There have been many theories proposed for the treatment of a cranial cruciate ligament 
rupture.  However, researchers do agree that once instability has occurred that progressive 
, degenerative joints changes will occur.  These changes in joint include, periarticular 
osteophytes, erosion of the articular surface and meniscal damage all within a few week of 
injury.

Conservative treatment involving splinting has been advocated in addition to cage rest for 
4-8 weeks post trauma.  These methods have a higher success rate in small breeds of dogs 
<20kg, however, it has been reported that dogs over 15kg uniformly function poorly.  All 
animals treated with conservative management will eventually develop degenerative joint 
changes. 

 Given this information, the recommended treatment of a cranial cruciate ligament rupture is 
surgical therapy.  However, it is important to note that no surgical technique will stop the 
development of degenerative joint disease.  Many clinicians have reported a 85-90% 
ÒsuccessÓ rate after surgery.  It is in the opinion of many surgeons  that regardless of the 
method chosen, the stifle joint should be opened and Òcleaned upÓ regardless of the surgery 
technique that is chosen. This includes examination of the stifle joint for articular erosions, 
osteophytes and other ligament and meniscal injuries. The remnants of the ruptures cranial 
collateral ligament are removed and often the joint is lavaged at this time to remove the 
debris.
 Both extra-capsular and intra-capsular techniques  are possible.  Extra-capsular methods 
stabilize the joint with use of heavy gauge suture although some extra-capsular methods 
involve transposition of soft or bony tissue. In the extra-capsular methods the tibia is 
anchored to the femur using sutures. In extra-capsular methods a suture is passed through 
the femorofabella ligaments and then through a hole in the tibial crest. When the suture is 
tied it prevents cranial displacement of the tibia during weight bearing.  Intra-capsular 
methods involve actual replacement of the cruciate ligament with either material obtained 
from the dogs itself (such as fascia) or  autologous grafts of synthetic material to replace the 
ligament.  Research has shown that both intra-articular and extra-articular methods are 
effective, however in dogs weighing over 20kg intra-articular method is more effective in 
returning the animal to its previous activity level.

Currently there are over 150 different surgical methods for repairing a cranial cruciate 
ligament rupture.  There is no ÒrightÓ way to fix a cranial cruciate rupture, instead much 
depends on the equipment one has at hand and the preference of the surgeon. 

For this case, we have chosen to do the Under and Over Method. The under and over 
method  utilizes a fascial graft to replace the ruptured cruciate ligament.  The graft is left 
attached to the tibia, passed through the joint and attached to the caudal and lateral side of 
the distal femur. This mimics the natural cruciate ligament and prevents cranial 
displacement of the tibia during weight bearing.  A lateral parapatella approach is utilized.  
The lateral 1/3 of the patella tendon is dissected from the patella and the fascia lata strip is 
included in the graft. A lateral arthrotomy is utilized. The graft is drawn up through the fat 
pad, under the intermeniscal ligament into the joint. The graft is grasped in the forceps and 
pulled through the joint. A small incision is made between the fabella and femur and the 
graft is pulled through the incision.  The graft is then looped around a screw that is placed 
in the femur, under a spiked washer and its pulled tight while tightening down the screw. 
The end of the graft is sutured to itself around the screw.

Post-operative care: minimal strength until approximately 6 weeks post repair.  Bonnie 
should be confined to a cage, or crate for about 10 days.  At 2 weeks postop a controlled 
exercise program can be initiated. This would include leash walking and possibly 
swimming. At 12 weeks postop Bonnie should return to normal function. At approximately 
6 months post surgery the screw and washer can be removed.

Pain management:
We would like to have Bonnie come in the night before surgery to apply a fentanyl patch 
will serve as preoperative and perioperative pain management.  The patch will be left on for 
2-3 days. We will also send Bonnie home with Carprofen, a nonsteriodal antiinflammatory 
for one week.  We may extend this depending on the progression of BonnieÕs 
improvement.