Management Plan

	Most surgeons do not advise waiting 8 weeks in large dogs 
because fewer of them will show clinical improvement and because 
degenerative joint disease can occur more rapidly in joints 
carrying a lot of weight.  Since Bonnie is a large dog and we have 
the necessary equipment and surgical skill at the VMRCVM we would 
use the intra-capsular reconstruction known as "Under and Over." 
In this procedure a graft made up of the lateral third of the 
patellar tendon and a strip of fascia lata is positioned to mimic 
the function of the torn cranial cruciate ligament.  The remnants 
of the actual ligament are removed.  The graft is first drawn 
through the fat pad, under the intermeniscal ligament and into the 
joint space.  From there a second set of forceps draws it between 
the femoral condyles and behind the fabella.  A screw and spiked 
washer are placed in the femur.  The graft is then passed around 
the screw, pulled tight, and the screw tightened.  The graft is 
sutured to itself after passing around the screw.  The incision is 
closed, and a Robert Jones bandage is applied for the first week.  
Bonnie should be confined to a crate for the first 2 weeks post-
operatively.  A week after surgery the bandage is removed and the 
incision checked.  After another week the sutures are removed and 
a program of controlled leash walking and swimming if available is 
begun.  The level of activity is gradually increased from 6 to 12 
weeks post operatively until normal activity levels are achieved 
at 12 weeks.  If there is any irritation as a result of the screw 
in the femur it can be removed 6 months after the original 
surgery.

Another high priority in managing this case is weight reduction.  
Bonnie is severely obese and the extra weight carried by her 
joints will eventually lead to even more trauma to the presently 
affected joint and to others. No weight is actually given in the 
case, but by looking at her she looks to be somewhere between 85 
and 95 pounds.  A more ideal weight for her is probably around 70 
lbs.  We would try to achieve this weight by feeding the daily 
calories required for the resting energy requirement at this 
weight.  This is calculated through the formula 70(BW)^0.75 where 
BW is the bodyweight in kg.  In Bonnie's case for an ideal weight 
of 70 lbs this would be around 940 kcal/day.  Her original diet 
contained almost 1500 kcal/day.  We will also feed a food 
formulated for weight loss such as Hills W/D so that she can still 
get her required nutrients even though she will be consuming a 
lower number of calories per day.  If she shows signs of hunger on 
the W/D she can be switched to R/D, which is even less calorie 
dense, so she would be able to consume a higher volume that would 
help her feel fuller.  The recommended amount of W/D is 4 cups per 
day, the same as her previous food, and the recommended amount of 
R/D is 4.6 cups per day.  Many dogs will clinically improve after 
being put on a weight loss regimen.  However most of these dogs 
continue to develop degenerative joint disease, so even in the 
absence of clinical signs surgery is still advisable to prevent 
the eventual loss of joint function.