Using integrative rehab for optimal outcomes in cranial cruciate ligament disease cases

By /
A dog undergoing medical acupuncture treatment.
This 11-year-old dog, Boba, presented acutely lame on the right pelvic limb, possibly due to a slip and fall on a hardwood floor. Treatments with medical acupuncture and rehabilitation improved the dog’s mobility and resolved the lameness. Photos courtesy Cura Core

How often have you heard the tibial plateau-leveling osteotomy (TPLO) referred to as the “gold standard” approach for cranial cruciate ligament disease (CrCLD)?1-6 Did you ever ask how, or if, it actually earned that status? The notion of “gold standard” treatments is receiving abundant criticism in human medicine. Veterinarians, too, should begin to question such claims. The tale of the TPLO tells us why.

An editor from a neuroscience journal wrote, “There are no gold standards, and nothing gold about a standard.”7 He continued, “Gold standard is a made-up term borrowed from the world of finance … Over time, we have created many different definitions to support this misdirected phrase. Unfortunately, the definitions themselves vary by author and use. The definitions used to define the term amount to little more than agreed-upon lies. To put it bluntly, there is no gold standard. Or at least, there is currently not a gold standard, and even when there was a gold standard, that standard was different than the standard several years prior.”

The editor added, “In healthcare, I interpret a standard as follows: ‘…this is what we’re doing today because the evidence supports that it is currently the best practice.’ When I read that an intervention, test, or treatment regimen is the gold standard, I question the assumption. Conceptually, we think of the gold standard as something that has stood the test of time and research.”

Employing this type of critical questioning, we might ask the following: Has TPLO stood the test of time and research? Is it the safest, most cost-effective approach? Does it lead to the best long-term outcomes?

No surgical procedure for CrCLD has demonstrated consistent superiority, including the TPLO.8 As some have stated, “[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.”9 Others have added, “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 (sic) 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.”10

Looking at TPLO complications

Compared to other surgeries for CrCLD, a TPLO causes the most severe trauma and complications. Think about it—none of the other surgeries sever and plate the tibia, modify directions of force, and reconfigure the stifle to resemble humans’ instead of dogs.’11-13 Surgeons insist a TPLO “restores normal function,” but it cannot. Revising pelvic limb architecture violates a foundational principle of science and engineering, i.e. the reciprocal interrelationship of structure and function.14 Change one and you change the other. A TPLO alters both—permanently.

Up to 30 percent of dogs will have chronic pain and lameness for years after a TPLO.15 Even after just one year, medium- to large-breed dogs may lose subchondral bone density in the lateral tibial plateau, reflecting abnormal loading patterns.16 Nearly all dogs that undergo a TPLO manifest thickening of the patellar tendon, producing pain and reducing range of motion.17 Normal? No.

The TPLO produces complications in almost a third of dogs. These span the gamut from swelling and bruising to fracture and osteomyelitis.18,19 Sawing and plating the tibia does not only impact bone; it can injure local tissues, such as nerves, vessels,20 muscles, menisci,21 and more. Some sequelae require surgical revision and implant removal, thereby adding to the trauma, pain, and expense.22,23 Unresolved inflammation, delayed healing, implant instability, and/or infection raise the risk of osteosarcoma (OSA).24

Dogs with a history of TPLO are 40 times as likely, compared to those without, to be diagnosed with proximal tibial OSA.25 That said, how many practitioners disclose this to clients beforehand?

Now that online and weekend courses are teaching TPLOs to general practitioners, more practices are offering the procedure, but with varying degrees of expertise. 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 postoperative change in tibial plateau angle (TPA).26

Further, fibular fractures occur postoperatively in up to 15 percent of dogs. They may result from the surgery itself, if performed without the aid of a jig, or when leaving drill holes unfilled.27 A fractured fibula reduces overall stability and does not heal on its own in 45 percent of cases.28 This means some dogs may need a second osteotomy, (i.e. one for the fibula).

A dog treated with dry needling and electroacupuncture.
Boba was treated with a combination of dry needling and electroacupuncture, designed to address pain, myofascial dysfunction, and inflammation through peripheral and central neuromodulation.
“I learned the importance of assessing the entire patient, at every appointment.  It is also concerning how many of my previous patients with cranial cruciate ligament (CCL) injury may have undergone surgery with underlying, complicating issues, and [that] may have been better served with integrative medical management. I have educated my colleagues regarding the importance of a neurological and myofascial exam for every patient, especially those presenting with a lameness. What is also striking about this case is the increased bond created between myself, Boba, and my clients during the treatment course. Boba is always happy to see me and becomes very excited when he knows it is time for his therapy. I enjoy watching him progress through his recovery.”45

Sarah Christiansen, DVM, cVMA, the veterinarian who provided acupuncture on Boba

Taking a different approach

Considering the shaky claims of gold standard status for the TPLO, why not start non-surgically? Research in smaller dogs suggests similar outcomes whether or not the dog receives a TPLO.29 Obese dogs that lose weight and receive therapeutic exercise have successful results after a year.30 Even if some instability remains, we can strengthen soft tissues to aid and protect the joint both mechanically and neurologically.31

Synovitis and osteoarthritis (OA) likely account for the majority of joint pain in cases of CrCLD.32 Rehabilitative therapies improve muscle function; they may also reduce pain and inflammation. A multimodal treatment protocol typically includes a mixture of the following: medical acupuncture,33 massage,34 photomedicine,35 stretching, therapeutic exercise, orthotics,36 medication, supplements, and more.37 Platelet-rich plasma is gaining popularity as well, helping to improve gait and reduce pain.38 A reference comparing the mechanisms of action of integrative rehabilitation and physical medicine (IRPM) to the TPLO is available for download.39

Let’s also re-examine the notion cruciate ligaments cannot heal. They can and do. Stephanie Filbay, the lead researcher of a study involving 120 human patients, stated, “What we found, surprisingly, was that two years after injury, in those who’d had rehabilitation only, 53 percent had signs of healing on MRI … Even more surprising was that those with signs of healing reported better outcomes than those who’d had surgery.”40,41

What does this mean for dogs? Give them time and try IRPM first. Cruciate injury is not an emergency and dogs develop OA whether or not they have surgery.

Surgeons and bone plate manufacturers will likely continue to push the TPLO. However, in this author’s opinion, clients deserve comprehensive, evidence-informed discussions of the pros and cons of various approaches tailored to that specific patient.42-44 While we’re at it, let’s update the old phrase, “A chance to cut is a chance to cure,” with “A chance to rehab is a chance to restore.”

Narda G. Robinson, DO, DVM, MS, FAAMA, practices osteopathic medicine and veterinary medicine. Dr. Robinson taught science-based integrative medicine at the Colorado State University College of Veterinary Medicine and Biomedical Sciences for 20 years. In 2016, Robinson established her own academy in Fort Collins, Colo., where she teaches medical acupuncture, integrative rehabilitation, medical massage, and other integrative medical approaches. Columnists’ opinions do not necessarily reflect those of Veterinary Practice News.

References

  1. 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/
  2. ACOSM Website. Accessed on June 14, 2023 at https://www.arizonacanineorthopedics.com/tplo.html
  3. https://www.bonevet.com.au/review-articles/ccl-treatment-options/#:~:text=TPLO%20is%20currently%20considered%20the,commonly%20favoured%20by%20orthopaedic%20surgeons
  4. https://www.youtube.com/@DePuySynthesVet/about
  5. https://www.embracepetinsurance.com/health/cruciate-ligament-injury
  6. 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.
  7. Olson DM. There are no gold standards, and nothing gold about a standard. Journal of Neuroscience Nursing, American association of Neuroscience Nurses. 2022; 54(2):53.
  8. Boudrieau RJ. Tibial plateau leveling osteotomy or tibial tuberosity advancement? Vet Surg. 2009; 38(1):1-22.
  9. 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.
  10. 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.
  11. Harasen G. Tibial plateau leveling osteotomy – part I. Can Vet J. 2004;45:527-528.
  12. 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.
  13. 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.
  14. American Association of College of Osteopathic Medicine website. About osteopathic medicine. Accessed on July 3, 2024 at https://www.aacom.org/become-a-doctor/about-osteopathic-medicine#:~:text=Four%20Tenets%20of%20Osteopathic%20Medicine&text=The%20body%20is%20a%20unit,and%20function%20are%20reciprocally%20interrelated .
  15. Molsa S. H., Hielmm-Bjorkman A. K., Laitinen-Vapaavuori O. M. Use of an owner questionnaire to evaluate long-term surgical outcome and chronic pain after cranial cruciate ligament repair in dogs: 253 cases (2004-2006) J Am Vet Med Assoc. 2013;243(5):689–695. doi: 10.2460/javma.243.5.689.
  16. 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.
  17. Bergh MS and Peirone B. Complications of tibial plateau levelling osteotomy in dogs. Vet Comp Orthop Traumatol. 2012;25:349-358.
  18. 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.
  19. Bergh MS and Peirone B. Complications of tibial plateau levelling osteotomy in dogs. Vet Comp Orthop Traumatol. 2012;25:349-358.
  20. 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.
  21. O’Brien CS and Martinez SA. Potential iatrogenic medial meniscal damage during tibial plateau leveling osteotomy. Vet Surg. 2009;38(7):868-873.
  22. 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
  23. 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/ .
  24. 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.
  25. 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.
  26. 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.
  27. 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.
  28. 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.
  29. Kwananocha I, Akaraphutiporn E, Upariputti R, et al. Short-term outcomes of cranial cruciate ligament rupture treated surgically with tibial plateau leveling osteotomy or non-surgically in small-breed dogs weighing less than 10kg. J Vet Med Sci. 2024; 86(4):428-435.
  30. Wucherer KL, Conzemius MG, Evans R, et al. Short-term and long-term outcomes for overweight dogs with cranial cruciate ligament rupture treated surgically or nonsurgically. J Am Vet Med Assoc. 2013 May 15;242(10):1364-72. doi: 10.2460/javma.242.10.1364.
  31. 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.
  32. Creamer DG and Muir P. Arthroscopic treatment of chronic cruciate ligament rupture in the dog without stifle stabilization: 13 cases (2001-2020). Case Rep Vet Med. 2023;2023:6811238.
  33. 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.
  34. 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.
  35. 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.
  36. 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.
  37. 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.
  38. Kaneps AJ. A one-health perspective: use of hemoderivative regenerative therapies in canine and equine patients. JAVMA. 2023;261(3):301-308.
  39. Robinson NG. MOVE Integrative Rehabilitation and Physical Medicine (IRPM) Handout. Accessed at https://curacore.org/vet/wp-content/uploads/070324-IRPM-Handout-03102022-Narda-Review-2.pdf on July 4, 2024.
  40. Malone U. Study debunks longstanding medical myth that a torn ACL can’t heal. Accessed at https://www.abc.net.au/news/2024-04-28/study-debunks-myths-around-acl-injury-healing-and-surgery/103773576?utm_campaign=abc_news_web&utm_content=link&utm_medium=content_shared&utm_source=abc_news_web on July 4, 2024.
  41. Filbay SR, Roemer FW, Lohmander LS, et al. Evidence of ACL healing on MRI following ACL rupture treated with rehabilitation alone may be associated with better patient-reported outcomes: a secondary analysis from the KANON trial. British Journal of Sports Medicine 2023;57:91-99.
  42. 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 .
  43. DePuy Synthes Vet. TPLO Chapter 5: Benefits of TPLO. https://www.youtube.com/watch?v=7nZK4GcQXO8
  44. 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
  45. https://curacore.org/vet/2024/07/06/stop-unnecessary-surgery-medical-acupuncture-rehab-instead-of-tplo/

Using integrative rehab for optimal outcomes in cranial cruciate ligament disease cases

By /
A dog undergoing medical acupuncture treatment.
This 11-year-old dog, Boba, presented acutely lame on the right pelvic limb, possibly due to a slip and fall on a hardwood floor. Treatments with medical acupuncture and rehabilitation improved the dog’s mobility and resolved the lameness. Photos courtesy Cura Core

How often have you heard the tibial plateau-leveling osteotomy (TPLO) referred to as the “gold standard” approach for cranial cruciate ligament disease (CrCLD)?1-6 Did you ever ask how, or if, it actually earned that status? The notion of “gold standard” treatments is receiving abundant criticism in human medicine. Veterinarians, too, should begin to question such claims. The tale of the TPLO tells us why.

An editor from a neuroscience journal wrote, “There are no gold standards, and nothing gold about a standard.”7 He continued, “Gold standard is a made-up term borrowed from the world of finance … Over time, we have created many different definitions to support this misdirected phrase. Unfortunately, the definitions themselves vary by author and use. The definitions used to define the term amount to little more than agreed-upon lies. To put it bluntly, there is no gold standard. Or at least, there is currently not a gold standard, and even when there was a gold standard, that standard was different than the standard several years prior.”

The editor added, “In healthcare, I interpret a standard as follows: ‘…this is what we’re doing today because the evidence supports that it is currently the best practice.’ When I read that an intervention, test, or treatment regimen is the gold standard, I question the assumption. Conceptually, we think of the gold standard as something that has stood the test of time and research.”

Employing this type of critical questioning, we might ask the following: Has TPLO stood the test of time and research? Is it the safest, most cost-effective approach? Does it lead to the best long-term outcomes?

No surgical procedure for CrCLD has demonstrated consistent superiority, including the TPLO.8 As some have stated, “[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.”9 Others have added, “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 (sic) 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.”10

Looking at TPLO complications

Compared to other surgeries for CrCLD, a TPLO causes the most severe trauma and complications. Think about it—none of the other surgeries sever and plate the tibia, modify directions of force, and reconfigure the stifle to resemble humans’ instead of dogs.’11-13 Surgeons insist a TPLO “restores normal function,” but it cannot. Revising pelvic limb architecture violates a foundational principle of science and engineering, i.e. the reciprocal interrelationship of structure and function.14 Change one and you change the other. A TPLO alters both—permanently.

Up to 30 percent of dogs will have chronic pain and lameness for years after a TPLO.15 Even after just one year, medium- to large-breed dogs may lose subchondral bone density in the lateral tibial plateau, reflecting abnormal loading patterns.16 Nearly all dogs that undergo a TPLO manifest thickening of the patellar tendon, producing pain and reducing range of motion.17 Normal? No.

The TPLO produces complications in almost a third of dogs. These span the gamut from swelling and bruising to fracture and osteomyelitis.18,19 Sawing and plating the tibia does not only impact bone; it can injure local tissues, such as nerves, vessels,20 muscles, menisci,21 and more. Some sequelae require surgical revision and implant removal, thereby adding to the trauma, pain, and expense.22,23 Unresolved inflammation, delayed healing, implant instability, and/or infection raise the risk of osteosarcoma (OSA).24

Dogs with a history of TPLO are 40 times as likely, compared to those without, to be diagnosed with proximal tibial OSA.25 That said, how many practitioners disclose this to clients beforehand?

Now that online and weekend courses are teaching TPLOs to general practitioners, more practices are offering the procedure, but with varying degrees of expertise. 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 postoperative change in tibial plateau angle (TPA).26

Further, fibular fractures occur postoperatively in up to 15 percent of dogs. They may result from the surgery itself, if performed without the aid of a jig, or when leaving drill holes unfilled.27 A fractured fibula reduces overall stability and does not heal on its own in 45 percent of cases.28 This means some dogs may need a second osteotomy, (i.e. one for the fibula).

A dog treated with dry needling and electroacupuncture.
Boba was treated with a combination of dry needling and electroacupuncture, designed to address pain, myofascial dysfunction, and inflammation through peripheral and central neuromodulation.
“I learned the importance of assessing the entire patient, at every appointment.  It is also concerning how many of my previous patients with cranial cruciate ligament (CCL) injury may have undergone surgery with underlying, complicating issues, and [that] may have been better served with integrative medical management. I have educated my colleagues regarding the importance of a neurological and myofascial exam for every patient, especially those presenting with a lameness. What is also striking about this case is the increased bond created between myself, Boba, and my clients during the treatment course. Boba is always happy to see me and becomes very excited when he knows it is time for his therapy. I enjoy watching him progress through his recovery.”45

Sarah Christiansen, DVM, cVMA, the veterinarian who provided acupuncture on Boba

Taking a different approach

Considering the shaky claims of gold standard status for the TPLO, why not start non-surgically? Research in smaller dogs suggests similar outcomes whether or not the dog receives a TPLO.29 Obese dogs that lose weight and receive therapeutic exercise have successful results after a year.30 Even if some instability remains, we can strengthen soft tissues to aid and protect the joint both mechanically and neurologically.31

Synovitis and osteoarthritis (OA) likely account for the majority of joint pain in cases of CrCLD.32 Rehabilitative therapies improve muscle function; they may also reduce pain and inflammation. A multimodal treatment protocol typically includes a mixture of the following: medical acupuncture,33 massage,34 photomedicine,35 stretching, therapeutic exercise, orthotics,36 medication, supplements, and more.37 Platelet-rich plasma is gaining popularity as well, helping to improve gait and reduce pain.38 A reference comparing the mechanisms of action of integrative rehabilitation and physical medicine (IRPM) to the TPLO is available for download.39

Let’s also re-examine the notion cruciate ligaments cannot heal. They can and do. Stephanie Filbay, the lead researcher of a study involving 120 human patients, stated, “What we found, surprisingly, was that two years after injury, in those who’d had rehabilitation only, 53 percent had signs of healing on MRI … Even more surprising was that those with signs of healing reported better outcomes than those who’d had surgery.”40,41

What does this mean for dogs? Give them time and try IRPM first. Cruciate injury is not an emergency and dogs develop OA whether or not they have surgery.

Surgeons and bone plate manufacturers will likely continue to push the TPLO. However, in this author’s opinion, clients deserve comprehensive, evidence-informed discussions of the pros and cons of various approaches tailored to that specific patient.42-44 While we’re at it, let’s update the old phrase, “A chance to cut is a chance to cure,” with “A chance to rehab is a chance to restore.”

Narda G. Robinson, DO, DVM, MS, FAAMA, practices osteopathic medicine and veterinary medicine. Dr. Robinson taught science-based integrative medicine at the Colorado State University College of Veterinary Medicine and Biomedical Sciences for 20 years. In 2016, Robinson established her own academy in Fort Collins, Colo., where she teaches medical acupuncture, integrative rehabilitation, medical massage, and other integrative medical approaches. Columnists’ opinions do not necessarily reflect those of Veterinary Practice News.

References

  1. 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/
  2. ACOSM Website. Accessed on June 14, 2023 at https://www.arizonacanineorthopedics.com/tplo.html
  3. https://www.bonevet.com.au/review-articles/ccl-treatment-options/#:~:text=TPLO%20is%20currently%20considered%20the,commonly%20favoured%20by%20orthopaedic%20surgeons
  4. https://www.youtube.com/@DePuySynthesVet/about
  5. https://www.embracepetinsurance.com/health/cruciate-ligament-injury
  6. 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.
  7. Olson DM. There are no gold standards, and nothing gold about a standard. Journal of Neuroscience Nursing, American association of Neuroscience Nurses. 2022; 54(2):53.
  8. Boudrieau RJ. Tibial plateau leveling osteotomy or tibial tuberosity advancement? Vet Surg. 2009; 38(1):1-22.
  9. 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.
  10. 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.
  11. Harasen G. Tibial plateau leveling osteotomy – part I. Can Vet J. 2004;45:527-528.
  12. 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.
  13. 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.
  14. American Association of College of Osteopathic Medicine website. About osteopathic medicine. Accessed on July 3, 2024 at https://www.aacom.org/become-a-doctor/about-osteopathic-medicine#:~:text=Four%20Tenets%20of%20Osteopathic%20Medicine&text=The%20body%20is%20a%20unit,and%20function%20are%20reciprocally%20interrelated .
  15. Molsa S. H., Hielmm-Bjorkman A. K., Laitinen-Vapaavuori O. M. Use of an owner questionnaire to evaluate long-term surgical outcome and chronic pain after cranial cruciate ligament repair in dogs: 253 cases (2004-2006) J Am Vet Med Assoc. 2013;243(5):689–695. doi: 10.2460/javma.243.5.689.
  16. 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.
  17. Bergh MS and Peirone B. Complications of tibial plateau levelling osteotomy in dogs. Vet Comp Orthop Traumatol. 2012;25:349-358.
  18. 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.
  19. Bergh MS and Peirone B. Complications of tibial plateau levelling osteotomy in dogs. Vet Comp Orthop Traumatol. 2012;25:349-358.
  20. 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.
  21. O’Brien CS and Martinez SA. Potential iatrogenic medial meniscal damage during tibial plateau leveling osteotomy. Vet Surg. 2009;38(7):868-873.
  22. 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
  23. 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/ .
  24. 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.
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  43. DePuy Synthes Vet. TPLO Chapter 5: Benefits of TPLO. https://www.youtube.com/watch?v=7nZK4GcQXO8
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