February 2010 Issue
Table of Contents
Alternatives to Canine Surgeries
Conservative management is an often overlooked but frequently effective option for ligament injuries.
Dogs go lame for all kinds. Arthritis, Lyme disease, paw injuries, muscle sprains, bee stings, interdigital dermatitis, and dislocated kneecaps can make any dog limp. But when an active dog suddenly can’t put weight on a hind leg, the most common diagnosis – for more than a million American dogs every year – is a torn cruciate ligament. In 2003, according to the Journal of the American Veterinary Medical Association, the cost of treating those injuries exceeded $1.32 billion, and the price tag keeps rising.
The most common prescription for canine knee injuries is surgery. Unfortunately, operations don’t always work and some patients, because of age or other conditions, are not good candidates. In recent years a nonsurgical approach called “conservative management” has helped thousands of dogs recover from ligament injuries, and it is growing in popularity. At the same time, conservative management is not a cure-all. It doesn’t always prevent the need for surgery, it is not necessarily less expensive, and it can require as much time and effort as post-surgical rehabilitation. At its best, conservative management improves the outcome of whatever treatment is needed for full recovery.
“Conservative management consists of any nonsurgical treatment of injuries,” says Faith Rubenstein, who founded an online forum devoted to the subject in 2004, “including physical therapy, chiropractic adjustments, acupuncture, massage, nutrition, the use of a leg brace, nonsteroidal anti-inflammatory drugs, medicinal herbs, prolotherapy, weight loss for overweight dogs, and other noninvasive treatments.”
Rubenstein, who now lives in Austin, Texas, first encountered ligament injuries when her 100-pound Briard, Dakota, then six years old, experienced a partial tear of his cranial (anterior) cruciate ligament. “When our veterinarian recommended that we see an orthopedic surgeon,” she says, “I went looking for answers.” An academic researcher who is now a private investigator, Rubenstein discovered the term “conservative management” in a veterinary textbook.
The orthopedic surgeon diagnosed a partial tear in both of Dakota’s knees and recommended immediate TPLO (tibial plateau leveling osteotomy) surgery. In this procedure, the tibia is cut, then rotated and held in place with a metal plate and screws so that after the broken bone heals, weight-bearing exercise stabilizes the knee joint.
“I had misgivings about this method,” she says, “especially because surgeons at the School of Veterinary Medicine at the University of Pennsylvania don’t use it. I spoke with Gail Smith, the head of the University’s department of clinical research, and with Amy Kapatkin, a board-certified orthopedic surgeon who was then at Penn. What Dr. Kapatkin said made perfect sense to me. She asked, ‘Why break a bone to fix a ligament?’ My whole interest in conservative management was triggered by my fear of the TPLO.”
The University referred Rubenstein to an orthopedic surgeon who used other methods. He found Dakota to have so few symptoms that he agreed to write a prescription for physical therapy in hopes that it might make surgery of any kind unnecessary.
“Physical therapy and exercise made all the difference,” she says. “Dakota never needed surgery, and neither did his littermate, Aubrey, who tore his cruciate ligament a few months later. Many veterinarians believe that the only effective treatment for these injuries is surgery – either TPLO or another surgery – but that simply isn’t true. Conservative management can help most patients, including those who eventually have surgery, and then recover and lead active, happy lives.”
The stifle (knee) connects the femur (thigh bone) and tibia (leg bone) with a patella (kneecap) in front and fabella (a small bean-shaped bone) behind. Cartilage (the medial meniscus and lateral meniscus) cushions the bones, and ligaments hold everything in position.
Two key ligaments, the anterior (front) and posterior (back) cruciate ligaments, cross inside the knee joint. In animals, these ligaments are called cranial and caudal, respectively. The anterior or cranial cruciate ligament prevents the tibia from slipping out of position.
Veterinarians see most ligament patients immediately after their injuries, when symptoms are acute, or weeks or months later, after symptoms become chronic. If not immediately treated, most ligament injuries appear to improve but the knee remains swollen and abnormal wear between bones and meniscal cartilage creates degenerative changes that result in osteophytes (bone spurs), chronic pain, loss of motion, and arthritis. In some patients, osteophytes appear within one to three weeks of a ligament injury. Swelling on the inside of the knee, called a “medial buttress,” indicates the development of arthritis in patients with old injuries.
The main diagnostic tools for ligament injuries are X-rays, which can rule out bone cancer as a cause of leg pain, and a procedure called the “drawer test,” in which the veterinarian holds the femur with one hand and manipulates the tibia with the other. If the tibia can be moved forward, resembling a drawer being opened, the cruciate ligament has been torn or ruptured.
The drawer test is not necessarily conclusive because the tense muscles of a frightened or apprehensive dog can stabilize the knee temporarily. To produce more accurate results in such cases, patients may be sedated before being tested.
In the tibial compression test, which is another way to check for ligament damage, the femur is held steady with one hand while the other flexes the dog’s ankle. A ruptured ligament allows the tibia to move abnormally forward.
“A complete cranial cruciate ligament tear is always a surgical case,” says Stacey Hershman, DVM, of Hastings-on-Hudson, New York, “since otherwise the knee cannot function as a hinge joint.” Advocates of conservative management recommend that whenever the tear is partial, nonsurgical techniques be given an eight-week try. If symptoms improve during that time, they say, the odds favor nonsurgical recovery. If symptoms don’t improve, conservative management techniques can be used as pre- and post-operative conditioning and therapy.
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