The purpose of this page is to explain the extracapsular lateral suture (ECLS) stabilization technique formerly used as a treatment for cranial cruciate ligament (CCL) rupture in dogs.
At The Hometown Veterinarian, we do not normally perform this technique. About 15 years ago, The Hometown Veterinarian owner, Dr. Jacobson stopped performing extracapsular lateral suture stabilizations after much better procedures came to exist. He had extensive experience, performing hundreds of these surgeries for over a decade and it was through that experience and the review of published clinical studies that led him (and most veterinary surgeons) to decide that ECLS should no longer be performed on dogs. While aspects of the procedure may have a place in providing temporary stability in certain situations, they just do not hold up when compared to modern alternatives such as TPLO or TTA and should no longer be considered appropriate first-line treatment of cruciate disease in dogs.
For general information about cranial cruciate ligament and disease in dogs, see our overview page: Cranial Cruciate Injury in Dogs
Cranial cruciate injury is easily the most common orthopedic problem in dogs and we offer information to help pet owners learn so that they can be fully informed if faced with the problem.
Extracapsular Lateral Suture Stabilization
What is extracapsular lateral suture stabilization surgery?
ECLS surgery is probably the oldest known method of surgically treating cranial cruciate rupture in dogs. The surgery's name comes from the method of repair where a suture or other heavy line is placed outside of the stifle's (knee's) joint capsule. The line is tightened with the intention of replacing the stability that the cranial cruciate ligament was meant to provide. There are several variations to the procedure but the suture line is usually tunneled through a channel drilled through the front of the tibia at the level of the shin and another on the lateral (outer) side of the end of the femur. Sometimes, the line might be passed between the fabella and the femur but studies have shown that many surgeries using that method failed to place the suture in the correct location and do not actually provide support. The line is then placed under tension and is either tied or secured with a metal crimp clamp.
What is the problem with lateral suture stabilization surgery?
In the 1990's, ECLS was what we had to help a dog with a ruptured cranial cruciate ligament, extracapsular stabilization surgery was considered state-of-the-art. We were aware of some flaws but there just wasn't anything better widely available at the time.
- Success requires exact placement of the implant but the anatomy of the area can often be misleading and many surgeons who thought they had the line positioned properly later found out that it was pulling free of the tissues that it was supposed to be locked through.
- Dogs take longer to return to function after ECLS surgery than a surgery like TTA.
- ECLS will eventually fail. The heavy lines used will not hold up to a lifetime in a dog. They fatigue and either break or will loosen enough to no longer provide support. The concept of the surgery accepted that the line would break but the hope was that there would be enough thickening of the joint tissues that the dog can walk. The problem is that once the support is gone, the dog will eventually return to painful lameness. This usually means a second (or even a third) surgery to help relieve the problem.
- Lateral suture joints continue to become arthritic. When ECLS surgery was our only option, we thought the progressive arthritis was just normal. With modern procedures such as TPLO and TTA, that progressive deterioration of the joint just doesn't commonly appear.
If my dog has ruptured a cranial cruciate ligament, is extracapsular lateral suture or TPLO better?
There is no question that ECLS is an inferior procedure. It is not that it was a bad idea, it's time has simply passed. TPLO (or TTA) will normally give a dog a faster recovery and is a better long-term solution to the problem of CCL rupture. With TPLO or TTA, once the bone is healed, it is healed. The implants are no longer being relied upon as a corrective measure. In the rare case that TPLO or TTA implants needed to be removed, the dog will do just fine because the repair is the new shape of the dog's own bone.
Does extracapsular lateral suture stabilization cost less?
The only advantage that ECLS has to procedures such as TPLO or TTA is the lower initial cost involved. The problem is that it should not be looked at as a "forever" solution. As stated above, within a few years, the implant will fail and most of those dogs are then left with an arthritic knee that needs more surgery. Additional surgeries are generally not straight forward and typically will cost much more than if TPLO or TTA had been performed in the first place.
Is extracapsular lateral suture stabilization fine in small dogs?
The concept that ECLS surgery is fine for small (or old) dogs has been debunked. Implants in small dogs will fatigue and fail just like they do in large dogs. All of the same joint problems seen in large dogs, such as painful arthritis, will happen to the small dog. In the past, there simply were not small TPLO or TTA implants so surgeons had to use what was available to them. At this time, both TPLO and TTA are successfully performed on toy breed dogs just as they are in large and giant breed dogs.
What if I cannot afford TPLO surgery right now?
In the United States, TPLO (and TTA) are considered "standard of care" for the treatment of CCL rupture in dogs. While ECLS surgery may have a lower up front cost, chances are very high that the dog will return to suffering from cruciate disease. This will likely mean additional surgery and the need for life-long pain relief. It might be tempting to go for the "cheap" option but strongly consider how much more affordable it is to repair a problem correctly the first time. Removal of broken extracapsular implants and osteotomy to support the cruciate rupture are a surgery that is not uncommon at our hospital.