In-Hospital Training Opportunities
Tibial Plateau Leveling Osteotomy
Goal: To acquaint the participant with the biomechanics of the canine stifle and how tibial plateau leveling 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 (pending) 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:
- 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 TPLO implants
- Pain control
- Sterile methods of surgical preparation
- Choosing the right patient for TPLO
- The TPLO surgical procedure, including potential mishaps surgical and postoperative
- Postoperative radiographic analysis
- Model building for client "show and tell"
- Equipment acquisition
Participants are free to schedule 1-3 surgeries in a one-day period. You may also bring in one other veterinarian if you wish, and videotape the procedure. Group teaching rates are also available, as well as state convention presentations.
Costs vary depending on location, number of procedures performed, and number of days at your location. For an estimate, please call 425-608-2614, or 425-218-1400, or send an email to JMayoDVM@comcast.net.
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Tibial Plateau Leveling Osteotomy
"TPLO" was first invented and described by Dr. Barclay Slocum in 1993 (www.slocumenterprises.com). At the time, the procedure was patented, as was the equipment, and there was a long waiting list of people wanting to take the course. Veterinarians were then certified and placed on their website listing (www.slocumenterprises.com/TPLO) after completing the course, then allowed to purchase the implants and equipment necessary to perform the procedure. TPLO is one of the best and most proven methods of repairing a torn cranial cruciate ligament in the knee of a dog, particularly large and active breed dogs. The procedure has also been performed successfully on smaller dogs, as well as cats. A lot of research has been completed on the procedure to either prove or disprove the theory that it works. Nonetheless, it remains the current "gold standard" for repair of the cranial cruciate ligament in dogs, and is the technique of choice, as well as the one to which others are compared. The objective of traditional surgeries, based on the passive model, is the elimination of cranial drawer sign. This procedure, commonly called the "modified-retinacular imbrication" technique, simply involves placing a large gauge nylon suture from the lateral fabella of the knee into the tibial tuberosity. Although this procedure commonly works, most dogs have some degree of arthritis a few years later, and this procedure can fail. If one simply considers the biomechanics of the stifle joint, with the high tendency of the tibia to rotate inwards during flexion of the knee, it seems obvious that the amount of stress placed on the suture should force it to break eventually, resulting in failure.
Cranial tibial thrust is a force created in the knee of the dog when the dog bears weight on the leg. If one thinks of the knee joint as being a hill, the top of the tibia is the hill, and the end of the femur is a car. When the parking break is damaged (the cranial cruciate ligament), the car rolls down the hill. Clinically, we see this when the tibial moves forward relative to the femur when a force is applied to the foot of the dog much in the way the dog bears weight on the leg. This cranial tibial thrust creates pain, damages the meniscus, and leads to the development of muscle atrophy and arthritis in the leg. Further, this pain causes the dog to shift the weight to the good leg, in a sense doubling the weight load on that limb, resulting in potential damage to the good leg if the injured one is not repaired soon.
The objective of the tibial plateau leveling osteotomy is neutralization of the cranial tibial thrust and not elimination of the drawer sign. The stifle is redesigned 
(Fig. 9. The rotation of the proximal tibia (arrow indicates the direction of rotation) makes the tibial axis (B) perpendicular to the tibial plateau axis (A) which neutralizes cranial tibial thrust. The rotation is held by a special plate (C).) so that the cranial cruciate ligament is no longer necessary for stifle stabilization while under active muscle force conditions, and there is minimal reliance on the caudal cruciate ligament as a passive restraint. 
(Fig. 10. Redesigning the stifle creates a balance between weightbearing and active muscle forces (A,B) eliminates the need for passive components for stability. The special plate (labeled C, note that there are many of them on the market now) holds the rotational osteotomy in place until bone healing.) In essence, the cranial translation during functional loading and activity is neutralized. Think of as instead of repairing the break on the car, we leveled out the hill so the car will not roll down the hill anymore. In an in vitro study assessing the CTT in the CrCL deficient stifle placed under axial tibial loading before and after TPLO resulted in caudal drawer movement following plateau leveling. Increasing tibial loads in the tibial plateau leveled CrCL deficient stifle increased caudal tibial thrust.(6) The cranial drawer sign may still be present after TPLO surgery. According to Slocum, a certain amount of drawer sign is built into the procedure to protect the integrity of the caudal cruciate ligament. However, as the in vitro study suggests, over rotation of the tibial plateau may predispose the caudal cruciate to excessive stress.
(Fig. 11. A technical error of over rotation would create an imbalance between flexor muscle forces (B), and active weightbearing and extensor muscle forces (B). The resulting caudal tibial thrust may predispose the caudal cruciate ligament (D) to excessive stress, and further meniscal (C) trauma.
The success of the TPLO procedure has been based on the return of full flexion of the stifle, muscle mass and limb function, and the apparent lack of joint inflammation or progressive degenerative joint disease within the joint. The persistence of cranial drawer after a TPLO is not a valid test for stifle stability and is not a SIGN OF FAILURE. The procedure has provided performance dogs the ability to return to normal function handling the highly competitive demands of their sport or work. Thus, the family pet is even better able to participate in normal daily activities without restriction of activities or residual lameness as often experienced with traditional surgical procedures.
Post-Operative Instructions
Tibial Tuberosity Advancement/Tibial Plateau Leveling Osteotomy
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.
(1) First 48 hours – 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.
(3) After 48 hours, 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!
(4) No other exercise is recommended for the first two weeks.
(5) Clean the wound daily if needed with dilute hydrogen peroxide, 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.
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.
Tibial Plateau Leveling Osteotomy
The slide show above is the
TPLO technique using Innovative-TPLO(R)
Lori Melhorn, (888) 551-4394
Interested in learning TPLO, or obtaining the equipment?
If you are a doctor interested in learning the TPLO procedure, either in your hospital, or in a formal class setting, please contact one of the following people for more information. For more information on where to obtain the equipment, contact one of the following people.
Lori Melhorn, Innovative Animal Products, (888) 551-4394;
David Anderson @ Securos, (877) 266-3349; or myself, Jeff Mayo, DVM through this website.