MMP or TTA rapid?

Re: MMP or TTA rapid?

Malcolm Ness — Sun, 19 Jan 2014 10:12:16 GMT

[quote user="karen jones"]Thanks [quote user="kirsty"]Go to orthomed.co.uk CPD courses listed there.

[/quote][/quote]

pm me if you want more detail.

Re: MMP or TTA rapid?

Malcolm Ness — Sun, 19 Jan 2014 10:11:06 GMT

[quote user="karen jones"]Do you run cpd courses to learn this technique,if so how do you book on them . Thanks[/quote]

Orthomed run quite a few courses - approx one a month at BVA headquarters in central London and one a month at our Hospital in Northumberland plus others in UK and overseas.

Course comprises a couple of hours of theory, underpinning knowledge etc then a practical component with a chance to do your own MMP on a synthetic-bone model stifle. PM me if you want more detail.

Re: MMP or TTA rapid?

karen jones — Sat, 18 Jan 2014 20:05:09 GMT

Thanks [quote user="kirsty"]Go to orthomed.co.uk CPD courses listed there.

[/quote]

Re: MMP or TTA rapid?

kirsty — Sat, 18 Jan 2014 17:42:14 GMT

Go to orthomed.co.uk CPD courses listed there.

Re: MMP or TTA rapid?

karen jones — Sat, 18 Jan 2014 14:14:57 GMT

[quote user="Malcolm Ness"]

MMP and TTA Rapid are different procedures. TTA rapid is essentially a TTA with the fixation plate ommited - the concept was explored and published by a group from Liege vet school - according to the published results, it met with varying success and the technique that is currently being marketed is very different from that recommended by the Belgians.

MMP is a procedure that I was involved in developing (and in which I retain a significant financial interest). It differs from other TTA techniques in that it involves a fixed-length, instrument guided osteotomy, the use of a Titanium foam wedge to advance and fix the tibial tuberosity and the use of robust implants (thick orthopaedic wire or a Ti staple) to control and secure the distal end of the tibial tuberosity.

The procedure has clinical outcomes comparable to TPLO or TTA and though complications are seen, these are most often due to technical error (and therefore less likely with experience). Most complications are resolved easily and sucessfully. The most serious complication is a tibial diaphyseal fracture occurring, we believe, in about 1% of cases. Some of these fractures are successfully managed conservatively and the others resolved with a single bone plate.

MMP is not a specialist procedure - it is achievable by most reasonably competent, experienced surgeons in primary care practice following a short training course. The aim of the MMP project was to make the perceived benefits mechanics-modifying surgery available to a bigger number of dogs. To date more than 10,000 MMP procedures have been performed by surgeons world-wide, most of them in primary care practice.

The procedure has its detractors some of whom are specialists and most of whom share some similar traits - first, they are not fully informed about the procedure and second, they are seeing their ability to charge many thousands of pounds for cruciate surgery being curtailed by neighbouring practices offering MMP!

There is a range of technical and other information including animations and cadaver surgery video available at the Orthomed website for anyone that is interested.

[/quote] Do you run cpd courses to learn this technique,if so how do you book on them . Thanks

Re: MMP or TTA rapid?

Evelyn Barbour-Hill — Mon, 09 Dec 2013 00:31:40 GMT

I see.

Thank you.

Re: MMP or TTA rapid?

Malcolm Ness — Sun, 08 Dec 2013 20:26:20 GMT

[quote user="Evelyn Barbour-Hill"]when was the idea of directly replacing the cranial cruciate ligament by one prosthesis or another abandoned, and why?[/quote]

There are still a few folk doing variations on this theme. Most abandoned it in favour of the lateral suture that were quicker, easier and produced similar or better clinical outcomes.

The problems with a like-for-like CCL replacement are many: first the original CCL does not function as a single ligament - it has an immensely complex structure. The clever-dicks point to two distinct "bands" but there is more to it than that. Second, the origin is over a large area of the femur right out the back of the inter-condylar notch and not at all accessible for surgery. Third, we (ie mankind) does not have access to a material that is anything like strong enough or stiff enough to work as a suitable prosthesis and finally we don't have a reliable method of attaching the prosthesis (if it existed) to the bone in a way that is robust enough and reliably long-lasting.

Re: MMP or TTA rapid?

Evelyn Barbour-Hill — Sun, 08 Dec 2013 18:28:50 GMT

It's a long time since I did any knee surgery other than lateral suture, but I'm wondering: when was the idea of directly replacing the cranial cruciate ligament by one prosthesis or another abandoned, and why? Development of osteoarthritis? Genuinely interested.

Re: MMP or TTA rapid?

John Flynn — Sun, 08 Dec 2013 15:43:20 GMT

Thanks very much, Malcolm, for taking the time to post that!

I'll sleep better tonight

Re: MMP or TTA rapid?

Malcolm Ness — Sun, 08 Dec 2013 14:53:31 GMT

[quote user="John Flynn"]One thing re tibial tuberosity advancement for the cranial cruciate deficient stifle that I'm not totally clear on is how it works![/quote]

You are not alone! The original TTA theory was based on the existence of a "crossover point" where neither the cranial nor the caudal cruciate was under tension and that was said to occur with a patellar tendon angle of ninety degrees. However, the source paper is weak, it relates to the human knee and hasn't been validated in dogs and is contradicted to a significant degree by other work relating to dogs and goats.

[quote user="John Flynn"]more in the direction of the missing cruciate ligament and your dog will be able to use it by tensing his big quads muscle when he's walking to replace the function of the missing cruciate ligament[/quote]

I am with you on this - the benefit of tibial tuberosity advancement seems likely to come simply from re-direction of the quadriceps pull - incidentally, some of the published papers reviewing the original Maquet procedures in humans made this suggestion 30 or more years ago.

[quote user="John Flynn"] I read the account of one surgeon recently who chooses the size of advancement at the time of surgery by trying different levels of advancement and seeing which, intra-operatively, leads to no tibial thrust[/quote]

You are correct - it is nonsense to suggest that the surgery can be assessed intra-operatively in this way. Similarly, post op rads are useless as the tibia remains unstable relative to the femur, therefore the stifle can be arranged on the X ray cassette pretty much where you want it to be! In the absence of muscle tension and other forces, there will be just as much cranial tibial thrust at the end of the op as there was at the start.

Re: MMP or TTA rapid?

John Flynn — Sun, 08 Dec 2013 13:39:24 GMT

One thing re tibial tuberosity advancement for the cranial cruciate deficient stifle that I'm not totally clear on is how it works!

Even cynical old me accepts that it does work and very likely works better than placing extracapsular restraints in many dogs.

But I always feel I'm fudging an answer when I try to explain precisely why it works, and that makes me slightly nervous.

Here's my current attempt at explanation for critique and correction:

"Here's a [lateral] xray of your dog's knee."

"The [cranial] cruciate ligament used to run from here to here; it has gone"

"This is the big strong ligament that runs from your kneecap to the pointy bit on the bone below [patellar ligament/tendon]"

"If we cut this bit of bone [tibial tuberosity] and pull it forwards, then the ligament will be running like this, more in the direction of the missing cruciate ligament and your dog will be able to use it by tensing his big quads muscle when he's walking to replace the function of the missing cruciate ligament"

Something else that I'm confused about. I read the account of one surgeon recently who chooses the size of advancement at the time of surgery by trying different levels of advancement and seeing which, intra-operatively, leads to no tibial thrust. I had previously thought that remaining 'passive' tibial thrust post-surgery was fine as it was a procedure conferring dynamic stability to the stifle under the control of the dog's quadriceps tension [as I alluded to above]; if this surgeon's approach is correct, then would that mean that the aim is to simply remove any slack from [or indeed mildly tension] the patellar ligament so that it passively prevents cranial translation of the tibia relative to the femur?? So is it OK to have passive cranial tibial thrust present post-op of not then?

Re: MMP or TTA rapid?

Malcolm Ness — Thu, 05 Dec 2013 20:41:59 GMT

There is a range of technical and other information including animations and cadaver surgery video available at the Orthomed website for anyone that is interested.

Re: MMP or TTA rapid?

David Mills — Thu, 05 Dec 2013 00:57:26 GMT

I'm sure Mr Ness who developed the MMP will be along soonish to rightly add his opinion, but the beauty of MMP is that it gives the same result as TTA without the risks of the tibial crest ending up in bits about the dogs ears. It is also much less invasive than TPLO, and the latter has only equivocal evidence base over lateral suture for return to function. The MMP is very quick - most people doing them regularly will have the dog waking up after 30 mins. They also (I believe) show a far quicker return to function (6 weeks IIRC) and weight bear very quickly meaning both physiotherapy and recovery is quicker and the dog/owner happier. They are much cheaper than TPLOs in most centres.

My mother's dog (anecdote alert) a hefty Lab had one done and I was very impressed with the post-op comfort and rapid resumption of activity. It went on to have a late meniscal tear (recognised complication) which was easily sorted arthroscopically.