In canine cranial cruciate ligament rupture is outcome following TPLO improved compared with lateral suture?

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Appraisal, application and reflection

Eight papers and one addendum were identified as relating to this question. The best quality evidence available was a randomised, blinded, controlled clinical trial (Gordon-Evans et al., 2013), this was a single centre study, with some variations in procedure and aftercare protocol.

Three non-randomised prospective observational studies were identified (Conzemius et al., 2005, Nelson et al., 2013, Au et al., 2010). In each case, treatment group allocation was based on owner preference.

The remaining papers were retrospective case series (Molsa et al., 2013, Frey et al., 2010, Lazar et al., 2005, Molsa at al., 2014).

The studies identified generally focused on one or more of the following categories; postoperative limb function, owner satisfaction, complication rates and radiographic evidence of OA.

Six studies looked at postoperative limb function (Molsa et al., 2013, Molsa et al., 2014, Gordon-Evans et al., 2013, Conzemius et al., 2005, Nelson et al., 2013, Au et al., 2010). One study (Molsa et al., 2013) found no significant difference between treatment groups as determined by non-validated, owner-completed questionnaire. Two studies (Conzemius 2005, Au et al., 2010) found no significant difference between treatment groups as determined by force plate analysis, however Au et al. (2010) reported a non-statistically significant increase in PVF in the TPLO group. One study (Molsa et al., 2014) found significantly less postoperative periarticular swelling and stifle joint crepitation in the TPLO group, but the clinical relevance of this was not clear. Two studies (Nelson et al., 2013, Gordon-Evans et al., 2013) found patients treated with TPLO had superior limb function to those treated with LFS, as determined by force plate analysis.

One study (Gordon-Evans et al., 2013) surveyed owner satisfaction after surgical repair of CCL rupture and reported that owner satisfaction at 12 months postoperatively was significantly higher in the TPLO group.

Three studies reported complication rates (Au et al., 2010, Frey et al., 2010, Gordon-Evans et al., 2013). The largest (Frey et al., 2010) reported the incidence of infected-inflamed wounds only and noted that 'TPLO was associated with a significantly higher rate of infection-inflammation’. The remaining two studies (Au et al., 2010, Gordon-Evans et al., 2013) reported the rate of all surgical complications and did not find a difference in rate between treatment groups.

Two studies looked at radiographic evidence of OA (Lazar et al., 2005, Au et al., 2010). The first (Lazar et al., 2005) found that dogs with larger OA score differences between preoperative and follow-up radiographs were 5.78 times more likely to have had LFS placement than TPLO. The second (Au et al., 2010) found no significant difference in OA scores between groups.

The conclusions made within the Clinical Bottom Line component of this knowledge summary are based on the following points;

• The best quality paper available reported a significant improvement in the kinematic results of the TPLO group compared to the LFS group at 6 and 12 months postoperatively (Gordon-Evans et al., 2013). This finding was supported by a second observational study (Nelson et al., 2013). Two studies of equivalent evidentiary quality (non-randomised, observational) found no statistical significance in force plate analysis between treatment groups. However the first study (Conzemius et al., 2005) reported follow-up to 6 months only, later studies reported the greatest difference in treatment groups to occur after 6 months (Nelson et al., 2013, Gordon-Evans et al., 2013). The second (Au et al., 2010) found a non-statistically significant improvement in the TPLO group compared with the LFS group between 6 and 24 months postoperatively. Both of these studies (Conzemius et al., 2005, Au et al., 2010) assessed patients at walking velocity only, it has been reported that trotting velocity is more sensitive for detection of low grade pelvic lameness (Voss et al., 2007).
• Only one paper – a retrospective case series – reported an improvement in any outcome (complication rate) after LFS compared to TPLO (Frey et al., 2010), however wounds were classified as infected-inflamed on the basis of retrospective medical record review and the clinical relevance of findings (i.e. if patients required additional treatment) was not clear. Two other papers recorded complication rates, Au et al. (2010) reported that there was no significant difference between groups and Gordon-Evans et al. (2013) reported that the complication rates of both procedures were similar.
• Only one study (Frey et al., 2010) found a difference in complication rates between procedures.
• Only one paper (Gordon-Evans et al., 2013) looked at owner satisfaction as an outcome and found a significant improvement in the TPLO group compared to the LFS group at 12 months postoperatively.

However extrapolating the data reported here to make recommendations for changes in current clinical practice does have several inherent problems:

Firstly, all procedures reported were performed at referral centres. Thus it may not be correct to assume this data can be extrapolated to LFS and TPLO performed in general practice, or where the choice is between LFS performed in a first-opinion practice, and referral to a specialist centre for a TPLO procedure.

Thirdly, this summary discusses the impact of procedure selection on a limited number of outcomes. Other factors such as cost, hospitalisation duration, aftercare and local availability of services are not considered here, however are expected to vary between procedures and accordingly influence client choice.

In conclusion this knowledge summary suggests that TPLO results in superior limb function and owner satisfaction compared to placement of a LFS; however further research – including multi-centre, randomised, controlled clinical trials and investigation of the outcomes of surgery performed in general practice – is indicated.

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