Why would a vet recommend surgery if that's not right for Fido?
---- Isn't it best to trust the vet?
"Just close your eyes and trust the doctor" is seldom a good approach to 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.
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.
"...But the vet was so confident that Fido needs surgery..."
All doctors, including vets, know that their clients will put more faith in a doctor who presents his conclusions
confidently. So doctors state their opinions as though those opinions are solid facts. But the history of medical treatment
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.
What Supports The Vet's Claim That Your
Dog Requires Surgery For His Ligament Injury?
Let me begin answering this question by answering the related question "What would we prefer to see
supporting any treatment recommendation?"
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 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 dog ligament injury treatment. There are vets who recommend all
the various treatment options, but none of them can point to a Class I or II research study that backs up their opinion.
If there is no Class I or II research, 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."
---- Please see the page 'But the vet said...' here at this website
for more on the nature of these Class III & IV articles.
(Left column navigation bar)
What Influences Vets To Prefer Surgical Approaches?
The training which student vets
receive about dogs' ligament injury treatment is largely based on the opinions of instructor-surgeons at their university.
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 something
surgeon-instructor Bluster was wrong about. Many dogs can recover very well after ligament injury without surgery.
Other Factors May Influence
A Vet To Recommend Immediate Surgery
Vets often tell me that dogs' people want them to treat their dogs' injuries aggressively. They say
many clients would not be 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. After a surgical procedure has been done, clients will take restriction seriously. But if there
has been no surgery, then 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".
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. A vet today is likely to leave university & begin practice
with a substantial student loan debt of several hundred thousand dollars, on top of which are the day-to-day costs of his/her
practice and personal expenses. Vets need to have money coming in, and they make very little money by telling a client
to carefully restrict the dog & be patient. 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.
Once we recognize that vets have a personal financial
interest in their treatment recommendations, we can see that what is best for the dog is not necessarily
what is best for the vet. You want your dog to have whatever treatment is best for the dog, but the vet makes his money
by selling treatment. If no treatment is needed, or a less costly treatment would be better, the vet would decrease
his income by advocating what is best for your dog.
---- People admire and trust vets, and want to think of vets
as being morally above letting self-interest influence treatment recommendations. Certainly there are vets who are above
reproach, but should we assume all vets are? Could it be true that some vets are betraying their duty in this way?
Are substantial numbers of vets increasing their profits by selling inappropriate treatment? Is there a way to tell
if that is the case? Yes there is. One clear and simple widespread example of abuse of the trust placed in
vets is that many vets recommend yearly vaccinations to dog owners in spite of the fact that we have known for a number
of years that yearly vaccinations are not needed and are potentially harmful. Vets do this because convincing dog owners
that annual vaccinations are needed will get many dogs into their offices where the vet can charge for exams and
recommend other treatments. Vaccines themselves cost the vet a few cents each and bring in a large percentage profit
per dog on large numbers of dogs. This is not a complicated situation where the need for a treatment is uncertain.
We know for a fact that annual vaccinations are undesirable, and we know that many vets know this and recommend them anyway.
So there is no doubt that these vets knowingly go against the best interests of their clients' dogs to increase profits.
Are these vets and other vets capable of recommending questionable surgeries in order to increase their profits? Yes,
Make no mistake: Veterinary service is a business. These are not non-profit outreach programs
staffed by saints. A primary goal of any business is making money. In the veterinary services business,
there are many instances where making money for the vet coincides with your dog's best interests. But there are
other situations where unneeded services are recommended and sold to people who want the best for their dogs and trust medical
professionals more than they should.
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 activity 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
---- 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
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".
a vet telling you that immediate surgery prevents or reduces future arthritic problems?
---- Horsefeathers! Not True!
see the page 'Arthritis Risk?' here at this website
Some dogs who have surgery have serious complications.
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.
What results are really obtained with surgery?
---- Vets who are promoting surgery may mislead clients by saying or implying
that the surgery they sell will almost certainly result in the dogs' return to pre-injury function. They
may 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.
"An article in...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 than 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.
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 very many dogs have recovered 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. ..."
--- Ron Hines DVM PhD
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. ..."
Here is a quote
from highly respected vet & author
Doctor Mike Richards
"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
A Short Allegory
Picture this: It's 5000 years ago and we're living in a small agricultural village.
We depend on our grain crops and we're worried. It has been a very dry season and the crop needs water badly.
We beat our drums & sing & pray to the rain god all night every night asking for rain. After a week of singing
and dancing and praying, it rains!! The rain god must have answered our prayers for rain, right? -----
Well, no. It just rained without divine intervention and our singing & dancing & praying didn't matter
at all. It's human nature to look for cause and effect in the world. And we find it. Sometimes we find it
when it isn't really there.
---- In cases where ligament surgery is done, often the
surgeon gets credit for success after the long recuperation when in fact the dog would have recovered from the ligament injury
just as well or better without the surgery. The dog actually recovers in spite of the surgery, rather than because of it.
When you read or hear someone who is convinced that surgery was the cause of her dog's recovery
from a ligament injury, ask yourself "How could she know the dog would not have recovered without the surgery?"