MIss Phoebe has been diagnosed with..
Submitted by carol on August 22, 2013 - 11:50ama luxating patella and a probably torn cruciate. The vet is recommending surgery after we return from China. In the meantime she will be kept quiet at home by a wonderful young woman who will stay with her. He is suggesting TTA surgery with isoflurane as the anisthetic. He will use ketamine to sedate her initially. She will also have an epidural which will lessen the amount of anisthetic needed. He says she will need an 8 week recovery period with short walks after two weeks.
Does this all sound reasonable? Want to make sure she will get the best care possible.
Yes - But
I would possibly get another opinion and the epidural would worry me.
How old is she?
Cleo was diagnosed at around 2 yrs with a Grade 3 luxating patella. I opted not to do surgery, since she had already gone through 3 surgeries, 1 being a CCL surgery on the opposite leg. She has some complications with the last surgery so I wasn't in any hurry to put her through another one.
I crate and ex-pen rested her a good 6 weeks.
A year after that patella diagnosis I had my vet check that same knee (without reminding him of his prior diagnosis) and he said it felt very good, hum????? Now I'm very hesitant to have surgeries unless it has become painfully noticable to me that indeed surgery is required.
Cleo is 8 now and totally sound on both of her back legs and knees. She has some stiffness and athritis in a front shoulder.
So IMO don't make a hasty decision on surgery and you can always get a 2nd opinion. Patella and CCL surgeries are not emergencies. You biggest worry is the long term outlook re: athritis.
Also not experienced with the TTA, it's the newest method. Last year my conversation with a vet/surgeon was that the TTA was the new thing, but nothing sensed that it was better then the TPLO. Infact she was very comfortable with the old method of surgery and said there are plenty of new studies in the past year that show that the old method with the new fibers used in the surgical thread are so strong that studies are showing that method is a very viable option.
I have had the old method done twice on CCL surgeries, both recommended by specialists and both very successful.
Ester's 1/2 sister had the TPLO done which was very successful, but this method is very invasive and she had some minor complications and the recovery time was a good 10 weeks. I always worry about these methods that cut bones and change that total relationship with the spine, hip, leg function.
My biggest problem with these surgeries are the total lack of statistics to their success. There are none! These surgeries are big business for the surgeons that perform these expensive 4k surgeries without anything substantial to support their success rates or failures.
Thank you, you...
raise a lot of good questions and have given us more food for thought. I think the idea of a second opinion is a really great idea. Phoebe is a year and a half old.
There are some interesting reads on the TPLO, TTA and TTO
surgeries that cause me great concern. Since I prefer to be as informed as possible and I know we all are just doing what is best for our dogs, I'm going to share this website because I find it has some intersting points.
Some of these points were brought up in my discussion with the vet last year. And she concurs with many of the points written. Mostly that there is no ## to substantiate that the TPLO and TTA are the better methods.
This also should provide you with some great questions to ask your surgeon.
http://tiggerpoz.com/id8.html
Again I had 2 old method stabilization surgeries done on 2 of my dogs. Norbert was 7 when he ruptured his ligament and his meniscus and Cleo was around a year old. Cleo had an almost full rupture (tiny thread still holding). I got to see the video of the surgery, ewwww! She is active, about 50 lbs and that knee at 8 years old has really held up. Neither of my surgeons recommended the TPLO, TTA was not around at that time.
Good Luck!
Great reading for sure but...
now I feel more unsure than ever of what to do. It was however interesting to read that for the double problem of patella and ligament that surgery is often the answer. Maybe not so much if it was just the ligament. Have made an appt for a second opinion. Will keep you posted.
Patella and CCL
Yes if she has both then as this article says the more invasive methods are likely the better options.
I didn't really want to make you unsure, just informed, so you could make the best decision. That is why I was hesitant to post this site and have never posted it before.
It's not substantiated....but neither are the procedures. And that has been substantiated by my vet, who concurs that there are no studies that can substantiate that TPLO and TTA are the better methods.
BUT talking points to have with your specialist to make the best decision.
Whatever you decide and whatever method you decide, you are doing what is best for her.
The post surgery recovery is very important for the surgery to be totally successful. So heed those instructions.
Keep use posted.
Forgot to ask..
what your concerns around the epidural would be. Seemed to me to be a good way to lessen the amount of anisthetic needed. Am I wrong in my thinking?
I agree a second opinion is good advice.
I would also have an orthopedic surgeon do the surgery. Sadie was 8 when she tore her CCL. The surgeon suggested the TTA over the TPLO for us because of Sadie's size, age, level of activity and recovery. Sadie weighed 48 lbs and her activity level was low therefore the TTA was good. With Phoebe being so young and probably pretty active the TPLO might be a better option. I would definitely speak to the surgeon to determine what is best for your girl. Sadie is now 13.5 and doing good except for the arthritis in her front leg shoulder.
Ortho Surgeon
agree that any TPLO, TTA or TTO surgery should be done by a specialist. The old method can be done by a vet that has tons of experience with surgeries.
My vet not an Ortho specialist but specializes in surgeries did Cleo's surgery and I wouldn't hesitate to have him do another surgery. He does all our C-sections and has tons of experience with surgery. I had an Ortho specialist do Norbert's surgery.
Epidurals just scare me with dogs, likely because I don't have experience with them. I just worry about paralysis.
All surgical options
What I find curious is that all methods available are not even being suggested. Only the most invasive and the most expensive.
There is a possibility that I will have to have Kohl's CCL repaired and I will not be doing either TPLO or TTA. He is 3 and 65 lbs.
I'm wondering
what procedures you would prefer over the TTA or TPLO? I am not really aware of other corrections. Thanks
lateral suture stabilization
Surgery
At Metropolitan Veterinary Associates we offer two surgical options:
1.lateral suture stabilization (Extracapsular technique), and
2.Tibial Plateau Leveling Osteotomy (TPLO).
We do not currently offer the Tibial Tuberosity Advancement (TTA) or the Tight-Rope technique. These two techniques are relatively new and there is currently very little published data to support their use.
With either the lateral suture stabilization or the TPLO technique the first part of the surgery is the same and involves exploring the stifle joint and removing the damaged cruciate ligament since it cannot be repaired and releases inflammatory mediators into the joint that cause continues pain, lameness and progression of arthritis.
We also evaluate the meniscal cartilages inside the joint. These cartilages act as shock absorbers and can become damaged when the cruciate ligament is damaged. If there is meniscal injury, the damaged portion of the meniscus is removed. If the meniscal cartilages are not damaged they are left in place since they provide an import role in the joint – however, dogs do have a slight risk of developing an isolated meniscal injury in the future, requiring re-exploration of the joint.
Lateral suture stabilization
This technique is a traditional technique that seeks to replace the function of the CCL with a prosthetic ligament made of strong Nylon suture material. In addition, the tough tissue outside the joint (fascia) is tightened to provide additional stability to the joint. This Nylon suture is a temporary stabilization, since over time the suture stretches and can ultimately break. The success of this technique relies on the development of fibrous tissue around the joint that takes over the function of the lateral Nylon Suture and stabilizes the joint. It has been used successfully in veterinary surgery for over 40 years in all sizes of dogs and cats.
Tibial Plateau leveling Osteotomy (TPLO)
This is a newer procedure that stabilizes the joint differently from the lateral suture technique. Many animals with cruciate ligament injury have a sloped top to their tibia (shin bone). This slope puts excess stress on the cruciate ligament and contributes to it rupturing. During surgery the top of the tibia is cut and rotated to a new position to level the top of the tibia, creating a level weight bearing platform. It is held in the new position using a bone plate and screws. This eliminates the slope of the tibia and changes the biomechanics of the joint- essentially eliminating the need for a CCL.
This technique is used most frequently in large and giant breed dogs, obese dogs, performance dogs and dogs with cruciate injury in both legs.
In our experience, dogs tend to bear weight on their operated leg a little quicker after the TPLO surgery than they do with the lateral suture technique. This is of benefit when they have cruciate ligament injury in their other knee.
This is a very strong fixation and less likely to have implant failure than the lateral suture technique, so is of benefit in very large dogs or dogs that are overweight. However, failure of the implants (breakage of the plate or screws or pull out of the screws from the bone) is possible and is more difficult to deal with than complications associated with the lateral suture technique.
Success Rate
Currently the success rate of either surgery is between 85-90%. This means your pet should get back to normal or near normal activity over a 2-4 month period. There are a small percentage of dogs and cats that do not do well following cruciate ligament injury, no matter how they are treated.
Complications of Cruciate Surgery
With any surgical technique there are risks.
Anesthesia
There is always a risk with anesthesia although it is rare that we have significant problems. All animals anesthetized at Metropolitan Veterinary Associates are continuously monitored by a veterinary nurse throughout the procedure. They are placed on intravenous fluids and their heart rates, respiratory rates and blood pressure are constantly monitored. They are also placed on a circulating warm water blanket to help maintain their body temperature under anesthesia.
Infection
There is always the potential for infection with any surgery. Our infection rate is extremely low. In most cases infection occurs when the animal licks or chews at the surgical incision postoperatively. That is why we send you pet home with a protective collar that they should wear at all times to prevent them licking or chewing at the incision. With either surgery- if an infection develops it can delay healing and necessitate the removal of the implants (the stabilizing Nylon suture or the bone plate and screws), which is additional anesthesia and surgery for your pet and additional cost.
Implant failure
Premature breakdown of the stabilizing Nylon suture can occur and is more likely in very large, active dogs or obese dogs. It is also more likely if dogs do not have their activity restricted as directed postoperatively. If the Nylon suture breaks prematurely it can lengthen the recovery process and in some cases necessitate further surgery.
The bone plate and screws used in the TPLO are very strong but by cutting the bone – this is essentially the same as having a fractured bone that requires time to heal. Initially the strength of the repair is provided by the plate and screws alone. Over the next few weeks, as the bone begins to heal, the bone starts providing additional strength to the repair. It is rare that we have implant failure with this technique but if the plate or screws break, the plate pulls off the bone, or the bone breaks around the screws further surgery is required and it can be very difficult to perform this additional repair.
Isolated meniscal injury
As previously stated, dogs do have a slight risk of developing an isolated meniscal injury in the future, requiring re-exploration of the joint. This can occur with either the lateral suture technique or the TPLO and it is not possible to predict which dogs will be affected.
Fabella Pain
This is a potential complication of the lateral suture stabilization technique. The fabella is a small bone at the back of the dog’s knee that the Nylon stabilizing suture is placed around. In a very small percentage of dogs this can cause some discomfort and occasionally we need to remove it under a very short anesthesia.
Tibial Tuberosity fracture (fracture through the top, front part of the tibia or shin bone)
This is a potential complication of the TPLO procedure. It occurs infrequently but depending on how long it occurs after the surgery and the displacement of the piece of bone that breaks, it may require placement of metal pins to repair the damaged piece of bone.
Patellar Tendon Inflammation
This is an uncommon complication following the TPLO procedure and can prolong the recovery period. It does not require surgery but can necessitate a prolonged period of activity restriction.
Persistent Lameness secondary to osteoarthritis
This affects between 10-15% of dogs. This is a potential complication with either surgery and there is no way to predict which dogs will have significant problems with arthritic pain. It requires life-long activity moderation (less free running and jumping, more slow leash walks and swimming) and the use of non-steroidal anti-inflammatory drugs long term (drugs such as Rimadyl, Deramaxx, Metacam and Previcox).
Postoperative Treatment
Specific instructions will be given at the time your pet is discharged from the hospital including what medications to give (antibiotics and pain medications). In general animals come back in 10-14 days to have their incisions checked and the skin sutures or staples removed. The stability and comfort of the joint will be checked at this visit.
Following surgery your pet will require strict activity restriction. Patient activity is generally restricted for at least 2.5-3 months.
For the first 10-14 days your dog should be confined to a crate or small room with minimal furniture. Steps should be kept to a minimum. They should go outside on a short leash (not at the end of an extendible leash) to go to the bathroom only – no free running, jumping or playing is allowed. This can result in failure of the implants and may result in the need for more surgery.
If your dog will tolerate it you can apply an ice pack to the incision upto 4 times daily for 3-5 minutes for the first 3-5 days. Do not try to force this if your dog will not let you.
Once the skin staples have been removed you can start the following walking program at home – all other restrictions still apply and your dog should still not be allowed to roam free in the house:
Week 3 post operatively: Slow, on a short leash walks for 5 minutes upto 3-4 times daily. You can also start making your dog walk in some small circles and figures of 8 with the operated leg on the inside of the circle/8.
Week 4 postoperatively: Slow, on a short leash walks for 10 minutes upto 3-4 times daily.
Week 5 postoperatively: Slow, on a short leash walks for 15 minutes upto 3-4 times daily.
Week 6 postoperatively: Slow, on a short leash walks for 20 minutes upto 3-4 times daily.
For dogs that have had a TPLO, weeks 7 and 8 should be the same as week 6: Slow, on a short leash walks for 20 minutes upto 3-4 times daily.
If your dog is hard to control on the leash and is liable to injure themselves their activity should be completely restricted to leash walks to the bathroom only for the first 6 weeks.
Following the lateral suture surgery dogs are then seen for a recheck at 6 weeks; further activity instructions will be given at this visit.
Dogs that have TPLO performed come back for follow-up X-rays at 8 weeks to make sure that the cut in the bone is healing. There is an additional charge for these X-rays and sedation. If the cut in the bone has not healed at 8 weeks, further X-rays will be taken at 12 weeks postoperatively. Dogs that have had a lateral suture stabilization do not require follow-up X-rays in most cases.
All pets with stifle problems should maintain an ideal body weight and you may need to decrease the amount you are feeding during the postoperative recovery period.
The amount of arthritis that an animal develops after cruciate ligament injury is variable and there is no way to predict how it will affect your pet. It is important that once they have healed from surgery that they have regular exercise, maintain an ideal body weight and if possible stay on a Glucosamine/Chondroitin joint supplement for life.
In addition, some animals may require the tactical use of non-steroidal anti-inflammatory drugs such as Rimadyl, Deramaxx, Previcox or Metacam. These can be obtained from your regular veterinarian and be used on an “as needed” basis. Arthritis tends to cause more discomfort after periods of sudden very heavy exercise (free running, jumping, ball chasing) and when the weather is colder and damper.
Another Article - lateral suture stabilization vs TPLO
I'll find a page for you with the 3 different procedures.
Changing Views On CCL Repair
By Narda G. Robinson, DO, DVM, MS, FAAMA
Cranial cruciate ligament (CCL) injury in dogs is big business. In 2003, the cost of treatment for CCL ruptures in dogs exceeded $1.32 billion.1
However, even in human medicine, “No studies have shown that ACL (anterior cruciate ligament) reconstruction restores dynamic knee stability or enables full return to preinjury activity level in all subjects.”2
Similarly, in a 2005 report in Veterinary Surgery, Aragon and Budsberg noted: “In reviewing the evidence currently available, there is no single surgical procedure that has enough data to suggest a potential for long-term success in terms of return to normal function, prevention of osteoarthritis or any claim of superiority to other surgical techniques. Subjectively, popular opinion on the short-term recovery and function favors the TPLO (tibial plateau leveling osteotomy). However, a recent study evaluated the outcome of surgical techniques on limb function. … The authors concluded at the two- and six-month postoperative evaluations that the lateral suture stabilization technique and TPLO were statistically similar. … Given the overall lack of convincing data available, it is impossible to favor one procedure (TPLO, extracapsular suture stabilization, fibular head transposition, intracapsular ligament replacement) over another at this time.”3
Furthermore, research into the etiopathogenesis of CCL rupture is destabilizing the dogma that wayward biomechanics bear the brunt of the blame.
Instead of focusing on altering bony relationships by cutting and repositioning them, practitioners may in the future direct their efforts at controlling inflammation and immune dysregulation, the newest suspects in ligament laxity.4-6 Research on its mechanistic origin is pointing toward the intrinsic and gradual degradation of the ligamentous matrix via matrix metalloproteinases and inflammatory mediators over a sudden traumatic episode.7
With this in mind, the prospect of maintaining CCL integrity through diet, exercise, weight loss and other preventive medicine methods gains prominence.
Some food manufacturers are making strides in this regard by eliminating pro-inflammatory substrates such as corn and corn byproducts and by adding antioxidants and anti-inflammatory fatty acids. Inflammation-reducing herbs such as bromelain, boswellia, turmeric and others could be integrated into the diet or provided as a supplement. Even weight loss for obese dogs confers anti-inflammatory benefit.8
Prolotherapy
Without a doubt, the most compelling nonsurgical option about which clients ask most frequently9 is prolotherapy. Prolotherapists typically inject sclerosing or proliferant solutions into or around joints to strengthen lax ligaments.10
Also referred to as regenerative injection therapy, or RIT, the scope of prolotherapy is expanding to include the injection of growth factors or growth factor stimulants that induce regeneration or repair of normal cells or tissues.11 In vivo studies have provided strong evidence that prolotherapy leads to ligament proliferation, thickening and improved tensile strength.
By reducing mechanical instability and abnormally excessive forces on ligaments, tendons and joint capsules, prolotherapy also reduces nociceptive stimuli emitted from these tissues and ultimately lessens pain. Studies testing prolotherapy for ACL laxity show short and long-term improvement in pain during walking, swelling, flexion and objectively measured ACL laxity.12-13 Further investigation in dogs with high-quality randomized controlled trials seems warranted.
Osteoarthritis
Despite improvements in joint function and stability even with surgery, osteoarthritis often sets in.14 Efforts to limit its progression may involve the administration of chonrdroprotectants. Polysulfated glycosamin-oglycan may inhibit the progression of OA in canine stifles by maintaining chondrocyte viability and protecting against extracellular matrix degradation.15 Orally administered chondroitin sulfate, glucosamine hydrocholoride and manganese ascorbate may modulate the metabolism within the articular cartilage matrix as well.16
Several other integrative pain and rehabilitation methods are similarly taking hold.
Low-level laser therapy for the treatment of soft tissues in and around joints has expanded in recent years.17-18
Pain relief and functional restoration with massage, acupuncture and therapeutic exercise are gaining acceptance.
Hydrotherapy and underwater treadmill exercise have become wildly popular in recent years, but the risks of overexuberant rehabilitation offset their value in some cases.
Individualized Rehab
While protocol-driven rehabilitation interventions offer the allure of rapid training and implementation, its assembly-line-style implementation sacrifices careful and astute attention to the individual’s biomechanical, cardiovascular and neurologic capabilities in favor of high patient numbers. Instead, a cogently designed, patient-driven format optimized for stabilization and strengthening in light of each patient’s functional demands and unique abilities and limitations will reduce the potential for injury, relapse and pain while maximizing outcomes.19
Certain Chinese herbal prescriptions have been found effective in reducing swelling, pain and joint restriction. A 2005 study on the value of a Chinese herbal preparation designed to improve the strength of previously injured ligamentous tissues demonstrated value even when applied externally, echoing the results of similar reports both from herbal plasters and ingested compounds.20
If change truly comes from within, then modifying the internal milieu by providing reparative biochemical factors through plants, foods, light, regenerative injections and mechanical stimuli may together form a viable alternative to surgical intervention in some cases.21
Deciding which patients qualify as suitable candidates for nonsurgical rehabilitation may be the first step, and randomized, controlled trials comparing outcomes over the long term, the second.
FOOTNOTES:
1. Wilke VL, Robinson DA, Evans RB, et al. Estimate of the annual economic impact of treatment of cranial cruciate ligament injury in dogs in the United States. JAVMA. 2005;227(10):1604-1607.
2. Moksnes H, Snyder-Mackler L, and Risberg MA. Individuals with an anterior cruciate ligament-deficient knee classified as noncopers may be candidates for nonsurgical rehabilitation. Journal of Orthopaedic & Sports Physical Therapy. 2008;38(10):586-595.
3. Aragon CL and Budsberg SC. Applications of evidence-based medicine: cranial cruciate ligament injury repair in dogs. Veterinary Surgery. 2005;34:93-98.
4. Fujita Y, Hara Y, Nezu Y, et al. Proinflammatory cytokine activities, matrix metalloproteinase-3 activity, and sulfated glycosaminoglycan content in synovial fluid of dogs with naturally acquired cranial cruciate ligament rupture. Veterinary Surgery. 2006;35:369-376.
5. Muir P, Manley PA, and Hao Z. COL-3 inhibition of collagen fragmentation in ruptured cranial cruciate ligament explants from dogs with stifle arthritis. The Veterinary Journal. 2007;174:403-406.
6. Barrett JG, Hao Z, Graf BK, et. al.
7. Krayer M, Rytz U, Oevermann A, et al. Apoptosis of ligamentous cells of the cranial cruciate ligament from stable stifle joints of dogs with partial cranial cruciate ligament rupture. Am J Vet Res. 2008;69:625-630.
8. Yamka RM, Friesen KG, and Frantz NZ. Identification of canine markers related to obesity and the effects of weight loss on the markers of interest. Intern J Appl Res Vet Med. 2006;4(4):282-292.
9. Author’s experience.
10-12. Kim SR, Stitik TP, Foye PM, et al. Critical review of prolotherapy for osteoarthritis, low back pain, and other musculoskeletal conditions: a physiatric perspective. Am J Phys Med Rehabil. 2004;83:379-389.
13. Reeves KD and Hassanein KM. Long term effects of dextrose prolotherapy for anterior cruciate ligament laxity. Alternative Therapies. 2003;9(3):52-56.
14. Johnson KA, Hulse DA, Hart RC, et al. Effects of an orally administered mixture of chondroitin sulfate, glucosamine hydrochloride and manganese ascorbate on synovial fluid chondroitin sulfate 3B3 and 7D4 epitope in a canine cruciate ligament transaction model of osteoarthritis. OsteoArthritis and Cartilage. 2001; 9:14-21.
15. Sevalla K, Todhunter RJ, Vernier-Singer M, and Budsberg SC. Effect of polysulfated glycosaminoglycan on DNA content and proteoglycan metabolism in normal and osteoarthritic canine articular cartilage explants. Veterinary Surgery. 2000;29:407-414.
16. Johnson KA, Hulse DA, Hart RC, et al. Effects of an orally administered mixture of chondroitin sulfate, glucosamine hydrochloride and manganese ascorbate on synovial fluid chondroitin sulfate 3B3 and 7D4 epitope in a canine cruciate ligament transaction model of osteoarthritis. OsteoArthritis and Cartilage. 2001; 9:14-21.
17. Fung DTC, Ng GYF, Leung MCP, and Tay DKC. Therapeutic low energy laser improves the mechanical strength of repairing medial collateral ligament. Lasers Surg Med. 2002;31:91-96.
18. Khan AS, Sherman OH, and DeLay B. Thermal treatment of anterior cruciate ligament injury and laxity with its imaging characteristics. Clin Sports Med. 2002;21:701-711.
19. Andersson C, Odensten M, and Gillquist J. Treatment of acute rupture of the anterior cruciate ligament: a randomized study with a long-term follow-up period. Clinical Orthopaedics and Related Research. 1991;264:255-263.
20. Fung DTC and Ng GYF. Herbal remedies improve the strength of repairing ligament in a rat model. Phytomedicine. 2005;12(1-2): 93-99.
21. Canapp SO. The canine stifle. Clinical Techniques in Small Animal Practice. 2007;22:195-205.
Thank you so much for...
taking the time to send me all this informaton. It is such a challenge to sort through it all and decide which is the best route to go. I do read all the articles sent so that when I talk further to our vet I will at least be able to ask pertinent questions and have a reasonable knowledge of the situation. So thank you for enlargine my knowledge base. I appreciate it.