Vet School 101 Walking the TightRope on cruciate repairs

Got a pet with a cruciate ligament injury? Well then, get ready, I’m armed with information and opinions.

This time it’s not about the injury itself or specifically about the cost of its repair (check out parts one and two of this series for more info). No, this post is about the new pup on the block, the so-called TightRope technique for cranial cruciate ligament repairs (“cruciates” for short)––with some money-oriented considerations thrown in out of necessity.

In case you’re not super tuned-in to the happenings on the surgical side of veterinary medicine, here’s the skinny:

Cranial cruciate ligament injuries are a common problem in the canine knee. It can happen suddenly, but more often it’s a slow burn kind of injury that occurs as the ligament degrades over time.

Often, owners have no idea their pet has a problem since pets are masterful at occulting their discomfort. In fact, it’s typical for me to have to “prove it” by asking owners to feel the "thicker" knee for themselves, compare it to the other, and observe the amount of loss of muscle on the affected side.

The cranial cruciate ligament is a critical structure that plays an indispensable role in stabilizing the knee joint. It’s injury leads to destabilization of the joint and its inevitable descent into osteoarthritis––that is, unless surgery is undertaken.

The surgical approaches to this problem are as numerous, varied and debated as climate change and natural selection. Sure, there’s science...but then there’s the very human element of surgical talent, price, personal opinion and an almost-religious adherence to some technologies over others.

To make it simple, you can think of the most common cruciate techniques as falling into two major categories.

1-The TPLO (tibial plateau leveling osteotomy), or one of a variety of other leveling osteotomy procedures, is the surgery most board certified surgeons recommend for dogs weighing in at over 25 pounds.

This procedure involves the placement of a metal plate at the knee. It’s goal is to closely replicate the natural position of the joint so as to limit the abnormal mechanical stresses caused by a destabilizing injury.

Sounds great. Lots of hard science backing it, too. Problem? It’s expensive. At $2,000 to $5,000 a knee, it can be a hard sell for pet owners when less expensive procedures are available. Furthermore, its use requires a certification process, making it less accessible to general practitioners.

2-The extracapsular repair is perhaps the still most widely performed surgery for cruciate ligament injuries. Its the one even board certified surgeons tend to perform on smaller dogs (and cats). And its lower price-tag ($750 to $2,000) makes it more attractive to owners who might not be able to afford the board-certified surgeon’s best advice. Moreover, it’s an orthopedic procedure many general practitioners are willing and able to perform.

The goal of this procedure is to mimic the ligamentous integrity of the knee by passing a strong suture material through two tunnels in the adjacent bone.

The trouble with extracapsular repairs is that while they may mimic the injured ligament, they can’t offer the same concessions to mechanical integrity that the TPLO and its variants do. The knee is never as stable as with the TPLO, say TPLO proponents––unless, that is, we’re talking about a smaller dog (or cat).

The extracapsular repair is not so hard to do as the TPLO, but, as many boarded surgeons like to say...it’s hard to do well.

That’s why a new entry into the cruciate surgery market is making a big splash. The TightRope device, marketed by surgical equipment manufacturer Arthrex, promises to make extracapsular repairs more stable, more minimally invasive and more foolproof.

Consisting of strong bone anchors and a super-strong, braided polyethylene band, the TightRope device has become so popular that it’s become synonymous with the procedure itself. Surgeons I’ve surveyed, however, urge caution in the face of popularity: It’s not a new procedure at all, they say, it’s more like a “new and improved” version of an extracapsular that may not be so “improved.”

If my read of the online surgical community’s consensus holds, the TightRope might be a great device for the same candidates who were formerly excellent subjects for exctracapsular repairs (cats and smaller dogs), but the TightRope is not a surefire fix for most cruciates that ail us.

That’s because the TightRope, like other extracapsular repairs, does not limit the shearing forces that affect the unstable knee like the TPLO is designed to do. Therefore for larger breeds, it’s faulty by design, some say. This anti-TightRope camp proposes that its implementation in larger breed dogs is equally ineffective as any other extracapsular repair.

In other words, the TightRope may well be a swan...but it’s still in the duck family. And at a higher pricetag (add another $250-$750 for the TightRope version of the extracapsular repair)...is it really worth it?

Moreover, though the TightRope is touted as minimally invasive, it requires three bone tunnels instead of two and three incisions instead of one. Though the incisions are meant to be smaller, the ones I’ve seen online don’t measure up to my local surgeons’ smallish TPLO cuts. (The yellow lines below indicate skin incisions.)

And yet there’s no doubt that the TightRope’s new twist on and old stand-by is at least that––a novel approach––one that deserves the test of time to see whether it will truly make a difference over other extracapsular repairs...or maybe even measure up to the TPLO for large breed dogs (though most surgeons strongly doubt this latter possibility).

The sad truth is that while a tremendous amount of research has gone into the study of this common injury and its surgical repair, studies evaluating the outcomes of surgical treatment are still lacking. Does it make a difference which procedure we choose? The degree of surgical skill employed? Which size or conformation of pet is treated?

The answer is likely to be yes on all three fronts. But the degree of importance of each of these factors is missing from our knowledge base. And then there’s the issue of price: At what price is the TPLO repair too much? Is it worth the hefty price differential to have a boarded surgeon perform a repair (whatever your choice of procedures) rather than your general practitioner?

If cruciate injuries in dogs will continue to occur, unabated (as we expect them to), and if we don’t determine all of the answers to the above questions, then veterinarians like me will still have to make recommendations based on theoretical knowledge, our own observations and recommendations from those who know better than we.

Since that’s the case I’ll parrot the surgical community I respect and urge caution should you choose to walk the TightRope. Novelty and innovation are necessary in veterinary medicine, but with what we know today, I would still expect your large and giant breed dogs to receive a board-certified recommendation for TPLO.

If you do choose an extracapsular or its TightRope varietal just be sure your veterinarian can answer all your questions and offers significant cruciate experience (mo’ experience is always mo’ better). And remember, regardless of what anyone might say, a board-certified surgeon is always best––regardless of what you can or can’t afford.

March 2nd, 2009

Add Comment74 Comments

Wonderful post. Simply wonderful

Gina Spadafori March 2nd, 2009 08:26:44 AM

My pit bull had a bilateral TPLO about two years ago. Both my vet and my surgeon nixed the extracapsular repair for her. They both said it would only be a temporary fix and that I would most probably see her go back under the knife within a couple of years if I went that route. People think I'm crazy to have spent $5k on knee surgery for my dog when the less expensive option was out there but my question to them was "Is it really less expensive if chances are so high that I'll have her back in the surgeon's office to be done again?" This is one of those cases where cheaper does not equal better.

Kristie March 2nd, 2009 08:33:29 AM

Fascinating, and I love the pictures! I noted that recommendation of TPLO is for canines over 25 lbs. , what is typical treatment for smaller dogs?

I have been lucky to not ever have to consider this surgery and/or injury, even with the few large dogs I've had and the new agility sport, where this seems to sometimes cause this injury.

I'm still curious as to the difference (or none) to a luxating patella repair?

Barb Albright/NH

Pocket's Story from NH March 2nd, 2009 09:06:23 AM

Sorry Barb, should've been more specific, perhaps: extracapsulars tend to be employed in smaller breed dogs, but it all depends on conformation, body condition score, degree of injury, etc. In many cases surgeons will recommend TPLOs for even 10-15 pound dogs. Similarly, some breeds over 25 pounds can do well with extracapsulars. The cutoff isn't always so strict, as so many factors come into play.

Dr. Patty Khuly March 2nd, 2009 09:28:42 AM

I had a retriever with bilateral cruciate injuries and was able to successfully rehab one using conservative management and had a variation of the extracapsular surgery done on the other. This is a timely post for me as I have a 10 pound dog right now that I suspect has a torn cruciate. Thank you.

YesBiscuit March 2nd, 2009 10:49:28 AM

I had not heard of this one. Interesting.

We did bilateral TPLO on our lab-greyhound mix when he was nearly 4. He is 9 now. It was absolutely the right decision for us. And, we did use a board-certified surgeon. Not cheap.

I blogged about it recently, including photos from the scope, showing the blown ligaments, and x-rays.

Roxanne @ Champion of My Heart March 2nd, 2009 11:07:30 AM

Wasn't/isn't there a grafting procedure used as well?

JenniferJ March 2nd, 2009 11:21:30 AM

JenniferJ: I'm sure someone is trying grafting-style procedures on dogs since they're commonly used for repairing ACLs (the human version of the CCL). But it's not among the typical choices, I can assure you.

Dr. Patty Khuly March 2nd, 2009 11:53:37 AM

Here, Jennifer, is a link to a bit I found in a 2005 Atlas of orthopedic surgery. It's apparently more common than I thought. I'll get back to you on what my surgeon references say about this approach.

Dr. Patty Khuly March 2nd, 2009 11:57:12 AM

I was sure it was around, I am 98% certain that it's what we had done with our first cruciate rupture, 15 years ago.

She recovered beautifully, I would assume in part due to the fact the injury which was sudden/traumatic and fixed within days and mostly due to the fact that it was done by a frankly amazing surgeon.

The two we've had to do since were both TPLOs, performed by the, same surgeon. One essentially perfect recovery, one very decent recovery on a dog with congenitally not so great knees to begin with.

JenniferJ March 2nd, 2009 01:22:41 PM

I had an extracapsular repair done on one of my pit bull girl's knees, and a TTA on the other. The TTA was a FAR FAR better option. Recovery time was so much shorter, and her knee is great. The extra-capsular repair? Not so much. I know it's not stable even though she didn't have drawer even under full anesthesia (I had her TTA surgeon feel the knee when she was out for her TTA because it was giving her problems). She's lame on it if she runs hard and it's got a big knob on the inside.

Katie March 2nd, 2009 02:19:22 PM

Katie, If your girl is still lame on the knee that had the extracapsular repair, and has no drawer under GA, she might be lame on it for a number of reasons: 1) it's overtightened (this is one of the main drawbacks of extracapsular repair, it puts the joint into compression) 2) the knots or crimps (most surgeons these use crimps to secure the thread but I daresay some old fashioned types still knot) may be causing soft irritation 3) some animals get secondary meniscal injury (cartilage damage) which can occur regardless of whether has had surgery or not. Meniscal damage seems to occur more commonly if they don't have surgery, but surgery does not guarantee dogs won't get meniscal injury later on. If still lame, I'd get her checked out. In my experience, extracapsular repair does not suit active dogs as well as they are more likely to pull up a bit sore after intense activity. That said, it can suit inactive, quiet dogs well. Grafting does not seem to have the same success rates in dogs as it does in humans. This is probably because cruciates in dogs are degenerative in nature, rather than purely traumatic. Sure, the event associated with onset of lameness may be a minor trauma such as jumping, playing, but often the ligament has been breaking down for some time. Which is why 50% of dogs with cruciate rupture go on to do the other one within 12 months. It's also probably the reason why grafting has poor success rates in dogs and why we have to resort to seemingly more radical methods including cutting bone (like the TPLO).

AlexH March 2nd, 2009 02:43:09 PM

My Rottweiller had Tplo surgery last june cost was 4,000 i have ins.for both my dogs ins.co.paid 3,000 and the monthly premiums cost 38.00.it is well worth having ins.My Rotie is doing so well running,swimming and so happy.my vet said he could do the other procedure,but he did not recomend for a big dog.i am glad i listened,it it so great to see her happy and pain free.Alena

alena March 2nd, 2009 03:50:48 PM

"Sure, the event associated with onset of lameness may be a minor trauma such as jumping, playing, but often the ligament has been breaking down for some time. Which is why 50% of dogs with cruciate rupture go on to do the other one within 12 months."

I have had one dog with the degenerative form of cruciate disease, it's why we opted for an extracapsulare "repair" of the knee that had not yet failed when he had his TPLO.

The other two cruciate injuries in my dogs were indeed traumatic and there was nothing minor about it. The first, "Grizzi" who had a graft done, was a four year old bitch who was home with a five year old bitch she had always gotten along very well with. My son fell ill and we were delayed getting home for about six hours. Sometime in there, they decided to declare full blown war on each other, blood everywhere, ears shredded, multiple puncture wounds. Both were severely bruised and chewed about the neck and shoulders with deep punctures in their axilla and inside front legs. There's no doubt that this was a serious serious fight, they were never able to left alone together and it took a fair bit of persuasion to get them to behave at other times around one another. We surmise that either a stray cat or coyote coming up to the big window in our dining room set them off and someone bit some one and well, there you go. Both were always fine around other dogs, most cats, any human being before and after. This was personal.

It was no surprise that Grizzi was on three legs with a swollen knee, She was half the other girls size. It's a miracle no one died. I can only assume on all the violent twisting, ripping and shaking that must have gone on (both girls had large areas of skin separated from the underlying tissues, drain city for the next three weeks), her knee was hyperextended or pushed violently sideways while she had her foot dug in for bracing.

The other trauma was a 22 pound fox terrier who belonged to my husband. He put him in the car for a drive and got distracted, (mild autumn weather, car in the shade, he knows the rules) when he came back ten minutes later Buster had gotten his foot hopelessly wedged between the seat and the casing of the gear shift and apparently panicked and spun and flipped around and blew his knee out six ways to Sunday. Although not a big dog, he was so active and spent most of his life on his hind legs so the surgeon and we agreed that TPLO was a better option.

the degenerative knee dog was classic, sometimes a little stiff after resting up from hard play, a little muscle loss etc...The ice storm Last year was the final straw, he went running outside afterwards, slid and boom, there you go. One TPLO, one extracapsular repair to avoid the second TPLO and a low impact enviroment over looking the Pacific with a good friend of mine.

The two trauma dogs were radiographed on both knees and had excellent tibial plateau angles.The other dog had tibial planes that were far too steep, a cruciate failure was virtually a guarrantee.

"Grizzi" lived to eleven on her graft and was always sound. Buster passed last year at sixteen and you would never have known he had a plate in his leg.

I think in general, if the basic health and conformation of the knee is good, the dog will always have a better chance for near perfect recover versus a dog with inborn weakness of the ligament or poor conformation of the knee and stifle

I have show friends and working dog friends and friends in agility and flyball. My best friend's husband hunts with dogs. I've seen plenty of pre and post cruciate repair dogs. I'm so so so with Dr Khuly on this, no matter what the procedure, a board certified surgeon who has the touch for cruciate work is key.

JenniferJ March 2nd, 2009 03:55:46 PM

Dr. K: Thanks for the response. I'm guessing that maybe a heavy bodied, short leg terrier would need the TPLO, and perhaps a lighter weight--longer legged conformation might get the other? I do hear more about it, particularly the "active sports" engaged, but without pictures, it was hard to relate! Great post. Barb A.

Pocket's Story from NH March 2nd, 2009 06:28:11 PM

Oh how I wish I had read this two weeks ago, instead of today...

My 9-yr old lab ruptured her CCL two weeks ago and had surgery two days later (I felt the sooner, the better). At the time, I didn't understand all of my options and I honestly didn't even know if there were any ortho surgeons in my area (KY isn't really a hot spot for the latest in vet techniques, other than equine). I went with a vet that I felt comfortable with and he recommended the traditional repair for her... even though she is larger (60 lbs) and extremely high energy. And while I may have made that decision anyway (for cost reasons, as well as her age), I sure would have liked to have known ALL my options.

I haven't read your other posts on this yet (I'm mentally scolding myself for not looking here first, since I've followed your blog forever!), but I'm about to. Right now I'm looking mostly for info on rehab and physical therapy though, since that is the phase we're in.

I've also been keeping on online journal of this (http://lifewithdoghair.blogspot.com/), partly for myself (in case I ever need to go through it again, horrors!) and partly to keep all my friends and family updated. While I know you're very busy, if you have a moment I would love it if you could take a brief look-through it and offer any small advice you might have.

Dawn March 2nd, 2009 06:28:59 PM

After reading this post, I'm so very glad my first excursion into this type of surgery involved a small dog which was head spinning enough. So after the obesity post, my girls got a reduction in their meal rations; after I read this one this morning, another reduction. I'm finding it much easier to stick to their diet since I'm now feeling far more guilty about their fat than the other stuff. Yesterday, my Shiba ran my b*** off on a mid day walk and wanted to go again late in the evening and there's this nifty fold of skin at her tummy and she can easily curl her back legs up while sleeping now. I noticed my Lab's harness had slack in it on our last walk this evening. (And I have an offer pending on a yard [attached to a house of course]). THANK YOU DR. K and the girls send kisses your way.

Barb, my Shiba had cruciate and luxating patella repairs. While I'm still not the least bit sure I truly understand the surgery that was done, I believe the surgeon said these were different but related and often concurrent. This is similar to the papers my surgeon gave me about the patella http://www.vetsurgerycentral.com/patella.htm My Shiba's ACL was initially damaged as a young pup and conservative treatment was very effective for 7 years. (Now suppressing rant against former Vets. Has it been 2 weeks yet?) Then she blew out the ACL and since I wasn't home when she did it, I'm just guessing that she jumped off my bed and landed wrong. In the interim years, the patella luxation seems to have become a problem. (And more suppressing.)

PJBoosinger March 2nd, 2009 08:38:44 PM

Wow, haven't heard of a prophylactic repair of the cruciate before. That's an interesting one. I personally am a fan of TTOs (a cross between the TTA and the TPLO). Much better know in the UK and Australia, not that well known in the US.

AlexH March 3rd, 2009 12:20:51 AM

Some info on the TTA (tibial tuberosity advancement) and the TTO (triple tibial osteotomy) for those of you wondering why I missed these. These are other versions of the 'leveling osteotomy' procedures that are similar to the TPLO in their attempt to re-establish knee integrity with concessions to biomechanical stability. Here's something on the TTO. And some more on the TTA.

As I said in the post, my presentation was a simplification of all the many procedures now out there. Thanks for bringing up these other procedures by way of alluding to the complex nature of this problem.

And agreed with AlexH: my quick-and-dirty surgical reference (over dinner last night) tells me grafting doesn't get the thumbs up due to the preponderance of degenerative cases. Though that's a bit of an oversimplification, too. Sigh...

Dr. Patty Khuly March 3rd, 2009 04:44:40 AM

Dawn: I'll check it out. Do you have access to a pool or a lake? I know, I know, it's cold. Perhaps I'll cover basic rehab soon if I get myself motivated to attack another area of intense controversy.

Dr. Patty Khuly March 3rd, 2009 04:46:58 AM

Hi Dr. Patty,

Unfortunately, I don't have access to a lake (which my dog would LOVE), but there is an animal rehab center near here with therapy pools, underwater treadmills, etc. and my vet did say he would give us a referral there. It sounds perfect, but also expensive. I may end up there anyhow, if I can't get my lab to cooperate with our range of motion exercises.

Would love a post on all of it though!! :-)

Dawn and Bailey (2/17/09 trad CCL surgery)

http://lifewithdoghair.blogspot.com/

Dawn March 3rd, 2009 05:16:07 AM

My Staffie just got diagnosed with an ACL tear yesterday. We're going to have surgery on it soon. She's a 55 lbs dog, so I'm assuming that TPLO would be the recommended proceedure for her? She's only about 5 years old, so she has a lot of an active life ahead of her...

Brent March 3rd, 2009 09:26:21 AM

We had an extracapsular repair done by our regular vet on our small terrier mix's right knee when the dog was about 3 years old. The repair only lasted for a year, and then the dog blew out BOTH knees at the same time. We then had the board-certified orthopedic specialist flown in from California (he was the closest one available), and he performed TPLO on both knees at the same time. Doing both knees at once saved us over $1000, and the dog had absolutely no problems at all during recovery. She had her little Flashdance bandages on and was so mobile that we had trouble keeping her still. Five years later her knees seem to be in incredible condition (with the help of some supplements) -- she just flies around the house and yard as fast as a greyhound. If anything, I wish she'd slow down a bit so she doesn't get hurt, but there's absolutely no sign of any residual arthritis: http://flickr.com/photos/flippyo/16047390/in/set-337767/ To get back to the point of this post, given my experience, I think it was good that we went with the TPLO, even though our dog only weighs 15 lbs. Maybe our inactive shih-tzu would be a good candidate for extracapsular/TightRope, but I think the terrier is too hard on her joints for the more basic repair. If money isn't a consideration for a client, and there's a trained specialist available to do the surgery, I think I'd go with TPLO the first time, regardless of the weight of the animal.

Leigh-Ann March 3rd, 2009 10:43:59 PM

Affordable rehab options would be a great post, Dr. Patty. I see way too many dogs with cruciate damage who won't be going into surgery due to a combination of reasons: inadequate owner budgets, advanced age, and obesity. After taking a lot of time explaining the anatomy and mechanics involved, I'm always a bit ashamed to send people home with only AINS, GA+CS, recommendations for controlled exercise and especially: weight loss(!!) If I could provide even a few techniques and advice on how to reduce weight and favour healing exercise (all lakes are frozen right now, won't thaw till May), that would be great. ;-)

brebis noire March 4th, 2009 04:28:54 AM

My 8 year old whippet was diagnosed with an ligament tear on Saturday. The injury occured friday night. When I picked him up immediately following the injury, I heard a popping noise which I assumed was a dislocation or break. However based upon the examination by our vet using the "drawer" test, and xrays, the diagnosis of a a ligiment injury was made. He is 35 lbs which puts him in the range for TPLO. While he is not the most energetic of dogs, when he does run it is full out (if you have ever had a whippet - you know what I mean). I am looking for a recommendation on which technique should be applied. Also is their a diagnostic explanation for the popping sound the leg/joint is making? Thank you for any feedback.

Chris March 4th, 2009 06:52:06 AM

just to let you all know the tplo is not without fault. My newf blew out her ccl and had the tplo surgery. two days into rehab/before she left the vet. she totally tore up the repair/shattered her tibia and eventually we had to put her down all at the ripe age of 2. Even though the cost is greater and better for large breeds it certainly isn't foolproof.

jim pollack March 4th, 2009 09:17:54 AM

Jim: Excellent point. No surgery is without its very serious risks. The TPLO is not foolproof, nor is any other approach to these knees. It's simply the best we've got at the moment. I can only hope that ten years from now I'll be writing a post poking fun of the TPLO's inadequacies in the face of newer, better and safer surgeries for cruciates.

And so sorry for your loss.

Dr. Patty Khuly March 4th, 2009 10:24:13 AM

My now eleven year old Lab had two TPLO's, one at age 8 and the other at age 9. She has done well and although it absolutely busted my budget I am very happy I had it done. Finding a good surgeon is crucial, as is keeping the dog strictly confined and safe until x-rays show bone healing at about eight weeks. I found a wealth of support and information on the Yahoo message board called "Orthodogs."

To find a board certified surgeon in your area, try here:

http://www.acvs.org/AnimalOwners/FindaSurgeoninYourArea/

Alice March 4th, 2009 11:59:17 AM

Dr. Khuly; I really need to talk to you. I had Tightrope CCL November 7th, 2008 for my 2 year old female Doberman and things REALLY went wrong.... Desperate in Ocala, FL

Susan March 5th, 2009 04:37:44 AM

Great blog. I found out about TPLO (@ Miami Vet Specialists!) AFTER my own vet operated my big 110-lb. rottie mix 3X doing the less expensive proceedure. He claimed he could "save me money" and I of course trusted him as the professional at that time and took him at his word that he studied under the originator of the simpler proceedure and that he'd "never failed to fix an ACL with it." "Boo Boo" was not an active dog; he tore his after wallowing in his wading pool and walking into the tile floored garage wet and slipping. After 3 surgeries and 8 months my vet finally referred me for TPLO. Boo's bone had deteriorated so much by then he was on Rimadyl for life at 3-yrs. of age for arthritis. But even tho he limped he WALKED on all fours and that was good enough for me. The pain a dog lives in with a torn ACL ligament I understand is horrendous; I lost Boo in October to cancer and even tho I had to take out a 2nd mortgage to finance his surgery he was worth every penny for his TPLO and oncology treatments. I just wish I hadn't been made to wait 8-months for the referral - it was a BIG lesson in learning to question diagnoses and treatments until I thoroughly understand them, and that not all vets fit the need at hand. I now use 3-4 vets depending on how in depth a need is.

Lee March 7th, 2009 08:45:06 AM

Lee: Sounds like me. I use about 3-4 different vets for my dogs, too. Second opinions are soooo important. So happy you found my peeps over at MVS as delightful as I do. ;-)

Dr. Patty Khuly March 7th, 2009 01:09:27 PM

Dr. Sardinas performed Boo's TPLO surgery. He didn't overpromise his recovery, but Boo did extremely well afterwards - so much better than his previous 8-months. When he passed from cancer his back legs had given out and I at first thought he'd fallen and injured the TPLO limb. Xrays showed nothing wrong with the original surgery nor either back leg; vet thought maybe he just needed a day's rest. He died overnight and it's presumed the cancer went to his brain. Anyway, I regret putting him under the knife 4/x when he could have had TPLO initially. The vet who performed the failed surgeries says Boo was his "learning curve" and he refers all dogs "over 50 lbs. for TPLO." From what you post he's still risking the weight limit by 25 lbs more than recommended. I will definitely come see you sometime this year! Thanks for the invite with male cats!

Lee March 8th, 2009 09:27:45 AM

Great comments, congratulations on such insightful work Dr. Khuly. I had someone locally send me one of your articles. I take my hat off to you in your completeness of explanation. You have a gift. I don't know how you find the hours in the day to do all you do. Regarding cranial cruciate instablitiy: I am a general practitioner that has performed several different kind of stabilization techniques over the past two decades. I rarely recommend the TPLO any longer for multiple reasons. 1. The TTA procedure produces greater reduction of unstable forces and ultimately less secondary OA over time. (I own Tampa Bay K-9 Rehabilitation Center so I get to see more or these cases post op then other general practitioners). 2. If a TPLO fails for one reason or another, amputation is a likely scenario to follow because the TPLO involves all of the weight bearing part of the tibia. If the TTA fails it does not involve any weight bearing components of the tibia and repair of the failure is possible. 3. Though you recommend a board certified surgeon, I've seen many post op TPLOs that were done by surgeons that had a long recovery and I questioned the experience of the surgeon. I've also seen surgical cases from other surgeons that seem to always heal faster and with less pain. Not all boarded surgeons are good at orthopedics. I know many general practitioners that perform the TTA, TPLO, tight rope procedures that I would put up against many surgeons so telling folks to seek out a specialist sells many of your colleagues short. I would suggest that if an experienced general practitioner who performs many kinds of surgery wants to do this surgery then there are specific questions that can be asked of them to proove their metal. My TTAs include post rehabilitation. Many surgeons don't believe in rehab and shame on them. So here is the list. How long have you been performing stifle surgeries? How many do you do a year? Can I speak to one of your clients that have had this procedure done recently? What kind of procedure do you recommend and why? With warm regard, Doc Brown

Doc Brown March 12th, 2009 06:27:41 AM

Is there any response to Susan's post on problems with a tightrope CCL repair.? I have a 130 lb. , 6 year old, Anatolian Shepherd with a torn CCL and am trying to decide between tightrope repair and TPLO. Any help in making this decision would be greatly appreciated.

Terry March 18th, 2009 11:18:08 PM

Hi there! I have two Olde English Bulldogges who are litter mates. They are 10 months old. Iggy weighs about 60 lbs and he tore his left ccl when he was very young (probably between 5-7 months old!), his brother Lemmy tanks in at 80 lbs and he tore his right ccl last month. Having two dogs that needed knee surgery at the same time, I opted for the traditional surgery (I could not afford twin TPLO surgeries). They went in for surgery last Monday (3/9/09). I got a call from my vet later that morning telling me the good news and the bad news. Good news, Lemmy's knee was functioning at about 80%, and the vet felt as though the surgery was rather unnecessary. i have him on a strict diet, to try and lose 10-15 lbs, and restricted activity until further notice. He also is on rimadyl. The bad news, Iggy had since torn his right knee and would need to have surgery in a few months. I asked if he could have both knees done at once, and was told no because he wouldn't be able to walk. makes sense. It has been almost two weeks since the surgery, and Iggy has been doing very well. The first couple days were sore and he didn't have an appetite (normal). But soon enough his little sparkle came back and he was starting to put weight on his repaired leg. i was very pleased until today. He was acting a little sad, so I gave him a pain pill (I forget the name, but I have been giving it to him about once a day although I am able to give it to him up to 3 times per day). After a drug indiced snooze he got up to have some water. Sure enough he was putting all weight onthe repaired knee and was holding his other knee up and refusing to put any weight on it. I know he has torn his right knee all the way, and I don;t know how to fix him. I am still awaiting my veteranarian's return call, and have Iggy locked up in his crate for the time being. I am pretty distressed and don't know what I am going to do! Any advice would be greatly appreciated!

Ali S March 19th, 2009 04:52:01 PM

Buffy, age 12, a 63 pound Shepherd/Sam X,in need of CC repair is 8 days from onset of her inury which was not traumatic. We saw our DVM in a small practice in a small town, and he recommended TPLO done by non-Board Certified (we checked) roving surgeon, surgery to be done in local vet's office. Blood work was done and she is healthy in that respect. She saw the surgeon who confirmed her need for surgery. I made an appointment for TPLO and was told to bring in the dog for surgery (no food) next week. Nobody took a stethoscope out or anything - just two guys squeezing her leg. She was given Rimadyl and Tramadol and we were given the price of $3200 but not a breakdown of what that entails. She's an old dog who has been on Glyco-flex for a couple years and glucosamine/Chrondroitin for about six months. Worried, I spent three days on line researching. This morning I postponed the TPLO. She is an "elderly" 12-year old who has needed a step to get into the low mini-van for a couple years. She was not infirm since she loves to chase cats and she has been a happy dog. We adore her, she's a wonderful dog. The TPLO controversy made me uncomfortable. The whole set-up made me uncomfortable. Money is a problem for us right now. I'm leaning toward finding a BC surgeon in a larger town and have the traditional surgery done on her. Is this nuts for a 63- pound dog? I figure conservative management is out although if I could have a limping dog who is pain free that would be my choice. However, since she is large (about five pounds overweight) and seems to have a bad CC problem (the degree of which I know not except scar tissue already exists) this won't be an option. Is time critical - is she damaging herself more with each passing day? The pills have helped a lot. She goes down two steps to the yard PRN and walks on leash about 200' to a potty stop in a vacant lot next door and that is all. Thanks so much for any guidance you might be able to provide.

Barbara Ann March 30th, 2009 09:04:28 PM

Two things- what's up with the sancsrit or whatever in the 2 posts above me? Second- Beaner my pitbull is scheduled to undergo a tightrope procedure next month..but after reading here I am wondering if this is just putting off the inevitable PTLO.. Beaner is a very active spaz of a pitbull who weighs 55 lbs....

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My elderly Maltese had the extracapsular repair on one leg and it failed twice, then got infected, and after treating the infection, we gave up. Then recently the other knee failed. We've considered the TPLO on the "good" leg. I am told the referral surgeon thinks he is a candidate. I've started wondering if he might have thin bones due to his medical history of endocrine diseases and treatment--and if the screws might not hold. Is there a way of knowing about that from the x-rays or visual exam of the bones once the surgery has begun?

maggie April 27th, 2009 10:10:54 PM

I have an 11 year old pitbull, 63lbs, with an ACl injury. I can't make my mind up about the TPLO or the Ex-Cap repair. The TPLO seems so extreme. with plates and screws, not to mention how many hours she will need tp be under.

Liz April 30th, 2009 09:15:58 PM

I have a 4 year old Schnauzer mix and he is 45 LBS. He has a ligament injury. what do type of surgery do you recommend?

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To Liz with the 11year old pit bull or anyone who wants to research another option. There is a newer technique introduced to the USA in 2004 called the (TTA) "TIBIAL TUBEROSITY ADVANCEMENT." It is considered a little less expensive than the "TPLO" and is less invasive to your pet. At her age, ask various vets for their opinions on what would be the best options. Best of Luck!

MMP May 28th, 2009 04:08:22 AM

This time it's not about the injury itself or specifically about the cost of its repair (check out parts one and two of this series for more info). No, this post is about the new pup on the block, the so-called TightRope technique for cranial cruciate ligament repairs ("cruciates" for short)--with some money-oriented considerations thrown in out of necessity.

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