Almost all websites about TPLO and TTA are the sites of surgeons who are
selling these high-profit surgical procedures. This page is here to provide you with the facts about TPLO and TTA that you
won't find at TPLO and TTA surgeons' websites or hear from them at their offices.
---- Sometimes surgical procedures become more popular with
surgeons than comparative results and risks justify. This is the case with TPLO and TTA, which are useful procedures in some
rare circumstances, but are not the best treatment choice for most dogs with ligament injuries. There are some
honest vets who have been caught up in this faddish enthusiasm for aggressive bone alteration as a ligament injury treatment.
There are other surgeons who are simply profiteering. They are making fortunes selling these hugely profitable procedures
to people who love their dogs and accept vets' recommendations too readily.
Ligament injuries cause a dog's stifle joint (the canine knee) to be unstable. Many dogs
can re-stabilize the stifle without surgical intervention. But some dogs cannot and will need surgery. For most
dogs with ligament injuries which need surgical intervention, the best surgical choice has always been one of the procedures
which provide stabilization for the injured joint. TPLO & TTA do not stabilize the stifle joint, but instead
alter the relationship between the bones of the leg as described below. The surgical procedures which do stabilize the stifle
are referred to as 'Conventional' surgeries and are described in more detail elsewhere on this website. These conventional
stabilization procedures have much less risk of serious complications and catastrophic failure than the bone-cutting
surgeries TPLO & TTA.
---- Until recently the bone-geometry alteration of TPLO or TTA could be the best surgical choice
for very large, highly energetic dogs. This was because the only materials previously available to be used
in conventional stabilizations were not strong enough for the pressures a large, high-energy dog would put on them. In
the past, conventional stabilizations with the old materials were failing too often with that kind of dog. Now
new ortho-surgical materials have changed the situation so that TPLO & TTA are no longer the best choice for the vast
majority of even large high-energy dogs.
---- While they used to be a reasonable choice for those big high-energy dogs,
TPLO & TTA were never a good choice for most dogs with ligament injuries. For the vast majority of dogs with
a ligament injury, the best strategy has always been to re-establish stability at the joint, not to radically alter the dog's
bone structure. But in recent years the 'trendy' surgical bone alterations TPLO and TTA have been widely recommended
for almost any dog who had a ligament injury.
----There are no Class I or Class II research studies supporting claims that there
is any advantage to TPLO or TTA over other treatment choices. After talking with a TPLO orTTA surgeon, you may have
the impression that these surgeries are universally believed to be the best possible treatment choice for all dogs with ligament
injuries. That is not true.
---- TPLO surgeons claim to have wonderful success rates when they speak to potential customers.
Since this website has been up, I hear of TPLO tragedies and poor outcomes daily, yet almost every TPLO surgeon I speak with
tells me his record of TPLO success is near perfect. The statistics from research on TPLO results do not support
the claims TPLO surgeons make. Someone must be bending the truth. Is it the dog owners and the objective researchers?
Or is it the surgeon who wants to sell you a $3500 one-hour TPLO surgery?
In recent years the very profitable TPLO and TTA have unjustifiably grown in popularity among
surgeons. If a vet has told you your dog should have a TPLO or TTA procedure, this is probably not true.
TPLO & TTA are not best for the dog in most cases where they are recommended.
---- Situations where TPLO or TTA are the best surgical choice do exist, but these situations
are rare. TPLO may still be the best surgical choice when the TPA is pathologically steep (see section on
TPA lower on this page) or when there is angular limb deformity or patella luxation associated with the ligament rupture.
These situations are a small minority of ligament injury cases.
It is simply common sense that the best approach to treatment is the method that provides the
best results with the least risk. TPLO & TTA are not the best choice for most dogs because these methods
do not have superior expectable results for most dog's ligament injuries but do have greater risk of serious
complications and potential catastrophic failure. TPLO & TTA also provide a very high profit for the surgeon.
That is the root of the problem. TPLO & TTA are now commonly recommended for
any ligament injury by some ortho-surgeons, regardless of the dog's size, age, or activity level.
Question: "Does it ever happen that a surgeon misrepresents the facts about a dog's
injury in order to sell a high profit procedure?"
---- Yes, that does happen. You need to be cautious. Some profiteering surgeons will tell
people that their dog has some congenital bone defect or in some other way is doomed to a horrible fate of crippling arthritis
unless the clients buy the surgery the surgeon is selling. Be cautious & skeptical.
*********************************
While many dogs do recover at least moderately well after TPLOs or TTAs, and some have very good
recoveries, these successes do not change the fact that these procedures have much more risk of very serious complications
and catastrophic failure than the alternatives. TPLO & TTA have much greater risk without any reasonable expectation
of better results than dogs have with conventional surgery. The wise choice in ligament injury surgery is the one that
gives the best results with the lowest risks of serious complications. That will not be TPLO or TTA in most cases.
The UPDATE at the bottom of this page describes the recent advances
in surgical treatment mentioned above.
____________________
'TPLO' stands for Tibial Plateau Leveling Osteotomy.
This surgical procedure cuts off one of the bones of the dog's leg using a special kind of power saw to make an arc-shaped
cut, then rotates one section of the bone through part of the arc, and re-attaches it at a different angle with a metal plate
and screws. This reduces the Tibial Plateau Angle, (the TPA).
---- 'TTA' stands for Tibial Tuberosity Advancement.
This is another leg-geometry-altering procedure which accomplishes an effect similar to TPLO's by altering the dog's bone
structure in a different way to achieve the result of lessening the TPA. It is somewhat less invasive than TPLO.
---- The idea behind both TPLO and TTA is that changing the leg bones' relationship
to each other in this way to decrease TPA will make stifle stability less important for joint function. This is true
to an extent. Dogs will often bear weight on the leg more quickly in the time period shortly after TPLO or
TTA. But longer term results are not superior and there are significant risks of catastrophic failure and severe
complications with these very invasive surgeries.
This
website was last updated in June 2009.
The
information here is current and accurate.
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
a TPLO or TTA done on their dog.
In searching for information on TPLO or TTA, when you see articles that speak highly of TPLO
or TTA, look to see who the author is and what his relationship to these procedures is. Does he sell these highly profitable
procedures? Chances are that he does. There are many Class III and Class IV "studies" by TPLO & TTA surgeons
which claim great outcomes for the surgeries which are their bread & butter. This kind of article is not true research,
but self-serving subjective opinion, as is explained on this website's page titled "But The Vet Said...". Link="But the vet said..."
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.
--- On his website, Dr Ron Hines DVM PhD quotes this statistic from an article published in The
Journal of the American Veterinary Medical Association:
"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 sometimes have complications resulting in ongoing pain, crippling, amputation
or other very poor outcomes, most dogs recover after TPLO or TTA to the extent that they have at least moderate use of the
leg. However, other treatment options have better expectable success and less risk of severe complications
than TPLO or TTA. Long-term outlook after TPLO or TTA bone alteration surgeries 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'. Many
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 efforts will be
ineffective, and then surgery will be appropriate. Conventional stabilization surgery, done by an experienced and skilled
vet, is the best choice for most dogs when surgery is needed. Conventional surgery aims to stabilize the injured joint
without altering the dog's bone structure. Conventional surgical 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 treatment 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:
"Self-deceit comes easily.
For what each man wishes to be true,
that same thing he will readily accept as true".
--- We would all like it to be true. When a surgeon recommends TPLO or TTA, 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 & TTA success rates are not superior. They are extremely invasive procedures which
have 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 less than one hour. (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 Slocum Enterprises patent on TPLO now expired, TPLOs are being sold at a lower price 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 over $3000? But I learned
that a TPLO didn't take long to do, 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-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. 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 may be 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 as needing TPLOs
("Limping? Needs a TPLO then. Lets set up a surgery appointment right now on the phone.") And people write
me that they have had surgeons 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 brought about by the extremely high profit in each TPLO / TTA.
Our dogs' best interests are not served by our blindly trusting that all vets have as their primary concern the
welfare of our dogs. There are some vets who are building fortunes on the combination of 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?
--- Can anyone believe that the excessively high profits made doing TPLOs aren't a factor in
ortho-surgeon vets' 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 mistakenly favor TPLO. 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. Longer-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 procedure!" 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 preferable
for dogs based on what 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 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. Even well-meaning
surgeons' opinions may be affected by self-interest in the same way.
"TPLO is a great procedure!"
Great for who?
What you must do to make the best decisions for your dogs is to be skeptical about the expressed
opinions of anyone who will profit from your acceptance of their recommendations. When the profit will be large, your
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'
TPA --- Tibial Plateau Angle
"My 2 year old dog has been improving slowly in the weeks since his injury, but when
I took him to an ortho-specialist I was told he needs TPLO. The vet did measurements of the joint and told me the 'Tibial
Plateau Angle' was too steep and that meant Fido had to have TPLO on the injured leg. And he said that Fido should also
have a TPLO on the other rear leg because the angle is too steep and Fido is bound to injure that leg the same way.
It sounded reasonable the way he explained it. Doesn't Fido need TPLO on both legs because of those steep angles?"
---- Probably not. A dog's Tibial Plateau Angle (TPA) is seldom a reason for surgery.
Although many TPLO surgeons claim that the basic design of dogs' legs is flawed in this way, objective research shows that
a steeper Tibial Plateau Angle (TPA) which is within the normal range is not associated with ligament injury in dogs.
In rare instances a dog may have a TPA which is pathologically steep. This would be a TPA over 32 degrees. (Some experts would
say over 30 degrees.) If your dog grew up from puppyhood without recurrent stifle problems and then had a ligament injury
as an adult, it is highly unlikely that he has pathologically steep TPAs. When a dog does have TPA over 30-32 degrees,
this would be an instance where TPLO would be the appropriate surgical choice.
---- I need to add a warning here. There are some TPLO surgeons who, to be blunt,
are crooks pushing overpriced unnecessary surgeries. They may lie about the TPA measurement or anything else in order to sell
you on the TPLO. They will say anything to frighten you into buying the TPLO they are selling. Most vets are honest,
but as in all professions, there are some who are not.
---- Dogs with steeper TPAs which are within the normal range are not more likely to have
ligament injuries, nor are they necessarily going to need surgical help to recover. If your dog improves with careful restriction
after the injury, and slowly continues to improve, then no surgery is needed, regardless of what a TPLO surgery salesman told
you. If your dog cannot improve when activity is properly restricted, surgery may be necessary, but in most cases TPLO
would not be the best choice.
Here is the summary from a Swiss research study on this subject:
VCOT - Veterinary and Comparative Orthopaedics and Traumatology 2004 17 4: 232-0.
Tibial plateau angles with and without cranial cruciate ligament rupture
Division of Clinical Research, Department of Clinical Veterinary Medicine,
University of Berne, Switzerland
Summary
The tibial plateau angles (TPA) of dogs with and without cranial cruciate ligament (CrCL) injuries were evaluated and
further compared to the TPAs of dogs from a previous population and of wolves. Similar TPA measurements were found in all
groups, suggesting that any possible changes in breeding practices, breed preferences, nutrition or other factors have not
significantly influenced the TPA over time. Moreover, a difference was not found in the TPA between any group and
the group affected with CrCL injury, suggesting that the TPA is not a clinically relevant predisposing factor in the development
of canine CrCL rupture.
UPDATE
As was mentioned at the top of this page,
new developments in materials have made TPLO & TTA inappropriate for most of the large high-energy dogs for whom these
procedures used to be the best choice.
---- Conventional stabilization surgeries
have always been the best surgical choice for most dogs who could not re-stabilize an injured joint non-surgically.
These surgeries are much safer and less invasive than TPLO or TTA, and do not alter the dog's bone's natural relationship
to each other as TPLO & TTA do. But large, highly active dogs have had a higher risk of failure of conventional
stabilization surgeries since the orthosuture used to stabilize the joints in these conventional surgical procedures sometimes
could not withstand the pressures from big active dogs during the months of post-surgical recovery. So with large
highly energetic dogs, when the ligament injury was severe, and non-surgical recovery was not successful, it was appropriate
to have one of the bone-geometry-altering procedures TPLO or TTA in preference to conventional stabilization surgery.
Now that has changed since it has become possible to overcome the problem of insufficient material strength in
the stabilizing materials.Advances in materials available for conventional stabilization make it possible for conventional stabilization
surgeries to be several times stronger and more resistant to breaking/stretching/abrasion than was possible with the previously
available materials.
---- 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. Using these new materials makes possible a stabilization that is several times
stronger than with the old conventional surgical materials.
---- In light of these developments, the
TPLOs and TTAs which have been considered the best choice for large, high-energy dogs will no longer be appropriate in most
circumstances.
Please see the 'Conventional
Surgeries / TightRope' page here at this website for more on this.
