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Options for Cruciate Ligament Disease Treatment

 

This page is a bit wordy - bear with me... 

So, we know how the condition occurs, and also how it is diagnosed. What about options for treatment? This is a big one. 20 years ago it was generally considered that while big dogs needed surgery for a cruciate rupture, small dogs could probably do without. This is predominantly because 20 years ago we didn't as a profession have a good, reliable solution for cruciate ligament rupture in all cases. Luckily, now we do. 

If you got twenty veterinary surgeons who were specialists and non-specialists in a room, and asked: "Which cruciate ligament repair method do you use and why?", you would likely get quite rapidly get an argument, sometimes reasonably heated. Everyone has their favourite.

But aside from academic interest it is probably true to say that a good canine cruciate surgeon has access in their armoury to many choices of surgery, although they might have a default setting choice, there are perhaps reasons sometimes that a different surgery is better suited to an individual case.

Roughly speaking the surgeries are divided between:

1. Surgeries which neutralise the forces previously discussed which act on the ligament, stabilising the joint with the existing, previously under-used structures. These are the Tibial Plateau Levelling Operation (TPLO), Tibial tuberosity Advancement (TTA), Triple tibial osteotomy (TTO) and tibial wedge osteotomy (TWO) surgeries.

Dr Franklin has performed all of these surgeries within the last 12months, for one reason or another, but his 'default setting' for this type of surgery is the TPLO procedure. For dogs which require stabilisation of a kneecap along with a cruciate ligament instability - he occasionally chooses a triple tibial osteotomy. There are few situations where he would preferentially choose to perform a TTA surgery, in Dr Franklin's experience (and that of a large number of specialists also) the surgery doesn't perform as well as TPLO, TTA remains an option in our clinic if for some reason it is desired.

2. Surgeries which replace the ligament with an implant which performs a similar function to the original ligament (note I said similar function, this is because we don't have a like-for-like anatomical replacement in the style of a human surgery, access to the correct regions of the joint is too difficult.). These surgeries are loosely termed 'Extra-capsular cruciate techniques', as that is where the implant goes - 'extracapsular' - outside the capsule. Some examples are the 'Tightrope' , "Corkscrew - Suture Anchor', 'De-angelis', "Fabello-tibial suture' techniques.

At PVC many of our branch vets are happy to perform one or many of these techniques, Dr Franklin is intermittently employed by Device techologies (Australian distributers of the Arthrex 'tightrope system') to demonstrate the 'tightrope extracapsular cruciate' method, and it remains his default setting for this type of surgery.

Choice of Surgery:

It is advised in our clinics that in medium to large size dogs, and in athletic dogs, that the best choice is the TPLO. This is due to the mounting evidence that the TPLO is capable of getting dogs back to normal function (as measured by pressure plate analysis and thigh diameter). It is also the best choice for partially torn ligaments, as it has been shown to preserve a partially torn ligament in those dogs who have sufficient function left in their cruciate to be useful. TPLO is (compared certainly to TTO and TWO) the surgery on which the lion's share of the research is performed, and is therefore more 'backable' based on facts rather than word of mouth.

TPLO is the gold standard cruciate ligament technique of all the veterinary surgical specialists in Melbourne, and across the USA too.

There is no reason not to do a TPLO in a smaller dog (<15kg) , they will do very well with a TPLO, it probably is still the gold standard solution. It is just that a small dog will also often do very well with an extra-capsular cruciate ligament technique, such as a tightrope. The tightrope is cheaper to perform than a TPLO surgery, and is available in all of our branches, although I still do perform these surgeries.

Dr Franklin has statistics for complication rates for these surgeries in his hands - which we have listed on a separate page.

As with the bone cutting surgeries - it is important for a cruciate ligament surgeon to have range of surgeries at their disposal - so that you can be sure the surgery suggested is not purely suggested due to the fact that the surgeon can only perform that one surgery. This way you can be sure your pet is getting the best possible treatment, not just the best available.

Dr Chris Franklin (Jan 2018)