Surgical Recommendation?

"Just close your eyes and trust the doctor" is very seldom a good way to approach medical decision making. To be able to make the best treatment decisions, you need to understand the nature of the problem, the different treatment options, and the factors that shape doctors' recommendations.

Recovery without surgical intervention for dogs' ligament injuries is very often effective and is low-risk. But nonetheless many vets routinely state that surgery is the only option for treatment of dogs' ligament injuries.

--- Why is this so? Why is it that a potentially very successful and low-risk way to deal with dogs' ligament injuries is not even mentioned to dog owners by many vets? This page considers that question and related questions.

All doctors, including vets, know that their clients tend to put more faith in a doctor who presents his conclusions confidently. Therefore doctors are inclined to state their opinions as though those opinions are solid facts. But the history of medical science clearly shows that many things which doctors have firmly believed have been shown to be false when scientifically done research tested those beliefs. Don't think that something must be true because a person with a medical degree asserted it confidently. Doctors very often disagree among themselves, and even when a large majority agree with each other it is not unusual for research to eventually be done which proves them wrong.

'Evidence-Based Medicine' is a superior method of making treatment decisions which uses carefully designed Class I & Class II research studies as the foundation for choosing among treatment options. But because evidence-based medical treatment requires extensive and costly research to have been done, it is often the case that there have been no Class I or II studies done on some aspect of medical treatment. This is the case with dogs' ligament injury treatment. There are vets who believe in all the various treatment options, but none of them can point to a Class I or II research study that backs up their opinion.

With no Class I or II research on which to base treatment decisions, what is the basis of claims from vets that surgery is required for dogs' ligament injuries?

---- While there are no Class I or II research studies on which to base ligament injury treatment decisions, there are Class III & IV 'studies'. These are subjective and written by vets regarding their experiences with and opinions concerning the procedures they perform. These articles almost always claim good results for the procedures being sold by the authors. These 'studies' have the same kinds of potential flaws that would be more obvious if you saw a newspaper article titled "Local Ford Dealer Completes Study Which Finds Fords Are Superior and You Should Buy One."

---- Please see the page 'But the vet said...' here at this website for more on the nature of these Class III & IV articles.

Link="But the vet said..."

The training student vets receive about dogs' ligament injury treatment is often largely based on the opinions of the instructing surgeons at their university. Not surprisingly, the opinions of surgeons tend to be strongly biased in favor of surgical approaches. When they were students, vets absorbed what they were taught by surgeons about ligament injury treatment. Now, as practicing vets, they confidently assert the opinions of their instructors as though these were facts. In regard to ligament injury treatment, what they were taught by those surgeon-instructors is wrong. Very many dogs recover wonderfully well from even severe stifle injuries without surgery. I hear about them every day. Because of this website, I get a lot of emails about dogs' ligament injuries. One of the things I am often told by people is that their vets were surprised to see their dogs had recovered well without surgery. The vets had told them that surgery was absolutely necessary. Then, a number of months later, here is the dog in front of the vet having recovered without surgery! The vet is amazed! How could this dog have well-functioning stabilized stifles when Professor Bluster at the university taught his vet students this was not possible? Well, it is not a miracle healing. It is simply that the subject of ligament injury treatment was one of the things surgeon-instructor Bluster was wrong about. Many dogs can recover very well after ligament injury without surgery.

There Are Non-Medical Factors Which May Influence A Vet To Recommend Immediate Surgery

---- The careful restriction necessary for a non-surgical recovery is more trouble that many dogs' people are willing to undertake. When a vet is making treatment recommendations, he must take into consideration what can be expected from clients. Recommending non-surgical treatment which will not be done by the dog's people does the dog no good. The conventional surgeries do provide temporary stability enhancement which makes the early stages of recovery easier in some ways for dogs' people. There is always some degree of increased risk with surgery. But when the clients would not provide the careful restriction required for a non-surgical recovery, surgery may be the best choice for the dog. Therefore even vets who understand the potential of non-surgical recovery may believe that recommending surgery is best.

---- Vets often tell me is that people want them to treat dogs' conditions actively. They say many clients are not happy with a recommendation for a long period of cautious restriction which the client may see as 'doing nothing'. Vets tell me: "If I recommended no surgery and careful restriction, my clients would go down the road to another vet who would promise them fast results from surgery. People want a vet to do something dramatic immediately. I'd lose clients left & right if I recommended conservative treatment for dogs' ligament injuries."

---- And vets tell me they can't trust people to properly restrict dogs who haven't had surgery. As soon as the limp eases up, the vets say, many people will let the dog return to normal activities too quickly. This often results in a re-injury. One vet called this failure to restrict properly "The exasperating inability of owners to follow instructions".

Vets' Self-Interest Weighs In Favor Of Surgery

In the judicial system, when a judge has a financial or personal interest in a case being tried in court, he is 'recused'. Disqualified from judging that case. This is not because we think he is crooked, but because we recognize that it is human nature to be influenced by self-interest. The judgements all people make are influenced by self-interest in ways they themselves may not be aware of.

---- Vets are usually people who became vets because they wanted to help animals. But they are not angels with no need for money. They need to pay the bills and pay staff and support themselves and their families. Upton Sinclair said "It is difficult to get a man to understand something when his income depends on his not understanding it." It seems that it is difficult for some vets to understand the great potential for success with non-surgical recovery when surgery has such a compelling comparative advantage for the vet, if not for the dog.

Another reason to be wary of a surgical recommendation is that misdiagnosis is common *

Many dogs have had a recommendation for surgery as a result of misdiagnosis when the problem was a muscle injury or other minor injury. Careful restriction has the wonderful quality of being curative for many problems that cause lameness. Once you are sure there is not a broken bone, there is no reason to rush to surgery for a ligament injury or other soft-tissue injury. If you carefully restrict your dog and he recovers in just a few weeks, you will know that injury wasn't a ligament rupture at all. There may have been a muscle injury or some other minor injury. You may never know the exact nature of the injury, but you will know that you avoided an unnecessary and potentially crippling surgery.

---- If the dog does have a serious ligament injury, recovery will take much longer. Non-surgical treatment is usually the best first-choice option in my opinion. This avoids the risks of surgery while providing the best possible re-stabilized stifle after recovery. A dog who has the capacity to recover non-surgically will usually show improvement within 8 weeks. Not full recovery in that time---but noticeable improvement. You would be able to observe the dog at 8 weeks after beginning careful restriction and say "Fido is better than he was at 2 weeks after the injury. Not completely recovered, but better." That improvement should continue slowly over the course of at least several months. If recovery is very slow or there are repeated re-injuries, a brace would be a good idea. (See the 'FAQ' page for brace information.) If a dog can not improve even though carefully restricted and stabilized with a brace, then surgery is probably appropriate.

* Here are some of the things that can cause lameness and that can be mistaken for torn-ligament-caused lameness:

--- Most likely are minor sprains and strains and contusions. Also tick-borne diseases; Panosteitis; Neurologic conditions, such as degenerative myelopathy or herniation of an intervertebral disc; Hemarthrosis, typically due to von Willebrand's disease but infrequently due to immune-mediated thrombocytopenia; anticoagulant rodenticide toxicosis or other causes of coagulopathy; Neoplasia, including osteosarcoma (most often of the proximal end of the tibia); and synovial cell sarcoma or immune-mediated arthridities. I have also heard of paw injuries and other unrelated-to-the-stifle injuries being diagnosed as ligament injuries. It is unfortunately true that there are vets who, when they cannot find a reason for a limp, assume it must be a ligament injury in spite of a lack of 'drawer' indication simply because ligament injuries are common and they hate to say "I don't know".

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Is a vet telling you that immediate surgery prevents or reduces future arthritic problems?

---- Horsefeathers! Not True!

Please see the page 'Arthritis Risk?' here at this website.

Link=Arthritis Risk?

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Some dogs who have surgery have serious complications.

There are quite a few variations of intracapsular & extracapsular surgeries for ligament injury, and there are also TPLO and TTA surgeries. All ortho-surgeon vets claim to have very good success rates with whichever surgical methods they prefer. But these claims conflict with the fact that there are many dogs whose surgeries have been failures. With some dogs it is immediately clear that surgery has failed. Others never recover properly after surgery or have complications arise months or even years later. Sometimes surgical complications have led to great suffering, multiple additional surgeries to try to correct the problems caused by the original surgery, amputations, euthanasia, etc. There is no way to know with accuracy what percentage of surgeries these failures represent, but the risk of being damaged rather than helped by surgery is not insignificant. (Please see below for synopsis of recent JVMA article regarding surgical outcomes)

---- With this risk associated with surgery, and little risk involved in non-surgical Conservative Management, why rush to surgery? Immediate surgery is very seldom a wise choice. Surgery is recommended in very many instances when non-surgical recovery would be a much better option. I think a person would be wise to be cautious about agreeing to surgery before trying Conservative Management.

---- If a vet does not consider a non-surgical recovery to be the preferable first-choice treatment option in most cases, then in my opinion his understanding of ligament injury treatment is flawed. If Conservative Management's careful restriction of activity does not result in improvement which leads to recovery, surgery is still an option. Rushing to immediate surgery destroys the possibility of a low-risk non-surgical recovery.

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The very large profit can make the surgeon's potential financial gain the major factor in a recommendation for TPLO or TTA surgery. Please see the 'TPLO/TTA' page here at this website.

Link=TPLO --Very Seldom A Good Choice

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What results are really obtained with surgery?

All the surgeons I have heard about tell clients that they have very high success rates with their surgeries. Do they really? Here's a synopsis of an article from the Journal of the AVMA from Dr Ron Hines DVM PhD's website. Dr Hines does ligament surgery himself.

"An article in the January 15th 2005 issue of the Journal of the AVMA does not give an overly optimistic evaluation of surgery for cruciate ligament damage. This paper found that only 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." Journal of the American Veterinary Medical Association January 15, 2005, Vol. 226, No. 2, Pages 232-236doi: 10.2460/javma.2005.226.232

This does not mean that the surgeries leave all dogs except these small minorities with no use of their injured legs. It means that only these small percentages regained full normal leg function (pre-injury ability). Some dogs have complications during surgery or after surgery which leave them much worse off that before, but among dogs who do not have problems caused by surgery most recover to the extent that they have moderately good use of the leg but not full pre-injury ability. After recovery is complete they probably will not have the ability with the leg they had before the injury. They may have a limp which increases after a walk or be stiff when first getting up. Things like that. But they can live good lives and enjoy moderate stress activities, running and playing fairly normally in moderation. The same is true for dogs who recover with non-surgical methods.

---- Surgeons often mislead clients by saying or implying that the surgery they sell will almost certainly result in the dogs' return to pre-injury function.

Imagine I have a product which I claim cures the common cold-- let's call it "Max's Cold Cure" or "MCC". The truth is that MCC is completely ineffective, but I tell everyone it has an amazing 99% success rate and I back up my claim by pointing out that people who have colds and take MCC recover in just a few weeks!---- Of course you recognize the problem with my claim. People's own bodies' ability to recover from illness and injury is what is really responsible for their recoveries. People took MCC, and they recovered from their colds. Their recoveries came after taking MCC, but not because of taking MCC. There is not a cause and effect relationship.

---- The fact that my dog and thousands of others I know of recovered very well without surgery after vets' statements that surgery was necessary certainly casts doubt on surgically-inclined vets' claims. The surgeons do their surgeries and then instruct the dogs' owners to restrict the dog for a long post-surgical period. Those who advocate non-surgical recovery advise restricting in a very similar way but without the surgery. All the recoveries, with or without surgery, take place during a long period of restriction and reduced activity. Hmmmm......

"...When widely differing procedures all result in improvement with time it is wise to question whether time itself may be the curative element. None-the-less, it is considered good practice in veterinary medicine in the United States to treat all these cases in larger breeds surgically. ..."

--- from the website of Ron Hines DVM PhD

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Here is a quotation from the journal 'Veterinary Surgery' (please see the page 'But the Vet Said....' here at this website for citation.)

"... At this time, the application of evidence-based medicine in analyzing the current available evidence suggests that there is not a single surgical procedure that has enough data to recommend that it can consistently return dogs to normal function after CCL injury. ..."

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Here is a quote from highly respected vet & author

Doctor Mike Richards DVM ----

"There is an old joke about a man walking around the city banging two sticks together. When asked why, he replies 'I'm keeping elephants away.' When told that there aren't any elephants in the city, the man replies 'See, it's working!'

"I feel a little like I'm talking to this man when I ask veterinarians about the results they get when they attempt to stabilize a dog's stifle joint after cranial cruciate ligament ruptures occur. Most veterinarians strongly advise surgery. Most dogs who have surgery eventually walk pretty well. However, most dogs who don't have surgery eventually walk pretty well, too. Most dogs who don't have surgery develop arthritis in the knee over the years and require medical treatment for the discomfort as they age. Most dogs who have surgery develop arthritis and require medical therapy for the discomfort at some point, as well. As near as I can tell after observing a great many of these patients, there isn't much difference between surgically stabilized knees and knees that are allowed to heal on their own without cranial cruciate ligament surgery. Some dogs in both groups do worse than expected and require more attention. Every time one of these dogs hasn't had surgery a surgeon is quick to say 'Think how much better this dog would be if surgery had been performed.' When things go bad, though, few surgeons ever say, 'Think how much better this patient would have been if I hadn't done surgery.' Instead, they say 'Well it would have been worse if we hadn't tried.' It is hard to be a surgeon without being able to tell yourself things like that when surgeries don't work well. Unfortunately, even though I sometimes say it too, I think that statement is the veterinary equivalent of beating sticks together to keep the elephants away -- it is very hard to prove that it isn't true but just a little bit of common sense makes a person suspicious."

--- Mike Richards, DVM

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