COLUMBIA — Veterinarian James Cook still remembers Smokey.
Five years ago, Cook performed double-knee surgery on the 3-year-old Rottweiler, but the dog began having problems before he even left the hospital — and his condition quickly worsened.
As a result of the initial injury and surgical complications, one of Smokey's knees had virtually "exploded," said Cook, a surgical specialist in veterinary medicine and a faculty member at MU.
Although he was able to salvage both legs after four more surgeries, the dog suffered immense physical pain and was hardly better than before his treatment started.
The owners, who had come to Columbia from St. Louis for the procedure, left with little but emotional scars and pocketbooks that were $3,800 lighter.
Smokey’s case is the type that drove Cook to develop TightRope, a surgical technique he hopes will eradicate the extreme, though rare, problems dogs sometimes face after knee surgery.
The procedure, which he started experimenting with in 2006, is named after the rope-like material Cook uses to link the two bones in the knee joint.
Cook has taught the TightRope procedure to other veterinarian surgeons on a one-on-one basis for the last two years, and the results in a few hundred cases have been tracked for at least 12 months. In those, Cook has seen few complications.
Urged on by good results, Cook started teaching formal classes this summer. Since leading labs in the U.S. and Germany, he has heard from veterinarians around the world who hail his procedure as a simpler and more effective method of dealing with damaged knees, the biggest problem in canine orthopedics.
Every year, veterinarians perform more than 1.2 million knee surgeries on the 70 million or so dogs in America. That’s about five times the number of knee surgeries performed on humans, though the U.S. population is more than 300 million.
Pet owners are now driving hundreds of miles across the U.S. and Canada to have TightRope surgery performed on their dogs. Cook said he gets at least two e-mails per day from owners who have heard about the surgery and who want to know where their dogs can be treated.
“It’s exploding right now,” Cook said.
Veterinarians agree that the initial results of Cook’s procedure look promising, but exactly when the technique should be used and how good those results will look three or four years down the line are still matters of debate.
“There’s been some excitement, and like with any new surgery, people get overenthusiastic,” said Ian Holsworth, a canine orthopedic specialist who practices in Ventura, Calif.
TightRope is the newest in a long line of procedures developed to repair the ligament that attaches the dog’s thigh bone to its shin bone. The cranial cruciate ligament is the equivalent of the human ACL , a crucial bit of leg tissue frequently injured by athletes.
When a dog is diagnosed with a damaged CCL, the owner can choose from three types of treatment.
The owner can opt to treat the leg nonsurgically, limiting treatment to medicine or physical therapy. Although this avoids the possibility of surgical complications, it can also limit the amount of function a dog retains. More important for many owners, nonsurgical treatment might do little to decrease a dog’s pain.
Sometimes people are financially forced into this option. Cook estimates that only 5 to 10 percent of pet owners have insurance for their animals, and price tags for surgical knee work can range from $1,000 to $6,000 depending on the expertise of the veterinarian, type of procedure and location of the practice.
If the owner opts to have surgery for their animal, there are two main types: surgeries to move the CCL’s workload to other healthy ligaments and muscles around the knee and surgeries to replace the function of the CCL by adding grafts or synthetic materials inside or outside the joint.
TightRope falls into the latter category, and the method is fairly straightforward: A lightweight but strong synthetic “rope” is used to connect the thigh bone and shin bone as the CCL once did.
The rope acts like a suture, Cook said. It is there to hold the healthy bits steady until the dog can naturally compensate for the damage.
Cook teamed up with medical company Arthrex when he decided to pursue his new take on the replacement technique in 2006. Taking inspiration from established canine surgeries and a surgery for human ankles, the veterinarian began small experiments at MU.
He first tried the method on cadavers and then moved to practice on a limited number of animals. After following up with those dogs for six months, he increased his usage of TightRope and applied for a patent that he expects to come through this year.
But a patent does not necessarily denote complete innovation. The surgery both is and is not new, surgical veterinarian Holsworth said. Although TightRope requires an innovative material, the technique “is an adaptation of a procedure done for the last 20 years,” he said.
Holsworth predominantly uses a canine knee surgery popularized in the 1990s called TPLO (tibial plateau leveling osteotomy). This technique, one of the more popular procedures used to shift the CCL’s workload, involves “cutting bones” to compensate for the lost ligament and is more complex than TightRope, he said.
In the last 450 cases of TPLO performed at his practice, Holsworth said he has seen a less than 0.25 percent complication rate. Unlike most veterinarians, however, Holsworth had additional training as a surgical fellow, and his studies have made him better equipped than the average veterinarian to perform complicated procedures, he said.
Out of the 1.2 million canine knee surgeries performed annually, 1 million are performed by general practitioners, meaning that only one-sixth are done by surgical specialists such as Holsworth.
This means that TPLO can be at least as effective in the hands of a specialist. TightRope is, however, a much safer technique for the majority of veterinarians to use.
Will Wright, who earned his veterinary degree in 1966, has found TightRope a “very simple” new procedure to learn.
Wright, who has not attempted to perform a TPLO, said he is thrilled with Cook's “phenomenal” new technique.
“I’ve had nothing but good to excellent results,” Wright said of the 40 TightRope surgeries he has performed at his practice in Springfield, Ill.
Cook is candid about the financial benefits he gets from people such as Wright using the procedure. As the inventor, Cook receives a "small percentage" of the profits from sales of the TightRope materials provided through Arthrex, the company that funded his initial research.
His financial involvement was part of what led him to be so slow with the release of TightRope; he didn’t want anyone to worry that thoughts of business were clouding his judgment of patient care.
“The safety factor is so important to me,” he said.
Mark Albrecht, a veterinarian who has known Cook and his wife since veterinary school at MU, vouched for Cook's methods.
“Anywhere but the basketball court, Jimi is the most honorable man you can find,” Albrecht said, laughing.
Albrecht runs a veterinary practice in Bozeman, Mont., and he estimates that knee problems constitute 70 percent of his business. "It’s probably wrong to think that one size fits all” when it comes to surgery, he said, but “in a lot of cases, TightRope is the answer.”
He recalled one couple who drove more than 650 miles from Edmonton, Alberta, to have their pet undergo TightRope at his practice.
He said he’s been impressed by the dedication of owners who have heard about the technique and will travel so far to have it performed on their pets.
“It’s been a cautious, limited release,” he added. “There hasn’t been this big fanfare among the vets. The clients are the ones creating all the buzz."
Cook said he was aware of at least 800 instances of the TightRope procedure being used worldwide as of August.
He has personally performed the surgery 110 times, and said that his complication rate was around 6 percent, the majority of which could be attributed to insufficient post-operative care from owners.
Those complications have not included any of the severe problems that Cook saw after other CCL surgeries — the Smokey scenario has not been repeated.
“That alone justifies the procedure,” Cook said.