Cranial Cruciate Ligament Repair: Extracapsular Repair and Tightrope Procedure

If Dr. Burns has suggested surgically fixing my dog’s CCL using an external capsular repair technique called ECLS. What does this surgery involve?

The traditional ECLS technique is the oldest surgical correction for cruciate ligament injury in dogs. The name of the procedure originates from the fact that the joint is stabilized outside the joint capsule (externally).

In simplest terms, a loop of a special type of suture material (an artificial ligament) is placed from the back of the knee joint around to the front, where it is anchored just below the knee. This suture material stabilizes the joint and prevents the tibia from slipping back and forth after the cruciate ligament has torn. This procedure typically requires two bone channels (tiny holes) to be drilled — one at the front of the tibia and the other on the outer (lateral) aspect of the femur at the level of the stifle joint —so the artificial ligament can be passed through them.

CCL repair surgery typically consists of an initial examination of the inside of the knee. This examination may either be done by opening the joint capsule and peering inside or by using an arthroscope. Any damaged or torn portions of the CCL are removed. The “shock absorber,” or cartilage meniscus, that cushions the knee and sits between the femur and tibia, is examined. If the meniscus is torn or damaged, that part will be removed. After the joint capsule has been examined and any cartilage or ligament fragments are removed, the joint capsule is sutured closed.

“If the meniscus is torn or damaged, that part will be removed.”

In the ECLS procedure, a suture is passed from the outside/lateral aspect of the knee joint to the front of the tibia. Some surgeons refer to this as “imbricating,” or overlapping the extracapsular tissues to pull the joint tight and create stability to prevent front-to-back sliding of the femur and tibia. Usually, one or two bone channels or holes will be required to pass the suture from back to front.

There have been several innovations in external capsular repair during the past decade. New materials, anchoring devices, and tools have allowed veterinary surgeons to perform this surgery more successfully than ever before.

Several surgical product manufacturers have created advances that make this procedure viable for many dogs, including some large and athletic breeds Larger, more active dogs  may do better with TPLO/TTA procedures (see article of TPLO and TTA).

Perhaps the biggest advancement in CCL surgery has been in how the suture material is joined together. In the past, veterinarians relied on bulky knots that could come undone or irritate the surrounding tissues. Today, there is a variety of suture connectors that are much more reliable, effective, and less irritating. The use of bone anchors and modified bone drills and bits for varying sizes of dogs has also improved ECLS. Strong, specialized knee suture materials have also been developed that make the surgery simpler, more effective, and less risky than in the past.

“New materials, anchoring devices, and tools have allowed veterinary surgeons to perform extracapsular repair more successfully than ever before.”

My veterinarian mentioned that she might use the TightRope® procedure to repair my dog’s torn CCL. What does this surgery involve?

Different materials and a slight variation in the traditional extracapsular repair have resulted in the TightRope® procedure. This method uses a customized needle and a special suture material affixed to bone anchors.

The TightRope® procedure requires drilling two bone channels (resulting in four holes) — one from side to side through the tibia and the other from side to side through the femur — to run the suture material through, thereby stabilizing the joint. The use of these unique bone anchors helps reduce the need for additional suture material in the joint.

Is one of these procedures better than the other?

Both the traditional ECLS and Tight Rope® procedures are considered extracapsular or external repairs of CCL injury. Both yield similar results with similarly low risks. The two primary risks of extracapsular surgical repairs are infection and failure. With either type of extracapsular repair, success rates have been found to be at least 85% and infection rates reported to be only 1% to 4%.

Because both procedures are nearly identical in their respective potential risks, it is up to the surgeon to determine the procedure he or she is most confident will give your dog the best chance of full recovery.

“Either traditional ECLS or the TightRope® procedure is considered adequate for most small to medium sized dogs.”

Either traditional ECLS or the TightRope® procedure is considered adequate for most small to medium sized dogs and for cats. Larger dogs may benefit more from TPLO or TTA procedures. In most cases, any surgery is better than none, especially in medium- to large-breed dogs.

Dr.  Burns will discuss your dog’s condition and which procedure is best. There is no right or wrong answer when it comes to choosing your pet’s surgery, only what is most likely to achieve the desired outcome.

Pain management during and after stifle surgery is critical, so be sure to give all medications as prescribed and use them until they are gone. Physical rehabilitation post-operatively will speed healing. Ask your veterinarian about incorporating rehabilitation into your dog’s recovery plan.

For information on other types of surgery used to correct CCL injuries in dogs, see the handouts in our Pet Health Section of our website.“Cranial Cruciate Ligament Repair: Tibial Plateau Leveling Osteotomy (TPLO) and Tibial Tuberosity Advancement (TTA).”

This client information sheet is based on material written by: This client information sheet is based on material written by Ernest Ward, DVM, and Robin Downing, DVM, CVPP, DAAPM.

© Copyright 2013 LifeLearn Inc. Used and/or modified with permission under license.