Our ten year old Husky, about 75 lbs. went lame in her back leg after repeatedly climbing our new chain-link fence and chasing neighborhood cats. Our vet recommended the new tightrope surgery to repair her torn CCL as less costly and less invasive. To keep our options open he did tell us about all the procedures currently being done. However, since he did not actually preform TPLO and we’d have to go to a board of surgeons to have this more expensive TPLO surgery done we opted to have the tightrope procedure done at the end of March ‘10.

We thought we were prepared for the restrictions, and had no idea the extent of the complications, as we had not done our homework. We just took the word of the expert. Statistically, I think we had all the bad Tightrope surgery complications, and then some.

At the end of the 2nd week post-operatively we discovered when we went to get her stitches out, there was instability in the leg again. Something about the tightrope had failed and failed quickly. In addition, three, what appeared to be seromas or limpomas, had formed at various places along the incision. One on the upper inside, one on the outside just along the stitch, and the final further back on her outside hip. The one along the stitch continued to grow.

The vet at week 3 post-op recommended a second surgery saying, “Let’s go in see what is happening with the tightrope and look at the seroma”. (it turned out not to be a sermoa as it was not fluid filled and must be something else) We prepared for a 2nd tightrope ligament repair surgery, in case it was needed. Sure enough the first tightrope was “loose” with no explanation. It had been tight during surgery and one week post op. The buttons were fine and the knots tight. It was just loose. He removed the loose tightrope, drilled new holes at a slight angle this time, put in the 2nd tightrope and removed the largest growth – a golfball sized granuloma laying along the lateral side of the tightrope but not directly encasing it.

The granuloma was caused by a foreign body (triggered by either the suture material or tightrope) and it had a highly resistant staph infection in it. We found out 7 days after the second surgery when the pathology report came back. All the little antibiotics we’d given her for the past month had no effect. We had to start her on clindemycin which was one of two antibiotics that the staph was not resistant to. My concern was the whole week the new tightrope was in, and we did not know a staph infection was present.

Three weeks out after this second surgery her leg again tested with a draw sign that it had become unstable again. Why? The vet recommended a third surgery. He went in and the tight rope was secure and tight, so what was the instability? Her menicus on one side in her knee had torn and flipped. She’d not exhibited the normal pain this should have caused so the vet had no reason to suspect prior to this 3rd surgery. This slight damage to this cushion is what had shown up as instability when he did the drawer sign before the 3rd CCL surgery.

He was also glad that at surgery #2 he’d not opened the knee joint to look because for sure he would have spread the staph infection to the joint when so far it had been along the surface of her leg. We didn’t know that at the time, but looking back it was probably a good thing. He cut and removed the damaged menicus and released the lateral one. Then he also put in another stabilizing feature – the original Extracapsular Technique, also known as a traditional repair. This would give our girl two stabilizing features: the second tightrope that was still intact and the new lateral stabilizing suture (extracaspular) and they would not interfere with one another. We had high hopes.

For another month (this would be two months of antibiotics, a total of 3 different kinds before we got to the 4th for the staph infection) we had her on antiobitics following this 3rd surgery. At week 3 post op, of the 3rd surgery, she was still stable but she developed a horrible yeast infection in her ears that we also had to begin treating her for. We think this was probably caused by all the antiobitics. We finished the third and final round of antibiotics at week 4, believing the staph infection totally destroyed. How could it not be after that hit with antiobitics… 30 days?!

However, one week after she went off antibiotics in week 5 the instability seemed to be coming back, and each day we watched her use that leg less and less. She walked in a stilted way with a hitch and thunk look (no sound). It began to shake as she lifted it. Day after day we watched this get worse… thinking surely not, surely it’s just today. Finally we called and the vet said only time, let’s give it more time. Week 6 post-op of the third surgery she refused to use the leg at all and it was a little puffy. The next day it was more firmly swollen from the hock to the crest of her knee. She hiked it up and hopped on the other… something she had not done since before the first surgery.

Back to the vet who said that the leg was again more unstable and that apparently both stabilizing features had failed. We put her back on antibiotics and steroids for the swelling.

Our options going forward:

1) TPLO
We don’t have an additional $3500 for a more invasive surgery on a less than pristine leg that has already had 3 surgeries and known complications from infections including staph. I don’t know that bone healing or foreign body reaction would be any better with metal plates and cutting her bones.

2) (Another) Tightrope
Why do another tightrope surgery when we’ve failed each one. No one can tell me why it failed and failed quickly. She’s remained totally restricted, very very very little activity… walks to eat and leash walking to the bathroom. There was some talk about her soft tissue not healing well and that’s just her so that’s the cause of the failure and instability. That’s the guess. It still seems strange that soft tissue could cause an fibrous material like the tightrope which is supposed to be so strong and durable to weaken after a couple weeks in her body more than once.

3) Conservative Management – Rest and Medication
Time and medicine we can do, but the problem is her leg, the bone to bone action is again unstable. So give her antibiotics for two weeks and fix the swelling or infection. But when she goes off of it the instability is still there to again cause damage that would cause swelling again requiring more medicine. The endless cycle. I also wonder if the tightrope itself does not now have staph in it and will continue without constant antibiotic to infect her leg every time.

I don’t know that it would have been any different if we’d gone with the TPLO first. Our vet has helped us with the cost of the second and third surgeries, but the cost to our family emotionally had been huge. As someone else in here said… any surgery has risks. My vet has done 10 tightropes in the past spring and ours was the only failure… 10% chance doesn’t sound like much until your dog is the 10% one.

It is disheartening. It has taken time off work. Patience from everyone in the family who have had to pitch in to help. It hurts to watch your dog-companion in pain, not understanding and restricted. A friend told me my dog was tough and just to hang in there. She said if my dog has to be a lap dog and hang out in the house for the rest of her life that’s okay. Besides she’s just about to turn 11 so she’s not in the prime of her life. And I worry… what if she’s in the 50% who blow out the other leg? My mother would say I’m borrowing trouble to even think about it. She’d also be one of the first realistic ones to say it may come to putting her down. Gosh it would be easier to not have to go through this. But we love our furry friends. And that’s not so easy. We don’t give up that easy do we? It has been one of the most horrible long-term experiences of my life.

We are at 6 weeks post-op surgery #3 with a swollen, infected and mostly useless leg. But we’re giving medicine, food, love and prayers. I believe the medicine will help. I’m not sure what next steps will be. But today. That’s all we’re really promised anyone. Today – we’re hanging in there together.

UPDATE – 7 Weeks Post Op
During the third surgery, they did add the Extracapsular repair. When we talked with the vet this week he believes the Tightrope & Extracapsular are still intact, but that the isometry of her leg causes a shift that keeps them from holding the knee completely stable. It will make the scaring, tightening process slower. Her swelling has gone down on this round of antibiotics and steroids, which we’ll decrease over the next week. She’s walking on it a little more in this post op week #7 and resting a lot.

Tightrope Surgery Complications – Husky is a post from: Dog Knee Injury

Prices for veterinary surgery vary greatly depending on where you are located no matter whether you choose TTA, TPLO, TR, or a lateral suture method.  The prices can also fluctuate due to the availability of a certain procedure, number of surgeons performing the surgery, and the size of your dog. A number of veterinary practices will include a number of weeks of post-op physical therapy, including hydrotherapy, as part of a package price for the surgery. It is important when comparing prices to understand what is included in the quoted price, so you are able to compare apples to apples.  Taking these factors into consideration can help to explain the wide variance in prices presently for the Tightrope (TR) CCL repair surgery.

We would expect TR costs to be substantially lower than TPLO or TTA, but slightly higher than a conventional Lateral Suture Surgery (extracapsular imbrication, traditional repair).  Reported Tight Rope costs have ranged from $700 to $2500, and seem to depend mostly on geographic location and type of facility where the surgery was performed.  At a private practice in North Dakota an owner paid $1108 for everything, which included exam, diagnostics, anesthesia, scope, surgery, FiberTape implant, post operative monitoring, bandages, and medications (TPLO was $1900 at the same practice). At one major US state university vet facility, the total bill for TR done by top ortho surgeons including was in the $2200-2500 range.

The materials used in TR are a lot less expensive than those used in TPLO/TTA, and the surgery itself is a lot less complex. A typical TPLO procedure takes about one hour, whereas TR is completed in about 20 minutes. Less time under anesthesia, less surgical time, a simpler procedure, and fewer materials should translate into a lower cost for dog owners. I expect in the future we will see the prices for Tightrope repair somewhere in the $1000 range as more veterinarians become trained and proficient in this technique.

Remember, when looking for a veterinary surgeon, a higher price does not necessarily mean a better surgeon or superior procedure.

Below is the invoice for an estimate I received when contemplating Tightrope repair for my dog.  The low end of the estimate was $3,551.16 and the high end of the estimate was $3,635.94 for Tight rope surgery.

A few things to note before going into the details of the invoice:

1)  My dog in an American Bulldog weighing roughly 90 pounds (normal weight), and is 5 years old.

2)  He is in good health with no pre-existing conditions that would complicate anesthesia or surgery.

3)  This estimate, although some of the information has been blacked out to protect privacy, is from a speciality veterinary clinic with veterinary surgeons who specialize in cranial cruciate ligament repair surgeries in dogs.

4)  I live in Southern California, and this estimate is from a veterinary office in that area.

I will go line by line to go over the charges included in the cost of Tightrope surgery.  For smaller animals some of the values will be less, and accordingly for larger dogs.  Hopefully this invoice will give you a basic picture of what you can expect to pay for a Tight rope repair, and where all of the money goes.

EST Tightrope Procedure – $0 – Placeholder to tell us what type of estimate we are looking at.

CBC and Chemistry Profile – $163.80 – Blood panel including complete blood count and general chemistry to make sure your dog is healthy enough to tolerate anesthesia and the TR procedure.

Radiograph, 2 Views – $224.70 – X-rays needed prior to surgery to both confirm diagnosis of torn CCL (rule out other possible causes of lameness), and to act as a guide for the veterinary surgeon during the procedure.

Radiology Interpretation – $45.68 – Cost to have a veterinary professional examine and read the x-rays.

Catheterization, Intravenous – $94.00 – An IV will be placed in your dog’s vein through which your pet will receive medication and fluids during and immediately following surgery.

Surgery Room Use – $113.82 – Fee associated with use of the operating room for the duration of time required to perform the Tightrope surgery (this value is significantly more for a TPLO).

Isoflurane Gas Anesthesia, Initial 15 Min – $117.88 – Cost for the anesthetic gas used to put your dog under anesthesia during the procedure.

Isoflurane Gas, Additional – $168.60 for 60 minutes and $252.90 for 90 minutes – Cost for additional quantities of anesthetic gas depending on how long the ccl repair takes.

Tightrope Standard – $470. 00 – Cost of Tightrope surgery related supplies, this is mostly the cost of the Fiber Tape.

Surgical Anesthesia, Level I – $294.00 – Cost associated with keeping your dog under anesthesia during surgery and providing medications/monitoring.

Surgical Supplies, Orthopedic – $268.54 – Fee for use of general surgical supplies used during Tightrope repair (scalpel, drapes, cautery tools, etc.), this does not include the cost of the actual Tightrope Fibertape material.

Surgeons Fee 2 – $960.75 – Price the surgeon charges to perform Tightrope repair surgery.

Elective Ortho Hospitalization, General – $138.92 – Fee to have your dog kept in the veterinary hospital overnight following the CCL surgery with monitoring.

Misc. Medications, Surgical – $400.00 – This includes prescription medications given to your pet post operatively and those sent home with you during the post operative period.  They would include a sedative (Acepromazine), pain relief (Tramadol), anti inflammatory (Rimadyl), and an antibiotic(Cephalexin), and possibly other medications at your veterinarian’s discretion.

Fentanyl 75 mcg patch – $65.00 – Pain relief patch that will be placed in your pet to control post operative discomfort.

Buster Collar 25 cm, Clear – $23.86 – Collar to be placed on your dog during the post operative period to prevent them from ripping out their stitches or injuring the surgical site.

Also included are all of the post operative recheck visits, but be aware that if you pet develops any complications related to the surgery you will be required to pay for any additional expenses incurred.

What Does TightRope Surgery Cost? is a post from: Dog Knee Injury

The newest surgical technique to repair torn cranial cruciate ligaments in dogs is the tightrope procedure.  Tightrope CCL is an extracapsular technique which uses lateral suture stabilization in conjunction with a virtually indestructible material called FiberTape for knee joint stabilization.  The Fiber Tape is placed in the dog’s knee through a few small incisions, mostly done arthroscopically, which create tunnels through the bone, and is considered to be one of the least invasive surgical approaches to canine cruciate injury repair. 

Unfortunately, not every dog is a good candidate for the tightrope procedure.  Below you will find some general criteria that excludes certain dogs from tightrope surgery.  Remember – This list is in no way conclusive or exhaustive, your veterinarian will take into consideration many factors including your dog’s age, weight, health history, onset of injury, and physical conformation when making a treatment recommendation for your pet.

Who is not a Candidate for Tightrope CCL Repair?

1)  Dogs weighing less than 30-40 pounds.

2)  Dogs (and people) that cannot follow a physical rehabilitation protocol after surgery.

3)  Canines with limb deformities of any kind.

4)  Dogs with a steep tibial plateau, usually an angle of more than 30 degrees.

Is My Dog a Candidate for Tightrope Surgery? is a post from: Dog Knee Injury

How is Tightrope CCL Different from Extracapsular Imbrication or Traditional Repair?

The major difference between extracapsular imbrication/traditional repair methods and tightrope ccl is the way in which the knee joint is stabilized.  In a traditional CCL repair, a leader line (suture, or you can also think of this as a fishing line) is woven across the knee in a figure-eight pattern, connecting a bony protrusion on the femur to a small hole drilled in the top of the tibia.  The veterinary surgeon is able to access the knee through an incision on the knee a few inches long.   During the healing process, the leader line serves as a temporary way to stabilize the knee while scar tissue forms.  Eventually the leader line will break, and the scar tissue is solely responsible for providing knee joint stability.

In tightrope repair, a stronger material called Fiber Tape is used to connect bone to bone.  The FiberTape is held in place on the bone via metal anchors and small holes drilled through the bone.  The surgeon makes a few small incisions to access the points of attachment to the bone.  While the Fiber Tape will eventually degrade and possibly break over time, it is thought of as a superior material for larger dogs due to its greater durability and strength – buying your dog more recovery time.  While in place the Fiber Tape will act to control tibial thrust and prevents the cranial drawer sign, while allowing your dog to maintain full range of motion.

Both traditional repair and tightrope are considered to be minimally invasive procedures when compared to other surgical options like TTA and TPLO, which both involve cutting and changing of bone angles.

Tightrope Surgery vs. Extracapsular or Traditional Repair is a post from: Dog Knee Injury

The standard rehabilitation procedure for Tightrope repair is a bit different than TTA and TPLO, due to the less invasive nature of the procedure.  When dogs return home from Tightrope repair, owners are instructed to allow their dog to utilize the leg as they wish.  For some dogs this means they will start putting weight on it the next day, and for other dogs it could be 2-4 weeks before they feel comfortable bearing weight on the surgical leg.  Keeping your dog still while in the house, and keeping leashed walking to a minimum (bathroom breaks only) is critical during the first few weeks home no matter what procedure you choose, and exercise/movement restriction is advised for the first 8 post operative weeks.

At 4 weeks post op, most veterinarians will instruct owners to begin introducing their dog back to walks, particularly walking uphill in an attempt to rebuild loss muscle mass.  It is a good idea to start out by taking a few short walks every day, gradually working up to longer and less frequent walks.  This will prevent strain on the knee joint, which can hinder the healing process.  Post operative exercises need to be controlled, leashed walks, as any running, jumping, or roughhousing during the first 8 weeks can be detrimental to the stability of the knee and recovery process.

Upon his arrival home, your dog will need to take a number of medications for pain, inflammation, infection prevention, and possibly sedation.  If your buddy is not a willing pill taker, it is a good idea to try to get them into the habit of taking a small snack such as a piece of cheese, peanut butter, or a hot dog slice after their meals.  Each dog is different with regard to how long they need to be on a particular pain, inflammation, antibiotic, and sedation regimen, but usually the antibiotics are taken over 10 days, with the pain/inflammation/sedation used on an as needed basis.

As a general rule, just pay close attention to your dog and be sure to tailor their recovery to their particular needs.  There is no such thing as having a post operative dog rest too long, but there is always the risk of damage to the repair if your dog tries to do too much, too soon.  Tightrope CCL, like other traditional repair methods (lateral suture, extracapsular imbrication), is simply a way to stabilize the joint while scar tissue is being formed, it is not a replacement ligament.

Tightrope CCL Surgery Recovery is a post from: Dog Knee Injury

The Tightrope CCL repair surgery is the newest surgical option available for dogs with cranial cruciate ligament injury.  Unlike in humans, canine CCL tears and damage generally takes place over a period of months or years, rather than being associated with a single traumatic event.  Because of the nature of these injuries, and their degenerative process over time, this new procedure focuses on a technique used in human ankle joints using bone to bone fixation in a minimally invasive way.

Tightrope CCL is an extracapsular technique using the lateral suture stabilization (LSS) procedure in conjunction with a material called FiberTape to provide bone to bone stabilization.  The Fiber Tape is placed in the dog’s knee through a few small incisions which create tunnels through the bone.  Once the implant is anchored to the bone it is able to control cranial tibial thrust, and provide correction for the canine drawer sign, all while allowing internal rotation of the knee joint and normal range of motion.  Similar to traditional extracapsular repairs using monofilament sutures (similar to a leader line or fishing line), the Fiber Tape used in TR repair will degrade over time and is not meant to provide permanent stablization to the knee joint.  Bascially, the Fiber Tape is there to hold the joint in place while the knee forms scar tissue around the knee to permanently stablize the joint.

The cases of failure in the study were related to incidences of not properly following guidelines related to physical therapy in the post operative period.  A recovery period of 10-12 weeks is recommended for all dogs recovering from CCL repair surgery, and this is the same guideline used for the Tightrope surgery.

Right now this surgery is still in the clinical phases, but with such encouraging preliminary results, I expect to see much more on this procedure in the very near future.

Tightrope CCL Procedure is a post from: Dog Knee Injury

Not surprisingly, surgery is almost always advocated by surgeons . It is likely that surgery does help reduce the amount of arthritis that occurs, but in a long term study of cruciate ligament surgery in dogs in Australia, about 50% still had detectable arthritis in surgically repaired joints and about 10% of dogs were persistently lame despite attempts to surgically stabilize the joint. Tibial plateau leveling osteotomy (TPLO) has become the top choice for surgical CCL repair among many orthopedic veterinarians, and it can be done in both large and small dogs. Supporters of TPLO will say its good choice for the situation in which there is a bilateral cruciate rupture since it seems to be a strong repair procedure, but there are many instances where dogs have done equally as well with either TTA or a traditional repair.

One benefit of doing a traditional extracapsular repair, in addition to saving a few thousand dollars, is that you still have other options for repair if for some reason the traditional repair fails. If you are choosing surgery for a dog with a double CCL rupture, make sure to research each procedure carefully before blindly going along with a procedure you know nothing about. TPLO, TTA and traditional repairs are all very different procedures, and each carry their own set of risks vs. rewards. The best way to find out what is right for your pet is to do as much research as you can and find a veterinarian that is willing to discuss your many options for surgical intervention.

If surgery absolutely isn’t an option, there is a very good chance that in a few weeks, to a few months, you will find that your dog is doing OK without any type of surgical intervention -especially if you can manage the weight loss. There are a number of great resources both on this website and the web with instructions on how to succeed with CM.

CCL Injury in Both Back Legs is a post from: Dog Knee Injury

There are a few different surgical options for dogs with canine cruciate injuries, and not all veterinarians are trained in each procedure. It is important to find out from your vet what procedures they perform, and ask for referrals to specialists if you would like more information on a different type of procedure. There are vets the specialize in orthopedics and, if possible, it is preferable to choose a physician with this type of experience. Be sure to read up on each of the 4 surgical procedures before talking to your veterinarian about which one he/she recommends.

Surgical Repair Techniques for CCL Repairs:

1. Traditional Repair or Extracapsular Imbrication Technique – A leader line is woven in a figure-eight pattern through the joint beginning at the outer aspect of the femur to the tibial crest. The heavy suture will eventually be replaced by scar tissue providing support for the joint.
2. Tibial Plateau Leveling Osteotomy or TPLO – The head of the tibia is surgically altered and plated to create a new joint angle and prevent the femur from sliding off of the tibia. This procedure is an invasive on and involves cutting and plating of bone; it is associated with a higher rate of complications than the other surgical options.
3. Tibial Tuberosity Advancement or TTA – This is very similar to TPLO, yet considered to be less invasive, and involves stabilization of the stifle joint by cutting the bone and changing the angles of the knee.
4. Fibular Head Transposition – The head of the fibula is rotated and the lateral collateral ligament is moved in such a way that it mimics the cruciate ligament. The new positioning of the fibula is held in place using pins and wires. This procedure is not done very often and you may have a hard time finding a veterinarian that will actually perform it.
5. Tightrope Repair – An extracapsular technique using the lateral suture stabilization (LSS) procedure in conjunction with a material called FiberTape to provide bone to bone stabilization.   Similar to traditional repair, the joint will form scar tissue, but the Fibertape will also provide support for a greater length of time.
   

Surgical Repair Options for Cranial Cruciate Ligament Repair is a post from: Dog Knee Injury