Tibial plateau leveling Osteotomy in Dogs


Cruciate ligament treatment and TPLO surgery Question: Mike, Thanks so much -- your email reply helped me to sort things out and take action. I have read it several times and will continue to go over it. I have some questions, and have put them all together, at the end. Dr. D. will be coming to the house tomorrow or Thursday, and he will bring the reversible anesthetic with him so he can examine Junior's leg. As you suggested, I will ask him to decide if X-ray is needed after he has examined Junior. He did immediately mention surgery, if it is the ligament, and he was sounding like "immediately." The trip for my grandaughter's birthday is buying me some time, as I cannot possibly cancel it. I forgot to tell you that, after the injury occured, even though Junior intermittently walked holding that rear leg off the ground, he continued his habit of jumping high in the air and landing on both hind legs, when excited (e.g., when it was meal time). In order to prevent this, I have been feeding him before regular mealtime, but today, when he saw me coming out to bring him inside, he performed that jumping feat again. I am hoping that if a 78 pound dog can jump so that his nose reaches the top rail of a six foot kennel, land squarely on both back legs, and bounce right back up again like a pogo stick, it means he cannot have a fracture. I am even hoping that it means that he cannot have a torn or partially torn cruciate ligament. Junior still sometimes keeping that foot off the ground, sometimes walking on all fours with a mild limp, and sometimes (briefly) trotting or loping along quite naturally. Never seeming to be in pain, always in high spirits. Just when I think maybe he might get over it, there he is, holding that foot off the ground, looking at me, accusation in his eyes, like, "Well, Mom, what are you going to do about this?" After reading your email, TPLO is the only surgery I would consider, and I sure would love to avoid that, as well, since the long term results are not yet in. We would gladly pay the same amount of money for some non-surgical treatment, if it would help. I fear this, thinking of all the usual risks of surgery, and, too, I sense it has the potential for becoming a nasty business -- somehow the risk of complications and/or some persistent infection come to mind -- and then there is the pain and trauma and that long convalescence for Junior, who currently seems rather undisturbed about his condition. And after all that, it may not be of any help. Since you say that, if it turns out to be the ligament, given Junior's age, you would do the TPLO, I would like to read about the procedure, and if you can refer me to something to read on line, I would be very grateful. We'll be picking the dogs up from the boarding kennel on 12/27, about four weeks from the time the injury occurred, so I will have two additional weeks to observe him after we return (within the 6 weeks time frame), and I will mention the aspirin and glucosamine/chondroitin supplementation to Dr. D. Questions: 1-Would the fact of Junior's jumping feat reduce the likelihood of his having a torn or partially torn cruciate ligament? 2-If Junior does have a partial or complete cruciate ligament tear and I decide against any kind of surgery, what would be the prognosis for Junior? 3-Is there anything you can recommend that I read, to support or dispute my bias against traditional surgery? 4-Would it be accurate to say that, if there has been a tear or partial tear, Junior may never again be quite the same as before, *whether or not we have surgery done*? 5-Would it be accurate to say that there is the likelihood of some arthritis developing, no matter what course of action we follow? 6-During the six week period, what is the extent of the exercise Junior should be allowed? I must say, once again, that I cannot imagine taking care of all these dogs without your expert and kind counsel. Thanks, Mike. helen Answer: Helen- There are a bunch of web sites that can be located by using a search engine like Google and typing in "tibial plateau leveling osteotomy canine" (without quotes). The originator of this surgery wrote the first site listed below --- but never updated it (he died, so it won't ever be updated, probably). http://www.slocumenterprises.com/anterior_cruciate_ligament.htm http://www.petsurgery.com/tibialplateaulevelingosteotomy.htm http://www.medvet-cves.com/Articles/TPLO.htm The signs that you are seeing are pretty suggestive of a partial tear but might also be seen with cartilage damage in the knee, which sometimes occurs without cruciate ligament injury. It is also possible that hip dysplasia is present and was exacerbated by the play, or that a strain or sprain occurred in any of the joints or muscles. I am still most suspicious of a partial tear in the cruciate ligament, though. A lot of dogs have the ability to have normal activity but still seem slightly lame between bouts of doing normal things when there has been a partial tear. One of the sites mentions taking X-rays to look for degenerative arthritic changes but it takes at least three weeks and usually more like six to eight weeks for these changes to be visible on X-rays. When we suspect cruciate ligament ruptures we often have the X-rays reviewed by a radiologist because they are good at seeing the subtle signs but not imagining them (which is my specialty). Once in a while partial tears don't progress. We had a doberman when we first got married who had a partial tear diagnosed by arthroscopy (so pretty certain) but she got better clinically (no lameness) and never did experience a worsening of the tear, although she only lived about 2 years after it happened. 1) reduces the likelihood of a complete tear by a lot. Doesn't rule out partial tears or degeneration of the ligament that sometimes occurs as an aging change. You almost completely rule out a fracture of anything bigger than a toe at this point. 2) Our experience has been that almost all dogs will develop arthritis after a complete tear, most after partial tears. Most dogs do reasonably well without surgery but may require pain relief medications later in life when the arthritis gets more severe. 3) I think the articles above have references to the problems with traditional surgery. There are no studies that I know of that compare surgery success to doing nothing over the lifetime of dogs who have one or the other experience. I think that these studies don't exist because they never looked very good for the surgery and so surgeons weren't too interested in doing them. But that could just be my biased opinion, too. 4) So far the two dogs in our practice who I have seen post surgically seem to be doing really well with the TPLO surgeries. One is a hunting dog (duck hunting, so not especially tough on the knees) and has returned to full hunting days with no problems. I really do not see much difference over the long run between doing nothing and doing any of the other surgeries that are offered for cruciate ligament repair. 5) We don't have enough long term followup on TPLO surgeries to know how much arthritis will occur (at least in our practice experience). 6) When the TPLO surgery is done the tibia is fractured deliberately and then a bone plate is applied. So the recovery is exactly like recovering from a broken leg. For the most part the plate is very strong and it is unlikely that problems will develop but it is best to enforce rest ( even to consider cage confinement) until the fracture site is healed and then to gradually return to normal activity through leash walking or controlled activity. You can get a better idea of this when you read the web sites. I don't see a big problem with waiting until after you get back no matter what you decide -- but if there is a really severe tear there would be a slight increase in the risk of cartilage damage secondary to the cruciate ligament rupture. With Junior's jumping behaviors a complete tear of this magnitude is very unlikely, though. Good luck with all of this. Mike 12/7/02

Tibial Plateau Leveling Procedure (TPLO) on large dog

Question: Dr. Mike:

I have a large dog - Great Dane mix who just tore his right back knee's ACL within the last 4 days.

He just turned 2 years old, weighs about 110 lbs, and is fairly active.

My vet has stated that my dog needs surgery. I understand there are two surgical options - one is the traditional ACL repair and the other one is new surgery called Tibial Plateau Leveling Procedure (TPLO). My Vet suggested that my dog should have surgery within the next month. He suggested that since my dog is young and active, we should consider the TPLO surgery.

Could you provide further information on this procedure TPLO? Would it be beneficial to my dog? Would TPLO reduce the need for future surgeries?

Thank you very much for your help in this matter.

Answer: V-

At the present time all of the orthopedic surgeons who I have communicated with recommend the tibeal plateau leveling osteotomy (TPLO) procedure for dogs weighing over 100 lbs. This surgery appears to be more successful in large breed dogs than traditional surgeries. It is a relatively new procedure, with wide-spread acceptance only in the last three years or so. In this surgery, the tibia (bone below the stifle or knee) is reshaped (broken carefully and then put back together with a bone plate to hold the repair), in order to make it act as a sort of "stop" for forward movement of the femur (the bone above the stifle) which is the motion that the cruciate ligament controls. Since the ligament isn't functioning, this procedure does the same job. The surgery works better than the surgeries in which a replacement for the ligament is fashioned in some manner because the stress on the replacement is just too much in most cases in very large dogs. There is no really long term follow-up study that I am aware of on dogs who have had this procedure, probably because there hasn't been enough time since this procedure was invented to do a long term follow-up. At this time, based on the information available, if I had to consider cruciate ligament surgery for my rottweiler, I would have the TPLO surgery done on her, though.

I hope that helps some.

Mike Richards, DVM 2/22/2001

Tibial plateau leveling osteotomy - Bullmastiff

Question: Dear Dr. Mike,

I recently found out my 7 year old Bullmastiff mix has severe arthritis in both knees. Three vets at the local practice have looked at the x-rays and examined the dog. The films were sent to a radiologist, and they have been seen by a board certified surgeon (she also examined the dog). They all agree about the arthritis. The radiologist and the surgeon think there may be partially torn cruciates (whether anterior, posterior - I don't know). One knee is worse than the other. This dog also has mild hip dysplasia. In the past few years he has exhibited some stiffness and occasional slight lameness, which has always resolved. Three weeks ago he had an impact with my other dog, and was on three legs and had purple bruising on his inner thigh. After a few days he was weight bearing again but definitely favoring one side. That is when I had him x-rayed. The radiologist and surgeon said the films were indicative of an OLD injury! Could an injury of this nature have occurred without the dog becoming non weight bearing on the leg?

The dog seems recovered from the impact. He is walking in the usual manner, wants to run and play as usual. As far as I can tell, "Life is good". The surgeon and one of the other vets feel he should have surgery now. The other two vets feel it can wait until he definitely needs it, and recommend anti-inflammatories to try and slow down arthritis. The most experienced of the vets (25 plus years) says in a dog his size (85 pounds, lean), the results of the surgery isn't always that good. The surgeon herself, also indicated that the surgery is usually much more successful in dogs under 50 pounds. She did mention a surgery called TPLO (?) that she does not do, that is supposed to be better for large dogs. One of the other vets mentioned arthroscopy.

What has your experience been with cruciate repairs on dogs of his size? The surgeon he saw said she would do a "subcapsular stabilization with nylon monofiliment" or something of that nature, but strongly suggested looking into the TPLO. The older vet said there are many procedures. In your opinion, would the surgery itself be different if it's done now as opposed to when (if) the leg gets non weight bearing? Would surgery stop the arthritis? If the joint were cleaned up, how long before degeneration started again?

I guess I have reservations about cutting into a dog that's apparently functioning pretty well (he's not altering his lifestyle at this point) and having him laid up and painful for weeks - especially if it's not a clean "Fix" (compared to how, say, a hip replacement, is a definite fix). However, I am prepared to do what needs to be done, either now or when he worsens (which the surgeon says is inevitable - for both knees). My regular vets pretty much suggest a conservative approach at this point - sort of, "let's not fix it until we know it's broken".

The dog is on Adequan, Synovi-msm, and Rimadyl now. I'm supposed to try and limit his activity, yet, keep him exercised. None of the vets indicated that, even after surgery and healing, unbridled activity should be allowed.

I know it's difficult to render opinions without having seen the animal, but any thoughts or ideas you may have, will be appreciated. Especially regarding this TPLO procedure. What do you know of it and is it significantly better than the traditional procedures? The surgeon said the knee isn't stabilized with any kind of cord, in the TPLO. Would it be delinquent of me to hold off on any surgery for a while?

Thank you very much! Chris

Answer: Chris-

The procedure that is referred to as a TPLO in your note is a "tibial plateau leveling osteotomy". This is a procedure that was developed by Barclay Slocum (I think) and described in an issue of the Veterinary Clinics of North America. It is currently the favored approach my many orthopedic surgeons for big dogs. I think that the bigger the dog is, the more likely that this approach will be better than other ones. There have been a lot of approaches to cruciate ligament repair since I have been in practice, with five or six different surgeries seeming to offer improvements over the "older" repairs but none of these procedures has been consistently effective enough to make surgeons stop looking for a better repair method.

I honestly don't know if the tibial plateau leveling procedure will prove over time to be good enough to become the surgery of choice for cranial cruciate ligament injuries in dogs over fifty pounds of body weight, or not. But at the present time, it has the best reviews that I can remember for a new surgical approach to repair of cruciate ligament injury and based on anecdotal evidence, it seems to be the best option. A major advantage of this procedure, which is a big selling point for me, is that the aftercare necessary to help ensure success is much less with this procedure than with many of the other ones. That makes it a lot more likely to work, in my opinion.

Most cruciate ligament injuries in dogs are probably the result of degeneration of the ligaments over time. Often, there is enough laxity in the ligaments to allow pretty significant degenerative joint disease (arthritis) prior to the time the ligament actually gives way entirely (ruptures). So I think that it is very likely that this problem could develop in your dog without a significant traumatic event.

Every surgeon I have ever talked to would like to do cruciate ligament repairs early, rather than later. There is less degeneration of the joint to contend with and less chance of secondary problems like torn meniscal cartilage when repairs are performed early. If you are going to consider surgery as an option, early repair is better.

Many of my clients opt not to have cruciate ligament injuries repaired. Their dogs develop very arthritic joints but the fibrosis associated with this does eventually stabilize the joint in most cases and allow the dog to be functional. With the older surgical techniques it was often hard to distinguish dogs that had repairs and those that didn't, based on clinical signs six months to a year after surgery. I do not have any personal experience with the recovery from the tibial plateau leveling osteotomy procedure in patients in our practice, as we have not had a single patient who was treated with this procedure. From talking with other vets, there may be improvement that is actually noticeable at this time period, in patients after TPLO procedures, especially larger dogs.

Basically, I think that if you can afford the surgery and if you can accept that there is not a guaranteed outcome, it is probably better to do surgery. If it is enough of a financial burden to impact the overall care of your pet (if you won't have money for other necessary health needs) or if you are going to be really upset if there isn't significant improvement, then you may wish to pass on this surgery. Most dogs will be able to function well enough to get around even without surgery -- but they probably live with more pain than dogs who have had this problem repaired.

I would opt for the TPLO procedure, if possible, at this time, even though I can't say with absolute certainty that it will still look like the best procedure ten years from now.

Hope that helps some in the decision making.

Mike Richards, DVM 9/26/2000

Tibial plateau leveling (giant breeds)

Q: If I need to find out the best surgeon for tibial plateau leveling (giant breeds) in the country, where would I look? ** I have already taken my dog to Dr. Slocum in Oregon, but am looking for someone closer!! (I live in Ohio).


A: Ann-

I am sorry but I don't know if there is a "best" surgeon for this procedure. All I know is that Dr. Slocum pioneered this procedure for repair of ruptured cruciate ligaments and that there are other veterinarians endorsing the technique who appear to be well qualified to do so. As surgeries go this is still a relatively new technique and it requires some specialized training and equipment which I think Dr. Slocum provides, so it may be best just to call Dr. Slocum and get referrals from him for veterinarians in your area.

Mike Richards, DVM


Michael Richards, D.V.M. co-owns a small animal general veterinary practice in rural tidewater Virginia. Dr. Richards graduated from Iowa State University's College of Veterinary Medicine in 1979, and has been in private practice ever since. Dr. Richards has been the director of the PetCare Forum...