Is a stifle orthosis the right solution for you and your dog?
Injury to the cranial cruciate ligament (CCL also called the ACL) is the most common orthopedic injury in the dog. This injury is due to a partial or complete tear of a ligament inside the stifle (knee). The resulting instability leads to pain and arthritis.
Stabilization is recommended for best short and long-term function, quality of life, and comfort. Stabilization is traditionally done surgically either with a joint realignment surgery (TPLO or TTA) or with a pseudo-ligament surgically placed outside the joint (tight rope or lateral suture). These procedures are considered standard of care in general. In the past 7 years the use of custom orthosis (brace) has become available as an alternative to surgery when surgery is not appropriate for any reason. These reasons may include other health issues, unacceptable surgical or anesthesia risk, advanced age, and financial constraints, among others.
Because an orthosis is not the correct therapy for all patients, before choosing an orthosis the following points are important to keep in mind:
- The device MUST be put on and removed daily. The orthosis stabilizes the stifle from the outside, while surgery does so from the inside. Because of this it must be used whenever your dog will be standing and/or moving about. The device is not used when the dog is confined and at night. Without the brace on, your dog must not be allowed to move about at night (jump on or off bed, wander the house, go outside through a dog door, etc.).
- Adjustments are expected and are a normal part of the custom orthosis process. The device is custom-made for your dog. Every effort is made to accurately fit the device and 2 complimentary adjustments are included in order to meet the requirements for an appropriate fit. Changes in amount and intensity of activity can expose fit issues requiring adjustment. Additional adjustments are most commonly required in the first few months and as time goes on (see importance of follow-up #4).
- Orthotics for dogs are a new solution to an old problem. Modern medicine moves forward at a rapid pace. It takes a lot of time and many thousands of dollars to perform a controlled clinical trial to compare a new therapy to the standard therapies in common use. As such there is no published study directly comparing use of a stifle orthosis to surgical stabilization for CCL injury in the dog. As the industry leader using our unique, anatomically aligned, and mechanically sound custom design, we at OrthoPets provide stifle orthoses for nearly 1000 dogs per year. This level of experience allows us to carefully select the patients best suited for a stifle orthosis and trouble shoot interesting individual patient challenges. This is not a substitute for clinical data, but is referred to as empirical (or experiential) data. This is the current state of orthotics for animals. OrthoPets and our own medical director, Dr. Patsy Mich, continue to work closely with university professionals to develop studies to prove and improve the use of orthotics in animals.
- Follow-up is critical to success. An orthosis is considered a “durable medical device.” This means that proper use is necessary to meet therapeutic goals and to ensure its safe application over the lifetime of your dog. In the first few months of fitting, your OrthoPets Case Manager will evaluate pictures and video your dog for fit checks and coaching with regard to device use. Annual to twice annual appointments, depending on age and activity of your dog, are needed with your regular veterinarian. At these appointments your pet’s doctor will thoroughly assess your dog’s orthopedic condition and evaluate the condition and fit of the device. Recommendations will be made for continued success in the device. If major overhaul of the device is needed it will be necessary to send the device in to our lab in Denver, CO.
- Even with an orthosis, surgery may be required. When the cranial cruciate ligament is torn sometimes the meniscus is also torn. The meniscus is a comma shaped cushion on the inside of the stifle. There are two, one on the middle and one on the outer side of the stifle. The medial, or middle, meniscus is most commonly injured and this may occur at the time of the initial cranial cruciate injury, or any time later due to too much activity on an unstable joint. A torn meniscus is very painful and if not treated will cause continued lameness despite stabilizing the joint with surgery or an orthosis. If this occurs, a surgical procedure called a partial medial menisectomy is required. It can be done by itself or with a surgical stabilization (see first paragraph). A torn medial meniscus is diagnosed either at surgery, by MRI (rarely), ultrasound where available, or based on clinical judgment with or without use of an orthosis. If your veterinarian suspects a meniscus tear please talk with your Case Manger about options available for your dog.
- Rehabilitation, the first key for success. Whether your dog undergoes surgical or orthosis stabilization for a torn cranial cruciate ligament, and whether or not surgery is required for a torn medial meniscus, it will take time to recover full comfortable function. The best way to ensure the highest level of success is to follow your Veterinarian’s or Rehabilitation Specialist’s recommended rehabilitation schedule and techniques. Each patient’s condition and abilities are unique and as such an individualized rehabilitation program is needed.
- A proactive approach to arthritis management is the second key to long-term success. Just as rehabilitation is important whether your dog undergoes surgical or orthosis stabilization, arthritis management is also key. All dogs will develop arthritis after injury to the CCL regardless of the stabilization techniques chosen. The difference is the severity and speed of development of that arthritis. Steps taken early on and continued throughout your dog’s lifetime will make a difference in terms of regaining and maintaining comfort and an active life-style well into the senior years. We encourage you to work with your Veterinarian or Pain Management Specialist to create an individualized, integrative arthritis management plan for your dog.