NEW VIDEO VetSurgeon Talking Point. First up, cruciate repairs.

RE: NEW VIDEO VetSurgeon Talking Point. First up, cruciate repairs.

Andy Moores — Wed, 18 May 2022 14:38:07 GMT

Hi Ann, a pubmed search will find many references, but the one I specifically mentioned in the post above is:

Nelson, S.A. et al., 2012. Long-Term Functional Outcome of Tibial Plateau Leveling Osteotomy Versus Extracapsular Repair in a Heterogeneous Population of Dogs. Veterinary Surgery, 42(1)

For a review of treatment options, see

Systematic review of surgical treatments for cranial cruciate ligament disease in dogs.

Bergh MS, Sullivan C, Ferrell CL, Troy J, Budsberg SC.J Am Anim Hosp Assoc. 2014 Sep-Oct;50(5):315-21

RE: NEW VIDEO VetSurgeon Talking Point. First up, cruciate repairs.

Ann Hopkirk — Wed, 18 May 2022 11:35:04 GMT

Really interested that there is now proper evidence for choice of surgery-could you post some links to references please?

RE: NEW VIDEO VetSurgeon Talking Point. First up, cruciate repairs.

Andy Moores — Tue, 17 May 2022 11:36:24 GMT

All very good points, well-made, Steven

RE: NEW VIDEO VetSurgeon Talking Point. First up, cruciate repairs.

Colin Whiting — Tue, 10 May 2022 21:34:14 GMT

RE: NEW VIDEO VetSurgeon Talking Point. First up, cruciate repairs.

Steven Odell — Tue, 10 May 2022 21:13:00 GMT

I have been following the discussion with interest and a number of points raised have piqued my interest. Arlo's final post has raised what I think is a very interesting topic regarding referrals, and it is this to which I feel able to add to the debate.

I think we must first define what a referral is. This may seem simple, but could mean asking an enthusiastic colleague within the practice to have a look at a chest xray (no imaging cert), scan a heart of a CKCS to see if an obvious enlargement and warrants meds for B1 murmur (no cardiology cert), or tackle a horrid fractured mandibular canine extraction (no dental cert). Equally, it could entail referring a patient to the other end of the country to see the top RCVS specialist in a particular field. And every scenario in between, and all with prices to match.

In my opinion, all of the above are appropriate, provided that the owners are made aware of all of the options and of the level of expertise they are paying for. We can't all be experts in everything so may need to refer, but clients can't necessarily afford the most expensive options or be willing to travel to a distant referral centre and thus we must be able to offer them the full range. One thing that does irk me is that some practices are charging Specialist level fees, but with procedures being performed by vets who in some circumstances don't even have certificates (I know of one vet charging £4000 for a TPLO with no formal qualifications and the completion of a one day course before he decided to "crack on"...). Transparency and honesty, as always, are the key. If we don't then many clients and their pets are going to fall between the cracks and get no help or treatment at all. There aren't enough Specialists and Diploma holders available to see every difficult case which the GP vet wishes to refer, and some owners cannot afford the fees charged to see these extremely qualified colleagues, so surely it is OK for certificate holders or even experienced non-certificate holders to see cases, provided they inform the client of their level of experience, training and expertise. Using my PgC in surgery I have started seeing cases for other practices, but at the outset I tell owners and the referring vets how many TPLOs I have done, the complication rate, costs, and all of their other options. If owners are happy with what I tell them, I am within their budget, and they seem to like me then we proceed. Equally, they are free to leave with absolutely no hard feelings on either side.

Informed consent and honesty are the keys to appropriate referral, rather than the exact letters after your name.

RE: NEW VIDEO VetSurgeon Talking Point. First up, cruciate repairs.

Arlo Guthrie — Tue, 10 May 2022 16:36:33 GMT

A few days later, and I'm really pleased with the reaction to the first VetSurgeon Talking Point, and the way it provoked discussion here and elsewhere.

Thanks in particular to Colin Whiting for being the brave guinea pig, to Andy Moores for stepping in, and to Beats and ian bates for your positive thoughts.

My thoughts:

Michael Woodhouse, it is actually a good thing to have people who disagree. If everyone agrees, there's not much of a discussion to be had.

I also think the question of whether referrals should demand a certain level of qualification is not a bad debating point (personally, I would argue - very passionately - that they should not).

BUT, I don't think it was right to make that point in the context of this discussion.

It just came across as a bit snide, which is unfortunate, because it will make it harder for me to get others to come and express opinions for debate if they think some smart arse is going to shoot them down! As Ian said, a respectful atmosphere is critical to the success of this initiative.

That, I think, is the most important learning from this first VetSurgeon Talking Point.

By all means disagree with an opinion. But keep it friendly.

Otherwise you'll kill my efforts to stimulate interesting discussions on important veterinary topics.

RE: NEW VIDEO VetSurgeon Talking Point. First up, cruciate repairs.

Alistair Graham-Evans — Thu, 05 May 2022 23:17:56 GMT

Agree with all you have said Colin.

I am a GP vet doing TTO’s with good results.
Occasionally we do a surgery on one leg and unfortunately there aren’t the funds to do the other and years later the dog has one good stifle and one big uncomfortable one. I don’t delay for dieting in obese dogs now- it just doesn’t seem to work- seems better to operate and get them active.

I have given up trying to predict speed of recovery as so many variables and every dog and every stifle is different.

RE: NEW VIDEO VetSurgeon Talking Point. First up, cruciate repairs.

Andy Moores — Thu, 05 May 2022 20:25:56 GMT

[quote userid="3169" url="~/001/veterinary-clinical/small-animal/orthopaedics/f/discussions/30284/new-video-vetsurgeon-talking-point-first-up-cruciate-repairs/237086#237086"]If you want some controversy - is a TPLO ~8X better than an extracapsular technique costing ~1/8 as much? Maybe I'm wrong, but I think a general practice should be able to handle 80% of the ortho surgical caseload and only send on the greatly wealthy, well insured, and very unlucky to the 'specialists'.[/quote]

Oh there is so much wrong with these statements and I know I should know better but I can't resist... Michael, one surgery returns patients to normal activity, and one does not (force plate data 12 months after surgery). If you asked your clients if they would pay 8x as much for a surgery that works versus one that does not, I think you would find most would be willing to pay the extra. There is now a wide body of evidence that TPLO offers better outcomes than other surgical options (sutures, TTA, etc). This is no longer controversial, it is widely accepted. This does of course assume that the TPLO is performed appropriately, which is of course true of all surgeries, and the value to clients of a referral to a specialist surgeon is that they (and you) can have better confidence that this will be the case. Your phrase 'send on' implies that you are the primary decision maker regards referral. Do you not think that your clients should be the primary decision maker? Do you not think that all clients would like the option of referral to an orthopaedic surgeon who is very likely to be more experienced and better trained than you (harsh but true), regardless of their perceived financial circumstances?

How about that for cats and pigeons!

And well done Colin -completely agree with your comments. Always a shame to come across the cruciate case that has been treated, sometimes for years, for its 'knee arthritis', with no consideration that surgery could have solved that dog's issue a long time ago.

RE: NEW VIDEO VetSurgeon Talking Point. First up, cruciate repairs.

Colin Whiting — Wed, 04 May 2022 22:59:01 GMT

Hi Beats, thank you for both the very useful points and the very constructive tone!

1. Our fee to the client is £2,800 inc VAT for TPLO, including 6week review radiographs (we're a peripatetic surgical team, we then split that fee 50:50 with each host practice, we work a consulting and ops list at each practice, on a regular 3weekly 'tour'. The procedure is routine and therefore efficient, and means we can offer the procedure as affordably as possible. The fee is still substantial, but in the range of fees being charged very reasonable, and in some cases a non-osteotomy capsular repair procedure may have similar fee level. I love everything that works towards efficiency within our business, keeping costs as affordable as possible; the client consultation is however an imperative (and constructive) use of substantial amount of time, and we wouldn't have that any other way. In short, I think we can 'offer more for less' in terms of optimum procedures if we are as efficeint as posisble.

2. Agreed, but minimised with expertise/familiarity and non-osteotomy procedures also carry risk; and conservative management alone has higher likelihood of more advanced OA. Its a matter of selection of which risk, rather than avoidance of risk altogether, I feel.

3. Absolutely agree. Extracapsular stabilisation is my treatment of choice for a proportion of genuine 'true-traumatic' cruciate ruptures - the 9month old labrador or collie that didn't quite make the five bar gate, has a joint effusion like a football, massive cranial drawer, and the ligament hasn't failed by avulsion of its insertion together with bone attachment (if it has, I screw that back in place). Perhaps one case every three years plus. Everyone else - degenerative, and so a TPLO is preferred. A lateral fabella suture has nothing whatsoever to offer a partial tear - the remaining caudolateral band of the CrCL will still be the primary stabiliser of the stifle, before the restraint fo teh suture. And then when you come to perform a cranial drawer 6weeks later...

4. I think CrCL cases are a progressive degeneration. Whatever caused the first bit to be vulnerable still applies to the rest. I do think some degenerate very slowly, and there is an argument for the older/life limited patient to rest alone; plus quite reasonable for an owner to say my dog is in its very latter years and I don't wish to spend a few thousand poounds on a knee op, for sure. I think detecting a partial tear can be difficult, and I;ve sent some away to subsequently be proved wrong. But I think postive sit test, discomfort /laxity on tibial compression test performed in stifle flexion, and an effusion/early osteophytosis on a radiograph is sufficient to be convinced.

5. If there is palpable controlateral stifle effusion I start the conversation with the client. We regularly perform bilateral TPLO surgery, if there is signs of partial on the controlateral. Aside from overall cost savings to the client (single stage bilateral much cheaper than 2 x unilateral), I think there is a very major advantage in one, single, post-op period. If we are staging repeated procedures, its a long time for the family dynamic to be set in 'nurse:patient' mode, rather than 'owner:pet' and it can be hard for them to ever come out the other side and get back to the very essence of their relatinship - enjoyign each other's company, going on walks, etc without 'medicine' looming over their shared life together.

6. RCVS cruciate registry - great idea, info gathring needs streamlining, in my opinion. We all signed up and the team found each aptient admit extended by half an hour in the morning, which makes it impractical. Having some discussions for advice on how to get past that. I have a human ortho consultatnt pal I was quizzing about their hip replacement registry; lots that they have about streamlining data capture (as well as a grumble that french surgeons just tick all their own outcome boxes!). Agree on follow-up of conservative cases. Its hard to get unbiassed data (or opinions!), including mine, and I was braced for the 'well he would say that anyway' comment when a surgeon talks about doing surgery proactively.

7. Fairly confident. I used to work doing internal and external referrals within a large first opinion group; I certainly didnt see all the lamenesses, but we were very open about discussing cases. I think optimising bodyweight is the single most magnificent thing you can do for an OA patient, but I don;t think you can diet away a cruciate degeneration.

8. Agree, but that doesn't really come up in my framework for advice on cruciates; but has rarely arisen as a concern in other conditions, imposing a timeframe on decisions. I remember a letter in the vet record by Gary Clayton-Jones, perhaps even 15years ago, on this very point with regard to hip replacements - he saw patients that didn't need one YET, but if he didn't do it within 12months, they couldn't have one ever.

9. I get the temptation to justify surgery costs by comparing to long-term meds, but I think speaking about 'what gives us the best result' is more the territory to follow, wherever possible. Espeically where surgery is a compoonent of management, rather than the definitive/curative that clients often hold in their perception. 'This surgery will not cure your dog' is a phrase I use, (especially for elbows!) followed by a few seconds silence to let it sink in, before going on to unpack the statement - component of management, etc

THanks again for the very detailed and constructive thoughts/debate; hope my replies are useful for you too.

Kind regards,

Col

RE: NEW VIDEO VetSurgeon Talking Point. First up, cruciate repairs.

Colin Whiting — Wed, 04 May 2022 22:22:12 GMT

Hi Groove. Thanks for the comment... there are studies that have followed outcomes, including in smaller breeds, showing the benefit of TPLO surgery especially. And in partial tears, that TPLO can stop further progression of this degenerative process - 'save the ligament' as it were. Smaller, terrier breeds often have steeper tibial plateau angles and are therefore more prone to ending up in resting cranial tibial translocation or a permanently subluxated stifle, which accentuates lameness too. Agree, meniscal damage is a very marked exacerbator of osteoarthritis within the joint, and if we can avoid it vastly better to do so. I'm not a cavalier surgeon and very drawn to rest/conservative/mother nature/tincture of time for many conditions, but the first sniff of a CrCL tear in my own dog and I'd be out with the TPLO kit like a rat up a drainpipe!

RE: NEW VIDEO VetSurgeon Talking Point. First up, cruciate repairs.

John Dennis — Wed, 04 May 2022 21:26:02 GMT

I have no problem with the larger breeds but possibly lighter dogs and cats need more long term investigations of the later prognosis. I have performed numerous techniques over the years including autologous blood which of course is now performed as stem cell transfer.

Thanks for your candid opinion.

RE: NEW VIDEO VetSurgeon Talking Point. First up, cruciate repairs.

Miriam Lodewyks — Wed, 04 May 2022 21:14:11 GMT

I don’t have a strong opinion on this, but I’m still not convinced that any of the surgical interventions have THAT much better an outcome than rest and NSAIDs in all but the most massive of dogs (then again the Dogue de Bordeaux seems to have been bred specifically for generalised and complete joint collapse so they’re going to be crippled by the time they’re 6, regardless!)

I used to work at a referral practice where we saw plenty of cases 2, 3, 5 years later with the most awful arthritis, despite the TPLO, TTA or extracapsular technique.
Arguably they were treated too late, after the damage to the menisci was done, so I guess Colin has a point there…

RE: NEW VIDEO VetSurgeon Talking Point. First up, cruciate repairs.

John Dennis — Wed, 04 May 2022 19:47:29 GMT

Hello. Are we been informed that orthopaedic procedures involving the joint will cause no long term arthritic changes? Have any long term surveys of all management techniques for CCL damage ever been done? Does a twisted stifle joint with some effusion and pain always warrant major surgery with potential complication risk? I think not.

Interesting topic. Lots of point in one short video. Thanks

RE: NEW VIDEO VetSurgeon Talking Point. First up, cruciate repairs.

Arlo Guthrie — Wed, 04 May 2022 09:30:21 GMT

Thank you Ian, that is lovely to hear.

[quote userid="11249" url="~/001/veterinary-clinical/small-animal/orthopaedics/f/discussions/30284/new-video-vetsurgeon-talking-point-first-up-cruciate-repairs/237089#237089"]One of the keys to success will be to foster an atmosphere where those brave enough to contribute are not in fear of being shot to pieces for their opinions.........[/quote]

Very interesting point and very much at the forefront of my mind. As I have wittered on about for ages, the written word polarises.

It lacks nuance.

It lacks eyebrows (as Colin and I were discussing the other day). The importance of eyebrows in debate is not to be underestimated )

So debates that start on social media with one short provocative sentence are set up to turn into a bunfight and become bitter and acrimonious

I think that setting the scene with an opinion expressed on video sets the scene for a far better quality of debate.

It's harder to shoot someone when you're looking in their eyes.

Video gives the nuance of facial expression and inflection.

Early indicators (responses to the video here and on Facebook) are looking very encouraging on that front.

RE: NEW VIDEO VetSurgeon Talking Point. First up, cruciate repairs.

ian bates — Wed, 04 May 2022 09:19:56 GMT

I think this could be a really useful and entertaining addition to vetsurgeon.org

Thanks Arlo (and colin)

One of the keys to success will be to foster an atmosphere where those brave enough to contribute are not in fear of being shot to pieces for their opinions.........

I will always be interested in the thoughts of colleagues on the back of these videos - there are some very inciteful people contributing on this platform.

RE: NEW VIDEO VetSurgeon Talking Point. First up, cruciate repairs.

Beats — Wed, 04 May 2022 08:50:33 GMT

I think you can't get much more controversial than cruciates!

I think it's an interesting talking point and has got me thinking.

I would rarely launch into surgery before there is a clear problem, though I will sometimes "operate early". On thinking why I currently (perhaps I'll change after this discussion) have that approach to the average case. I think of the following points:

Osteotomy techniques are expensive
Osteotomy techniques have the potential for significant harm
I struggle to see what good an extracapsular suture does in a partial, or early, cruciate tear with minimal instability.
Some cases do appear to settle (either because I have misdiagnosed them in first place, or they are fairly clinically unaffected by the progressive joint disease that is occurring, or they genuinely settle).
It is not uncommon to note some joint effusion in a contralateral stifle at the time of surgery on a lame cruciate stifle, and that not progress to any significant clinical problem in the following years. (Although more often than not it does progress).
I think the RCVS knowledge cruciate registry is a fantastic idea - I think it could be even better with the inclusion of non-operated cases.
I think Colin's observation is very interesting, but assume that he operates on all stifles with evidence (radiographic or otherwise) of cruciate disease from what he says. The cases he refers to are ones managed by other vets that have not had a satisfactory outcome with weight management, NSAIDs and time; is he confident that there is not a subset of cases that he does not see that have had a satisfactory outcome with weight management, NSAIDs and time?
Another reason, not mentioned, to "operate early" with an osteotomy technique is that many owners that have pet insurance that may pay for such an operation (and any complications that may occur afterwards) have a limit of, say, 12 months from problem first being noticed. This can be a practical point, where financially the choice may be osteotomy-now-or-never.
I once watched a presentation where a (very good) specialist was advocating early total hip replacement and had a slide demonstrating how the cost of this over lifetime was less than rimadyl - I still don't know where they were buying their rimadyl, but the numbers didn't stack up on a lot of fronts!

RE: NEW VIDEO VetSurgeon Talking Point. First up, cruciate repairs.

Arlo Guthrie — Wed, 04 May 2022 07:25:46 GMT

Great, thank you Michael Woodhouse

[quote userid="3169" url="~/001/veterinary-clinical/small-animal/orthopaedics/f/discussions/30284/new-video-vetsurgeon-talking-point-first-up-cruciate-repairs/237086#237086"]

Arlo Guthrie said:
Meantime, what do you think about the point Colin raises?

Very little indeed. It's 2022, supposedly an era of evidence based veterinary medicine, and we present one man's opinion.

[/quote]

I think you're slightly missing the point. We're not presenting one man's opinion as evidence. The clue is in the name . It's meant as a talking point, no more, no less. And in the ensuing discussion lies the opportunity to present and discuss evidence.

It can be difficult to get people to stick their head above the parapet and express an opinion, still more so to camera, so I think it was important to start with a scene setter, that is to say something not overly controversial.

That's not to say we won't tackle more controversial topics.

Thank you, yes, those are two good ones. Three in fact.

Would you like to do one? It involves a chat on zoom with me to make a rough cut recording of a max 60 second opinion to use as the template, then you film it on a mobile phone (better quality) and email to me.

RE: NEW VIDEO VetSurgeon Talking Point. First up, cruciate repairs.

Michael Woodhouse — Wed, 04 May 2022 01:38:14 GMT

Ok, I'll rise to it

[quote userid="2100" url="~/001/veterinary-clinical/small-animal/orthopaedics/f/discussions/30284/new-video-vetsurgeon-talking-point-first-up-cruciate-repairs"]Meantime, what do you think about the point Colin raises?[/quote]

Very little indeed. It's 2022, supposedly an era of evidence based veterinary medicine, and we present one man's opinion. I'm not even sure it's a particularly controversial opinion and I have personally operated on many dogs in similar circumstances. Hell, it might even be the rest and NSAIDs that 'fix' the problem rather than the surgery......

If you want some controversy - is a TPLO ~8X better than an extracapsular technique costing ~1/8 as much? Maybe I'm wrong, but I think a general practice should be able to handle 80% of the ortho surgical caseload and only send on the greatly wealthy, well insured, and very unlucky to the 'specialists'.

Or if you want real controversy - should someone with only a certificate even be taking referrals.......

(I see Fitspatrick's charging ~£4k for a hip toggle - that's a profitable hour in surgery with a £30 toggle. I'm undercharging)

RE: NEW VIDEO VetSurgeon Talking Point. First up, cruciate repairs.

Arlo Guthrie — Tue, 03 May 2022 22:01:47 GMT

Well, that sure threw the cat in amongst the pigeons ;)

***NEW VIDEO*** VetSurgeon Talking Point. First up, cruciate repairs.

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