Literature and Studies

Below are scientific articles reviewing the TPLO procedure.

Articles reviewing TPLO outcomes

Systematic Review of Surgical Treatments for Cranial Cruciate Ligament Disease in Dogs

  • The strength of the evaluated evidence most strongly supports the ability of the TPLO in the ability to return dogs to normal function
  • Provides strong support that functional recovery in the intermediate postoperative time period was superior following TPLO compared with lateral extracapsular suture.

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Long-Term Functional Outcome of Tibial Plateau Leveling Osteotomy Versus Extracapsular Repair in a Heterogeneous Population of Dogs

  • Dogs achieved normal limb loading faster after TPLO than extracapsular suture repair
  • TPLO resulted in operated limb function that was indistinguishable from the control population by 1 year postoperatively.

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Long-Term Functional Outcome of Tibial Tuberosity Advancement vs. Tibial Plateau Leveling Osteotomy and Extracapsular Repair in a Heterogeneous Population of Dogs.

  • At the walk, tibial tuberosity advancement (TTA) achieves normal function by 12 months; however, at the trot, TTA is indistinguishable from extracapsular repair
  • TPLO resulted in operated limb function that was similar to the control population by 6-12 months postoperatively at the walk and the trot.

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Comparison of the lateral fabellar suture and tibial plateau leveling osteotomy techniques for treatment of dogs with cranial cruciate ligament disease

  • Dogs in both groups improved after surgery
  • Kinematic and owner satisfaction results indicated dogs that underwent TPLO had better outcomes than those that underwent lateral fabellar suture (LFS)
  • Owner satisfaction was 93% for patients undergoing TPLO and 75% for patients with LFS

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Lameness and osteoarthritis development following Tibial Plateau Leveling Osteotomy (TPLO) and potential prognostic predictors. A long-term retrospective study.

  • Good to excellent results were obtained in 90.4% of patients up to 6.8 years after TPLO surgery
  • In the long term, there was a moderate but significant progression of OA following TPLO
  • Patients with totally ruptured CCL were significantly more likely to have a meniscal injury than dogs with partially ruptured CCL
  • Dogs with partial meniscectomy had a significantly higher rate of “excellent” long-term clinical results and less frequently showed the progression of OA compared to those having the meniscus released or left untouched.
  • The overall complication rate was 22.2%, with the type of complication having no influence on the long-term clinical outcome.

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Comparison of surgical treatment options for cranial cruciate ligament disease in large-breed dogs with excessive tibial plateau angle.

  • Owner-perceived outcome was superior for eTPA group dogs when TPLO resulted in TPA<or=14 degrees compared with those with postoperative TPA>14 degrees.
  • Postoperative complications were more common in dogs with eTPA than in dogs without eTPA; however, no difference in owner-perceived outcome was identified.
  • Postoperative TPA<or=14 degrees and the addition of ancillary implants are recommended when using TPLO to treat dogs with eTPA.

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Early kinematic outcome after treatment of cranial cruciate ligament rupture by tibial plateau leveling osteotomy in the dog.

  • Pelvic limb stance duration significantly increased during the 12 week study period, recovering to near-normal values.
  • The range of pelvic limb paw velocity also significantly increased but did not reach normal values by 12 weeks postoperatively.

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Second look arthroscopic findings after tibial plateau leveling osteotomy.

  • Stifles with an early partial tear had normal to near normal appearance of intraarticular structures
  • Most dogs with a complete or incompetent partial CCL tear had grades 3 or 4 articular cartilage abrasion of the medial or lateral femoral condyle
  • Early diagnosis of a CCL injury and treatment by TPLO may be protective against further CCL disruption lending stability to the joint and decreasing the incidence of meniscal injury and articular cartilage damage.

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Comparison of tibial plateau angle changes after tibial plateau leveling osteotomy fixation with conventional or locking screw technology.

  • Stifles in the locking screw group had significantly less change in postoperative tibial plateau slope than stifles in the conventional screw group
  • Locking screw fixation had significantly higher grades of osteotomy healing

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Short-term and long-term outcomes for overweight dogs with cranial cruciate ligament rupture treated surgically or non-surgically

  • Dogs were randomly assigned to nonsurgical (physical therapy, weight loss, and NSAID administration) or surgical (TPLO) treatment groups; dogs in both groups received the same nonsurgical treatments.
  • Owner questionnaire responses indicated dogs in both groups improved during the study, but dogs in the surgical treatment group had greater improvement.
  • Body fat percentages for dogs in both treatment groups significantly decreased during the study
  • Surgical treatment group dogs had significantly higher peak vertical force for affected limbs versus nonsurgical treatment group dogs at the 24- and 52-week evaluation times.
  • Surgical treatment group dogs had a higher probability of a successful outcome versus nonsurgical treatment group dogs

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Partial Cranial Cruciate Ligament Tears Treated with Stem Cell and Platelet-Rich Plasma Combination Therapy in 36 Dogs: A Retrospective Study.

This study evaluated outcomes in 36 dogs with a partial cranial cruciate ligament (CCL) tears (<50% torn) treated with autologous bone marrow aspirate concentrate (BMAC) or adipose-derived progenitor cells (ADPC) with platelet-rich plasma (PRP) combination.

  • Stifle arthroscopy results performed at 90 days posttreatment were available in only 13 of the 36 dogs.
  • In nine dogs, a fully intact CCL with marked neovascularization and a normal fiber pattern was found with all previous regions of disruption healed.
  • One dog revealed significant improvement and received an additional injection.
  • The remaining three dogs had a >50% CCL tear, and a TPLO was performed.
  • Four additional dogs were known to have had a TPLO performed elsewhere.
  • The authors concluded the use of BMAC-PRP and ADPC-PRP shows promise for the treatment of early partial CCL tears in dogs. Further studies are needed and should be randomized, blinded, and controlled.

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Risk Factors For ACL Tear

Tibial plateau angle in four common canine breeds with cranial cruciate ligament rupture, and its relationship to meniscal tears.

  • Labrador Retrievers, Rottweilers, Boxers, and German Shepherd Dogs had mean tibial plateau slopes of 25.9 degrees, 26.2 degrees, 25.9 degrees, and 28.2 degrees, respectively.
  • The tibial plateau slope of German Shepherd Dogs was significantly higher than that of the other breeds of dogs examined
  • TPA higher than the mean for dogs in this study did not significantly increase the risk for concurrent meniscal injury

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Age, tibial plateau angle, sex, and weight as risk factors for contralateral rupture of the cranial cruciate ligament in Labradors.

  • Subsequent CCLR occurred in 48% of dogs at a median time of 5.5 months
  • Bilateral CCLR on admission was identified in 10.6% of patients
  • There were no significant differences between dogs with or without a contralateral rupture in regards to age or weight at initial rupture, sex or tibial plateau slope
  • There were associations toward longer time to contralateral rupture for dogs older than the median age and female dogs (intact and spayed)
  • There were no significant differences in age, sex, weight, or tibial plateau slope of dogs with bilateral CCL ruptures compared with initial unilateral ruptures
  • There was a trend toward dogs presenting at an older age and with lower tibial plateau slopes in the bilateral rupture group.

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TPLO In Small Dogs

Long-term outcome after surgical treatment of cranial cruciate ligament rupture in small breed dogs. Comparison of tibial plateau leveling osteotomy and extra-articular stifle stabilization.

  • Twenty-one of 23 operated limbs (91.3%) treated with TPLO and five of 17 (29.4%) treated with the capsular fascial imbrication (CFI) showed absolute values comparable to healthy dogs when evaluated by peak vertical force, vertical impulse and its symmetry index during objective gait analysis
  • Both groups showed mild, but the continuous progression of osteoarthritis
  • TPLO led to a significantly faster recovery and a higher degree of owner satisfaction

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Short-term outcome and complications of TPLO using anatomically contoured locking compression plates in small/medium-breed dogs with “excessive” tibial plateau angle.

  • Short-term radiographic and clinical outcome of TPLO stabilized with anatomically contoured locking compression plates for the treatment of small dogs with large tibial plateau angle suggests a very low risk of complications
  • Rotation beyond the “safe point” is necessary to perform a full rotation in some cases, but does not appear to incur an increased risk of tibial tuberosity fracture.

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Short-term complications associated with TPLO in dogs using 2.0 and 2.7 mm plates.

  • The purpose of this study was to evaluate short-term complications associated with TPLO in small and medium size dogs
  • Radiographic evidence of delayed healing of the TPLO osteotomy site was the most common complication in the dogs (9%), none of which had clinical signs attributed to delayed healing
  • Other common complications included patellar tendon thickening (8%) and tibial tuberosity fracture (6%)
  • Seven percent of the complications were considered major (requiring additional surgical intervention)
  • Fifty-two percent of complications did not require treatment

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Potential Complications

Predictive variables for complications after TPLO with stifle inspection by arthrotomy in 1000 consecutive dogs.

  • The overall complication rate was 14.8%, of which 6.6% were major complications.
  • The incidence of primary meniscal injury (PMI) was 33.2%, and subsequent meniscal injury (SMI) 2.8%.
  • Postoperative infection occurred in 6.6% dogs.
  • Bilateral CCL rupture was diagnosed in 14.6% dogs
  • No statistically significant complication incidence difference was recorded for simultaneous or staged bilateral surgical procedures.
  • Administration of postoperative antibacterial therapy and being a Labrador reduced infection incidence
  • Increased body-weight and being an intact male increased infection risk.
  • Increased body-weight and complete (versus partial) CCL rupture were significant predictors of overall complications.

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Radiographic outcome and complications of tibial plateau leveling osteotomy stabilized with an anatomically contoured locking bone plate.

  • Use of an anatomically contoured, locking TPLO plate was associated with accurate tibial plateau leveling, reliably excellent bone union at follow-up exam, minimal change in the tibial plateau slope (minimal loss of rotation), and a lower complication rate than previously reported.

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Risk factors for surgical site infection-inflammation in dogs undergoing surgery for rupture of the cranial cruciate ligament: 902 cases (2005-2006).

  • Infection-inflammation developed in 6.1% of surgeries within 6 months after surgery
  • There was a significant difference in infection-inflammation rate after the extracapsular suture (ECLS) surgeries (4.2%), compared with rate after the TPLO surgeries (8.4%).
  • Factors associated with a significantly lower rate of infection-inflammation included the use of suture material other than stainless-steel staples for skin closure and postoperative oral administration of antimicrobials.

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Complications associated with tibial plateau leveling osteotomy: a retrospective of 1519 procedures.
This retrospective study identified complications associated with tibial plateau leveling osteotomy (TPLO) and predisposing factors for these complications in a large population of dogs

  • Total complication rate (major or minor) was 11.4%
  • The major complication rate was 3.1%
  • The minor complication rate was 8.3%
  • Factors associated with the development of complications included being a German shepherd dog tibial plateau slope > 30°, and heavier weights
  • Tibial plateau leveling osteotomy is a common treatment for dogs with cruciate ligament deficiency and has a low complication rate.

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Complications with and owner assessment of the outcome of tibial plateau leveling osteotomy for treatment of cranial cruciate ligament rupture in dogs: 193 cases (1997-2001)

  • Complications were identified in 20% of the TPLO’s
  • 93% of owners were satisfied with the outcome of surgery
  • Assessments of outcome were not significantly different between owners of dogs that had complications and owners of dogs that did not

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A client-assessed long-term outcome in dogs with surgical site infection following tibial plateau leveling osteotomy

  • Surgical site infection (SSI) occurred in 4.7percent of procedures
  • Of the dogs with SSI, 37.5 percent required implant retrieval
  • Later onset SSI was associated with the increased requirement for retrieval
  • Crossbreed dogs had a lower risk of developing SSI
  • There was no association between SSI and long-term functional outcome in dogs following TPLO
  • Later onset of SSI is more likely to require implant retrieval to resolve

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Comparison of complications following tibial tuberosity advancement and tibial plateau leveling osteotomy in very large and giant dogs 50 kg or more in body weight

  • Surgical site infection (SSI) was the single most common major complication following both TTA (15.4%) and TPLO (25.9%) surgery.
  • There were no significant differences between TTA and TPLO treatment regarding the rate of SSI, surgical revision, or overall occurrence of major complications.
  • Postoperative antibiotic therapy significantly reduced the risk of a major complication in all dogs ≥50 kg

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A retrospective study of 476 tibial plateau leveling osteotomy procedures. The rate of subsequent ‘pivot shift’, meniscal tear and other complications.

  • Postoperative complications were reported in 9.7% of patients; 4.2% were classified as major complications requiring an additional surgical intervention, and 5.5% as minor complications.
  • No risk factors associated with postoperative complications were identified.
  • Subsequent meniscal injuries occurred in 2.1% of stifles with normal unaltered menisci at time of TPLO with a median postoperative time of 9.5 months.
  • Signs of postoperative ‘pivot shift’ were reported in 3.1% of stifles, and all stifles with a ‘pivot shift’ had a complete CCL rupture or a debrided partial CCL rupture
  • Medial meniscectomy was identified as a risk factor for a ‘pivot shift’
  • Dogs with intact medial meniscus had a significantly higher activity level and a shorter time to peak function than dogs that underwent meniscectomy according to an owner questionnaire.

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Risk factors associated with fibular fracture after tibial plateau leveling osteotomy.

  • Fibular fractures occurred in 5.4% of TPLOs.
  • Body weight, change in tibial plateau slope, and preoperative tibial plateau slope were significantly higher in dogs with a fibular fracture.
  • TPLO without the use of a jig was significantly associated with fibular fracture.
  • Age, postoperative TPA, and plate type were not significantly associated with fibular fracture.

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Radiographic evaluation and comparison of the patellar ligament following tibial plateau leveling osteotomy and tibial tuberosity advancement in dogs: 106 cases (2009-2012).

  • Patellar ligament thickening occurred following TPLO and TTA in dogs. The clinical relevance of this thickening remains unknown.

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Radiographic and ultrasonographic evaluation of the patellar ligament following tibial plateau leveling osteotomy.

  • Significant thickening of the distal patellar ligament was noted postoperatively as evidenced by thickness and area measurements and a decreased radiographic ratio
  • Body weight (kg) and postoperative TPLO angle had a significant influence on 1-month postoperative distal patellar ligament area
  • Clinical significance (i.e., correlation with a residual lameness) was not evaluated in this study

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Meniscal Injuries

Incidence and type of meniscal injury and associated long-term clinical outcomes in dogs treated surgically for cranial cruciate ligament disease.

  • Meniscal tears were diagnosed in 83% of stifles assessed by arthroscopy and 44% of stifles assessed by arthrotomy
  • Subsequent meniscal tears were diagnosed in 6.7% of patients with median time to diagnosis of 5.8 months.
  • Cases treated with meniscal release did not have subsequent meniscal tears, whereas dogs not treated with meniscal release had a subsequent meniscal tear rate of 11%
  • Cases diagnosed and treated for concurrent meniscal tears were 1.3 times more likely to have a successful long-term outcome

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The incidence of medial meniscal tears after arthroscopic assisted tibial plateau leveling osteotomy.

  • Concurrent meniscal tears were found in 32.2% of patients
  • Late-onset meniscal tears occurred in 5.6% of patients
  • There was a significantly lower prevalence of concurrent meniscal tears and incidence of late-onset meniscal tears in dogs that had a partial CCL tear compared with those that had a complete CCL tear.
  • All dogs with late-onset meniscal tears treated by partial meniscectomy (PMM) returned to peak postoperative limb function

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Effect of meniscal release on the ate of subsequent meniscal tears and owner-assessed outcome in dogs with cruciate disease treated with tibial plateau leveling osteotomy.

  • Subsequent meniscal tears were diagnosed in 6.3% of patients
  • The subsequent meniscal tear was 3.8 times more likely to occur in patients with an open arthrotomy without meniscal release than for those with an open arthrotomy with meniscal release or arthroscopy without meniscal release.
  • No significant differences among groups were noted for measures of outcome.
  • Authors suggest that a meniscal release is performed when complete and thorough exploration of the joint and meniscus cannot be, or are not, performed.

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PT and the recovery

Effect of bandaging on post-operative swelling after tibial plateau leveling osteotomy.

  • The use of a modified Robert-Jones bandage after TPLO did not prevent statistically significant postoperative swelling, and thus may not be indicated for this purpose

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Safety and functional outcomes associated with short-term rehabilitation therapy in the post-operative management of tibial plateau leveling osteotomy.

  • This retrospective study compared the perioperative complication rates of TPLO surgery and the 8-week, 6-month, and 1-year functional outcomes, between rehabilitation and traditional post-operative management 
  • “Traditional” management involved restriction to cage rest and leash walking; “rehabilitation” was performed by a certified practitioner
  • There was no statistically significant difference in complication rates in the perioperative period between the 2 treatment groups
  • The rehabilitation group was 1.9 times more likely to reach full function at 8 week
  • The traditional group was 2.9 times more likely be categorized as having an acceptable function at 8 weeks after surgery
  • This study suggests that rehabilitation performed by a certified practitioner is safe and may improve short-term outcomes when used in the initial postoperative management for dogs treated with TPLO

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Effects of early intensive postoperative physiotherapy on limb function after tibial plateau leveling osteotomy in dogs with deficiency of the cranial cruciate ligament.

  • Before surgery, CCL-deficient limbs had significantly reduced thigh circumference (TC) and reduced flexion and extension range of motions (ROMs), compared with values for the contralateral control limb
  • Six weeks after TPLO, the physiotherapy group had significantly larger TC than the home-exercise group, with the difference no longer evident between the affected and non-affected limbs
  • Extension and flexion ROMs were significantly greater in the physiotherapy group, compared with values for the home-exercise group, 3 and 6 weeks after surgery
  • Six weeks after surgery, the difference in flexion and extension ROMs was no longer evident between the affected and non-affected limbs in the physiotherapy group
  • Both groups had improvements in lameness and weight-bearing scores over time, but no difference was found between the 2 groups.

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Preoperative low-level laser therapy in dogs undergoing tibial plateau leveling osteotomy: A blinded prospective, randomized clinical trial.

  • Dogs undergoing TPLO were randomly assigned to receive either a single preoperative low-level laser therapy (LLLT treatment, 800-900 nm dual wavelength, 6 W, 3.5 J/cm2, 100 cm2area) or a sham treatment
  • No major complications occurred.
  • At eight weeks postoperatively, a significant difference in peak vertical force analysis was noted between the LLLT and sham groups
  • Although not significant, a greater proportion of LLLT dogs (5/8) had healed at the eight-week time point than in the sham group (3/12)

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