What is a Veterinary Surgeon?

An “ACVS Diplomate” or “Veterinary Surgeon” is a veterinarian who has completed additional training after veterinary school, and has been board-certified as a specialist in veterinary surgery by the American College of Veterinary Surgeons (ACVS). Only veterinarians who have successfully completed the certification requirements set forth by the ACVS can be called specialists in veterinary surgery. ACVS Diplomates have completed at minimum a one-year internship followed by a three-year residency program following veterinary school. The ACVS requires residents to meet specific training and caseload requirements, perform research, and have their research published in a scientific journal. Following completion of these requirements, the veterinarian must pass a rigorous examination to become board-certified. Only then does the veterinarian earn the title of ACVS Diplomate.

What is a Veterinary Surgeon?

An “ACVS Diplomate” or “Veterinary Surgeon” is a veterinarian who has completed additional training after veterinary school, and has been board-certified as a specialist in veterinary surgery by the American College of Veterinary Surgeons (ACVS). Only veterinarians who have successfully completed the certification requirements set forth by the ACVS can be called specialists in veterinary surgery. ACVS Diplomates have completed at minimum a one-year internship followed by a three-year residency program following veterinary school. The ACVS requires residents to meet specific training and caseload requirements, perform research, and have their research published in a scientific journal. Following completion of these requirements, the veterinarian must pass a rigorous examination to become board-certified. Only then does the veterinarian earn the title of ACVS Diplomate.

TPLO/CCL Handout

CLICK HERE TO DOWNLOAD TPLO/CCL HANDOUT (PDF)

What is the cranial cruciate ligament (CCL) and what does it do?

Rupture of the cranial cruciate ligament (CCL) is the most common cause of lameness in dogs. The CCL is equivalent to the ACL in humans, and it performs three main functions to stabilize the stifle (knee). These functions include preventing hyperextension of the knee, preventing excessive internal rotation of the knee, and preventing the tibia (shin bone) from moving forward in relation to the femur (thigh bone) when the animal places weight on its leg. Dogs have two, medial (inside) and lateral (outside), menisci in each of their stifles, which also act to help stabilize and provide shock absorption for the knee.

Why do CCL ruptures happen in dogs?

In people, ACL ruptures are typically due to an injury (ie. football injury or skiing accident), while these acute injuries do occur in dogs, they are rare. More often than not, CCL ruptures in dogs occur due to progressive degeneration of the ligament over time. The underlying cause for this slow degeneration is not completely understood, but there are multiple contributing factors to this disease process including anatomic variations, genetics, conformation, breed, obesity, and poor physical condition. Cranial cruciate ligament rupture is more prevalent in large breed dogs, but many small and medium-breed dogs are also frequently affected. Many CCL ruptures start as a partial rupture, and eventually progress to complete ruptures. Meniscal injury also commonly occurs with complete ruptures of the CCL, though is less likely with partial ruptures due to some degree of stability provided by the remaining intact cruciate ligament fibers.

Since this is a degenerative disease process, approximately 40-60% of dogs that have a CCL rupture on one side will go on to rupture the other side, This typically occurs within 1-2 years of the first side rupturing.

What are treatment options for CCL rupture in dogs?

The vast majority of dogs with CCL rupture require surgical stabilization of the stifle to achieve the best outcome. The top of the tibia (tibial plateau) is angled caudally (backwards) in the dog. This means that every time the dog places weight on their foot, the femur slides off the back of the tibia when the CCL is ruptured. Surgical treatment for CCL ruptures in dogs focuses on providing stability of the stifle without needing the CCL to be intact. The two big categories of stabilization procedures are extracapsular stabilization (ie. lateral suture) and osteotomy procedures (ie. tibial plateau leveling osteotomy or TPLO). There are multiple procedures that fall under these two categories, though this discussion focuses on the lateral suture and TPLO specifically, as these are the procedures that MVS performs.

Extracapsular Stabilization (Lateral Suture)

The lateral suture technique involves wrapping a heavy gauge nylon suture around the stifle to stabilize it long enough for organized scar tissue to form around the joint. The suture has a limited functional lifespan, and will eventually stretch out or break. The objective is that this failure happens after enough scar tissue has formed to ultimately provide long-term stability for the joint. For this reason, lateral sutures are generally only recommended for patients that are less than 20 pounds or in patients that are not very active, as the functional lifespan of the suture tends to be shorter in larger dogs or those that are active.

Tibial Plateau Leveling Osteotomy (TPLO)

The TPLO procedure involves making a biradial (semicircular) cut in the proximal (top) of the tibia, and then rotating the proximal segment down, so that the tibial plateau is more flat or parallel with the ground. This changes the biomechanics of the knee by creating compression across the stifle joint, which provides stability to the stifle when the dog steps down on the leg, thus removing the need for the CCL to be intact. The tibial fragments are then stabilized in their new position using a bone plate and screws. Once the bone has healed in its new position, the implants are no longer needed, but the patient keeps those implants for the rest of their life unless they develop a complication.

What surgery will be recommended for my dog?

The first decision that must be made is whether surgery is the best treatment for your pet. As stated before, surgery is most often recommended to give your pet a stable knee and slow the progression of arthritis, which provides them with the best chance of a good long-term outcome. However, surgery may not be recommended if your pet has other significant comorbidities that preclude surgery or anesthesia, or if you and your veterinarian decide to pursue other avenues of treatment.

The tibial plateau leveling osteotomy (TPLO) has been shown to have the best, and most consistent, outcome of all of the described procedures for cruciate ligament ruptures in dogs. However, every patient is unique, and your veterinarian/surgeon will determine the best treatment option for your pet.

What are the potential risks/complications of CCL surgery?

Just like with any surgical procedure, there are potential complications associated with CCL surgery. However, the risk of developing most surgical complications can be significantly reduced by keeping your pet calm and quiet during the recovery period and by keeping their mouth off of the incision during the first 2 weeks postoperatively. We expect most patients do well following CCL stabilization surgery when postoperative recommendations are followed.

Lateral Suture

Potential complications associated with the lateral suture procedure include anesthesia related complications, intraoperative hemorrhage, implant failure (suture breaking/stretching out prematurely) leading to recurrent instability, implant infection (possibly necessitating removal once sufficient healing has occurred), postoperative meniscal injury, incisional complications (infection, dehiscence, and/or seroma (fluid accumulation) formation – swelling around the ankle can occur due to gravity pulling the fluid towards the foot), and potential lameness due to osteoarthritis development.

TPLO

Potential complications associated with the TPLO procedure include anesthesia related complications, intraoperative hemorrhage, implant failure, tibial tuberosity fracture, implant infection or sensitivity possibly requiring implant removal, patellar tendinosis (inflammation of the patellar ligament), postoperative meniscal injury, incisional complications (infection, dehiscence, and/or seroma (fluid accumulation) formation – swelling around the ankle can occur due to gravity pulling the fluid towards the foot), and potential lameness due to osteoarthritis development or long-term bone sensitivity.

What does recovery from CCL surgery involve?

Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision.

Most orthopedic surgeries take approximately 8-12 weeks for healing to occur. This means that the implants used for repair/stabilization are responsible for bearing most, if not all, of the weight that is placed on the affected limb until complete healing has occurred. To protect the repair and maximize potential healing, your pet will need to be crate rested during this 8-12 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled off leash activity. In addition, he/she must also be kept off of furniture and stairs during this period. Canine patients may be allowed to go outside to urinate and defecate 3 to 4 times daily, and must always be kept on a leash. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate or small room, such as a bathroom or laundry room to prevent him/her from having free access to the house or jumping onto things.

Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost.

What is the prognosis following CCL surgery?

Most patients do well following CCL stabilization surgery with 80-90% of patients following lateral suture surgery and 90-95% of patients following TPLO surgery returning to normal or near normal activity level once completely healed. Peak recovery can take up to 4-6 months to be achieved following surgery. In some cases, professional physical therapy is recommended to maximize recovery.

Postoperative Care

You will be provided with discharge instructions outlining specific postoperative care recommendations for your pet. If you have additional questions or concerns, please contact MVS or your primary care veterinarian. If you have urgent concerns after hours, please contact your local veterinary emergency hospital.

Postoperative confinement is critical for surgical procedures to have a successful outcome. Failure to follow the prescribed postoperative instructions can result in complications or failure of the surgical repair, resulting in the need for additional diagnostics, treatments, and/or surgery for an additional cost.

Recovery from orthopedic surgery typically takes approximately 8-12 weeks for complete healing to occur. During this time, your pet should be activity restricted. This means no running, jumping, playing with other animals or people, or any uncontrolled off leash activity. In addition, your pet must also be kept off of furniture and stairs during this time. Canine patients may be allowed to go outside to urinate and defecate 3 to 4 times daily, and must always be kept on a leash. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate or small room, such as a bathroom or laundry room to prevent him/her from having free access to the house or jumping onto things.

Recovery from soft tissue surgery typically takes approximately 3-4 weeks for complete healing to occur, and requires the same level of activity restriction as outlined above for orthopedic surgery recovery during that time.

Incisional healing typically takes approximately 10-14 days to be achieved following surgery. Some swelling and bruising are normal following surgery. However, if you notice excessive swelling or redness around the incision or discharge from the incision, please contact us or your veterinarian for advice. It is imperative that your pet not be allowed to lick or chew at the incision, which means your pet will be required to wear an Elizabethian collar (E-collar or cone) at all times until incisional healing is confirmed by your veterinarian. The incision should remain clean and dry until it has healed, which means no baths should be given until complete incisional healing is confirmed.

For orthopedic and soft tissue procedures performed on the hindlimbs, some swelling around the ankle will commonly occur due to gravity pulling fluid (edema) down towards the foot. This will typically resolve within a week or two. If you have any concerns, please seek veterinary assistance.

Cold compresses applied to the incision will help decrease inflammation and swelling and improve comfort for the first 3 days after surgery. This may be done as frequently as 3 to 4 times daily for 10-15 minutes, assuming your pet tolerates it easily during the initial postoperative time. Always place a protective layer, such as a thin towel, between the ice pack and the skin.

After 3 days, you may switch to a warm compress 3 to 4 times daily for 10-15 minutes for 3 to 5 more days if the surgical site appears bruised, painful or swollen. Always test the warm pack to make sure it is not too hot and place a protective layer, such as a thin towel, between the warm pack and the skin.

If your pet has a bandage, it must be kept clean and dry at all times. The bandage must be covered with a plastic bag when your pet goes outside, and the bag needs to be removed each time your pet comes inside again. Please monitor bandages carefully for any wetness, slipping, odor, or sudden irritation or discomfort. These could all be potential signs of irritation, and require an appointment to change the bandage as soon as possible to limit the development of bandage sores or other complications.

Immediately following surgery, you can expect your pet to be a little tired the first couple of days. However, over the next few days, you should see your pet acting more like themself. Please allow at least 2 hours after getting home before offering water or food. Please contact your veterinarian if your pet loses their appetite, refuses to drink water for more than 24 hours, shows signs of weakness or depression, has vomiting, or develops diarrhea.

Bowel movements may be delayed after illness, anesthesia, or surgery. Several days may be needed before the gastrointestinal system returns to normal, and bowel movements are likely to be small and infrequent until your pet is eating with a normal appetite. If you are concerned about constipation, canned pumpkins can be added to the food to help speed the process. Please reach out to your veterinarian if your pet begins straining to defecate or has not had a bowel movement after 4 days.

If your pet seems painful at any time during recovery, please contact your veterinarian to have your pet evaluated and determine if medications and/or dosages can be adjusted.

Small Animal Conditions

Explore a world of small animal conditions and treatments on the ACVS website. Click the link below to discover comprehensive information on veterinary care for your furry companions.

Educational Resources