Cruciates- Is OTT over the hill?

Re: Cruciates- Is OTT over the hill?

Malcolm Ness — Fri, 14 Feb 2014 11:59:41 GMT

[quote user="Richard Carter"][quote user="robloxley"]against the relatively low incidence of meniscal injuries[/quote] I was under the impression that the severe lameness as opposed to reluctant to use the leg properly withy CCL rupture was due to the presence of meniscal damage and that expl arthrotomy should be routine part of the investigation if the case is so lame it requires surgery.[/quote]

In fact, meniscal injury is very common in dogs with CCL failure - some papers report incidence of 75% and more with injuries to the lateral meniscus appearing as common as those to the medial. However, there is little, if any evidence to show that all, or even most meniscal injuries are associated with additional pain, lameness or indeed any other morbidity. There is similarly little evidence to show that "tidying up" a damaged/injured meniscus at the time of CCL surgery affords any benefit to the dog in the short or longer term and that is not terribly surprising given that all you are doing to treat an injured meniscus is to injure it further, albeit profitably and with a scalpel! There is even less evidence to suggest that exploring the stifle at the time of CCL surgery does anything to reduce the likelihood of later lameness associated with meniscal damage - in my experience such cases will often resolve without additional surgery but sometimes need an arthrotomy and removal (almost always) of a severely damaged caudal horn of the medial meniscus.

All that said, there are some very firmly held, and loudly expressed opinions on this subject with some extremist "academics" suggesting that if you don't do things their way then you are negligent - The Meniscal Mujahadeen!

A lot of this meniscal speculation comes from extrapolating fragments of the human medicine experience/literature and applying it unthinkingly to dogs. Interestingly, even in humans there is considerable and increasing controversy and a recent paper in New England Journal of Medicine reports a study of arthroscopically explored and treated medial meniscal injuries in human knees. The control group comprised medial meniscal injuries that were explored arthroscopically but not debrided or otherwise treated - they just got a good "peering-at" through the arthroscope. There were no differences detected between the groups.

Re: Cruciates- Is OTT over the hill?

Richard Carter — Fri, 14 Feb 2014 10:19:07 GMT

[quote user="robloxley"]against the relatively low incidence of meniscal injuries[/quote] I was under the impression that the severe lameness as opposed to reluctant to use the leg properly withy CCL rupture was due to the presence of meniscal damage and that expl arthrotomy should be routine part of the investigation if the case is so lame it requires surgery.

Re: Cruciates- Is OTT over the hill?

Malcolm Ness — Fri, 14 Feb 2014 10:07:29 GMT

I've been away for a few days so I missed tis thread.

Many vets still claim to perform OTT procedures. I say "claim" because almost nobody uses the procedure as initially described by Arnosczy which involved harvesting the middle third of the straight patellar ligament attached to a wedge of the patella which was used to secure the graft firmly to the lateral condyle. All of the subsequent modifications involve a graft or a fixation method that is considerably less stiff and considerably less strong than the original. In fact, even following the original method leads to a graft that dies and is replaced by fibrous connective tissue that is neither stiff enough nor strong enough to effectively stabilise the joint (which is the whole point of the technique). This observatin led to the more widespread use of the fabello-tibial suture techniques which appeared to produce comparable clinical outcomes but more easily, more quickly and more economically.

The nylon-crimp method was investigated fairly rigorously and Securos marketed a crimping tool that applied optimum force - too little and the nylon slips, too much and it snaps. Numerous "me-too" manufacturers have marketed similar looking devices which may, or may not perform similarly.

So, in response to the OP, is OTT over the hill? Who knows. Any discussion on veterinary cruciate surgery reveals that almost every surgeon claims at least 95% success (whatever that might mean) and some claim to use a technique that works well all the time in their hands. My view is that you should use the most inexpensive, least aggressive technique that is likely to restore pain-free athletic function.

David's comment about the dangers of drawing on human ACL experience to inform CCL treatment in dogs is pertinent.

Re: Cruciates- Is OTT over the hill?

David Mills — Fri, 07 Feb 2014 20:49:24 GMT

[quote user="CatherineThomas"]

I ruptured my cruciate ligament when I was at uni. When I discussed surgery with the consultant he told me that they would be doing an OTT with my hamstring. There were no other options - he said that was accepted to be the best treatment. When it actually came to surgery it turned out that my hamstring wasn't good enough so they did it using my patellar tendon. If it's used so much in human medicine surely it can't be that bad.

[/quote]

Cuation care with comparing dogs and humans - the biomechanics due to quadruped/biped are very very different. Confusing animals and humans, according to some, is what has held back canine cruciate innovation for a while.

Re: Cruciates- Is OTT over the hill?

Rob Loxley — Fri, 07 Feb 2014 16:52:34 GMT

My feeling (and orthopods I've spoken to) is that if you do a full lateral arthrotomy there's more trauma, recovery is slower and there's more postop pain to control; balanced against the relatively low incidence of meniscal injuries, to make the argument for not routinely doing an arthrotomy. Maybe arthroscopy is the answer, but that's not often available in general practice?

Re: Cruciates- Is OTT over the hill?

Hannah Wynne Richards — Fri, 07 Feb 2014 15:08:41 GMT

That's how I do it - without opening the joint capsule. Might not work in a racing greyhound, but restores function in your average pet, who doesn't seem in pain afterwards.

Wynne

Re: Cruciates- Is OTT over the hill?

Robin Grimmer — Fri, 07 Feb 2014 14:10:26 GMT

[quote user="Martin Atkinson"]

[quote user="Hannah Wynne Richards"]

I thought one of the +s of the lateral suture was that one didn't open the joint

Wynne

[/quote]Good point. I have tried an extracapsular lateral suture, just laying it under the lateral patella ligament and found that it wasn't as secure as there is too much soft tissue under it to get it tight enough. IME opening the joint capsule adds a few minutes to the procedure and doesn't seem to prolong recovery but allows the suture to be laid more securely.

[/quote]

You don't need to open the joint capsule to do a lateral suture. You need to open the fascia lata to get access to the fabella. Once you've got your suture round the fabella, you can go under the patellar tendon. I usually use blunt scissors for this, then bring the suture back through the hole you've made in the tibial crest. Simples! But that muscle next to the tibial crest does get a bit in the way, I normally reflect it out of the way a bit. There's a good video of this on the VI website:

https://www.veterinary-instrumentation.co.uk/pages.php?pageid=182

It does show opening of the joint to inspect the menisci.

Re: Cruciates- Is OTT over the hill?

patrick murphy — Fri, 07 Feb 2014 10:39:45 GMT

my matron told me that she had heard not only of them not inspecting the joint (unless they want to play with their scope), but actually ??? doing the other one in predisposed breeds. is that true??

Re: Cruciates- Is OTT over the hill?

Martin Atkinson — Fri, 07 Feb 2014 09:30:38 GMT

[quote user="Hannah Wynne Richards"]

I thought one of the +s of the lateral suture was that one didn't open the joint

Wynne

Re: Cruciates- Is OTT over the hill?

Martin Atkinson — Fri, 07 Feb 2014 09:25:16 GMT

[quote user="CatherineThomas"]

[/quote]As I told you all before, I didn't have mine repaired and I've never had a repercussion except that I'd be wary about playing football or rugby and wear a brace as a precaution when skiing but not snowboarding because that doesn't put as much strain on the knees - you just break your coccyx, fingers and wrists!!. Interestingly, back to Theo Walcott's knee, the reason they gave for using the patella ligament was that as he is an explosive runner they didn't want to weaken his hamstring which.. So as you say it is still a good technique. TTAs etc that we do on dogs are not necessary in humans because we don't have the joint deformities that some dogs suffer from due to selective breeding and lateral suture is not a permanent fix it only gets the joint stable for long enough for it get a nice bit of fibrosis going and stabilise itself plus most dogs only need to go for walkies they don't have to charge around football fields or hurtle down mountains on planks.

Re: Cruciates- Is OTT over the hill?

Hannah Wynne Richards — Fri, 07 Feb 2014 09:18:25 GMT

I thought one of the +s of the lateral suture was that one didn't open the joint

Wynne

Re: Cruciates- Is OTT over the hill?

Martin Atkinson — Fri, 07 Feb 2014 09:09:15 GMT

[quote user="Robin Grimmer"]

Regardless of technique, do people always open and inspect the joint to look for damaged mensici? I always find this the most challenging part and sometimes wonder whether I am doing more harm than good. I did cruciates in both HLs in a jrt about a year apart and the first one I opened the joint and the second one I didn't. The owners said the dog had a much quicker recovery the second time.

[/quote]I absolutely and categorically agree with you Robin. I only explore the joint if I can feel an obvious clicking or locking sensation on manipulation. There is no doubt that in my experience that dogs where I've just done a lateral suture without exploration recover much faster. Two well respected orthopods I know well privately say the same, what they would say in open play I'm not sure! However I don't consider a lateral suture to be orthopaedic surgery its still soft tissue for me and as the world's worst orthopaedic surgeon I would probably cock up meniscal removal and make it worse anyway!

Re: Cruciates- Is OTT over the hill?

CatherineThomas — Fri, 07 Feb 2014 07:11:47 GMT

Re: Cruciates- Is OTT over the hill?

Michael Woodhouse — Fri, 07 Feb 2014 01:36:12 GMT

[quote user="robloxley"]

[quote user="Martin Atkinson"] why are you so weak you can't crimp the tube[/quote]

The cheaper, standard VI crimper takes some squeezing; invest in a compound action crimper

[/quote]

I'm quite a big bloke and I agree!

We got a compound crimper from http://www.vetisco.com/index.php?route=product/category&path=328_337_289 as Vet Inst discontinued theirs.

If you order from Vetisco it's worth ringing your rep and haggling, something Vet Instrumentation were never really up for in my experience.

Re: Cruciates- Is OTT over the hill?

Rob Loxley — Thu, 06 Feb 2014 23:50:24 GMT

[quote user="Martin Atkinson"] why are you so weak you can't crimp the tube[/quote]

The cheaper, standard VI crimper takes some squeezing; invest in a compound action crimper

Re: Cruciates- Is OTT over the hill?

Robin Grimmer — Thu, 06 Feb 2014 23:46:49 GMT

Re: Cruciates- Is OTT over the hill?

Evelyn Barbour-Hill — Thu, 06 Feb 2014 23:27:57 GMT

[quote user="Hannah Wynne Richards"]

Aisling... the way we were taught to do cruciates 30 years ago.

Wynne

[/quote]

Yeah? We were taught Paatsama's method.

Re: Cruciates- Is OTT over the hill?

Martin Atkinson — Thu, 06 Feb 2014 19:26:56 GMT

[quote user="patrick murphy"]and is there not the guy who advertises, Dr. Paul Manning, a 0% major, and 1% minor complication rate, 98% success over a 15 year period?a cruciate graft technique?[/quote]There is and his methods and results are largely greeted with scepticism amongst orthopaedic surgeons. The bottom line is you can quote whatever anecdotal figures you want and success is subjective. The vast majority of animals will return to reasonable function i.e. can walk and run without discomfort whatever you do. I claim >90% success i.e. return to function with no visible limp within 6-12 weeks and virtually no complications with a lateral suture technique but there are those sceptics who will challenge me on. However it is certainly better than I would have claimed for the OTT technique.

Re: Cruciates- Is OTT over the hill?

patrick murphy — Thu, 06 Feb 2014 18:50:16 GMT

and is there not the guy who advertises, Dr. Paul Manning, a 0% major, and 1% minor complication rate, 98% success over a 15 year period?a cruciate graft technique? back in the old times we were successfully doing working dogs with OTT.

I thought that most studies said the best results were the technique that you were personally best with.

Re: Cruciates- Is OTT over the hill?

ChrisBVSc — Thu, 06 Feb 2014 18:45:42 GMT

I agree with the suggestion of trying a different crimper. We have two - they look identical but one has very slightly longer handles than the other. I find I can't get a good 'crimp' with the shorter one, and the nylon still slips under tension. However the longer crimper works well every time.

Re: Cruciates- Is OTT over the hill?

Martin Atkinson — Thu, 06 Feb 2014 17:12:19 GMT

I haven't performed the OTT technique for many years and have used the lateral suture method very successfully. Obviously it takes a fraction of the surgical time with a much quicker recovery time. Interesting you can't crimp the tube though. Its not intended as a rude question but why are you so weak you can't crimp the tube and why can't someone stronger do it for you? Are you using the proper crimping tool?

Interestingly however, I read that Theo Walcott, or at least Arsenal, had rejected the hamstring method of repairing his ruptured ACL which may have got him back in time for the World Cup and elected for what they described as a method 'using a strip of the patella ligament with tunnels drilled through the bone', so presume they mean what we understand as the OTT method, as although it would take longer for him to recover, ultimately it would give a better result. So maybe you're right after all.

Re: Cruciates- Is OTT over the hill?

John Flynn — Thu, 06 Feb 2014 16:55:10 GMT

While the OTT has most certainly fallen out of fashion, the empirical evidence to suggest that it is a less favourable technique is hardly compelling to the objective reader. As most surgery is technique-dependent, it is hardly a huge surprise that no-one has proven (at least nowhere near my standards of empirical proof) superiority of other techniques over the OTT; 9 out of 10 vets may get better results when they perform an extracapsular repair while 1 out of 10 may get better results when they do an OTT - you could be in the latter camp and does not mean that your outcomes are necessarily inferior to others doing an extracapsular repair.

I personally believe that an extracapsular technique is much easier to learn and at least as if not more reliable than the OTT; given that to do a good OTT is technically really quite demanding, there is little to encouarge younger members to take up this technique.

But if you are already proficient in the OTT and get acceptable results, then I can see no reason not to perform it; you may well get just as good, if not better, results than neighbouring colleagues who perform an extracapsular repair - there is (to my mind) no reliable way of knowing which is the difficulty.

Auditing outcomes sounds like a good means, but in practical terms looking at your past performance may be a poor predictor of future performance as is rather retrospective and there are numerous other pitfalls that make this unlikely to be genuinely helpful to the general practitioner performing infrequent procedures.

[quote user="An On MRCVS"]My questions is it negligent[/quote]

No. Not by my gauge.

[quote user="An On MRCVS"]leave cruciates to my more orthopaedic minded colleagues or should I still offer it perhaps for those who cannot afford referral.[/quote]

That's a decision you'll have to make yourself based on your confidence level in your own procedures and the referral ones, expense of referral, how affordable this is to your client base, ; you can try to provide estimates of "success" rate to the owner and pros and cons and explain the options as best you can, but ultimately they're likely to either ask your opinion or try to read from you what you are secretly recommending - i.e. you are likely to influence them one way or another at least to an extent.

[quote user="An On MRCVS"]I have no strength in my hands for the crimp.[/quote]

There's a variety of crimpers out there - if your technical issue is genuinely nylon slipping through crimp, then either a knot technique or alternative crimper might leave you loving the extracpsular repair? http://www.securos-europe.eu/neue-produkte/power-x-crimping-device/?L=1

Re: Cruciates- Is OTT over the hill?

Hannah Wynne Richards — Thu, 06 Feb 2014 16:07:38 GMT

Aisling... the way we were taught to do cruciates 30 years ago.

Wynne

Re: Cruciates- Is OTT over the hill?

Hannah Wynne Richards — Thu, 06 Feb 2014 15:52:23 GMT

I've had lengthy arguments with Malcolm (recognised orthopaedic specialist ) on this one. Like you, I was taught the OTT technique, and used it for years. Unlike you, I have no problems with lateral suture,which works well for me.

Problem. What to do withthose cases (too large, tibial plateau too angled ) for lateral suture. First choice option.......... undoubtedly refer to an orthopaedic Specialist for 1 of the newer techniques.

What to do if owner refuses referral. Fortunately my clients are 80% insured,so it's ages since that's happened, but I'd still say the dog is better off with me doing the OTT procedure (experienced and confident ) as opposed to a lateralsuture in the small % of dogs in which it's obviously inadequate, or bumbling through one of the newer techniques (inexperienced, and non-confidant )

Malcolm disagreed

Wynne

Re: Cruciates- Is OTT over the hill?

Aisling McGrath — Thu, 06 Feb 2014 15:47:28 GMT

Relatively recent grad here - just wondering - what is an OTT cruciate op?

Apologies for my ignorance!