Tibial Tuberosity Advancement: My Two Cents on the TTA Repair

The tibial tuberosity advancement (TTA) was one of the first modern surgical options to address cranial cruciate ligament tears in dogs.

The TTA neutralizes the abnormal forces in the joint that result from a CCL rupture differently. Even though it also involves cutting a bone, it uses the strength of the patellar tendon to stabilize the knee.

This technique underwent several evolutionary steps. Over time, surgeons fiddled with how they cut the bone, how they secure it, and how to best facilitate healing.

Tibial Tuberosity Advancement: My Two Cents on the TTA Repair

Introduction

Which treatment is best for you dog, depends on your individual dog and the criteria include:

  • age
  • size
  • activity level
  • individual anatomy
  • post-op care
  • the amount of arthritis and other joint disease

Tibial tuberosity advancement (TTA) is one of the surgical repairs that alter knee anatomy to achieve stabilization. Because it affects a non-weight-bearing part of the shin bone, it has some advantages, including earlier weight-bearing. As well as it is a relatively simpler procedure, which reduces some of the risks.

Below, you can compare the differences yourself.

Tibial Plateau Leveling Osteotomy: My Two Cents on TPLO Repair
Tibial Plateau Levelling Osteotomy. Image Riverbend Veterinary
Tibial Tuberosity Advancement: Schematic Representation
Tibial Tuberosity Advancement. Image Semantic Scholar

In the TTA, the surgeon makes a cut in the front of the shinbone. An implant pushes it forward, taking the patellar tendon along with it. This alters the forces on the bones enough to prevents excessive forward thrust of the shinbone.

At the time of Jasmine’s torn CCL diagnosis, the TPLO and TTA were the only available options of their class. I leaned toward the TTA because it looked less invasive and intrusive. My main question, though, was what are the odds of the bone fracturing.

Comparing the incidence of complications following TTA and TPLO surgery

As it turns out, the TTA doesn’t seem to be any more vulnerable to complications than the TPLO. As with any such intervention, the likelyhood of serious complications increase with the size of the dog. When compared, TTA seems to come on top.

TTATPLO
Total incidence of major complications19.8%27.8%
Surgical site infections15.4%25.9%

Infections are the most common complication. Appropriate post-op antibiotic therapy reduces that risk dramatically. As far as complications requiring surgical revision there was no difference between the techniques according to this study.

Further information: Comparison of complications following TTA and TPLO in dogs 50 kg or more in body weight

In general, the debate on which technique is better is ongoing and might boil down to individual preference. More options are emerging, including the Cora-based Leveling Osteotomy (CBLO) that offers improvements to the original TPLO. At this time, CBLO would be one of my primary preferences.

Cora-based Leveling Osteotomy: My Two Cents on (CBLO) Repair
Cora-based Leveling Osteotomy (CBLO). Photo United Veterinary Clinic

Further information: Cora-based Leveling Osteotomy: My Two Cents on CBLO Repair

Another take is that the two surgeries are comparable when things go well but dealing with complications is substantially easier with the TTA: TTA vs TPLO – Similar Until There Are Complications.

Why consider the Tibial Tuberosity Advancement (TTA)?

The primary criteria for deciding which surgery to choose should include:

  • the individual dog
  • availability of different options
  • skill and experience of the surgeon

Some surgeons began to offer this option since 2004, but many stick strictly with the TPLO. Does that mean one is better than the other? Not necessarily. Some specialty hospitals recommend one on the other after they evaluate their canine patient. These days, you might find different specialists and clinics offer different combos of options.

One underappreciated advantage of the TTA over either TPLO or CBLO lies in the straight rather than a round cut. TTA shares this advantage with the Triple Tibial Osteotomy (TTO). Straight cut decreases the risk of overheating the bone which eliminates delay in healing.

TTA and TPLO outcome comparison

Judging by the ultimate outcome, both TTA and TPLO surgeries are comparable. However, with TTA the intervention affects a non-weigh-bearing part of the bone. As a result, it seems that dogs have a better response to the procedure and appear more comfortable using the leg post-op.

One distinct plus for the TTA might be the implant material. The tibial tuberosity advancement uses titanium implants that are stronger and have lower risk or infection and implant rejection.

Further information: Short-term comparison of TTA and TPLO in dogs with CCLt disease using kinetic analysis
Further information: TTA vs TPLO

TTA potential complications

Some post-op complications are possible with any surgery. Serious complications specific to the TTA include:

  • post-operative patella luxation
  • tibia fracture
  • meniscal injury
  • loosening implant

Implant failure and infections are less common because of the material used in this procedure.

Further information: TTA vs TPLO

The evolution of the TTA procedure

The modifications to the TTA technique focus primarily on the area that was my main concern. They aim to lower the risk of bone fracture and speed up the healing process. I describe the newest variants below.

Tibial Tuberosity Advancement 2 (TTA2)
Tibial Tuberosity Advancement: TTA-2

TTA-2 sought to improve on the original TTA making it simpler and less invasive. The improvements include:

  • only a partial cut to the bone
  • using only a single implant
  • smaller and fewer holes
  • replacing screws by stabling

Further information: Tibial Tuberosity Advancement 2 (TTA2)

Tibial Tuberosity Advancement Rapid (TTA-R)
Tibial Tuberosity Advancement: TTA-Rapid

Compared to the standard TTA technique or TPLO, TTA-R is less invasive and quicker. If you take a look, you’ll see that this one uses a single titanium implant. The surgery takes less time, and it is less complicated—both of which decrease associated risks.

The implant consists of a plate and a cage with open mesh construction which promotes stability and healing—it allows the bone tissue grow through the sponge construction rapidly.

Are you wondering about the little round hole at the end of the cut? It is there to prevent unwanted splitting of the bone beyond the cut. Cool, isn’t it?

Very elegant and clever in my opinion. I like these improvements a lot.

This technique works successfully for dogs of any size.

Further information: Tibial Tuberosity Advancement – Rapid (TTA –R)

There have been other variations on the procedure out there. Your options likely depend on what each individual surgeons offer.

Summary

Naturally, any dramatic intervention in the body caries risks of complications. Some of the TTA modifications look smart and likely to improve outcomes. Such a small modification, as the round hole at the end of the cut, can make a substantial difference.

As always, before making a decision for the treatment of your dog’s cruciate ligament tear, do your homework. Research available technique, see which options are applicable in your area and make an informed decision.

Would I select the TTA repair for my dog’s CCL injury? If it was available, I would give the Tibial Tuberosity Advancement Rapid (TTA-R) strong consideration.

Related articles:
Talk to Me About Dog CCL Injuries

Further reading:
Cranial Cruciate Ligament Repair: Tibial Tuberosity Advancement (TTA)

Categories: CCL injuriesCruciate ligament injuriesJoint issuesKnee issuesTibial tuberosity advancement (TTA)

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Jana Rade

I am a graphic designer, dog health advocate, writer, and author. Jasmine, the Rottweiler of my life, was the largest female from her litter. We thought we were getting a healthy dog. Getting a puppy from a backyard breeder was our first mistake. Countless veterinary visits without a diagnosis or useful treatment later, I realized that I had to take Jasmine's health care in my own hands. I learned the hard way that merely seeing a vet is not always enough. There is more to finding a good vet than finding the closest clinic down the street. And, sadly, there is more to advocating for your dog's health than visiting a veterinarian. It should be enough, but it often is not. With Jasmine, it took five years to get a diagnosis. Unfortunately, other problems had snowballed for that in the meantime. Jasmine's health challenges became a crash course in understanding dog health issues and how to go about getting a proper diagnosis and treatment. I had to learn, and I had to learn fast. Helping others through my challenges and experience has become my mission and Jasmine's legacy. I now try to help people how to recognize and understand signs of illness in their dogs, how to work with their veterinarian, and when to seek a second opinion. My goal is to save others the steep curve of having to learn things the hard way as I did. That is the mission behind my blog and behind my writing. That is why I wrote Symptoms to Watch for in Your Dog, which has turned out being an award-winning guide to dog owners. What I'm trying to share encompasses 20 years of experience.

11 Comments
  1. Both options look like they would include a painful recovery! I would probably choose the second option if my vet agreed with it, since it seems a little less risky.

  2. I think it is SO important to be aware of all options that are available when we’re trying to make a decision on how to best care for our pups. This was fascinating, something that I knew nothing about before. That being said – if I had a dog that may benefit from this, I would probably seek out a vet that specializes it for their opinion before deciding on a course of treatment. Why not having the conversation at least, right?

    • Yes, the steps to a good decision are two-part:
      1) researching what is out there
      2) finding a vet/surgeon you trust and discuss the options

      Not all options work in all cases. On the other hand, sometimes one has to find a vet who comes with the preferred solution. We did that when we wanted to explore stem cell therapy.

  3. My husband’s partner’s dog tore a ligament a few weeks ago and had very intrusive surgery for $4500. A huge dog and a disaster. He ended up tearing another ligament during recovery. Knees and ligaments are so tricky – not sure what I would choose. Just have to hope Kilo doesn’t injure his.

    • So sorry about your husband’s partner’s dog. Unfortunately, most of these surgeries cost around that. And, also unfortunately, the other knee often goes too sooner or later.

      I have an article where I explain all this.

  4. Wow if I was a dog owner I would be so glad I found your site. This post is admirably comprehensive and clear about the options available and what happens and why. I can sympathise with a dog owner faced with this kind of issue but your post will be a help to a lot of worried dog owners.

  5. Really interesting and am learning every week about treatments for our dogs that I have not thought about as I just go with the flow as such, thanks

  6. Very interesting! I know a bit about CCL issues such as the symptoms to look out for etc, but never knew much about how a rupture would be treated. I hope it’s something I don’t ever have to deal with first hand, but it’s good to know what treatment options are currently available.

    • I hope you never have to deal with a CCL injury either. It is, however, important for people to realize how many potential options there are out there because it is quite likely they will only be recommended one or two.

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