Quick pick of your brains for a cruciate case...

RE: Quick pick of your brains for a cruciate case...

Eilidh Corr — Mon, 05 Dec 2016 13:41:32 GMT

I don't dispute any of that Kate. I'm just saying that there's no cost advantage if clients going to a local TTA-performing practice are charged the same as they would be charged for a TPLO in the hands of an RCVS Specialist. Which is my experience.

RE: Quick pick of your brains for a cruciate case...

Kate Richardson — Mon, 05 Dec 2016 08:55:33 GMT

[quote user="Eilidh Corr"]As a mixed practice vet I totally believe in first opinion vets having good enough surgical skills to tackle anything everything[/quote]

I'm no orthopod, but as a first opinion vet, I believe most clients prefer not to have to travel to a referral centre for a procedure for a common condition that can be done at their own practice. As a practice whose boss has been involved in developing the MMP procedure, if the genuine aim is to provide a procedure that can be performed, with appropriate training at an affordable price (no different to any surgical procedure one hasn't done before) then how can this be a bad thing?

RE: Quick pick of your brains for a cruciate case...

Eilidh Corr — Mon, 05 Dec 2016 07:37:39 GMT

[quote user="Neil Wheadon"]so that non referral vets can do the procedure reducing cost to the client [/quote]

Or so they can make the money themselves by doing quick TTAs between cat spays and dentals? How benevolent I feel towards this procedure being done in first opinion practice hangs heavily on cost, so we need to know what practices are charging, and whether it really is cheaper to the client. If it turns out to be a way for first opinion vets to cream off huge fees instead of making a referral, when it's supposed to be cheaper than TPLO, then it's actually taking advantage of clients.

I have nothing against the procedure itself, but I'm not sure that it's genuinely bringing affordable cruciate surgery to the masses. As a mixed practice vet I totally believe in first opinion vets having good enough surgical skills to tackle anything everything, but is there a possibility that this is bringing the potential to earn bags of (insurance?) money to relatively inexperienced surgeons?

Devil's advocacy at work here, I'm afraid

RE: Quick pick of your brains for a cruciate case...

Eilidh Corr — Mon, 05 Dec 2016 07:18:51 GMT

I have no idea why the costs are the same. The TPLO costs our clients almost exactly the same as the TTA. The orthopaedic surgeon offering the former has far greater experience than the vet offering the latter. I know where I'd take my own dog - that's not a criticism of the TTA procedure or the vet who's performing it, but my preference when all factors are taken into consideration. It just isn't as simple as one procedure being better than the other.

RE: Quick pick of your brains for a cruciate case...

Malcolm Ness — Mon, 05 Dec 2016 06:20:31 GMT

[quote user="grumpyoldman"]they take approximately the same amount of time, (40-50 minutes) [/quote]

The newer TTA procedures take about half that time.

[quote user="grumpyoldman"] and depending where you purchase them, the metalwork costs are roughly the same.[/quote]

That is true, though it probably shouldn't be. There is no independent quality control of veterinary implants and those companies (there are two or three in the vet market) who involve themselves in targeted research and development and manufacture to "human" standards end up charging about the same as those companies (there are lots of them) who buy on the open market (India, Taiwan , China and middle East) and resell into the vet market. At that end of the market I have seen TPLO plates on offer for as little as 2 (two) US dollars each and bone screws for 25 cents.

RE: Quick pick of your brains for a cruciate case...

grumpyoldman — Mon, 05 Dec 2016 00:34:11 GMT

[quote user="Neil Wheadon"]Why is a TTA costing the same as a TPLO? [/quote]

a couple of points, I suspect with an experienced operator they take approximately the same amount of time, (40-50 minutes) and depending where you purchase them, the metalwork costs are roughly the same. The other costs probably involve tooling up which will be considerably more for a Slocum radial saw which only has one possible use, and the first 10 cases which is always the slowest and most stressful part of getting to grips with anything new.

RE: Quick pick of your brains for a cruciate case...

Neil Wheadon — Sun, 04 Dec 2016 21:30:16 GMT

[quote user="Eilidh Corr"]This argument always makes me feel like EBM gone wrong - everyone standing around arguing over how to split a hair when actually almost all of these dogs do really well - surely there are more important things a bunch of intelligent, talented and resourceful surgeons could be putting their energies into [/quote]

You have missed a fundamental point that Malcolm has made.

Why is a TTA costing the same as a TPLO? Is it because a referral centre feels it can? This is why a cheaper but equally effective method is being developed so that non referral vets can do the procedure reducing cost to the client which must be a good thing not only to the clients finances but also to the surgical advancement of a practitioner as who wants to spay bitches for 30 years?

Neil

RE: Quick pick of your brains for a cruciate case...

Eilidh Corr — Sun, 04 Dec 2016 21:13:08 GMT

This debate runs and runs. Our usual referral practice offers TPLO. We have only minimal experience of TTA procedures being carried out elsewhere. Going back to the point about variables including the skill and experience of the surgeon, I'm happy to endorse the TPLO in our trusted referral surgeon's hands, because the complication rate is very low and the dogs recover quickly, and TTA costs exactly the same. I don't honestly think any of these procedures can clearly have any truly significant advantage over the others when there are so many factors contributing to the outcome.

This argument always makes me feel like EBM gone wrong - everyone standing around arguing over how to split a hair when actually almost all of these dogs do really well - surely there are more important things a bunch of intelligent, talented and resourceful surgeons could be putting their energies into

RE: Quick pick of your brains for a cruciate case...

Evelyn Barbour-Hill — Sun, 04 Dec 2016 18:49:50 GMT

[quote user="Scarlett Creasey"]Then obviously the big debate about which CCL surgery is the best....[/quote]

I should find out who is marking the exam and recommend whatever it is that they are devoted to.

RE: Quick pick of your brains for a cruciate case...

Malcolm Ness — Sun, 04 Dec 2016 17:05:12 GMT

[quote user="Neil Wheadon"]There was a very nice time graph shown, time on the horizontal, lameness on the vertical. TTA were better after a month, TPLO crossed this after year. He did go on to mention a case where one dog had had a TTA on one leg and a TPLO on the other but hadn't asked the question (or hadn't got the answer he wanted?)[/quote]

Being devil's advocate, it is easy to draw impressive graphs to support a point (the mainstream newspapers do it all the time) the key is to look at the source data, or in this case look FOR the source data.

[quote user="Neil Wheadon"]The talk as far as I recall didn't compare this method , which I recall was due to lack of data[/quote]

Not entirely true. There are a couple of papers specifically about MMP in the peer reviewed literature and a further half dozen or so proceedings, posters and invited podium presentations at, for example, Veterinary Orthopaedic Society. In addition, MMP is a modified TTA procedure and there are many dozens of TTA papers published and hundreds of abstracts, posters and podium presentations. If these are to be discounted from the MMP evidence then for consistency, surgeons using for example a locking TPLO plate should surely consider and count "their" evidence apart and separate from the other TPLO papers. A self-serving and rather misleading inconsistency at work I fear.

[quote user="Neil Wheadon"]Which are?[/quote]

TPLO complications are many and varied. Lots of infections; lots of meniscal lameness; tibial fracture; tibial tuberosity fracture; patellar fracture; fibular fracture; patellar tendonitis; screws in the stifle; drill bits and K wires left in situ and migrating; iatrogenic angular limb deformity; other malunions; delayed union; non-unions; late implant associated infection and of course the much-publicised osteosarcomata. The published rates vary quite considerably but most series are written by experienced referral surgeons and the occasional series published by neophyte TPLO surgeons show particularly higher incidence of complication.

[quote user="Neil Wheadon"]but would be interested if you can confirm or deny.[/quote]

That does sound like the Florida work which suggests that TTA and not TPLO is "kinder" to the stifle in terms of contact mechanics.

[quote user="Neil Wheadon"]I called 3 referral centres in regards to TTA and we had 2 estimates at £2500, [/quote]

Often the 'phone quote is the "list price" for the op - by the time the consultation, the rads, the arthroscopy, the hospitalisation, the follow up evaluations etc etc etc are added on, the total cost of care is rather more than the first number.

RE: Quick pick of your brains for a cruciate case...

Neil Wheadon — Sun, 04 Dec 2016 16:17:19 GMT

[quote user="Scarlett Creasey"]Agree on the studies front - very easy to cherry pick. I have spent an hour reading papers about risk factors and the surgeries and most contradict each other, then the reviews just say there isn't enough evidence. Sigh[/quote]

Welcome our world (the GP vet)

The more you dig the more the contradiction

Neil

RE: Quick pick of your brains for a cruciate case...

Scarlett Creasey — Sun, 04 Dec 2016 16:07:49 GMT

Thank you Malcolm! That is great info. Will be looking up about the MMP now. Definitely agree that case selection is essential... Just not quite sure how you select the right dogs for the right surgery just yet...

Agree on the studies front - very easy to cherry pick. I have spent an hour reading papers about risk factors and the surgeries and most contradict each other, then the reviews just say there isn't enough evidence. Sigh

RE: Quick pick of your brains for a cruciate case...

Anthony Todd — Sun, 04 Dec 2016 15:35:46 GMT

[quote user="Neil Wheadon"]Which are?[/quote]

Dare I even think about mentioning a control group which, after all, all good experimental data should have, particularly if you are measuring response after a year and £3000.

Easy; just have a glance through this: http://tiggerpoz.com/

RE: Quick pick of your brains for a cruciate case...

Neil Wheadon — Sun, 04 Dec 2016 15:25:14 GMT

[quote user="Malcolm Ness"]A declaration of interest: more than a decade ago, I embarked upon a project to make tibial osteotomy surgery more widely available through primary care (non-specialist) practice. The MMP, which is a variant of TTA is the result and I benefit financially from my involvement in that project. [/quote]

Thankyou

The talk as far as I recall didn't compare this method , which I recall was due to lack of data

[quote user="Malcolm Ness"]Looking across the plethora of published papers on TPLO and TTA, I don't see where that conclusion is coming from.[/quote]

There was a very nice time graph shown, time on the horizontal, lameness on the vertical. TTA were better after a month, TPLO crossed this after year. He did go on to mention a case where one dog had had a TTA on one leg and a TPLO on the other but hadn't asked the question (or hadn't got the answer he wanted?)

[quote user="Malcolm Ness"]With MMP tibial diaphysial fracture is the second most common major complication and occurs in less than 2% cases[/quote]

Ouch! that's 1 in 50. I'll be talking about this to clients in future

[quote user="Malcolm Ness"]This complication rate is no worse than the reported major complication rates with other types of TTA or TPLO.[/quote]

Which are?

[quote user="Malcolm Ness"]I am not familiar with that and it isn't referenced in the proceedings.[/quote]

Lovely coloured pictures. Basically showed that once surgery done there was an increased force through certain areas of the menisci (much like digital ulcers in cattle if the foot grows abnormaly, I thought) It varied depending on the surgery performed. Mis-remembered? I don't think so, but would be interested if you can confirm or deny.

[quote user="Malcolm Ness"]Finally, In a country where median disposable income is about £6000.00 per annum and a privately funded TPLO at a specialist referral centre is about £3000.00, it is ludicrous to be discussing treatment of cruciates without any reference to costs.[/quote]

What an interesting figure that is (The £6000)

I called 3 referral centres in regards to TTA and we had 2 estimates at £2500, whilst a visiting orthodox did it for £1000.

Now consider a phone call last week. Splenic ultrasound on a cat..... wait for it........ £800.....unreal, and there's a tangent.

Neil

PS Thanks for the expert intervention Malcolm

RE: Quick pick of your brains for a cruciate case...

Malcolm Ness — Sun, 04 Dec 2016 14:47:10 GMT

[quote user="Neil Wheadon"][quote user="Scarlett Creasey"]Then obviously the big debate about which CCL surgery is the best.... I have just been reading papers about that - there is no answer aha[/quote][/quote]

Of course there isn't, and there never will be because the best option in any specific case depends on a whole lot of things (size of dog, its breed, its fitness, its purpose in life, specifics of injury, concomitant pathology, availability of treatments, expertise of diagnostician, expertise of surgeon, available funds, experience of surgeon, luck (good and bad!), quality of post-surgical supervision etc etc etc).

A declaration of interest: more than a decade ago, I embarked upon a project to make tibial osteotomy surgery more widely available through primary care (non-specialist) practice. The MMP, which is a variant of TTA is the result and I benefit financially from my involvement in that project. These simplified TTA procedures have become anathema to some specialist orthopaedic surgeons who prefer TPLO which is easier to sell as a "referral only" procedure. Very many others, including private referral surgeons and some vet school specialists use MMP and other TTA procedures as first choice. Cruciate surgery is the financial backbone of vet ortho referral practice yet surprisingly few of these surgeons declare their indirect, but still very real, financial interest in their preferred technique.

[quote user="Neil Wheadon"]plenty of evidence base and good science.[/quote]

I missed some of the talk (I was elsewhere teaching MMP/TTA to 50 primary care practitioners!) but I read the notes and discussed the presentation with several surgeons who, like me, took a very different view to Neil. This was an old-fashioned "Eminence-Based" polemic with "evidence" cherry-picked from the published literature and elsewhere. An evidence based presentation leaves no potential to say things like, [quote user="Neil Wheadon"]TPLO is the best technique in his opinion[/quote] Bear in mind that fewer than 10% of dogs undergoing CCL surgery in the USA get a tibial osteotomy and probably less than half of those are treated in specialist referral centres or universities by experienced, specifically trained vet ortho surgeons yet almost every published paper ("The Evidence") is about dogs treated by tibial osteotomy in a specialist referral practice or university.

[quote user="Neil Wheadon"]1) They look better than TPLO after a month (weight bearing) however by a year TPLO have caught up and overtaken. In fact he inferred that TTA's never go 100% sound.[/quote]

Looking across the plethora of published papers on TPLO and TTA, I don't see where that conclusion is coming from. There are several published systematic reviews that conclude that the evidence base is insufficient to make any such statement. My own personal experience of many hundreds of TPLOs and TTA/MMPs is that the long term outcomes are indistinguishable but TPLO takes longer to get to best improvement.

[quote user="Neil Wheadon"]There are reports of TTA's splitting the tibia post op. Several radiographs shown and a few vets in the audience also recounted this.[/quote]

With MMP tibial diaphysial fracture is the second most common major complication and occurs in less than 2% cases(late meniscal lameness at about 5% is the most common). These data come from first and second hand experience (our own cases and those of others hospitals systematically recording their cases) plus data reported by MMP users. This complication rate is no worse than the reported major complication rates with other types of TTA or TPLO. Where it is different is that it includes data from newly trained surgeons, GP vets and some specialists. In contrast, the published TPLO data is exclusively from experienced orthopaedic surgeons in specialist referral practices. Learning curve effects are very important and despite its longevity, these have not yet been published for TPLO. It is inappropriate to imply that TPLO is a safe, or even a safer tibial osteotomy surgery, even in experienced hands.

[quote user="Neil Wheadon"] What I found really interesting where weight bearing studies through the menisci post op and how these changed. Again I recall that TPLO was better.[/quote]

I am not familiar with that and it isn't referenced in the proceedings. However, the work of Pozzi, Kim, Lewis and others at Florida addressed exactly the same question using the same technique and found the opposite!! I wonder if this has been mis-remembered.

[quote user="Neil Wheadon"] he wasn't convinced about dogs under 15kg would do any better with anything more complicated than a lateral suture and I tend to agree[/quote]

See my first paragraph - it depends upon a lot more than the weight of the dog and many dogs probably do well despite surgery and not because of it.

The evidence base remains extremely weak - there is not a single negatively controlled surgical case series published and hardly any with any kind of comparator or control group at all. My opinions are these: the clinical outcome in terms of likelihood of a return to normal levels of activity is better following a well-executed tibial osteotomy than any other technique, medical or surgical; there is little, if anything to separate the tibial osteotomies (A recent paper failed to show any clinically detectable difference between TPLO and a crude, closing wedge technique. Interestingly, one of the authors was Alistair); surrogate outcome measures such as tibial plateau angle, palpable stability, response to diagnostic manipulation, peak ground reaction force, symmetry index, osteophytes on radiographs etc etc should be viewed with extreme scepticism unless and until they are shown to have a biologically plausible explanation AND they are shown to correlate with primary outcome measures; you can't know a dog needs CCL surgery until you have tried it on NSAIDs for six weeks first; the choice of surgery for any individual dog will depend on a whole range of variables; I don't think we should be routinely exploring the stifle and interfering with the medial meniscus at the time of CCL surgery.

Finally, In a country where median disposable income is about £6000.00 per annum and a privately funded TPLO at a specialist referral centre is about £3000.00, it is ludicrous to be discussing treatment of cruciates without any reference to costs.

RE: Quick pick of your brains for a cruciate case...

grumpyoldman — Sun, 04 Dec 2016 13:33:43 GMT

if your not sure which one to do first .tap the joints 1. get the synovial fluid examined 2. its a youngish dog with multiple problems so rule out IMPA as they are often pyrexic and inappetant, if you tap them one at a time put 3ml of lidocaine in post tap and see which one improves the most. That is the one to operate on first . If neither improves much the other joint problems are significant and you may wish to reconsider how you approach it. TPLO works very well for me , 4-6 weeks in between .

RE: Quick pick of your brains for a cruciate case...

Scarlett Creasey — Sun, 04 Dec 2016 08:26:49 GMT

Sorry Kate, I didn't want to overwhelm you with all the info we got. The exam works that we had an exam on Friday, two of which were cases that was presented to you - history, physical exam - then you have to describe what possibilities there are and what diagnostics you want to do, trying to make you logically problem solve. Then after the exam they give you some diagnostics and over the weekend you have to work out whats wrong and prepare for whatever questions they could give you about the cases on Monday - most often how you'd go about treating, advantages and disadvantages etc.

So treatment so far - 8 weeks ago NSAIDs and they worked, 3 weeks ago again more NSAIDs but then had no effect.

Positive tibial thrust and cranial draw in both stifles, and the abnormal changes on radiographs were only described to us. Full range of movement in hip joints except some pain at full extension, there is joint effusions at the stifles with pain at full extension, a soft tissue swelling at the tarsus.

No back pain, neurological exam normal, bloods normal. I think that's all I have, would you agree CCLR?

RE: Quick pick of your brains for a cruciate case...

Kate Richardson — Sat, 03 Dec 2016 22:33:56 GMT

So what is the exam question exactly?

Has the dog had any treatment so far and what response did it have?

Assume has had xrays as have diagnosis of bilat HD and other OA changes- any other investigations been performed?

RE: Quick pick of your brains for a cruciate case...

Neil Wheadon — Sat, 03 Dec 2016 21:59:27 GMT

[quote user="Scarlett Creasey"]Then obviously the big debate about which CCL surgery is the best.... I have just been reading papers about that - there is no answer aha[/quote]

Well

London Vet Show lecture from Alasdair Renwick which I thought was one of the best I have ever been too, plenty of evidence base and good science.

TPLO is the best technique in his opinion. Reasons being that long term the dogs do better and we are talking greater than 12 months.

TTA which is popular seemed to have issues

1) They look better than TPLO after a month (weight bearing) however by a year TPLO have caught up and overtaken. In fact he inferred that TTA's never go 100% sound.

2) There are reports of TTA's splitting the tibia post op. Several radiographs shown and a few vets in the audience also recounted this.

What I found really interesting where weight bearing studies through the menisci post op and how these changed. Again I recall that TPLO was better.

I sat next to Robin Grimmer and he wasn't convinced about dogs under 15kg would do any better with anything more complicated than a lateral suture and I tend to agree

Neil