I'm a visual learner and despite reading about the various CCL surgery methods and seeing illustrations, my brain didn't kick in until I recently saw a CGI video kicking around on Facebook of a TTA, TPLO and tightrope type surgery. When I saw the TTA the first thing that came into my head is "won't that cause patellofemoral / patellar tendon problems?" because of the change in tibial tuberosity location. I also wondered if the TPLO surgery would have effects at other areas in the lower limb due to the altered stifle joint anatomy. To my, very simple, brain, the tightrope made the most sense because it preserves the original anatomy of the joint, but I know there are concerns regarding the effectiveness of this technique in larger dogs.
So, after that long winded introduction, my question is for those of you that have had long term follow-up with dogs that have had CCL surgery, have you seen any secondary long term effects, either around the stifle or at other parts of the hind limb?
Anyone else have thoughts about the long-term effects (good or bad) of the anatomical joint changes these surgeries create?
Long Term Effects of CCL Surgery?
Re: Long Term Effects of CCL Surgery?
This is a great question / discussion Stella. So, yes, with both the TPLO & TTA, one of the common (albeit minor) complications is that of patellar tendinopathy. The patellar tendon has to take on a great workload. Nobody in Calgary is doing these - so I can't offer much first hand insights on this, other than, I'm not a big fan of the biomechanics as they related to resultant soft tissue stresses.
TPLO's often never look normal to the trained eye. Yes, the dogs can function well with them after surgery, but my brain would point out that the angles of the joint are forever altered, and if the dog doesn't have bilateral TPLO's, it's like wearing a pair of flats and heels at the same time. Sure, they're both size 9, but different mechanics are used to walk with the different models of 'shoes'. So I find that often dogs will off load the TPLO leg in standing, they will often externally rotate that leg, and if muscle is not adequately build up, then their gait is altered as the joint has inadequate 'dynamic' support.
Dr. Gail Smith (DVM & Engineer) gave an interesting lecture back in 2007 that discussed "the inconvenient vector'... that being that without the CCL, there is one less mechanism attaching the tibia to the femur and holding the joint together from a 'vertical' standpoint. One would think that this has to have a consequence. Additionally, I think that there is a hyper-rotational to not addressing the vertical component.
Now, I might be starting to sound anti-TPLO or TTA... and that's just a 1/2 truth. What I do think is that the 'best' technique has not yet been invented.
The tightrope seems like a 'fancy' extracapsular (de Angelis) method. I think it's 'overkill' for what it is. I've seen disasters from this technique as well. And my concern is that the microshifting of the filament at each of the bone entrances can create a 'bone sawing' effect, thereby eroding the bone and allowing for less stability over time (and often a short period of time). The post-op recommendation has been to limit or delay rehab / movement after the surgery for about 8 weeks to prevent this. That time frame is critical to gain normal use, muscular stabilizing, strengthening, etc. For this technique, I'll come flat out and say, 'I'm not a fan'.
I have a number of astute dog-owners that look for a vet doing a good extracapsular repair. It may not be for every dog, but I think we may have 'thrown the baby out with the bathwater' in disregarding it completely.
There's my long winded answer! Thanks for posting Stella!
I'd love to hear more first hand experiences from others out there!
Cheers,
Laurie
TPLO's often never look normal to the trained eye. Yes, the dogs can function well with them after surgery, but my brain would point out that the angles of the joint are forever altered, and if the dog doesn't have bilateral TPLO's, it's like wearing a pair of flats and heels at the same time. Sure, they're both size 9, but different mechanics are used to walk with the different models of 'shoes'. So I find that often dogs will off load the TPLO leg in standing, they will often externally rotate that leg, and if muscle is not adequately build up, then their gait is altered as the joint has inadequate 'dynamic' support.
Dr. Gail Smith (DVM & Engineer) gave an interesting lecture back in 2007 that discussed "the inconvenient vector'... that being that without the CCL, there is one less mechanism attaching the tibia to the femur and holding the joint together from a 'vertical' standpoint. One would think that this has to have a consequence. Additionally, I think that there is a hyper-rotational to not addressing the vertical component.
Now, I might be starting to sound anti-TPLO or TTA... and that's just a 1/2 truth. What I do think is that the 'best' technique has not yet been invented.
The tightrope seems like a 'fancy' extracapsular (de Angelis) method. I think it's 'overkill' for what it is. I've seen disasters from this technique as well. And my concern is that the microshifting of the filament at each of the bone entrances can create a 'bone sawing' effect, thereby eroding the bone and allowing for less stability over time (and often a short period of time). The post-op recommendation has been to limit or delay rehab / movement after the surgery for about 8 weeks to prevent this. That time frame is critical to gain normal use, muscular stabilizing, strengthening, etc. For this technique, I'll come flat out and say, 'I'm not a fan'.
I have a number of astute dog-owners that look for a vet doing a good extracapsular repair. It may not be for every dog, but I think we may have 'thrown the baby out with the bathwater' in disregarding it completely.
There's my long winded answer! Thanks for posting Stella!
I'd love to hear more first hand experiences from others out there!
Cheers,
Laurie
LAURIE EDGE-HUGHES
Re: Long Term Effects of CCL Surgery?
Hi Everyone,
Laurie, I love your response to this excellent question. As a boarded surgeon that has done all 3 techniques I am still on the fence about what is best!
I don't do TTA's anymore because I just did not see the patients do as well as the TPLO, and the TTA is definitely not as versatile. It is very expensive to keep equipment around that you are not using.
I am continually amazed how well TPLO dogs do with quicker return to function after cutting their bone.
This also seems to pan out in force plate assessments in papers that have been published in recent years.
But comparisons are usually with the lateral suture using fishing line and not with the Tightrope.
I spend a lot of time with measurements pre-TPLO and making sure I place my cut and the plate in the optimal place. I have seen every imaginable TPLO complication - not mine - I don't think I do enough to see these complications. And TPLO complications can be catastrophic.
I do like the Tightrope and favor the simplicity of the traditional lateral suture but I use bone anchors and Orthofiber instead of fishing line so I feel that these do not stretch or break as easily.
If you place the bone tunnels in the quasi-isometric points recommended I find that the loosening by the prosthetic cutting into the bone doesn't happen.
I used to send all my post-op Tightropes into the UWTM soon after suture removal, but got more conservative and now wait for the 6 week post-op recheck due to advice from other surgeons who are ACVSMR boarded. I make an exception for dogs that have UWTM experience before surgery.
I restrict all my ACLs for a minimum of 12 weeks from jumping (except to the couch at 6 weeks) and running (except for trotting in a straight line at 10 weeks).
Caroline
Laurie, I love your response to this excellent question. As a boarded surgeon that has done all 3 techniques I am still on the fence about what is best!
I don't do TTA's anymore because I just did not see the patients do as well as the TPLO, and the TTA is definitely not as versatile. It is very expensive to keep equipment around that you are not using.
I am continually amazed how well TPLO dogs do with quicker return to function after cutting their bone.
This also seems to pan out in force plate assessments in papers that have been published in recent years.
But comparisons are usually with the lateral suture using fishing line and not with the Tightrope.
I spend a lot of time with measurements pre-TPLO and making sure I place my cut and the plate in the optimal place. I have seen every imaginable TPLO complication - not mine - I don't think I do enough to see these complications. And TPLO complications can be catastrophic.
I do like the Tightrope and favor the simplicity of the traditional lateral suture but I use bone anchors and Orthofiber instead of fishing line so I feel that these do not stretch or break as easily.
If you place the bone tunnels in the quasi-isometric points recommended I find that the loosening by the prosthetic cutting into the bone doesn't happen.
I used to send all my post-op Tightropes into the UWTM soon after suture removal, but got more conservative and now wait for the 6 week post-op recheck due to advice from other surgeons who are ACVSMR boarded. I make an exception for dogs that have UWTM experience before surgery.
I restrict all my ACLs for a minimum of 12 weeks from jumping (except to the couch at 6 weeks) and running (except for trotting in a straight line at 10 weeks).
Caroline
Re: Long Term Effects of CCL Surgery?
Thanks guys for your replies. Certainly to me, anatomically, the extra capsular surgery makes more sense but the delay in rehab is not ideal. How about early post-op rehab while wearing a brace??
I only have two vets locally doing CCL surgery, one seems to do TTA exclusively and the other does both TPLO and TTA. Neither refer to me!! Although I do see some of their post-op dogs when the owners contact me directly.
So, my next question - why isn't / can't it be done in a similar method to the 'people' surgery? Where the ligament is actually reconstructed and the bony integrity of the joint preserved?
Ok, and another question - I'm on a roll now! Neither the TTA or TPLO address concurrent meniscal injury, am I correct? So, if there is a meniscal injury and the dog has TTA or TPLO and continues to have issues post-op, could it be because of the meniscus??
I only have two vets locally doing CCL surgery, one seems to do TTA exclusively and the other does both TPLO and TTA. Neither refer to me!! Although I do see some of their post-op dogs when the owners contact me directly.
So, my next question - why isn't / can't it be done in a similar method to the 'people' surgery? Where the ligament is actually reconstructed and the bony integrity of the joint preserved?
Ok, and another question - I'm on a roll now! Neither the TTA or TPLO address concurrent meniscal injury, am I correct? So, if there is a meniscal injury and the dog has TTA or TPLO and continues to have issues post-op, could it be because of the meniscus??
Re: Long Term Effects of CCL Surgery?
Reconstruction of the ACL as is done in humans may become possible in dogs in the future - I think that is what we are striving for - everything done minimally invasively.
Intra-articular repairs however, require ligament to heal into bone which requires very careful protection of the repair immediately post-op. We don't routinely put dogs in braces that lock out the knee and they can't use crutches like humans. They would not tolerate those range of motion machines.
So the human owner would have an even more tremendous responsibility to manage their pets post-op with intra-articular repairs. Also we know from humans that they can break down.
Our goals post-op are to provide a repair that a dog could immediately fully weight bear on.
Of course they don't initially because of pain, but we definitely want them to be able to use it ASAP.
I have thought about supporting a prosthetic repair with a brace but have never tried it.
Another $700 on top of a $3-4000 surgery maybe is too much to ask an owner? and then worrying about keeping the brace on or it causing problems with the incision healing.....
NONE of the repair techniques will prevent a meniscal tear. So if the meniscus is not already torn, the surgeon usually does one of 2 things -1) leaves it alone with an up to 25% chance they might see this patient again with a meniscal tear and a very upset owner OR 2) perform a meniscal release which moves the meniscus out of harms way, BUT essentially is no better than just removing it because it causes arthritis to progress more rapidly (but clinically most dogs seem to tolerate it).
I feel like our approach to ACL injuries has become more complex over the years. It may be due to higher owner expectations, higher cost of surgeries?
Caroline
Intra-articular repairs however, require ligament to heal into bone which requires very careful protection of the repair immediately post-op. We don't routinely put dogs in braces that lock out the knee and they can't use crutches like humans. They would not tolerate those range of motion machines.
So the human owner would have an even more tremendous responsibility to manage their pets post-op with intra-articular repairs. Also we know from humans that they can break down.
Our goals post-op are to provide a repair that a dog could immediately fully weight bear on.
Of course they don't initially because of pain, but we definitely want them to be able to use it ASAP.
I have thought about supporting a prosthetic repair with a brace but have never tried it.
Another $700 on top of a $3-4000 surgery maybe is too much to ask an owner? and then worrying about keeping the brace on or it causing problems with the incision healing.....
NONE of the repair techniques will prevent a meniscal tear. So if the meniscus is not already torn, the surgeon usually does one of 2 things -1) leaves it alone with an up to 25% chance they might see this patient again with a meniscal tear and a very upset owner OR 2) perform a meniscal release which moves the meniscus out of harms way, BUT essentially is no better than just removing it because it causes arthritis to progress more rapidly (but clinically most dogs seem to tolerate it).
I feel like our approach to ACL injuries has become more complex over the years. It may be due to higher owner expectations, higher cost of surgeries?
Caroline
Re: Long Term Effects of CCL Surgery?
Thanks for your reply Caroline! I am a 'human' physio who is now working with dogs after doing the Animal Rehab Divisions Diploma. So, my brain still thinks of the human way of doing things first! Following human ACL reconstruction (hamstring graft), the goal is to get them off crutches and full weight bearing asap, so protecting the repair wouldn't be so much of an issue in dogs - no more than any post-op surgical restrictions. If the dog would tolerate wearing a brace, I wondered if that would be way to help with protecting the graft in the immediate post-op period and through the remodelling period.
Hmmm, I guess I'm always trying to think, what would I do if it was my own dog, and I'm not thrilled with any of the current veterinary options that involve changing the shape and mechanics of the joint. But, being the owner of a larger dog, I know that extra-capsular might not be the best option either! It will be interesting to see where technology takes us. I understand that ligament reconstruction would be a more intricate surgery, more specialized, and so would also push the price up further.
Hmmm, I guess I'm always trying to think, what would I do if it was my own dog, and I'm not thrilled with any of the current veterinary options that involve changing the shape and mechanics of the joint. But, being the owner of a larger dog, I know that extra-capsular might not be the best option either! It will be interesting to see where technology takes us. I understand that ligament reconstruction would be a more intricate surgery, more specialized, and so would also push the price up further.