The ABCs behind the challenges of TPLO

For dogs with cranial cruciate ligament disease, this kind of activity is likely the “good old days.” Bigstock/chrisukphoto Ask any small animal veterinarians what they consider the “gold standard” approach for cranial cruciate ligament disease in dogs, and you will most likely hear, the “TPLO.”1-7 From veterinary school forward, we hear from surgeons that the tibial plateau leveling osteotomy (TPLO) delivers a more rapid recovery and return to normal function, even when compared to other surgical techniques such as the tibial tuberosity advancement (TTA) and the triple tibial osteotomy (TTO).8 In contrast to other procedures, the TPLO supposedly causes fewer complications, less meniscal injury, and slower progression of osteoarthritis. For those who are unfamiliar with this procedure and its history, the TPLO is a traumatic procedure, involving severing the tibia, changing the angle of the tibial plateau, and then plating the two parts of the tibia back together. By altering the dog’s anatomy, the veterinarian hopes to stop the proximal tibia from thrusting forward during weightbearing and locomotion for canine patients whose cranial cruciate ligament has failed.9 Proponents claim this “restores normal limb function,” but this is an impossible claim to defend.10 Altering structural conformation does not and cannot restore “normal” function for that dog, breed, or species. Moreover, one year after TPLO, medium- to large-breed dogs showed lower subchondral bone density in the lateral tibial plateau relative to controls, implicating changes in long-term loading patterns.11 Nearly all dogs exhibit patellar tendon thickening following the TPLO which can lead to pain and reduction in range of motion.12 Not so normal, after all. Despite the number of articles, mostly authored by surgeons, touting the advantages of the TPLO, no one procedure has demonstrated consistent superiority over others.13 As recently as 2022, veterinary researchers concluded, “[N]o method can be clearly preferred, as most of the studies evaluated were subpar. Studies with a high level of evidence are therefore urgently needed for such a common surgical procedure.”14 Furthermore, “Various surgical treatment options have been developed and established in treating this condition; however, there is no consensus on the most effective technique. Whereas intra-articular and extra-articular surgical techniques aim to stabilize the stifle joint by miming the function of the intact cranial cruciate ligament and, therefore, reduce the cranial drawer, they have shown deficiencies in restoring full functionality…. [T]here remains a lack of profound kinetic and kinematic studies, as well as high-quality clinical trials, which makes a review and comparison of long-term clinical outcome challenging.”15 Go for the gold? So, what, exactly is “gold standard care”? Does it mean a “treatment or procedure widely deemed to be the best available?”16 If the TPLO’s status as “top dog” is not based on research evidence, why do veterinarians perpetuate this claim? The market size for treatment of cranial cruciate ligament disease is close $3 billion.17 Clearly, this condition in dogs is generating income for an industry banking on clients opting for surgery. For a few thousand dollars, veterinarians can ostensibly learn to perform the procedure in a one- or two-day course18 and make that money back in a matter of days. The TPLO places a difficult financial burden on pet parents and can cause moral distress among those who prefer a less invasive alternative.15 Still, they are led to believe the TPLO would give their dog the best chance of having a high quality of life after cruciate rupture.19 To do anything less, proponents may imply, is robbing your dog of an ideal solution. Sometimes, the discussion ends there, with insufficient education of the possible final costs and extended healing phase. They may hear the term “most rapid recovery” applied to the TPLO but not realize even optimal results require months of limitations and rehabilitation. They may learn “[t]he cost of TPLO surgery can range from $3,000 to $8,000 or more depending on the dog’s size, the location of the veterinary clinic and the surgeon’s experience.”20 Yet, that may cover only the procedure itself. Imaging may add hundreds of dollars for radiographs or thousands for magnetic resonance imaging. Add charges for medications, orthotics, post-operative rehabilitation, and the correction or treatment of intra-operative and post-surgical complications, and the total may amount to well over $10,000. Unfortunately, published reports assessing injury rates from the TPLO likely undercount the true number, especially as more veterinarians without board certification in surgery take up the technique after a one- or two-day course.21-23 Complications to consider In the process of severing and plating the bone, vulnerable tissues in the region – nerves, vessels, 24 muscles, menisci,25and more, may suffer injury. Sometimes the attempt to repair the osteotomy fails. Several types of TPLO complications may require more surgery and negatively impact both short- and long-term outcomes.26 As stated by Zuckerman et al, “The efficacy of TPLO depends on several factors, including adequate rotation of the proximal tibial segment, appropriate positioning of the osteotomy, and fixation techniques that minimize post-operative change in tibial plateau angle (TPA).27 Furthermore, when complications occur, some may require surgical revision and prolonged antibiotic therapy.28 One study found major complications occur in over 27 percent of dogs weighing over 50 kg.29 Another reported the rate of complications range from 10 to 34 percent; they ranged in severity from swelling and bruising to fracture and osteomyelitis.30 Fibular fractures occur postoperatively in up to 15 percent of dogs and may result from the surgical technique itself (e.g., performed without the aid of a jig and the presence of unfilled fibular drill holes).27 A fractured fibula reduces overall stability and typically do not heal on their own in 45 percent of cases.27 This means some dogs may need a second osteotomy, i.e., one for the fibula. Now, as has happened in humans who have metal orthopedic implants, hypersensitivity reactions, including dermal metal hypersensitivity, are showing up in dogs. Delayed Type-IV hypersensitivity (DTH) may result from the release of metal particles in tissues due to wear, corrosion, and dissolution.31 The accumulation of metal ions from implants such as TPLO plates can become a trigger for the neoplastic transformation of nearby cells.32 While certain plates may demonstrate a higher rate of metal ion release, the development of osteosarcoma at implant sites may arise from ongoing inflammation generated by the presence of a plate, delayed healing, implant instability, or infection.32 In fact, “dogs with a history of TPLO were 40 times as likely to develop proximal tibial osteosarcoma as were dogs with no history of TPLO.”33 How many clients whose dogs may receive this procedure or have already done so received information prior to surgery that because of this experience, their risk of cancer multiplies 40 times? How many veterinarians who evaluate dogs with new or worsening hind limb lameness, one or more years after TPLO, include osteosarcoma in the differential? How many pro-TPLO websites even mention the terms “cancer” or “osteosarcoma”? Few to none. After all, if clients realized putting their dog through the reconfiguring trauma of the TPLO might not seem worth the investment if they realized they’ve just put their dog at a much higher risk of having an incurable cancer. They would need to look elsewhere for answers. Fortunately, alternatives exist; and, they have evidence. The massive amount of pro-TPLO media, perpetuated largely by surgeons and bone plate producers,34-35 tends to drown out discussion of nonsurgical approaches and their advantages over surgery.36 These approaches, such as integrative rehabilitation and physical medicine (IRPM) would begin by first with determining whether the stifle actually does exhibit instability. That is, if nature has stabilized the stifle with new bone formation (i.e., a “medial buttress”) after ligament rupture, no need for surgery exists. Nevertheless, some surgeons contend that finding a medial buttress in itself constitutes justification for surgery. According to one professor, “Shortly after CrCLR (cranial cruciate ligament rupture), most, if not all patients, develop a distinct, firm swelling over the proximo-medial tibia in the region of insertion of the medial collateral ligament….[This sign] provides ample indication for surgical joint exploration even in the absence of a cranial drawer sign.”37 That simply makes no sense. Why put the patient at risk of pain and injury and further drain client resources? How can any surgery designed to remedy tibial thrust help an animal whose has already solved this problem by their own innate healing processes? Even if a dog does show some stifle instability, whether the cruciate ligament is intact or not, many other soft tissues produce functional joint stability through sensorimotor control over joint integrity.38 Astute palpation of muscles and connective tissues that support stifle integrity gives the examiner insight into the balance of agonists and antagonists to cranial cruciate function. One may then choose from the wide range of IRPM techniques to resolve issues that instigate stifle imbalance. These include medical acupuncture,39 massage,40 photomedicine,41 stretching, therapeutic exercise, conscientious use of orthotics,42 and more.43 Many therapies that normalize muscle function also reduce pain, inflammation, and limitations in function. Platelet-rich plasma is rapidly rising in popularity for CrCLD, showing improvement in gait parameters and reduction in pain.44 In essence, who gets to decide that “gold standard” care is the TPLO, without sufficient evidence of superiority over other approaches, surgical or not? In 2002, the highly revered veterinary ethicist, Bernie E. Rollin, PhD, wrote a commentary on “The use and abuse of Aesculapian authority in veterinary medicine.”45 Drawn from a text that examined power differentials in human medicine,46 Rollin defines Aesculapian authority as, “[T]he uniquely powerful authority vested in those that society perceives as healers, historically traceable to the time when medicine was inseparable from magic and religion.”45 Rollin continues, “The ability to create powerful performative utterances accrues naturally to those possessed of Aesculapian authority. A physician or veterinarian is required to declare one sick and thereby create the sick role…[and], a physician or veterinarian can create uniquely powerful performative utterances. We have all heard of people who, when told by a physician, “you have only six months to live,” will obligingly die during that period (whereas others, less trustful of physicians, will make it a point to confute that prognosis). The same holds true of “you will never walk again” or “your animal will never walk again.” …Even if the veterinarian is physiologically wrong, many clients will not, after that pronouncement, attempt to have the animal walk, thereby, through lack of attempt or through subsequent muscle atrophy, validating the prognostication! It follows from this discussion that Aesculapian authority is an extremely powerful notion and, like any other power, is subject to abuse.”45 In this author’s opinion, our society endows surgeons with a surplus of Aesculapian authority – so much that even fellow professionals are loathe to challenge their recommendations. It’s time we level the playing field and begin talking about the true costs of the TPLO – not only for the clients but for the patients whose lives and limbs are put at risk with a “surgery first” mentality. Narda G. Robinson, DO, DVM, MS, FAAMA, is a graduate from Harvard/Radcliffe (AB), the Texas College of Osteopathic Medicine (DO), and Colorado State University College of Veterinary Medicine and Biomedical Sciences (DVM, MS). She served on the faculty of the CSU-CVMBS for 20 years and headed the Center for Comparative and Integrative Pain Medicine. She is vice-chair of the American Board of Medical Acupuncture, the board-certifying organization for physician acupuncturists, and is a Fellow of the American Academy of Medical Acupuncture. Dr. Robinson is the CEO and president of CuraCore MED and CuraCore VET, which educate human and veterinary practitioners in science-based integrative medicine and rehabilitation/physical medicine approaches. Her website is CuraCore.org. Opinions do not necessarily reflect those of VPN Plus+. References Veterinary Surgical Services Victoria Website. Accessed on June 14, 2023 at https://static1.squarespace.com/static/5b3e7bb712b13f681a61b5a8/t/5dbff453753cb13f2b3f9e0c/1572861012115/VSSV_TPLO_ClientFlyer_12.09.19.pdf The City Vet Clinic Website. Accessed on June 14, 2023 at https://thecityvetclinic.com/tplo-technique-the-gold-standard-for-cranial-cruciate-ligament-rupture-repair/ ACOSM Website. Accessed on June 14, 2023 at https://www.arizonacanineorthopedics.com/tplo.html . https://www.bonevet.com.au/review-articles/ccl-treatment-options/#:~:text=TPLO%20is%20currently%20considered%20the,commonly%20favoured%20by%20orthopaedic%20surgeons. https://www.youtube.com/@DePuySynthesVet/about https://www.embracepetinsurance.com/health/cruciate-ligament-injury Spinalla G, Arcamone G, and Valentini S. Cranial cruciate ligament rupture in dogs: Review on biomechanics, etiopathogenetic factors and rehabilitation. Vet Sci. 2021 Sep; 8(9):186. Doi: 10:3390/vetsci8090186. BoneVet Orthopaedics. Accessed on June 14, 2023 at https://www.bonevet.com.au/review-articles/tplo-tta-ecr/. Harasen G. Tibial plateau leveling osteotomy – part I. Can Vet J. 2004;45:527-528. Nanda A and Hans EC. Tibial plateau leveling osteotomy for cranial cruciate ligament rupture in canines: Patient selection and reported outcomes. Veterinary Medicine: Research and Reports. 2019; 10:249-255. Leach ES, Krotscheck U, Goode KJ, et al. Long-term effects of tibial plateau leveling osteotomy and tibial tuberosity advancement on tibial plateau subchondral bone density in dogs. Veterinary Surgery. 2018;47(4):566-571. Bergh MS and Peirone B. Complications of tibial plateau levelling osteotomy in dogs. Vet Comp Orthop Traumatol.2012;25:349-358. Boudrieau RJ. Tibial plateau leveling osteotomy or tibial tuberosity advancement? Vet Surg. 2009; 38(1):1-22. Wemmers AC, Charalambous M, Harms O, et al. Surgical treatment of cranial cruciate ligament disease in dogs using Tibial Plateau Leveling Osteotomy or Tibial Tuberosity Advancement – A systematic review with a meta-analytic approach. Front Vet Sci. 2022 Nov 30;9:1004637. Wemmers AC, Pawlak S, Medl N, et al. Economic considerations on costs and pricing of two surgical techniques for treating cranial cruciate disease in dogs. Animals. 2023;13:1505. Davidson J. Defining gold-standard care. Vet Times. June 2, 2021. Accessed on June 14, 2023 at https://www.vettimes.co.uk/defining-gold-standard-care/ . Jury Trial Proceedings, (January 5, 2023) US District Court, Middle District of Florida, Jacksonville Division, DePuy Synthes Products, Inc. v Veterinary Orthopedic Implants, January 2023. Case No. 3:18-cv-1342-HES-PDB, p. 110. https://nexus.vet/wp-content/uploads/2021/01/Tibial-Pllateau-Leveling-Osteotomy-TPLO-2-Day.pdf Colorado Canine Orthopedics website. Accessed on June 14, 2023 at https://www.canineortho.com/tplo/?gad=1&gclid=CjwKCAjwyqWkBhBMEiwAp2yUFvCDZc6fpw4DjM3SS6jrYRBHYmd-90lWp_ZxYBpJOylZoZR_7wu_8BoCVkYQAvD_BwE Pai M. How much does ACL surgery for dogs cost? (2023 Guide). Forbes Advisor. Updated May 16, 2023. Accessed on June 14, 2023 at https://www.forbes.com/advisor/pet-insurance/pet-care/acl-surgery-cost-dogs/#:~:text=The%20cost%20of%20TPLO%20surgery,clinic%20and%20the%20surgeon%27s%20experience. https://nexus.vet/course/tibial-plateau-leveling-osteotomy-tplo-1-day/ American College of Veterinary Surgeons (ACVS) Website. Cranial Cruciate Ligament Disease. Accessed on June 11, 2023 at https://www.acvs.org/small-animal/cranial-cruciate-ligament-disease. Engdahl KS, Boge GS, Bergström AF, et al. Risk factors for severe postoperative complications in dogs with cranial cruciate ligament disease – a survival analysis. Preventive Veterinary Medicine. 2021;191:105350. Matres-Lorenzo L, McAlinden A, Bernarde A, et al. Control of hemorrhage through the osteotomy gap during tibial plateau leveling osteotomy: 9 cases. Vet Surg. 2018;47(1):60-65. O’Brien CS and Martinez SA. Potential iatrogenic medial meniscal damage during tibial plateau leveling osteotomy. Vet Surg.2009;38(7):868-873. American College of Veterinary Surgeons (ACVS) Website. Cranial Cruciate Ligament Disease. Accessed on June 11, 2023 at https://www.acvs.org/small-animal/cranial-cruciate-ligament-disease. Zuckerman JS, Dyce J, Arruda AG, et al. Fibular osteotomy to facilitate proximal tibial rotation during tibial plateau leveling osteotomy. Veterinary Surgery. 2018;1-9. Montalbano C, Deabold K, and Miscioscia E. An understanding of the potential complications following TPLO surgery can help guide therapy and enable improved client counseling. Today’s Veterinary Practice. October 6, 2021. Accessed on June 3, 2023 at https://todaysveterinarypractice.com/rehabilitation/evaluation-after-tibial-plateau-leveling-osteotomy-a-guide-for-the-general-practitioner/ . Hans EC, Barnart MD, Kennedy SC, et al. Comparison of complications following tibial tuberosity advancement and tibial plateau levelling osteotomy in very large and giant dogs 50 g or more in body weight. Vet Comp Orthop Traumatol.2017;30(4):299-305. Bergh MS and Peirone B. Complications of tibial plateau levelling osteotomy in dogs. Vet Comp Orthop Traumatol.2012;25:349-358. Filliquist B, McKay R, Marcellin-Little DJ, et al. Metal reactivity is present in dogs with tibial plateau leveling osteotomy and total hip replacement implants. Am J Vet Res. 2023;84(3). https://doi.org/10.2460/ajvr.22.08.0141 Sprecher CM, Milz S, Suter T, et al. Retrospective analysis of corrosion and ion release from retrieved cast stainless steel tibial plateau leveling osteotomy plates in dogs with and without peri-implant osteosarcoma. Am J Vet Res. 2018; 79(9).DOI: https://doi.org/10.2460/ajvr.79.9.970. Selmic LE, Ryan SD, Ruple A, et al. Association of tibial plateau leveling osteotomy with proximal tibial osteosarcoma in dogs. J Am Vet Med Assoc. 2018;253:752-756. McVey CL. Two orthopedic surgeries in two years return retriever to eight-mile hikes. Cornell University College of Veterinary Medicine website. Accessed on June 15, 2023 at https://www.vet.cornell.edu/news/20180920/two-orthopedic-surgeries-two-years-return-retriever-eight-mile-hikes . DePuy Synthes Vet. TPLO Chapter 5: Benefits of TPLO. https://www.youtube.com/watch?v=7nZK4GcQXO8 Robinson NG. 5.13.2020 Ten Troubling Truths about the TPLO (Tibial Plateau-Leveling Osteotomy) CuraCore.org/VET. https://www.youtube.com/watch?v=knOUZCZAB4E Roush JK. Canine cranial cruciate disease: updating our knowledge about pathogenesis & diagnosis. Today’s Veterinary Practice. July/August 2013, pp. 16-20. Accessed on June 15, 2023 at https://todaysveterinarypractice.com/wp-content/uploads/sites/4/2016/09/T1307F02.pdf . Riemann BL and Lephart SM. The sensorimotor system, Part I: The physiologic basis of functional joint stability. J Athl Train. 2002;37(1):71-79. Xu J, Zhou X, Guo X, et al. Effects of unilateral electroacupuncture on bilateral proprioception in a unilateral anterior cruciate ligament injury model. Med Sci Monit. 2018;24:5473-5479. Zaita J. Massage therapy protocol for post-anterior cruciate ligament reconstruction patellofemoral pain syndrome: a case report. Int J Ther Massage Bodywork. 2008;1(2):11-21. Bublitz C, Medalha C, Oliveira P, et al. Low-level laser therapy prevents degenerative morphological changes in an experimental model of anterior cruciate ligament transection in rats. Lasers Med Sci. 2014;29(5):1669-1678. Hart JL, May KD, Kieves NR, et al. Comparison of owner satisfaction between stifle joint orthoses and tibial plateau leveling osteotomy for the management of cranial cruciate ligament disease in dogs. J Am Vet Med Assoc. 2016;249(4):391-398. Baker SJ and Baker GJ. Surgical versus nonsurgical management for overweight dogs with cranial cruciate ligament rupture. J Am Vet Med Assoc. 2013;243(4):479. Kaneps AJ. A one-health perspective: use of hemoderivative regenerative therapies in canine and equine patients. JAVMA.2023;261(3):301-308. Rollin BE. The use and abuse of Aesculapian authority in veterinary medicine. JAVMA. 2002;220(8):1144-1149. Siegler M, Osmond H. Models of Madness, Models of Medicine. New York: Harper Colophon, 1974;88–120.

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The ABCs behind the challenges of TPLO

It’s time for a new gold standard of care for cruciate disease in dogs

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