Tibial Plateau Leveling Osteotomy (TPLO) in Cats: A Comprehensive Literature Review

1. Introduction and Historical Background

Rupture of the cranial cruciate ligament (CrCL) is one of the most common orthopedic diseases in dogs and leads to significant functional limitations. In cats, this condition was long considered rare and was often overlooked [1]. Only in recent decades has attention been drawn to this problem in feline patients, leading to an increasing number of case reports and smaller studies. Tibial plateau leveling osteotomy (TPLO) is a surgical procedure originally developed by veterinary surgeon Slocum that has achieved revolutionary results in the treatment of cruciate ligament ruptures in dogs [2].

TPLO is based on biomechanical principles that aim to neutralize the abnormal forward movement of the tibia during the stance phase [3]. While degenerative, chronic ruptures are predominant in dogs, the situation appears to be significantly different in cats. Several studies suggest that a traumatic event is more likely to underlie cruciate ligament rupture in cats [1]. Despite these differences, TPLO is now being used with increasing frequency in feline patients, although long-term outcomes are not yet as well documented as in dogs.

(C) M. Frizzi, L. Ballarini, and D. Gaio

2. Anatomy and pathophysiology of cruciate ligament rupture in cats

2.1 Differences between cats and dogs

The pathophysiology of cruciate ligament rupture differs fundamentally between cats and dogs. In dogs, rupture is typically a chronic, degenerative process with frequent partial lesions [1]. In contrast, several studies indicate that in cats, cruciate ligament rupture is more likely to be caused by a traumatic event. This is supported by the clinical presentation: many cat owners report direct jumps or other acute trauma immediately preceding lameness [1].

2.2 Demographics and risk factors

Studies of cats with cruciate ligament rupture show characteristic patterns. The average cat is older than 8 years and weighs more than 5 kg [1]. In a large retrospective study of 23 cases, the mean age was 8.7 years with a mean weight of 6.8 kg [1]. Interestingly, no breed or sex preference was found, although neutered cats were more common, possibly due to innovation practices in urban areas [1].

A significant finding is that approximately 68% of cats with cruciate ligament rupture exhibit dystrophic mineralization in the cranial compartment of the knee joint, along with dislocal displacement of the sesamoid popliteus bone [1]. The tibial plateau angle (TPA) in cats with cruciate ligament rupture averages approximately 24.8 degrees, which is slightly higher than in healthy cats at approximately 21 degrees [1]. This anatomical variation could represent a risk factor for the development of cruciate ligament ruptures [4].

2.3 Accompanying injuries

A particularly significant feature of cruciate ligament rupture in cats is the high incidence of concomitant meniscal injuries. Current literature reports that approximately 671 TP3T of cats with isolated cruciate ligament rupture also exhibit meniscal injuries [1]. In a more recent study of 23 cases, the rate of concomitant meniscal injuries was even higher, at 761 TP3T [1]. These injuries are typically longitudinal fractures of the medial meniscus or avulsions of the cranial horn [1], indicating a high-energy trauma.

Of particular interest is that all three documented cases of cranial meniscal horn avulsions occurred in Maine Coon cats [1]. This could indicate a genetic predisposition in this breed, but requires further investigation with larger sample sizes. In contrast to dogs, bilateral ruptures are rare in cats, with only about 4–131 TP3T of cases being bilaterally affected, and these typically occurring more than a year apart [1].

3. Diagnostics and Imaging

Diagnosing a cruciate ligament rupture in cats can be challenging, as the clinical signs may be more subtle than in dogs. Classic clinical tests such as the drawer test and tibial compression test are less reliable in cats, especially in cases of partial rupture. Many cats exhibit variable lameness that worsens with exercise and is often intermittent.

Radiological imaging plays an important role in diagnosis. Typical radiological findings may include joint effusion, soft tissue swelling, and early arthritic changes. In some cases, dystrophic mineralization may be observed in the cranial compartment of the knee joint [1]. Advanced imaging techniques such as CT or MRI can provide additional information but are less common in routine clinical practice in cats.

4. Biomechanics of TPLO in cats

The TPLO aims to alter the tibial plateau angle to neutralize cranial tibial thrust. This principle is based on the assumption that the posterior cruciate ligament is intact and that stability is ensured after the plateau repositioning [4]. This is a critical point in planning a TPLO, as the Slocum TPLO technique requires the integrity of the posterior cruciate ligament [4].

In cats, the anatomical and biomechanical conditions differ from those in dogs due to smaller joint size and different stress profiles. Nevertheless, experimental and clinical studies show that TPLO is technically feasible in cats and can lead to stable joint conditions.

5. Surgical technique and adaptations in cats

Surgical techniques in cats require special adaptations due to their smaller anatomy. These include the use of mini- and micro-implants [1] and careful measurement of osteotomy parameters [1]. Furthermore, simultaneous mini-arthrotomy is almost always necessary, as a large proportion of cats have meniscal injuries [1].

Preoperative planning includes determining the tibial plateau angle, defining the degree of rotation, and selecting appropriate implants. Intraoperatively, precise work and atraumatic soft tissue handling are essential.

6. Results, complications and follow-up

Based on the available literature, TPLO is a safe and effective treatment option for cats with cruciate ligament rupture [1]. The available studies originate from various geographic regions and veterinary institutions, which increases the generalizability of the results. Long-term results up to 24 months are excellent, with high rates of return to normal function and minimal osteoarthritis progression.

The reported complication rate is approximately 24%, with most complications being minor [1]. Severe complications are less common and are often associated with postoperative management (e.g., lack of movement restriction).

7. Alternative Therapies

7.1 Extracapsular stabilization

Extracapsular stabilization is an alternative to TPLO in cats. These techniques use sutures or wires running from the fabella to the tibial crests to restore joint stability. A recent study investigated stabilization with a novel absorbable polylactide bone anchor and compared it to suture fixation alone and non-absorbable anchoring [7]. The results showed that the absorbable anchor was able to stabilize the joint with respect to internal rotation and craniocaudal movement, representing a promising approach.

The extracapsular technique has several advantages: it is technically less demanding, does not require osteotomy, causes less bone injury, and is more cost-effective. However, stability can decrease over time, especially if the suture stretches or tears [8]. In cats with significant internal rotational instability, a combined technique of TPLO and extracapsular stabilization may be necessary [4].

7.2 Tibial Tuberosity Transposition in Cats

Tibial tuberosity transposition (TT) is an alternative osteotomy technique that can be used in the combined treatment of cruciate ligament rupture and patellar luxation. A case series successfully described the use of tibial tuberosity transposition and advancement (TTTA) in four stifle joints in three cats to treat both cruciate ligament rupture and concomitant medial patellar luxation [9]. The surgical technique involved medial meniscectomy, partial parasagittal patellectomy, femoral trochleoplasty, and tibial tuberosity transposition and advancement using a cage.

The results were encouraging: at the 2-week follow-up, lameness was minimal and the joints were stable. Radiographic follow-up at 8 weeks showed adequate bone healing progression. One case suffered a major complication with a tibial fracture after insufficient rest, which was successfully treated with revision surgery. At the mid-term follow-up, all cats returned to their previous level of function [9].

7.3 Conservative therapy and long-term management

Although not extensively documented in the literature for cats, there are reports of successful conservative treatment of some cases of cruciate ligament rupture. One study compared short-term outcomes between surgical (TPLO) and non-surgical treatment in small-breed dogs, but also found relevant findings for small patients [10]. The non-surgically treated group also showed clinical improvements during the follow-up period, although muscle atrophy did not improve.

For cats, conservative therapy could be considered in selected cases, especially in older patients with comorbidities. This would include rest, restricted movement, weight management, and nonsteroidal anti-inflammatory drugs. However, the high rate of concomitant meniscal injuries in cats (76%) indicates that most would likely benefit from surgical intervention [1].

Frequently Asked Questions (FAQ) about TPLO in cats

1. How common is cruciate ligament rupture in cats and why is it often diagnosed late?

Cruciate ligament rupture was long considered a rare condition in cats. While cruciate ligament injuries are indeed less common in cats compared to dogs, they are often diagnosed late or not at all, primarily because the clinical symptoms are often much more subtle. Many cats do not exhibit pronounced, persistent lameness, but rather intermittent reluctance to move, reduced jumping ability, or inconsistent weight-bearing on the hind limbs.

Furthermore, classic clinical tests such as the drawer test or the tibial compression test are less reliable in cats than in dogs. These tests can be negative, especially in cases of partial ruptures. Combined with the cat's generally pain-adaptive nature, this often means that cruciate ligament ruptures are only detected when secondary changes such as meniscal damage or arthritic processes are already advanced.

2. How do cruciate ligament ruptures in cats differ from those in dogs?

The crucial difference lies in the pathophysiology. While cruciate ligament ruptures in dogs are in the majority of cases the result of a chronic degenerative process, numerous studies suggest that cruciate ligament ruptures in cats are predominantly traumatic in nature. Owners often report a specific triggering event, such as a fall, a failed jump, or an accident.

The associated injuries also differ significantly: cats exhibit a strikingly high rate of meniscal injuries, affecting up to 76% of cases in studies. Furthermore, bilateral cruciate ligament ruptures occur considerably less frequently in cats than in dogs. These differences have direct consequences for diagnosis, treatment decisions, and surgical planning.

3. Why is TPLO also a sensible treatment option for cats?

Tibial plateau leveling osteotomy follows a biomechanical principle that works regardless of the animal species: By flattening the tibial plateau, the cranial thrust force is neutralized, which leads to instability when the anterior cruciate ligament is absent. A prerequisite for this is an intact posterior cruciate ligament – a condition that is generally met in cats.

Although TPLO was originally developed for dogs, clinical studies show that it is also technically safe and feasible in cats, resulting in stable joint conditions. Long-term results are very convincing: up to 24 months post-operatively, most cats show complete or near-complete restoration of limb function with minimal progression of osteoarthritis.

4. What are the specific challenges of TPLO surgery in cats?

Feline anatomy places special demands on the surgical implementation of TPLO. Due to the smaller size of bones and joints, specially adapted mini- or micro-implants must be used. Preoperative planning also requires the utmost precision, particularly in measuring the tibial plateau angle and determining the degree of rotation.

Another key point is the high prevalence of meniscal injuries. For this reason, a simultaneous mini-arthrotomy is almost always necessary in cats to reliably identify and treat meniscal damage. The surgery therefore requires not only technical expertise but also a deep understanding of feline-specific biomechanics.

5. Are there alternatives to TPLO in cats, and when are these appropriate?

As an alternative to TPLO, extracapsular stabilization techniques and other osteotomous procedures such as tibial tuberosity transposition are available. Extracapsular techniques are technically less complex, less expensive, and do not require osteotomy. However, their long-term stability can be limited, especially in cases of pronounced rotational instability or severe meniscal injuries.

Conservative treatment approaches – consisting of restricting movement, pain management, and weight reduction – can be an option in individual cases, such as in older cats with relevant comorbidities. However, given the high rate of meniscal injuries, most cats benefit in the long term from surgical stabilization. TPLO represents the most biomechanically stable and best-documented option in this regard.

conclusion

Tibial plateau leveling osteotomy (TPLO) is a safe and effective surgical treatment for cruciate ligament rupture in cats. Unlike in dogs, where rupture is typically degenerative, cruciate ligament rupture in cats appears to be primarily traumatic and is often accompanied by extensive meniscal injury [1]. Preliminary results with up to 24 months of follow-up are excellent, with a complication rate of only 241 TPLOs, most of which are minor [1].

All cats in the largest available series showed complete recovery without recurrence, and osteoarthritis progression was minimal [1]. However, the technique requires specific adaptations for the smaller feline anatomy, including the use of mini- and micro-implants [1] and careful measurement of osteotomy parameters [1]. Simultaneous mini-arthrotomy is almost always necessary, as approximately 761 TP3T of cats have meniscal injuries [1].

With increasing experience and available literature, TPLO in cats will establish itself as a valuable surgical option, especially for cats with cruciate ligament rupture and concomitant meniscal injuries. The existing evidence suggests that TPLO in cats is not only technically feasible but can also offer superior clinical outcomes compared to other techniques. Minimal osteoarthritis progression over 24 months, combined with excellent functional results and low complication rates, makes TPLO a standard treatment option that should be considered for suitable candidates [1].

Sources

1. M. Frizzi, L. Ballarini, and D. Gaio, “Tibial plateau leveling osteotomy in cats: A retrospective study of 23 cases,” VCOT Open, 2025.
2. A. Nanda and E. Hans, “Tibial plateau leveling osteotomy for cranial cruciate ligament rupture in canines: Patient selection and reported outcomes,” Veterinary medicine, 2019.
3. S. Tinga et al., “Femorotibial kinematics in dogs treated with tibial plateau leveling osteotomy for cranial cruciate ligament insufficiency: An in vivo fluoroscopic analysis during walking.” Veterinary surgery, 2019.
4. “20123392770,” Unknown Year.
5. “Abstract 27709223,” Unknown Year.
6. E. Nam, M. Amano, M. Mochizuki, and M. Honnami, “Correction of pivot shift phenomenon following tibial plateau leveling osteotomy using lateral fabellotibial suture in a toy-breed dog with cranial cruciate ligament rupture,” Open Veterinary Journal, 2025.
7. L. Koch, B. Bockstahler, A. Tichy, C. Peham, and E. Schnabl-Feichter, “Comparison of extracapsular stabilization techniques using an ultrasonically implanted absorbable bone anchor (Weldix) after cranial cruciate ligament rupture in cats: An in vitro study,” Animals, 2021.
8. S. Tinga et al., “Femorotibial joint kinematics in nine dogs treated with lateral suture stabilization for complete cranial cruciate ligament rupture.” Journal of the American Veterinary Medical Association, 2021.
9. E. Bula and K. Perry, “Tibial tuberosity transposition advancement for treatment of concomitant cranial cruciate ligament rupture and medial patellar dislocation in four feline stifles,” JFMS open reports, 2021.
10. I. Kwananacha, E. Akaraphutiporn, R. Upariputti, C. Lekchareonsuk, and C. Wangdee, “Short-term outcomes of cranial cruciate ligament rupture treated surgically with tibial plateau leveling osteotomy or non-surgically in small-breed dogs weighing less than 10 kg,” Journal of Veterinary Medical Science, 2024.
11. EG Bester, G. Zeiler, GG Stoltz, AJ Oberholster, and AM Kitshoff, “Influence of tibial plateau angle in cranial cruciate ligament-deficient stifle on patellar ligament strain: An ex vivo study.” American Journal of Veterinary Research, 2025.
12. M. Shimada, S. Murakami, T. Tanigawa, N. Kanno, Y. Harada, and Y. Hara, “Comparison of patellar position and moment arm between tibial plateau leveling osteotomy and cranial closing wedge ostectomy: An ex vivo study,” Open Veterinary Journal, 2023.
13. AC Wemmers, M. Charalambous, O. Harms, and H. Volk, “Surgical treatment of cranial cruciate ligament disease in dogs using tibial plateau leveling osteotomy or tibial tuberosity advancement: A systematic review with a meta-analytic approach,” Frontiers in Veterinary Science, 2022.

February 1, 2026

author

Veterinarian Susanne Arndt

Veterinarian Susanne Arndt is the majority shareholder and medical director of the doc4pets group. She studied veterinary medicine at the University of Leipzig and subsequently gained extensive clinical experience – including six years as an assistant veterinarian at the small animal clinic of Dr. Thomas Graf (Cologne) and a year helping to establish and expand a small animal department at the Lahr Animal Health Center. Since 2013, she has owned small animal practices in Karlsbad-Ittersbach and Karlsbad-Langensteinbach. Today, she is responsible for the medical direction of the group, which includes small animal centers in Karlsruhe, Idar-Oberstein, and Appenweier, as well as practices in Malsch and Karlsbad. She is pursuing further professional development, including a Master of Small Animal Science, and is a member of the German Veterinary Medical Society (DVG).

Here is the complete article as a PDF for download: TPLO in cats

You can find the article by Frizzi, Ballarini and Gaio here here.
And Abstract 20123392770 here.