitation Practitioner, Brandi. 360-757-3722
- PROM: Once your dog is completely bearing weight and using the leg regularly, PROM can be decreased to twice a day. Your rehab practitioner will help you decide when this can be done, during your pet’s sessions in the clinic.
- Walks & Activity: If your pet is comfortable, the slow leash walks can begin to be increased in the length of time, 5-10 minutes, 3-4 times each day. At anytime if your pet becomes painful after activity, decrease the length of time of walks.
- Physical Rehabilitation: Once weekly sessions should continue in the clinic, as new exercises will be implemented to further build strength and balance, and complete use of the leg, and an at home program will be tailored for optimal progress. Swim therapy may be discussed and decided on. Outcome assessments each week will help with the rate of recovery, as adjustments can be made specifically for your pet.
Day 22-6 Weeks
- NSAIDS: You may need to continue to give pain and anti-inflammatory medication as your dog begins using the leg more frequently.
- PROM: Your dog should be making improvements as he/she becomes stronger and more eager to use the leg. Keep up with the flexion and extension exercises, to help prevent loss of range of motion.
- Walks & Activity: Slow leash walks 10-15 minutes, 3-4 times each day. If your pet is consistently bearing weight and using the limb well, you can start to introduce some uneven terrain, such as a slight hill. A physical rehabilitation plan will introduce more complete activities specifically chosen for your pet, as they progress.
- Physical Rehabilitation: Continue scheduled once weekly rehab sessions in the clinic for the best outcome and return to function.
6 Weeks and Beyond
Each individual pet will recover at a different rate, depending on several various factors, including weight, presence of arthritis, chronic nature of the injury, and post-operative care and physical rehabilitation. We generally see return to normal function within 6 months. It is important to continue physical rehabilitation, and gradually introduce your pet back to their regular activity. Keep in mind the limitations that have been discussed with you, however, such as jumping and vigorous activity. If at anytime you notice signs of pain, limping, or have other concerns, please contact us.
Our physical rehabilitation practitioner is available to answer any questions you may have about your pet’s physical rehabilitation program.
Brandi Knapp, LVT, CCRP | Phone: 360-757-3722 | E-mail: firstname.lastname@example.org
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