Conservative Partial CCL rupture- answers to Rick Wall

[Guest guest]

Rick, I want to thank you for giving me some food

for thought and doing more research on my rationale for Conservative management

of CCL (C-ccl) disease in dogs. Before

responding to your questions I took the time to read the enclosed published

material to see where your concerns lie with regards to C-CCL in dogs. I should preface my answers to your questions below

with the following: Before doing C-CCL

on any dog I ensure I discuss all surgical options to every client, possible

outcomes (of both surgery and conservative), and more importantly look at the

client who will be performing the home exercises, as well as a pathofunctional

examination of the dog during all stages of rehab. After all our goal for clients is ensure that

client expectations are realistic and can be met, as well as ensuring that pain

management concerns during all phases are achieved using functional scales. Please see my responses to your questions below:1)

In your conservative management of CCL disease in dogs, how are

you addressing the apparent biologic component, (Cook 2010) (Hayashi 2003)

(Bresherars 2010) (Bleedorn 2011) (Comerford 2011)? if I am to understand these papers -readers

digest version: is various methods to look at biomechanics and biology as it

affects failure rates of CCL in dogs, and the clinical signs of

lameness,

pain…and how to improve preventative, diagnostic, and therapeutic

strategies for our canine patients. Also

noted is OA and its role during the various stages of cruciate ligament

breakdown, as compared with dogs with no CCL rupture. These are determined by tested functional OA

assessments.in response I look at each dog, muscle loss, amount of drawer sign, pain assessment

through Helsinki pain score, x-ray results, and overall conformation of the

dog. When doing conservative management

no two dogs have the same presentation, nor do the owners have the same

goals…this is critical in the assessment and possible outcomes in working with

C-CCL dogs. So the long winded answer

is, I use clinical assessment to determine candidates for conservative management. If i have a client that wants to participate in agility with a 1 year old border collie, i would recommend surgery (as an example) 2)

Do your patients that do not have medial buttress formation at

the beginning of your therapy go on to develop it during or following therapy? I would say approximately 80% (this is

a guess, but I know it is a high number) dogs already have a medial buttress

present at the initial assessment.

However, as therapy continues I do not note increased medial buttress

development. Again this is

anecdotal. So I assume most of the dogs

I see, have had the injury for some time (typically over one year- through

questioning with the owner) and most of the medial buttress formation has

occurred.For the dogs that I see that have had

an acute onset, there is no medial buttress, and from what I can determine, the

medial buttress formation is minimal, I will try one month of conservative management and if there is no appreciable improvement in lameness/pain score i will recommend surgery.3) ny had second look arthroscopy at some period of time after initial procedure in those meniscal patients? Was debridement of the CCL performed? I do not have any clients that have

arthroscopy performed only. There are no

surgeons here that will only perform meniscal debridement.4)

In your practices is conservative management offered as an

alternative to surgical correction for any and all patients or only those that

perhaps surgery is not an option? All my patients with C-CCL are referred

from neighbouring general practice veterinarians as an alternative. The median age for large breed dogs is 8-10

years, and for smaller dogs (under 30 lbs) they are any age from 3- 13. Typically the client profile are those who

either do not have funds for surgery, or feel that surgery is too invasive. A smaller number have dogs over 12 years of

age and do not want to risk anesthetic or feel that the rehab time is too long to reap the benefits of the surgery.5)

Do you recognize any conformations that might predispose the

conservatively managed patient to less than desirable outcomes (Griffon 2010)Since

the studies I have read do not give definitive evidence that either TP or PT-TP

angle as a risk factor, I have found the following considerations to affect the

overall outcome:1)

body score: the higher the score the harder it is to

rehab them to a successful point. Sadly

some rDVM’s send them to me because they are worried about surgery for an

overweight dog- a bit of a catch 22!2)

muscle mass (typically the more

muscular breeds- mastiffs, bostons, pitbulls.

Do better than those with poor muscle integrity3)

angle of the tibial plateau and

concurrant hyperflexion of the tarsal joint.

I find that dogs that have a very straight TP also have some form of

hyperflexion of the tarsal joint. These

dogs do not seem to do well despite giving lots of exercises to encourage

flexion of the two joints.4)

Owner compliance is a huge factor…if

I find after one month the owner is not doing the home exercises that I have

given, I will re-evaluate and possibly recommend surgery…these dogs never seem to

improve!5)

Last and not least, EVERY client I

see for C-CCL is told that if there is no appreciable reduction in pain, limb

use, and/or increase in muscle mass in one month, I refer them back to the rDVM

for re-evaluation to discuss surgical management.I hope this answers some of your

questions. If i am to summarize my rationale for C-CCL i would say that client expectations must be met, and overall functional scales to determine daily living (i.e. stairs, walks, lying sitting etc..) should show little to no limitations. if this is not met, then my role in providing a positive outcome has no basis. After all, in humans, we can do a hundred tests, and many surgeries to correct various orthopaedic problems, but at the end of the day, if the person is still not able to function with basic daily living tasks, despite what the studies show, then other measures must be taken.Tania CostaCCRP, VT, CAAP, CMT