I suggest using careful restriction as a first step in determining how best to
deal with a dog's ligament injury. This careful restriction for 8 weeks is the best diagnostic tool to determine if the dog
will be able to recover well without surgery. Very often a dog will begin to improve and continue to slowly
improve over time when activity is carefully restricted. Some ups & downs are likely as the weeks go by, but a general
direction of improvement shows that the stifle is being re-stabilized by the body's natural ability to heal and recover from
injuries. Full recovery will take more time than the original 8 weeks. How long a recovery will take depends on many variables---
severity of injury, size & age of the dog, etc.
When a dog cannot improve significantly during this period of careful restriction,
surgery may be needed.
There are basically two surgical strategies.
----1) Hold the bones in position at the joint with a surgically installed restraint which
will allow near-normal movement of the joint while preventing improper movement. Tough fibrous scar tissue will then
build up around the joint. This scar tissue will provide long-term stability. These are called 'Conventional'
or 'Traditional' surgeries.
---- 2) Cut the bones and reposition sections of the bones using metal plates or
implants to alter the relationship of the bones to each other, changing the tibeal plateau angle at the stifle joint.
The procedures used to do this are TPLO and TTA.
-- Some vets will recommend TPLO or TTA for most or all dogs with ligament injuries.
These very invasive bone altering procedures have much greater risk of serious complications than conventional surgery but
do not have superior long-term outcomes. Please see the 'TPLO / TTA' page here at this website for more information
on TPLO / TTA.
This page focuses on Conventional Stabilization Surgery. There are dozens of intracapsular
and extracapsular variations of conventional stabilization. The theory behind all these surgeries is that by holding the bones
in place at the joint in a way that allows near-normal joint movement, the surgical stabilization will provide conditions under
which the body can begin building up the permanent scar tissue stabilization. Extracapsular procedures are generally
recognized as the best choice among the various conventional procedures in most cases. For many
years vets have used monofilament nylon orthosuture (similar to fishing line) drawn tight and secured, to stabilize the
joint in most extracapsular procedures. There are now stronger materials available, but for most dogs the standard nylon orthosuture
is still a good choice. For large high-energy dogs you will want to consider other orthosuture materials which are described
lower on this page. The installed orthosuture strands will provide temporary stability while over a period of months the dog's
body builds up tough fibrous scar tissue which will permanently support the joint. The surgically installed orthosuture will
always stretch or break after several months. It is not meant to be a permanent stabilization. Its function is to give the
body the help it needs to get started on establishing the stabilizing scar tissue. Whether or not surgery is needed to get
a start on re-stabilizing the joint, ultimately it is the dog's own healing process which provides the new scar tissue support
for the joint.
Unlike human ligament surgeries, dog ligament surgeries do not re-attach or permanently
replace the ligaments. Some vets will fail to make this clear to their clients, leading people to believe that the surgery
is a 'repair' in the sense that the damaged ligaments will be restored to function or permanently replaced. Ironically,
a statement that some vets use in recommending surgery is "Those ligaments won't repair themselves." It's true
that ruptured ligaments don't repair themselves, but it's also true that the surgery the vet wants to do isn't going to repair
the ligaments either. Ligament repair or replacement with surgery is just not an option for dogs.* The ligaments, once
fully torn, are gone forever. Anyone who tries to tell you otherwise is either mistaken or being deceitful. Permanent
stabilization of the joint depends on the tough new fibrous scar tissue described above.
*---- There is one exception to this. In rare cases where the ligament remains whole
but has pulled loose a chip of bone which is large enough for reattachment. If that has happened then a repair is possible
by reattaching the bone chip. But that is very rare. If the ligament itself is torn, as is usually the case, repair
of the ligament is not possible.
________________________________________
Here's an analogy for the change in stabilization method:
---- Imagine you have an umbrella which keeps you dry in the rain, but a storm wind destroys
your umbrella. It is ruined beyond repair. It is not possible to get another umbrella, but you can get a raincoat
which has a hood. The raincoat is not an umbrella, but it does the same job the umbrella did of keeping you dry.
---- Analogously, when the ligament is torn, it is not possible to repair it or replace it with
another ligament, but it is possible to accomplish the function the ligament formerly accomplished in a different way.
By restricting activity so that tough new fibrous scar tissue will be able to build up around the joint to hold the bones,
proper movement will be possible after recovery while improper movement will be prevented.
_________________________________________
Clicking? Popping?
People are often incorrectly told that a clicking or popping sound in the joint is doubtless
a sign that surgery on the meniscus is required. In fact, these sounds may indicate meniscal injury, or they may have
a different cause. And if there is meniscal damage, surgery may or may not be best. People are sometimes led to
believe that the meniscus will be repaired by surgery when in fact meniscal surgery will simply remove part or all of the
meniscus. Removal of part or all of the meniscus will have negative consequences for the joint in the long-term, so
this is not something that should be done without good cause. Sometimes removal of part or all of the meniscus is the
best choice, depending on the severity of the injury to the meniscus, but this must be carefully considered.
Please read these pages if you need to know more:
"Clicking? Popping?"
"Meniscus Info"
When joint instability requires surgery, then a conventional stabilization surgery
is the best choice for most dogs. But until recently the best choice for large highly active dogs might have been one
of the more invasive bone-geometry-altering procedures TPLO or TTA. This was because the usual synthetic monofilament
ortho-suture used in the conventional procedure would be likely to fail with a large, very active dog. However,
there have been advances in the materials available for conventional stabilizing surgery which make conventional stabilizing
surgery appropriate for these large high-energy dogs. These advances make it possible to avoid the changes
in bone structure involved in TPLO / TTA and the associated risks.
---- Advanced ortho suture materials* are much stronger and more resistant to stretching and
abrasion when used in stifle stabilizations than the standard ortho-suture monofilament material. Improved bone anchors
and improved methods of securing the suture material also add to the overall increase in the capacity of the stabilization
to resist failure.
---- In light of these new developments, TPLOs & TTAs are no longer a reasonable choice for
the majority of dogs for whom they are still being recommended. These very invasive surgeries have special risks of
very serious complications including catastrophic failure potentially resulting in amputation or death. They have this
disadvantage without any longer providing a counterbalancing advantage. TPLO & TTA used to be defendable
as appropriate for large highly active dogs in the past when conventional surgeries had a much greater risk of failure
in large active dogs. Today, with advances in conventional stabilization available to us, TPLO & TTA are only rarely
a good choice. (When is TPLO appropriate? Please
go to the 'TPLO/TTA' page here at this website and look for the section on TPA.)
*-- Examples of advanced orthosuture materials include Ethibond [Ethicon, Somerville, NJ], FiberTape and FiberWire
[Arthrex, Naples, FL], OrthoFiber [Securos, Fiskdale, MA], Orthocord [DePuy-Mitek, Norwood, MA], Hi-Fi [ConMed Linvatec, Largo,
FL], Ultrabraid [Smith & Nephew, Andover, MA], ForceFiber [Stryker Endoscopy, San Jose, CA], MagnumWire [ArthroCare, Sunnyvale,
CA], MaxBraid PE [Arthrotek, Warsaw, IN]
One stifle stabilization technique which is gaining recognition is the 'TightRope
CCL' procedure.
Here is a link to a full description of TR step-by-step, with photos.
---- The 'TightRope CCL' procedure uses a material from human ortho-surgery which is new to veterinary
use called 'FiberTape' in place of ortho-suture material to stabilize the joint. The TightRope CCL technique (hereafter
I'll refer to it as 'TR') was developed by James Cook, DVM, who is an ortho specialist at the University of Missouri.
Here's some information on TightRope CCL:
<<"The components of TightRope CCL consist of a stainless steel toggle
button,
a round suture button and FiberTape. FiberTape is an ultra-
high strength tape utilizing a structure similar to FiberWire
suture.
The weave of the FiberTape allows for smooth, atraumatic
passing through tissue and bone, and desirable tying
characteristics.
Testing has shown FiberTape to have an ultimate
load of 225 lbs. and high stiffness characteristics."
"The TightRope CCL technique was developed to provide
a minimally invasive method for extracapsular stabilization of the cranial cruciate ligament-deficient canine stifle. TightRope
CCL seeks to optimize the lateral suture stabilization technique by employing bone-to-bone fixation, an implant with superior
strength and stiffness designed specifically for ligament repair, and a method for consistent isometric implant placement.
As such, TightRope CCL can counteract cranial tibial thrust, drawer, and internal rotation, while providing optimal joint
range of motion.">>
**************************
Are There Any Special Risks associated with TR or with the use of the other advanced
orthosutures?
FiberTape is a woven product, as are the other advanced orthosutures. These have a
greater potential to harbor bacteria than does the monofilament orthosuture commonly used in extracapsular stabilizations.
If an infection gets a start inside the leg during or after surgery, their woven nature makes the infection harder to
treat. (Bacteria hide-out in the nooks & crannies of the weave.) It is sometimes necessary to remove
the orthosuture in an additional surgery if the infection cannot be controlled with drugs. Surgical removal is
only rarely needed. Being meticulous about proper aseptic technique in the operating room greatly reduces infection
rates.
Should Your Dog Have the 'TightRope' Procedure?
In deciding on a type of surgery, it is important to understand that all the
stabilizing surgeries, including TightRope, have only a temporary purpose. They are not expected
to act permanently as support for the joint. They provide a temporary stabilization which will do its
job for several months as new fibrous scar tissue builds up to provide permanent stabilization for the joint. Therefore the
reason to choose the greater strength, resistance to abrasion, etc, of TR's FiberTape, (or any other advanced suture material)
over monofilament is that your dog is a large high-energy dog who is likely to put too much stress on the temporary stabilization
in those months just after surgery before Fido's body has had time to build up that new scar tissue support.
There is no other reason to prefer the advanced materials to monofilament nylon. Using one of the new superior
orthosutures (including FiberTape) will not provide better long-term stabilization for the injured joint.
Long term stabilization is the result of the scar tissue development. Its strength is not dependent on the
type of surgically installed materials used for the temporary surgical stabilization.
---- Some dogs are much bouncier & harder to restrict post-op than others. If
your large dog is a relatively easy-going dog, I think that as long as you are careful to prevent excessive stresses
during the several months of his post-op recovery, an extracapsular stabilization done with monofilament orthosuture would be
fine. And for most smaller dogs there is no advantage in the advanced materials since the nylon ortho-suture
will not be over-stressed. But for a large high-energy dog who will unavoidably put a lot of pressure
on the joint during the post-op months, TR or an extracapsular stabilization using another of the high strength advanced
ortho-sutures would be the best choice.
********************
Dog Size as it relates to TightRope Suitablity
TR requires that a dog be larger than a minimum size of approximately 30 to 40 pounds. Thirty to forty
pounds is a rough estimate of the minimum size of dog who could have the TightRope procedure. The actual limiting factor
is the drill tunnel size to accommodate the FiberTape, which has greater bulk than ortho-suture. The drilled tunnel
required for the FiberTape is 3.6 mm and you do not want a tunnel more than 1/3 the diameter/width of the bone. The 30-40
pound weight is just a rule of thumb for that. If a dog is 30-40 lbs then the vet should measure the femur on X-ray
and if it is 12 mm or above then TightRope is size-appropriate for that dog.
MiniTightRope
The kit for "MiniTightRope" is intended for smaller dogs. The 'MiniTR' involves drilling a 2.7
mm tunnel, and so can be used on dogs with femurs measuring 9 to 12 mm. Theoretically, the miniTR might be preferred to a
standard stabilization based on many of the same factors as for large dogs, ie bone-to-bone fixation, isometry, less
soft tissue disruption. But TRs are harder to accurately place as the patient’s bones get smaller, and the expected
outcome for small dogs who have extracapsular stabilization with nylon monofilament is also excellent since small
dogs will not put great stresses on the stabilizing ortho-suture.
Cost of TightRope?
The cost for a TightRope procedure will vary. At this point you may find that because it
is still fairly new, TR is only being done near you by a few ortho-specialist surgeons who charge more money for
their time. I expect that in the near future more & more vets will be doing TR and there will be more competition
in price along with wider availability.
---- 'TightRope' costs today should be significantly lower than TPLO / TTA costs, but somewhat
higher than conventional stabilization surgery costs. Reported TightRope costs vary from around $700
(US dollars) up to several thousand dollars for the total bill. As of March 2009, at one major US state university vet
facility, the total bill for TR done by top ortho surgeons including exam, diagnostics, anesthesia, scope, surgery, TR implant,
ICU, bandages, meds, would be $2200-2500 (US dollars).
---- Some surgical practices will include a number of weeks of post-op hydrotherapy sessions and/or
other rehab therapy as part of a package price for the surgery & recovery. It is important when comparing prices
to understand what is included in the quoted price.
---- A TR procedure takes about one third the time it takes to do a TPLO. About 20 minutes for
TR as opposed to an hour for a TPLO. This, together with the lesser complexity of the TR when compared to TPLO or TTA,
should result in considerably lower costs to clients. But many surgeons who are currently making very large profits
doing TPLO can be expected to try to charge similar outrageous prices for 'TightRope' if they can convince people to pay those
prices. I hear of that happening now. A profiteer is a profiteer, whether he is overcharging for TPLO or
'TightRope'.
---- When looking for a TR surgeon, remember that a higher price does not mean a better surgeon.
************************
Question:
"Max, After reading about the 'TightRope' procedure, I talked about it with the ortho-surgeon
my vet recommended . He says that 'TightRope' is too new. That because it is new it may have problems that haven't
become apparent yet. He says that TPLO has been around for years so he knows what could go wrong in doing TPLO.
He wants to do TPLO on my dog. Isn't it better to go with a surgery that is not so new?....."
---- It is usually wisest to be cautious about new techniques and materials until they have a
history of success. But 'TightRope' is not really a brand-new procedure. 'TightRope' is basically a well-known
type of extracapsular stabilization made more suitable for large highly-active dogs by advances in materials.
These new materials are not untested or unknown to medical use. The 'FiberTape' used in TR is new to veterinary use
but has been used for several years in human orthopedic surgery procedures. In my opinion the claim that TR
is too new to be trusted is not at all convincing. The potential complications associated with TPLO and TTA can
be much more serious than those with TR or any other conventional surgery, and I believe it is appropriate for me
to highly recommend conventional stabilizations done with these stronger materials, including the TightRope
procedure, as being very much preferable to TPLO or TTA for large high-energy dogs in most cases.
---- The adoption of new methods and materials can move slowly in medical / surgical treatment.
There are going to be a lot of surgeons out there still telling people that their dog needs a TPLO when in truth the dog would
be much better off with a less invasive and less risky conventional surgery using either nylon monofilament ortho-suture or
the new stronger materials. I very much prefer a surgery that does not alter the bone structure as TPLO &
TTA do, and does not expose the dogs to the substantial risks inherent in the much more invasive TPLO & TTA.
(Question continued)"...The TPLO surgeon also tells me that he
knows of several dogs who had TightRope done and had problems."
---- All the surgical procedures have potential complications.
Here are some statistics:
In the original study comparing TightRope to TPLO, 12.5% of the TightRope
dogs had complications, compared to 17.4% of the TPLO dogs. More recently, surgeons reporting on their TR results in a total
of 302 cases said that the outcomes were "Good to Excellent" in 93.7% of dogs. That is a few percentage points better than
would be expected with TPLO. More than half of the complications referred to above are minor in
both TR and TPLO groups.
___________________________________
Jimi Cook sent this following information March 27, 2009:
<<" Arthrex and I are 100% committed to continually monitoring and
reporting all outcomes and complications associated with TR intensively – we gather data from every center doing TR
that will send it to us and we badger them to report it to us – we know of no other company/technique/surgery group
doing this. From this constant monitoring (data on over 500 cases collected), we are seeing a worldwide infection rate
with TR of 3.1% for major infections and 2.2% for minor infections – this compares very favorably to reported rates
for TPLO, TTA, and lateral suture or any orthopaedic procedure done in dogs. ">
___________________________________
It is very important to be careful about proper activity restriction during
the months of post-op recovery. Activity must be sufficiently restricted to allow the new supporting scar tissue
to slowly develop without being damaged by excessive stresses on the joint. This takes months. People sometimes allow too much activity too soon. This can result in serious problems. Many surgeons are
too aggressive in their recommendations for increases in post-op activity. Dogs
who are not restricted properly will have greatly increased risk of failure. A slow, cautious, watchful approach to
activity increases during recovery is best by far whether the dog is recovering after surgery or without surgical intervention. The stabilizing material used in conventional surgeries will inevitably
stretch or break. Greater amounts of activity and higher stresses will speed the stretching/breaking of the suture
stabilization. If the dog's body has not yet fully developed new stabilizing scar tissue at the stifle when this happens,
there will be renewed instability at the stifle. A slow cautious approach to increasing activity during the post-op
recovery is best. The amount of time needed will vary with the dog's age and size, so it is not possible to state a
certain length of time will be needed to be confident that the re-stabilized stifle is safe from re-injury. Larger & older
dogs will require more time. Being cautious is always best when deciding on activity for a recovering dog.
Re-Injury After Conventional Surgical Stabilization?
There's more about how to handle this on the FAQ page.
________________________________
Finding The Right Surgeon
You will be able to discover whether a vet is familar with new ortho-suture materials by asking
what materials the vet would use in the conventional procedure for your dog. With small dogs and most non-highly-active
dogs, the standard monofilament nylon ortho-suture (like fishing line) will be fine. But if your dog is a bouncy active
large dog, the surgeon should be intending to use advanced materials and should be able to tell you about the type of ortho-suture
& bone anchors he would use. If you ask and he doesn't have good answers, he is not the right surgeon for your dog.
---- The TightRope CCL procedure was developed by James Cook of the University of Missouri in
association with the Arthrex company, which developes and markets medical products. I have a list of 132 surgeons in
the United States who have purchased 5 or more of the 'TightRope' kits from Arthrex as of March '09. If you email me
& ask, I will send you the list.
Dr James (Jimi) Cook, can be contacted at the University of Missouri. It is likely that
he will be able to name more surgeons near you who have experience with TR.
Here is his contact info.
James L. Cook, DVM, PhD, Diplomate ACVS
William C. Allen Endowed Professor for Orthopaedic Research Director, Comparative Orthopaedic
Laboratory
University of Missouri 900 East Campus Drive Columbia, MO 65211
There may be a vet referal service in your area which would have the names of surgeons who list
themselves with the service as doing TightRope CCL.
Many vet practices which are listed with referal services as performing TightRope have several vets in the practice but
only one of them is experienced in or interested in TightRope. I have heard of people making an appointment at a vet practice
which is said to do TightRope, but when they come in with their dog they are seen by a vet who knows nothing about TightRope
and immediately tries to sell them a TPLO. When you make an appointment, be sure that you are making an appointment
to see a vet who does TightRope, not whichever vet from the practice is available.
__________________________________________________________________________
