Comparison of Long-Term Outcomes Associated with Three Surgical Techniques for Treatment of Cranial Cruciate Ligament Disease in Dogs

Scott A. Christopher, VMD, CCRP, Jodi Beetem, RVT, CCRP, and James L. Cook, DVM, PhD, Diplomate ACVS & ACVSMR, Veterinary Orthopedic & Sports Medicine Group, Annapolis Junction, Maryland and Comparative Orthopaedic Laboratory, University of Missouri, Columbia, Missouri.

Corresponding Author: James L. Cook DVM, PhD, Diplomate ACVS & ACVSMR, Comparative Orthopaedic Laboratory University of Missouri, 900 E Campus Dr, Columbia, MO 65211. E-mail:

Submitted July 2011 Accepted December 2011. DOI:10.1111/j.1532-950X.2013.12001.x

Objective: To evaluate long -term (>1 year) outcomes with respect to function and complications in dogs undergoing TightRope (TR), tibial plateau leveling osteotomy (TPLO), or tibial tuberosity advancement (TTA) for treatment of cranial cruciate ligament (CCL) disease.
Study Design: Retrospective clinical cohort study.

Methods: Medical records from 2006 to 2009 were searched and cases included when all data were availabl e and clients returned a completed questionnaire based on their assessment of their dog at least 1 year after surgery. Outcomes associated with TPLO, TTA, and TR were determined and compared based on medical records and questionnaires data regarding return to function, presence and degree of pain, and complications.

Results: Case meeting inclusion criteria were: TPLO (n = 65), TR (n = 79), and TTA (n = 18). TTA was associated with significantly (P 1 year after surgery was 93.1%+ 10.0% for TPLO, 92.7%+ 19.3% for TR, and 89.2%+ 11.6% for TTA. Significantly (P = 0.016) more TPLO and TR cases were classified as reaching full function than TTA. The highest levels, frequency, and severity of pain were noted in TTA cases, however, no significant differences were noted among groups.

Conclusion: Long-term outcomes for TPLO and TR were superior to TTA based on subjective client and DVM assessments. Each technique was associated with a high long-term success rate with TR showing the highest safety-to-efficacy ratio.



Clinical comparison of a novel extracapsular stabilization procedure and tibial plateau leveling osteotomy for treatment of cranial cruciate ligament deficiency in dogs.

Cook JL1, Luther JK, Beetem J, Karnes J, Cook CR.

OBJECTIVE: To develop and test a novel extracapsular technique, TightRope CCL technique (TR), and compare its 6month clinical outcomes to tibial plateau leveling osteotomy (TPLO) in dogs with cranial cruciate ligament (CCL) deficiency.

STUDY DESIGN: Prospective clinical cohort study.

ANIMALS: Medium, large, and giant breed dogs (n=47) with CCL deficiency.

METHODS: Before clinical use, TR was evaluated by mechanical testing and the surgical technique was developed and evaluated in canine cadavers. For the clinical study, dogs were assigned to either TR (n=24) or TPLO (n=23) groups and the assigned technique performed after arthroscopic assessment and treatment of joint pathology. Postoperative management was standardized for both groups. Outcome measures were performed immediately postoperatively and up to 6 months after surgery and included complication types and rate, subjective measurement of cranial drawer and tibial thrust, subjective assessment of radiographic progression of osteoarthritis (OA), and function using a validated client questionnaire (6 months only).

RESULTS:TR with a fiber tape suture had superior mechanical properties for creep, stiffness, yield load, and load at failure. Duration of anesthesia, total surgical time, and stabilization procedure (TR versus TPLO) were all significantly (P<.001) shorter for TR compared with TPLO.  Complications requiring further treatment occurred in" 12.5% of TR cases and 17.4% of TPLO cases.  No significan differences were noted between groups  for cranial tibial thrust, but cranial drawer was significantly (p<0.05) lower in TR stifles at all postoperative time points.  No significant differences were noted between groups for radiographic OA scores.  No statistically or clinically significant differences were noted between TR and TPLO for scores for each of the client questionnaire categories. 

CONCLUSIONS: TR resulted in 6-month outcomes that were not different than TPLO in terms of radiographic progression of osteoarthritis and client-evaluated level of function. TR was associated with shorter anesthesia and surgery times as well as a lower complication rate.

CLINICAL RELEVANCE: The TR technique is safe and effective and can be considered an appropriate surgical option as part of the overall treatment plan for CCL deficiency in dogs.




Multicenter Outcomes Study for Evaluation of Tightrope CCL for Treatment of Cranial Cruciate Deficiency in Dogs: The First 1,000 Cases

Conference Paper · February 2010 James L. Cook       Conference: Annual Conference Veterinary Orthopedic Society




Introduction: Tightrope CCL (TR) is an extracapsular stabilization procedure for treatment of cranial cruciate ligament (CCL) disease in dogs. As part of a commitment to critically assess outcomes, we enrolled veterinarians in a multicenter study to further assess safety and efficacy in 1,000 cases.

Materials and Methods: This study falls within guidelines of participating institutions’ IACUC/ethical treatment of animals standards. Centers were enrolled to prospectively collect outcomes data for all dogs treated with TR. Criteria for reporting time frame, outcome, and complications were from a system proposed for clinical orthopaedic studies in veterinary medicine and were set a priori. Data were reported by each center for descriptive analyses and ANOVA to analyze differences among time frames.

Results: 29 centers reported on 1,004 TR cases (weight, 2-93 kg). 58.7% of outcomes were short term (3-6 mos), 31.1% mid term (6-12 mos), and 10.2% long term (>12 mos). Subjective outcomes were considered successful in 93.9% of cases - 54.1% “full function”, 39.8% “acceptable function”, and 6.1% “unacceptable function”. No catastrophic complications were reported. Major complications occurred in 9.9% - subsequent meniscal tears (4%), infection (2.8%), and failure (3.1%). Minor complications were reported in 10.1%, primarily seroma formation. No significant differences in function or complications were noted among time frames.

Discussion/Conclusion: Tightrope CCL is associated with successful outcomes in ~94% of patients. Complications requiring further surgical or medical treatment occur in ~10% of TR cases. These subjective data indicating safety and efficacy of TR for treatment of dogs with CCL disease can be broadly applied.

Acknowledgments: Sincerest thanks to the conscientious veterinarians at the participating centers who helped bring TR to clinics in a safe and effective manner and honestly reported these data.




Effect of surgical technique on limb function after surgery for rupture of the cranial cruciate ligament in dogs.

J Am Vet Med Assoc. 2005 Jan 15;226(2):232-6.


Conzemius MG1Evans RBBesancon MFGordon WJHorstman CLHoefle WDNieves MAWagner SD.

Author information



To determine the outcome and effect of surgical technique on limb function after surgery for rupture of the cranial cruciate ligament (RCCL) and injury to the medial meniscus in Labrador Retrievers.


Prospective clinical study.


131 Labrador Retrievers with unilateral RCCL and injury to the medial meniscus and 17 clinically normal Labrador Retrievers.


Affected dogs had partial or complete medial meniscectomy and lateral suture stabilization (LSS)(note:  this study was done before the Tightrope procedure was developed.  The LSS technique is the older artificial ligament procedure, and is more similar to the Tightrope than to TPLO), intracapsular stabilization (ICS), or tibial plateau leveling osteotomy (TPLO). Limb function was measured before surgery and 2 and 6 months after surgery. Treated dogs were evaluated to determine the probability that they could be differentiated from clinically normal dogs and tested to determine the likelihood that they achieved improvement.


No difference was found between LSS or TPLO groups, but dogs treated with ICS had significantly lower ground reaction forces at 2 and 6 months. Compared with clinically normal dogs only, 14.9% of LSS-, 15% of ICS-, and 10.9% of TPLO-treated dogs had normal limb function. Improvement was seen in only 15% of dogs treated via ICS, 34% treated via TPLO, and 40% treated via LSS.


Surgical technique can influence limb function after surgery. Labrador Retrievers treated via LSS, ICS, or TPLO for repair for of RCCL and medial meniscal injury managed with partial or complete meniscectomy infrequently achieve normal function (emphasis added). Results of LSS and TPLO are similar and superior to ICS.