TTA, TPLO and LSS: Helping the Client Ensure Optimal Recovery After Surgery

If you work in a veterinary practice that offers orthopaedic surgeries, you have probably found yourself assisting in many cruciate ligaments repairs. One of our roles as nurses, is to discharge these patients after surgery and ensure that the clients fully understand and adhere to all post-operative instructions. Today, I will discuss how you, as a veterinary nurse, can assist your clients in recognizing the importance of following all post-operative instructions and support their dog’s in achieving the best possible recovery.

Step One: Explain the Surgery 

Why does my dog need surgery? 

Dogs can tear their cruciate ligament (specifically the cranial cruciate ligament or CCL), in several ways. The CCL (which is equivalent to the ACL in humans), is a ligament in the knee joint that helps stabilize the movement of the bones. When the CCL is torn, it causes instability and pain in the knee, leading to lameness. Most commonly, a dog can tear it’s CCL due to sudden twisting or overextension of the knee joint. Some other reasons can include:

- Sudden Movement or Trauma: A dog might tear its cruciate ligament during an abrupt change in direction while running, jumping, or playing, which puts excessive stress on the knee joint.

- Slipping or Falling: A slip or fall on a slippery surface, such as ice or wet floors, can cause the knee to twist abnormally, leading to a ligament tear.

- Degeneration Over Time: Some dogs experience gradual weakening of the ligament due to aging or genetic factors. Over time, even a minor movement or normal activity can result in a tear.

- Obesity: Overweight dogs are at a higher risk because the extra weight puts additional stress on the joints, making them more susceptible to injury.

- Repetitive Strain: Repeated stress on the knee joint, such as from regular running or jumping, can lead to wear and tear of the ligament, eventually causing a rupture.

These injuries can occur in any breed, but certain breeds like Labradors, Golden Retrievers, and Rottweilers are more prone to cruciate ligament injuries.

How is it diagnosed?

Diagnosing a ruptured cruciate ligament in dogs typically involves several steps:

1. Clinical Examination:

• History and Symptoms: The veterinarian will review the dog's medical history and assess symptoms such as limping, pain, and difficulty bearing weight on the affected leg.

• Physical Examination: The vet will perform a thorough physical exam, including palpating the knee to check for swelling, tenderness, and abnormal joint movement.

2. Orthopaedic Tests:

• Drawer Test: This test assesses the stability of the knee by checking for excessive forward movement of the tibia relative to the femur, which indicates a ruptured cranial cruciate ligament.

• Tibial Compression Test: This test evaluates the tibia's ability to move forward relative to the femur, also indicating ligament damage.

3. Imaging:

• X-Rays: X-rays can reveal joint effusion (fluid in the joint), signs of arthritis, or secondary changes such as bone deformities. While X-rays alone can't directly visualize the ruptured ligament, they help assess the extent of joint damage and rule out other conditions.

• MRI or CT Scans: In some cases, advanced imaging techniques like MRI (Magnetic Resonance Imaging) or CT (Computed Tomography) may be used to visualize the soft tissues, including the cruciate ligament, to confirm the diagnosis and assess the extent of the injury.

  
  

4. Arthroscopy:

• Less commonly, the vet might perform an arthroscopy, a minimally invasive procedure where a camera is inserted into the joint to directly view and assess the ligament and other joint structures.

How is it fixed?

Fixing a ruptured CCL typically involves surgery. There are several surgical techniques used to repair a ruptured CCL, each with its own approach and benefits. The most commonly preformed (the surgeries I will be covering today) are:

My dog Shadow's leg post TTA

• TTA

 A TTA, or Tibial Tuberosity Advancement, is a surgical procedure used to treat a cranial cruciate ligament (CCL) rupture in dogs. TTA surgery aims to alter the alignment of the patellar tendon, so that it is perpendicular to the tibial plateau when the dog is weight-bearing, which stabilizes the knee joint without the need for the CCL. The surgeon makes a cut in the front part of the tibia (the tibial tuberosity) and moves it forward. A specialized implant (often a cage, plate, and screws) is used to secure the bone in its new position. By advancing the tibial tuberosity, TTA surgery changes the forces in the knee joint, reducing the sliding motion of the tibia relative to the femur, which compensates for the lack of a functional CCL. TTA surgery has a good success rate, and it typically preformed on medium to large dogs.

• TPLO

A TPLO, or Tibial Plateau Levelling Osteotomy, is also a surgical procedure used to treat CCL ruptures. A different technique is used for a TPLO. The goal of TPLO surgery is to reduce the angle of the tibial plateau (the top part of the tibia) to make it nearly perpendicular to the patellar tendon, thereby stabilizing the knee without relying on the CCL. The surgeon cuts the tibia and rotates the tibial plateau to change its angle. The bone is then stabilized with a metal plate and screws. By altering the tibial plateau angle, TPLO surgery changes the biomechanics of the knee joint, making the tibia less likely to shift forward relative to the femur when the dog bears weight on the leg. This eliminates the need for a functioning CCL. TPLO is considered highly effective, especially for larger, more active dogs.

• LSS (or Lateral Line)

Lateral Suture Stabilization (LSS), is yet another surgical procedure to treat CCL ruptures. This surgery involves placing a strong suture outside the knee joint to mimic the function of the CCL. The suture is anchored to the bones to stabilize the knee. This surgery is best for smaller, less active dogs or dogs for whom more invasive surgery might not be suitable.

Ultimately, the choice between TTA, TPLO and LSS, depends on the individual dog, the veterinary surgeon’s experience and preference, and specific case factors. All three surgeries have high success rates in stabilizing the knee joint and allowing dogs to return to their normal lifestyle. 

Step Two: Pre-Surgery Preparation

It is very important to prepare the client for what they should expect when their dog comes home after surgery. I like to give the client all the information beforehand, so they have plenty of time to prepare. Some things the client should expect include:

• Shaved Area & Surgical Site: I like to warn clients that the area around their dog’s knee will be shaved to allow for a clean surgical site. This is obviously the case for all surgical procedures, but some clients genuinely do not know this. There will be also an incision where the surgery was performed, which will be closed with sutures or staples. These sutures/staples are taken out 14 days post op (after surgery).

• Buster Collar (Cone): Their dog will be wearing a cone to prevent them from licking or chewing at the incision site. This might make them look a bit uncomfortable, but it’s important for preventing infection and ensuring proper healing. The cone must stay on until the sutures/staples come out, so 14 days post op.

• Confinement: The client will need to find a crate or a cage to keep their dog confined for the next 6-8 weeks. A crate or playpen is what I usually recommend to clients to confine their dog post op. The crate should be large enough for their dog to comfortably lie down, stand up, and turn around, but not so large that they can move around excessively, which could risk harming the surgical site. They will only be permitted to leave confinement for short periods of time post operatively.

• Overnight Stay: I also like to inform clients that in our practise, we like to keep the patient for at least one night post op, in order to mange their pain and monitor how they're doing. If the dog is doing well the next morning—for example, if they have a normal temperature, they've eaten overnight and are in good spirits—they can go home.

  
  

Step Three: Post Operative Instructions

Post operative care is arguably the most important part. Diligent post-op care helps maximise the success of the surgery and enhances the well-being of the dog during the recovery period. Providing detailed instruction and clear communication can help our clients to feel confident in managing their dog’s recovery. Always provide written instructions, as this can be a lot of information to take in and can be quite overwhelming at times for the client. Go through the post operative instructions step by step, and be sure to answer any questions the client has along the way.

Post Op Information Sheet

1. Affects of General Anaesthetic (GA): In most cases, while the primary anaesthetic effects wear off within a few hours, residual effects like drowsiness, lack of coordination, and decreased appetite may persist for a day or two.

2. Feeding: Feed a quarter of what they would usually feed them when they first come home. Anaesthetic drugs can cause nausea as they wear off, which makes a dog more prone to vomiting, gastrointestinal sensitivity and slowed gut mobility. Feeding a smaller portion reduces the risk of any of this occurring. Dogs can return to their normal portions as soon as anaesthetic effects wear off.

3. Wound Management: It’s important for the client to monitor the surgical site (surgical wound) closely and watch for any signs of complications or signs of infections.

   • Redness and Swelling: Some redness and swelling are normal, but if it increases over time or extends beyond the wound edges, it could indicate an infection.

   • Discharge: Clear or slightly blood-tinged fluid is normal initially, but thick, yellow, green, or foul-smelling discharge is a sign of infection.

   • Warmth: The area around the wound should not feel significantly warmer than the surrounding skin.

   • Odour: A foul smell coming from the wound can also indicate infection.

4. IV Catheter Placement: There will be a small shaved area on the pet's foreleg where an IV catheter was placed or IV medication was administered. A small bandage is covering this spot, which should be removed two hours after the pet returns home.

5. Medication : Their dog will be going home with medication after surgery to manage pain, inflammation, and prevent infection. Some of the medication that may be prescribed post op include:

• Pain Relief: Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), are commonly prescribed to reduce pain and inflammation after surgery. Opioids, stronger pain medications (e.g. Gabapentin) may be prescribed, especially in the first few days after surgery.

• Antibiotics: Antibiotics are prescribed to prevent infections, particularly at the surgical site. This is usually a short course.

• Gastroprotectants: Because NSAIDs can sometimes cause stomach upset or irritation, gastroprotectants are sometimes also prescribed (especially if the dog has a history of stomach issues!).

• Sedatives or Anti-Anxiety Medications: If the dog is very active or anxious, they might be prescribed a mild sedative or anti-anxiety medication to help keep them calm and ensure they rest adequately during the initial recovery period.

All medications are administered orally, and should be started the day after the pet goes home. All instructions to each medication should be clearly printed or written on the packet.

6. Buster Collar (cone): Ensure the client understands that the cone must stay on until the sutures/staples come out of the incision site or until the surgical wound is fully healed. The cone must stay on to prevent their dog from licking or chewing at the incision site and causing damage.

7. Confinement (crating): It's crucial to keep the dog confined after surgery for at least 6-8 weeks, to ensure proper healing. After surgery, the knee is vulnerable to injury. Limiting activity helps prevent sudden movements, that could disrupt the healing process or damage the surgical repair. Crating also helps control the dog’s movements, reducing the risk of overuse or stress on the surgical site. This is especially important in the first few weeks post-surgery when the healing tissues are most delicate. Finally, excessive movement or accidental injury can lead to complications such as re-injury, implant failure, or increased swelling and pain. Confinement minimizes all of these risks. The crate should be large enough for the dog to stand up, turn around, and lie down comfortably, but not so large that the dog can move around excessively. I usually recommend that clients put the crate in a quiet area of the house to help their dog remain calm.

7. Physiotherapy: Physiotherapy is very important after surgery for a number of reasons:

• Helps to stimulate blood flow to the surgical area, which promotes healing of the tissues and reduces swelling.

• Helps to rebuild muscle strength, improve joint mobility, and restore normal function.

• Helps to prevent complications such as muscle atrophy (loss of muscle mass), joint stiffness, and loss of range of motion.

• Encourages them to use the surgical leg properly, promoting balanced weight bearing and preventing secondary issues in the uninjured leg.

• Helps manage pain by reducing inflammation and stiffness through controlled movement.

• Helps to strengthen the muscles and stabilize the knee joint, reducing the risk of re-injury to the surgical site or the opposite leg (which is at higher risk of injury after the first leg has undergone surgery).

Passive Range of Motion: This movement is what we recommend for clients to do at home. This involves slowly and gently moving the joint through its normal range of motion. Gently bend (flex) the knee, bringing the lower leg towards the upper leg, and then slowly straighten it (extend).

Physical Rehabilitation Sheet

I like to take the client into an empty consult room and demonstrate the movement on a model dog we have in our clinic. In some cases, I might ask the client to try on the model dog also. This really helps the client to understand how do it correctly, and build confidence before trying on their own dog. I always go through our physical rehabilitation sheet thoroughly, and ask the client to take it home.

Step Four: Follow Up

Their dog will need to return 7 days after surgery for a post-operative check-up to inspect the surgical site and ensure that healing is progressing as expected. During this visit, we will also assess your pet's overall condition and discuss any necessary adjustments to their care plan, such as modifying medication dosages or extending treatment duration.

A second follow-up visit will be required 7 days later (14 days post-operation) for the removal of sutures or staples from the surgical site. If the wound has fully healed, the buster collar can be removed at this time, which is often a relief for both the client and their dog.

Finally, their dog will need to return for follow-up x-rays 6 weeks later (8 weeks post-operation), coinciding with the end of their confinement period. These x-rays are crucial for evaluating the knee's healing progress and ensuring that any plates or screws used during surgery are still properly positioned. If the x-rays show satisfactory results, the dog can gradually resume their regular exercise routine.