Anterior Cruciate Repair

Re: Anterior Cruciate Repair

Gerry Henry — Mon, 12 Dec 2011 12:11:26 GMT

Wynne,

Better the Angel of recent aquaintance than the Devil you know.

:^)

Re: Anterior Cruciate Repair

Hannah Wynne Richards — Mon, 12 Dec 2011 09:47:46 GMT

Malcolm Imay take you up on that There is though the feeling "better the devil you know "

Wynne

Re: Anterior Cruciate Repair

Gerry Henry — Sun, 11 Dec 2011 11:42:07 GMT

I'm old enought to remember when blood injections or OTTs were the norm; I never remember them walking into the surgery 1wk post op 9/10 sound; there really have been significant advances in #AC techniques in the last decade, particularly in the larger breeds where nothing worked before the advent of the TPLO.

Re: Anterior Cruciate Repair

Anthony Todd — Sun, 11 Dec 2011 10:54:11 GMT

[quote user="Judith Joyce"]I get to do cruciate revisions because[/quote]

As the OP I'm not sure I'm any better off.

I remember my boss, when the first skin implants were described, saying that, in the time when no ops were done, he didn't see loads of limping dogs wandering round E11....

I wonder just how many dogs would be sound after, say a year, by doing absolutely nothing except restricted exercise?

Certainly my son, who had an early ant. cruciate repair by the then top man still has a gross drawer reflex but is sound.

Re: Anterior Cruciate Repair

Judith Joyce — Sat, 10 Dec 2011 21:16:01 GMT

[quote user="Hannah Wynne Richards"] I don't understand how you come to do revisions[/quote]

I get to do cruciate revisions because a significant number of our colleagues believe that they can do orthopaedic surgery and get acceptable results without ever defining what that acceptable result actually is and without ever following up cases in a systematic way. Armed with an excess of confidence over competence, a number of failures occur - not complications but technical errors. Sometimes, even apparently competently executed lateral suture cases fail and they contribute to the revision caseload.

Emphatically, this is not a primary care vs referral discussion. As Gerry has pointed out, the technical aspects of the surgery is fairly straight forward and there for any reasonably competent MRCVS who is prepared first to learn basic surgery (no, it isn't taught at college) and then to invest a little time learning and then practising (dead dogs) the relevant techniques. The remark that elicited my original brusque response was one that seemed to suggest that whatever you did surgically, the dog would get better because of scar related stability. That is nonsense considering that the osteotomy techniques leave the stifle passively unstable and any fibrosis will diminish the outcome. Furthermore, that poster mentioned a combined OTT and lateral suture. I simply do not believe that these techniques provide "acceptable" outcomes. There is certainly nothing published to support that kind of surgery, and before you dismiss my views as an ivory tower specialist, I too have served my time (and still do) in general practice and I have operated ??2000 cruciates over the years.

Come up and see us some time - we can teach you some new tricks. There is Sleazy-Jet flight from Bristol to Newcastle so we can't be more than a couple of hours away!

Malcolm N

Re: Anterior Cruciate Repair

Hannah Wynne Richards — Fri, 09 Dec 2011 16:14:18 GMT

Malcolm Rob didn'tsay that OTT was better than one of the osteotomies He said he had good results-and you immediately challenged him to publish results tocompare with others who had changed techniques Those who have changed are probably mainly either Specialists,or Certificate holders Rob is a 1st opinion practitioner He doesn't deserve to have his head bitten off for saying what works for him-and not all cases can be referred-because the OWNERS WON'T

I refer cruciates when I can because I agree with Malcolm that one of the osteotomies is the gold standard, but like Rob I get acceptable results from OTTs , so will continue with this technique for large dogs WHOSE OWNERS WON'T REFER

Wynne

Re: Anterior Cruciate Repair

Hannah Wynne Richards — Fri, 09 Dec 2011 16:01:54 GMT

To make things absolutely crystal clear

My approach with cruciates is:

1) suggest referral

If the referral is refused then :

under 20kg-tibio-fabellar technique

over 20 kg-OTT technique

Maybe if I was close enough to Malcolm to attend his evening CPD course,I would tackle his new technique-but I think my approach is a pragmatic solution,which ends up as the best that owner will allow

Wynne

Re: Anterior Cruciate Repair

Hannah Wynne Richards — Fri, 09 Dec 2011 15:54:57 GMT

Malcolm I don't understand how you come to do revisions,as I would agree with you that with cruciates,referral is the best option for many 1st opinion surgeons If the owner is prepared to refer for a revision then unless the referring surgeon is a very capable orthopod,a referral should have been offered in the 1st place,and would probably have been accepted by the owners

I'm talking about the best course of action with animals whose owners have been offered,and refused referral

I've referred cruciates for TPLO,with good results

I've also done both tibio-fabellar, and OTT techniques,also with good results, as after 30 years I'm reasonably competant I'm not claiming my results are as good as a well performed TPLO,but when the owners WON'T refer,then I think the animal is better off with me performing an operation which I'm both practised,and confident with,rather than trying something which is beyond my capability, or refusingto treat at all

Wynne

Re: Anterior Cruciate Repair

Alistair Cliff — Fri, 09 Dec 2011 15:17:42 GMT

Hi,

I'm really interested in this. Seems like a more simple technique both from a principle perspective and also from surgical technicalities. I have been performing Lateral Sutures exclusively since graduation but would really like to offer one of the osteotomies in practice and this seems like a good option. Have you seen many complications?

Alistair Cliff

Re: Anterior Cruciate Repair

Judith Joyce — Fri, 09 Dec 2011 15:13:26 GMT

[quote user="Hannah Wynne Richards"] if the Specialists rubbish simpler techniques[/quote]

I didn't

[quote user="Hannah Wynne Richards"] theyattempt an operation beyond their capability[/quote]

That often happens anyway (and it is nothing to do with qualification or status, merely training)

[quote user="Hannah Wynne Richards"]fromsimpler operations[/quote]

OTT cruciate surgery is one of the most complex and technically demanding surgical options. Few, if any, now do the original OTT technique and most use untested (and often quite irrational) variations on the original theme.

[quote user="Hannah Wynne Richards"]A second rate technique done well is better than a first rate technique done badly[/quote]

I know of no evidence to support that statement, and in any case it surely depends upon which technique and how badly it is being done.

The most commonly revised cruciate surgery in our hospital is the fabello-tibial stabilisation using nylon and crimps - one of the simplest, least technically demanding and most effective of non-osteotomy cruciate surgeries. In almost every case, the tibial hole through which the nylon passes is placed way too distally. There is no excuse for choosing a "second rate" technique ahead of this one and, equally, there is no excuse for surgeons using this technique when they don't know how to do it properly.

Malcolm N

Re: Anterior Cruciate Repair

Hannah Wynne Richards — Fri, 09 Dec 2011 14:22:48 GMT

It'snota black/white either/or situation By allmeans refer if the client can afford it,but if the Specialists rubbish simpler techniques,then 1st opinion practitioners especially new grads willbe discouraged fromsimpler operations,and the result willbe either theyattempt an operation beyond their capability or the animaldoesn't get treated at all

A second rate technique done well is better than a first rate technique done badly

Wynne

Re: Anterior Cruciate Repair

Judith Joyce — Fri, 09 Dec 2011 14:02:25 GMT

[quote user="Rob Wilson"]I have always had good results with the OTT repair +/- a supporting lateral suture.[/quote]

Publish your results if they are so different from those of us who moved to other techniques because the outcomes were better.

[quote user="Rob Wilson"]Am I wrong in thinking that, whatever the technique used, it's the periarticular healing/fibrosis that produces stability?[/quote]

Yes.

Malcolm N

Re: Anterior Cruciate Repair

Robert Wilson — Fri, 09 Dec 2011 01:01:19 GMT

I have always had good results with the OTT repair +/- a supporting lateral suture.

The really old fashioned way of treating cruciate rupture was to take blood form the jugular and inject it into the joint ! I think the majority did fine! Am I wrong in thinking that, whatever the technique used, it's the periarticular healing/fibrosis that produces stability?

Re: Anterior Cruciate Repair

Bob Russell — Thu, 08 Dec 2011 16:01:06 GMT

[quote user="Eamon McAllister"]

[quote user="Gerry Henry"]

PS Had to laugh at the bit where he says 'the RCVS takes a dim view of vets working outside the limits of their competence', IT overspend, basement conversion overspend, pot, kettle.

[/quote]

That's rich coming from him. If my memory serves me well he set himself up in practice very shortly after qualifying and was soon dispensing Veterinary advice on a late night LBC phone-in programme. "Untainted by experience" was what sprang to mind.

[/quote]

But he likes a good gamble according to other articles in Vet Practice!

Re: Anterior Cruciate Repair

Eamon McAllister — Thu, 08 Dec 2011 15:42:56 GMT

[quote user="Gerry Henry"]

PS Had to laugh at the bit where he says 'the RCVS takes a dim view of vets working outside the limits of their competence', IT overspend, basement conversion overspend, pot, kettle.

[/quote]

Re: Anterior Cruciate Repair

Gerry Henry — Thu, 08 Dec 2011 11:58:39 GMT

Just read Bradley Viner's 'Reflections' in this week's Vet Times. He remarks that all tibial plateau levelling procedures 'need referral standard facilities'. Not sure what that means. I'm not a referral centre but have invested in all the kit (£3.5k's worth) plus many days of self funded CPD scrubbing in with a local hospital orthopod, watching and assisting. IMHO, and I stress the H, a TTO is well within the capabilities of a competent first opinion surgeon provided he/she has 1) the skill 2) the kit 3) made the effort to learn the technique.

We will frequently refer clever stuff to JF, AM or MN but in truth I don't regard TTos as being particularly clever, just a bit of carpentry really, am I missing something?

PS Had to laugh at the bit where he says 'the RCVS takes a dim view of vets working outside the limits of their competence', IT overspend, basement conversion overspend, pot, kettle.

Re: Anterior Cruciate Repair

Hannah Wynne Richards — Thu, 08 Dec 2011 11:50:22 GMT

+hotel +locum ????????????

Wynne

Seriously I would like to know more, but Northumberland for an evening meeting is a bit too far

Wynne

Re: Anterior Cruciate Repair

Gerry Henry — Thu, 08 Dec 2011 11:30:01 GMT

Go on, treat yourself, last time Malc even bought us lunch!

Re: Anterior Cruciate Repair

Hannah Wynne Richards — Thu, 08 Dec 2011 10:48:16 GMT

Along,long way from Swansea to Northumberland

Wynne

Re: Anterior Cruciate Repair

Judith Joyce — Wed, 07 Dec 2011 17:34:36 GMT

Happy to discuss MMP with you - PM if you want.

We have been using the technique for well over a year and have done 100 or so cases in our hospital. More than 1000 cases operated world-wide - it is very popular in referral practices and universities in Germany - as well as a significant number of primary care practices in UK.

Technique takes less than 30 minutes skin to skin time and results appear at least as good as with TPLO or conventional TTA. We do it as a day-patient procedure. Implant costs about £150; not too many special instruments.

There is a short introductory MMP talk/meeting at our Hospital (Northumberland) next Thursday for seriously interested surgeons. No charge but you will need to contact Orthomed to register an interest.

NB - I do have a vested interest in the technique as I developed it so my views are not impartial.

Malcolm N

Re: Anterior Cruciate Repair

An On MRCVS — Mon, 05 Dec 2011 11:32:28 GMT

[quote user="Chris Barker"]Will report back after the session I am attending next month.[/quote]

Would be interested to hear how you got on and what your views are.

We are looking to invest in some form of 'fancy' cruciate surgery kit (currently only offer extracapsular nylon leader line) and I'm trying to price up the various options in terms of initial investment in equipment and surgeon-training and cost per procedure, as well as level of complications, learning curve, success rate etc. I'm currently looking at the MMP and it appears quite favourable, as we're likely to be stuck with the same kit for the next 10 years, it's quite a big decision.

PS - Anon posting due to local practice politics.

Re: Anterior Cruciate Repair

Anthony Todd — Sat, 13 Aug 2011 13:47:27 GMT

Happy to help; PM me if you need any.

Re: Anterior Cruciate Repair

Ben Walton — Fri, 12 Aug 2011 11:13:17 GMT

[quote user="robloxley"]

Now I'd be interested to see the outcomes of Lat Suture ops comparing general practitioners, certificate holders and diplomates?

[/quote]

I daresay there are myriad factors that have at least as much effect on outcome as surgical technique. I recently applied for funding from the Pet Plan Trust to conduct an international, web-based survey of owners of dogs with cruciate failure. The survey will include a validated outcomes measure, so a reliable estimate of long-term outcome will be gleaned. We will aim to capture the usual demographic and clinical data, which will include whether the dog was referred or not. We also intend to capture some more novel, and hopefully interesting, information on the owners.

The application has been recommended to the board, and it looks likely that the funding will be awarded. We find out for sure next month.

Re: Anterior Cruciate Repair

Rob Loxley — Thu, 11 Aug 2011 19:33:09 GMT

[quote user="Chris Barker"]Haven't got the particular edition to hand but JSAP ran an editorial review on just this subject[/quote]

See my earlier post

[quote user="Chris Barker"]And given that 50% of dogs that do a cruciate go on to do the other, the swift return to weightbearing could be advantageous[/quote]

But equally make sure the insurance isn't all spent on the 1st procedure with nothing left to do the other leg; client gets pretty upset at that point...

[quote user="Chris Barker"]he did admit that as an orthopod he had a vested interest in such a decision[/quote]

I reckon however that the 'orthopod' could do a Lat Suture a lot quicker and at a lot lower cost than any more complicated procedure, and it maybe could even be more profitable?

Now I'd be interested to see the outcomes of Lat Suture ops comparing general practitioners, certificate holders and diplomates?

Re: Anterior Cruciate Repair

Chris Barker — Thu, 11 Aug 2011 08:40:04 GMT

Haven't got the particular edition to hand but JSAP ran an editorial review on just this subject. The gist was that longterm there was little evidence that any particular procedure was better than any other, but that the impresion gained was that in large breed dogs the more technical procedures gave them their mobility back more swiftly. And given that 50% of dogs that do a cruciate go on to do the other, the swift return to weightbearing could be advantageous. So on reflection the reviewer concluded that he would continue to perform the -otomies on large dog, but he did admit that as an orthopod he had a vested interest in such a decision!

Of course we all have our anecdotes - I can detail the Rottie who is 'perfect' after a lateral double suture, another which self-stabilised with NO intervention whatsoever. Currently it is though that the more complicated procedures provide relief by the advancement of the point of distal insertion of the patellar ligament, eliminating forward tibial 'thrust' which thereby reduces the 'need' for an anterior cruciate. The discussion then has to be around which method achieves this most safely and most cost-effectively. The TTA is prone to catastrophic failure, indeed the TPLO is not without its own technical failures.

And just to add fuel to the fire, yet another procedure has emerged. The MMP procedure advances the tibial tuberosity by a single osteotomy allowing the insertion of a wedge of titanium foam. Details from Orthomed. (www.orthomed.co.uk) The procedure is simple, quick, advances the line of the patellar ligament without destabilising and narrowing its attachment to the distal tibia. Success rates are good, so much so that one prominent orthopod no longer does TPLOs And he can knockout this procedure at half the cost. CPD sessions being held already - this should be a procedure applicable to most 1st opinion surgeries. Will report back after the session I am attending next month. But should its longterm follow up be as good as the initial results then this may have a major impact on the TPLO gravy train for many orthopods while allowing a more affordable -otomy option for clients with large breed dogs

Chris B