Animal Emergency & Specialty Care

TPLO

Does your dog have a knee problem?
Have you noticed the following warning signs of cruciate disease?

  • Walking on three legs or “hiking” a leg up
  • Shifting weight off the painful hind leg
  • Unwillingness to play or exercise
  • Sitting with one hind leg extended out to the side
  • Painful reaction when the affected leg is moved
  • Stiffness in the morning or while getting up

Damage to the cranial cruciate ligament (CCL), a ligament referred to as the anterior cruciate ligament (ACL) in humans, is one of the most common orthopedic injuries in dogs. The resulting instability in your pet’s knee leads to pain, inflammation, and eventually arthritis. Traumatic injury can lead to a ruptured CCL, but in most dogs, we consider this problem to be a disease. This is because the ligament undergoes degeneration over time and many dogs “injure” their CCL without any real trauma. Other dogs may sustain rupture of the ACL when performing activities that you would not expect to cause injuries, such as simply jumping off the couch.

TPLO surgery may be the answer
TPLO stands for tibial plateau leveling osteotomy. This procedure changes the biomechanics of the knee so that it can remain stable without the ligament. The surgeon can rotate the upper portion of the tibia, leveling it and improving stability of the knee. A bone plate is applied to keep the bone in its new position while it heals. Locking screws also maximize the overall stability of the repair and reduce complications. Most animals live and move comfortably with the plate in place, so it is usually not removed after healing is complete. In some instances, your surgeon may speak with you about other options including CBLO, TTA and other procedures if they may benefit your pet.

How can the surgeon be certain of the diagnosis?
Besides the symptoms you’ve observed, your pet’s surgeon will also look for:

  • Excessive fluid in the knee
  • Clicking during flexion and extension of the knee
  • Instability in the knee (your surgeon can usually show you drawer movement or tibial thrust if you are interested)

If the above clinical signs are present, radiographs (X-Rays) are indicated and further evaluation of your pet under mild conscious sedation may be required.

A few other points to consider
Once cruciate disease has been diagnosed, there are several important points to understand before considering treatment options. As mentioned above, rupture of the ligament is a degenerative process in dogs, rather than an injury. The ligament deteriorates until it may rupture under normal everyday activity. The same factors that led to ligament degeneration in one knee will also be present in the other (contralateral) knee, resulting in a 40-70% chance that the CCL will now tear in the other knee. All dogs with cruciate disease also have osteoarthritis, which cannot be cured. The good news is that surgical intervention greatly limits its progression, leading to an excellent prognosis when the problem is addressed early.

Treatment: Types of joint exploration
At AESC, our surgeons always use arthroscopy, a minimally invasive method, to explore the joint and provide treatment. Arthroscopy utilizes a tiny camera (2.3 to 2.7mm in diameter) to confirm the diagnosis of a torn CCL and to check the joint for other injuries. Once the diagnosis is confirmed, any treatment needed inside the joint can also be performed in this minimally invasive manner.

Arthroscopy: Why it’s important, and how it works
Every surgeon must look inside the joint to confirm the diagnosis, remove any diseased ligament and identify other common injuries, including meniscal tears (torn cartilage pad).
There are two ways to inspect the joint:Open Arthrotomy—a large incision into the joint
Arthroscopy—exploration of the joint using a tiny camera through a small portalCompared to arthrotomy, arthroscopy provides:

  • A smaller overall skin incision
  • Only 2-3 mm incision into the joint capsule
  • Less pain on recovery
  • Less osteoarthritis over time
  • A faster recovery after surgery
  • Maintenance of more muscle mass after surgery
  • Improved weight bearing in the days and weeks following surgery
  • Less fibrosis (scar tissue)
  • Improved visualization of important anatomic structures during surgery

We encourage you to ask questions about a surgeon’s approach to joint exploration. Some surgeons use arthroscopy only to confirm the diagnosis and then if a concurrent meniscal injury is identified, they rely on arthrotomy, making a full-length incision into the joint. This cannot be considered minimally invasive.

Completely opening the joint at any point during the procedure increases pain, exacerbates existing arthritis and prolongs the recovery in patients with CCL injury.

AESC is committed to providing our patients with the best care available. That’s why our surgeons have acquired the advanced training and high definition equipment to both identify and address meniscal tears through arthroscopy.

Only when diagnosis and treatment are addressed through the camera and a tiny incision can a procedure truly be considered “minimally invasive.”

Be sure to understand your surgeon’s approach. We believe you and your pet will be much happier with a fully arthroscopic approach.

Treatment: Types of joint stabilization
Once arthroscopy is completed, the knee must be stabilized in some manner. There are three main approaches for stabilizing the knee:

  1. High tibial osteotomy—bone cutting techniques
    Because of the success of tibial plateau leveling osteotomy (TPLO), it is the most common type of joint stabilization procedure currently performed in the U.S. TPLO is a type of osteotomy, along with CORA-based leveling osteotomy (CBLO), tibial tuberosity transposition (TTA) and others. With TPLO, it is important to understand that the procedure changes the biomechanics of the knee so that it can remain stable without the ligament.
  2. Intracapsular (IS)—inside the joint techniques
    These procedures are not commonly performed in dogs for a variety of reasons. Complication rate is higher with this type of procedure than other techniques available today.
  3. Extracapsular (ES)—outside the joint techniques
    Among the original methods of treating CCL tears, ES procedures attempt to replace the function of a ruptured ligament with a suture or implant.

    • Lateral Suture Stabilization (LSS), or the “fishing line” technique, places a suture just outside the joint. In many cases, this suture eventually breaks or stretches, so it provides stabilization only until scar tissue forms around the knee to provide long-term stability.
    • TightRope (TR) and bone anchor (BA) are modified LSS techniques using stronger materials known as FiberWire and FiberTape. Ideally, bone tunnels or anchor sites are placed to maximize normal function of the joint. These procedures are sometimes touted as “minimally invasive,” but as explained in the callout box, this is only the case if your surgeon combines the technique with the use of arthroscopy. If an open arthrotomy is performed, this procedure cannot be called minimally invasive.

So how can you choose what’s best for your pet?
Recovery time for all procedures is approximately 6-8 weeks, and they each have advantages and disadvantages. Clinical research has shown that the TPLO procedure provides the fastest return to function with a relatively low complication rate compared to ES and TTA techniques. However, not all techniques have been clinically evaluated together in the same study.

AESC surgeons have advanced expertise in cruciate disease, including published research on the topic. They recommend that the best outcomes with the least number of complications can be achieved for most patients by providing the following:

  1. Arthroscopy (use of a camera in joint) rather than arthrotomy (cutting open the joint)
  2. TPLO using the highest quality and strongest implants on the market
  3. Rehabilitation of the limb by a physical therapist (PT) certified in canine rehabilitation

Circumstances may indicate that one procedure has advantages over another. The surgeons at AESC will guide you to a recommendation based on the latest available scientific evidence and your pet’s individual details.

Prognosis: Why we support TPLO surgery
The success rate of TPLO surgery is extremely high, with nearly all pets returning to normal or almost normal function. These results have made TPLO the treatment of choice in not only large-breed and athletic dogs, but also smaller dogs. Complications are possible, but nearly all can be avoided if post-operative directions are followed. Adequate rehabilitation also helps the patient return to normal function.

What to expect after surgery
You’ll receive instructions on post-operative care when you pick up your dog after surgery. Just like with people, it’s vital that you restrict exercise to give your pet time to heal. Physical therapy also plays an essential role in the recovery process. We’re committed to helping you every step of the way and guiding you through the rehabilitation process.

Why choose AESC for your dog’s CCL injury?
Your family vet is your go-to for routine care, but for help when your dog runs into more complicated healthcare issues, including a CCL injury, you need specialized medicine from doctors with advanced training in treating these injuries.

As an emergency and specialty veterinary hospital, AESC performs advanced surgeries every day, providing the experience and equipment needed to keep your pet healthy, calm and comfortable, while achieving optimal results.

At AESC, we carefully consider every possible detail that will provide you and your pet with the most stress-free experience, with the best available outcome. That means prioritizing all the “little things” that can add up to make a big difference.

Not every hospital will offer you the following options, but the surgeons at AESC incorporate ALL the following into your surgical package:

  • Multiple board-certified small animal veterinary surgeons on staff. All surgeons are board-certified by the American College of Veterinary Surgeons.
  • Extensive initial evaluation with surgeon and follow-up x-rays, plus an 8-week evaluation with suture removal—all included in your price
  • Insurance accepted for our TPLO operations
  • Arthroscopy (camera exploration) for every patient with no need to “open” a joint
  • Pain management by epidural, allowing less gas anesthetic for safer anesthesia and excellent post-operative pain support
  • The strongest plate/screw constructs available, including locking screws, rather than standard screws.
  • Overnight hospitalization for all patients, so your pet is not sent home in pain the same day
  • Doctors and technicians present on-site 24/7 for hospitalization throughout the night
  • Experienced AESC surgeons who have performed thousands of TPLOs with excellent success
  • Dedicated orthopedic operating room (gastrointestinal cases are performed in separate operating rooms to guard against infections)
  • Dedicated anesthesia recovery suite overseen by our board-certified surgeons and criticalists
  • On-site rehabilitation with a Certified Canine Rehabilitation Therapist
  • Properly outfitted and maintained operating rooms that are comfortable and familiar to our surgeons. All our equipment is on-site so we can efficiently address any unusual circumstances, should they occur.

The surgeons at AESC are board certified through academic residency training programs and ultimately through examinations by the American College of Veterinary Surgeons and/or the American College of Veterinary Sport Medicine and Rehabilitation.

Thank you for taking time to understand the basics of your pet’s situation and medical options. Please ask any questions you may have so you can feel comfortable with your pet’s treatment plan. Feel free to contact us at 720-842-5050 to schedule an appointment with one of the surgeons and the whole surgical team at AESC.

If you’re interested in learning more about our TPLO procedure or would like to have your pet evaluated by one of our surgeons, fill out the form below and we’ll contact you.