Cruciates - refer or do in house?

Re: Cruciates - refer or do in house?

Gerry Henry — Tue, 27 May 2014 10:28:40 GMT

Refer everything, do nothing in house, complete the total de-skilling of first opinion practice, that's what the Royal College wants, just give it to them, its easier in the long run.

Re: Cruciates - refer or do in house?

Francisco Gomez — Sat, 24 May 2014 23:07:56 GMT

Thanks!

Re: Cruciates - refer or do in house?

Malcolm Ness — Sat, 24 May 2014 19:15:36 GMT

[quote user="Francisco Gomez"]I think the question would be (and I realise that it isn't an easy question to answer)... Is it acceptable for a first opinion clinician to start doing MMPs unsupervised if they have been to the MMP course and have only experience with the lateral suture technique? (knowing that your success rate with lateral suture is averagely good and you have a lower rate of re-operation than 7.5%)[/quote]

It depends on the surgeon but a large proportion of the people attending the course are as you describe above and most of them go on to perform MMP effectively. Most will practice on a couple of cadaver limbs first.

I am away from work so I can't find the details of the paper easily - one author was Dominique Griffon, previously at Edinburgh but now back in the US. The paper is in the most recent Vet Surg. The TTA learning curve paper was by Proot and Corr published in VCOT, I think last year.

Re: Cruciates - refer or do in house?

Francisco Gomez — Sat, 24 May 2014 17:07:14 GMT

[quote user="Malcolm Ness"]

a recent paper in Vet Surg shows technical errors to be common and not easily detected on rads

[/quote]

A link to this paper would be most appreciated Malcolm.

[quote]

Our data indicates a re-operation rate of around 7.5% for inexperienced surgeons (fewer than 10 MMPs) and this falls once the surgeon has a little experience of the technique (the technique requires careful attention to detail and most complications arise from earlier technical errors or deviations from the stated technique).

[/quote]

I think the question would be (and I realise that it isn't an easy question to answer)... Is it acceptable for a first opinion clinician to start doing MMPs unsupervised if they have been to the MMP course and have only experience with the lateral suture technique? (knowing that your success rate with lateral suture is averagely good and you have a lower rate of re-operation than 7.5%)

Re: Cruciates - refer or do in house?

Malcolm Ness — Sat, 24 May 2014 14:59:48 GMT

First, a declaration of interest - I was involved in the development of the MMP technique and I receive royalty payments from the sale of the MMP instruments and implants. That means that I am not completely independent but it also means that I am fairly well informed. I have been treating dogs with lameness due to CCL failure for thirty years or so and in that time I have gained experience of most techniques and through our hospital we have seen in the region of 5000 cases over that period.

There isn't a single "go to" operation for CCL related lameness. The mechanical modification techniques (TPLO, TTA and some of their derivatives including MMP) are widely accepted to give better mid and long term clinical outcomes than the best of the "stabilisation" techniques. However, their drawbacks preclude them from widespread use (an estimate by a US vet researcher suggested that only one of every 12 cruciates operated in US involved TTA, TPLO or similar while most vets felt that these were the "plan A" procedures). Cost, complexity and complication risk seem to be the main barriers to widespread use. The aim of the MMP project when we started 10 + years ago was to develop a CCL procedure that was as good as the best in terms of clinical outcome yet accessible/affordable. MMP has now been done in a lot more than 10,000 dogs worldwide - some referral practices and universities but overwhelmingly, in primary care practice. Our first-hand experience along with feed-back from users shows the clinical outcomes to be comparable with TPLO and conventional TTA. Complication rates appear similar to, or lower than those reported for TPLO, TTA and as Chris B has mentioned, there is a strong tendency for the procedure to "fail safe". Beware glib "success rates" bandied about by clinicians, eminent or otherwise - it all depends on what you mean by success and how many of the failures are excluded from the reckoning (assuming there has been a reckoning and not just a guessing!!). It is worth remembering that until about the mid 1980s it seems that it was virtually impossible to get a cruciate paper published unless you could claim "95% success" so Martins claim of 80% success looks unimpressive!!

Our "bench-mark" was the fabello-tibia suture technique using stiff mono nylon and crimps. This technique is relatively easy (though not as easy as many imply - a recent paper in Vet Surg shows technical errors to be common and not easily detected on rads) and the outcomes are reasonable in most cases (again, liable to be "talked-up") If success is defined as good enough to allow the separation of client and money, then the technique is almost infallible. We needed MMP to be as "accessible" in terms of cost and complexity as this technique; to give better clinical outcomes and to have an acceptably low serious complication rate. While we are confident that we have succeeded with the latter two criteria, the MMP technique is more technical than fabello-tibial suturing though well within the capability of an experienced primary care practitioner with a willingness to learn.

The technique has its detractors, not least amongst those in referral practice finding it increasingly difficult to charge £3,500.00 and more for cruciate surgery. We have made a rod for our own back by sharing all the available data about risks, outcomes and complications with anyone that comes on a course - our openness has left us open to the blow-hards who claim 95-100% success and no complications. Fortunately, most vets are bright enough to see through that. Our data indicates a re-operation rate of around 7.5% for inexperienced surgeons (fewer than 10 MMPs) and this falls once the surgeon has a little experience of the technique (the technique requires careful attention to detail and most complications arise from earlier technical errors or deviations from the stated technique). Most complications are easy to manage and "fail-safe" to the extent that a good clinical outcome is usually seen even when a complication has occurred. We are hoping that someone will perform and publish an independent "learning curve" evaluation of the technique soon. To put things into context, a recent paper about conventional TTA showed the learning curve to be approximately 50 cases - the learning curve is defined as the number of cases needed before the major complication (reoperation rate) falls below the published average. For conventional TTA, the published major complication/re-operation rate is 10% - bear in mind that that is the work of experienced diplomate and resident surgeons.

In response to the question posed at the start of this thread, operate in-house or refer. Provided there is someone in the practice ready to make the investment in time, training and equipment then there is no reason why most cruciates can't be handled in primary care practice. Most, (but certainly not all) smaller, more sedentary dogs will do acceptably well (but few will return permanently to full athletic activity) following a well-executed fabello-tibial "stabilisation". Mechanical modifying procedures appear to be superior in terms of clinical outcome and they are becoming more affordable and more widely available in primary care practice.

Re: Cruciates - refer or do in house?

Francisco Gomez — Fri, 23 May 2014 22:17:44 GMT

[quote user="Michael Woodhouse"]

Or words to that effect[/quote] Fair enough

Re: Cruciates - refer or do in house?

Chris Barker — Fri, 23 May 2014 22:12:11 GMT

[quote user="James Allsop"]

Having spoken to some ortho surgeons recently I understand that there is growing concern regarding the complication rate and the difficulty of repairing a complication should it arise. regarding the MMP

[/quote]I'd be interested to here more detail on these complications, given that both TPLOs and (plate based) TTAs have the potential to fail quite spectacularly, both techniques involving the separation of a narrow strip of tibial bone attached to the distal patellar ligament which can fracture post-surgery. Repairing either technique after failure cannot be much fun. Malcolm Ness is unlikely to defend the MMP here, given his financial involvement with the company that produces the titanium foam wedge, but it is a fairly simple technique that tends to 'fail safe' For example we had a dog which tested the technique to destruction', ripping the figure of eight wire through the distal bone wedge and bending the arthrodesis wire. Surgical correction consisted of sliding the bone back along the arthrodesis wire, reseating it on the titanium wedge, inserting a new, wider pin and a heavier suture wire Uneventful final recovery

Re: Cruciates - refer or do in house?

Michael Woodhouse — Fri, 23 May 2014 21:45:08 GMT

[quote user="Francisco Gomez"]What do you really mean with 'failed'?[/quote]

It's a good question, and one we never went into in depth.

Conversation along the lines of: "We have recently bought the equipment to stabilise ruptured cruciates in the practice. Whilst the technique is new to us it falls well within our general surgical competences. It's a relatively low risk procedure as if the suture fails then we are just left in the same place we were before surgery. As this is new to us if the operation is a failure I am quite happy waiving the fee".

Or words to that effect. Initial cases were picked as unable to refer due to cost and no improvement with rest NSAIDS. All but one case did well, and the one that did badly ended up with a tumour (but no cranial draw at PTS :D)!

Re: Cruciates - refer or do in house?

grumpyoldman — Fri, 23 May 2014 21:29:06 GMT

I think a lot depends were your working , if your clients have little or no insurance and funding is very limited often your left with no option other than giving it your best shot ,letting it hop , or putting it in a bag . I do not think there is a problem with older people and arrogance , the referral culture is basically insurance driven but the 85% uninsured are excluded from it , so if you can you get on with it. I always liked Australian and Kiwi locums because even if only 2-3 years out their surgical skills were much better developed than Uk graduates because of a lack of a referral culture and geography forcing them into activity .

Re: Cruciates - refer or do in house?

Francisco Gomez — Fri, 23 May 2014 20:53:24 GMT

[quote user="Michael Woodhouse"]The first few I did I was completely honest with the owner and offered them their money back if it failed.

[/quote]

What do you really mean with 'failed'?

I'm expecting that all rupture cruciate are predispose and will eventually cause osteoarthritis changes in the long term (despite technique used). So the dog will limp again in that particular leg. Did you give them a time-frame or something of the sort?

Re: Cruciates - refer or do in house?

Michael Woodhouse — Fri, 23 May 2014 20:27:32 GMT

A young, giant breed that was insured I would push for referral.

I would always mention it, but I am quite convinced that I can fix most of these dogs. I've done some literature searches and there doesn't seem to be much convincing evidence that any method is vastly superior to another. I have always followed the post op advice from Vet Instrumentation and increased exercise slowly, but you could argue the repair is at its strongest the day you place it!

The other thing I like about the lateral sutures is should it fail to repair the dog, nothing is prejudiced for further surgery. The first few I did I was completely honest with the owner and offered them their money back if it failed. It's just so simple - easier that spaying a bitch.

Thanks for everyone's input.

Re: Cruciates - refer or do in house?

Martin Atkinson — Fri, 23 May 2014 14:19:44 GMT

[quote user="robloxley"]Is the problem to be laid just at the feet of the Universities who are running/farming out students to referral clinics; or at the state of 1st opinion practice where experienced GP vets are not there to pass on/train their new graduates in skills which are not day-1 competencies, but not beyond the capability of a decent general practitioner??[/quote] I feel that the former is the major factor at present along with the indoctrinated fear factor but as us self-confident, omni-competent old fogies gradually fade away to be replaced by the younger generation who have not progressed because of lack of experience/confidence the latter will become a major factor. One could envisage a situation where everything except the most basic surgery is farmed out to 'specialists'. This will be both a great loss of opportunity, challenge and job satisfaction and to the detriment of the pet owning public.

Re: Cruciates - refer or do in house?

Rob Loxley — Fri, 23 May 2014 13:49:42 GMT

[quote user="ChrisBVSc"] I definitely qualified with a feeling of "if it's anything remotely complicated that I don't have full confidence I can perform, I should get someone else to do it because I'll probably be sued if it goes wrong" - the 'have a go' approach is definitely something I felt scared of trying. Luckily I've managed to learn lateral sutures by assisting a colleague who could already do them.[/quote]

Is the problem to be laid just at the feet of the Universities who are running/farming out students to referral clinics; or at the state of 1st opinion practice where experienced GP vets are not there to pass on/train their new graduates in skills which are not day-1 competencies, but not beyond the capability of a decent general practitioner??

Re: Cruciates - refer or do in house?

James Allsop — Fri, 23 May 2014 13:19:36 GMT

Re: Cruciates - refer or do in house?

James Allsop — Fri, 23 May 2014 13:19:34 GMT

Re: Cruciates - refer or do in house?

James Allsop — Fri, 23 May 2014 13:15:43 GMT

I tend to offer my clients 2 options - a lateral suture by myself which has a good outcome for a reasonable cost and should it be unsuccessful (very rare) easy to repeat or try alternative OR a TPLO by referral surgeon which based on a paper i read last year has some evidence of better post op return to function although the severity of post op complication is more challenging to fix should it go wrong. I do not offer TTA as my local ortho referral prefers TPLO. unfortunately with a fairly high level of insured clients I find myself doing cruciate surgery only rarely now

Having spoken to some ortho surgeons recently I understand that there is growing concern regarding the complication rate and the difficulty of repairing a complication should it arise.

Re: Cruciates - refer or do in house?

Hannah Wynne Richards — Fri, 23 May 2014 12:33:38 GMT

Depends on :

a) size of dog

b) angle of tibial plateau

and

c) your expertise

Don't tackle anything you sren't confident with ( or not unless the owner won't give you any option) but neither should cruciates be regarded as referral only procedures.

Wynne

Re: Cruciates - refer or do in house?

ChrisBVSc — Fri, 23 May 2014 11:04:59 GMT

[quote user="Kate Richardson"]I believe we have an obligation to offer the best treatment- and that means if we don't have the experience to do a certain procedure or have experience but don't do it regularly then we should offer the owner the option of going to someone who does.[/quote]

I absolutely agree we should give them every option and let them make an informed choice, I'd always give them the 'superior' option of referral even if it was a small dog I'd be happy to do a lateral suture on. But probably wouldn't push it as much as I would with a large/athletic breed. The point I was making was more about the 'fear factor' instilled in a lot of new graduates, which can make it difficult to even get to the stage of giving an in-house option, let alone becoming a boss with a surgery certificate any time soon.

Re: Cruciates - refer or do in house?

Martin Atkinson — Fri, 23 May 2014 10:22:35 GMT

[quote user="Kate Richardson"]We ALL have the option (and the obligation) of becoming more experienced and keeping up to date with new techniques in any aspect we wish via CPD or spending time working with a more experienced surgeon. I do feel there is some arrogance on the part of some vets that they can do it all. (And that is not directed at anyone)[/quote] I know that this comment expands to include a much wider range of procedures but as the OP is about repairing ACL's let's stick to that for now.

There is a world of difference between a novice surgeon performing a lateral suture with a leader line and crimp with a little guidance from a textbook, which IMO is much easier and less risky that spaying a bitch (something that is supposed to be a day 1 skill), and getting the TPLO kit and performing a highly technical procedure on a wing and a prayer. OK its academic because you need to have done the training to get the kit but it illustrates the point.

And yes I do belong to a generation which just 'had a go' because we really had few other options and maybe a little arrogance has crept in as a result because 99% of things turned out alright but I do know my limits. Maybe viewing things with the benefit of hindsight it is easy to say this but, even as a new graduate today I would have little hesitation in performing a lateral suture repair on a ruptured ACL.

Re: Cruciates - refer or do in house?

Kate Richardson — Fri, 23 May 2014 10:04:33 GMT

I believe we have an obligation to offer the best treatment- and that means if we don't have the experience to do a certain procedure or have experience but don't do it regularly then we should offer the owner the option of going to someone who does. If the owner then chooses to let you treat their animal then that is fine, they have made an informed choice and therefore have to accept any risks that go with it. If all goes wrong because of your lack or relative lack of experience and they find out later that they had the option of referral than they are quite within their rights to be angry. I find many owners will continue with treatment in house (and am not just talking about cruciate surgery here) as they don't wish to travel/cannot afford/have faith in their vet and want to work with someone they know and trust.

We ALL have the option (and the obligation) of becoming more experienced and keeping up to date with new techniques in any aspect we wish via CPD or spending time working with a more experienced surgeon. I do feel there is some arrogance on the part of some vets that they can do it all. (And that is not directed at anyone)

I have the luxury of having a boss with a Cert SAO, so my situation is different, but MMP is the procedure here, with occasional lateral sutures in small dogs/more limited finance and cats. I believe the MMP takes him approx 20 minutes (but obviously he does a lot!) and the dogs return to full function very quickly, certainly much quicker than 3 months.

Re: Cruciates - refer or do in house?

Martin Atkinson — Fri, 23 May 2014 10:01:52 GMT

[quote user="ChrisBVSc"]We were also taught that steroids are evil but I probably shouldn't bring that up here[/quote]Well that one is true! And this is coming from someone who belongs to a generation of vets many of whom were/still are guilty of handing them out like sweeties.

Re: Cruciates - refer or do in house?

ChrisBVSc — Fri, 23 May 2014 09:24:59 GMT

[quote user="Martin Atkinson"]I feel that young vets referring what is a relatively simple procedure, in say a 15kg terrier that went suddenly lame after putting its foot down a rabbit hole and will do admirably with a lateral suture, is just another example of them coming out of college with the fear of litigation and disciplinary action hard-wired into them which is one of the greatest shames of the latest generation.[/quote]

Unfortunately Martin this is exactly how it is - as a 7 year graduate I can imagine it's even worse now. I definitely qualified with a feeling of "if it's anything remotely complicated that I don't have full confidence I can perform, I should get someone else to do it because I'll probably be sued if it goes wrong" - the 'have a go' approach is definitely something I felt scared of trying. Luckily I've managed to learn lateral sutures by assisting a colleague who could already do them. I distinctly remember one talk we had in final year where we were told "at least one of you will be sued in your 1st year out" - thanks, really encouraging stuff! (I don't think anybody actually was) We were also taught that steroids are evil but I probably shouldn't bring that up here!

Re: Cruciates - refer or do in house?

Martin Atkinson — Fri, 23 May 2014 09:10:32 GMT

There is a statistic somewhere which states that the success rate of repair of traumatic ruptured ACLs whatever method you use is 80%. This should speak volumes. A certain Mr Ness has shot me down in flames over this previously but I would say that in my hands the lateral suture method carries a higher success rate than that if success is rated by the dog being back to apparently normal function, running around with no apparent limp within 3 months rather than clever stuff like using pressure plates.

Notwithstanding this, if I was presented by a young dog of a large breed known to have predisposition to non-traumatic rupture I would offer the option of referral for more advanced surgery. However, the fact that the proponents of the various techniques like TPLO/TTA etc argue amongst themselves as to which is better should also speak volumes!

I feel that young vets referring what is a relatively simple procedure, in say a 15kg terrier that went suddenly lame after putting its foot down a rabbit hole and will do admirably with a lateral suture, is just another example of them coming out of college with the fear of litigation and disciplinary action hard-wired into them which is one of the greatest shames of the latest generation.

Re: Cruciates - refer or do in house?

ChrisBVSc — Thu, 22 May 2014 22:50:34 GMT

I just give them the straight options of refer to ortho specialist for the 'optimal' chance of success for the animal, which would currently result in a TPLO with our nearby centre, or lateral suture in-house (with disclaimer of not being a specialist etc but obviously much cheaper). I've been doing these for the last couple of years & had good success so far despite the initial longer recovery. If I'm going to 'steer' anyone it's likely to be clients who have the means for referral but can't decide - big dogs I'll actively encourage it, small dogs I'll be happier to just get them booked in for a lateral suture. The MMP procedure sounds interesting, haven't seen any post-op TTA cases yet. We refer loads for TPLO so it could be well worth investigating.

Also slight hijack question - what do people think of cat cruciates? I've actually done 3 in the last year with lateral suture & they've done well. Apparently they can just stabilise over time anyway but I've always thought it's worth doing something if you can..

Re: Cruciates - refer or do in house?

grumpyoldman — Thu, 22 May 2014 22:43:22 GMT

Depends on the dog and funding , ideally small medium sized dogs de angelis , Intra- articular grafts work really well ,but are possibly out of fashion these days . . > 30KG TPLO, which also go really well , I have looked at TTA several times and thought about it , but heard and seen a few horror stories and decided to stay with what works well regularly . Probably a different mind set ,when I graduated no one referred CCL for surgery ,everyone did it themselves , Generally its fair to say that best results are obtained by doing something that cuts bone and reduces tibial table thrust.

Fashion in surgical procedures are factor in your decision making, what you do not want is someone going down the road to a rival practice where some bright eyed bushy tailed soul casually remarks , i did not know anyone did that anymore or I was not taught about that particular technique.