The Dynamic Tibial Plateau Leveling Procedure – A Novel Surgery for Cranial Cruciate Ligament Rupture in Immature Dogs
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Article Written by Dr. Daniel A. Degner, Board-certified Veterinary Surgeon (DACVS)

Key Points

A new technique, called the dynamic tibial plateau leveling procedure (TPLP), can be used to treat cranial cruciate ligament rupture in growing immature dogs

The timing of the surgery is critical, and is specific to the breed of dog

This technique involves placing a screw in the cranial aspect of the growth plate of the tibial plateau

As the dog grows the top of the tibia levels, in essence the final result is the same as the TPLO, but with a much less aggressive surgery


Causes of cranial cruciate rupture in dogs

  • Cruciate ligament rupture can occur in all ages of animals, including very young dogs. The etiology of this problem is multi-factorial. Bow-legged conformation, patellar luxation, narrow intercondylar notch, trauma, nonisometric ligament attachments to the bones, and steep tibial plateau are contributing factors.
  • Bow-legged hind limb conformation and medial patellar luxation cause excessive internal tibial rotation which strains the ligament and may lead to cranial cruciate ligament rupture.
  • The cranial cruciate ligament passes through the intercondylar notch of the femur bone. A narrow intercondylar notch can impinge the cranial cruciate ligament which results in continual friction and fraying of the ligament.
  • Ligaments must be attached to isometric points on the bones. This means that the ligament is not stretched during extension versus flexion or visa versa. If the bone growth is such that these isometric points are altered, increased forces are exerted on the ligament, which results in permanent elongation of the ligament with resultant instability of the joint.
  • The slope of the tibial plateau plays a significant role in stressing the cranial cruciate ligament. The steeper the plateau slope, the greater the forces that are exerted on the cranial cruciate ligament. A comparative example is this: greater force is required to pull a wagon up a steep hill than on a level surface. A steep slope results in repeated maximal loading of the ligament, which ultimately stretches the ligament beyond its elastic phase into the plastic phase resulting in permanent elongation and weakening of the ligament.

Methods of Repair

  • Many repair methods exist for cranial cruciate rupture. Extracapsular repair has been the most popular technique for a number of years. Many extracapsular techniques exist, however most surgeons use the "Flo" and the lateral imbrication technique. Board-certified Surgeons in the United States have recognized that these and many other traditional techniques do not allow dogs to return to working or athletic activities without lameness. In our experience, dogs treated with the tibial plateau leveling osteotomy (TPLO) technique have an excellent chance to successfully return back to these types of activities.

Progression of Arthritis

  • Another study evaluated the progression of degenerative joint disease in dogs following intra- and extra-capsular surgical techniques and a group of cranial cruciate ligament deficient dogs having no surgery. Interestingly, all groups of dogs developed the same degree of degenerative joint disease. In contrast, a study that evaluated the progression of arthritis in dogs receiving the TPLO versus the imbrication technique demonstrated four times less progression of degenerative joint disease with the TPLO technique. We have also noted in our clinical cases that arthritic changes in most cases progresses very slowly or is arrested.

Very young dogs and cruciate injury

  • One of the challenges that the orthopedist faces is rupture of the cranial cruciate ligament in very young dogs (6 months or less). As mentioned above, arthritic changes progress rapidly with the traditional techniques that have been used in the past. As a result, this is not an ideal treatment. The standard TPLO is also not ideal for very young dogs either, as the growth plate is cut during the procedure, which may result in continued flattening of the tibial plateau as the dog grows.

Dynamic tibial plateau leveling procedure

  • A new technique, called the dynamic tibial plateau leveling procedure (TPLP), can be used to treat cranial cruciate ligament rupture in growing immature dogs. The timing of the surgery is critical, and is specific to the breed of dog. This technique involves placing a screw in the cranial aspect of the growth plate of the tibial plateau. Growth is stopped at this region of the tibial plateau, yet the caudal aspect continues to grow. Over time the tibial plateau angle is leveled. The amount of leveling of the plateau is dependant on the preoperative tibial slope and the age of the dog at which the procedure is performed.
  • Below is a preoperative and postoperative dynamic TPLP radiographs. Take note of the 26 degree slope at the time of surgery; the cancellous screw is placed at the cranial aspect of the tibial plateau. Four months later the tibial slope has decreased to about 4 degrees.

     

Aftercare

  • Typically patients receiving the dynamic TPLP have a fairly low morbidity rate associated with the procedure. Postoperative pain appears to be fairly low, as minimally invasive techniques are used to perform the procedure; therefore, these patients can return home the same day as the procedure is performed. Exercise is limited to leash walks for about 2 months. Typically, this is the period of time during which the lameness resolves. To evaluate the effect of the procedure, radiographs of the tibia are taken initially at 8 weeks after surgery, and then every 1 to 2 months until the dog has matured.

Benefits of the dynamic TPLP

  • Advantages of this technique include short recovery from surgery, minimal pain, and less cost for the procedure in comparison to the standard TPLO procedure used to treat cranial cruciate rupture. If indicated, the procedure can also be safely performed bilaterally.

Frequently Asked Questions After Surgery

When should my dog have the first bowel movement after surgery?

  • Many dogs will not have a bowel movement for the first 4 to 5 days after surgery
  • Reasons that a dog will not have regular bowel movements after surgery include:
    • The dog has been fasted prior to surgery
    • Dogs do not eat well during the hospital stay
    • They frequently do not eat well when they go home
    • They are fed highly digestible food that produces little stool
    • Pain medication that contain narcotics (such as morphine, fentanyl patches, and tramadol) can be constipating
  • If a pet does not have a bowel movement on the 5th day of being home, a stool softener such as metamucil can be fed
    • Dose of metamucil is 1 tsp per 25 Kg mixed in with each meal (canned dog food); feed immediately after mixing, as the metamucil will gel the food and may make it less palatable

My pet had surgery and will not eat.  What can be done?

  • Dogs
    • Most pets will not eat their regular dog food after surgery, especially if it is kibble.
    • Offer a cooked diet having a 1:1 ratio of a protein source and carbohydrate source.  The protein source can be any meat (example: chicken breast, turkey breast, lean hamburger) that is low in fat and should be cooked (drain off all fat after the meat has been cooked).   The carbohydrate can be pasta, potato or white rice.
    • Try canned dog food; to enhance the flavor sprinkle a very small amount of garlic powder or chicken or beef broth (Chicken-in-a- MugTM or Beef-in-a-MugTM products)
    • Try Gerber strained meats for babies such as the chicken, beef, turkey, or veal
    • Try Hill's A/D diet available at most veterinary hospitals
    • Hand feeding: place a small amount of food in the mouth so that your dog gets the flavor
    • Warm the food slightly in a microwave, as the food will be more aromatic; stir the food before feeding and test the temperature on the bottom side of your wrist; it should only be luke warm.
    • Remember that most pets will not eat the first day or two after they get home from surgery
  • Cats
    • Offer smelly foods that contain fish such as tuna or smelly cat foods
    • Try Gerber strained meats for babies such as the chicken, beef, turkey or veal
    • Hand feeding:  with your finger place a small amount of food on the roof of your cat's mouth; use a syringe to get soft food into the mouth
    • Warm the food slightly in a microwave as the food will be more aromatic; remember to stir the food before feeding and test the temperature; it should be only luke-warm
    • Some cats will only eat dry food, try kibble if your cat normally has been fed that food
    • Petting and stroking your cat frequently will help to stimulate appetite
    • Remember that most pets will not eat the first day or two after they get home from surgery
    • Appetite stimulants such as cyproheptadine may be helpful
    • If your cat refuses to eat anything for 7 days a stomach tube or nasogastric tube should be placed to provide nutrition so that a serious liver problem (hepatic lipidosis) does not develop

My pet is vomiting.  What can be done?

  • The first thing for you to discern is whether your pet is vomiting or regurgitating.  Both will result in fluid or food being brought up.  Vomiting always will have heaving or retching of the abdomen prior to expulsion of the vomitus.  Regurgitation is not associated with heaving and the pet usually just opens the mouth and fluid or food will be expelled.  Usually the regurgited material will be clear or brown colored fluid. 
  • Next is to identify the cause of the vomiting or regurgitation.
  • Causes and treatment of vomiting after surgery
    • When some pets return home after a stay in the hospital they may drink excessive amounts of water at one time and then vomit; if this appears to be the case, the water should be limited to frequent smaller amounts.
    • Medications such as antibiotics, narcotics or nonsteroidal anti-inflammatory medication commonly cause vomiting after surgery.  In order to see which medication is causing the problem, the administration of each drug should be separated 2 hours apart.  Usually the pet will vomit or appear nauseated (drooling and sick look) within 1 hour of administration of the medication that they are sensitive to.  The antibiotic in some cases may be changed to a different one, or may be discontinued. 
    • Stomach upset from anesthesia is a potential cause of vomiting and will pass within a couple of days. 
    • An uncommon cause of vomiting after surgery is internal organ failure.  Blood testing will confirm this problem. For this reason vomiting should not be ignored if it persists for more than 24 hours.
    • If your pet had surgery of the bowels or stomach, vomiting is always a concern, as it may indicate that infection of the abdominal cavity, called peritonitis, is present.  Do not ignore this sign.
    • Symptomatic treatment of vomiting involves withholding food for 12 to 24 hours, then introducing small amounts of bland food such as rice and lean cooked hamburger, if your pet does not vomit after that then gradually wean him/her back onto the regular diet after 3 days.  In order to decrease the acidity of the stomach, Pepcid AC 0.5 mg/kg can be given by mouth twice daily for 5 days.  Metoclopramide and Cerenia are good anti-vomiting medications for dogs and cats.  You should always consult a veterinary healthcare professional before administering medication.
  • Causes and treatment of regurgitation after surgery
    • The most common cause of regurgitation is reflux of acid from the stomach into the esophagus while your pet is under anesthesia.  Acidic fluid from the stomach can cause a chemical burn of the esophagus and result in a bad case of heart burn, called esophagitis.  This results in poor motility of the esophagus, therefore water and food will accumulate in this structure.  In most cases, esphagitis is self-eliminating and will resolve within two or three days. 
    • If the esophagitis is severe the esophagus may develop one or more strictures.  A stricture is a narrowing or stenosis of the esophagus and does not allow passage of food down the esophagus, in regurgitation that lasts longer than one week.  This problem should be brought to the attention of your pet's doctor within the first two weeks so that it can be treated by ballooning the stricture (minimally invasive procedure, as it is done with the aide of an endoscope).  If an esophageal stricture is chronic surgery is needed.
    • Symptomatic treatment of regurgitation caused by esophagitis includes feeding bland food, and administering a coating agent (sucralfate) and an acid blocker (omeprazole or other).  Consult a veterinary health care professional if the regurgitation continues for more than a couple of days.

How do I know that my dog is in pain following surgery?

  • Signs of pain include
    • crying
    • biting if you get near the surgical site
    • grimacing (lips are pulled back and the the dog looks anxious)
    • tragic facial expression
    • panting
    • restlessness and unable to sleep; pacing
    • if abdominal surgery was done the pet will not lie down on the incision, or will continually sit up in spite of appearing very tired
    • the worst pain will be for the first 2 to 3 days after surgery

What can I do to control my dog's pain?

  • Narcotic medications that control pain: tramadol, butorphanol, Duragesic (fentanyl patch)
  • Anti-inflammatories used to control pain: Deramaxx, Rimadyl, Previcox, or Etogesic
  • If an orthopedic surgery has been done cold packing the surgical site may be helpful
    • A cold pack may be a pack of frozen peas, crushed ice in a Ziploc bag, or a cold gel pack; place a thin barrier between the skin and the cold pack.  An alternative to a cold pack is to freeze water in a styrofoam cup; after frozen cut the bottom of the styrofoam cup out. Cool the surgical site around the incision by rubbing the exposed ice directly on the skin in a circular pattern.  Cooling the surgical site helps to numb the area.

How do I know that my cat is in pain following surgery?

  • Pain is more difficult to assess in cats versus dogs, as signs can be more subtle and they usually do not vocalize when in pain
  • Signs of pain in a cat include the following:
    • biting if you get near the surgical site
    • growling or deep cry
    • not wanting to eat
    • hiding and not wanting to be near owner (remember that this could also be caused by the cat just being upset about leaving home and coming back)

What can be done for pain at home for my cat?

  • Pain medication such as buprenorphine or a Duragesic (fentanyl) patch
  • Tylenol will kill a cat as they lack abundant glutathione enzyme in the liver
  • Anti-inflammatories can be used, but the dose is much less than dogs

Is it okay for my pet to lick the incision?

  • If a dog licks the incision, the healing process may be delayed.
  • Licking can remove stitches and cause the incision to open
  • Licking can become a severe habit that is difficult to break
  • Licking can cause infection as the mouth has many bacteria
  • Dogs will frequently lick the incision when the owner is not watching such as at night time; if the skin looks red or excoriated the most common cause is from licking.
  • To stop your pet from licking the following can be tried:
    • Elizabethan collar can be placed on the neck; this will not help stop your pet from scratching at the region
    • Cervical collar (bite not collar) is a less awkward device and can be effective at stopping a pet from licking the surgical site
    • A tee shirt can be used to cover an incision on the chest or front part of the abdomen; gather the waist of the shirt up over the dog's back and wrap an elastic band around this part of the shirt.
    • A bandage or sock can be used to cover an incision on a limb; fasten the top of the sock to the dog's limb with tape.
    • Bitter apple can be applied around the incision; many dogs will continue to lick  after application of this topical
    • Bitter Apple and Liquid HeetTM (obtain this from a drugstore...it is used for sore muscles) mixed in a 2:1 ratio can be applied around the skin incision
    • Antipsychotic medication in some cases is needed

Board-certification by the American College of Veterinary Surgeons

What does it mean?

  • Four years of advanced training in surgery beyond the Doctor of Veterinary Medicine Degree

  • Experience in the development of new surgical treatments

  • Rigorous examination by the American College of Veterinary Surgeons to ensure competency in advanced surgical techniques

  • Assurance that a veterinarian is a surgical specialist

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