TPLO -- Not A Good Choice

The praise you hear for TPLO comes from the people who are making large profits selling TPLOs. When people take their dog to an ortho-specialist vet, they expect a consultation with an expert who will provide them with the objective facts they need to make a well-informed decision. But if the consultation is with the wrong surgeon, what they get instead may be a TPLO sales presentation. The treatment of ligament injury in general, and their own dog's condition in particular, may be described in a slanted manner intended to influence them to agree to have an TPLO done on their dog although TPLO is seldom the best choice for dogs with ligament injuries.

What rates of success are really obtained with TPLO surgery?

--- No evidence-based objective research backs up the excessive claims made by many TPLO surgeons. Only the biased opinions and pseudo-studies of other TPLO surgeons support those claims.

(See this website's page titled "But the vet said...")

On his website, Dr Ron Hines DVM PhD quotes this statistic from an article published in The Journal of the American Veterinary Medical Association. (Dr Hines' statement is quoted in more detail on the 'Surgeons and Surgery' page) "An article in... the Journal of the AVMA does not give an overly optimistic evaluation of surgery for cruciate ligament damage. This paper found that only...10.9% of the dogs treated with tibial plateau leveling osteotomy (TPLO) regained normal leg function subsequent to surgery. ..."

--- This doesn't mean that the other 89.1% of dogs who have TPLOs have no use of the leg after a TPLO surgery and recuperation. While TPLOs can have complications resulting in ongoing pain, crippling, amputation or other very poor outcomes, most dogs recover after TPLO to the extent that they have at least moderate use of the leg.

--- Other treatment options have better success rates and less risk than TPLO.

--- Long-term outlook after TPLO is especially questionable.

The problems that can develop during and after a TPLO can be extremely serious.

---- All surgeries have risk, but there are some especially nasty potential complications that are specific to TPLO surgery:

-- Cracking and splintering of the bones where the metal plates are attached to bone with screws;

-- Persistent infections in the bones;

-- Failure of the patellar ligament due to increased stress on that ligament caused by the altered geometry of the joint.

-- Failure of the bone to knit back together.

-- Further damage to the joint menisci following the 'meniscal-release' often done in association with TPLOs.

-- Loosening of the metal plates caused by backing-out of the screws after surgery or failure of the screws' attachment from crumbling bone or other causes .

---Tibial tuberosity fracturing;

-- Spinal problems resulting from the altered bone structure;

-- Increased cancer rates associated with the metal implants.

-- And more.

With TPLO you have these risks, plus the risks that unavoidably exist in all surgeries, and all without a potential outcome superior to other treatment options. There is seldom a good reason to choose to subject your dog to these risks.

The most reasonable first choice when dealing with most dogs' ligament injuries is non-surgical treatment.

---- This is called 'Conservative Management' or 'Conservative Treatment'. Most dogs recover well from ligament injury without surgery. Carefully restricting a dog's activity to prevent excessive stresses to the injured leg is the best possible diagnostic tool to find out if the dog really requires surgery. A dog who improves over the course of 8 weeks of restriction and continues to slowly improve is almost certainly not in need of surgery. There is more information on other pages here at this website about the non-surgical treatment option.

---- For some dogs with ligament injuries, non-surgical Conservative Treatment will be ineffective, and surgery will be appropriate. In most such cases the best possible surgical success could be expected from a 'Conventional' (also called 'Traditional') surgery. Conventional surgery aims to stabilize the injured joint without altering the dog's bone structure. One type of conventional surgery, an 'Extracapsular Stabilization' procedure, done by an experienced and skilled vet, is the best choice for most dogs when surgery is needed. These procedures are much less invasive and less expensive than TPLO. While not risk-free, they do not have the horrific potential complications that are specific to TPLO. There is more information on conventional surgery and non-surgical Conservative Management elsewhere on this website.

When you want to find the truth about the qualities and reliability of a car you're thinking of buying, you look for objective evidence like that found in a 'Consumer Reports' review of the car. You don't just accept the statements of the car salesman about the car. He will profit from your decision to buy. He wants to convince you to buy, whether or not that is best for you. You need to recognize that the TPLO surgeon will make thousands of dollars profit on the sale if he convinces you to get the TPLO. Be skeptical of a TPLO sales-pitch. Most ortho surgeon vets are not crooks, but when large profits for the provider of a service are involved you need to be cautious in accepting his description of the situation as accurate.

--- There are several websites that describe good experiences people had with their dogs' TPLOs. On these websites you often see secondhand claims about TPLO, such as "My surgeon told me two-thirds of dogs he does TPLOs on have amazingly superior results and the other third does well too!..." I think these are written by honest good-hearted people who are happy their dogs recovered well. They haven't looked into the subject in any depth. They are simply repeating what they have been told by TPLO surgeons. Don't fall into the trap of accepting this kind of claim as true because you read it on a nice person's website. You need to look at the objective evidence, not the sales pitch. The sales-pitch may come directly from the surgeon or be innocently repeated secondhand by a dog-loving person you feel friendly toward.

Demosthenes said: "Nothing is easier than self-deceit. For what each man wishes, that he also believes to be true".

--- We would all like it to be true. When a surgeon recommends TPLO, we want very much to believe that there is available to us a remarkably superior, very successful surgery for our dogs. We want to believe that if we just pay a high price for this surgery then our dogs will recover wonderfully well. But the sales-pitch is not the truth. TPLO success rates are not superior. TPLO is an extremely invasive procedure which has mediocre success rates along with the potential for horrific complications.

Here's how Slocum Enterprizes, developer of the TPLO procedure, responded to an inquiry asking for information regarding problems associated with TPLO:

--- Question "...I am interested in follow-up studies regarding the type and frequency of problems encountered by surgeons while performing TPLOs, and also interested in information on post-op complications following TPLOs..."

--- Answer from Slocum Enterprises:

"...To answer your question regarding post-operative studies, there is no legal requirement between Slocum Enterprises and any veterinarian who performs the TPLO procedure to report their surgeries and/or complications to us. ..."

--- Why would Slocum Enterprises take this position when asked about complications associated with their TPLO procedure? Wouldn't you expect Slocum Enterprises to be making all possible efforts to gather information on problems encountered during TPLO surgery? Wouldn't feed-back about such problems and post-op complications make it possible to improve treatment? Why would they decide against gathering such information?

--- Or is it possible that in fact Slocum Enterprises does compile such information, but then keeps that information private under cover of a claim that the information was not legally required to have been gathered?

---- If a tire manufacturer reacted like Slocum Enterprises when asked about problems with their tires, what would you think was the likely reason?

Consider what orthopedic experts who are not selling TPLOs say:

Here is a quote taken from an email written by Gail Smith, Professor of Orthopedics and Department Chairman at the University of Pennsylvania Vet School:
"... [In regard to TPLO there is a] virtual absence of research to show that this highly invasive and expensive method has any benefits whatsoever in post operative clinical function over other less invasive and expensive methods. I have taken a stand early in my career to avoid endorsing procedures that are not evidence-based ...and TPLO is a classic case of surgeons ... jumping on the bandwagon without adequate investigation to demonstrate the purported benefits of the procedure.

Sincerely, Gail"

[Gail Smith - Professor of Orthopedic Surgery; Chairman, Dept of Clinical Research, University of Pennsylvania Vet School]

--- I think there is one main reason those vet-surgeons Professor Smith refers to "jumped on the TPLO bandwagon". That reason is money. TPLO is a very high-profit procedure. It would not be realistic to believe that this very large profit potential could not influence surgeons' treatment recommendations.
---- Training to do TPLO is a few hours and a few hundred dollars at Slocum Enterprises' training facility. Or a vet can simply buy a teaching DVD from Slocum, watch it, spend several thousand dollars buying from Slocum Enterprises the special saw and other equipment required and he's ready to do the surgery. Costs involved in doing the procedure are very small relative to the price charged. There is a huge profit.
---- The TPLO procedure usually takes between one and two hours. (Some vets have been known to do 6 or more a day.) Surgeons commonly charge well over $2500 and sometimes over $4500. It is not at all unusual for an ortho-surgeon vet to do over 1000 TPLOs in a few years as part of his practice. If we use an estimate of $2000 in profit for each TPLO (and that's a very low estimate of the average profit), the surgeon makes two million dollars in profit on 1000 TPLOs. This one type of procedure has tripled the income of a bunch of orthopedic specialist vets.

[ With the patent now expired, TPLOs are being sold somewhat more cheaply by some surgeons in some locations. This does not make TPLO a better choice.]

---- When I first looked into ligament injury treatment, I assumed that a TPLO must be a very time-consuming operation which required expensive specialized equipment. Why else would it cost well over $3000? But I learned that a TPLO didn't take long and the equipment & training costs to the surgeon were modest. Why the high cost to dog owners then? The TPLO surgeons I talked with could offer no good explanation for the cost. In my opinion the explanation for the high price is that Slocum Enterprises originally set up the marketing of the patented TPLO with high profits for surgeons built-in in order to attract ortho-specialists to adopt the procedure, and that pricing has usually been maintained (unofficially with a wink and a nod) among TPLO surgeons since the patent expired. It is easy for surgeons to market this procedure at this high price because dog owners love their dogs and are easily convinced that the high cost means it is a superior procedure. People are inclined to trust medical professionals. If an ortho-specialist vet tells them TPLO is the best, they seldom question his motives. The high price can even be a selling point. "You love your dog and want the best? The surgeon recommends TPLO and it is quite expensive. Must be good if it costs so much, eh?"

---- TPLO's profitability has fueled its popularity among vet ortho-surgeons. The very high profit in TPLO surgery has led to a great increase in a special kind of risk for dogs. The risk of being subjected unnecessarily to a very invasive surgery which involves the possibility of horrific complications. Dogs may be subjected to TPLOs simply because of the procedure's profitability for the surgeon. Some dogs are maimed and crippled by TPLO surgeries when they would have recovered well without any surgery or with a less invasive surgical procedure. This happens because there are thousands of dollars of profit in every TPLO.

---- Some TPLO surgeons are truly despicable in their willingness to put dogs at risk with inappropriate TPLOs. In my email I often hear from people who have been given a sales-pitch for a clearly inappropriate TPLO procedure. For example, sometimes dogs have a limp but recover well while waiting a few weeks for an appointment with an ortho-specialist. Quick recoveries like that indicate the dogs had minor injuries for which no honest vet would recommend surgery. But when seen by the TPLO surgeon they are often diagnosed as needing TPLOs. It seems that there are a number of TPLO surgeons who try to sell TPLOs to everyone who comes through their office door. In fact, you don't need to come through the door to get the sales pitch from some of them. --- I hear of dogs diagnosed over the phone by ortho-specialists as needing TPLOs ("Limping? Needs a TPLO then. Lets set up a surgery appointment right now on the phone.") People write me that they have had TPLO vets try to frighten them into agreeing to the surgery by telling them that they must choose between TPLO and amputation, or in other cases that they must choose between TPLO and euthanasia.

---- All this malpractice is driven to a great extent by the extremely high profit in each TPLO.

Our dogs' best interests are not served by our blindly trusting that all vets have as their primary concern the welfare of our dogs. That is not the case. There are some vets who are building fortunes on our love for our dogs and our misplaced trust.

Just look at the facts and think it through:

--- Can anyone point to real evidence that TPLO should be preferred for some reason except in the rare circumstances described lower on this page? Can anyone show any reason to believe TPLO is a generally superior treatment option for ligament injury? That is, show real evidence from objective studies, rather than opinion-piece pseudo-research articles from ortho-surgeons who have made millions doing TPLOs?

--- Can anyone believe some TPLO surgeons are not profiteering? Does anyone think several thousand dollars is a reasonable profit for vets who do this procedure in an hour and a half?

--- Can anyone believe that the excessively high profits made doing TPLOs aren't a factor in Ortho-surgeon vets' surgical recommendations?

--- Could referral fees paid by TPLO surgeons to general practice vets influence them to send ligament-injured dogs to the TPLO surgeons?

You may be thinking:

----"My vet isn't like that. He wouldn't send Fido to a TPLO surgeon unless he believed it was best."

---- You may be right that your vet is not someone who would do this kind of thing to dogs for money. Many honest vets are misled by the claims that they hear from TPLO surgeons. It is true that improvement in leg use in the first few weeks after TPLO or TTA will be better than with non-surgical treatment or conventional surgery. Long-term results are not superior with these very invasive procedures, and the risks of serious complications are much greater, but this rapid improvement in the short-term may have influenced your vet's opinion of the procedures. Also, general-practice vets depend on specialists to be the experts in their fields. If the ortho-specialist vets they know are saying "This TPLO is a great thing!" then many general-practice vets will just accept that as true. To see the problem with TPLO, they would need to first recognize that greed could be affecting some ortho-specialists' views of treatment. Then they would need to dig into the professional literature with an eye to weeding out the subjective, self-interest-based articles while looking for evidence-based objective research in order to find the truth. GP vets are very busy with their patients and can't keep up with what's new in dozens of different specialized areas. They depend on ortho-specialists to be knowledgeable and objective in recommending treatment for this kind of injury. So it's easy for claims to be made by specialists and accepted by your regular vet. Your vet could honestly believe that TPLO is a worthwhile procedure for all dogs based on what some TPLO surgeons have told him.

---- The surgeons who convinced him may have tripled their incomes and become millionaires doing TPLOs. It is not hard to understand why some ortho-specialists see TPLO so favorably. If a plumber makes ten times the profit in the same time installing sink 'B' as he does sink 'A', which sink will he tend to think of most favorably? Which sink is he most likely to recommend? Plumbers and surgeons are equally human and equally subject to human weaknesses. When the plumber tells you "This sink 'B' is great!", he may really believe it. His opinion of sink 'B's attributes has been affected by self-interest. The surgeon's opinion may likewise be affected by self-interest.

---- What we must do to make the best decisions for our dogs is to be skeptical about the expressed opinions of anyone who will profit from our acceptance of their recommendations. When the profit will be very large, our skepticism should also be large. We automatically do this in most situations where someone wants to sell us something. But we tend to trust medical professionals more than we should.

---- The trust we place in vets and our expectation that medical professionals will not be influenced by profit help create this situation. The ortho surgeons who recommend and do inappropriate TPLOs bear the most responsibility. But we as our dogs' decision makers are also at fault. Blindly trusting that a TPLO surgeon's recommendation is not affected by the large profit he makes on the procedure is not wise. We should know better.

"...Medical history is littered with once-popular procedures that subsequently proved ineffective or dangerous. ..."

---A quote from Consumer Reports 'On Health'