TPLO vs TTA vs ECR vs TTO: a review of scientific studies
Comparing surgical options for cranial cruciate ligament tears
Surgical options currently available for the management of canine cranial cruciate ligament tears include osteotomy procedures e.g. tibial plateau levelling osteotomy (TPLO), tibial tuberosity advancement (TTA) and Triple tibial osteotomy (TTO), 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 that present objective evidence of superior results for TPLO vs TTA and ECR.
What about Triple Tibial Osteotomy (TTO)?
A search of the veterinary literature revealed six publications on TTO, none of which provided any objective outcome data (e.g. force plate analysis, kinematic gait analysis) for TTO. Further to this, there is no study comparing the outcomes of Triple tibial osteotomy (TTO) to any other technique used in the management of canine cruciate ligament insufficiency. i.e. there is no scientific evidence that performing TTO yields results that are any better, or even as good as placing a lateral fabello-tibial nylon suture (DeAngelis technique), let alone extensively studied osteotomy techniques such as TPLO. Four of the six publications document case series reporting minor and major complication rates that are significantly higher than TPLO. In the absence of objective data and the increased potential for serious complications as reported in the veterinary literature, it is difficult to justify recommending TTO ahead of other widely studied alternatives.
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. However, to succinctly summarise all the information presented:
TPLO is the recognised Gold Standard
TPLO is considered the gold standard for the management of CCL tears in all sizes of dogs and is the overwhelming technique of choice for orthopaedic surgeons in Referral Centres worldwide. Compared to alternative options, the benefits of TPLO include:
- rapid recovery
- better short and long-term limb function
- significantly lower rates of minor and serious post-surgical complications compared to TTA & TTO
- a significantly lower rate of post-surgical meniscal injury
- a significantly slower rate of progression of osteoarthritis over time
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", "TPLO ECR", "TTA ECR", "TPLO Deangelis", "TTA Deangelis", "triple tibial osteotomy", "TTO" "canine cruciate ligament". Pubmed can be found here: www.ncbi.nlm.nih.gov/pubmed
TPLO vs TTA vs ECR: key points from the literature
In a 2018 survey of Veterinary Orthopaedic Society members:
- 78.6% preferred TPLO
- 13.9% preferred TTA
- 5.9% preferred LFS
- 1.6% preferred Tightrope
In a 2014 survey of ACVS board-certified surgeons, for a medium sized dog with a complete cranial cruciate ligament tear:
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.
Results of a survey of Veterinary Orthopedic Society members on the preferred method for treating cranial cruciate ligament rupture in dogs weighing more than 15 kilograms
Dirsko J F von Pfeil, Michael P Kowaleski, Mathieu Glassman, Loïc M Dejardin J Am Vet Med Assoc Sept 2018
Method: All registered VOS members received an online survey to determine their preferred procedure.
Results: 78.6% of respondents preferred TPLO. 13.9% preferred TTA, .9% preferred LFS and 1.6% preferred Tightrope.
Conclusion: TPLO was preferred by the majority of respondents for treating CCLR in dogs weighing > 15 kg. The Tightrope procedure was perceived as having the highest complication rate.