Is Surgery Really Necessary For Your Dog's ACL / CCL Ligament Injury?

Dogs' ACL / CCL Ligament Injuries are the subject of this website.
There is nothing being sold here.
 
Surgery is often recommended for dogs' stifle(knee) ligament injuries in cases where surgery is not the best treatment choice.  When they have ligament injuries, most dogs will recover well without surgery.  Sometimes surgery will be needed, but it is a mistake to accept any vet's claim that your dog needs surgery without first considering the facts presented here at this website.
---- It is important for your dog that you understand these injuries and treatment options. "Just trust the doctor" is not a good way to make medical decisions. This is especially true with dogs' ligament injuries for the reasons explained at this website. 

This website was most recently updated in October 2014.
The information here is current and accurate.

In addition to in-depth study of the research literature on this subject, I have communicated with hundreds of vets experienced in treatment of these injuries, and with researchers who have studied all the various treatment options. Since this website was first created I have heard from thousands of people who have dealt with these injuries in their own dogs about their experiences with surgery and non-surgical recovery.
I have reached these conclusions:
----That the majority of the surgeries done on dogs diagnosed with ligament injuries are unnecessary, and do not improve ultimate recovery outcome.  
----That surgery is often described to clients by vets as a medical necessity in cases where it is neither necessary nor the best treatment option.
----That the reasonably expectable results of ligament-injury-related surgical procedures are often misrepresented.
----That all the ligament-injury surgeries, especially the bone-altering TPLO, TTO, and TTA, have risks which are often not disclosed to clients by surgeons.
----That non-surgical recovery, while usually the best first-choice treatment for dogs' ligament injuries, is frequently inaccurately portrayed or ignored in surgically-inclined vets' presentations to clients of the available treatment options.
----That bone-altering surgeries TPLO and TTA have become cash-cows for a number of veterinary ortho-surgeons who are making huge profits selling these questionable procedures by misrepresenting potential outcomes and risks to clients.

"...Medical history is littered with once-popular procedures that subsequently proved ineffective or dangerous. ..."
         
----A quote from Consumer Reports 'On Health'
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When a dog has been diagnosed with a damaged ligament, there are many vets who routinely recommend immediate surgery.  In the majority of cases these surgeries are unnecessary and potentially harmful.  Most dogs will recover very well without surgical intervention if given the chance.  It is not wise to let a vet rush you into agreeing to surgery.  The way to determine if your dog needs surgery is to carefully restrict the dog's activity for a period of 8 weeks as described on the pages of this website. If you see improvement in symptoms during the 8 weeks, this will indicate that your dog is beginning to recover and will restore stability to the joint without surgical intervention. (This does not mean the dog will be fully recovered in 8 weeks.)  If you can look back at week 2 from week 8 and see that your dog has been improving during that time, Fido is stabilizing that injured joint.   

A quick decision whether to have surgery is not necessary at the time of diagnosis.  Proper restriction of activity will minimize the risk of further injury to the joint while answering the question "Does Fido really need surgery?"  Any vet who pushes you to quickly agree to surgery should not be trusted.  
Some vets try to push people into immediate surgery by telling them that without immediate surgery their dog will be crippled with arthritis.  That is not true.  Vets may claim that only immediate surgery can protect against further injury to the joint.  That is also false. Controlling the dog's activity during recovery is the key to minimizing both future arthritic risk and the risk of further injury during recovery.  Please see the page 'Arthritis Risk?' here at this website and the pages describing non-surgical recovery based on proper activity restriction. 

When your dog has a ligament injury, the easiest thing for you to do is to accept the vet's recommendation for surgery.  It can be a relief to hand over the burden of decision-making to someone who seems to be an expert.  But it is not wise to be so trusting. To be the best decision-maker for your dog, you need to be cautious and skeptical, not blindly trusting.

The vet who diagnosed your dog may have talked to you about your dog's injury as though surgical intervention is a universally accepted medical necessity whenever there is injury to this CCL/ACL ligament.  That is not true.   Non-surgical recovery using careful activity restriction is almost always the best first-choice treatment option for dogs.  When these injuries have recently occurred the dog is usually holding up that leg and in distress. It is easy for Fido's people to be tricked into believing this is an emergency requiring immediate surgical intervention. But actually this injury is very similar to a sprained joint you might have. Painful and swollen but NOT needing surgery. It is not an emergency. Non-surgical recovery is usually successful for all sizes and types of dogs. If non-surgical treatment is not successful, surgery will still be available as a treatment option.
Vets promoting surgical approaches may make claims like this:
---" Large dogs always require surgery when they tear these ligaments"
--- "If a complete rupture rather than a partial tear is diagnosed, then surgery is necessary."
--- "Research shows that only a very small percentage of dogs over 30 pounds can recover without surgery."  
----- You may see other websites which unquestioningly accept such statements and repeat them as though they were proven facts.  But these are not facts. When I dug into the research literature looking for evidence that would back up such statements, I found that these statements are based on low quality Class III & IV articles written by surgeons promoting the surgeries they sell.  These 'studies' are full of methodological flaws and outrageously sloppy reasoning which would be laughed at by anyone familiar with the accepted norms of medical research. (See the page "But the Vet Said..." which is linked in the column at left.)
---- Many large dogs recover well without surgery, as do many dogs diagnosed with complete ligament ruptures.  These non-surgical recoveries disprove the claims that dogs-over-so-many-pounds always require surgery or dogs-diagnosed-with-complete-ligament-tears always require surgery.  Sweeping statements like "Large dogs require surgery" in the absence of any solid evidence, and in spite of numerous successful non-surgical recoveries by large dogs, shows that these vets are either incompetent or primarily interested in selling high-profit surgical procedures.
---- Small dogs almost never need surgery for these injuries, so it is true that large dogs with severe injuries are more likely to require surgery than small dogs.  But the majority of large dogs and those diagnosed with severe injuries do also recover well without surgery. 

The only way to know if a particular dog needs surgery is to restrict activity and see if the dog begins to re-stabilize the joint.
This kind of injury does not require a rush to surgery. Give your dog 8 weeks of careful restriction, then judge whether he is improving or not. If he is improving by the end of 8 weeks, he will almost certainly continue to improve in the following months as you carefully & gradually increase activity.  Eight weeks is not the total time of restriction.  Recovery is not complete in eight weeks.  Recovery from joint injuries is very slow.  Even many vets who recommend non-surgical recovery fail to appreciate how slow, and tell people to resume normal activity after 8 weeks or 12 weeks.  This will often result in re-injury.  There is no certain length of time for recovery.  The time needed varies with the severity of the injury and the size and age of the dog.  By increasing activity gradually, watchfully, and cautiously, you will eventually come to the best possible recovery, but no one can know how long that will take.  You must carefully restrict activity and you must have patience. 

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Has a vet told you he is certain that your dog must have surgery?  We receive emails every day from people who tell us they succeeded in helping their dogs recover non-surgically after having been told by vets that surgery was their only choice. For example:
-----"Hi Max, I was told my dog needed TPLO surgery but decided to try the non-surgical approach instead after finding your website. I am extremely happy with the results. My dog is able to run, hunt, play, swim, in other words live a complete life and does not limp or favor his right rear leg. He appears to be totally pain free. I am extremely pleased that I did not subject my friend to the pain, trauma, and uncertainty of major surgery. Also, saving that kind of money does not hurt my feelings.
From one dog lover to another, thanks."
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It is not surprising that vets who sell high-profit procedures praise those procedures.
Vets reduce their own income significantly by recommending non-surgical recovery.
Nevertheless, there are vets who recommend what is best for dogs even if that means they make much less money.

"I have read over your website. I think it is fantastic. I am a veterinary surgeon and have been board certified for 10 years. I have performed almost all of the procedures described for cruciate rupture. I have worked at multiple surgical practices with many surgeons. As you mentioned there is no real proof that any of these surgeries are truly more effective than non surgical management. I feel that a large number of people are unhappy with the outcome of surgery regardless of the procedure. In addition, people forget that surgery can do harm. I have seen more than one dog that required an amputation due to surgical complications. I have yet to see a dog require amputation when surgery was not performed. Over the past 2 years I have managed more and more patients without surgery. I find that it is uncommon that people are disappointed in the outcome. Unfortunately not all patients do great, but then again, not all patients that have surgery do great either. Needless to say my view on treatment of cruciate disease is not popular among my peers. My thoughts on cruciate disease have caused me great grief with other veterinarians. However I feel confident I'm doing the right thing for clients and patients."
(Name withheld), DVM, MS DACVS
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Many people have been told by vets that surgery was necessary, but those who rejected surgery usually had great recoveries without surgery by simply following the suggestions you will find here on this website.  Do not make the mistake of assuming the vets you have seen must know best. Any vet who examines a dog and claims to know based on that exam that the dog needs surgery for an ACL / CCL injury is not acting as an objective medical professional. He is a surgery salesman telling dog owners that they need to buy what he is selling. When a sales pitch comes from a car dealer most people can see that a sales pitch is what it is. But people may make the mistake of thinking the vet is only thinking of what is best for Fido and doesn't care about money.
Eight weeks of careful activity restriction will tell you whether your dog is one of the small minority of dogs with ACL/CCL problems who really need surgery.
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Non-surgical recovery is based on careful activity restriction which provides the conditions necessary for the dog's body to re-stabilize the joint without surgical intervention.  Most dogs will recover well from ligament injury without surgery if given the chance.  More information on non-surgical recovery, and information about surgery, can be found on this website's pages. 
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Misdiagnosis is common.  Dogs with other causes for their symptoms may be misdiagnosed as having ligament injuries.  There is a list of some of the problems which have been misdiagnosed as ligament injuries on the 'Looking Deeper Into a Surgical Recommendation' page.  During a period of activity restriction it can become evident that the cause of the problem is something other than a ligament injury.  This is one more reason to decide against rushing into surgery.
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In cases where surgery is needed, the type of surgery you choose is important.  The 'TPLO/ TTO/ TTA' page here at this website explains further why you should be skeptical of a recommendation for TPLO, TTO, or TTA. 

Question: "I have been going to the same vet for years and I trust him.  He says TPLO is the 'Gold Standard' in treatment.  Why shouldn't I depend on his judgment?"
-- "Why do some general practice vets refer dogs to orthosurgeons to have these very invasive bone-alteration surgeries?"
---- There are several factors involved in referrals that need to be considered:
---- All vets are concerned about their relationships with the oversight boards which have the power to impose sanctions on them. Vets are seen by those boards as having what is called 'The Duty To Refer'. This means that when a vet is confronted with a situation which is in the province of a specialist, he must refer the client to an appropriate specialist or face sanctions from the oversight board. In cases where there is a ligament injury (which is considered an orthopedic problem), a general practice vet can recommend to a client that he give the dog a short period of restricted activity, but when that client and his dog come back a few weeks later and the dog's owner says "He is a little better but still limping", that vet isn't going to want to risk sanctions by saying "Be patient and continue to restrict activity". That vet worries about being called in front of the oversight board to explain why he didn't refer the dog to an ortho specialist when quick recovery wasn't forthcoming. He is going to protect himself by sending the client to the specialist. In many medical situations referral to a specialist would be the right thing to do. But in this situation it is not good for the dog if the specialist is a TPLO / TTA profiteer. Fido's person may be told by the specialist that Fido must have TPLO or TTA which are not truly needed but which are very profitable for the surgeon.
---- Also, a general practice vet's opinion can be heavily influenced by the specialists he has relationships with. The huge profit in these bone-alteration procedures has resulted in large numbers of ortho-specialists enthusiastically promoting them.  (A TPLO takes about one hour in the operating room and costs the surgeon a few hundred dollars to do. TTO and TTA are similarly quick and inexpensive to do. Prices charged average over US$3500.  Several thousand dollars profit per surgery.) When your general practice vet hears from specialists that they prefer to recommend TPLO, TTO, or TTA, he may not ask himself if the thousands of dollars of profit in each surgery could be the reason the specialists think so highly of the procedure they recommend. There are many honest, well-intentioned general practice vets who mistakenly believe that these bone-alteration procedures are a good first-choice treatment for the majority of dogs with ligament injuries based on what specialist ortho-surgeons have told them.
---- Also, it is true that improvement in leg use in the first few weeks after TPLO, TTO, or TTA will be better than with non-surgical recovery or conventional surgery.  Longer-term results are not superior with these very invasive bone-altering procedures, and the risks of serious complications are greater, but this rapid improvement in the short-term influences vets' opinions of the procedures.
----"My regular vet doesn't make any money by sending me to a TPLO surgeon, so his high opinion of TPLO must not be influenced by the big profit on TPLO."
Maybe your vet isn't getting paid for referrals by the ortho-specialist surgeon he recommends to you, but maybe he is.   Referral fees are illegal, so you can bet that no doc is going to tell you that he is getting referral fees.  But there are ways to get around reporting referral fees, and with these high profit surgeries there is plenty of money available to reward docs who send customers to ortho-specialist surgeons.  An ortho-surgeon could pay your vet handsomely for post-op reports on patients he referred, or overpay him for some apparently unrelated service, or he could do it the old fashioned way with unreported cash. -- Now let me be clear that I am not saying that every vet is taking hidden payment for referrals.  I am saying that it is something that does go on, and should not be ignored as a possibility.  But there are honest vets who do not take part in such things.  And there are honest GP vets who truely believe in TPLO.  They are misguided, but they are not crooked.  The point I am making is that it would be incorrect to assume that no money could possibly be changing hands when referrals to specialist TPLO surgeons are made.  There are thousands of dollars of profit in every one-hour TPLO, and profits like that invite corruption.

Choosing the Expensive Option Instead of The Best Option.
When our dogs are injured, we are not concerned about cost.  We want what's best for our dogs, regardless of cost. It is easy to trick ourselves into thinking that because a surgery is more expensive it must be better. A better car costs more. Better shoes cost more. The best of anything is usually more costly. When faced with choices where we are unfamiliar with the options available but want the best, we may assume (or be easily convinced) that the more expensive options are the best options. But with dogs' ligament injuries, the more expensive options can be the poorer choices. Surgery is usually not the best option for the dog. The more expensive surgeries can be the worst choices of all. 

Exaggerated claims by surgeons about the results that should be expected from the surgeries they sell---
Have you been told that the surgery being recommended for your dog will return Fido to pre-injury condition?  An article on canine ligament injury surgeries in the 'Journal of the American Veterinary Medical Association' looked into what results could be expected from the various ligament surgeries in terms of percentages of dogs who regained normal leg function after surgery.  The expectable results determined in this study and published in this article are quoted here at this website on the 'Looking Deeper Into a Surgical Recommendation' page. 
"... 14.9% of dogs treated with lateral suture stabilization (LSS), 15% of dogs treated with intracapsular over-the-top stabilization (ICS) and 10.9% of the dogs treated with tibial plateau leveling osteotomy (TPLO) regained normal leg function subsequent to surgery."
---- Many dogs do recover fairly well after all the above-named surgeries.  Those very small percentages-- 14.9%; 15%; 10.9% --- are the dogs who "...regained normal leg function subsequent to surgery ..." and does not include the many dogs who recovered well enough to have use of the leg, but not to full 100% pre-injury capacity.  The point I am making is that vets often over-promise what can be reasonably expected from the surgeries they sell. 
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"...There are no studies that I know of that compare [ligament injury] surgery success to doing nothing over the lifetime of dogs who have one or the other experience. I think that these studies don't exist because they never looked very good for the surgery and so surgeons weren't too interested in doing them..."
---Author & vet Mike Richards DVM
I don't like Mike referring to non-surgical recoveries as "doing nothing" since this might imply to some readers that the dog can be allowed to decide his own activity during recovery.  But I agree with the implied conclusion that surgeons are in the business of selling surgery, and their preference for surgical approaches should be viewed skeptically. 
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There are more than a few vets who are admirably selfless in putting the good of the dog first ahead of the vets' own profits, but for dog owners to assume that all vets are like that is not realistic.  Don't think vets in general are any less interested in making money than anyone else who sells a service.  You should be as skeptical of a recommendation for surgery as you would be in any other situation where you were being told you needed to purchase a service by the person who would profit by your purchase. 
---- Also, to assume vets are always correct in their diagnoses and in their understanding of what are the best treatment options is not realistic.  Don't think any doctor must be right because he is a doctor. 
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I hope you will find the information here at this website useful in making the best decision for your dog.  I welcome questions and comments.  My name is Max.  My email address is on the 'Contact Address' page.

Why is this website here?

My dog Tigger ruptured ligaments in both rear legs in 2002.  He weighed over 100Lbs and at the time of the injuries he was 7 years old.   He was severely disabled by the injuries.  The orthopedic-specialist vets said he absolutely must have TPLO surgery.   But special circumstances made surgery impossible.
Tigger recovered very well without surgery.
Tigger's excellent recovery without surgery raised this question in my mind:

"If Tigger could recover so well without surgery from severely disabling ligament ruptures, what about all those other dogs that orthopedic specialists and other vets are insisting must have surgery?
--- Was Tigger's recovery some kind of miracle?
--- Or could surgery be unnecessary for many other dogs too?"
That question prompted me to look deeply into canine ligament injury and its treatment. What I found made me decide that it was necessary to create this website in order to 'pay forward' to other dogs with ligament injuries.  People want to do what is best for their dogs.  But they are often too trusting that vets' surgical recommendations are solidly based and vets' motives selfless. 
The following was written in May 2007, five years after Tigger's injury:
 --- It is five years since Tigger ruptured ligaments in both rear legs. His injury was severe. His non-surgical recovery was very successful. Since his recovery he has had no trouble with his stifles(knees).  He has led a very active life, both before his injury and after his recovery.  Big dogs like Tigger age more quickly than smaller dogs, and he is showing his age now at 12.  He has slowed down and is no longer a frisky young fellow, but the joints that were badly injured and recovered without surgery are still fine.  Looking back I am glad that I rejected TPLO surgery for Tigger.  It was difficult to decide to go against the specialists' advice then. They presented themselves as so certain that surgery was absolutely necessary. Time has proven that Tigger did not need TPLO or any other surgery.  I know now that some surgeons misrepresent the facts about TPLO in order to sell people on this very profitable procedure.  Many dogs who are subjected to TPLOs would recover from their injuries without surgery just as Tigger did if they were given a chance to do so.   I am confident that the best way to approach a dog's ligament injury is to first try the non-surgical approach. Improvement over the first 8 weeks will indicate that the dog can probably successfully recover without surgery.  Agreeing to immediate surgery puts the dog at risk for various complications and imperfect results which could be avoided with a non-surgical recovery. While surgery is sometimes necessary, I believe that surgeries are recommended and done much more often than they should be.
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Tigger died later in 2007.  His joints functioned well all the years of his life after his non-surgical recovery in 2002.
(There's more about Tigger's recovery on the 'Success Stories' page).

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Tigger with friends