A tibial tuberosity advancement (TTA) is used to treat a torn cranial cruciate ligament (CCL). Unlike other procedures, the goal of this surgery is not to recreate or repair the ligament itself, but rather change the dynamics of the knee so that the cranial cruciate ligament is no longer necessary for stabilizing the joint. In this procedure, a linear cut is made along the length of the tibial tuberosity, which is the front part of the tibia. This cut bone is then advanced forward, and a specialized bone spacer is placed in the open space between the tibia and the tibial tuberosity. Finally, a stainless steel metal plate is applied in order to secure the bone in place. Because the patellar tendon attaches to this tibial tuberosity, once it is advanced, the tendon keeps the femur from sliding back and forth and therefore stabilizes the knee joint and eliminates the need for an intact cranial cruciate ligament.

Additionally, rupturing the cranial cruciate ligament leads to instability in the knee, which can lead to damage to other structures within the joint, including menisal tears. This is where appropriate diagnostics become important. Finding the extent of the injury will aid in choosing the correct procedure for your dog, and will increase the chances of a successful recovery.

What you need to know about recovery?

Regardless of which surgery you choose, it’s the post-operative care that will determine how successful the procedure is. Dogs that are non-weight bearing will quickly begin to lose muscle mass and range of motion in the affected leg. The sooner the knee is stabilized, the less muscle atrophy that occurs, and the faster the recovery post-op.

Current evidence suggests that TTA surgery allows for a more rapid return to full function than extracapsular repair. Recovery from a TTA differs from extracapsular repair in that follow-up radiographs (x-rays) must be performed to ensure that the bone is healing as expected and that the implant remains in place. Dogs that have undergone TTA must be restricted in their exercise for 8-16 weeks until healing of the bone is confirmed via x-rays. Once the bone is healed, more vigorous rehabilitation exercises can be used but must be done under the guidance of your veterinarian, surgeon, and/or rehabilitation practitioner. In the last 20 years, human physical therapy principles and techniques have been developed and adapted to help dogs recover properly after major orthopedic surgery. Physical therapy for dogs is correctly referred to as Canine Rehabilitation, and many of the techniques used are similar to those that would be used if you had to see a physical therapist after orthopedic surgery. These exercises focus on safe weight-bearing of the limb, combating muscle atrophy, and improving range of motion while taking care not to damage the metal implant in the knee.

Keep in mind that like humans, not all dogs recover at the same speed. It is best to be conservative and consistent. Do not force your dog to do certain exercises if they are unwilling. It is always best to seek professional guidance if available. It is important to note that while recovery takes up to 16 weeks, it may take longer to have complete healing and return to function.

What are the alternatives?

Although TTA repairs are becoming increasingly more common, it is not the only option for repairing your dog’s torn cruciate ligament. Therefore, it is important to have a conversation with your veterinarian or veterinary surgeon to discuss all of your options. As previously mentioned, there are several things that should be considered when choosing the right surgery. Here is a list of things to consider:

• Age of the dog
• Size and weight of the dog
• Activity level of the dog
• Financial considerations
• Post-operative care and access to a canine rehabilitation facility
• Degree of joint disease (arthritis or other concurrent joint diseases/injury)
• Access to a board-certified orthopedic surgeon versus a general surgeon or practitioner

Additionally, not every dog is an ideal candidate for this procedure. In some cases, the anatomy and conformation of the stifle may make this procedure not feasible or not effective.

Three of the most common alternatives to extracapsular cruciate ligament repair are:

• Tibia Plateau Leveling Osteotomy (TPLO)
• Extracapsular Ligament Repair/ Suture Stabilization 

What are the complications?

According to the American College of Veterinary Surgeons (ACVS), the long term prognosis for animals undergoing surgical repair of the cranial cruciate ligament is good, with reports of improvement in 85-90% of the cases. However, all surgical procedures carry the risk of complications. The most common complications encountered with this particular procedure are infection, lack of stabilization, and implant failure. The most common complication caused by a torn cranial cruciate ligament is osteoarthritis of the affected joint. Unfortunately, arthritis progresses regardless of treatment but is much slower when surgery is performed and the knee is stabilized. It is important to realize that arthritis is a progressive disease and develops fairly quickly in an injured stifle joint.  Therefore, arthritis management and prevention and joint supplements are recommended for any dog with this injury, no matter which surgical procedure is chosen. Complications that can arise which are specific to TTA surgery include delayed healing of the bone, non-healing of the bone, healing in an incorrect position, fracture of the bone, and failure or breaking of the metal implants. Although they are uncommon, these complications can be serious and may require corrective surgeries. Therefore, seeking out an experienced surgeon and following exercise guidelines are very important in increasing the chances of a positive outcome and minimize complications