A retrospective evaluation of complications associated with forkless tibial tuberosity advancement performed in primary care practice

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.

Role of Tibial Tuberosity Fracture/Fissure through the Maquet Hole in Stifle Osteoarthritis after Porous Tibial Tuberosity Advancement in Dogs at Mid-Term Follow-Up

Tibial tuberosity advancement (TTA) is used to treat cranial cruciate ligament rupture of the stifle joint in dogs. Tibial tuberosity fracture/fissure is a complication of TTA that may have a favorable prognosis. The aim of this study was to detect how tibial tuberosity fracture/fissure through the Maquet hole worsens the progression of osteoarthritis (OA) in the stifle joint of dogs treated with porous TTA. Seventeen cases were included in the study, divided into two groups. The first group (n = 10) included subjects that had tibial tuberosity fracture/fissure through the Maquet, and the second group included subjects that had no complications (n = 7). Both groups showed significant progression compared to OA at 3 months after surgery. We observed that at T0, the control group showed a higher level of OA. For this reason, we normalized the OA scores, evaluating the percentage difference from T0 and T1. We verified that there were no statistically significant differences between the two groups. The results confirm that OA progression in subjects undergoing TTA was not significantly influenced by fracture/fissure of the tibial tuberosity through the Maquet hole. Therefore, fracture fissure through the Maquet hole should be considered as a common minor complication during TTA.

Tibial Diaphyseal Fracture as a Major Complication of Tibial Tuberosity Advancement With Cranial Fixation (TTA CF)-A Case Report

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.

Mesenchymal stem cells in osteotomy repair after tibial tuberosity advancement in dogs with cranial cruciate ligament injury

Background

The cranial cruciate ligament rupture (CCLR) is the most commonly encountered orthopedic condition in dogs. Among the various techniques to treat this condition, tibial tuberosity advancement (TTA) has been used to obtain rapid recovery of the affected knee. The objective of this study was to evaluate the viability of the use of mesenchymal stem cells (MSC) implanted in the osteotomy site obtained by TTA in nine dogs diagnosed with CCLR.

Methods

The MSC were isolated from the adipose tissue of the dogs and cultured for eight days, the animals were divided into two groups. Animals from the treated group (GT) received cell transport medium containing about 1.5 millions MSC, and the animals from the control group (GC) received only the cell transport medium. The study was performed in a double-blind manner using radiographs acquired on days 15, 30, 60 and 120 after the procedure. Evaluations of the density of the trabecular bone were performed using image analysis software. The results were subjected to descriptive statistical analysis, followed by the normality test, Chi-square test, Mann-Whitney test and Tukey’s multiple comparison test for p ≤ 0.05.

Results

After 30 days of the procedure, the animals of the GT presented an ossification mean 36.45% greater (p ≤ 0.033) than the GC, and there were no statistical differences for the other periods.

Conclusions

Despite the total bone ossification within the expected period, there was no minimization of the estimated recovery time with the application of MSC, and inflammatory factors should be considered for reassessment of the therapeutic intervention time.

Relationship between Tibial conformation, cage size and advancement achieved in TTA procedure

Background

Previous studies have suggested that there is a theoretical discrepancy between the cage size and the resultant tibial tuberosity advancement, with the cage size consistently providing less tibial tuberosity advancement than predicted. The purpose of this study was to test and quantify this in clinical cases. The hypothesis was that the advancement of the tibial tuberosity as measured by the widening of the proximal tibia at the tibial tuberosity level after a standard TTA, will be less than the cage sized used, with no particular cage size providing a relative smaller or higher under-advancement, and that the conformation of the proximal tibia will have an influence on the amount of advancement achieved.

Results

One hundred sixty-four dogs met the inclusion criteria. The mean percentage under-advancement was 15.5%. All dogs had an advancement less than the stated cage size inserted. An association between the proximal tibial tuberosity angle (increased in cases with low patellar tendon insertion), and percentage under-advancement was found, with an increase of 0.45% under-advancement for every 1 degree increase in angle a (p = 0.003). There was also evidence of a difference between the mean percentage under-advancement in breeds (p = 0.001) with the Labrador having the biggest under-advancement. Cage size (p = 0.83) and preoperative tibial plateau angle (p = 0.27) did not affect under-advancement.

Conclusions

The conformation of the tibial tuberosity and therefore the relative cage positioning have an impact on mean percentage under-advancement of the tibial tuberosity after standard TTA. In all evaluated cases, the advancement of the tibial tuberosity was less than intended by the cage size selected.

Single-stage bilateral tibial tuberosity advancement for treatment of bilateral canine cranial cruciate ligament deficiency

Objective: To report complications in dogs with naturally occurring cranial cruciate ligament rupture following single-stage bilateral tibial tuberosity advancement (SS-BTTA) procedures, and to compare these complications to a population of dogs undergoing unilateral tibial tuberosity advancement (UTTA).

Methods: Medical records and radiographs of client-owned dogs treated with tibial tuberosity advancement between August 2008 and December 2011 were reviewed. Forty-four client-owned dogs with bilateral cranial cruciate ligament rupture that underwent SS-BTTA procedures and 82 client-owned dogs that underwent UTTA proced -ures were randomly selected from our hospital population. Complications were recorded and analysed. Major complications were defined as fractures or any complication requiring a second surgery. Minor complications were any problem identified that did not require surgical management.

Results: Incidence for major and minor complications in the UTTA group was 2.3% and 24.4%, respectively. Incidence for major and minor complications in the SS-BTTA group was 12.5% and 26.1%, respectively. Single-stage bilateral tibial tuberosity advancement procedures had a four- to five-fold increase in odds of a major complication (p <0.050) compared to UTTA.

Clinical significance: The findings of our study indicate that SS-BTTA procedures are associated with an increased risk of major complications compared to UTTA procedures.

Risk factors for tibial tuberosity fracture after tibial tuberosity advancement in dogs

Objective: To retrospectively identify factors that predispose to tibial tuberosity (TT) fracture after tibial tuberosity advancement (TTA) in dogs.

Methods: The medical records and radio-graphs of a group of control dogs (n = 212) that had TTA surgery (n = 241 procedures) and did not sustain a fracture between 2008 and 2013, and those of 12 dogs that did sustain a fracture (n = 13 procedures) between 2008 and 2013 at two veterinary teaching hospitals were evaluated to determine the effect of signalment, body weight and surgical inaccuracies on TT fracture. Multivariable logistic regression was performed with the occurrence of TT fracture as the outcome variable of interest.

Results: Signalment and body weight were not found to be associated with TT fracture. Of the surgical inaccuracies, osteotomy shape (p = 0.003), plate position (p = 0.009), and cage position (p = 0.039) were factors significantly associated with TT fracture.

Clinical significance: This study provides data to support the hypothesis that poor plate position, poor cage position, and narrow distal osteotomy width are associated with TT fracture after TTA. We conclude that it is of paramount importance to pay careful attention to surgical technique in order to reduce this risk.

Incidence of complications associated with tibial tuberosity advancement in Boxer dogs

Objective: To retrospectively review and describe the incidence of complications associated with tibial tuberosity advancement (TTA) surgical procedures in a group of Boxer dogs (n = 36 stifles) and compare the data with a non-Boxer control population (n = 271 stifles).

Methods: Retrospective analysis of medical records to identify all dogs that underwent TTA surgery due to cranial cruciate ligament disease. These records were categorized into two groups: Boxer dogs and non-Boxer dogs (controls – all other breeds).

Results: Of the 307 stifles included, 69 complications were reported in 58 joints. The complication rate differed significantly for Boxer dogs (16/36 stifles) and non-Boxer dogs (42/271 stifles), corresponding to an odds ratio of 5.8 (confidence interval: 1.96–17.02; p-value <0.001). Boxer dogs were more likely to undergo revision surgery and to develop multiple complications. The incidence of tibial tuberosity fractures requiring surgical repair (2/36 versus 1/271) and incisional infections requiring antibiotic treatment (three in each group) was significantly higher in the Boxer group.

Clinical significance: Boxer dogs had more major and multiple complications after TTA surgery than the control non-Boxer group; these complications included higher rates of revision surgery, tibial tuberosity fractures requiring stabilization, and infection related complications. The pertinence and value of breed-specific recommendations for cranial cruciate ligament disease appears to be a subject worthy of further investigation.

Risk factors for tibial damage associated with the modified Maquet technique in 174 stifles

OBJECTIVE

To identify risk factors for tibial damage associated with the modified Maquet technique (MMT) in dogs with cranial cruciate ligament (CCL) disease.

STUDY DESIGN

Retrospective study.

SAMPLE POPULATION

One hundred and seventy-four stifles from 147 client-owned dogs.

METHODS

Medical records of dogs diagnosed with CCL disease and treated with the current version of MMT were reviewed. Dogs were included if immediate postoperative radiographs were available. Cortical hinge fracture or fissure, tibial tuberosity fracture, and diaphyseal fractures of the tibia were recorded. Age, body weight (BW), thickness of the tibial cortical hinge, and angle of opening of the osteotomy were tested as potential risk factors for tibial damage by univariate logistic regression analysis.

RESULTS

Tibial damage included intraoperative tibial fissures in 37% of MMTs, intraoperative fractures of the cortical hinge in 3.4% of MMTs, postoperative tibial fractures in 14% of MMTs. Risk factors for intraoperative fissure included BW (P = .0153) and thickness of cortical hinge (P = .0006). The angle of opening of the osteotomy was identified as a risk factor for intraoperative cortical hinge fracture (P = .0034), angles below 11° being preventive. No risk factor was identified for postoperative fracture.

CONCLUSION

Based on these results, preventive measures against tibial damage associated with MMT should include: a thickness of cortical hinge based on the equation related to the BW; a length of osteotomy adjusted to the amount of TTA with an osteotomy angle below 10°; and slow advancement of the tibial tuberosity.

Comparison of complications following tibial tuberosity advancement and tibial plateau levelling osteotomy in very large and giant dogs 50 kg or more in body weight

OBJECTIVES

To analyse and compare major complications in dogs ≥50 kg undergoing tibial tuberosity advancement (TTA) or tibial plateau levelling osteotomy (TPLO) for treatment of cranial cruciate ligament disease.

METHODS

Medical records and radiographs of client-owned dogs (≥50 kg) treated for cranial cruciate ligament disease with either TTA or TPLO between January 2011 and November 2015 were reviewed. Ninety-one TTA cases and 54 TPLO cases met the study inclusion criteria. All complications within one year of surgery were recorded. Major complications were those requiring surgical revision or intervening medical therapy to resolve. Logistic regression analysis evaluated for associations with major complication occurrence. Major complications were statistically compared between TTA and TPLO treatment groups.

RESULTS

Incidence of major complications following TTA and TPLO surgery were 19.8% and 27.8%, respectively. Surgical site infection (SSI) was the single most common major complication following both TTA (15.4%) and TPLO (25.9%) surgery. There were no significant differences between TTA and TPLO treatment regarding the rate of SSI, surgical revision, or overall occurrence of major complications. Postoperative antibiotic therapy significantly reduced the risk of a major complication in all dogs ≥50 kg (p = 0.015; OR: 0.201: 95%CI: 0.055-0.737).

CLINICAL SIGNIFICANCE

Major complications occurred frequently following TTA and TPLO treatment of cranial cruciate ligament disease in dogs ≥50 kg. The increased chance for SSI should be considered and postoperative antibiotic therapy is recommended.

Complications and outcome of a new modified Maquet technique for treatment of cranial cruciate ligament rupture in 82 dogs

OBJECTIVES

To describe the complications, short and long-term outcome and owner satisfaction of dogs with cranial cruciate ligament rupture treated with a recently described new osteotomy for the modified Maquet technique (N-MMT).

MATERIALS AND METHODS

Medical records and radiographs of 82 dogs (84 stifles) were reviewed. Details regarding short-term outcome and complications were recorded from the medical records. Long-term follow-up information was obtained by telephone interview. Historical data and complications were statistically analysed.

RESULTS

Major complications occurred in 34/84 stifles. Intra-operative complications occurred in 26/84 stifles, all of which were fissures or fractures of the cortical hinge. Twenty-one of these fractures or fissures were repaired with a figure-of-eight wire. The second most common major complication was late meniscal tears in 3/84 stifles. One dog sustained a complete tibial fracture. Non-displaced fracture of the cortical hinge was the most common postoperative minor complication, which occurred in 5/84 stifles. The median preoperative lameness score was 3 out of 6. Final in-hospital re-evaluation of limb function was available in 58 dogs. The median lameness score at that time was 0 out of 6. Development of osteotomy related complications was not associated with a significant change in the postoperative lameness score.

CLINICAL SIGNIFICANCE

Subjectively assessed clinical outcome with the N-MMT was good to excellent in this cohort of dogs. However, a high rate of intra- and postoperative complications of the N-MMT procedure was also present in these dogs.