Last Updated on 2021-10-28 by Admin
The Appeal of Conservative Treatment
Before starting with the conservative treatment for my Boxer girl Annie, a great deal of effort and research went into learning about the various surgeries and non-surgical options. After considering all things, I decided to go with the conservative treatment.
I was not fond of most dog knee surgeries like the TPLO, TTA and MMP procedures because they are very invasive and require cutting bone. That, to me, seemed a very radical approach to fix a torn tendon\ligament.
As for the conservative\none surgical treatment, I liked that with time scar tissue would be built. And that the scar tissue was healing\stabilizing the knee. That seemed a gentler, natural and more reasonable approach to fix a broken tendon.
Planning for a Successful Conservative Treatment
For Annie’s treatment, we bought a custom Posh knee brace for added knee support. Her activity got restricted heavily early on. And eventually, we gradually increased the length of time of our walks. Many joint supplements got tested till we found some that worked well.
I learned how to do acupressure and massaging on Annie to relieve discomfort and keep her muscles limber.
Things started to get better for a while, but there were always setbacks. And after a setback, it was like starting all over again.
After more than one Year of Treatment, we did not see acceptable results.
We expected Annie to play ball, run like crazy, and be a happy, pain-free dog. But eventually, we had to acknowledge that the treatment was not working. And that leads to the decision to go with surgery.
The Decision to go for Surgery
My wife and I find cutting bone pretty radical for fixing a torn cruciate ligament. So I searched for a surgeon that could perform the Tightrope ® procedure even though our Veterinarian recommended the TPLO procedure.
So I referred to one of my old posts that shows animated videos about the most popular knee procedures to find who makes the parts used for the Tightrope® procedure. I then contacted the Arthrex Medical Device company and asked if they could provide us with some surgeons in my area who performed the Tightrope ® procedures. They promptly sent me a list of surgeons. That is how I then got in touch with Dr. Gillick. A surgeon from the Fuzzypaws Mobile Surgery, whom I entrusted Annie with the surgery. You can read more about Dr. Gillick at https://www.fuzzypaws.ca/.
I will refer back to Dr. Gillick a few more times as he answered my questions so well. Also during surgery he showed that he is a true professional that cares. You can read all about it my post Dog Knee Surgery and Recovery Our journey.
What a Dog Owner needs to Know about the Dog Knee and Conservative Treatment
Taking a Closer Look a the Conservative Treatment and the Dog Knee
Now that I have experience with conservative treatment. It surprises me that I never read about what it takes for scar tissue to stabilize a knee. What is written, for the most part, is pretty simplistic. Restrict the dog’s activity and give it time so scar tissue can build to stabilize the knee. That pretty much sums it up.
What are the effects of one broken item in a knee on all the other parts of the knee? Again, that is generally not part of the conversation about conservative treatment. But it should be. Because the knee still is used while on treatment. Although much less than usual.
Evaluation by the dog owner of the conservative treatment gets based on how the dog behaves. Later, I would like to share my experience of why a dog’s behaviour may not be a good indicator to determine if a knee issue is fixed.
Because conservative treatment is a lengthy process, one can get in a never-ending loop. You see some progress, then a setback. You continue, and things get better again till the subsequent lapse. And that can lead to what seems like a never-ending treatment. One way to address this entrapment is Setting the length for treatment and specific outcome expectations. Which is another subject I never read about in conjunction with conservative treatments.
Almost contrary to a dog owner who wants to treat a dog with conservative treatment. Is talking to a surgeon. I learned too late: Talk to a specialist\surgeon to get the best information to make well-informed decisions.
Next, I would like to closer look at the shortcomings I mentioned earlier. And share some of what I learned.
What it Takes for Scar Tissue to be able to Stabilize a Knee – An explanation from Dr. Gillick, a Veterinary Surgeon
Would You not expect that my Boxer girl Annie will have a lot of scar tissue after over one year of conservative treatment? After all, I used a brace to stabilize the knee, gave her good supplements and restricted movement when it made sense. But guess what, this is not the case.
A couple of days after Annie’s Surgery, I sent an email to the surgeon Dr. Gillick who operated on Annie and asked why after six months after the Tightrope surgery, there will be enough scar tissue that Annie can run. Yet after almost two years of conservative treatment, there is only little scar tissue? Here is his answer.
The problem with conservative management is that scar tissue needs some form of stability and “scaffolding” to form.
Scar tissue does not have a good sense of humour about too much motion – so when the cruciate is torn and the dog walks, the Tibia still gets pushed forward (tibial thrust). Any time they are weight bearing there is excess movement (tibial thrust).
With a soft tissue repair technique like the TightRope – it prevents the tibial thrust (as well as excess internal rotation) so allows more consistent scar tissue to form while at the same time allow flexion and extension of the stifle (the reason for this is that the TightRope placement is very close to an isometric point – meaning there is little to no elongation or strain on the suture in either flexion or through extension.
It’s not the flexion and extension of the knee that breaks down the scar tissue, it’s the tibial thrust which is why stifle braces do not work very well – they do not adequately eliminate tibial thrust.
I hope this relatively generalized explanation helps.
Mitchell Gillick, DVM, MVSc
Fuzzypaws Mobile Surgery
To help visualize what Dr. Gillick is explaining, please refer to the following images. In case You wonder, the stifle is the medical term for a dog’s knee.
Please also refer to these pictures when You read the next section.
The Effect of one Broken Item in a Knee on All the Other Parts
Please note that I’m a dog owner, not a veterinarian. And want to make the point that when something in the knee breaks, other parts are also affected. You should consult a veterinarian for specifics about Your dog.
Since the pictures above so nicely illustrate the dog’s knee. When a cruciate ligament in the knee is torn, the knee has more than normal free play, and some stabilizing support is lost. Let’s take a closer look at what is affected when a cruciate ligament is broken.
Meniscus, Tibia and Femur
Sandwiched between the top leg bone, the Femur and the bottom bone, the Tibia, is the meniscus. The meniscus acts as a lubricant and a buffer between the Femur and Tibia.
It is easy to imagine that when a cruciate ligament is torn, that friction increases on the meniscus with more free movement in the knee. Like any other part of the knee, the meniscus is attached to something, and those points will also experience added stress.
This extra movement can wear down the meniscus and cause damage. That is what happened to Annie’s knee. Once the meniscus function to lubricate and buffer is sufficiently diminished. The bone ends will eventually start rubbing together, which is called osteoarthritis. Osteoarthritis is a painful condition for the dog and is not reversible as far as I know. It will get worse as the dog ages.
In Annie’s case, osteoarthritis got diagnosed way before the torn cruciate ligament tear.
Soft tissue does not show on x-rays
How do you know then what issues a dog has with a knee? The many soft tissue items in a knee like a meniscus and cruciate ligament don’t show on an x-ray. Osteoarthritis will be visible on an x-ray because it is bone. A drawer test is performed to test for a torn cruciate ligament to see how much excess play there is in the knee.
Making a decision
Now that we know a little more about the dog’s knee, how it works, and the difficulty of assessing the full damage. We are better prepared to make a better-informed decision what a conservative treatment or surgery can potentially fix.
Why a Dogs Behaviour May Not Be a Good Indicator to Determine if a Knee Injury is Fixed
A week or so before the scheduled Surgery for Annie, she was running and playing on the retractable line like I have not seen her do in almost a year. The most amazing part about it was that Annie was not on any supplements for two weeks.
I started to wonder if she now finally had sufficient scar tissue build-up. I asked myself if there was something like ultrasound to detect how much scar tissue was built up. Could it be that Annie no longer needed surgery? I was puzzled. So I wrote Dr. Gillick an email about my experience and asked if there was a way to measure Annie’s scar tissue build-up?. His replay was:
“not really. Mainly by palpation – but ultimately, its how they are doing clinically that is important. If You feel she is “normal” – I would increase here activity for the next few day and see how she does – odds are the lameness will return – its just a matter of time”.
I found his reply caring, and Dr. Gillick understood that how Annie behaves is how I determine her state. It is easy to forget that how they are doing clinically that is important, not how they behave. That is especially true when You invested a lot of time end effort into something. Sometimes You can’t see the trees from all the forest.
Setting a length for treatment and specific outcome expectations.
Because the conservative treatment for dog knee injuries can be varied, there should be a start and end date with an expected result by the end date. Define what aspects: Brace, PRP (Platelet Rich Plasma), supplements, Acupuncture, Massage etc., to include. Then set a goal\expectation. An example of such a goal might be: I want my dog to be able to play with other dogs and run freely by the end date.
Doing so will prevent getting into a never-ending conservative treatment loop.
Talk to a specialist to get the best details required to make a well-informed decision
Why should You talk to a surgeon when you want a conservative treatment? The simple answer is vast experience with knees for all kinds of dog breeds. I was glad to pay for a consultation with a surgeon. No veterinarian I spoke to gave me this much time and information.
In my consultation, I got all my questions answered, regardless if they were Surgery or conservative Treatment related.
How A Surgery Addresses the Dog Knee Issue Compared to the Conservative Treatment
There are many different types of dog knee surgeries. What they all have in common is to stabilize the knee. How they achieve this varies greatly. By stabilizing the knee quickly, the wear and tear from extra movement in the knee are stopped or significantly reduced.
The wear and tear continue with a conservative treatment until the knee is stabilized by scar tissue, which takes many months. In the case of my Boxer girl, it never happened.
Many types of surgeries also include corrective measures on soft tissue like ligaments and meniscus. Often the two ends of a torn ligament are removed. What exactly need’s to be done will depend on the condition of the knee and the surgeon. When it comes to conservative treatment, the broken parts remain in place.
Recovery after surgery is fast, once past the initial few weeks. That should not be surprising, now that we know that a stable knee is required for scar tissue to form. In contrast, I spent a year on conservative treatment with little results. Annie will be able to run free and play with other dogs six months after surgery. I might add that Annie will be more active roughly three months after surgery than when she was on the conservative treatment.
Cost of Surgery vs Conservative treatments
Non-surgical treatment is considered to be much less costly than surgery. But after reviewing the various estimates, the gap is smaller than expected.
Have a look at the table below with estimates.
|Item||Low Estimate||High Estimate||Comments|
|Custom Brace||$ 1000||$ 2600||I get various estimates from online sources, manufacturers and a Veterinarian.|
|Joint supplements||$ 45 a month or|
$ 540 a Year
|$80 a month or|
$960 a Year
|Only joint supplements, no omega 3 or other supplements are included. You may or may not need that after surgery as well.|
|Follow-up X-ray, Veterinarian Visits related to limping. Pain Medication etc.||$ 375||$ 750||Again may or may not be required after surgery. With conservative treatment, You may need more than just one visit. I had two but only added one because I assume Annie’s conservative treatment started after Annie’s complete ligament tear.|
|One Year Total||$ 1915||$ 4310|
|Surgery||$ 2600||$ 6000||The cost of surgery depends on the type of surgery and location.|
The estimates were for Tightrope, TPLO and TTA procedures.
What is not known is what each estimate includes.
As I mentioned at the beginning of this article, many details related to a conservative treatment don’t seem to get any attention. Having a defined time frame and goals are too important to ignore. So are the many aspects of what happens to the knee when something breaks. But the biggest letdown for me is that I was hopping on building scar tissue with my treatment. And that did not happen.
I can see that an older dog or dog with health issues may not have the option of surgery. And for some dog owners, the cost is what stands in the way of moving forward. The conservative treatment has its place. But I can’t help but wonder how many others with a young, healthy dog chose a conservative treatment because of a lack of insightful information. For them, I hope this article fills that lack.
With all the information gained, a dog owner can make a better-informed decision regarding treatment. It also should help evaluate some of the many conservative treatment options like laser therapy, massage, acupuncture, brace etc. And what they realistically can and can not address.