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Complications in
Canine Cranial
Cruciate Ligament
Surgery
Complications in
Canine Cranial
Cruciate Ligament
Surgery
Edited by

Ron Ben‐Amotz, DVM, MS, CCRP,

DACVS-SA, DECVS
Koret School of Veterinary Medicine
Jerusalem, Israel

David L. Dycus, DVM, MS, CCRP,

DACVS-SA
Nexus Veterinary Bone & Joint Center
Baltimore, United States
This edition first published 2022
© 2022 ACVS Foundation
This work is a co-publication between the American College of Veterinary Surgeons Foundation and Wiley-Blackwell.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form
or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how
to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.
The right of Ron Ben‐Amotz and David L. Dycus to be identified as the authors of the editorial material in this work has
been asserted in accordance with law.
Registered Office
John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA
Editorial Office
111 River Street, Hoboken, NJ 07030, USA
For details of our global editorial offices, customer services, and more information about Wiley products visit us at
www.wiley.com.
Wiley also publishes its books in a variety of electronic formats and by print‐on‐demand. Some content that appears in
standard print versions of this book may not be available in other formats.
Limit of Liability/Disclaimer of Warranty
The contents of this work are intended to further general scientific research, understanding, and discussion only and are
not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by
physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental
regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is
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or device for, among other things, any changes in the instructions or indication of usage and for added warnings
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Library of Congress Cataloging-in-Publication Data
Names: Ben-Amotz, Ron, editor. | Dycus, David L., 1983- editor. | American
College of Veterinary Surgeons, issuing body.
Title: Complications in canine cranial cruciate ligament surgery / edited
by Ron Ben-Amotz, David L. Dycus.
Other titles: Advances in veterinary surgery
Description: First edition. | Hoboken, NJ : Wiley-Blackwell ; [Germantown,
Md.] : American College of Veterinary Surgeons, 2022. | Series: Advances
in veterinary surgery | Includes index.
Identifiers: LCCN 2021028940 (print) | LCCN 2021028941 (ebook) | ISBN
9781119654377 (hardback) | ISBN 9781119654391 (Adobe PDF) | ISBN
9781119654346 (epub)
Subjects: MESH: Anterior Cruciate Ligament Injuries–surgery | Dog
Diseases–surgery | Intraoperative Complications–veterinary | Anterior
Cruciate Ligament Injuries–veterinary | Rupture–surgery |
Intraoperative Complications–therapy
Classification: LCC SF991 (print) | LCC SF991 (ebook) | NLM SF 992.J64 |
DDC 636.7/089747–dc23
LC record available at https://lccn.loc.gov/2021028940
LC ebook record available at https://lccn.loc.gov/2021028941
Cover Design: Wiley
Cover Image: © Ron Ben-Amotz and David L. Dycus
Set in 9.5/11.5pt Palatino by Straive, Pondicherry, India

10 9 8 7 6 5 4 3 2 1
Contents

List of Contributors vii 5 Complications Associated

with Proximal ­Tibial Epiphysiodesis 61
Prefaceix
Aldo Vezzoni, Joshua S. Zuckerman,
Forewordxi and Ron Ben‐Amotz
Acknowledgmentsxiii
III Extraarticular Repair
Disclosuresxv Techniques 85
I Introduction 1 6 Extracapsular Stabilization Using
Synthetic Material 87
1 Pathology, Diagnosis, and Treatment Ian G. Holsworth
Goals of Cranial Cruciate Ligament
­Rupture and Defining Complications 3 7 Complications Associated with
David L. Dycus, Jeffery Biskup, Michael G. ­Extracapsular Stabilization Using
Conzemius, and Ron Ben‐Amotz Monofilament Material 109
R. Randy Basinger
2 Surgeon and Patient Preparation to
­Minimize Surgical Site Complications 8 Complications Associated with
and ­Infection Surveillance Programs 15 ­Extracapsular Stabilization using
Katie L. Hoddinott, J. Scott Weese, ­Multifilament Material 121
and Ameet Singh Matt Corse and Ian G. Holsworth

3 Identification, Addressing, and

IV Osteotomy Repair Techniques 145
­Following Up on Surgical Site I­ nfection
After Cranial Cruciate Ligament
9 Complications Associated with
­Stabilization 33
Cranial Closing Wedge Osteotomy 147
Katie L. Hoddinott, J. Scott Weese,
Bill Oxley
and Ameet Singh
10 Complications Associated with Tibial
II Intraarticular Repair ­Plateau Leveling Osteotomy 163
Techniques 43 Ron Ben‐Amotz and Joshua S. Zuckerman

4 Complications Associated with 11 Complications Associated with

Intraarticular Repair Techniques 45 CORA‐Based Leveling Osteotomy 189
Jeffery Biskup and Michael G. Conzemius David L. Dycus and Don Hulse

v
vi Contents

12 Complications Associated with Tibial VI Adjunctive Information 261

Tuberosity Advancement 199
Matthew D. Barnhart 16 Complications Associated with Feline
Cranial Cruciate Ligament Techniques 263
13 Complications Associated with the Sorrel J. Langley-Hobbs and
Modified Maquet Technique 217 Eva Schnabl‐Feichter
Marc H. Balligand
17 Complications Associated with
V Nonsurgical Management and Arthroscopic Evaluation of the Stifle
Physical Rehabilitation 235 and Decision Making 287
Brian S. Beale, Stephen C. Jones,
14 Complications Associated with Stifle and Selena Tinga
Orthotics 237
Bryan T. Torres and Steven C. Budsberg 18 Complications Associated with the
Meniscus and Decision Making 307
15 Complications from Cranial ­Cruciate Stephen C. Jones, Selena Tinga, and
Ligament Surgery: Rehabilitation Brian S. Beale
­Considerations 247
Matthew W. Brunke, David Levine, David L. Index327
Dycus, and Denis J. Marcellin‐Little
List of Contributors

Marc H. Balligand, DMedVet, PhD, CertSAO, Matthew W. Brunke, DVM, CCRP, CVPP,
Diplomate ECVS CVA, Diplomate ACVSMR
Full Professor and Head Medical Director,
Small Animal Surgery Service Veterinary Surgical Centers Rehabilitation
Faculty of Veterinary Medicine, Vienna, VA, USA
University of Liège
Liège, Belgium Steven C. Budsberg, DVM, MS, Diplomate,
ACVS
Matthew D. Barnhart, DVM, MS, Diplomate
Professor of Orthopedics
ACVS
College of Veterinary Medicine
Surgery Specialty Leader
University of Georgia
MedVet Medical & Cancer Centers for Pets
Athens, GA, USA
Worthington, OH, USA

R. Randy Basinger, DVM, Diplomate ACVS Michael G. Conzemius, DVM, PhD,

VetSurg LLC Diplomate ACVS
Irmo, SC, USA Endowed Professor of Surgery
Veterinary Clinical Sciences
Brian S. Beale, DVM, Diplomate ACVS University of Minnesota
ACVS Founding Fellow Minimally‐Invasive St Paul, MN, USA
Surgery (Orthopedics)
CEO and Surgeon
Matt Corse, DVM, MS, Diplomate, ACVS
Beale’s Best LLC
Chief of Orthopedic Surgery
Beale Veterinary Specialists and Emergency
Northlake Veterinary Surgery
Victoria, TX, USA
Clarkston, GA, USA
Ron Ben‐Amotz, DVM, MS, CCRP,
Diplomate ACVS, ECVS David L. Dycus, DVM, MS, CCRP, Diplomate
Section Head, Small Animal Orthopedics ACVS
Koret School of Veterinary Medicine Chief of Orthopedic Surgery
Lecturer, The Hebrew University of Jerusalem Nexus Veterinary Bone & Joint Center
Jerusalem, Israel Medical Director
Nexus Veterinary Specialists
Jeffery Biskup, DVM, Diplomate ACVS Co‐Founder/Co‐Director
Small Animal Surgeon Veterinary Sports Medicine and Rehabilitation
Animal Health Partners Institute (VSMRI)
North York, ON, Canada Baltimore, MD, USA

vii
viii List of Contributors

Katie L. Hoddinott, BSc, DVM, DVSc, Bill Oxley, MA, VetMB, DSAS(Orth), MRCVS
Diplomate ACVS Director Vet3D
Assistant Professor, Small Animal Surgery Billy’s Space
Atlantic Veterinary College, University of Staveley, UK
Prince Edward Island
Charlottetown, PE, Canada Eva Schnabl‐Feichter, Diplomate ECVS
Team Leader Small Animal Orthopedics
Ian G. Holsworth, BSc, BVSc, MANZCVS Department for Companion Animals and Horses
(Surgery), Diplomate ACVS University Clinic for Small Animal Surgery
ACVS Founding Fellow Minimally‐Invasive University of Veterinary Medicine
Surgery (Orthopedics) Vienna, Austria
Director
VetSurg
Ameet Singh, DVM, DVSc, Diplomate ACVS
Ventura, CA, USA
Associate Professor
Don Hulse, DVM, Diplomate ACVS, ECVS Ontario Veterinary College
Professor of Orthopedics University of Guelph
College of Veterinary Medicine Guelph, ON, Canada
Texas A&M University
College Station, TX, USA Selena Tinga, DVM, PhD, Diplomate ACVS
Assistant Professor
Stephen C. Jones, MVB, MS, Diplomate Veterinary Clinical Sciences
ACVS, ECVS The Ohio State University
Assistant Professor Small Animal Surgery Columbus, OH, USA
College of Veterinary Medicine
The Ohio State University Bryan T. Torres, DVM, PhD, Diplomate
Columbus, OH, USA ACVS, ACVSMR
Assistant Professor
Sorrel J. Langley‐Hobbs, MA, BVetMed,
Orthopedic Surgery – Small Animal
DSAS(O), Diplomate ECVS, FHEA, FRCVS
Director of the Motion Analysis Laboratory
Chair in Small Animal Orthopaedic Surgery
Department of Veterinary Medicine and Surgery
RCVS Specialist in Small Animal Surgery
College of Veterinary Medicine
(Orthopedics)
University of Missouri
EBVS® European Specialist in Small Animal
Columbia, MO, USA
Surgery
Bristol Vet School, University of Bristol
Bristol, UK Aldo Vezzoni, med. vet., S.C.M.P.A.,
Diplolmate ECVS
EBVS® European Specialist in
David Levine, PT, PhD, DPT, CCRP, FAPTA
Small Animal Surgery
Professor and Walter M. Cline Chair of
Clinica Veterinaria Vezzoni srl
Excellence in Physical Therapy
Cremona, Italy
Department of Physical Therapy
The University of Tennessee at Chattanooga
Chattanooga, TN, USA J. Scott Weese, DVM, DVSc, Diplomate
Veterinary Care and Specialty Group, ACVIM, FCAHS
Chattanooga, TN, USA Professor, Ontario Veterinary College
Director, Centre for Public Health and Zoonoses
Denis J. Marcellin‐Little, DEDV, Diplomate University of Guelph
ACVS, ACVSMR Guelph, ON, Canada
Professor, Orthopedic Surgery
Department of Veterinary Surgical and Joshua S. Zuckerman, VMD, Diplomate ACVS
Radiological Sciences Staff Surgeon
University of California, Davis Cape Cod Veterinary Specialists
Davis, CA, USA Buzzards Bay, MA, USA
Preface

The American College of Veterinary and prevention of complications in c­ ranial cru-

Surgeons Foundation is excited to present ciate surgery. We are sure you will find this ref-
Complications in Cranial Cruciate Ligament erence extremely valuable.
Surgery in the book series entitled Advances The ACVS Foundation is an independently
in Veterinary Surgery. Cranial cruciate liga- chartered philanthropic organization devoted
ment repair is likely the most common to advancing the educational, scientific, and
orthopedic surgery performed on dogs and charitable goals of the American College of
a book dedicated to the complications of the Veterinary Surgeons. The mission of the ACVS
procedures we use is appropriate. My sage Foundation is to support the advancement of
mentors taught me that complications are surgical care of all animals through funding of
an unfortunate part of surgery and our duty educational and research opportunities for vet-
is to own them, manage them to get the best erinary surgical residents and board‐certified
possible outcome for our patients, and learn veterinary surgeons.
from them to minimize the chance of future The ACVS Foundation’s collaboration with
complications. As one of the key missions of Wiley Blackwell benefits all those who are inter-
the ACVS Foundation is to promote cutting‐ ested in veterinary surgery by presenting the
edge education for diplomates, this topic is latest evidence‐based information on relevant
timely and very reflective of the educational surgical topics. The ACVS Foundation is proud
mission of the Foundation. to partner with Wiley Blackwell in this impor-
Complications in Cranial Cruciate Ligament tant series and is honored to present this newest
Surgery is edited by Drs Ron Ben‐Amotz and book in the Advances in Veterinary Surgery series.
David L. Dycus. I’d like to congratulate and
thank them for taking on this project. They R. Randy Basinger, DVM, ACVS
have chosen a group of strong contributing Chair, Board of Trustees
authors to detail the identification, ­management, ACVS Foundation

ix
Foreword

I have tremendous respect and gratitude chapter answers the question, “What do I do
towards Drs Dycus and Ben‐Amotz for taking now?” so that readers are provided with deci-
on the challenge of putting together this book sion‐making algorithms, tools, and techniques to
as a vital resource for veterinarians who want address complications, both intraoperatively and
to treat patients and educate clients in the most postoperatively, and to know when and how to
optimal and comprehensive way possible. revise cases in order to rescue the outcome. This
While a book project is always daunting, it is text is well written and well illustrated such that
relatively easy to write about “when things go the knowledge provided is readily applied to
right,” but extremely difficult to write about “real‐life” clinical practice.
“when things go wrong” as the authors and Again, I sincerely compliment the editors
editors have done for this valuable text. and the authors on their valuable effort, which
Speaking from experience, the latter is much has resulted in a rich resource for everyone
more important, so I highly recommend that involved in the care of dogs with cranial cruci-
every veterinarian involved in preoperative, ate ligament disease. I hope that veterinarians
intraoperative, and/or postoperative care of of all experience levels will take advantage of
dogs being treated for cranial cruciate ligament this resource by taking it to heart and using the
disease adds this book to their daily‐use library. same evidence‐based approach put forth in this
Acknowledging and understanding complica- book in their delivery of care to patients and
tions are the keys to avoiding them, and this all‐ honest communication with clients.
star line‐up of experienced authors communicates
these keys in a comprehensive and transparent James L. Cook, DVM, PhD
way that is refreshing and inspiring. Importantly, William and Kathryn Allen Distinguished
the editors and authors committed themselves to Chair of Orthopedic Surgery
an evidence‐based approach to each and every Director, Thompson Laboratory for
chapter such that information provided is both Regenerative Orthopaedics
reliable and pragmatic. Equally importantly, each University of Missouri

xi
Acknowledgments

To err is human – an existence and experience owe many thanks to former resident‐mates, who
marred by miscalculation and misjudgment. endured the initial training with me, and to my
Errors infiltrate every aspect of our existence, current and former students and residents who
including our professional lives. As surgeons, ensure that my knowledge base remains sharp
we carry a greater burden than most, operating and up to date. Of course, that knowledge
daily with the knowledge that our errors may wouldn’t even be there without the help of my
be catastrophic. mentors and professors, all of whom contributed
The idea for this book arose from an unre- in unique and unforgettable ways, and the AO
warding reference search. We all know that com- community, who welcomed me as a young fac-
plications occur, and that countless publications ulty member, and whose members tirelessly
exist in which these complications are described work to advance our chosen field. In particular, I
in detail. But my question was this: what hap- owe special thanks to Dr Jonathan Dyce, who
pens next? In particular, I noted a surprising lack pushed my boundaries and expected nothing
of answers to this question even with regard to less than excellence and perfection in return, Dr
the surgical treatment of canine cruciate liga- Robert Orsher, who has been invaluable in his
ment disease, one of the most common orthope- support of my professional aspirations, and Dr
dic problems we routinely address. It was then Joshua Zuckerman, who enthusiastically accom-
that I began to realize that providing these panies me on my writing expeditions.
answers in an accessible format would serve not I would like to express my most sincere
only our residents, novice surgeons, and general thanks to the distinguished authors who con-
practitioners, but the entire surgical community. tributed an incalculable wealth of knowledge
As David and I embarked on the mission of and experience to this textbook. All of your
editing this book, I was continuously reminded dedication and hard work resonates within
of Benjamin Franklin’s quote: “by failing to these pages. Thank you as well to the ACVS
­prepare, you are preparing to fail.” Not only Foundation for their endorsement and belief in
must we prepare for every surgery we perform, this project, and to Merryl Le Roux and Erica
we must also know how to face our mistakes Judisch from Wiley Blackwell, without whom it
when things do not go according to plan. could never have become a reality.
Understanding and, more importantly, acknowl- I am indebted to my parents, Gadi and Lia,
edging our mistakes is the key to avoiding them who have supported me along every step of my
in the future. We must have the courage and education and career. They taught me the
humility to admit when things go wrong before importance of hard work, compassion, perse-
we can attain the wisdom to correct them. verance, dedication, and honesty. To my sister
Without the dedicated support and encourage- Dana and my brother Oded, I am grateful for
ment of those who have joined me on this jour- their belief that I can overcome every hurdle
ney, I could never have become who I am today. I encountered along the way.

xiii
xiv Acknowledgments

The true dedication of this book belongs to my today without the help of many mentors, col-
beloved wife Shir‐Raz, who sacrificed everything leagues, interns, residents, and general practi-
so I could fulfill my dreams. She tirelessly sup- tioners. It is the collection of everyone that has
ported my goals, traveled the world with me, and shaped me and helped me grow. Mentors have
never gave up on me. Without her I would not be pushed me, taught me, and helped me when I
who I am or where I am today. Finally, to my beau- was struggling. There are far too many to list
tiful children Shai, Yoni, and Gali, who remind me here; however, a special thank you to Dr Ron
every day what is really important in life. McLaughlin who from my first year in veteri-
And of course, to our canine and feline com- nary school to the last day of my surgical resi-
panions, who bring joy to our lives. We owe dency instilled in me the desire to achieve
them our compassion, professional dedication, perfection and laid the groundwork for me to
and love. get to where I am today. In addition, the words
given to me by Dr Don Hulse to “make it bet-
Ron Ben‐Amotz ter” have never been truer. His advice to never
stop learning and keep thinking outside the box
We as surgeons always want the best for our have helped evolve my desire to always keep
patients, and when we put the scalpel to the pushing forward to help our patients.
skin should be prepared to provide that. As Dr However, the book is truly dedicated to my
Atul Gawande has stated, “No matter what wife Brooke and daughter Kennedy. Without
measures are taken, doctors will sometimes fal- both of them I am nothing. My hope is that as
ter, and it isn’t reasonable to ask that we achieve my daughter grows older, she understands the
perfection. What is reasonable is to ask that we work ethic I have tried to instill in her and recog-
never cease to aim for it.” I remember back in nizes the commitment that I have put forth in
2018 when Dr Ben‐Amotz approached me about the veterinary industry. I hope she takes these
an idea for a book dedicated to complications things to become a successful woman who is
for a particular disease condition. Recognizing able to critically think for herself and is always
the commonality of cruciate ligament disease in striving to make the world a better place. For
veterinary medicine and the vast array of proce- Brooke, who has been with me since day one;
dures led to the birth of this textbook. We real- she is my rock, best friend, and partner. There is
ized that stabilization techniques are briefly no way I would have survived veterinary school,
taught in veterinary school, and in‐depth train- internship, residency, private practice, perform-
ing comes in the form of a formal surgical resi- ing research, and teaching without her. She has
dency. However, the majority of individuals “held the fort” for all the years of me working
learn these techniques through mentorship in late at night, traveling, and working through the
practice or through continuing education. As an weekends. For this I owe her a debt of gratitude.
instructor for courses that teach stabilization In addition, a special thank you to my parents,
techniques, it became apparent that we were Don and Vickie, who instilled in me to be the
teaching individuals how to perform the proce- best I can be in whatever I do. While hard at
dure but lacking on the preparation for mini- times, I was taught the value of hard work and a
mizing complications, identifying intraoperative strong worth ethic. The principles, values, and
complications, and how to recognize and morals they taught me set me up to succeed not
address postoperative complications. My hope only as a veterinarian but also as a human.
is this textbook serves to fill in those gaps. Finally, no veterinarian would be able to do
Many thanks are due to Erica Judisch, and what we do without our patients and their
various editors from Wiley Blackwell, for sup- owners. Recognizing the bond that animals
porting us in the development of this book. bring to our lives helps inspire all veterinary
They were supportive from the conception of professionals to do our best. Animals bring out
this book and through the entire process. In the best in all of us and we certainly don’t
addition, a thank you is due to the ACVS deserve them, so being able to help them in a
Foundation for supporting the book series as time of need is one of the most humbling and
well as believing in the need for this book. wonderful experiences.
I still consider myself a young and develop-
ing surgeon and I would not be where I am David L. Dycus
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