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Carwardine D, Mather A, Schofield I, Langley-Hobbs S, Carbonell-Buj E, Belch A, Barthelemy N, Parsons K. Medial versus lateral transcondylar screw placement for canine humeral intracondylar fissures: A randomized clinical trial. Vet Surg 2024; 53:264-276. [PMID: 37435744 DOI: 10.1111/vsu.13993] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/24/2023] [Accepted: 06/26/2023] [Indexed: 07/13/2023]
Abstract
OBJECTIVE To determine the influence of screw direction on complications following transcondylar screw placement for the treatment of canine humeral intracondylar fissures (HIFs). STUDY DESIGN Equivalence, parallel group, randomized clinical trial. SAMPLE POPULATION Fifty-two client owned dogs (73 elbows). METHODS Transcondylar screw placement was randomized to either a medial or lateral approach. The primary outcome was the incidence of postoperative complications. RESULTS There were 37 cases in the lateral approach group and 36 cases in the medial approach group. There was a significantly greater proportion of postoperative complications following placement of transcondylar screws from a lateral to medial direction (p = .001). There were seven cases with complications (19%) in the medial approach group versus 23 cases with complications (62%) in the lateral approach group. The majority of complications were seromas (n = 13) and surgical site infections (n = 16) with 4 complications requiring further surgery. Implant area moment of inertia (AMI), normalized to bodyweight, was lower in dogs with a major complication (p = .037). CONCLUSION Transcondylar screws placed from lateral to medial for canine HIFs had a greater proportion of postoperative complications in this randomized clinical trial design. Implants with a lower AMI, relative to bodyweight, were more likely to lead to major complications. CLINICAL SIGNIFICANCE We recommend placing transcondylar screws from medial to lateral for canine HIFs to reduce the risk of postoperative complications. Relatively small diameter implants had an increased risk of major complications.
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Affiliation(s)
| | | | | | - Sorrel Langley-Hobbs
- Faculty of Health Sciences, Bristol Veterinary School, University of Bristol, Bristol, UK
| | | | - Alex Belch
- Langford Veterinary Services, Bristol, UK
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Wiseman W, Wilson L. A modified triple tibial osteotomy for management of canine cranial cruciate ligament disease: retrospective assessment of 309 procedures (2017-2020). N Z Vet J 2024; 72:53-60. [PMID: 37830539 DOI: 10.1080/00480169.2023.2271438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 10/09/2023] [Indexed: 10/14/2023]
Abstract
CASE HISTORY Medical records from a single referral hospital (Animal Referral Hospital, Sinnamon Park, Australia) of dogs treated with modified triple tibial osteotomy (TTO) for management of cranial cruciate ligament (CrCL) disease from June 2017 to June 2020 were reviewed. Modifications to the originally described TTO procedure included a modified wedge angle calculation and performing the tibial osteotomies without the use of pre-drilled guide holes. CLINICAL FINDINGS A total of 253 dogs met the inclusion criteria. Two dogs were excluded, leaving 251 dogs that had undergone 309 procedures for assessment, and data from these, including complications, were reviewed. Complete, partial competent, and partial incompetent rupture of the cranial cruciate ligament was identified in 202/309 (65.4%), 79/309 (25.6%), and 28/309 (9.1%) stifles, respectively. Medial meniscal injury was identified in 207/309 (67.0%) stifles at the time of initial surgery. TREATMENT AND OUTCOME Fifty-eight dogs had bilateral procedures, including both single-session and staged surgeries, and 48 of these were available for analyses. The modifications to the TTO procedure described herein resulted in a median wedge angle of 21° and a median post-operative tibial plateau angle of 5.8°. Tibial compression testing following surgery indicated elimination of cranial tibial thrust in all stifles in this series. The most common intra-operative complication was tibial tuberosity fracture (15/309; 4.9%). Minor post-operative complications occurred in 37/309 (12.0%) procedures, with infection being the most common (27/309; 8.7%). Major post-operative complications occurred in 9/309 (2.9%) procedures. The intra- and post-operative complication rates for dogs undergoing bilateral single-session TTO were both 8.3% (2/24). The intra- and post-operative complication rates for dogs undergoing bilateral staged TTO were both 4.2% (1/24). The low number of complications for both the bilateral single-session and bilateral staged TTO groups precluded statistical analysis. All complications resolved uneventfully as determined by the attending surgeon. CLINICAL RELEVANCE The modified TTO technique described here was safe and effective for the management of canine CrCL disease in the dogs included in the case series. Findings of this study suggest that, with careful case selection, the modified TTO may be performed as a bilateral single-session procedure in dogs with concurrent bilateral cranial cruciate ligament disease. Future studies analysing the effects of these modifications on stifle biomechanics would be beneficial. ABBREVIATIONS CrCL: Cranial cruciate ligament; SSI: Surgical site infection; TPA: Tibial plateau angle; TPLO: Tibial plateau levelling osteotomy; TTA: Tibial tuberosity advancement; TTO: Triple tibial osteotomy.
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Affiliation(s)
- W Wiseman
- North Coast Veterinary Specialists, Sippy Downs, QLD, Australia
| | - L Wilson
- Animal Referral Hospital, Sinnamon Park, QLD, Australia
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Figueirinhas P, Gonzalo-Orden JM, Rodriguez O, Regueiro-Purriños M, Prada I, Vilar JM, Rodríguez-Altónaga J. Multiparametric Comparison of Two TTA-Based Surgical Techniques in Dogs with Cranial Cruciate Ligament Tears. Animals (Basel) 2023; 13:3453. [PMID: 38003071 PMCID: PMC10668821 DOI: 10.3390/ani13223453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/01/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
Tearing of the cranial cruciate ligament causes hindlimb lameness in dogs. Different surgical procedures have been proposed to treat this condition. In this study, two different TTA-based techniques and implants were compared. A total of 30 dogs were separated into two groups according to the technique and implant used (Porous TTA® or Model Xgen®). The aim of the study was to assess whether one of these techniques has better functional recovery of the joint, better bone consolidation after the osteotomy procedure and fewer osteoarthritic changes. We compared both groups up to 3 months after surgery. No significant differences were found in any of the assessed parameters. Thus, both procedures were found to be equally effective and safe.
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Affiliation(s)
- Pedro Figueirinhas
- Departamento de Patología Animal, Universidad de Las Palmas de Gran Canaria, Trasmontaña S/N, 35416 Arucas, Spain; (P.F.); (J.M.V.)
| | - José Manuel Gonzalo-Orden
- Departamento de Medicina y Cirugia Veterinaria, Campus de Vegazana, Universidad de León, 24071 León, Spain; (J.M.G.-O.); (M.R.-P.); (I.P.); (J.R.-A.)
| | - Oliver Rodriguez
- Departamento de Patología Animal, Universidad de Las Palmas de Gran Canaria, Trasmontaña S/N, 35416 Arucas, Spain; (P.F.); (J.M.V.)
| | - Marta Regueiro-Purriños
- Departamento de Medicina y Cirugia Veterinaria, Campus de Vegazana, Universidad de León, 24071 León, Spain; (J.M.G.-O.); (M.R.-P.); (I.P.); (J.R.-A.)
| | - Ivan Prada
- Departamento de Medicina y Cirugia Veterinaria, Campus de Vegazana, Universidad de León, 24071 León, Spain; (J.M.G.-O.); (M.R.-P.); (I.P.); (J.R.-A.)
| | - José Manuel Vilar
- Departamento de Patología Animal, Universidad de Las Palmas de Gran Canaria, Trasmontaña S/N, 35416 Arucas, Spain; (P.F.); (J.M.V.)
| | - José Rodríguez-Altónaga
- Departamento de Medicina y Cirugia Veterinaria, Campus de Vegazana, Universidad de León, 24071 León, Spain; (J.M.G.-O.); (M.R.-P.); (I.P.); (J.R.-A.)
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Miller L, Maritato KC, Kennedy SC. Prospective measurement of outcomes and complications of tibial tuberosity advancement using novel mini plates in small breed dogs. Front Vet Sci 2023; 10:1268681. [PMID: 37954667 PMCID: PMC10634372 DOI: 10.3389/fvets.2023.1268681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 09/15/2023] [Indexed: 11/14/2023] Open
Abstract
Cranial cruciate ligament (CrCL) disease is a common orthopedic disease in canine patients. Tibial osteotomy procedures for the treatment of cranial cruciate ligament disease in small breed dogs (<15 kg) have previously been limited. A total of 22 client-owned dogs, 26 stifles, with cranial cruciate ligament disease were treated with novel mini-tibial tuberosity advancement plates. The most common intraoperative complications included the need for plate-cage overlap in 7 stifles (26.92%) and screw head fracture in 1 (3.85%). Post-operative complications included tibial tuberosity fracture (3.85%), post-operative medial patella luxation (7.69%), and persistent lameness (7.69%). Of the 26 stifles evaluated in the medium term (>6-12 months) post-operatively, 92.3% had no lameness, with the remaining 7.7% having Grade 1 lameness. A good to excellent clinical outcome was noted in all 26 stifles that underwent TTA with novel mini plates.
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Affiliation(s)
- Leah Miller
- MedVet Pittsburgh, Surgery, McMurray, PA, United States
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Motz AK, St. Germaine LL, Hoffmann DE, Sung J. A retrospective evaluation of the effect of oclacitinib (Apoquel) administration on development of surgical site infection following clean orthopedic stifle surgery. PLoS One 2023; 18:e0289827. [PMID: 37556416 PMCID: PMC10411735 DOI: 10.1371/journal.pone.0289827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 07/25/2023] [Indexed: 08/11/2023] Open
Abstract
The aim of this study was to determine the effect of oclacitinib (Apoquel) on development of surgical site infections in canines following clean orthopedic stifle surgery. Medical records of dogs undergoing unilateral, clean orthopedic stifle procedures were retrospectively examined for development of post-operative surgical site infections. Data collected for statistical analysis included age, sex, body weight, current medications, anesthesia and surgery times, white blood cell count, and neutrophil count. Surgical site infections were identified in 8.7% (34/390) of stifle procedures- 8.0% (29/364) in dogs not treated with oclacitinib and 19.2% (5/26) in dogs treated with oclacitinib (p = 0.053). There was a significant difference in development of surgical site infection in dogs with longer anesthesia times (p = 0.003) and higher body weights (p = 0.037). Dogs being treated with oclacitinib at the time of clean, orthopedic stifle surgery did not have a significantly higher incidence of surgical site infections. However, client education regarding risk of infection and increased patient monitoring post-operatively are recommended, especially in patients with increased body weight or longer anesthetic times.
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Affiliation(s)
- Alyssa K. Motz
- Surgery Department, Veterinary Specialists & Emergency Services, Rochester, NY, United States of America
| | - Lindsay L. St. Germaine
- Surgery Department, Veterinary Specialists & Emergency Services, Rochester, NY, United States of America
| | - Daniel E. Hoffmann
- Surgery Department, Veterinary Specialists & Emergency Services, Rochester, NY, United States of America
| | - Jed Sung
- Surgery Department, Veterinary Specialists & Emergency Services, Rochester, NY, United States of America
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Zólyomi D, Ipolyi T, Molnár P, Papp M, Szalay F, Németh T. Comparison of the short-term complications of TTA-rapid and modified cTTA procedures. Acta Vet Hung 2022; 70:305-312. [PMID: 36374308 DOI: 10.1556/004.2022.00033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/29/2022] [Indexed: 11/16/2022]
Abstract
The objective of this retrospective study was to determine the complications of the first 30 tibial tuberosity advancement rapid (TTA-rapid) and 30 modified circular tibial tuberosity advancement (mcTTA) procedures performed by our team, and to compare the results with the findings reported in the literature. Our research was based on 30 procedures in each group. All dogs were client-owned. Data were collected only for the study of cases that had a minimum follow-up period of 3 months. Intraoperative (IO) and postoperative (PO) complications were assessed, with the latter divided into two subgroups: major and minor. Results obtained for the TTA-rapid group: IO complications 23.3% (7/30), major PO complications 13.3% (4/30), minor PO complications 16.7% (5/30). Results of the mcTTA group: IO complications 0% (0/30), major PO complications 3.3% (1/30), minor PO complications 20% (6/30). Comparing the complication rates, we found that there was a significant difference between the two groups in the occurrence of IO complications (P = 0.01054); however, there was no significant difference in the incidence of major (P = 0.3533) and minor (P > 0.9999) PO complications between groups. Our results are consistent with the findings reported in the literature and suggest that both techniques are efficient and carry a relatively low complication rate.
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Affiliation(s)
- Dorottya Zólyomi
- 1Department of Small Animal Surgery and Ophthalmology, University of Veterinary Medicine Budapest, István u. 2, H-1078 Budapest, Hungary
| | - Tamás Ipolyi
- 1Department of Small Animal Surgery and Ophthalmology, University of Veterinary Medicine Budapest, István u. 2, H-1078 Budapest, Hungary
| | - Péter Molnár
- 1Department of Small Animal Surgery and Ophthalmology, University of Veterinary Medicine Budapest, István u. 2, H-1078 Budapest, Hungary
| | - Márton Papp
- 2Centre of Bioinformatics, University of Veterinary Medicine Budapest, Budapest, Hungary
| | - Ferenc Szalay
- 3Department of Anatomy and Histology, University of Veterinary Medicine Budapest, Budapest, Hungary
| | - Tibor Németh
- 1Department of Small Animal Surgery and Ophthalmology, University of Veterinary Medicine Budapest, István u. 2, H-1078 Budapest, Hungary
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Wemmers AC, Charalambous M, Harms O, Volk HA. 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. Front Vet Sci 2022; 9:1004637. [PMID: 36532339 PMCID: PMC9748159 DOI: 10.3389/fvets.2022.1004637] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/11/2022] [Indexed: 12/17/2023] Open
Abstract
Tibial Plateau Leveling Osteotomy (TPLO) or Tibial Tuberosity Advancement (TTA) are commonly used surgical techniques for correction of cranial cruciate ligament (CCL) rupture in dogs. This systematic review aims to investigate whether one technique is superior to the other. Seventy-two studies on surgical management of CCL rupture have been identified and evaluated in regard of subjective and objective gait analysis criteria, development of osteoarthritis (OA), thigh circumference measurements, goniometry, joint stability, pain and complication rates. Almost half (47.2 %) of the studies were considered of low quality of evidence, leading to high heterogeneity in quality among studies; this posed a major limitation for an evidence-based systematic review of both surgical techniques. Out of 72 studies, there were only eleven blinded randomized clinical trials, of which five were rated with a low overall risk of bias. However, both techniques were considered to be successful management options. Subjective and objective gait analysis revealed no lameness at long-term evaluation for the majority of the patients. However, it appeared that TTA lead to better OA scores up to 6 months postoperatively, while TPLO had a lower rate of surgical site infections. In summary, no method can be clearly preferred, as most of the study evaluated were subpar. Studies with a high level of evidence are therefore urgently needed for such a common surgical procedure.
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Affiliation(s)
- Annika Christina Wemmers
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hannover, Germany
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Zólyomi D, Ipolyi T, Molnár P, Németh T, Faragó D, Kiss R, Szalay F. Biomechanical testing of canine tibiae: Changes resulting from different tibial tuberosity advancement techniques - Pilot study. Acta Vet Hung 2022; 70:230-235. [PMID: 36037048 DOI: 10.1556/004.2022.00023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 07/28/2022] [Indexed: 11/19/2022]
Abstract
The objective of the present pilot study was to determine the force required to break (a) intact canine tibiae, (b) tibiae following the osteotomy of the tibial tuberosity and (c) tibiae following Tibial Tuberosity Advancement- (TTA-) rapid surgery. Six pairs of tibiae of dogs between 15 and 35 kg body weight were used in a cadaver study. Three groups were created with four tibiae in each group; intact (Group 1), osteotomy of the tibial tuberosity and tibial crest (Group 2) and TTA-rapid (Group 3). The tibiae were put under static axial compressive load, applied until failure. The force required to break the tibiae was termed maximal force (F max). The mean of F max was 8193.25 ± 2082.84 N in Group 1, 6868.58 ± 1950.44 N in Group 2 and 7169.71 ± 4450.39 N in Group 3. The sample size was small for a statistical analysis but as a preliminary result, we have determined the force (F max) required to break canine tibiae. Furthermore, we hypothesise that osteotomies result in weakening of the tibial structure.
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Affiliation(s)
- Dorottya Zólyomi
- 1 Department of Small Animal Surgery and Ophthalmology, University of Veterinary Medicine Budapest, István u. 2, H-1078, Budapest, Hungary
| | - Tamás Ipolyi
- 1 Department of Small Animal Surgery and Ophthalmology, University of Veterinary Medicine Budapest, István u. 2, H-1078, Budapest, Hungary
| | - Péter Molnár
- 1 Department of Small Animal Surgery and Ophthalmology, University of Veterinary Medicine Budapest, István u. 2, H-1078, Budapest, Hungary
| | - Tibor Németh
- 1 Department of Small Animal Surgery and Ophthalmology, University of Veterinary Medicine Budapest, István u. 2, H-1078, Budapest, Hungary
| | - Dénes Faragó
- 2 Research Center for Biomechanics, Faculty of Mechanical Engineering, Budapest University of Technology and Economics, Budapest, Hungary
| | - Rita Kiss
- 2 Research Center for Biomechanics, Faculty of Mechanical Engineering, Budapest University of Technology and Economics, Budapest, Hungary
| | - Ferenc Szalay
- 3 Department of Anatomy and Histology, University of Veterinary Medicine Budapest, Hungary
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Corr S. Update on the management of canine cruciate disease. IN PRACTICE 2022. [DOI: 10.1002/inpr.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Morgera AE, Hoelzler MG, Scavelli TD, Hackett AL. Surgical site infection-inflammation in dogs draped with a single-layer Kraton elastic seal extremity drape for stifle surgery. Vet Surg 2022; 51:464-473. [PMID: 35102581 DOI: 10.1111/vsu.13773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 12/10/2021] [Accepted: 01/08/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare the incidence of surgical site infection-inflammation in dogs undergoing elective orthopedic surgery of the stifle after draping with a single-layer Kraton elastic seal patient drape or conventional double-layer drapes. STUDY DESIGN Prospective clinical trial. SAMPLE POPULATION A total of 789 dogs. METHODS Dogs were assigned to one of two groups: (1) conventional draping with 4-corner drapes and an overlying patient drape (n = 390) or (2) a Kraton seal extremity patient drape without 4-corner drapes (n = 399). All dogs were evaluated for surgical site infection-inflammation by 21 days and 6 months postoperatively. RESULTS The distribution of surgical procedures did not differ between draping techniques and included tibial tuberosity advancement (TTA, n = 480), tibial plateau leveling osteotomy (TPLO, n = 10), extracapsular lateral suture (ECLS, n = 130), medial patellar luxation repair (MPL, n = 63), lateral patellar luxation repair (LPL, n = 1), ECLS/MPL (n = 68), TTA/MPL (n = 12), TTA with joint capsule biopsy (n = 1), and stifle arthroscopy combined with TTA or TPLO (n = 24). Duration of follow up was 180 days (range 3-180 days) for clinical examinations and 182 days (range 2-182 days) for phone communications. Infection-inflammation was documented in 9 dogs after double-layer draping and 11 dogs after single-layer draping at 21 days postoperatively and in 12 dogs after double-layer draping and 7 dogs after single-layer draping at 6 months postoperatively. CONCLUSION No difference in postoperative infection-inflammation was detected between canine stifle surgeries draped with a single-layer Kraton extremity patient drape or double-layer drapes. CLINICAL SIGNIFICANCE The single-layer Kraton extremity patient drape is a viable alternative to conventional double-layer draping in canine stifle surgery.
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Affiliation(s)
- Alison E Morgera
- Surgery Department, Garden State Veterinary Specialists, Tinton Falls, New Jersey, USA
| | - Michael G Hoelzler
- Surgery Department, Garden State Veterinary Specialists, Tinton Falls, New Jersey, USA
| | - Thomas D Scavelli
- Surgery Department, Garden State Veterinary Specialists, Tinton Falls, New Jersey, USA
| | - Amy L Hackett
- Surgery Department, Garden State Veterinary Specialists, Tinton Falls, New Jersey, USA
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Engdahl KS, Boge GS, Bergström AF, Moldal ER, Höglund OV. Risk factors for severe postoperative complications in dogs with cranial cruciate ligament disease - A survival analysis. Prev Vet Med 2021; 191:105350. [PMID: 33892253 DOI: 10.1016/j.prevetmed.2021.105350] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 04/07/2021] [Accepted: 04/11/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To analyze the effect of surgical technique and other risk factors on severe postoperative complications in dogs with cranial cruciate ligament disease (CCLD). MATERIALS AND METHODS A cohort study of 255 dogs (287 stifles) surgically treated for CCLD at two veterinary university hospitals (2011-2016) was performed. The electronic medical records were reviewed and dog owners and referring veterinarians contacted for additional information. The complications were classified as minor, major and catastrophic, where major and catastrophic were considered severe. A multivariable Cox proportional hazards model was applied to assess risk factors for severe postoperative complications. RESULTS Three surgical techniques were used; lateral fabellotibial suture (LFS, 141 stifles), tibial plateau leveling osteotomy (TPLO, 77 stifles) and tibial tuberosity advancement (TTA, 69 stifles). The most common severe postoperative complications were surgical site infections or complications related to the surgical implant. Severe postoperative complications occurred in 31 % of the stifles treated with TPLO, 22 % of the stifles treated with LFS and 25 % of the stifles treated with TTA. The multivariable Cox proportional hazards model identified surgical technique (p = 0.0258) as a risk factor for severe postoperative complications; TPLO had a significantly lower hazard than LFS (hazard ratio (HR) = 0.37, p = 0.007) when controlling for body weight and age, which also were identified as risk factors (HR = 1.05, p < 0.001 and HR = 0.91, p = 0.047, respectively). CONCLUSION AND CLINICAL RELEVANCE Although TPLO procedures had the highest occurrence of severe postoperative complications, the hazard was lower than for LFS after adjusting for body weight and age. This implies that it is important to consider potential effect-modifiers when comparing postoperative complications after CCLD surgery.
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Affiliation(s)
- Karolina S Engdahl
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, P.O. Box 7054, SE-750 07, Uppsala, Sweden.
| | - Gudrun S Boge
- Department of Companion Animal Clinical Sciences, Norwegian University of Life Sciences - School of Veterinary Science, P.O. Box 369 Sentrum, N-0102, Oslo, Norway
| | - Annika F Bergström
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, P.O. Box 7054, SE-750 07, Uppsala, Sweden
| | - Elena R Moldal
- Department of Companion Animal Clinical Sciences, Norwegian University of Life Sciences - School of Veterinary Science, P.O. Box 369 Sentrum, N-0102, Oslo, Norway
| | - Odd V Höglund
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, P.O. Box 7054, SE-750 07, Uppsala, Sweden
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Terreros A, Daye RM. Prospective Evaluation of a Citrate-Based Biomaterial Wedge for a Modified Maquet Procedure in the Treatment of Cranial Cruciate Ligament Rupture in Dogs. Vet Comp Orthop Traumatol 2020; 34:137-143. [PMID: 33157561 DOI: 10.1055/s-0040-1719058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of this study was to describe short- and mid-term outcomes, complications, implant bioabsorption and owner satisfaction for a modified Maquet procedure (MMP) in which a novel bioabsorbable citrate-based implant is used as the wedge component to treat cranial cruciate ligament rupture in client-owned dogs. STUDY DESIGN Prospective clinical study of dogs (n = 13) undergoing MMP (n = 15). Intraoperative complications, postoperative complications, clinical follow-up using a 5-point lameness score and radiographs at 8 weeks and 6 months postoperatively were obtained. Mid-term outcome was assessed via physical examination, radiographs, canine orthopaedic index and owner satisfaction questionnaires. RESULTS No catastrophic complications occurred. Major complications occurred in 3/15 stifles. All were surgical site infections and one case required implant removal. Minor complications occurred in 9/15 stifles. Non-displaced cortical hinge fractures were the most common minor complication, and these occurred intraoperatively (4/15) or postoperatively (2/15). Three dogs achieved full function, eight dogs acceptable function and the outcome was unacceptable in two dogs. Most owners were satisfied with the procedure (11/13). Complete implant bioabsorption was not confirmed on mid-term radiographs. CONCLUSION The described MMP with a citrate-based implant can produce satisfactory mid-term results. However, the long-term outcome of this procedure must be evaluated and technical modifications need to be implemented prior to larger-scale use of this implant.
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Affiliation(s)
- Alex Terreros
- Ohio Veterinary Surgery and Neurology, Metropolitan Veterinary Hospital, Akron, Ohio, United States
| | - R Mark Daye
- Ohio Veterinary Surgery and Neurology, Metropolitan Veterinary Hospital, Akron, Ohio, United States
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Matchwick AIM, Bridges JP, Scrimgeour AB, Worth AJ. A retrospective evaluation of complications associated with forkless tibial tuberosity advancement performed in primary care practice. Vet Surg 2020; 50:121-132. [PMID: 33085159 DOI: 10.1111/vsu.13502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 06/27/2020] [Accepted: 07/28/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To report postoperative complications associated with forkless tibial tuberosity advancement (TTA) performed in primary care veterinary practice and to compare results with previous publications. STUDY DESIGN Retrospective study. SAMPLE POPULATION Three hundred seventy-four forkless TTAs in 329 dogs performed by six nonspecialist veterinarians. METHODS Medical records of dogs treated with a standard forkless TTA (2013-2016) and with at least 12 months of postoperative follow-up were reviewed. Complications recorded by the referring practice or the operating veterinarian were classified as minor (medically treated) or major (surgically treated). RESULTS Complications occurred in 57 of 374 (15.2%) TTAs; 28 (7.5%) complications were major, and 29 (7.7%) complications were minor. Postliminary meniscal injuries were documented in 12 of 374 (3.2%) TTAs (12/57 major complications) and were more common when the ratio of cage size to bodyweight was ≤0.25 (P = .019). Mean TTA (cage size) was greater in this population than what has been previously reported for a lower median bodyweight. CONCLUSION The incidence of major complications was low and within the range previously reported for TTA in referral practice after adjusting for study design. The magnitude of advancement was greater, and the incidence of postliminary meniscal injury was lower than what has been previously reported, after accounting for dogs that had a preliminary meniscal injury or medial meniscal release. CLINICAL SIGNIFICANCE Forkless TTA may be successfully performed by experienced veterinarians in primary care practice with a low rate of complications. The incidence of postliminary meniscal injury may be reduced by a greater degree of advancement of the tibial tuberosity.
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Affiliation(s)
| | - Janis P Bridges
- School of Veterinary Science, Massey University, Palmerston North, New Zealand
| | | | - Andrew J Worth
- School of Veterinary Science, Massey University, Palmerston North, New Zealand
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Bernardi-Villavicencio C, Jimenez-Socorro AN, Rojo-Salvador C, Robles-Sanmartin J, Rodriguez-Quiros J. Short-term outcomes and complications of 65 cases of porous TTA with flange: a prospective clinical study in dogs. BMC Vet Res 2020; 16:279. [PMID: 32778092 PMCID: PMC7418395 DOI: 10.1186/s12917-020-02469-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 07/10/2020] [Indexed: 11/13/2022] Open
Abstract
Background Cranial cruciate ligament rupture (CrCLR) is the most common orthopaedic cause of lameness in the hind limb in dogs. Many surgical treatments have been described, but tibial tuberosity advancement (TTA) is one of the most commonly used today. Since it was first described, TTA has evolved to reduce major complications and to arrest the progression of osteoarthrosis. The aim of this study was to assess a surgical technique called Porous TTA with flange prospectively. This study was performed in 61 dogs that underwent 65 Porous TTA with flange procedures, to validate it as an alternative CrCLR treatment. Complications and clinical outcomes (pain, lameness, weight bearing, flexion, extension, crepitation and atrophy) were reported over 3 months, i.e. at 3, 6 and 12 weeks postoperatively. Results The results showed a positive clinical outcome, a minor complication rate of 47.69% at the first review 3 weeks postoperatively, 10.77% at the second one (6 weeks after the surgery) and 4% at the third one (at 12 weeks). Major complications were observed only at the last review, with one case that had an infection requiring implant removal; this represented 1.5% of cases. Variables evaluated for a relationship with complication scores and improvement were body condition score, sex, age, breed, body weight, breed size, side of the affected limb, traumatic anamnesis and time of lameness before surgery. No relationship was detected. Conclusions Clinical outcomes and complications show that Porous TTA with flange is an efficient alternative for surgical treatment of CrCLR in dogs.
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Affiliation(s)
- Cristina Bernardi-Villavicencio
- Facultad de Ciencias Agropecuarias, Universidad de Cuenca, c/ Diego de Tapia y Av. 12 de Octubre s/n, EC010205, Cuenca, Azuay, Ecuador. .,Hospital Clinico Veterinario Complutense, Departamento de Medicina y Cirugia Animal, Facultad de Veterinaria, Universidad Complutense de Madrid, Av. Puerta de Hierro, s/n, 28040, Madrid, Spain.
| | - Antonio Nicolas Jimenez-Socorro
- Hospital Clinico Veterinario Complutense, Departamento de Medicina y Cirugia Animal, Facultad de Veterinaria, Universidad Complutense de Madrid, Av. Puerta de Hierro, s/n, 28040, Madrid, Spain.,C.V. Eurocan, c/ Alfonso Senra, 4, 28440 Guadarrama, Madrid, Spain
| | - Concepcion Rojo-Salvador
- Seccion Departamental de Anatomia y Embriologia (Veterinaria), Universidad Complutense de Madrid, Av. Puerta de Hierro, s/n, 28040, Madrid, Spain
| | - Javier Robles-Sanmartin
- Hospital Clinico Veterinario Complutense, Departamento de Medicina y Cirugia Animal, Facultad de Veterinaria, Universidad Complutense de Madrid, Av. Puerta de Hierro, s/n, 28040, Madrid, Spain.,C.V. Eurocan, c/ Alfonso Senra, 4, 28440 Guadarrama, Madrid, Spain
| | - Jesus Rodriguez-Quiros
- Hospital Clinico Veterinario Complutense, Departamento de Medicina y Cirugia Animal, Facultad de Veterinaria, Universidad Complutense de Madrid, Av. Puerta de Hierro, s/n, 28040, Madrid, Spain
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Plyusnin A, Kulkova J, Arthurs G, Jalava N, Uppstu P, Moritz N. Biological response to an experimental implant for tibial tuberosity advancement in dogs: A pre-clinical study. Res Vet Sci 2019; 128:183-196. [PMID: 31816501 DOI: 10.1016/j.rvsc.2019.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/30/2019] [Accepted: 12/01/2019] [Indexed: 01/03/2023]
Abstract
In this study, we propose a novel bioresorbable bioactive implant for tibial tuberosity advancement (TTA). The implant consists of a gradually resorbing load-bearing shell which encompasses rapidly resorbing small casings loaded with silica-based bioactive glass (BG) particulates which promote bone formation and reduce the risk of infection. The shell and the casings are manufactured by 3D printing from two medical grade bioresorbable polymers (a polyglycolide/lactide based and a polydioxanone based) that have different degradation rates. The casings are expected to resorb within days after surgery to expose the BG particulates while the shell would retain the load-bearing properties of the implant for the time required by bone healing. Unlike the currently used metallic devices, the novel implant is resorbed and excreted from the body once its purpose is fulfilled. This study presents a logical progression from the in vitro characterisation of the materials and implants to the in vivo investigation of the experimental implants. This included mechanical testing of the materials, finite element analysis of a preliminary design of the novel TTA implant, assessment of the degradation behaviour of the polymers and the ion exchange of BG in simulated body fluid, and investigation of the biological response to the novel implants after implantation in rabbits. The osteointegration of the novel implants was comparable to the osteointegration of Ti6Al4V implants in the control group; the biological efficacy and safety were confirmed. The biological response was in line with the expectations. The proof of concept for the novel TTA implants was demonstrated.
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Affiliation(s)
- Artem Plyusnin
- Biomedical Engineering Research Group, Biomaterials and Medical Device Research Program, Itäinen Pitkäkatu 4B (PharmaCity), FI-20520 Turku, Finland; Department of Biomaterials Science, Turku Clinical Biomaterials Centre - TCBC, Institute of Dentistry, University of Turku, Itäinen Pitkäkatu 4B (PharmaCity), FI-20520 Turku, Finland
| | - Julia Kulkova
- Biomedical Engineering Research Group, Biomaterials and Medical Device Research Program, Itäinen Pitkäkatu 4B (PharmaCity), FI-20520 Turku, Finland; Department of Biomaterials Science, Turku Clinical Biomaterials Centre - TCBC, Institute of Dentistry, University of Turku, Itäinen Pitkäkatu 4B (PharmaCity), FI-20520 Turku, Finland.
| | - Gareth Arthurs
- Dick White Referrals, Station Farm, Long Road, Six Mile Bottom, CB8 0UH, UK
| | - Niki Jalava
- Biomedical Engineering Research Group, Biomaterials and Medical Device Research Program, Itäinen Pitkäkatu 4B (PharmaCity), FI-20520 Turku, Finland; Department of Biomaterials Science, Turku Clinical Biomaterials Centre - TCBC, Institute of Dentistry, University of Turku, Itäinen Pitkäkatu 4B (PharmaCity), FI-20520 Turku, Finland
| | - Peter Uppstu
- Laboratory of Polymer Technology, Faculty of Science and Engineering, Åbo Akademi University, Piispankatu 8, FI-20500 Turku, Finland
| | - Niko Moritz
- Biomedical Engineering Research Group, Biomaterials and Medical Device Research Program, Itäinen Pitkäkatu 4B (PharmaCity), FI-20520 Turku, Finland; Department of Biomaterials Science, Turku Clinical Biomaterials Centre - TCBC, Institute of Dentistry, University of Turku, Itäinen Pitkäkatu 4B (PharmaCity), FI-20520 Turku, Finland
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McCartney W, Ober C, Benito M, MacDonald B. Comparison of tension band wiring and other tibial tuberosity advancement techniques for cranial cruciate ligament repair: an experimental study. Acta Vet Scand 2019; 61:44. [PMID: 31578143 PMCID: PMC6775671 DOI: 10.1186/s13028-019-0481-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 09/25/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Cranial cruciate ligament (CCL) rupture is one of the most common causes of limb lameness in dogs. Surgical techniques based on tibial osteotomies such as tibial plateau leveling osteotomy and tibial tuberosity advancement are used to eliminate dynamic thrust. Tibial tuberosity advancement (TTA) uses an osteotomy fixated by cage, plates, forks and screws to change the relationship of the patellar tendon and tibial plateau angle. Tension band wiring technique is one of the most common surgical methods used to treat a tension fracture and remains the gold standard for the treatment of tibial tuberosity fractures. In this study, we compared experimentally the biomechanical effect of application of tension band wiring compared to other techniques for the fixation of the TTA osteotomy. The techniques compared to are standard commercially available systems for TTA fixation. RESULTS Tension band wiring (TBW) presented the higher resistance to failure compared to all the other surgical procedures, with the highest values found in the TBW group with 1.47 ± 0.07 N and the lowest in the TTA cage (0.82 ± 0.08) and TTA-2 (0.85 ± 0.06) groups with statistically significant differences in all cases (P < 0.001). TTA rapid and TTA plate groups exhibited a similar strength, and same happened between TTA-2 and TTA cage groups. All the other comparisons by pair were significantly different with P < 0.001. CONCLUSIONS Results suggest that fixating the osteotomy with tension band wiring increases the strength of the fixation and decrease the risk of implant failure. Further clinical studies are needed to demonstrate in vivo reliability and to test different variables such as size and weight of dogs. These results could have important clinical implications in the treatment of CCL ruptures.
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Morato GO, Rocha AG, Chung DG, da Conceição MEBAM, Minto BW, Filho JGP, Dias LGGG. Lyophilized and gamma-sterilized allogeneic bone implant used as a spacer for advancement of a modified tibial tuberosity in the treatment of cranial cruciate ligament disease in dogs. PLoS One 2019; 14:e0220291. [PMID: 31381582 PMCID: PMC6681943 DOI: 10.1371/journal.pone.0220291] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 07/13/2019] [Indexed: 11/22/2022] Open
Abstract
The objective of this study was to evaluate the use of a lyophilized and gamma-sterilized allogeneic freeze-dried bone wedge as a spacer for advancement of a modified tibial tuberosity (mTTA) in 16 knees that were clinically diagnosed with cranial cruciate ligament disease. Patients underwent radiography before the surgical procedure as well as immediately after surgery and at 30, 60, 90 and 120 days post-surgery, and their locomotion was evaluated at the same time points except for the immediate postoperative period. The surgical wounds were evaluated for signs of infection and rejection of the bone implant. Locomotion was graded on a scale of 0–5, with 0 indicating no limping and 5 indicating limb functional impotence. The "tibial-tibial bone-tibial implant" interfaces were evaluated radiographically, and each interface was assigned scores of 0–3, with 0 indicating no contact between the implant and adjacent bone and 3 indicating a bone bridge throughout the interface. The patients showed good clinical and radiographic recovery. The lyophilized bone spacer allowed for easy storage and transport and rapid and satisfactory execution of mTTA while showing resistance to drilling and fixation with screws in 87.5% of cases and a mean surgical time of 45.9 minutes. No immunogenic reactions were observed in 93.7% of the cases. One patient presented infection of the surgical focus, which showed remission after antimicrobial therapy. All patients showed functional recovery of the operated limb, with the number of clinically healthy patients being higher than those with claudication at 120 days (p ≤ 0.05). In all patients, it was possible to verify the incorporation of the bone implant into the tibia. Bone union occurred progressively, and the degrees of bone union observed on radiographs at postoperative days 60, 90, and 120 were significantly greater (p < 0.05) than those observed in the immediate postoperative period and at 30 days.
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Affiliation(s)
| | - Artur G. Rocha
- Hospital Veterinário Universitário, Centro Universitário Central Paulista (Unicep), São Carlos, São Paulo, Brazil
| | | | - Maria E. B. A. M. da Conceição
- Division of Veterinary Surgery, Department of Clinic and Animal Surgery, College of Agricultural Sciences and Veterinary Medicine, São Paulo State University "Julio de Mesquita Filho", Jaboticabal Campus, São Paulo, Brazil
| | - Bruno W. Minto
- Division of Veterinary Surgery, Department of Clinic and Animal Surgery, College of Agricultural Sciences and Veterinary Medicine, São Paulo State University "Julio de Mesquita Filho", Jaboticabal Campus, São Paulo, Brazil
| | - João G. Padilha Filho
- Division of Veterinary Surgery, Department of Clinic and Animal Surgery, College of Agricultural Sciences and Veterinary Medicine, São Paulo State University "Julio de Mesquita Filho", Jaboticabal Campus, São Paulo, Brazil
| | - Luis G. G. G. Dias
- Division of Veterinary Surgery, Department of Clinic and Animal Surgery, College of Agricultural Sciences and Veterinary Medicine, São Paulo State University "Julio de Mesquita Filho", Jaboticabal Campus, São Paulo, Brazil
- * E-mail:
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Ferrell CL, Barnhart MD, Herman E. Impact of postoperative antibiotics on rates of infection and implant removal after tibial tuberosity advancement in 1,768 canine stifles. Vet Surg 2019; 48:694-699. [PMID: 31168843 DOI: 10.1111/vsu.13250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 04/24/2019] [Accepted: 05/16/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To report infection rate, implant removal rate, and postoperative antibiotic therapy after tibial tuberosity advancement (TTA) in dogs. STUDY DESIGN Retrospective study. ANIMALS One thousand seven hundred sixty-eight stifles in 1,732 dogs. METHODS Medical records (January 2007-December 2011) of dogs treated with a TTA were reviewed. Cases were included if at least 1 year of postoperative follow-up was available and no additional procedures were performed on the stifle. Date of surgery, date of culture, culture and susceptibility results, postoperative antimicrobials used, and any implant removals were recorded. Use of postoperative antibiotics and implant removal were evaluated statistically for effect on infection occurrence and resolution. RESULTS Postoperative infections were diagnosed in 82 of 1,768 (4.6%) stifles. Implants were removed from 32 (39%) stifles, with plate and screw removal only in 23 (71.9%) stifles. The rate of infection did not differ between dogs with or without postoperative antibiotic therapy. However, dogs receiving postoperative antibiotic therapy were at risk for developing an oxacillin-resistant infection (P = .001). Oxacillin-resistant infections were associated with a requirement for implant removal to achieve resolution compared with other types of bacterial infections (P < .05). CONCLUSION No benefit was detected with the use of postoperative antibiotics after TTA in this population. Implant removal was infrequent, and the requirement for cage removal was not commonly required for infection resolution. CLINICAL SIGNIFICANCE This study does not provide evidence to support postoperative antibiotic therapy after TTA. Postoperative infection can be treated in most dogs without removal of the TTA cage.
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Affiliation(s)
| | - Matthew D Barnhart
- Department of Surgery, Medvet Medical and Cancer Centers, Worthington, Ohio
| | - Eric Herman
- Department of Surgery, Medvet Medical and Cancer Centers, Worthington, Ohio
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Zhalniarovich Y, Sobolewski A, Waluś G, Adamiak Z. Tibial Diaphyseal Fracture as a Major Complication of Tibial Tuberosity Advancement With Cranial Fixation (TTA CF)-A Case Report. Top Companion Anim Med 2019; 34:14-17. [PMID: 30808491 DOI: 10.1053/j.tcam.2018.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 11/07/2018] [Accepted: 12/04/2018] [Indexed: 11/11/2022]
Abstract
This article reports a major complication of tibial tuberosity advancement with cranial fixation for the treatment of cranial cruciate ligament rupture in a Boxer. Twelve days postoperatively the dog underwent revision surgery for fracture of the tibia and tibial tuberosity. The tibial tuberosity fracture was secured to the tibial diaphysis using the 2 K-wires and a medial 3.5 dynamic compression plate was used to stabilize the tibial diaphysis fracture. The fracture was reduced and the plate applied using minimally invasive plate osteosynthesis to preserve the blood supply to the bone. Two weeks after revision surgery, the dog was using the operated limb without apparent lameness at a walk and trot. No complications were observed after revision surgery. Tibial tuberosity fracture and tibial diaphysis fracture as complications after tibial tuberosity advancement with cranial fixation healed with satisfactory clinical outcomes but revision surgery was required.
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Affiliation(s)
- Yauheni Zhalniarovich
- University of Warmia and Mazury in Olsztyn, Faculty of Veterinary Medicine, Department of Surgery and Radiology with Clinics, Olsztyn, Poland.
| | | | | | - Zbigniew Adamiak
- University of Warmia and Mazury in Olsztyn, Faculty of Veterinary Medicine, Department of Surgery and Radiology with Clinics, Olsztyn, Poland
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Trumpatori B, Maritato KC. Editorial. Top Companion Anim Med 2018; 33:A2-A3. [PMID: 30243366 DOI: 10.1053/j.tcam.2018.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Brian Trumpatori
- Associate Editor - Topics in Companion Animal Medicine Chief of Surgery Veterinary Specialty Hospital of the Carolinas Cary, NC
| | - Karl C Maritato
- Department Representative - Surgery - Cincinnati & Dayton MedVet Medical & Cancer Centers for Pets
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von Pfeil DJF, Kowaleski MP, Glassman M, Dejardin LM. Results of a survey of Veterinary Orthopedic Society members on the preferred method for treating cranial cruciate ligament rupture in dogs weighing more than 15 kilograms (33 pounds). J Am Vet Med Assoc 2018; 253:586-597. [DOI: 10.2460/javma.253.5.586] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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