Treatment of cranial cruciate ligament (CCL) deficiency is one of the most common surgical procedures performed in veterinary orthopedics. While many different methods have been practiced, one procedure has not been proven better than another when it comes to safety and efficacy.

The Tightrope CCL technique was developed by Dr James Cook in hopes of reducing the complication rate in other procedures.

The Tightrope CCL technique is based on the lateral retinacular imbrication suture (LRIS) principle. The theorized advantages of the Tightrope (TR) over the LRIS include bone fixation at both tibial and femoral attachments, more accurate isometric placement, minimally invasive capabilities and the strength, stiffness and creep characteristics of the implant.

Because the Tightrope technique helps ensure optimal isometric placement, counteraction of abnormal cranial drawer and thrust and internal rotation with maintenance of stifle range of motion can be accomplished and maintained in the long term.

The technique involves complete evaluation and treatment of intra-articular structures, either via arthrotomy or arthroscopy, as indicated for comprehensive surgical management of CCL disease.

The joint is lavaged and closed if arthrotomy is done. The lateral aspect of the stifle is then exposed to the level of the joint capsule from lateral fabella to tubercle of Gerdy (accomplished through the approach for arthrotomy or a separate incision after arthroscopy).

The femoral and tibial tunnels are created for the Tightrope CCL by first placing k-wires (to ensure accurate tunnel location) followed by drilling with a cannulated drill bit over the wires.

The femoral tunnel extends from a point in the caudal aspect of the lateral femoral condyle just distal and cranial to the lateral fabella to the medial aspect of the distal femoral diaphysis just caudal to the vastus medialis at the level of the proximal pole of the patella.

The tibial tunnel extends from the most proximal aspect of the muscular groove of the lateral tibia deep to the long digital extensor tendon to the medial aspect of the proximal tibia. The Tightrope CCL (fiber tape with toggle and button) is then placed through the tunnels and secured to stabilize the stifle (Photos 1 and 2). Standard closure is then performed.

The Tightrope CCL was tested mechanically and in cadavers prior to clinical use. The first clinical patients treated (about three years ago) were compared to patients treated with TPLO in a prospective head–to-head study. As evaluated in that clinical study, Tightrope had equivalent functional outcomes at six months with a better safety profile.

Multicenter data compiled thus far suggests the Tightrope CCL can be performed successfully in medium, large and giant-breed dogs with CCL deficiency. Furthermore, in the ongoing multicenter study, 95 percent "good" to "excellent" outcomes are being consistently reported with less than 9 percent complications requiring additional treatment.

It is my professional opinion that the Tightrope procedure is a reasonable alternative to TPLO in dogs up to 100 lbs that have the tear in one leg only, as opposed to dogs with tears in both legs at the same time.