Letters to the Editor

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Surgical versus nonsurgical treatment of cranial cruciate ligament rupture in dogs

The recent report by von Pfeil et al1 provides results of a cross-sectional survey of Veterinary Orthopedic Society members regarding their preferences for surgical treatment of cranial cruciate ligament rupture in dogs weighing > 15 kg (33 lb). Although the study achieved its stated objective, it notably did not assess respondents’ attitudes toward nonsurgical treatment options for such dogs.

The report reminded me of a similar situation involving human patients with moderate to severe knee osteoarthritis. For years, total knee replacement was considered so obviously successful for these patients that there was no need for a randomized, controlled trial comparing total knee replacement with nonsurgical treatment and that any such trial would merely be a “parachute trial” (ie, the equivalent of a trial testing whether parachutes save the lives of people who jump out of airplanes2). In 2015, however, Skou et al3 reported results of just such a randomized, controlled trial comparing results for patients who underwent total knee replacement followed by 12 weeks of nonsurgical treatment with patients who received only 12 weeks of nonsurgical treatment. On average, the surgical treatment group had better outcomes after 12 months, compared with the nonsurgical treatment group. However, clinically relevant improvements were also seen in the nonsurgical treatment group, underscoring that patients should be provided counseling on the relative efficacy and risks of both options.

A similar study by Wucherer et al4 demonstrated, for overweight dogs with cranial cruciate ligament rupture, better outcomes following a combination of surgical (tibial plateau leveling osteotomy) and nonsurgical (physical therapy, weight loss, and NSAID administration) treatment than following nonsurgical treatment alone. However, nearly two-thirds of the dogs in the nonsurgical treatment group had a successful outcome after 1 year, suggesting that a nonsurgical approach might be a valid option for many dogs with cranial cruciate ligament rupture.

Although the results of the study by von Pfeil et al1 are interesting, it would also be interesting to survey Veterinary Orthopedic Society members for their opinions on effectiveness of and preferences and indications for nonsurgical treatment of cranial cruciate ligament rupture in dogs and whether they consider surgical treatment so obviously successful that a randomized, controlled trial comparing surgical and nonsurgical treatments would only be a “parachute trial.”

William Rogers, dvm

Pleasant Plain, Ohio

  • 1. von Pfeil DJF, Kowaleski MP, Glassman M, et al. Results of a survey of Veterinary Orthopedic Society members on the preferred method for treating cranial cruciate ligament rupture in dogs weighing more than 15 kg (33 pounds). J Am Vet Med Assoc 2018;253:586597.

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  • 2. Katz JN. Parachutes and preferences—a trail of knee replacement. N Engl J Med 2015;373:16681669.

  • 3. Skou ST, Roos EM, Laursen MB, et al. A randomized, controlled trial of total knee replacement. N Engl J Med 2015;373:15971606.

  • 4. Wucherer KL, Conzemius MG, Evans R, et al. Short-term and long-term outcomes for overweight dogs with cranial cruciate ligament rupture treated surgically or nonsurgically. J Am Vet Med Assoc 2013;242:13641372.

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The authors respond:

We thank Dr. Rogers for his letter concerning our study.1 The main objective of our work was to determine which method was preferred when surgical treatment has been selected for large-breed dogs with cranial cruciate ligament rupture (CCLR). In contrast, Dr. Rogers questions whether nonsurgical treatment should be pursued and suggests a survey of Veterinary Orthopedic Society members on the topic of surgical versus nonsurgical treatment. However, such a survey has already been performed, gathering results from 305 diplomates of the American College of Veterinary Surgeons and 1,145 primary care veterinarians.2 Nonsurgical treatment was recommended by < 6% of respondents, regardless of the patient's body weight (9.1 kg [20 lb] vs 27.2 kg [60 lb]).

These results only supported what has long been reported in the literature.3,4 For example, the study by Vasseur4 found that lameness persisted in 46 of 57 (81%) dogs weighing ≥ 15 kg (33 lb) that underwent nonsurgical treatment (ie, activity restriction, weight loss, and analgesic administration) of CCLR. Importantly, 73% of dogs in that study4 had severe meniscal injuries and degenerative joint disease at the time of final follow-up, both of which are painful conditions.

Unfortunately, a wide range of factors may force owners to not pursue surgical treatment for dogs with CCLR. In these instances, we support the recommendation of physical rehabilitation and supportive treatment. Wucherer et al5 did indeed report some success with nonsurgical treatment in such dogs. However, in their study, a “successful outcome” was defined, among other things, as a ≥ 10% improvement in questionnaire variables, meaning that dogs with possibly only 11% improvement were counted as a success. In contrast, patients that underwent surgical treatment had greater improvements in questionnaire scores and results of force-plate analysis and a higher probability of a successful outcome, compared with patients that underwent nonsurgical treatment.

Finally, approximately 50% of dogs with unilateral CCLR develop contralateral CCLR within 1 to 2 years.6 Dogs with bilateral CCLR may not be able to ambulate, which can lead to pressure sores, extreme discomfort, pain, and a poor quality of life. Therefore, surgical treatment is typically recommended for heavier dogs with unilateral CCLR.

Given the available published literature, we firmly believe that surgery is recommended for dogs with CCLR and that another survey on nonsurgical treatment is not needed at this time.

Dirsko J. F. von Pfeil, dr med vet

Mathieu Glassman, vmd

Friendship Surgical Specialists Friendship Hospital for Animals Washington, DC

Michael P. Kowaleski, dvm

Department of Clinical Sciences Cummings School of Veterinary Medicine Tufts University North Grafton, Mass

Loïc M. Dejardin, dvm

Department of Small Animal Clinical Sciences College of Veterinary Medicine Michigan State University East Lansing, Mich

  • 1. von Pfeil DJF, Kowaleski MP, Glassman M, et al. Results of a survey of Veterinary Orthopedic Society members on the preferred method for treating cranial cruciate ligament rupture in dogs weighing more than 15 kg (33 pounds). J Am Vet Med Assoc 2018;253:586597.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2. Duerr FM, Martin KW, Rishniw M, et al. Treatment of canine cranial cruciate ligament disease. A survey of ACVS diplomates and primary care veterinarians. Vet Comp Orthop Traumatol 2014;27:478483.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3. Pond MJ, Campbell JR. The canine stifle joint. I. Rupture of the anterior cruciate ligament. An assessment of conservative and surgical treatment. J Small Anim Pract 1972;13:110.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4. Vasseur PB. Clinical results following nonoperative management for rupture of the cranial cruciate ligament in dogs. Vet Surg 1984;13:243246.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5. Wucherer KL, Conzemius MG, Evans R, et al. Short-term and long-term outcomes for overweight dogs with cranial cruciate ligament rupture treated surgically or nonsurgically. J Am Vet Med Assoc 2013;242:13641372.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6. von Pfeil DJ, Sung J, Barry J, et al. Effect of doxycycline on contralateral canine cranial cruciate ligament rupture. A prospective randomized clinical trial in 69 dogs. Vet Comp Orthop Traumatol 2015;28:371378.

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Additional thoughts on debt and tuition

The Association of American Veterinary Medical Colleges (AAVMC) shares Dr. Care's concerns about the high cost of tuition at veterinary medical colleges in the United States.1 I want to point out, however, that this is an issue affecting all of higher education, not just veterinary medical colleges, and that many factors affect the cost of veterinary medical college tuition.

Importantly, tuition costs are set by university administrators, not by veterinary college deans, and the cost of education at American universities has risen much faster than the rate of inflation, largely because of increased administrative and personnel costs.2 There has been a substantial decrease in public funding for higher education over the past several decades, which has resulted in a shifting of the cost of education from the public to students and their families. In addition, providing a veterinary medical education is more expensive than providing most other types of education because of the high costs of maintaining training facilities such as laboratories and teaching hospitals; recruiting and retaining highly trained, board-certified faculty; and providing the high quality of academic programming required to meet the rigorous standards of accreditation.

Not surprisingly, tuition at veterinary medical colleges is not substantially different from tuition at medical colleges. Mean tuition and fees for first-year medical students at public universities for the 2017–18 school year was $30,958 for residents and $54,631 for nonresidents,3 compared with $26,354 for residents and $51,064 for nonresidents at public veterinary medical colleges.4

Similarly, educational indebtedness for veterinary medical graduates is not substantially different from that for medical students. Mean debt for 2017 medical school graduates with debt was $190,694,5 compared with a mean debt of $156,315 for 2017 veterinary medical school graduates with debt.4 The big difference, of course, is in salary. The Bureau of Labor Statistics reported that the annual mean wage in 2017 for physicians and surgeons was $214,700 but was $101,530 for veterinarians.6

Most of the factors affecting the cost of tuition, educational debt, and salaries are outside the control of the veterinary medical colleges. However, we are working diligently on the things we can control, such as raising endowments for scholarships. Nearly half of all students now receive some level of financial aid, and at some schools, the percentage is 100%.4

The Veterinary Debt Initiative is aimed at helping veterinarians thrive in financially sustainable and rewarding careers. The AAVMC and its member institutions are committed to providing the highest quality of education that will prepare students for a wide range of careers to meet societal needs.

Andrew T. Maccabe, dvm, mph, jd

Chief Executive Officer Association of American Veterinary Medical Colleges Washington, DC

Beyond reality

I read with interest the recent JAVMA News story1 on novel uses of augmented and virtual reality in veterinary medicine. I wholeheartedly agree that 3-D reconstructions may help veterinarians and veterinary students better appreciate and understand anatomy and anatomic abnormalities and am pleased to see this topic presented at the AVMA annual conference and covered in JAVMA.

In the story, Scott Birch, CEO of Pixelbreaker, is quoted as saying that he “wish[es] there were more applications for veterinary medicine that [he] could show” and lamenting that “[t]hey just don't exist yet.” Although it is true that these types of model applications are uncommon in veterinary medicine, Ivala Learn has been producing exactly the kinds of 3-D models that Mr. Birch describes for the past 3 years. In addition, a recent study2 at the Ross University School of Veterinary Medicine found that students who supplemented their anatomic learning with these models performed significantly better on subsequent anatomy examinations than did students who did not. This imaging library is available free to veterinary students and as part of membership through a partnership with the Veterinary Information Network. Ivala continues to develop additional content to augment veterinary education and professional development.

I anticipate that these types of computer-assisted technologies will become commonplace in veterinary education and clinical decision-making in the near future and look forward to continuing to contribute to these educational and clinical advancements.

Taimur Alavi, bvsc, bsc

Ivala Learn

  • 1. Augmented, virtual reality can help veterinarians see more. J Am Vet Med Assoc 2018;253:824825.

  • 2. Little WB, Artemiou E, Conan A, et al. Computer assisted learning: assessment of the veterinary virtual anatomy education software Ivala. Vet Sci 2018;5. .

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  • 1. von Pfeil DJF, Kowaleski MP, Glassman M, et al. Results of a survey of Veterinary Orthopedic Society members on the preferred method for treating cranial cruciate ligament rupture in dogs weighing more than 15 kg (33 pounds). J Am Vet Med Assoc 2018;253:586597.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2. Katz JN. Parachutes and preferences—a trail of knee replacement. N Engl J Med 2015;373:16681669.

  • 3. Skou ST, Roos EM, Laursen MB, et al. A randomized, controlled trial of total knee replacement. N Engl J Med 2015;373:15971606.

  • 4. Wucherer KL, Conzemius MG, Evans R, et al. Short-term and long-term outcomes for overweight dogs with cranial cruciate ligament rupture treated surgically or nonsurgically. J Am Vet Med Assoc 2013;242:13641372.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 1. von Pfeil DJF, Kowaleski MP, Glassman M, et al. Results of a survey of Veterinary Orthopedic Society members on the preferred method for treating cranial cruciate ligament rupture in dogs weighing more than 15 kg (33 pounds). J Am Vet Med Assoc 2018;253:586597.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2. Duerr FM, Martin KW, Rishniw M, et al. Treatment of canine cranial cruciate ligament disease. A survey of ACVS diplomates and primary care veterinarians. Vet Comp Orthop Traumatol 2014;27:478483.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3. Pond MJ, Campbell JR. The canine stifle joint. I. Rupture of the anterior cruciate ligament. An assessment of conservative and surgical treatment. J Small Anim Pract 1972;13:110.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4. Vasseur PB. Clinical results following nonoperative management for rupture of the cranial cruciate ligament in dogs. Vet Surg 1984;13:243246.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5. Wucherer KL, Conzemius MG, Evans R, et al. Short-term and long-term outcomes for overweight dogs with cranial cruciate ligament rupture treated surgically or nonsurgically. J Am Vet Med Assoc 2013;242:13641372.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6. von Pfeil DJ, Sung J, Barry J, et al. Effect of doxycycline on contralateral canine cranial cruciate ligament rupture. A prospective randomized clinical trial in 69 dogs. Vet Comp Orthop Traumatol 2015;28:371378.

    • Search Google Scholar
    • Export Citation
  • 1. Care D. Debt and tuition (lett). J Am Vet Med Assoc 2018;253:702.

  • 2. Ripley A. Why is college in America so expensive? The Atlantic. Available at: theatlantic.com/education/archive/2018/09/why-is-college-so-expensive-in-america/569884/. Accessed Oct 2, 2018.

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  • 3. Association of American Medical Colleges. Tuition and student fees. Available at: aamc.org/data/tuitionandstudentfees/. Accessed Oct 2, 2018.

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  • 4. Association of American Veterinary Medical Colleges. AAVMC public data. Available at: aavmc.org/about-aavmc/public-data. Accessed Oct 2, 2018.

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  • 5. Association of American Medical Colleges. Medical student education: debt, costs, and loan repayment fact card. Available at: members.aamc.org/iweb/upload/2017%20Debt%20Fact%20Card.pdf. Accessed Oct 2, 2018.

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  • 6. Bureau of Labor Statistics. May 2017 national occupational employment and wage estimates, United States. Available at: bls.gov/oes/current/oes_nat.htm. Accessed Oct 2, 2018.

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  • 1. Augmented, virtual reality can help veterinarians see more. J Am Vet Med Assoc 2018;253:824825.

  • 2. Little WB, Artemiou E, Conan A, et al. Computer assisted learning: assessment of the veterinary virtual anatomy education software Ivala. Vet Sci 2018;5. .

    • Crossref
    • Search Google Scholar
    • Export Citation

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