Choosing A Surgeon

ACL Rupture Questions To Ask

Your pet has been diagnosed with a condition that needs surgery and your doctor has recommended either referring your pet to a surgeon or bringing in a mobile surgeon to perform the surgery at their hospital. The purpose of this handout is to help you choose a qualified surgeon as prices can vary tremendously from doctor to doctor. There are many different levels of expertise among those willing to perform surgery and many general practitioners who do not exclusively do surgeries may offer to do your pet's surgery, often times at a much reduced fee. It is important that you understand how to "comparison shop" when getting other opinions on your pet's condition and be an educated consumer. A good thing to remember is that "good medicine is usually not cheap and cheap medicine is not necessarily good." The most important thing to understand is the types of surgeons that are available.

General Practitioner

General Practitioner Surgeon

General practitioners have entered private practice immediately after graduating from a four year graduate program. Virtually all general practitioners (GP’s) perform surgery as part of their overall practice. Routine surgeries, like spays and neuters, declaws, laceration repairs, C-sections, bladder stones, tumor excisions, are basic surgeries that all veterinarians are trained to perform in veterinary college. No special skills are needed for these procedures beyond basic surgical skills.

General Practitioner with "Special Interest" in Surgery

Some GP's have a "special interest" in surgery and attend continuing education training to learn more advanced skills. They are competent in many orthopedic procedures like cruciate rupture repair, hernias, fractures, etc. Most have also invested in specialized equipment to perform these procedures.

Surgeons With Formal Advanced Training

Internship Trained with Extensive Continuing Education and Wet Labs

After four years of veterinary college, a small percentage of veterinarians continue their training with an internship for one year in small animal surgery and medicine. Internships do not “specialize” in anything except companion animal or large animal training. In addition to an internship, surgeons with this training usually continue their training via seminars, wet labs, and other programs specifically designed for surgeons. These would include topics like advanced bone plating, external fixator use, IM nail, total hip replacement, ACL repair, etc.

Residency Trained (Board Qualified)

After completing an internship, some veterinarians continue their training in a surgical residency that can last three to four years. You become “board qualified” after this training and are a candidate to take the exam for board certification.

Board Certified Surgeon (Specialist)

The term "ACVS Diplomate" refers to a veterinarian who has been board certified in veterinary surgery. Only veterinarians who have successfully completed the certification requirements of the ACVS are Diplomates of the American College of Veterinary Surgeons and have earned the right to be called specialists in veterinary surgery.

Veterinarians wishing to become board certified must complete a three-year residency program, meet specific training and caseload requirements, perform research and have their research published. This process is supervised by current ACVS Diplomates, ensuring consistency in training and adherence to high standards. Once the residency has been completed, the resident must sit for and pass a rigorous examination. Only then does the veterinarian earn the title of ACVS Diplomate.

Experience versus Credentials

Only you can decide how to decide between credentials and experience. Some non-boarded surgeons have been doing certain procedures for 25 years or more and have excellent technique and outcomes compared to their boarded counterparts who may have graduated recently and done fewer of the more common procedures. In addition, some surgeons have certain procedures that they are particularly good at, like ACL ruptures, neurosurgery (slipped discs), fracture repair, or soft tissue surgery. For example, Dr. Karen Tobias at the University of Tennessee has done more liver shunt surgeries than anyone else in the world. Dr. Marcellin at University of North Carolina has done more hip replacement surgeries than almost any other surgeon in the world

The Shouldice Hospital outside Toronta is a group of surgeons who specialize in hernia repairs. They have the shortest surgical time and least percentage of recurrence. All they do are hernia repairs and not one of them is a board certified surgeon. Why go through all that training to learn all aspects of surgery when all they do is hernia repairs?

Some non-boarded surgeons who do the same type of surgery over and over again are very accomplished at what they do and have similar outcomes to their boarded counterparts. Be wary of anyone who calls themselves a "surgical specialist" without clearly declaring whether they are boarded or not. Boarded surgeons are highly trained and qualified and no one should be "masquerading" as a boarded surgeon when they are not. All boarded surgeons will have the designation DACVS after their name.

Here are some important questions to ask anyone offering to do surgery on your pet:

  1. Are you a board qualified or certified surgeon?
  2. Did you complete any advanced training?
  3. Which procedure will you be doing on my pet? (See handout Cruciate Surgery Options)
  4. How many of these procedures have you done?
  5. How long have you been doing this procedure?
  6. What complications have you had and in what percent of the cases?
  7. Do you run a pre-anesthetic blood test to screen for underlying conditions?
  8. Do you wear a cap, mask and gown during surgery?
  9. Will my pet have an IV catheter and fluids during surgery?
  10. Do you give intravenous antibiotics for the surgery and if so, before, during or after?
  11. Will my pet be on a warming blanket or fluid warmer during surgery? (Electric heating pads can malfunction and burn your pet)
  12. Do you monitor my pet while they under anesthesia with pulse ox, CO2, ECG, blood pressure and temperature? (Blood pressure and CO2 are the most sensitive to anesthetic problems that can arise and many veterinarians do not have these expensive monitors)
  13. What pain management do you utilize? Do you offer epidurals with morphine?

Since anterior cruciate repair surgery is the number one rear leg injury that surgeons encounter, here are some additional questions to ask when getting a second opinion for ACL repair surgery.

  1. Are you using nylon or Fiberwire for your repairs? (Nylon stretches and breaks and many specialists are now using Fiberwire which does neither.)
  2. Where are you drilling the hole in the tibia, in the tibial tuberosity or under Gerdy's tubercle? (Gerdy's tubercle is the new position for the hole as the old location was not isometric and led to suture stretching and breakage and loss of range of motion.)
  3. Are you doing an arthrotomy to check the meniscus, check the synovium, and clean out the torn ligament? (Some surgeons cut costs by just placing the suture outside the joint not inspecting the joint, which is critical to success.)
  4. Will you inspect the synovium for inflammation and biopsy it if necessary to rule out immune mediated synovitis?
  5. Are you performing a meniscal release? (This can prevent future meniscal tears but also increases post-operative osteoarthritis)
  6. Do you have specialized equipment like a stifle retractor, meniscal mini-blade (6400), meniscal clamp, and tensioning device if using medical grade fishing line?
  7. Do you do an epidural with preservative free morphine before surgery to help control pain?
  8. Do you dissect away the biceps femoris muscle before placing the suture around the fabella bone? (Not doing this entraps muscle in the suture which causes loosening post-operatively.)
  9. Do you remove any osteophytes that may have formed? (Many surgeons believe this helps the tissues glide smoothly over the joint by removing them and it is done in people.)
  10. Do you utilize magnification and head lamps to improve visualization of the inside of the joint during surgery?
  11. Do you offer physical therapy after surgery?
  12. Do you have a go home handout for me with detailed home care?
  13. How well are your patients using the leg at suture removal in ten to fourteen days? (Most should be minimally weight bearing by this time)

As you can see, there are many different factors in repairing a cruciate rupture. These questions do not apply to the TPLO surgery which has been shown in many studies to have twice as many complications as the suture technique and identical outcome at six months. TPLO should only be considered in very large, athletic pets but even then, the newer suture technique with Fiberwire has excellent outcomes in all size patients and is significantly less expensive. For patients over 55lbs, a new technique developed by Dr. Jimi Cook at University of Missouri called Tightrope is showing amazing results. I have been doing Tightrope surgery since March of 2008 with excellent outcomes in patients up to 200lbs. I do not recommend or offer "bone cutting" techniques like TPLO or TTA.

Since studies have shown that most of the twenty two (22) techniques available for cruciate rupture have identical outcomes at six months, you should focus on cost and complications as well as how quickly they return to function. Additionally, for agility or working dogs, long term osteoarthritis must be considered and TPLO and Tightrope seem to have the best outcome for minimal OA.

Please feel free to call me if you have any questions.