Aa
Cruciate tear
My Borzoi tore his left ACL this past weekend while lure coursing near our home. I am ready to go to surgery with him, but last night I had a friend tell me that I should shop around for better pricing. My DVM referred me to a veterinary surgeon (we have an appt on Monday) and my understanding is that he is going to do a TPLO (?) surgery and the price will be somewhere close to $3000. My friend says that her veterinarian (who is not a surgeon) can do the surgery using nylon suture material for about $1200. THEN...I noticed online last night that there is another surgery called a TTA that can be done.
Now I am really confused!! I want to do what's best for my dog, but I don't know which direction to turn right now. There are several surgeons in my area, but do I have to go to them? Can this other veterinarian help my dog just as well?
Now I am really confused!! I want to do what's best for my dog, but I don't know which direction to turn right now. There are several surgeons in my area, but do I have to go to them? Can this other veterinarian help my dog just as well?
MEDICAL PROFESSIONAL
Thank you Dr. Zeltzman for that clarification. My reference to 10 years was a casual reference to TPLOs more common use and availability to a general practice based clientele in this area. I am personally aware of a number of successful cases using TPLO and we have several Diplomates of the ACVS in the general area who do them.
MEDICAL PROFESSIONAL
Borzoiman,
I basically agree with the excellent summary Dr Goldman gave you.
One important point though: we do have much more than 10 years worth of experience with the TPLO. It was invented in 1981, ie 28 years ago! Now granted, not everybody started doing TPLOs in 1981.
I remember assisting with TPLOs in the mid-1990s, ie about 14 years ago. It was already mainstream then. Now, it's common. It's one of the most common precendures I do.
The list of questions Dr Goldman suggested is excellent.
Call me biased, but I would recommend at least consulting with a board-certified surgeon before jumping in. And my personal (profesionnal) recommendation would definitely be a TPLO in a Barzoi.
Good luck.
Phil Zeltzman, DVM, DACVS
www.drphilzeltzman.com
I basically agree with the excellent summary Dr Goldman gave you.
One important point though: we do have much more than 10 years worth of experience with the TPLO. It was invented in 1981, ie 28 years ago! Now granted, not everybody started doing TPLOs in 1981.
I remember assisting with TPLOs in the mid-1990s, ie about 14 years ago. It was already mainstream then. Now, it's common. It's one of the most common precendures I do.
The list of questions Dr Goldman suggested is excellent.
Call me biased, but I would recommend at least consulting with a board-certified surgeon before jumping in. And my personal (profesionnal) recommendation would definitely be a TPLO in a Barzoi.
Good luck.
Phil Zeltzman, DVM, DACVS
www.drphilzeltzman.com
MEDICAL PROFESSIONAL
By the way, TTA is "tibial tuberosity advancement."
MEDICAL PROFESSIONAL
Dear Borzoiman,
You are not alone in your confusion. ("Now I am really confused!!") ACL injuries are a surgical problem with multiple methods of repair available and little long term evidence of superiority in any one technique, for all cases. Several effective techniques exist which serve to re-create stability in a knee rendered unstable by the loss of an intact ACL. Success in any one technique may depend on the experience and skill of the individual performing the surgery, as much as the particular technique.
There is no question, that a board certified (residency-trained and American College of Veterinary Surgeons certified, surgeon) can often offer a wider variety of techniques and often a higher level of skill than many general veterinary practitioners. It is also true, however, that many general practitioners have developed a high level of competency addressing ACL tears, albeit with less complex techniques.
Where board certified surgeons excel is in cases with complications, unusual presentations and in the more complex repair techniques. Often the cost is higher for these more complex techniques, but in some cases, they may give a better long term result. The jury is out on that, as we have not seen 10+ years experience over many, many cases with techniques such as TPLO or TTA.
The ACL functions to prevent the lower leg from sliding forward relative to the upper leg when weight is applied to the knee as in standing, walking or running. That abnormal movement is painful and represents instability in the knee. All repairs serve to eliminate that instability in a way that reproduces and maintains anatomical structure and function. Often a torn ACL is a degenerating piece of tissue, the breakdown products of which cause inflammation and scarring within and of the joint capsule of the knee. This causes pain and loss of range of motion. Surgery always involves debriding (removing) this unhealthy and useless tissue. Sometimes also, due to the abnormal motion at the knee after the ACL tears, the meniscus (cartilage cushion) in the knee is also damaged. This may also need partial debridement at surgery. These manipulations are at least as important as the method of stabilization.
TPLO is "tibial plateau leveling osteotomy" and involves cutting the bone itself, changing the angles that the bones relate to each other in the knee and creating stability that way. It is effective and is touted as best for giant or heavily muscled breeds such as Rottweillers or Mastiffs. Boarded surgeons generally must be sought to have this technique performed. It is significantly more costly and while complications are known to be few, when they do occur can be disastrous, as the repair involves cutting the leg bones that bear weight and using metal plates to repair them.
TTA also involves cutting the bone and using metal plates, however, in a way which tightens the joint capsule rather than alters the angles of the bones themselves. This technique is relatively new though shows promise as an option.
The most common technique is the "lateral suture" technique which has been in use for 30 years in various forms and with various types of implants and materials. It is known to be effective when used by someone with experience in it.
In all techniques a stable, pain free, knee, without degenerating ligament or damaged meniscal fragments is the goal. Any of these techniques can achieve that in the carefully considered patient. While I know you "want to do what's best for my dog, but I don't know which direction to turn right now", you must understand there is no one right answer. Each dog and situation must be considered in its own context.
With respect to: "There are several surgeons in my area, but do I have to go to them? Can this other veterinarian help my dog just as well?" the answer is, it all depends.....on your dog's exact set of injuries and conditions, the experience of the veterinarian and a reasonable consideration on your part of what you are comfortable spending and most important the level of trust you have in the veterinarian you are considering using.
The questions to ask any veterinarian or veterinary surgeon should be:
How many of the procedures of the type you are recommending have you done in your life?
How many of them have you done in the last 6 months?
What has been your success rate? Your complication rate?
How have your previous patients done a year and 5 years after surgey?
When my mother needed a hip replacement, these were the questions I asked her surgeon. I recommend you ask something similar of your veterinarian. Don't worry too much. This is a common injury which is commonly repaired successfully. I am confident you will be able to attain a satisfactory result for your dog. Good luck!
You are not alone in your confusion. ("Now I am really confused!!") ACL injuries are a surgical problem with multiple methods of repair available and little long term evidence of superiority in any one technique, for all cases. Several effective techniques exist which serve to re-create stability in a knee rendered unstable by the loss of an intact ACL. Success in any one technique may depend on the experience and skill of the individual performing the surgery, as much as the particular technique.
There is no question, that a board certified (residency-trained and American College of Veterinary Surgeons certified, surgeon) can often offer a wider variety of techniques and often a higher level of skill than many general veterinary practitioners. It is also true, however, that many general practitioners have developed a high level of competency addressing ACL tears, albeit with less complex techniques.
Where board certified surgeons excel is in cases with complications, unusual presentations and in the more complex repair techniques. Often the cost is higher for these more complex techniques, but in some cases, they may give a better long term result. The jury is out on that, as we have not seen 10+ years experience over many, many cases with techniques such as TPLO or TTA.
The ACL functions to prevent the lower leg from sliding forward relative to the upper leg when weight is applied to the knee as in standing, walking or running. That abnormal movement is painful and represents instability in the knee. All repairs serve to eliminate that instability in a way that reproduces and maintains anatomical structure and function. Often a torn ACL is a degenerating piece of tissue, the breakdown products of which cause inflammation and scarring within and of the joint capsule of the knee. This causes pain and loss of range of motion. Surgery always involves debriding (removing) this unhealthy and useless tissue. Sometimes also, due to the abnormal motion at the knee after the ACL tears, the meniscus (cartilage cushion) in the knee is also damaged. This may also need partial debridement at surgery. These manipulations are at least as important as the method of stabilization.
TPLO is "tibial plateau leveling osteotomy" and involves cutting the bone itself, changing the angles that the bones relate to each other in the knee and creating stability that way. It is effective and is touted as best for giant or heavily muscled breeds such as Rottweillers or Mastiffs. Boarded surgeons generally must be sought to have this technique performed. It is significantly more costly and while complications are known to be few, when they do occur can be disastrous, as the repair involves cutting the leg bones that bear weight and using metal plates to repair them.
TTA also involves cutting the bone and using metal plates, however, in a way which tightens the joint capsule rather than alters the angles of the bones themselves. This technique is relatively new though shows promise as an option.
The most common technique is the "lateral suture" technique which has been in use for 30 years in various forms and with various types of implants and materials. It is known to be effective when used by someone with experience in it.
In all techniques a stable, pain free, knee, without degenerating ligament or damaged meniscal fragments is the goal. Any of these techniques can achieve that in the carefully considered patient. While I know you "want to do what's best for my dog, but I don't know which direction to turn right now", you must understand there is no one right answer. Each dog and situation must be considered in its own context.
With respect to: "There are several surgeons in my area, but do I have to go to them? Can this other veterinarian help my dog just as well?" the answer is, it all depends.....on your dog's exact set of injuries and conditions, the experience of the veterinarian and a reasonable consideration on your part of what you are comfortable spending and most important the level of trust you have in the veterinarian you are considering using.
The questions to ask any veterinarian or veterinary surgeon should be:
How many of the procedures of the type you are recommending have you done in your life?
How many of them have you done in the last 6 months?
What has been your success rate? Your complication rate?
How have your previous patients done a year and 5 years after surgey?
When my mother needed a hip replacement, these were the questions I asked her surgeon. I recommend you ask something similar of your veterinarian. Don't worry too much. This is a common injury which is commonly repaired successfully. I am confident you will be able to attain a satisfactory result for your dog. Good luck!
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