Final Management   Plan:

Based on Bonnie's signalment, body condition, and activity level, surgical management would be the optimal treatment option.  In general, this method is especially recommended for animals over 15 kg.  Furthermore,surgery speeds rate of recovery, helps to minimize  subsequent degenerative  changes , and enhances return to function.  Prior to surgery, placing Bonnie on a weight reducing diet , such as Hill's r/d, for approximately two weeks is recommended.  This time frame will allow for Bonnie to lose a target  amount  of 2-4 pounds but is short enough to avoid further degeneration of the joint before surgery. Pre- and postoperative weight reduction is of primary concern withBonnie since excess weight will place increased stress on her healing stifle. 
Since previous hematology and chemistry were performed on initial exam, preanesthetic bloodwork can be foregone.  Bonnie is an aging large breed dog that is overweight  so intracapsular ligament reconstruction coupled with  extracapsular joint stabilization should be performed.  The primary goal of intra-articular surgery is to anatomically  and functionally  restore  the cranial cruciate.  A medial parapatellar approach will be used to visualize the joint.  Prior to reconstruction, the remnants of the cranial cruciate should be removed from the joint.  Even though no crepitus was noted on orthopedic exam, any meniscal damage should be assessed.  If damage is present, depending on severity, partial or total menisectomy is indicated duet o poor blood supply and subsequent compromised healing.  Once debridement of the joint is complete, it should be lavaged to clean out any loose debris.  An autogenous tissue graft will be passed through the intercondylar notch to mimic the course of the cranial cruciate ligament.  The lateral one third of the patella tendon and the distal fascia lata are placed in a predrilled tibial tunnel and pulled through the fat pad and under the intermensical ligament into the joint.  Make an incision through the femoral fabellar ligament and use forceps to pull the graft through the joint and over the top of the lateral condyle.  The tibial tunnel must enter the joint at a point that is caudal and inferior to the point where the normal cruciate ligament originated.  Widening of the intercondylar notch should be considered in order to allow adequate room for the tissue graft.  After the graft is passed over the top of the lateral condyle it is sutured in place to the femoral fabellar ligament, fibrous joint capsule, and the patella tendon.  Before closing the surgical site, be sure that a 2-3mm cranial drawer is present.  Completely eliminating the cranial drawer would place excessive tension within the graft.  Also, make sure the graft does not impinge any tissue between itself and the adjacent bone.  Impingement could potentially  cause reduced tissue perfusion and subsequent necrosis.  In extracapsular reconstruction, a double strand of heavy nonabsorbable suture is passed between the lateral fabella and femur to provide increased stability to the stifle.  The suture passes through the deep fascia surrounding the fabella and travels cranially and distally to a predrilled hole in the tibial crest.  Tying the suture will eliminate excessive tibial displacement  during weight bearing. 
	Pre-operative medications include Acepromazine and oxymorphone given for sedation and analgesia respectively.  They are administered subcutaneously approximately 30 minutes prior to surgery.  A second dose of oxymorphone is given at extubation to sustain analgesia through recovery.  Also, oxymorphone is administered post-operatively every 6-8 hours for the first 24 hours.  Five days worth Rimadyl, or Tylenol  with codeine if the Bonnie is particularly painful, should be sent home with the owner for continued analgesia.  Cefazolin is administered intravenously pre-operatively and post-operatively to help control potential contamination of  the surgical site.  Cephalexin should be given orally every 8 hours for 7 days after surgery.  Bonnie will also be sent home with a chondroprotective agent like Glycoflex that will promote long term joint health.
	Bonnie should remain in the hospital 24 hours after surgery for observation.  The left hind leg should be placed in a Robert Jones bandage for one week.  At the end of the first week, Bonnie should return to the hospital for bandage removal and incision inspection.  After another week, the sutures can be removed.  Throughout these two weeks, Bonnie should be kept in a crate  and only taken out for bathroom breaks. Therapeutic flexion and extension of the stifle joint should begin two days after surgery and be performed daily to maintain range of motion. Until swelling subsides, the leg should be iced several times a day for 20 minute increments.  Following this period, heat and massage should be applied to increase circulation to the joint and promote healing.  Leash walking and swimming with a gradual increase in the time and distance can be instituted over the 10 weeks following suture removal. 
	

Prognosis, post surgical management, other surgical techniques?, conservative management =bad, other leg might rupture

2 weeks crate, 10 weeks leash walking and swimming = increasing exercise, in crate when can't be supervised, range of motion therapy.