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Short-term and long-term outcomes for overweight dogs with CCL treated surgically or nonsurgically | VETgirl Veterinary Continuing Education Podcasts

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In this VETgirl online veterinary continuing education podcast, we review short-term and long-term outcomes for overweight dogs with cranial cruciate ligament rupture – do they all need surgery?

Imagine this scenario: you have a canine patient come in for evaluation of acute hind limb lameness. On physical exam, the dog is overweight with a BCS 8/9 and is toe-touching lame on the right hind limb. Your orthopedic exam reveals pain on extension of the stifle and a nice cranial drawer sign, so you talk to the owner about cranial cruciate ligament rupture and options for medical and surgical management. We’ve all seen these cases, right? Well, do you have a feeling for the success rates of medical management alone, including weight loss, physical rehabilitation and non-steroidal anti-inflammatories (NSAIDs), versus surgical and medical management? What would you recommend for this patient?

Well, it turns out that there isn’t much evidence in the literature on this subject aside for some older, small retrospective studies, so Wucherer et al out of University of Minnesota wanted to investigate a little more. So, in a study called Short-term and long-term outcomes for overweight dogs with cranial cruciate ligament rupture treated surgically or nonsurgically, the authors performed a prospective, randomized clinical trial of 40 overweight dogs (defined as a BCS ≥ 6/9) with unilateral CCLR and looked at their outcomes over a 1-year period based on objective and subjective measures of lameness. Dogs in the medical management group were treated with NSAIDs (deracoxib 1-2 mg/kg PO Q24 for 12 weeks), a weight loss program and supervised physical therapy, and dogs in the surgical and medical group also had a TPLO performed.

So, what’d they find in this study? 40 dogs were initially included in the study, but some were excluded at various time points for various reasons, so data were available for 35 dogs at 6 and 12 weeks, 29 dogs at 24 weeks, and 23 dogs at 52 weeks. NOTE: Cranial cruciate ligament rupture in the contralateral limb was the most common reason for exclusion (11/40 dogs). Overall, there were no significant differences between groups for sex, age or duration of injury. The most common breeds were Labradors or Labrador mixes (11 dogs), American Staffordshire Terriers (3) and Rottweilers (3).

For subjective outcomes, owners completed 2 questionnaires, the canine brief pain inventory (CBPI) and the canine movement assessment visual analogue scale (VAS), at each time point. Lameness was also assessed by one of the investigators using a rating system. There were no differences in the groups before treatment, and in general, questionnaire scores improved at each time point for both groups. The only difference between the groups was at 52 weeks, when the dogs in the surgery group had better scores (lower pain) than in the non-surgical group. 90% of dogs overall had a good to excellent quality of life at 52 weeks according to owners, but the surgery group had more dogs with a good to excellent QOL (65%) compared to the non-surgery group (35%). Dogs in the surgery group also had great improvements in movement assessment visual analogue scale measurements during the study than dogs in the non-surgical group. Investigator-assignment lameness and pain scores decreased during the study period for both groups, but there were no significant differences between the groups.

For the objective measures of outcome, body weight, BCS, percentage body fat, hind limb length, velocity, acceleration and peak vertical force were assessed. Dogs in both groups lost weight (mean percentage of >10% during the first 12 weeks, with no difference between groups), lowered BCSs (no difference between groups) and decreased body fat percentage (no difference between groups). There were also no differences in mean hind limb length or velocity and acceleration, and peak vertical force increased for dogs in both groups over the study period, but the results were not significant. Ground reaction force (GRF) increased for dogs in both treatment groups, with no differences between the groups. Compared to the contralateral (normal) hind limb, GRF increased from 55.7% to 84.5% over the course of the study for the non-surgery group, and from 55.6% to 87.7% for the surgery group.

The authors defined a successful outcome as a net GRF > 85% of the value for a normal dog with owner questionnaire responses indicating a >10% improvement in lameness and QOL. At each time point, more dogs in the surgery group had successful outcomes than dogs in the non-surgery group, although this difference was only significant at 24 weeks. In the non-surgery group, the percentage of dogs with successful outcomes was 47.1%, 33.3% and 63.6% at 12, 24 and 52 weeks. In the surgery group, the percentages were 67.7%, 92.6% and 75% at the same time points.

So, what can we take away from VETgirl podcast?
As we all suspected, overweight dogs with CCLR treated with surgery and medical management had better outcomes compared to dogs treated with medical management alone. However, dogs treated with surgical management didn’t have better outcomes in all of the categories, and dogs treated without surgery did better than in previous studies. These findings suggest that dogs managed without surgery might still do well, even if the treatment isn’t ideal. What we liked about this study? This study is great because it is prospective and thus more controlled than the previous retrospective studies, but it did lose some power because of the cases that had to be excluded over the course of the study. Also, TPLO was the only surgical method evaluated. Ultimately, if you have an obese or overweight patient with a unilateral CCLR, surgery plus medical management, including a weight loss plan, NSAIDs and physical therapy is probably best. However, there is evidence that your patient might also do pretty well without surgery, so that might be important to keep in mind for owners who are against surgery. Again, overweight dogs with cranial cruciate ligament ruptures have better outcomes with surgery combined with medical management as compared to medical management alone. Let’s help our pets lose more weight!

References:
Wucherer KL, Conzemius MG, Evans R et al. Short-term and long-term outcomes for overweight dogs with cranial cruciate ligament rupture treated surgically or nonsurgically. J Am Vet Med Assoc 2013;242:1364-1372.

Abbreviations
BCS: body condition score
CBPI: canine brief pain inventory
CCLR: cranial cruciate ligament rupture
GRF: ground reaction force
NSAID: non-steroidal anti-inflammatories
QOL: quality of life
TPLO: tibial plateau leveling osteotomy
VAS: visual analogue scale

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