TTAvsTPLOvsTTO

Re: TTAvsTPLOvsTTO

Malcolm Ness — Fri, 25 Jun 2010 08:32:25 GMT

[quote user="Peter Ding"]I was actually asking for statistical evidence Malcolm. Is there any?[/quote]

Lots - review the literature including the |dds ratio relating to various breeds.[quote user="Peter Ding"]after atrophy [/quote]

Normal ligaments don't atrophy in response to physiological loading.[quote user="Peter Ding"] Is that not a perfectly plausible explanation for bilateral damage[/quote]

No. There is no evidence that contra lateral CCL failure occurs following genuinely traumatic failure, nor is there any evidence of increased incidence of contra lateral CCL falure following fracture or even amputation.[quote user="Peter Ding"]Might i suggest any animal running potentially puts significant very large forces thorough stifle ligaments. Whether the owner is aware of a fall or extraneous force or not is irrelevant, imho if the animal is off the lead on rough ground anything is possible. i have yet to see cruciate rupture occur during a period a dog has only been on a lead over flat ground.[/quote]

Stifle biomechanics is much more complex than you imply. CCL failure in leash exercised dogs is not unknown and conversely many cases occur in fit working dogs.[quote user="Peter Ding"]How do you know all those changes "degenerative" changes aren't part of the normal pathological response in un-exercised tissue to periodic excessive exercise? [/quote]

Simply because there is not a "normal pathological response" in un-exercised individuals as shown by the comparisons published comparing CrCL and CaCL degeneration.[quote user="Peter Ding"]Are the majority of pet dogs not exercised sub-optimally for their anatomy and physiology? The majority of owners certainly are![/quote]

There has been nothing published that I recall demonstrating a causal relation between inactivity and CCL failure nor any protective effect of exercise.[quote user="Peter Ding"]Have any studies ruled out all other variables in terms of establishing that "clinical degeneration of the cruciate ligament" is something more than the result of atrophy and repeated minor trauma?[/quote]

There is overwhelming evidence for degenerative CCL failure. Why and how it happens remains controversial. The latest edition of Vet Surgery is about stifles, specifically CCL disease - anyone reading that will appreciate that the concept of degenerative CCL disease as distinct from truly traumatic (ie mechanical failure of a previously normal CCL due to a single, non-physiologic tensile mechanical over-load) is a universally accepted concept. Indeed, the keynote paper is a review of how this degeneration occurs - there is no speculation at all about whether it occurs.

There is as John has pointed out, a poor understanding of how and why the CCL loses strength (ie degenerates) in some indiviuals but not others and similarly there is no understanding of what drives the process (hence the research into genetics, kinematics, immune modulation etc etc) but our lack of a complete understanding is not proof that the phenomenon does not exist.

Re: TTAvsTPLOvsTTO

Peter Ding — Thu, 24 Jun 2010 15:08:42 GMT

I was actually asking for statistical evidence Malcolm. Is there any?

I'm not so sure your rationale for believing trauma after atrophy isn't the primary cause of ruptured cruciate holds up to examination. Also why doesn't injuring one stifle immediately put more stress on the other leg? Is that not a perfectly plausible explanation for bilateral damage.

Might i suggest any animal running potentially puts significant very large forces thorough stifle ligaments. Whether the owner is aware of a fall or extraneous force or not is irrelevant, imho if the animal is off the lead on rough ground anything is possible. i have yet to see cruciate rupture occur during a period a dog has only been on a lead over flat ground.

In my experience the majority of stifle injuries occur with the dog off the lead after a period of the dog running on rough ground. Although i tend to agree there is often no particular fall seen by the owner, nor any gross lameness till they get home. However they seldom seem to occur in very fit well muscled dogs in my experience. Having said that so few are really fit these days that could be just proportionate.Similarly they tend to occur more in overweight dogs with bouncy dispositions and a history of a previous lameness in the same limb.

How do you know all those changes "degenerative" changes aren't part of the normal pathological response in un-exercised tissue to periodic excessive exercise?

Are the majority of pet dogs not exercised sub-optimally for their anatomy and physiology? The majority of owners certainly are!

Have any studies ruled out all other variables in terms of establishing that "clinical degeneration of the cruciate ligament" is something more than the result of atrophy and repeated minor trauma?

Why does John Innes in particular seem to think there is little good true evidence for "degeneration"?

Re: TTAvsTPLOvsTTO

Malcolm Ness — Sat, 19 Jun 2010 13:21:02 GMT

[quote user="Peter Ding"]i would also like to ask Malcom what good evidence he has that purely traumatic rupture is rare. Indeed what evidence does he have that degeneration of the cruciate ligament exists as a clinical condition rather than as a form of disuse atrophy associated with reduced exercise patterns, and/or the result of recurrent more minor trauma with imperfect repair.[/quote]

Evidence: The frequent occurence of bilateral CCL failure; the typical lack of significant trauma at the time of onset of lameness; the typical existence of signs of secondary disease pre-dating the onset of lameness; the common presentation of insidious onset or variable lameness; breed predispositions: the work of Bennet, Vasseur and many others describing degenerative changes in the CrCL developing more quickly than for example, those on the CaCL; the recognition of traumatic cruciate ligament failures which cause per-acute lameness following an often observed and significant incident ( in our first opinion practice it is often dogs turning at speed on the dry sand part of the beach while chasing a stick/ball which lands benhind them - these cases are very different in almost every way to the more common "degenerative" cases. WHY the CCL degenerates to the point that relatively low physiological loads cause failure is not obvious - over the years a number of potential primary (or at least precursor) aetiologies have been investigated including immune modulation. Currently there is interest in a genetic involvement hence the research projects at Liverpool and elsewhere.

OTT must be debated with some caution - although extensively researched and published, all the published work relates to the original technique involving a graft taken from the middle third of the straight patella ligament and incorporating a portion of the patella - this degree of complexity was considered necessary first to ensure a good attachment (hence the patella osteotomy); good vascularity (hence the size and and location of the graft) and appropriate mechanics (hence the use of ligament and not fascia etc). Very few vets discussing OTT use this technique and all the modifications are unproven. It is not appropriate to talk of all OTT procedures as equal or indeed even comparable and it is likely now that no two surgeons perform the same variation on the OTT theme.

There is indeed a need to do some basic efficacy research on this disease. However, the first need is to establish a reliable diagnosis. Many of the dogs operated for cruciate do indeed have a cruciate failure along with a secondary stifle OA. These dogs will present not because of the CCL or the chronic secondary stifle OA but because of an acute flare of the secondary stifle OA. That acute flare, in most cases, is destined to settle and the cynic in me would point out that if you do your surgery in that window of opportunity and don't do too much damage, then you can confidently expect the dog to improve bac to pre-flare levels of function - levels of function that the owner considered normal.

The second fact to consider is the reliability (or otherwise) of the diagnostic tests we use to evaluate the integrity of the CCL. One of my residents (Barbara Carobbi) recently conducted and published (JSAP) a pilot study to evaluate these tests and discovered that they are rather UNreliable.

Re: TTAvsTPLOvsTTO

Hannah Wynne Richards — Sat, 19 Jun 2010 12:06:54 GMT

Colin I hadn't heard of this one-will try it next time I have a large dog, or one with an angulated tibial plateau-and who's owner won't refer-would still prefer to send to an orthopod-thanks

Wynne

Re: TTAvsTPLOvsTTO

Colin Cameron — Sat, 19 Jun 2010 11:59:20 GMT

[quote user="Hannah Wynne Richards"] I did the OTT technique for years, and found the tibial tunnel very difficult to angle correctly[/quote]

I claim no specialist knowledge in this field but I haven't used a tibial tunnel for modified OTT for years.I simply use part of the joint capsule lateral to the patellar ligament and a strip of fascia lata, the whole strip being left attached to the insertion on the tibia. It is looped through the joint and sutured to the lateral epicondyle and to the attachment just lateral to the tibial crest ( as advised by orthopod). It seems to work quite well in medium sized dogs. I have recently been using a modified Flo's procedure in small to medium sized dogs with similar results. I agree that this is easier than modified OTT. Otherwise they get referred to our nearby orthopod who has all the necessary instrumentation etc.

Re: TTAvsTPLOvsTTO

Hannah Wynne Richards — Sat, 19 Jun 2010 11:55:52 GMT

Peter. I think you're right about more questions than answers-that's why stifle surgery is like vaccination schedules, and diet-guaranteed to set everyone arguing

I do however wonder whether your "remarkably sound " giant breeds, and Martin's cases are truly sound and, most importantly pain free, or whether they are merely altering hock angle to APPEAR sound-that's why plate measurements are better than the human eye in assessing if truly sound-if both hind legs are equally weight-bearing, then presumably the animal is pain free-or lame in both legs-old horse-dealers trick!!!!!!!!!

Wynne

Re: TTAvsTPLOvsTTO

Peter Ding — Sat, 19 Jun 2010 11:40:03 GMT

Whilst i think most of us would do what Malcom and Hannah have indicated, is it not about time to admit that there is very little good quality published evidence to distinguish between the treatment plan options and techniques listed.

In particular I've seen a couple of cases of very overweight giant breeds with palpably huge differences in anterior draw (under sedative or GA) and discernible changes on radiography, ( i.e. where one is fairly convinced of complete rupture) get remarkable sound after a few weeks cage rest and NSAIDS.

Has anyone done a good large series of promptly placed lateral fabellar sutures on large dogs (using appropriately sized materials) to clearly show it yields either poor or reasonable results?

Is there any correlation between the presence of bucket handle meniscal tears and use of the joint whilst unstable? i.e Is the incidence of such secondary damage far lower in first opinion surgery where surgery is carried out fairly soon after the injury? Or does such damage occur at the time of the original injury in the majority of cases?

i think stifle surgery still has more questions than answers attached to it.

i would also like to ask Malcom what good evidence he has that purely traumatic rupture is rare. Indeed what evidence does he have that degeneration of the cruciate ligament exists as a clinical condition rather than as a form of disuse atrophy associated with reduced exercise patterns, and/or the result of recurrent more minor trauma with imperfect repair.

Re: TTAvsTPLOvsTTO

Colin Cameron — Sat, 19 Jun 2010 11:09:07 GMT

[quote user="Malcolm Ness"](ACL is a human term and not appropriate in dogs though it is widely misused, especially by our American cousins - cue rant from Colin!!)[/quote]

This was not a rant!! I was simply asking why we always seem to end up with the American terminology. And finally, are you saying that OTT has no place in treatment of CCL rupture? I'm interested in the justification for each of the techniques so that I can better advise my clients. Where can I find the relevant information? Is there a definitive answer?

Re: TTAvsTPLOvsTTO

Hannah Wynne Richards — Fri, 18 Jun 2010 16:39:16 GMT

I although not an orthopaedic specialist, tend to agree with Malcolm

My rule of thumb is:

<15kg-try 6 weeks REST and NSAID

15 to 25 kg, fabello-tibial technique

>25 kg, or very angulated tibial plateau (Staff types ) try to get the owner to refer

Single handed practice, so don't see enough to have statistically valid results, but this seems to work-and since most of my clients are insured, it's ages since I had a big dog I couldn't refer-would probably try the OTT technique, but get the client to sign a disclaimer, that they had refused advice to refer

Wynne

Re: TTAvsTPLOvsTTO

Malcolm Ness — Fri, 18 Jun 2010 16:07:30 GMT

[quote user="Martin Atkinson"]I did imply that TPLO and TTA etc was indicated in cases of ACL rupture due to conformational abnormality[/quote]

This indicates a fundamental lack of understanding of these procedures - they do not aim to correct "abnormality" but to change stifle mechanics such that the function of the joint is no longer dependant on the CCL. (ACL is a human term and not appropriate in dogs though it is widely misused, especially by our American cousins - cue rant from Colin!!)

[quote user="Martin Atkinson"]but is probably unwarranted in purely traumatic rupture. [/quote]

"purely" traumatic ruptures are quite uncommon in dogs and you are expressing an opinion that is contrary to most specialist vet ortho surgeons worldwide. What is special/different about yout experience and perception.

[quote user="Martin Atkinson"] I can't argue with my results[/quote]

It is not for you to argue with your results - that is the purpose of peer review. Your claims are of results staggeringly better than what is widely accepted. It is for you to present these results and publish them so that we can all copy what you do, duplicate our results and thereby "up our game". Unless and until you do that, I quite simply do not believe the claim that you (or anyone else) can return a dog to "full function" within 12, let alone 6 weeks of cruciate failure and surgery.

[quote user="Martin Atkinson"]As an aside clearly not everyone is able or willing to pay several thousand pounds for orthopaedic surgery [/quote]

As a practitioner with some experience, that is not news to me.

[quote user="Martin Atkinson"]if one can obtain a satisfatory result for £300 [/quote]

If (that is a very big word despite having only two letters) a satisfactory result (what happened to full function in six weeks which could modestly be described as an excellent, even an incredible result) could be achieved predictably with a fabello-tibial sutures then I would be doing them in every case - what's more, I would be making more profit and freeing up a whole lot of time.

My preferred option for treating CCL failure is to do nothing and manage with NSAIDs - if that fails, or seems likely to fail then I will treat surgically using the cheapest, easiest technique that is likely to produce a good outcome. Many dogs get a fabello-tibial suture, bigger more active dogs are advised a mechanical alteration procedure (TPLO or TTA). Active, working or giant dogs get TTA/TPLO as first choice.

We are sent a number of dogs for revision surgery following failed fabello-tibial or (less frequently these days) OTT surgery. These typically get a TPLO.

Re: TTAvsTPLOvsTTO

Colin Cameron — Fri, 18 Jun 2010 15:19:12 GMT

[quote user="Derek Copeland"]On a smaller point one thing that is of no use whatsover in nit picking over some points and ignoring the main issue .My dogs really dont care if I operate perform surgery or carry out a procedure as long as i fix them.[/quote]

You missed the point, I think. I am not nitpicking , as you put it, but simply asking why there is this tendency to adopt the American names for everything? It never seems to be the other way round, does it? And, as a matter of interest , how many of your patients have in fact expressed either a preference or an opinion? The main issue is which is the best technique and my opinion is that all have their place and the best one is that which, on clinical grounds, works best for the individual dog and surgeon. The trickiest bit is appropriate case selection!!

Re: TTAvsTPLOvsTTO

Derek Copeland — Fri, 18 Jun 2010 13:38:47 GMT

Cruciate repiar , vaccination frequency and dog food always seem to stimulate a lot of response

What I think the previous points show is that there is a serious need for some good evidence based work in general practice. Whilst I think anaecdotal evidence has some value surely this is limited.

It would seem from various comments that OTT and lateral stabalising sutures used in some peoples hands have no failures at all - they certainly havent been mentioned . The problem is these techniques do not produce consistently brilliant results.

Like Malcolm I have used most of the techniques mentioned and still use lateral stabalising sutures.A significant number of dogs that have TTAs within a couple of months are pain free on no NSAIDs I could never get these results from other techniques.

If we are going to carry out these surgeries/operations /procedures then I think we should be carefully evaluating the results.I like many of you am in a primary referal situation and know there isnt enough time to do half the things we want to to run the perfect practice.However there is a mass of information in general practice that is left untapped.Bur sorry I am not sure how this is resolved.[quote user="Colin Cameron"]

[quote user="Derek Copeland"]We have performed about 50 surgeries [/quote] Why oh why are we suddenly calling surgical operations/procedures "surgeries" which until quite recently were taken to mean either the building or consulting sessions! Is this the way vet students are being taught or is it the undue influence of the many rather good textbooks from across the pond. I am aware that we are adopting American names for most of our drugs now ( never the other way round) but must we always adopt their names for everthing else. It just sounds a bit pretentious at times. What is wrong with the British names?? This is not a criticism, merely asking the question!!!.

[/quote]

On a smaller point one thing that is of no use whatsover in nit picking over some points and ignoring the main issue .My dogs really dont care if I operate perform surgery or carry out a procedure as long as i fix them.

Oh yes and I feed my cat and dog dry food(sometimes ndate sometimes not !)and vaccinate them every year !

Re: TTAvsTPLOvsTTO

Martin Atkinson — Fri, 18 Jun 2010 11:59:19 GMT

[quote user="Peter Ding"]

What is your evidence for deciding which sort of case is suitable for a lateral suture.

I tend to avoid doing it on big dogs, but i now understand there is little published evidence to justify this.

[/quote]

Young dog with no history of trauma of breed with known suspected dodgy stifle anatomy refer to someone who knows a lot more than me if owner is willing and able. If not and in traumatic rupture in dog with sensible conformation repair by lateral suture, the bigger the dog the stronger the leader line.

Re: TTAvsTPLOvsTTO

Vikki Halliday LLB — Fri, 18 Jun 2010 11:15:59 GMT

I haven't done an OTT for years, (did do quite a few in dogs that we considered too big for de Angelis technique), but did recall that the size of the dog made little difference in the outcome, more appropriate case selection (traumatic vs degenerative) and surgical technique were the things that made for the best outcomes.

Re: TTAvsTPLOvsTTO

Peter Ding — Fri, 18 Jun 2010 10:44:38 GMT

What is your evidence for deciding which sort of case is suitable for a lateral suture.

I tend to avoid doing it on big dogs, but i now understand there is little published evidence to justify this.

Re: TTAvsTPLOvsTTO

Hannah Wynne Richards — Fri, 18 Jun 2010 10:02:45 GMT

Case selection is the vital thing. I did the OTT technique for years, and found the tibial tunnel very difficult to angle correctly, then went on a CPD course where a specialist advocated the tibia/behind the fabellae technique for SUITABLE cases-not just size, but also tibial angle.

Since then I've used this technique if the patient is suitable, and found it much easier, and very successful. I refer those that I don't think suitable, and my usual orthopaedic referral veterinarian does TPLO, but I leave the decision on exactly which complicated process to use to him

Wynne

Re: TTAvsTPLOvsTTO

Peter Ding — Fri, 18 Jun 2010 08:37:12 GMT

There was a very interesting talk on Anthony Chadwick's Webinar by John Innes talking about Cruciate surgery and the relative incidences of complications for the various treatment options.

Discussing the results of his qualitative analysis of all existing published papers. It sought to answer the question of what is best practice.

How much of the whole current "mystique" is based on good evidence-based studies? The answer was very little!

Data was presented indicating that the only operation really justifiable on a risk benefit analysis of all previous studies was a lateral stabilizing suture. That there was next to no good evidence for the slow degeneration of ACL , nor that TPLO/TTA etc techniques. were any better, but the risks were certainly higher.

Quite contentious but limited because no-one has the data justifying and differentiating the different treatment approaches to small and large dog, age, weight, etc.

Re: TTAvsTPLOvsTTO

Martin Atkinson — Thu, 17 Jun 2010 19:35:14 GMT

[quote user="Malcolm Ness"]

.......so why isn't everyone doing fabello-tibial sutures? - it would be MASSIVELY more profitable for us if we did that instead of TPLO or TTA and charged a third of the price.

I did imply that TPLO and TTA etc was indicated in cases of ACL rupture due to conformational abnormality in young dogs but is probably unwarranted in purely traumatic rupture.

When it comes to cruciate surgery, every vet is an expert and the less they know of the subject, it seems, the greater the confidence in their expertise.

As a natural cycnic I can't argue with that and would be the first to accept mud slung back my way, so no defence.

If you can return dogs to "full function within 6-12 weeks" of cruciate surgery then you are a better surgeon than me or anyone I know.

Perhaps because the fabello-tibial suture causes less iatragenic damage and allows faster recovery time. I have no doubt you're a better orthopaedic surgeon than me Malcolm but that's why I use this technique which I consider more soft tissue surgery. Its not a boast but I can't argue with my results. If I performed a TPLO or TTA I have no doubt they would never walk normally again!

As an aside clearly not everyone is able or willing to pay several thousand pounds for orthopaedic surgery and if one can obtain a satisfatory result for £300 then there can be no argument with that. Basically there are no winners or losers in this debate.

[/quote]

Re: TTAvsTPLOvsTTO

Malcolm Ness — Thu, 17 Jun 2010 18:04:09 GMT

.......so why isn't everyone doing fabello-tibial sutures? - it would be MASSIVELY more profitable for us if we did that instead of TPLO or TTA and charged a third of the price.

When it comes to cruciate surgery, every vet is an expert and the less they know of the subject, it seems, the greater the confidence in their expertise.

If you can return dogs to "full function within 6-12 weeks" of cruciate surgery then you are a better surgeon than me or anyone I know.

Re: TTAvsTPLOvsTTO

Martin Atkinson — Thu, 17 Jun 2010 15:34:58 GMT

There was once a veterinary nurse who suggested that TPLO was an acronym for totally pointless leg operation and maybe we could use our imagination to conjur up a similar interpretation for TTO and TLO. Are you correcting abnormal tibial plateaus in the dogs you've operated on Derek or just repairing traumatic ACL ruptures in 'normal' dogs? If the former I can see some justification in complex surgery but for an ACL rupture in a middle aged mongrel even the OTT technique is unecessarily complicated which is why it may have fallen out of favour somewhat. Speaking as the world's worst orthopaedic surgeon I have found that lateral fimbrication with a de-Angelis suture using a crimped leader line is effective, with the overwhelming majority of patients returning to full function within 6-12 weeks and costs a fraction of the fee of a more complex technique. But being totally cynical, half of those would have got better with no surgery anyway. I can can speak from personal experience with a non-repaired ruptured ACL in my left knee. It causes me no problems for any sport and I only wear a brace for skiing as a precaution. From feedback from the orthopods I've spoken to I'd save the money and carry on doing TTAs if you must, those who have invested in the training and kit for TPLO will probably not want to lose face by admitting there's no difference in success rate.

Re: TTAvsTPLOvsTTO

Malcolm Ness — Thu, 17 Jun 2010 15:24:44 GMT

We have done TPLO and TTA in our practice in recent years and before that fabello-tibial sutures for everything. In the dear dark days beyond recall, we used the OTT technique as originally described by Arnosczy.

TTO is pointless - it offers no advantage over TPLO or TTA and is more complex than either as well as less precise.

TTA is technically more difficult than TPLO (the people "selling" the procedure claim otherwise!) TTA requires more, and more complex implants and, as Derek has discovered is rather prone to severe, albeit relatively uncommon complications. We prefere TPLO over TTA because of these reasons plus the fact that TTA is not appropriate for dogs with tibial plateau angles greater than about 24 degrees. Most TTA surgeons ignore this fact but it seems to me that when undertaking a major surgical procedure of this type, then I don't want to be compromising. TPLO works predictably well in our hands. With more than 3500 cases to date we have had no catastrophic complications and by using locking plates, the incidence of infection and other complications is now very low.

TTA has great potential but in its present form it seems over-complex to me. Hopefully some modifications will appear making it safer, more user friendly and less costly.

wrt other techniques - OTT is also unecessarily complicated compared with a fabello-tibial suture - there have been a number of papers showing it to be no better than a well-executed fabello-tibial suture.

The reason I go for TPLO or TTA over fabello-tibial suture in larger or more active dogs is the reliability of outcome. Prior to TPLO, if presented with a working dog with a failed CCL, the chances of returning the patient to full work were relatively small. With TPLO (or TTA in an appropriate case) I can be very confident of getting the dog back to work.

Re: TTAvsTPLOvsTTO

Colin Cameron — Thu, 17 Jun 2010 09:14:11 GMT

[quote user="robloxley"]

Do you equally therefore not mean you have 'operated' on some dog cruciate ruptures rather than 'done some cruciates'???

[/quote]

Touche!! Actually,I suppose, I have either operated on some dogs with ruptured cranial cruciate ligaments or have performed said procedures!! Point taken!! Off now to do what a Vet's got to do!!

Re: TTAvsTPLOvsTTO

Rob Loxley — Wed, 16 Jun 2010 23:05:32 GMT

[quote user="Colin Cameron"]

I have done some cruciates recently using the OTT technique with excellent results and needed no fancy equipment.

[/quote]

Do you equally therefore not mean you have 'operated' on some dog cruciate ruptures rather than 'done some cruciates'???

Re: TTAvsTPLOvsTTO

Colin Cameron — Wed, 16 Jun 2010 19:12:28 GMT

I have done some cruciates recently using the OTT technique with excellent results and needed no fancy equipment. I agree that case selection is important and giant or complicated cases will need these newer techniques but why is OTT suddenly being seen as no good and never discussed? A comment made by one client when discussing their case was that these vets recommended these more "advanced " prodedures which required special equipment so that only they could do them. A long discussion followed! Let's not deride older procedures which can give excellent results with careful case selection and good surgical technique. I recently repaired a cruciate case with a modified Flo's procedure which is also doing well. I feel that all these techniques have their place and so will continue to do OTT and FLO's when appropriate and refer others to nearby orthopod who has all the toys. The last comparative report I read was based entirely of force plate analysis showing these newer techniques to be slightly better with respect to force applied to the plate before and after treatment. Very little mention was made of how the dogs were clinically ,which I have always believed to be the better judgement. I may be a complete heretic in this our own results so far for both in house surgery or referral seem not too bad at all using a variety. No doubt one is bound to go wrong now!! I have nothing whatever against any new , advanced or better procedures or techniques but it seems to me that the level of improvement is sometimesat odds with the shedloads of kit required and vast expense of training etc. This is not a rant just asking the questions and seeking justification!!