TTO = TPLO + TTA

While still not very common in the US, the TTO is one technique available to repair a torn dog knee ACL ligament. The idea behind the TTO is to combine aspects of the TPLO and TTA to create a new angle within the injured knee joint. The goal of the TTO, or Triple Tibial Osteotomy, is to create a 90 degree angle between the tibial plateau and patellar tendon while the knee is extended.

During a TTO CCL surgery a veterinarian will make three cuts (where the “triple” comes from) into the dog’s tibia.  These three cuts into the tibia bone will allow the surgeon to then rotate the tibial plateau slightly (as they do in a TPLO), while moving the tibial tuberosity forward slightly (as is done in a TTA).  When the adjustments have been made, the veterinarian will screw a metal plate directly onto the bone to hold the new position.  After these cuts and bone angle changes are made the result is a 90 degree angle within the knee joint when the dog’s leg is in an extended position.

It is the opinion of some veterinarians that the TTO is the best dog knee ligament surgery because it, in effect, molds the bone into a new shape.  According to a study done in New Zealand, there is a very low incidence of implant failure associated with the TTO, with most patients experiencing good post operative results.   Another benefit of this procedure, according to veterinarians, is that the TTO technique is relatively easy to learn.  It does not require expensive instruments to perform, and the technique can be easily replicated on dogs of all sizes.

TTO Surgery for Dogs is a post from: Dog Knee and Leg Injuries, Cruciate Ligament Surgery, CCL Injury Diagnosis

Well I am happy to report that Taylor is doing great and is now 5 weeks post surgery. It has been a long 5 weeks. At approximately 1 week after surgery Taylor was no longer limping and was ready to go! It has been difficult to keep her at rest. We have enrolled in a cranial cruciate study and has had 4 rehab sessions. These sessions include water treadmill, and appropriate therapeutic exercises to facilitate neuromuscular re-education and to improve flexibility, strength, balance and gait patterning.

Taylor remains quiet and activity is limited to controlled exercises and short leash walks. She can also walk stairs slowly one at a time while supervised on a leash. I will post more pictures soon including post op pics and of course some rehab pics. She now walks without a limp and other than her shaved leg and some mild muscle atrophy she is doing great……I know there is still a possibility of complications including infection and rejection of the implanted screws and plates but all looks great at this point in time.

TPLO Post Op Update – Taylor is a post from: Dog Knee and Leg Injuries, Cruciate Ligament Surgery, CCL Injury Diagnosis

Our 3 1/2 year old yellow lab has had hind lameness after exercise for several months now. We tried rest and anti inflammatory meds for 3 weeks with no results, so finally had her examined and x-rayed.

She was diagnosed with a torn CCL, with some arthritis in her affected knee. It was a very difficult decision to make whether to operate or do conservative management. I spent nights crying about the consequences of both, and finally decided on the TPLO.

She was operated on 2 days ago and we brought her home yesterday. I was amazed that she was doing so well with some slight weight bearing on the affected leg, but was shocked at the swelling and bruising that resulted after the TPLO surgery. She is eating, drinking, peeing and pooping, and we hope that she remains infection free on her road to recovery. I am still on the fence with regards to my choice, but we shall soon see. Lots of friends have had success with TPLO surgeries on their dogs so I hope to have the same results.

Our dog was also part of a clinical trial involving CCL injury and TPLO surgery. She will be followed closely post op with regards to her gait, weight and hydro therapy.

TPLO Ligament Surgery – Taylor is a post from: Dog Knee and Leg Injuries, Cruciate Ligament Surgery, CCL Injury Diagnosis

Potato’s Story:

Potato tore her knee muscle in winter. I had insurance, but because she was limping prior to a minor sprain, they didn’t cover it. I couldn’t stand seeing her limping around anymore so i paid the $3000 for the kind of surgery where they cut the bone so the leg isn’t bowed anymore and so it stabilizes the knee (TPLO). She is doing ok and today is the second day after surgery.

I thought I had sedated her enough, but I left the room for two seconds, and somehow she got off her chair. I was going to let her sit in it with my help but now that is off limits. Then today, I left her in my bedroom with her cone on, I thought she wouldn’t be able to get on the bed…but when i got home she was on it. I have no idea how.

The most important thing I have learned from this is…THEY WILL DO WHAT YOU DON’T WANT THEM TO DO. She doesn’t understand that these two attempts could have easily ruined her newly operated knee, and me underestimating her also almost wasted that $3000. I’ve learned that i can’t leave her for one second, and that she is going to have to be crated. She really scared me.

Also, her ankle is a little swollen, but thanks to this web site i might not have to pay another $200 to see what it is. One of your contributors said that their dog had just fluids trapped there and that massage and ice helped with them. I called the vet, and they are calling the specialist who did the surgery for me and recommended heat. If it continues past the weekend I will go back to the vet, but this website helped me with the initial panic.

Thank you so much!

TPLO, 2 Days Post Op – Potato is a post from: Dog Knee and Leg Injuries, Cruciate Ligament Surgery, CCL Injury Diagnosis

What is a dog TPLO surgery?

TPLO stands for Tibial Plateau Leveling Osteotomy, which in simple english means that they are changing the bones of the knee joint to make them work in a different, more “level” manner.  The veterinary surgeon will start by making an incision in your dog’s injured leg, and the cut will be made down the length of the leg.  Through this incision the veterinarian will then access the injured acl (or ccl as it is more properly called in dogs) and begin by removing the severed, torn and/or ruptured ends of the ligament.  Once the cranial cruciate ligament damage has been removed, a cut is made in the top of the tibia.  Measurements are then taken and compared to those from the pre-op x-ray, and the tibial plateau is positioned to make the slope of the knee level.  A plate is then screwed into the top of the bone to allow the bone to heal in its new angular position; the metal plates can be removed later, although this involves another procedure.  To read more about this surgery click TPLO Surgery Procedure.

TPLO Cost?

A Tibial Plateau Leveling Osteotomy is a difficult veterinary procedure, and you should expect to be billed accordingly.  While prices vary across the US, I can tell you first hand an estimate I received for my 90 pound dog.  The estimate came with both a high and low price, and included all of the pre and post operative care, barring any complications, which are not included.  This estimate was from a veterinary speciality hospital, and my dog would have stayed overnight following the surgery with monitoring and pain control.  The low end of the estimate was $3,892.79 and the high end of the estimate was $4,03.58 for TPLO surgery.  The lowest quote I have seen for a TPLO knee repair was $2,500 at a rural veterinary clinic in one of the midwestern states, and I have heard up to $6-7,000 for a TPLO acl surgery at one of the leading veterinary school’s affiliated clinics.  Vets are aware that the cost of a TPLO surgery for your dog can be a difficult burden, and many are willing to work with you to cut out on extra costs and/or create payment plans.

TPLO Surgery Dogs is a post from: Dog Knee and Leg Injuries, Cruciate Ligament Surgery, CCL Injury Diagnosis

Timber is a 6 year old female shepard mix; she is my baby. In August 2006, Timber tore her left ACL and she underwent TPLO. She recovered beautifully from TPLO surgery. Nearly 4 years later, she developed an abscess over her TPLO scar. I took Tim to my local vet, and she said that it looks like it could have been a suture from her surgery that did not dissolve. In for surgery to remove the abscess she went.

After two weeks the abscess started to grow back, so I took her to the surgeons office (who did the surgery 4 years ago), to find out that the stainless steel plate she had, had become infected. He recommended to remove the plate left in after the TPLO surgery. On Feb 7, 2010, Timber went in for plate removal, and on that same day she was also diagnosed with a torn ACL in her right knee. I was told I needed to wait 1 month until she had her right knee operated on because she had 2 types of bacteria growing on the plate in her left leg; she needed a course of antibiotics.

So we waited, and mommy did her research. After plenty of reading I chose the TTA (Tibial Tuberosity Advancement) surgery, which uses a titanium plate. I felt that she was at a greater risk of rejecting the stainless steel plate with the TPLO surgery. I did my research on the two type of metals, and titanium seems to be the better of the two, so we went with TTA.

TTA Dog Knee Surgery, Timber’s Story is a post from: Dog Knee and Leg Injuries, Cruciate Ligament Surgery, CCL Injury Diagnosis

How much will a TPLO surgery for my dog cost?  How much should I expect to spend on a TPLO repair?

TPLO, also known as Tibial Plateau Leveling Osteotomy, is a CCL repair technique through which the veterinary surgeon alters the head of the tibia and plates it to create a new joint angle.  Simply put – your veterinarian will re-invent your dog’s injured knee joint to provide increased stability through changing the way the top and bottom of the leg meet at the knee joint.  This is the most invasive, and requires the most surgical skill, of all the surgical cranial cruciate ligament repair options; it is also the most expensive.  In this article we will break down an actual TPLO cost estimate and explore the cost of choosing this type of CCL repair surgery for your dog.

Below is the estimate I received for my dog to undergo TPLO 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.

Here is the estimate I received for a TPLO CCL repair.  The low end of the estimate was $3,892.79 and the high end of the estimate was $4,03.58 for TPLO surgery.

I will go line by line to go over the charges included in the cost of TPLO 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 TPLO, and where all of the money goes.

EST TPLO Surgery Med/Large – $0 – Just tells us what type of estimate we are looking at.

CBC and Chemistry Profile – $163.80 – Basic blood panel the veterinarian will want to run prior to surgery to determine if you dog is fit to be put under anesthesia and to rule out any other complications.  One way we could have saved money here was to have our dog’s regular vet perform this blood panel at a lower price than to have it done at the speciality clinic.

Radiograph, 2 Views – $224.70 – This is the x-rays that need to be performed prior to the TPLO so the surgeon is able to properly manipulate the tibia during surgery to create the desired angles.  These will need to be performed somewhere prior to TPLO, and some veterinarians will want to do the xrays themselves.

Radiology Interpretation – $45.68 – Fee charged for processing and reading the x-ray.

Catheterization, Intravenous – $94.00 – This fee is for the placement and maintainence of an IV catheter while your dog is undergoing and recovering from TPLO surgery.  Your dog will be given IV fluids and possibly medications through this catheter during the duration of surgery and post operative hospitalization.

Epidural Injection – $86.52 – Local anesthetic (pain relieving medication) will be injected into the lumbosacral (in the spine) space of your dog prior to surgery.  Depending on what types of medication(s) your veterinarian uses this can help to alleviate pain after surgery, and desensitize the effected site during surgery.

Surgery Room Use – $113.82 – Fee for using the Operating Room space to perform the TPLO.

TPLO Inhalant Anesthesia – $306.34 – Cost of putting your dog under gas anesthesia for the time required to perform the TPLO procedure.  This is used in conjunction with the epidural anesthesia.

Surgical Anesthesia Level 1 – $294.00 – Fee for dog to be put under anesthesia and monitored during TPLO surgery.

Surgical Supplies, Orthopedic – $358.05 – Cost for instruments to be used during surgery; this does not include the cost of the actual TPLO implant.

TPLO Surgical Implants, Med/Large – $358.05 – Cost of TPLO implant plates to be placed on the bone during surgery.

TPLO Surgeons Fee – $974.40 – Price veterinary surgeon charges to perform TPLO operation.

Radiograph, Post Op – $192.52 – Cost of x-ray to be taken following surgery to check placement of implant and knee joint angles.

Elective Ortho Hospitalization, General – $138.92 – Cost of overnight hospital stay following TPLO repair surgery.

Fluids – IV, Inital 24 Hours – $0-$190.31 – This would depend on whether or not your dog was being cared for at the hospital post operatively, and how much fluids your pet required.

Misc. Medications, Orthopedic - $450 – 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 – Pain relief patch that will be placed in your pet to control post operative discomfort.

Buster Collar, Clear – $25.26 – 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.

Included:  X-ray at 8 weeks to check the post operative recovery and  misc. sedative (not sure if this is sedative used during the surgery itself or the sedative medication to take home with you following TPLO surgery).

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 is the Actual Cost of TPLO Surgery? is a post from: Dog Knee and Leg Injuries, Cruciate Ligament Surgery, CCL Injury Diagnosis

Our dog Beau is a seven year old Golden Retriever and master of the household! He’s friendly, fun, energetic and spoiled! Unfortunately, we learned early in his first year that he also has hip dysplasia. Until now, this has not stopped him from having an active, doggy life. However, in late November we noticed some on again, off again limping and after a few days of this, we took him to the vet to check it out.
After an exam and x-rays (done under sedation) the bad news turned out to be a ruptured cranial cruciate ligament. Our vet said that this is a common injury in dogs, particularly large breeds and particularly dogs with hip dysplasia who tend to alter their gait and put added stress on the knee ligaments. While humans tend to tear these ligaments in sporting activities (the football player who misses the season due to a torn ACL), dogs put much more stress on their knees (stifles) and are more prone to rupturing these ligaments over time, without a significant trauma. We were presented with the following options for Beau:

1. No surgery. Treat with rest, physical therapy, pain and anti-inflammatory medications. Our vet did not feel that the ligament in a dog this size would heal on its own, however, and indicated that the likely outcome would be abnormal wear and tear leading to arthritis which would continue to worsen over time, becoming chronic and debilitating.

2. TPLO surgery (Tibial Plateau Leveling Osteotomy). This is a surgical procedure in which the head of the tibia is surgically altered and plated to create a new joint angle. A new angle is created in the stifle to prevent the femur from sliding off of the tibia. This surgery would need to be performed by an orthopedic veterinary surgeon and would be very expensive. We were never actually given an estimate for this surgery, but my research puts the cost in the $3,000 – $4,000 range. Our vet indicated that this procedure is considered by some to be the gold standard in treatment. However, due to it high cost and invasiveness, she did not recommend it for a seven year old dog.

3. Traditional Repair surgery (Extracapsular Imbrication). This procedure uses a strong leader line placed within the knee to provide stabilization. As it was explained to us, the downside of this procedure is that the line will eventually break and it is impossible to say when. It could be that the line lasts five years, or it might only last two months. With a large dog like Beau, our vet didn’t feel this was our best option.

4. Modified Traditional Repair surgery. This is the same procedure as in number 3 above, except that the dog’s own muscle is used to provide the stabilization, which is much stronger. As the area heals, it heals around this graft of muscle and further increases the knee stabilization. The cost of this surgery, as well as the surgery in 3 above, depended in part on whether or not the meniscus was damaged. The meniscus is the pad between the bones of the joint – a shock absorber. Estimates for this surgery were from $1,700-$1,900. Our vet recommended this option, which would be performed in their offices by a different veterinarian with extensive experience in this procedure.

To be honest, we didn’t give option 1 too much consideration. Neither my husband nor I could bear the thought of our middle aged (but not old), active dog declining early in such a painful manner. On the other hand, TPLO surgery was simply too expensive for us to consider and our veterinarian seemed to think this surgery would be warranted for a young dog, but not a seven year old dog. Option 3 seemed too risky and also was not recommended by our vet for a dog of Beau’s size. Thus, we elected for the Modified Traditional Repair using the dog’s own muscle to stabilize the knee. I was unable to find much information on this modified type of repair on-line, but it may be that there is a particular name for it which I was not searching under. I did see information on the Tightrope repair surgery, but our veterinarian felt that this was not in favor currently. One very sober fact: the vet told us that 40% of dogs that rupture the CCL eventually rupture the CCL in the other leg. Whatever choice we made, we best be prepared to make it again.
Unfortunately, we learned the next day that the veterinarian who was to perform the surgery was out of town for several weeks. The surgery was scheduled for December 8^th and our job was to keep Beau quiet and calm until then!

Our Dog Beau and His CCL Injury is a post from: Dog Knee and Leg Injuries, Cruciate Ligament Surgery, CCL Injury Diagnosis

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 and Leg Injuries, Cruciate Ligament Surgery, CCL Injury Diagnosis

So which is better, TPLO or TTA?

Well, if your veterinary surgeon has no experience performing TTA’s, as it was only introduced to US surgeons starting in 2004 so many vets do not, you will want to opt for the procedure with which your vet can demonstrate proficiency and results. Many veterinary surgeons perform both TPLO’s and extracapsular imbrication techniques, but there are not many who perform all three. If you have the option of choosing between a surgeon that does a TPLO and a TTA, and have an active, large breed dog that would not do well with a traditonal, or extracapsular imbrication, repair, you will want to weigh all the characteristics of both procedures.

Which is less invasive?

The TTA is surgically less invasive than the TPLO. The amount of stifle angle shifting that takes place during a TTA is minimal when compared to that of a TPLO, where the tibia (the weight bearing part of the knee joint) is surgically cut and altered. In the TTA the osteotomy is made into the tibial tuberosity (not a weight bearing part of the knee joint), not the tibial plateau itself, giving dogs a greater ease in healing, recovery and overall success of the procedure.

Which has a shorter recovery time?

The TTA, because it is a surgically less invasive process, has a shorter recovery time than the TPLO. While most TTA and TPLO dogs are able to begin weight bearing within the first 24 to 48 hours postop, TTA dogs continue to improve with time, whereas TPLO dogs often demonstrate a more gradual healing process taking place over months instead of weeks.
Which has less risks of complications?

What does each procedure cost?

The least expensive method of cranial cruciate ligament (or CrCL) repair is always going to be the extra capsular imbrication method, as it does not require the use of any implants or an osteotomy procedure, and you can expect to pay between $700-$1100 to have a traditional repair done. This procedure can be a great option for many dogs, and I encourage all owners to read more about its risks and benefits when considering surgery for a CCL rupture.

When comparing the TTA and TPLO, the TTA is less expensive, and this is due to the simpler nature of the procedure as well as the fact that it does not require as much equipment, despite the fact that titanium costs more than stainless steel. A typical price for a TTA will run between $1500-$2000 vs. a TPLO ranging between $2200-$2700, which usually includes all of the pre-operative testing, postop medications and post-op visits for suture removal, bandage removal (if applicable) and radiography.

TPLO vs. TTA for Cranial Cruciate Ligament Repair is a post from: Dog Knee and Leg Injuries, Cruciate Ligament Surgery, CCL Injury Diagnosis