TPLO vs TTA vs ECR as surgical options for cranial cruciate ligament tears

TPLO vs TTA

Surgical options currently available for the management of canine cranial cruciate ligament tears include osteotomy procedures e.g. tibial plateau levelling osteotomy (TPLO) and tibial tuberosity advancement (TTA), and extra-capsular repairs (ECR) e.g. various lateral suture techniques, including more recent innovations such as the "tightrope" procedure. Unfortunately, there is a wealth of misinformation regarding these procedures; the purpose of this article is to reflect the veterinary literature as it currently stands by highlighting the published results of scientific studies conducted by veterinary researchers. The publication by Duerr et al presents a particularly compelling finding; amongst board-certified veterinary orthopaedic surgeons, there is an overwhelming preference for TPLO over TTA. This is supported by a growing number of publications in the veterinary literature which present objective evidence of superior results for TPLO vs TTA and ECR.

The excerpts presented below highlight key findings and/or sentiments of their respective publications. We would encourage reading all the information presented, and ideally each paper in its entirety.

Methodology: PubMed literature search for papers published since 2010 comparing surgical techniques for the management of cranial cruciate ligament tears in dogs. Search terms "TTA TPLO", "Canine cruciate ligament".  Pubmed can be found here: www.ncbi.nlm.nih.gov/pubmed

TPLO vs TTA

TPLO vs TTA vs ECR: key points from the literature

For a medium sized dog with a complete cranial cruciate ligament tear:

          *     71% of ACVS board-certified surgeons recommended TPLO
          *     15% recommended TTA
Duerr et al

 

"the TPLO group was the only surgical group to achieve normal function"
Krotscheck et al

 

"TPLO is a more appropriate recommendation for active patients, if not for all patients considering an osteotomy procedure."
Krotscheck et al

 

"TPLO and TR were superior to TTA in terms of dogs achieving full function"
Christopher et al

 

"TTA was associated with the most complications, including the highest rates of major complications and meniscal tears"
Christopher et al

 

"In our opinion TTA is not the best treatment for correction of cranial cruciate ligament disease in patients with TPA above 25°"
Ferreira et al

 

"Kinematic and owner satisfaction results indicated dogs that underwent TPLO had better outcomes than those that underwent LFS"
Gordon-Evans et al

Treatment of canine cranial cruciate ligament disease: A survey of ACVS Diplomates and primary care veterinarians

F. M. Duerr; K. W. Martin; M. Rishniw; R. H. Palmer; L. E. Selmic Vet Comp Orthop Traumatol. 2014

Method: Survey of ACVS board-certified surgeons (diplomates) and primary care practitioners.

For a medium sized dog with a full CCL tear what is your recommended treatment of choice?

  • 71% of ACVS board-certified surgeons recommended TPLO
  • 15% recommended TTA
  • 6% Extra-Capsular (lateral suture)
  • 2 % Tightrope

For a medium sized dog with a partial CCL tear what is your recommended treatment of choice?

  • 69% of ACVS board-certified surgeons recommended TPLO
  • 14% recommended TTA
  • 5% Extra-Capsular (lateral suture)
  • 2 % Tightrope

ACVS diplomates were asked how they had treated or advised treatment for a dog owned by themselves, a family member or friend? (All weight ranges included):

TPLO 64%     Extra-Capsular 15%     TTA 10%     tightrope 2%

Long-Term Functional Outcome of TTA vs TPLO and Extracapsular Repair in a Heterogeneous Population of Dogs

Krotscheck U, Nelson SA, Todhunter RJ, Stone M, Zhang Z. Vet Surg. Feb 2016

Method: Force plate analysis preoperatively, then 2 weeks, 8 weeks, 6 months and 12 months.

Results / Discussion: Our results demonstrate that at the walk, both the TTA and TPLO group achieved normal function, albeit the TPLO achieved normalcy earlier than TTA. The ECR group did not achieve normal function at the walk.At the trot, the TPLO group was the only surgical group to achieve normal function when compared to the heterogeneous control group, whereas the TTA and ECR groups did not.

Conclusion: Our results lead us to believe that the TPLO is a more appropriate recommendation for active patients, if not for all patients considering an osteotomy procedure. As there is no difference at the trot between TTA and ECR (lateral suture), surgeons should consider carefully which of these procedures is preferable when taking into account client cost and surgical risk.

Comparison of long-term outcomes associated with three surgical techniques for treatment of cranial cruciate ligament disease in dogs

Christopher SA VMD, CCRP, Beetem J RVT, CCRP, Cook JL. DVM, PhD, DACVS, DACVSMR Vet Surg. April 2013

Method: Retrospective clinical cohort study.

Results: TTA was associated with significantly higher rates of major complications and subsequent meniscal tears than TPLO and TR, and TPLO had significantly higher rates of major complications and meniscal tears than TR. Significantly more TPLO and TR cases were classified as reaching full function than TTA.  The highest levels, frequency, and severity of pain were noted in TTA cases.

Conclusion: TPLO and TR were superior to TTA in terms of dogs achieving full function, TR was associated with the fewest complications, and TTA was associated with the most complications, including the highest rates of major complications and meniscal tears.

Disclosure: Dr. James Cook is a patent holder on and receives royalties related to TightRope CCL

Short-term comparison of tibial tuberosity advancement and tibial plateau levelling osteotomy in dogs with cranial cruciate ligament disease using kinetic analysis

Márcio P. Ferreira; Cássio R. A. Ferrigno; Alexandre N. A. de Souza; Daniela F. I. Caquias; Adriana V. de Figueiredo    Vet Comp Orthop Traumatol 3/2016

Method: Dogs were divided into two groups in a non-random fashion. Dogs with tibial plateau angle (TPA) < 25 degrees received TTA (mean TPA=22.33). All dogs with TPA > 25 degrees underwent TPLO (mean TPA=28.13).  Barpodometry was carried out pre-operatively, then at 14,30,60 and 90 days to assess ground reaction force distribution at a walk.

Discussion: We rejected our hypothesis that TPLO would yield better weight bearing out- comes on baropodometry than TTA at 90 days after surgery, which probably was because of the short follow-up time period. It was previously demonstrated that six months after surgery there were better results with TPLO in comparison with lateral extracapsular suture and in comparison with TTA after (six months to) one year.

In our opinion, TTA is not the best treatment for correction of cranial cruciate ligament disease in patients with TPA above 25°. Similar recommendations have been made by Kim and colleagues, Ferrigno and colleagues, and Vezzoni.......... we chose to restrict the correction of cranial cruciate ligament disease by TTA to dogs with a TPA below 25° (in this study). Therefore the preoperative TPA differed significantly between the TPLO and TTA groups. ........Hence, findings in this group should be considered in the light of the smaller TPA, and not extrapolated to dogs with higher TPA treated by the same procedure. Also, a recent study suggested that the outcome following TTA is worse in dogs with a TPA greater than 28°, compared with TPLO.

Conclusion: Tibial plateau levelling osteotomy and TTA (patients with TPA below 25°) were associated with equally improved weight bearing (at 90 days) in dogs affected with unilateral cranial cruciate ligament disease, under the conditions studied.

Comparison of lateral fabellar suture and tibial plateau levelling osteotomy techniques for treatment of dogs with cranial cruciate ligament disease

Gordon-Evans WJ; Griffon DJ; Bubb C, Knap KM; Sullivan M, Evans RB   J Am Vet Med Assoc Sept 2013

Method: Randomised blinded controlled clinical trial. All dogs were randomly assigned to undergo LFS (n = 40) or TPLO (40). Outcome measures were determined prior to surgery and at 6 and 12 weeks and 6 and 12 months after surgery.

Results: Peak vertical force of affected hind limbs at a walk and trot was 5% to 11% higher for dogs in the TPLO group versus those in the LFS group. Owner satisfaction ratings at 12 months after surgery were significantly different between groups; 93% and 75% of owners of dogs in the TPLO and LFS groups indicated a satisfaction score ≥ 9 (scale, 1 to 10), respectively.

Conclusion: Kinematic and owner satisfaction results indicated dogs that underwent TPLO had better outcomes than those that underwent LFS.