Management Plan

	Since Bonnie is an overweight, large breed dog we are suggesting a 
surgical repair 
of her cranial cruciate ligament rather than attempting conservative therapy.  
In order to 
improve her chances of a full recovery from the procedure we recommend that she 
be put 
on a rather intensive weight loss regimen for 1-3 months prior to when her 
surgery is 
scheduled, but no longer than 5-6 months.  We believe the "green bean diet" will 
help her 
lose weight quickly and safely and therefore reduce the strain placed on her 
fragile joint.  
The owner would need to replace one cup of Bonnie's food with one can of green 
beans.  
Once she gets used to the diet change another 1/2 to one cup of food may be 
replaced by the 
appropriate amount of green beans.  

	During this time frame Bonnie does need to be managed by the appropriate 
analgesic regimen.  Either aspirin, phenylbutazone, or Rimadyl may be dosed to 
effect to 
relieve most of her pain, but still leave her aware of her injury.  This will 
help her self-limit 
her activity.  The owner must also be certain to limit Bonnie's activity to 
short lease walks 
only to prevent further injury either due to playing by herself in the backyard 
or from 
excessive activity.  Use of stairs should be discouraged thereby restricting 
Bonnie to one 
floor of the house.  This is especially important when she's left unsupervised.  
It may also 
be helpful to crate Bonnie while the owner is away.

	When it is time to perform surgery we may or may not refer Bonnie to an 
orthopedic specialist, depending on the surgical expertise of the veterinarians 
in our 
practice.  There are many different surgical repair techniques for cranial 
cruciate ligaments.  
We have chosen to perform an intra-capsular reconstruction versus an extra-
capsular 
technique based on the perceived complications and success rates.  The intra-
capsular 
techniques are regarded as the better choice for large dogs and have 
consistently high 
success rates.  
With the under and over intra-capsular technique a fascial graft is used to 
replace the 
damaged 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.  This 
procedure is done using a lateral parapatella approach is used to collect the 
tensor fascia lata 
graft.  Then via lateral arthrotomy, the graft is looped through the joint and 
then fastened 
around a screw in the femur, under a spiked washer, and pulled tight while 
tightened down 
the screw.  Also, the end of the graft is sutured to itself around the screw.  
If no screws are 
available, the fascial graft can be sutured to the femorofabella ligament.
Postoperatively, the stifle will have minimal inherent strength until six weeks 
after 
repair because the joint is dependent on the strength of the graft alone.

	At this time, it is important to visualize both menisci to make sure they 
are intact.  If there are any fragments or tears, they should be removed.  It 
might also be wise, if possible, to visualize all of the other support 
structures to make sure they have not been compromised.  If any have been 
damaged they should be fixed at the time of surgery.

Bonnie will need 
strict confinement to a cage or crate for about 10 days.  During this period, 
scar tissue will 
form, strengthening the joint.  This will continue throughout her recovery 
allowing her to 
return to normal function.  Therefore, two weeks postoperatively a controlled 
exercise 
program can be initiated, which would incorporate leash walking and swimming.  
Twelve 
weeks after surgery she should be able to return to normal function, and the 
screw and 
washer can be removed six months after the surgery.  Her weight lose regimen and 
analgesic therapy should be continued as needed.

After surgery analgesia will be continued as appropriate to BonnieŐs progress.  
She should continue the green bean diet until her optimal weight is achieved 
(determined by BCS), and then gradually change to a high quality low calorie 
diet (HillŐs maintenance light).

Prognosis for Bonnie's condition is good to excellent depending upon several 
factors:  client expectation, obesity, exercise, the ease and success of the 
surgery, and the 
dog's attitude.  In general, all intra-capsular techniques have a consistently 
high success 
rate of 78-95%.