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TIBIAL TUBEROSITY ADVANCEMENT
Surgical Treatment of Ruptured Cranial Cruciate Ligament
 
Does your pet have a torn ACL? Are you looking for an alternative way to repair your pet's knee problem, other than the "TPLO"? Tibial Tuberosity Advancement (TTA) is one of the newest method for repairing the canine knee with a torn ACL ligament. 

Unfortunately, this condition does not repair itself and often requires surgical intervention. You may have been told that TPLO is the only way to rectify this situation. You may also have been told that lateral suture ("TightRope") works well for any dog, which is not always true. TTA or TPLO are better than lateral suture methods for many dogs. TTA works as equally well as TPLO, AND is easier to perform, less invasive, and your dog will recover faster after surgery.

When the ACL tears in your pet's knee, the tibia is able to slide forward when your pet stands on the leg, which is normally constrained by the torn ligament. This is very painful and causes arthritis in the joint. TTA works by changing the way the quadriceps muscle (the large muscles on the front of the leg) pull on the tibia. After a TTA, the muscle pulls the tibia back into its normal position when your dog stands on the leg.  TPLO works in a similar way.

For those of you with smaller dogs, your doctor may have told you that TTA or TPLO is not the best choice for your smaller pets. We offer the mini-TTA for dogs that weigh less than about 20 pounds of body weight. Very few doctors in the US are skilled or trained enough to perform the mini-TTA.  We also offer TPLO on dogs down to a weight of about 20 pounds and we have been very happy with the results.



The photo above is of a mini-TTA.

Not every dog is a candidate for surgery for various reasons. If you are interested in alternative therapies for arthritis in dogs, please see our sections entitled Platelet Enhanced Therapy and/or Stem Cells/Regenerative Medicine. We use PET (or platelet rich plasma) and stem cell therapy for dogs that have had surgery to enhance the recovery, or for those that might be too old to undergo surgical correction. We are starting to use stem cell and plasma therapy on patients that have had surgery on one leg and MIGHT need it on the other leg. It may help prevent the leg from getting worse, or possibly help it get better. 

We can offer knee braces for your dog with a torn cruciate ligament.  If your dog is too old for surgery, too unstable for surgery, or there are financial reasons, then we can help you get a brace for your dog.  The braces we use do not require special fitting.  They can be fit in one session. They are made by an orthotist.

Another good therapy to enhance your pet's recovery is laser therapy. Low power lasers deliver laser energy into the operated limb without causing pain. The patient only senses a slight increase in heat in the immediate area. This in turn brings in blood flow into the surgical area which will help it heal faster. For more information on laser therapy, please go to www.litecure.com. I encourage you to consider hydrotherapy at Splash Dog in Edmonds, WA.
 

How to do the TTA.
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The  video shown here is a simple explanation of how the TTA works. By advancing the tibial tuberosity cranially (anteriorly, or forward) it changes the way the quadriceps muscle pulls on the front of the leg, such that it now becomes the new "cruciate ligament".






 

 In-Hospital Training Opportunities

Tibial Tuberosity Advancement


    Goal: To acquaint the participant with the biomechanics of the canine stifle and how tibial tuberosity advancement alters those biomechanics to produce a stable knee when the cranial cruciate ligament has torn.

     

    Method: On-site training in your hospital using cadavers, real patients, or models, to instruct you hands-on in the proper technique of tibial tuberosity advancement for the treatment of cranial cruciate ligament disease in the dog. We send notes and a video prior to showing up in your hospital, and bring our own equipment to show you what you need to perform the procedure properly. We will even help you acquire the equipment if needed. We are available after the training by telephone or email to assess your technique radiographically, and help you develop postoperative rehabilitation programs.

     

    Instructional Itinerary Includes:

    • Pre-visit material includes TTA DVD 3rd Edition (free with training), and notes
    • Diagnostic methods for detecting cranial cruciate ligament disease, and rule outs for other causes of hindlimb lameness.
    • Radiographic analysis of the hindlimb
    • Radiographic analysis of tibial plateau angle, and proper preoperative choice of TTA implants; both the mTPA and common tangent methods of implant selection 
    • Pain control
    • Sterile methods of surgical preparation
    • Choosing the right patient for TTA
    • The TTA surgical procedure, including potential mishaps surgical and postoperative
    • Postoperative radiographic analysis
    • Using the TTA to correct for MPL or LPL, patella alta
    • Model building for client "show and tell"
    • Equipment acquisition - may include onsite training program

     

    Participants are free to schedule as many surgeries as they feel their staff can handle in a one-day period. I would highly encourage you to limit it to 5 cases in one day, else consider two days of training on-site. You may also bring in one other veterinarian if you wish, and I encourage you to videotape the procedures. Group teaching rates are also available, as well as state convention presentations. To keep prices down, if you already have equipment (drill, saw, TTA equipment), please let me know that when requesting a training session, as I am willing to adjusts costs accordingly.

     

    Costs vary depending on location, number of procedures performed, and number of days at your location. For an estimate, send an email to me at info@jeffmayodvm.com.


    Documents on Tibial Tuberosity Advancement
     
     DOCUMENTDESCRIPTION
     TTA CHART

    This chart is a summary of how to select for an implant, cage, and the appropriate width of screw for each of the parts. This is best taped to the wall in your surgery room. Updated 11/2009.

    TTA TEMPLATE
    This is the acrylic overlay for assessing the TTA implant sizes.
    TTA COMMON TANGENT DISCUSSION
    This file discusses the common tangent method of picking your advancement cage for implementing the TTA surgery.
    Controversies in RCCL Repair

    This short paper briefly discusses controversial topics in repair techniques for ruptured cruciate ligaments in dogs. 

    Cranial Cruciate Ligament Disease

    This paper is a discussion on diagnosis and pathology of ruptured cruciate ligaments in dogs. 

    mayotta

    This is an article from the May 08 issue of Vet Practice News on TTA. 

    Post-operative TTA

    This short paper discusses postoperative rehab for dogs with TTA repair. For more information, please refer to www.topdoghealth.com.  

    Reasons for Poor Recovery from TTA
    This paper covers the top reasons I have seen clinically as to why patients may not recover from TTA surgery as expected.
     TTA for the client A short paper to give to pet owners if their pet is going to have the TTA procedure done.
     
     

     

    Post-Operative Instructions

     

    For more information on Rehab, go to www.topdoghealth.com, or go to www.ttaguide.com.  For those who live the in the Seattle area and north, please see the section on Splash Dog for rehabilitation assistance.

     

    Tibial Tuberosity Advancement/Tibial Plateau Leveling Osteotomy

     

     THE MOST COMMON POSTOPERATIVE COMPLICATION IS SWELLING IN THE LEG:  This can be prevented by using a graft from a different part of the leg to fill the osteotomy site, or using a synthetic grafting material.

     

    Historically, rehabilitation on knee surgeries in general has been limited to one common recommendation – cage rest! Veterinarians have been reluctant to allow their patients to perform even the slightest of exercise movements postoperative, for fear that the patient will ruin the work (and expense) already performed. If we have learned one thing from human medicine, the sooner the patient is up and using the leg, the quicker will be the recovery. There is only one modification to this thought that should be stated here, if the leg does not hurt, the dog will use it, and premature overuse of the leg will result in critical damage to the proper healing process. We cannot overemphasize enough, do not let your dog run loose until the doctor has pronounced the surgery a success.

      

    First Two Weeks:  The first couple days when your pet comes home, the pain will be the worst. Why? Dogs are pretty smart, and they figure out right away that when they act like they are in pain, they will get more attention from their owners. It is important to not let your pet loose to run freely, particularly up and down stairs without assistance. They can go outside ON A LEASH to go to the bathroom, and then they must return inside and rest. At the end of this two week period, have the skin sutures removed by your veterinarian. I highly recommend www.ttaguide.com.

      

    (1)            First 5 days – ice packs 2-3 times daily for 10-20 minutes. This will help significantly with the swelling.

     

    (2)            Pain medication – as written by the doctor. If this is not working, do not overdose, call the office for further recommendations or additional medications. The most common protocols of pain medication include combinations of a non-steroidal medication and an additional medication called tramadol. DO NOT overdose the tramadol medication, it can cause seizures in your dog.

     

    (3)            After 5 days, apply heat to the area 2-3 times daily for 10-20 minutes. Afterwards, begin GENTLE range of motion of the leg that was operated on after the heat pack has been applied. If you are not clear about this, ASK! Do not move the leg through range of motion if it is significantly swollen.

     

    (4)            No other exercise is recommended for the first two weeks.

     

    (5)            Clean the wound daily if needed with dilute hydrogen peroxide or warm soapy water, and do not allow the dog to lick it. If he attempts to lick the wound, please get an e-collar.

     

    Second Two Weeks:  At this point, walking on leash is tolerated.

      

    (1)            Pain medication – should be off of prescription medicine, however, giving one aspirin for the average 50-100# dog  30 minutes prior to any physical therapy is advisable.

     

    (2)            Apply heat to the leg for 20 minutes, then exercise the leg through range of motion.

     

    (3)            Walking on a leash is acceptable, but begin with one block and stop. If the dog returns home and is not in pain, you may increase this in 1 block increments every 4-5 days as tolerated, provided your dog is not in pain when the walk is over.

     

    (4)            While walking, push the dog’s hips towards the operated leg slightly to help convince him/her that the leg can be used.

     

    (5)            Lift the front end of the dog for 5 second intervals prior to starting the walk to increase the strength of the leg. Try several repetitions.

     

    (6)    Ask your pet to sit and stand several times a day to help strengthen the limb.

      

    Third Two Weeks: By this time, walks should be in the 20 minute range or better, and tolerated well. Do not run yet. Increase the duration of walking as much as you can without causing the dog pain. Do not exceed the 20 minute range. If you have access to a pool, some hydrotherapy is ok, but NOT unattended nor allowed to swim in water over the dog’s head. Any hydrotherapy over 10 minutes is more likely to exaggerate patellar tendon inflammation and result in lameness.

      

    Fourth Two Weeks:  At the end of this period, it is time to come in for the follow up x-ray. We want to make sure everything has healed prior to increasing the exercise as tolerated. Be forewarned that if you just go home and turn the dog loose, he will be in pain. This is the point where you can SLOWLY build back up to full exercise.  If your pet is not doing well by this point, please consider (1) there may have been a complication, (2) an injury elsewhere, or (3) your pet may have significant arthritis preventing him from completely recovering.  We recommend PRP-HA injections with ALL knee surgeries to help combat osteoarthritis.