Long-term complications following tibial plateau levelling osteotomy in small dogs with tibial plateau angles > 30°

Effect of cranial tibial artery laceration on radiographic bone healing and perioperative complications in dogs undergoing tibial plateau leveling osteotomy

During tibial plateau leveling osteotomy (TPLO), the laceration of the cranial tibial artery (LCTA) may occur, and the ligation of the cranial tibial artery might lead to impaired blood supply to the osteotomy site. The present case-control study aimed to evaluate the effect of LCTA on TPLO healing and the occurrence of perioperative complications. The incidence and predisposing factors to LCTA were also investigated. Fourteen cases experiencing LCTA were retrospectively enrolled from medical records of two veterinary teaching hospitals (LCTA group), whereas 28 randomly selected TPLOs that did not experience LCTA were included in the control group. Signalment data, proximal tibial epiphysis conformation, osteotomy features, perioperative complications, and bone healing were compared between the two groups. Bone healing was evaluated using the modified radiographic union scale for tibial fracture and the visual analog scale. The mean incidence was 9.6%. Bodyweight was significantly higher in the LCTA group compared to the control group (P = 0.009). Dogs belonging to the LCTA groups were significantly younger (P = 0.01). Intraoperative hypotension was significantly overreported in the LCTA group (P = 0.0001). None of the other variables differed significantly between the two groups. Dogs' size seems to be a predisposing factor, with dogs weighing >15 kg having 22 times more chance of experiencing LCTA. Due to the well-developed collateral blood supply of the canine hindlimb, LCTA and the closure of the cranial tibial artery did not appear to delay the radiographic bone healing or affect the incidence of perioperative complications.

Objective and owner-reported outcomes after modified cranial closing wedge ostectomy: a case series

Immediate and longer-term outcomes of a cranial closing wedge ostectomy variant for management of canine cranial cruciate ligament disease were assessed in this single-center retrospective consecutive study. Records and radiographs were retrieved and assessed by three independent observers to evaluate tibial plateau angle, anatomical-mechanical axis angle, tibial tuberosity distalization, and mechanical axis length before and after surgery. Kinetic gait analysis and owner questionnaires were used to assess clinical outcomes. Seventeen stifles from fifteen dogs were evaluated radiographically. Mean error from target tibial plateau angle was 0.4 degrees. Anatomical-mechanical axis angles reduced from mean 2.9 degrees preoperatively to mean - 0.9 degrees postoperatively. Tibial tuberosity distalization was mean 5.0% of mechanical axis length, and mean reduction in mechanical axis length was 0.1%. Increased tibial plateau angles were noted in 8/17 stifles, with a mean of 9.6 degrees at short-term follow-up. Major complications were observed in 9/17 stifles. Long term follow-up (mean 832 days) was obtained with gait analysis in 8/15 dogs and with questionnaire in 11/15. Most dogs (9/11) were weakly to moderately affected by osteoarthritis symptoms. All values for peak vertical force and vertical impulse normalized to body weight exceeded local lower reference limits for normal dogs, indicating acceptable limb use. Satisfactory immediate and long-term clinical outcomes appear to be possible with this technique, but the high incidence of shorter-term complications may caution against the technique or the fixation and management described here.

Comparison of perioperative serum osteocrin concentrations between surgical techniques in dogs with cranial cruciate ligament rupture

The cranial cruciate ligament (CCL) rupture is a common orthopedic disease in dogs that is usually managed with tibial plateau leveling osteotomy (TPLO) or extracapsular lateral suture (ECLS). Osteotomy is generally associated with some complications, including nonunion. The periosteum plays an important role in bone growth and remodeling. Osteocrin (OSTN), which was recently identified and is involved in bone formation and differentiation, is produced in the periosteum and osteoblasts. The aimed to investigate whether the concentrations of serum OSTN change before and after stifle surgery in dogs and compare the OSTN concentrations in the two surgical techniques (TPLO: n = 20 vs. ECLS: n = 36). The postoperative serum OSTN concentration in the TPLO group was significantly lower than the preoperative value (p < 0.05), while serum OSTN concentrations differed statistically between the preoperative and suture-removal periods. In contrast, no significant differences were observed in the ECLS group. In conclusion, osteotomy affects serum OSTN concentrations during the perioperative period in dogs, which may be related to periosteal injury.

Tibial Plateau Leveling Osteotomy in small and large breed dogs: a comparative retrospective study of complications and outcomes

OBJECTIVE

To compare complication rates and outcomes of small and large breed dogs that had locking plate Tibial Plateau Leveling Osteotomy (TPLO) performed due to cranial cruciate ligament disease during the same time period at a single institution and identify potential influencing factors.

MATERIAL AND METHODS

136 cases with TPLO performed at a single institution between January 2013 and December 2015 were retrospectively reviewed. Dogs were grouped by plate sizes (2.0, 2.4, 2.7, 3.5 and 3.5 broad) and by small breeds (2.0-2.7 plate sizes) and large breeds (3.5 plates). Potential influencing factors on lameness and complications were recorded from the database and measured on radiographs and statistically compared.

RESULTS

Small dogs experienced fewer complications than large dogs (10% vs. 22%) and not a single major complication. Small dogs were significantly less lame at recheck and at long-term follow-up. Progression of bone healing had an influence on the lameness grade of dogs at recheck after TPLO. Distance of the most proximal screw from the joint was identified as a risk factor for implant failure. The width of the patella ligament correlated with body weight and uniformly increased 2.4 times after TPLO.

CONCLUSIONS

TPLO in small breed dogs has a lower overall complication rate than in large breed dogs. The TPLO plate should always be placed as close to the joint as possible to reduce the risk of implant failure.

CLINICAL RELEVANCE

TPLO can be recommended as treatment for cranial cruciate ligament rupture (CCLR) in dogs of all sizes.

Impacts of tibial plateau levelling osteotomy on the tibial insertion of the medial collateral ligament of the canine stifle joint - A cadaveric study

OBJECTIVE

The aim of this study was to assess the potential consequences of tibial plateau levelling osteotomy (TPLO) for the medial collateral ligament (MCL) tibial insertion (TI) with a particular focus on the effects of the TPLO planning technique and of the size of saw blade.

STUDY DESIGN

Eighty-six stifle joints were collected from 43 canine cadavers and dissected free of soft tissue to expose the MCL. The MCL insertion sites were first identified with Chinese ink on intact stifle joints, and then marked with radio-opaque barium sulfate after removal of the MCL. Mediolateral radiographs were made of each marked stifle joint and used for TPLO digital planning. For each stifle, planning the TPLO was performed by centring the osteotomy at the intersection of the tibial plateau and the mechanical axis of the tibia in group 1, and at the top of the intercondylar tubercles in group 2. Whenever possible, two saw blade sizes were tested in each group. Measurements were taken after TPLO simulation to assess how the procedure would alter the MCL TI.

RESULTS

In group 1, the integrity of the MCL TI was affected by the TPLO planning in 87.2% of the cases with the small saw blade and in 59.3% of the cases with the large blade, and in group 2, in 94.2% of the cases with the small and 77.9% with the large saw blade. In group 1, the osteotomy line was located above the TI, completely severing the MCL in four cases versus in 11 cases in group 2, while severing occurred in 14/15 cases with the small saw blade.

CONCLUSION

During TPLO, the osteotomy line transected the MCL TI in the majority of dogs. Centring the osteotomy at the intersection of the tibial plateau and the mechanical axis of the tibia and using the largest saw size that preserves tibial tuberosity and patellar tendon insertion seems to be the best way to preserve the MCL TI as much as possible. Further research is needed to evaluate the clinical impact of MCL TI transection.

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

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.

Comparison of incidence of medial meniscal injury in small dogs (≤15 kg) and medium-to-large dogs (>15 kg) with naturally occurring cranial cruciate ligament disease undergoing tibial plateau levelling osteotomy: 580 stifles (2015 to 2019)

OBJECTIVES

To investigate whether a difference exists in incidence of medial meniscal tears between small (≤15 kg) and medium-to-large (>15 kg) dogs with naturally occurring cranial cruciate ligament disease.

MATERIALS AND METHODS

Records were retrospectively reviewed to identify the incidence of medial meniscal tears in dogs undergoing tibial plateau levelling osteotomy. Degree of cruciate insufficiency, method of identification (arthroscopy or arthrotomy), tibial plateau angle, weight and signalment were recorded. A two-proportion z-test with clustering adjustment was used to compare the meniscal tear rate between the two groups. Logistic regression analysis was used to investigate the effects of variables on medial meniscal tears.

RESULTS

Seventy-six stifles in 67 small dogs and 504 stifles in 384 medium-to-large dogs were included. The rate of meniscal injury at index surgery was 38.2% in small dogs and 36.7% in medium-to-large dogs. The subsequent meniscal tear rate was 1.3% in small dogs and 8% in medium-to-large dogs. The difference in meniscal tear rate was not statistically significant at either index surgery or subsequently. Degree of cruciate ligament insufficiency and use of arthroscopy were significantly associated with medial meniscal tears at index surgery. No variables were significantly associated with subsequent medial meniscal tears.

CLINICAL SIGNIFICANCE

No significant difference exists in medial meniscal tear rate between small and medium-to-large dogs either at index surgery or subsequently. The index of suspicion of concurrent medial meniscal tears should be higher in dogs with complete tear of the cranial cruciate ligament but a partial tear does not preclude meniscal pathology.

Efficacy of a Customized Three-Dimensional Printing Surgical Guide for Tibial Plateau Leveling Osteotomy: A Comparison With Conventional Tibial Plateau Leveling Osteotomy

Objective: To prospectively evaluate the effect of a computed tomography (CT)-based three-dimensional (3D) printing surgical guide on surgical accuracy of tibial plateau leveling osteotomy (TPLO). Study Design: Cadaveric study. Animals: Canine cadaveric hindlimbs (n = 14). Methods: TPLO was performed on cadaver hindlimbs disarticulated at the coxofemoral joint to compare and evaluate the conventional TPLO method (n = 7) with one that used customized 3D printing surgical guides (n = 7). The operation time and postoperative tibial plateau angle (TPA) of the osteotomy were evaluated. Moreover, the osteotomy inclination, torsion, and distance and the direction of eccentricity were assessed using CT reconstruction. Results: Significant differences in the operation time (p < 0.001), postoperative TPA (p < 0.05), osteotomy inclination (p < 0.05), and osteotomy torsion (p < 0.05) were observed. Conclusion: The use of TPLO surgical guide reduced the operation time and inaccurate osteotomy. Clinical Significance: The surgical technique applied with a customized 3D printing surgical guide could be used to perform osteotomy and TPA adjustment more precisely than conventional TPLO.

Cranial cruciate ligament rupture in small dogs (<15 kg): a narrative literature review

Small breed dogs (<15 kg) affected by cranial cruciate ligament rupture secondary to cranial cruciate ligament disease are usually middle-aged (mean age at presentation: 5.4 to 9.8 years); terrier breeds, miniature and toy poodles are over-represented. Small breed dogs have a different morphology of the proximal tibia compared to medium and large breed dogs with a steep tibial plateau angle (mean tibial plateau angle 28.8° to 36.3°), absent base of the flare of the tibial tuberosity and a caudally bowed fibula. There is a lack of evidence regarding the optimal management of cranial cruciate ligament rupture in small dogs. The treatment options consist of conservative management, extracapsular stabilisation, cranial closing wedge ostectomy, tibial plateau levelling osteotomy and tibial tuberosity advancement. The limited evidence available shows that conservative management is likely to result in prolonged recovery time (average time to recovery approximately 4 months). There is paucity of reports focussing on extracapsular stabilisation in small breed dogs, and questions have been raised regarding the early failure of the extracapsular suture subject to higher loads due to the steep tibial plateau angle of small breed dogs. Cranial closing wedge ostectomy and tibial plateau levelling osteotomy have been reported to have low major complication rates and good subjective outcomes. It is controversial whether tibial tuberosity advancement is a suitable technique in dogs with steep tibial plateau angle, which includes most small breed dogs.

Risk factors for short-term postoperative complications in the 8 weeks after tibial plateau leveling osteotomy in dogs weighing less than 15 kilograms: A retrospective study

The purpose of this retrospective study was to evaluate the risk factors for short-term postoperative complications in the 8 weeks after unilateral tibial plateau leveling osteotomy (TPLO) for cranial cruciate ligament rupture in small dogs weighing less than 15 kg. Medical records were retrospectively reviewed for 90 dogs weighing <15 kg that underwent medial parapatellar arthrotomy with inspection of the meniscus and TPLO performed by the same surgeon between January 2012 and December 2017. The overall complication rate was 4.44% (4/90 dogs). There were four cases of partial incisional dehiscence, none of which required surgical revision. Complications were significantly more likely in dogs that had undergone placement of a 2.4-mm TPLO plate. Overall, the complication rate was less than that in previous studies of dogs weighing > 15kg. In this study, patients in which 2.4-mm TPLO plates were used were more likely to develop postoperative complications. Dogs weighing <15 kg that underwent TPLO had good short-term outcomes with minimal complications. In our study, the overall complication rate after TPLO in dogs weighing <15 kg is less than that historically reported in heavier dogs. Our data suggests that TPLO is a safe treatment option in small dogs with cranial cruciate ligament rupture.

Center of rotation of angulation-based leveling osteotomy combined with a coplanar cranial closing wedge ostectomy to manage cranial cruciate ligament insufficiency in dogs with excessive tibial plateau angle

OBJECTIVE

To describe outcomes of dogs with excessive tibial plateau angle (eTPA) and cranial cruciate ligament (CrCL) disease treated with center of rotation of angulation-based leveling osteotomy (CBLO) and cranial closing wedge ostectomy (CCWO).

STUDY DESIGN

Retrospective study.

ANIMALS

Twenty-one dogs.

METHODS

Medical records of dogs with CrCL disease and eTPA (>34°) treated with CBLO/CCWO were reviewed. Signalment, body weight, intra-articular structure appearance, TPA (preoperatively, postoperatively, and at osteotomy healing), postoperative function, and complications were recorded.

RESULTS

Twenty-one dogs (28 stifles) with CrCL disease/eTPA underwent CBLO/CCWO. Twenty stifles had complete CrCL tears and eight tears were partial. Mean age and weight of dogs were 4 years (range, 1-9) and 27 kg (range, 4-65), respectively. Medial menisci were normal in 20 stifles, torn in 5, and degenerative in 3. All lateral menisci were normal. The caudal cruciate ligament was normal in 26 stifles and partially torn in 2. Mean TPA was 43° preoperatively, 10° postoperatively, and 10° at final recheck. Grade 4 healing occurred in all osteotomies by 8 weeks postoperatively. Complications included one pin migration, breakage of two proximal screws (1 case), one late-onset caudolateral band CrCL tear, two late-onset meniscal tears, and one surgical site infection. Eighteen dogs returned to full function, and three dogs achieved acceptable function, at a mean of 27 months.

CONCLUSION

Center of rotation of angulation-based leveling osteotomy/CCWO resulted in grade 4 osteotomy healing by 8 weeks, minimal complications, and acceptable to full return to function.

CLINICAL SIGNIFICANCE

Center of rotation of angulation-based leveling osteotomy/CCWO should be considered to treat canine CrCL disease/eTPA.

Tibial Plateau Leveling Osteotomy for Cranial Cruciate Ligament Rupture in Canines: Patient Selection and Reported Outcomes

Cranial cruciate ligament (CCL) rupture is one of the most common causes of pelvic limb lameness in dogs. In a CCL deficient stifle, joint lameness develops from cranial tibial translation in relation to the distal femoral condyles. The tibial plateau leveling osteotomy (TPLO) is a well-described surgical procedure that neutralizes tibiofemoral shear force by altering the tibial plateau via a proximal tibial osteotomy, and subsequently restores normal limb function. Current literature for the TPLO was reviewed and used to describe the optimal patient selection and to report clinical outcome with the TPLO in comparison to other surgical options for CCL rupture. The clinical outcomes reported to date, particularly those utilizing objective outcome data, support the TPLO as being able to consistently return dogs to normal limb function with a low risk for long-term morbidity. The TPLO procedure was found to be widely applicable to dogs ranging from small breed to large and giant breed, and does not appear to have some of the limitations that exist with alternative surgical options. This review concludes that the TPLO is an excellent treatment option for any dog with CCL rupture due to the excellent long-term outcome and high rate of owner satisfaction previously reported. Despite these conclusions, it is important to remember that treatment selection for CCL rupture remains dependent on multiple considerations including patient factors, surgeon experience, and costs.

Patella tendinopathy Zoobiquity - What can we learn from dogs?

BACKGROUND

Patella tendinopathy is an overuse condition. Pathogenesis and identification of intrinsic risk factors have largely eluded the orthopaedic world. The cranial cruciate ligament (CrCL) in dogs is the equivalent to the human anterior cruciate ligament (ACL). We report the effect of two canine proximal tibial osteotomy procedures in the veterinary literature on patella tendon moment arm and describe the biomechanical rationale for a tibial tubercle osteotomy for treatment of patella tendinopathy in the human.

METHODS

A literature review of studies reporting clinical complications of TTA and TPLO to form an observational animal cohort study in dogs.

RESULTS

The veterinary literature reports an overall clinical complication rate of up to 61% for TTA and up to 50% for TPLO respectively. Complications associated with the extensor mechanism of the knee are <1% for TTA compared to 1.9-19% for TPLO. Radiographic thickening of the patella tendon and tendinopathy is seen in one to 80% of TPLO cases. The TPLO decreases the moment arm of the extensor mechanism meaning increased force is required in the patella tendon to achieve the same torque when compared to the TTA which increases the efficiency of the extensor mechanism. This difference may account, in part, for the post-operative complications reported to the patella and patella tendon following TPLO.

CONCLUSION

This observational animal cohort study demonstrates a biomechanical rationale for investigating diagnostic and potential treatment options, including a tibial tubercle osteotomy, for patella tendinopathy in humans based on this principle.