CCL Injuries Extracapsular Repair: My Two Cents on the Lateral Suture Stabilization or LSS in Dogs

The extracapsular repair or LSS is the oldest surgical technique in use for the treatment of dog CCL tears.

The procedure comes under several names. Along with the terms I already introduced, if your veterinarian refers to a traditional technique, or external capsular repair technique (ECLS), they are all the same thing. Different surgeons might use various modifications of the technique.

CCL Injuries Extracapsular Repair: My Two Cents on the Lateral Suture Stabilization or LSS in Dogs

Understanding the extracapsular repair

The goal of all the stifle surgeries is to stabilize the knee.

The extracapsular repair achieves this by running an external suture outside the knee capsule—hence extracapsular. At the top, the suture runs around the bony protrusion of the femur; at the bottom through a small hole drilled in the tibia.

As long as the suture holds, this is enough to prevent the forward thrust of the shinbone—drawer motion. You can think of it as an external ligament replacement of sorts. The placement and angle of the suture mimic the function of the cruciate ligament.

The suture secures things in place long enough for scar tissue to encapsulate the knee. The scar tissue is what ultimately provides stabilization after the recovery period.

While it looks rather flimsy, it can do the job quite well. It does mean, however, that the post-op period is more vulnerable to setbacks when the suture stretches or breaks.

Dog CCL Injuries Extracapsular Repair: Lateral Suture Stabilization
Traditional suture technique. Image Helping Hands

Advantages of extracapsular repair technique

The first distinct advantage of this technique is that it is substantially less invasive than, for example, the TPLO surgery. That was what we liked about it when Jasmine ruptured her cruciate ligament.

Further, the suture technique doesn’t require any specialized equipment. That makes it more affordable and general practice veterinarians can perform this surgery in their clinic.

Dog CCL injuries extracapsular repair disadvantages

The reasons veterinary surgeons went on to explore other options to repair cruciate ligament tears is that the suture is nowhere near as strong as the original ligament.

The post-op recovery time requires strict exercise restrictions and control. Overall, this repair is more vulnerable to failure and less forgiving should a mishap occur.

This is especially true for active young and large-breed dogs. Small breed dogs usually make it through the recovery without complications.

Extracapsular repair complications

Swelling, bruising, seromas, and incision issues are not unusual—typically minor—complication with any surgery. Infections can become a big deal if they affect the joint or bone but not common at this time and age.

What can happen with this technique is sutures breaking before enough scar tissue develops to stabilize the joint. Clearly, even the strongest suture is not as strong as a metal implant and the post-op recovery is relatively more vulnerable to setbacks.

On the other hand, busted sutures, while not welcome, aren’t the end of the world. Compare that to busted plates and even fractured bones that you could run into with say TPLO.

While the TPLO can take more beating and is less likely to fail, when it does it can be substantially more dramatic. As well as even after the recovery period is over, there is the potential of the dog developing an infection at the implant site.

Recovery period

The recovery period after the extracapsular repair is six months—the same as with TPLO. It is, however, less forgiving—preventing mishaps is essential.

Your surgeon should provide you with a detailed post-op plan as well as recommendations for physical therapy. The larger and more active your dog is, the more you need to control their activity.

Example post-op plan: L Surgery Post-Op Care: Example Plan for Your Dog’s Recovery after Cruciate Ligament Surgery

Recovery expectations

Your dog will be reluctant to use the leg for roughly two weeks after surgery and might continue to hop on three legs just as before the procedure. However, eventually they will start toe-touching and gradually increase the amount of weight they’ll bear on the leg. By two months your dog should walk on the leg normally.

Here is the good news. When you make it through the recovery period, your dog’s knee will be just as good as it would be with any other surgical technique.

A study that scrutinized the different surgeries and outcomes a year post-surgery. didn’t find any difference including large-breed dogs.

For larger dogs, there is great controversy. For all the theory behind TPLO and TTA, results one year post-operative seem to be the same regardless of which of the three procedures the dog had performed.

Dr. Wendy Brooks, DVM

Large versus small dog breeds

Most veterinarians recommend using the extracapsular repair only for dogs under 45 pounds. Is it a bad idea for a large dog?

It depends. After much debating and sweating it, we selected this technique for our Rottweiler, Jasmine. She had the surgery on both knees—three months apart. We made it through both post-ops with just one minor setback. Jasmine’s knees healed, and she regained normal function.

I just couldn’t stand the idea of the invasive TPLO for her. She was older and we had confidence we’d be able to control her activity well enough to make it. Should we fail, we still had the TPLO option to fall back on.

Jasmine’s veterinarian did extracapsular on many large dogs with success.

That said, I doubt we’d have the same luck with our wilder Rottweilers. It is important to evaluate what the odds are for each individual dog.

Extracapsular Repair Failure

Any of the CCL surgeries can fail during the recovery time quite easily. That is why strict post-operative care is important. If the joint is subjected to too much stress too early, things fall apart. One unfortunate jump of the couch can be all that is needed.

One of the reasons we opted for the extracapsular repair was, that the worst-case scenario seemed to be starting from square one, should something go wrong. It is the least invasive option from the three.

If the repair does fail and the sutures break, you have some soul searching to do.

Unless the reason for the failure was an accident that is not likely to happen again, you might want to consider one of the other surgeries, TPLO or TTA. The recovery time after TPLO and TTA is a bit shorter and not as strict. Keep in mind that every surgery requires a diligent rehabilitation though and things can go wrong with either of the ACL repairs.

In closing

For small dogs, there is no clear advantage to opting for the newer, more invasive procedures.

If you have a large or very active dog, you need to consider your options carefully. The newer surgeries are relatively more forgiving and there is some evidence that recovery to normal function may be faster.

I even heard a veterinary opinion that the reason TPLO is touted as a superior option is the surgeons’ propensity for shiny tools.

It’s up to you to research all options and figure out which one is best suited for your dog. We did select the suture repair for Jasmine but with JD or Cookie, I’d consider the risk of broken sutures too high.

Related articles:
Tibial Plateau Leveling Osteotomy: My Two Cents on TPLO Repair
Cora-based Leveling Osteotomy: My Two Cents on (CBLO) Repair
Triple Tibial Osteotomy: My Two Cents on TTO Cruciate Repair
Simitri Stable in Stride Stabilization

Further reading:
Cranial Cruciate Ligament Repair: Extracapsular Repair and TightRope Procedure
Ruptured Cranial Cruciate Ligaments in Dogs

Categories: CCL injuriesCruciate ligament injuriesDog health advocacyExtracapsular repairJoint issuesKnee issuesLateral suture stabilization (LSS)

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Jana Rade

I am a graphic designer, dog health advocate, writer, and author. Jasmine, the Rottweiler of my life, was the largest female from her litter. We thought we were getting a healthy dog. Getting a puppy from a backyard breeder was our first mistake. Countless veterinary visits without a diagnosis or useful treatment later, I realized that I had to take Jasmine's health care in my own hands. I learned the hard way that merely seeing a vet is not always enough. There is more to finding a good vet than finding the closest clinic down the street. And, sadly, there is more to advocating for your dog's health than visiting a veterinarian. It should be enough, but it often is not. With Jasmine, it took five years to get a diagnosis. Unfortunately, other problems had snowballed for that in the meantime. Jasmine's health challenges became a crash course in understanding dog health issues and how to go about getting a proper diagnosis and treatment. I had to learn, and I had to learn fast. Helping others through my challenges and experience has become my mission and Jasmine's legacy. I now try to help people how to recognize and understand signs of illness in their dogs, how to work with their veterinarian, and when to seek a second opinion. My goal is to save others the steep curve of having to learn things the hard way as I did. That is the mission behind my blog and behind my writing. That is why I wrote Symptoms to Watch for in Your Dog, which has turned out being an award-winning guide to dog owners. What I'm trying to share encompasses 20 years of experience.

  1. Thanks for sharing this experience, really helpful. I wonder how Jasmine is doing now? My GSD just had lateral suture. He’s 36 kg but we did not have the choice of TPLO or TTA (we live in Kenya, no such procedure exists). I’m a bit worried that the suture will not hold, although we try to be very careful. When you say post-op care, do you mean the 3 or 6 month restrictive movement?

    • Being careful is essential. Jasmine has passed since but the repair held for the rest of her life–four years. Once the knees heal up, the repair is as reliable as TPLO or any other techniques. Which means that all you have to do is to get through the post-op and you get a home run.

      Your veterinarian/surgeon should have provided a detailed post-op plan to follow. The restrictions, of course, are gradually reduced. Here is an example of what such post-op plan looks like:

      Don’t forget physical therapy.

  2. We have had to deal with a few leg injuries with our larger dogs in the past. While it is great that there are so many options available to help our hurt pets, it can be very confusing to understand.

    As always you take complicated medical procedures and make them easier to understand.


  3. I have not had to deal with knee injuries in any of my dogs yet (only my own torn ligaments and meniscus). I would always consider the less invasive option first. Glad it worked for Jasmine.

  4. This sounds like a great option for dogs that are having knee issues. I like that it is a less invasive option than the others. While you may need a more invasive surgery, it always seems that the least amount you can do to solve the problem is the best.

  5. It is sad to think that a vet would recommend a more invasive option because of surgeons’ propensity for shiny tools. This is good information that should be really helpful for anyone considering either surgery for their dog.

  6. This was an interesting read. I’ve never had a dog with this type of injury, so I’ve never had to dig into the repair options. That being said, I always love learning more about different medical procedures before it becomes necessary… You never know when you’re going to have to deal with moving forward as a dog parent!

    • Yes, while risking failure, we went with the least invasive option. Originally we were thinking regenerative therapy but her partial tear went to full tear before we could have done that.

      • our dog is 42 pounds, 5 year old border collie mix, having real reservations about the TPLO….cost, invasiveness, complications. Tough call for us, since our dog is on the on the edge of the weight limit
        for lateral suture.

  7. Interesting, I’d probably opt for the least invasive option. But I guess that’s not always the real right answer.

    • It is always a balance between noninvasive/safe and effective. While this repair worked for Jasmine, I doubt it would work for JD or Cookie.

  8. I’d never heard of cruciate ligament tears so this was very interesting. I appreciated the way you explained the treatment in a clear way that I could understand.

  9. Great post as always, an eye opener for me as I never think about dog injuries with Layla as she is aging and only walks, does not run or play but good to know

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