Canine orthopedics

Cranial Cruciate Rupture Surgery — Tibial Tuberosity Advancement (TTA)


The orange line shows where the tibia is cut for the advancement

The orange line shows where the tibia is cut for the advancement

The second surgery we want to discuss for cranial cruciate rupture is the Tibial Tuberosity Advancement technique.

The knee has three major bones:  the femur (thigh bone), the tibia (shin bone) and the patella (kneecap).  The cruciate ligaments (cranial and caudal) along with the medial and lateral collateral ligaments and the patellar ligament hold these bones in place.  Ligaments are extremely strong tissues that keep the leg from shifting.

A rupture of the cranial cruciate ligament will cause this whole mechanism of the knee to become moveable, painful, and typically will cause tearing of the medial meniscus which is the shock absorber of the knee.  Arthritis develops very quickly in the joint when this happen so stabilization of the joint soon after injury is recommended.

Tibial Tuberosity Advancement (TTA) is considered less invasive and similar results to a TPLO (Tibial Plateau Leveling Osteotomy).  Tibial Tuberosity Advancement initially has a quicker recovery than TPLO.

A typical joint angle between the tibia and the femur is approximately 115 degrees and TTA surgery will change the angle to about 90 degrees.  If the tibial plateau is too steep then TTA should not be used as the surgery.  Both TTA and TPLO surgeries are not usually done by general practitioners because they use specialized equipment along with specialized training.

Tibial Tuberosity Advancement surgery actually cuts the tibial tuberosity (boney projection on the front of the shin) and moves it forward.  A specialized bone spacer, plates and screws are used to hold the bone in place.  Bone graft tissue is placed in the space between to stimulate bone growth and healing.  The patellar ligament is aligned when the bone is moved and the ligament stops the abnormal movement from the rupture.

Post-surgical care is very similar to TPLO with cryotherapy, laser therapy, passive range of motion, massage, pain management and slow short controlled leash walks during the first few weeks. 

If your pet is not being treated by one of these therapies, he should be completely confined and quiet with no running, jumping, playing or climbing stairs due to the bone being fractured and needing to heal.  Rehabilitation using the above therapies along with controlled exercises can be started at about 3-4 weeks.

The rehabilitation therapy continues to increase exercises and endurance from 4-12 weeks using different modalities.  Radiographs of the surgical site will most likely be performed at 4, 8 and 12 weeks.

We at ARCC — Animal Rehab & Conditioning Center are here for your pet’s rehabilitation needs.

On a personal note, thank you to everyone for your kind thoughts and good wishes during our time of tragedy — you guys are the best.  Dr. Dicki

Extracapsular Repair for Cranial Cruciate Rupture

See the black dots -- that is where the "fishing line" goes to make a ligament.

See the black dots — that is where the “fishing line” goes to make a ligament.

So this is the second installment in discussing cranial cruciate rupture and the first in how we surgically treat this problem. Extracapsular surgery for cranial cruciate rupture is an older surgery that still does the job especially in smaller candidates weighing less than 50 pounds.  The surgery is practiced by most general practitioner veterinarians and does not need specialized equipment.

The surgery is performed when the cranial cruciate ligament has ruptured due to slow degeneration over time or acutely through trauma.  The surgeon will incise the joint and expose the joint itself.  The torn ends of the ligament are removed and the meniscus, the shock absorber of the joint, is examined for damage.

If your pet has a cranial cruciate rupture the chances are that his medial meniscus is also torn.  In about 40-50% of pets with cranial cruciate rupture an audible click can be heard when the leg is flexed this is usually the medial meniscus making the sound.  The debris in the joint is cleaned and the meniscus is either removed or sutured depending on the degree of trauma to it.

Non-absorbable suture (“fishing line”) is used to make a false ligament.  The suture is passed around the lateral fabella and through a hole drilled in the tibial crest.  The suture is tightened down and the joint is flexed several times through a range of motions prior to closing the skin. The two black dots on the picture show where the suture is situated.

This surgery can decrease cranial drawer movement but it can loosen over time.  It is not a surgery recommended for dogs over 50 pounds.  The suture eventually disintegrates and scar tissue is formed to stabilize the joint.  This surgery has been shown to improve the signs of lameness in about 85% of pets.  An unfortunate note is that if your pet has a torn cranial cruciate ligament there is a 33% chance that he will tear the other one also.

Rehabilitation exercises are recommended for recovery.  The rehabilitation exercises include cryotherapy, nsaids, passive range of motion exercises, and leash walks in the beginning.  As the incision heals treadmills and underwater treadmills can be incorporated.  The ideal situation would be for the pet to achieve normal range of motion values by 10 days post-op.  Strengthening exercises such as stairs, uphill walking and pulling carts will be added in eventually.  Jumping on the rear legs is prohibited for at least 10-12 weeks post-surgery.

If your pet has had or will have cranial cruciate surgery, please ask your veterinarian about rehabilitation post-op. If you need us, we are here for your pet’s recovery — ARCC — Animal Rehab & Conditioning Center.

Next week we will discuss one of the two specialty surgeries for cranial cruciate rupture.


Cranial Cruciate Ruptures — Pain in the Knee



It is spring so we all are getting out there more and having fun. It is a time of reckless abandonment. The wet, cold and windy season is supposed to be behind us and the sun is out longer. This time of year is one of my favorite seasons. With all the activities we are starting back into we need to remember that our muscles have not been exercised hard in a few months so warming up and cooling down is the key to safe and healthy fun.

One of the problems we tend to see in pets, especially dogs, is the rupture of the cranial cruciate ligament. This can happen any time of year but it tends to be when pets are running and playing that they hurt this ligament. A cranial cruciate ligament is also known in the human world as an ACL which we have all heard horror stories of human athletes tearing.

The cranial cruciate ligament is a small strong ligament that is between the femur (thigh bone) and the tibia (shin bone) (back legs). There are actually two ligaments between these bones, a cranial and a caudal, and they cross in the middle making an X — hence the name cruciate. These ligaments function include keeping the leg from shifting too far forward with each step, decrease internal rotation and prevent over-extending your kneeCCR drawing

Don’t laugh at my masterpiece!

This is typically a dog problem but it can be seen in cats. The way most people see this happen is that the pet is running around in the yard, they plant a foot and turn, yelp and come back carrying the leg. The rupture can actually happen slowly over time or all at once. The onset of arthritis starts within a week or so of the trauma. In fact, cranial cruciate rupture (ccr) is one of the major reasons for lameness in a dog and a major cause of degenerative joint disease in the knee. Along with tearing the cruciate ligament your pet can also tear the meniscus which acts as a shock absorber inside the knee joint.

All breeds are susceptible to cruciate disease but we do commonly see more larger breed dogs such as Labradors, Golden Retrievers, and Mastiffs; unfortunately, females tend to represented more than males.

If your pet becomes acutely lame, you should take them into the veterinarian. Your veterinarian will do a complete history, physical exam and may want to take radiographs (x-rays) of your pet’s knee. A test that veterinarian usually does is called a “drawer test”. In this test, your veterinarian will hold your pet’s femur and tibia and trying to move the tibia back and forth like opening a drawer. This test can be negative and a torn cruciate still be present especially if your pet is awake when the veterinarian tries the test.

There are a number of ways to treat cranial cruciate rupture and those surgery procedures will be discussed over the next couple of blog posts. The biggest way to decrease your pet’s chance of cranial cruciate rupture is to keep their weight down, warm your pet up appropriately prior to exercise, cool down appropriately after exercise and if they should become lame go see your veterinarian at once.

Rehabilitation has become a medical way to deal with cranial cruciate rupture. Rehabilitation can decrease muscle loss, decrease pain associated with cranial cruciate rupture and may decrease the amount of arthritis that invades the joint but the best course of action is surgery and then rehabilitation.

I do recommend weight loss, glucosamines, and pain medications while your pet is going through surgery or medical management. There are some bracing techniques also but again surgery has the best chance of correcting the problem.

If your pet should have any problems with his knee, consult with your veterinarian and then give ARCC — Animal Rehab & Conditioning Center a call — we will devise a plan for getting your pet back on his feet.



Orthotics & Prosthetics — Getting a Leg Up

Dog with 4 prosthetic legs

Dog with 4 prosthetic legs

I grew up with my great grandfather, Eli, having a wooden leg. Now he had different legs for different occasions – there was the staying at home leg, the Sunday go to meeting leg, and numerous other ones.

He once sent me in to get his leg, I was about five years old, and I crawled under the bed to get it and there were a bunch of legs laying there – I came out screaming and running. My great grandmother, Sadie, did not find this amusing but granddad protected me.

I later became a veterinarian and we were taught how to amputate legs but never how to help the pet after the amputation; in fact, we were taught that they would be fine because they had 3 others! So my career has amputated and recommended amputation numerous times but we never really thought about the consequences of what we had done.

I have a three legged cat, Icee, and she has done well throughout her life but we have made some adjustments for her. Icee has a step stool to get up and down on furniture because I could see how repetition of landing on that one front foot could cause arthritis but that was as far as I saw unfortunately.

I went to the North American Veterinary Conference in January and suddenly the world of orthotics and prosthetics is in the forefront of veterinary medicine. I went into the talk with the same old mindset that we weren’t really hurting the pets by amputating their legs but helping them.

Dr. Patrice Mich shined the light on the dark side of amputation; she showed research about how we are affecting not only the compensatory leg but the other legs, back, shoulder and neck – it was astounding and so very sad. I felt very sad about all the pets, including my own, that I had “helped” and not helped.

The saying is that “you don’t know what you don’t know” and that is so very true. I felt all those years that I was doing something good for those pets and helping them, but in some ways I was hurting them also. The orthotics and prosthetics talk was truly enlightening.

Right after that talk, I was working the dog show here in Greenville and I saw an amputee pet walking around; it physically hurt me to see her hobbling around and I went to her owner to speak with her about orthotics and prosthetics – hopefully she will be able to get her pet one very soon.

Last week, I made a cast mold of a dog’s hind leg to send to a company that will make her an orthotic for her cruciate disease. The pet is older, overweight and not a good surgical candidate so her mother is pursuing a brace to help with the knee.

This week I fitted a small dog for a wheelchair (video below) – one that he hopefully will not use long because I think he can eventually start to walk on his own. These two incidents have made me feel better because now I know how to help these pets live happier, fuller, and more comfortable lives.

If your pet has an orthopedic problem that needs some assistance, please call and let’s help your pet have a better quality of life.

A cast mold for a knee brace

A cast mold for a knee brace

Otto’s First Time in His Chair

Degenerative Myelopathy

Crumpet in her wheelchair

Crumpet in her wheelchair

One of my favorite pets appears to have degenerative myelopathy and the disease is heartbreaking to watch, but in the midst of all the sadness is the happiness of this little dog. Sure she can’t walk as well as she used to but she loves going on walks in her wheelchair and she loves to eat!

Her mom is lucky because she can take Crumpet to work with her so Crumpet gets lots of interaction all day long. When Crumpet goes on walks in her chair people stop to talk to her and pet her — they are curious about her and she is just so damned cute.

The wheelchair can be a big distraction because I was walking Crumpet here at ARCC and people were coming to an almost stop to see her walking in the chair. Crumpet is also my number one pinterest pin-up consistently week to week.

Crumpet came to stay with me over the weekend and we worked on the underwater treadmill — walking she wasn’t quite so happy about but when the water was raised and she could swim — she loved it; you could just see how much happier she was swimming. Crumpet’s back legs have lost their ability to move her but there were times in the water when you could see that the right rear was trying to help. She is an amazing little dog — I enjoy her immensely but I hate her disease.

Degenerative Myelopathy is a slow progressive rear limb weakness or paralysis that is usually painless.  It is a degeneration of the white matter of the spinal cord and is most common in German Shepherds and Welsh Corgis but can be seen in other breeds.

It is most common in pets five to seven years of age and seems to have a genetic component to the disease but may have an immune mediated basis.  The disease moves from the rear of the pet up along the spinal cord and towards the brain until the pet becomes completely paralyzed with fecal and urinary incontinence.

Signs of degenerative myelopathy can be confused with arthritis or hip dysplasia.  The signs can include:

  • Decreased activity

  • Weakness in getting up or laying down

  • Stumbling, knuckling of the hind feet , or scuffing

  • Ataxia – staggering

  • Worn nails on the rear feet or wearing on the inner toes of the rear feet

  • Tremors and loss of muscle in the rear limbs

The signs can be prone to waxing and waning leading the owner to think the pet has just “overdone it”.

Diagnosis is rarely definitive and usually is determined by exclusion of other diseases.  This should not keep you from pursuing all that can be done for your pet.  An examination along with neurological exam should be performed.  Radiographs may be needed but myelograms, MRI and CTs are usually needed also.  A CSF tap (cerebral spinal fluid) may also be needed.

Treatment consists of four basic items:

  1. Exercise – keeping the pet’s muscle tone at a maximum, maintaining good circulation and condition.  A regular program of exercise on an alternate day schedule is recommended at this time with aerobic exercise consisting of thirty minutes twice a week and an hour once a week.  Physical therapy, acupuncture and other alternative therapies may be helpful.
  2. Supportive measures – casts, braces, and wheelchairs are among the items in this category.
  3. Medication – vitamin supplements such as vitamin E and B twice daily have been advocated but the results are inconclusive at this time.  Pain medications if needed should be added but vitamin E levels may need to be decreased.  Aminocaproic acid has also been recommended and it has seen some improvement in 15-20% of dogs but again the results are inconclusive at this time.
  4. Minimization of stress – stress seems to play a role in the advancement of the disease so keeping your pet as happy as possible is suggested.

Long term prognosis of degenerative myelopathy is poor so getting a diagnosis and plan early on in the disease is vital.

There are online support groups if your pet has been diagnosed with Degenerative Myelopathy and there is ongoing research in the disease.

Hoping, looking and wishing for a cure – Dr. Dicki and Crumpet

Crumpet in her life vest getting ready for underwater treadmill

Crumpet in her life vest getting ready for underwater treadmill

Crumpet and Jaws2


Disk Disease in Dogs — Back Talk

Otto in his Doggles — getting ready for laser therapy.

Otto is a 5 year old Dachshund who three weeks ago became unable to walk; his parents took him to their veterinarian who sent him to a specialist for surgery. Otto had back surgery and he still is not walking but seems very happy. His parents brought him to ARCC — Animal Rehab & Conditioning Center for help with his rehabilitation. Otto is the typical dog seen for back problems — long bodied.

Intervertebral Disk Disease or IVDD is a common problem seen in pets.  In human terminology we call it a “blown disk” and it is a major cause of pain in humans and animals alike.  A blown disk can cause pain, ataxia (staggering), paresis and even paralysis.

Your dog’s spine is a lot like your spine.  There are hollow bead-like bones with a string (spinal cord) inside.  Between these beads is a tough fibrous material that acts as a shock absorber – this is the disk.  The disks run from the base of the skull to the tail.

There are two types of disk disease called Hansen Type I and Hansen Type II.

Type I is a sudden explosion of material from inside the disk outwards while Type II is a slow, progressive protrusion of disk material outwards.  Clinical signs are usually more severe with Type I and less severe with Type II.

When the disk ruptures it presses on the spinal cord and/or nerves causing pain and neurologic deficits such as ataxia, paresis, and paralysis.

Dachshund, Bulldog, Pekingese, and Cockers are more prone to Type I disk disease while Type II is more common in old, large breed dogs.

This disk can be damaged anywhere from the neck to the tail.

The spine is segmented into three major groups:

  1. Cervical
  2. Thoracic
  3. Lumbar

Cervical disk disease is usually seen in small middle age to older pets and is most commonly Type I in origin.  The most common breeds for this type of IVDD are:  Beagles, Dachshunds, Pekingese, and Poodles.  The most common site is at cervical vertebrae C2-C3.

The most common signs of cervical disk disease are neck pain, decreased movement in the neck, carrying the head down, vocalizing, spasms, and decreased jumping, stairs or even looking upwards.

Cervical disk disease can cause lameness in one or both front limbs and severe cases can lead to paralysis of all four limbs.

Thoracic disk disease is usually seen in young adults to middle aged pets with Type I being common in small dogs and Type II seen in larger dogs.  The breeds most seen for this type of disk disease include Dachshunds, Cockers, Beagles and Bassets.  The most common site is at thoracic vertebra T12-T13 and lumbar vertebra L1-L2 (where ribs end and lower back begins).

The most common signs of thoracic disk disease are ataxia (staggering) in the rear limbs, arched back, and complete paralysis.  It can affect one side more pronounced than the other.

Neurologic signs and presence of pain perception determines the prognosis and if surgery needs to be pursued.

Lumbar disk disease is commonly seen together with thoracic but we can see lower disk disease of the lumbar that is solitary in origin.

The most common signs seen with lumbar disk disease depends on whether it is the upper part of the lower back or the lower part of the back and the division is seen about midways.

We can see ataxia in the rear limbs along with other neurologic problems but the main issue with lumbar disk disease is the possibility of decreased bladder sphincter tone.

Diagnoses of all types of disk disease include an examination, neurologic exam, and radiographs, which can be non-diagnostic.  Radiographs may be non-diagnostic if the disk is newly herniated because it will not be calcified enough to be seen.  If the radiographs are non-diagnostic, myelograms, CT or MRI may be needed.

Treatment can consist of either medical or surgical options depending on the severity of the lesions and signs.

Non-surgical treatment consists of strict confinement with NSAIDs or steroids being administered along with possible muscle relaxants.  The strict confinement is usually for at least two to three weeks.  Disk pain and signs may reoccur if not treated surgically.

Surgical treatment consists of removing the disk material along with opening the vertebral space.

Physical therapy is recommended for both medically managed and surgically managed pets.  If the pet has neurologic issues, physical therapy is especially recommended.  Physical therapy is usually provided for a minimum of three weeks but may need more time depending upon recovery.

Otto was given balance and strengthening exercises for the next couple of weeks and then will be re-evaluated; hopefully, he will begin to walk but if not, we will get him a chair and pimp his ride!