TPLO vs TTA vs ECR vs TTO: a review of scientific studies

Method: Retrospective cohort study assessing passive range of motion (ROM) changes in stifle joints 1 and 6 months post-surgery for dogs treated with TPLO, TTA, and TightRope (TR).

Results: One month after surgery, dogs treated with TPLO achieved a significant improvement in both stifle extension and flexion. In contrast, dogs treated with TTA showed a significant worsening of flexion, and dogs treated with TR showed a significant worsening of extension.

Conclusion: TPLO provided the most significant early improvements to joint range of motion. This study confirmed the influence of surgical procedures on changes in ROM and provides useful indications that TPLO may speed up the postoperative rehabilitation process.

Method: A massive systematic review evaluating 72 published studies on surgical management of CCL rupture regarding objective/subjective gait analysis, osteoarthritis progression, and complications.

Results / Discussion: Both techniques were considered to be successful long-term management options. However, the review found that TPLO had a consistently lower rate of surgical site infections compared to TTA.

Conclusion: While both methods restore long-term function, the researchers highlighted that almost half of the historically published studies evaluating TTA vs TPLO suffered from a high risk of bias. They stressed the critical need to rely on the highest level of objective, randomized clinical evidence when selecting a procedure.

Method: Systematic evaluation of 91 published articles reporting short- or long-term outcomes and complications associated with TPLO and TTA.

Results: Objective gait analysis supports the superiority of TPLO. Fewer patients treated with TPLO were diagnosed with postoperative joint instability, and TPLO had a lower percent increase of osteoarthritis (OA) after surgery. The average major complication rates were significantly higher for TTA (13.2%) compared to TPLO (5.2%).

Conclusion: The assessed literature strongly supports the hypothesis that TPLO is associated with lower complication rates, an improved clinical-functional outcome, and less increase of OA compared to TTA.

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.
5.9% preferred LFS.
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.

Method: A massive retrospective cohort study evaluating the medical records of 1,223 stifles (knees) treated with either TPLO or TTA to objectively compare short- and long-term complication rates.

Results: The overall major complication rate was significantly higher for the TTA group compared to the TPLO group. Specifically, dogs treated with TTA had a significantly higher rate of late major complications (requiring additional surgery), most notably late meniscal tears.

Conclusion: TPLO is associated with fewer major and late-term complications than TTA. The authors advised that surgeons should carefully consider these different complication profiles when selecting a procedure.

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.

Method: Dogs were divided into two groups in a non-random fashion. Dogs with tibial plateau angle (TPA) < 25 degrees received TTA. All dogs with TPA > 25 degrees underwent TPLO. 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 outcomes 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°... 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.

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

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%

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.

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

Method: Objective kinematic gait analysis (using treadmills and computer tracking) to compare dogs treated with TPLO versus an extracapsular repair (lateral fabellar suture) at multiple time points up to 6 months post-operatively.

Results: Dogs in the TPLO group showed a significantly faster return to a normal gait pattern compared to the extracapsular group. At 6 months, the TPLO group had kinematic values much closer to healthy control dogs.

Conclusion: TPLO provides superior and faster restoration of normal joint biomechanics and limb function compared to traditional extracapsular repair.

Method: A milestone objective study utilizing force plate analysis to compare limb function at 6 months and >1 year between dogs treated with TPLO and Lateral Fabellar Suture (LFS), standardizing for post-operative rehabilitation.

Results: Force plate analysis demonstrated that dogs undergoing TPLO achieved significantly higher peak vertical force (PVF) and vertical impulse (VI) in the long term compared to the LFS group.

Conclusion: TPLO results in superior long-term limb function compared to LFS. This objective kinetic data provided critical evidence supporting the use of osteotomy over traditional extracapsular repair for optimal functional recovery.

Method: Retrospective study objectively scoring the progression of osteoarthritis (OA) using pre-operative and long-term post-operative radiographs (mean follow-up >3 years) for both TPLO and extracapsular stabilization groups.

Results: Both surgical groups developed progressive radiographic signs of osteoarthritis; however, the severity and rate of progression were dramatically different between the two techniques.

Conclusion: TPLO results in significantly less progression of osteoarthritis compared to extracapsular stabilization. This foundational paper cemented one of the most significant clinical advantages of altering stifle biomechanics via TPLO.