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Tibial Osteotomies For Cranial Cruciate Ligament Insufficiency in Dogs
Tibial Osteotomies For Cranial Cruciate Ligament Insufficiency in Dogs
Tibial Osteotomies For Cranial Cruciate Ligament Insufficiency in Dogs
37:111–125, 2008
INVITED REVIEW
STANLEY E. KIM, BVSc, ANTONIO POZZI, DMV, MS, Diplomate ACVS, MICHAEL P. KOWALESKI, DVM, Diplomate ACVS,
and DANIEL D. LEWIS, DVM, Diplomate ACVS
From the Department of Small Animal Clinical Sciences, University of Florida, Gainesville, FL; and the Department of Clinical
Sciences, Tufts Cummings School of Veterinary Medicine, North Grafton, MA.
Address reprint requests to Dr. Antonio Pozzi, Department of Small Animal Clinical Sciences, College of Veterinary Medicine,
University of Florida, Gainesville, FL 32610. E-mail: PozziA@vetmed.ufl.edu.
Submitted May 2007; Accepted November 2007
r Copyright 2008 by The American College of Veterinary Surgeons
0161-3499/08
doi:10.1111/j.1532-950X.2007.00361.x
111
112 TIBIAL OSTEOTOMIES FOR CRANIAL CRUCIATE LIGAMENT INSUFFICIENCY IN DOGS
Treatment of CrCL insufficiency aims to resolve lame- Our purpose was to review the biomechanical consid-
ness caused by joint instability and provide good long- erations, experimental investigations, and clinical data
term function of the affected hindlimb. Conservative pertaining to tibial osteotomy procedures for treating
management of dogs weighing o15 kg typically results in CrCL insufficiency in dogs.
acceptable limb function, with reported success rates
ranging from 84% to 90%.5,6 Surgical intervention is,
however, recommended for most dogs with CrCL CrCL BIOMECHANICS
insufficiency to reestablish joint stability, mitigate second-
ary degenerative joint disease, and address any concur- Because of the high prevalence of CrCL insufficiency,
rent meniscal injury.6,7 Over the past 50 years, a plethora and because CrCL transection in dogs is frequently used
of surgical techniques have been reported for treatment as an experimental model to induce OA,27 the structure
of this condition. This evolution of surgical procedures and function of the CrCL has been extensively investi-
reflects the controversy about optimal management of gated.28–32 Cadaveric experiments, in vivo kinematic an-
CrCL insufficiency, and to date, no one pro- alyses and theoretical models have contributed to
cedure has consistently demonstrated superior clinical understanding of CrCL biomechanics and subsequently
efficacy. lead to the development of tibial osteotomy techniques.
Traditional surgical techniques attempt to impart sta- Using a cadaver model, Arnoczky and Marshall dem-
bility using an autogenous, allogenic, or synthetic structure onstrated that the CrCL contributes to passive restraint
placed within or about the stifle that mimics the function of specifically limiting cranial translation of the tibia relative
the normal CrCL. Extraarticular techniques use periartic- to the femur, excessive internal rotation of the tibia, and
ular heavy gauge suture or wires,8,9 or the transposition of hyperextension of the stifle.29 Other structures that pro-
soft tissues10 to reduce stifle laxity, whereas intraarticular vide passive restraint of the canine stifle include the cau-
techniques attempt to anatomically reconstruct the CrCL dal cruciate ligament (CaCL), the collateral ligaments,
using autogenous tissues,11 allografts,12 or synthetic mate- and menisci.29,33,34 The loss of a passive supporting
rials.13 Most authors cite good to excellent limb function in structure about a joint may increase laxity, but does not
most of dogs that have had extra- or intraarticular proce- necessarily result in clinically relevant instability.35 Dur-
dures.14,15 Yet despite these reported satisfactory results, ing in vivo activity, joints are subject to other important
traditional methods are generally considered to yield sub- dynamic restraint mechanisms, such as those produced
optimal long-term outcomes, as these techniques fail to by muscular force.35 For instance, electromyographic
consistently maintain stability, arrest the progression of studies have shown that humans with anterior cruciate
OA, and prevent late meniscal damage.9,16,17 ligament rupture can inhibit anterior tibial translation by
As surgical techniques continue to evolve, the focus increasing hamstring tone and decreasing quadriceps ac-
has shifted to the concept of creating dynamic stability in tivity.36 Further, the magnitude of forces applied to a
the CrCL-deficient stifle by altering bone geometry. In joint to demonstrate and quantify joint laxity in vitro
1984, Slocum described the cranial tibial wedge osteo- may be considerably different than the physiologic loads
tomy (CTWO), a surgical procedure that attempts to that are sustained in vivo. Therefore, results of cadaver
eliminate cranial subluxation of the tibia during weight- experiments such as those reported by Arnoczky and
bearing by reducing the caudally directed slope of the Marshall do not fully define whether or not the CrCL is a
tibial plateau.18 By establishing dynamic stability of the primary stabilizer of the canine stifle.
CrCL-deficient stifle, passive restraint against laxity is not Kinematic studies in dogs, using stereo radio-
required. Recognition that stabilization could be achieved photogrammetry and/or instrumented spatial linkage,
in this manner led to the development of several proximal were able to confirm that CrCL transection results in
tibial osteotomy procedures, such as tibial plateau level- substantial cranial tibial subluxation during the stance
ing osteotomy (TPLO)19; combined TPLO/CTWO20; phase of gait.30,31 These findings demonstrate that mus-
proximal tibial intraarticular osteotomy (PTIO)21; triple cular forces are unable to compensate for the loss of re-
tibial osteotomy (TTO)22; and chevron wedge osteotomy straint provided by the CrCL. In all but 1 dog, cranial
(CVWO).23 The more recently described tibial tuberosity tibial translation did not occur during the swing phase of
advancement (TTA) procedure attempts to dynamically gait. Thus, the authors concluded that the stability of the
neutralize craniocaudal instability by altering the relative stifle during the stance phase of gait is dependent on the
alignment of the patellar tendon to the tibial plateau.24 CrCL, whereas stability during the swing phase of gait is
Although there are few studies evaluating long-term not dependent on the integrity of the CrCL. These ob-
functional outcomes of any of these tibial osteotomy servations are in agreement with findings from a study in
techniques, most have been associated with favorable goats that measured dynamic CrCL strain in vivo, where
clinical results.18–22,24–26 maximum CrCL force occurred in early stance phase, and
KIM ET AL 113
The authors identified a subset of CrCL-deficient dogs gulation of the tibia.20 With the growing recognition of
with steep TPAs attributed to proximal shaft deformities, proximal tibial angular limb deformities inducing steep
and theorized that the tibia would assume a more ana- TPAs, CTWO may gain wider acceptance in the treat-
tomically correct alignment after CTWO, as the proce- ment of CrCL insufficiency.
dure tilts the distal portion of the tibial shaft in relation to
the proximal portion.52 In our experience (A.P.), correc- TPLO
tion of substantial proximal tibial varus or torsion are
also more easily addressed by CTWO compared with Like CTWO, TPLO aims to provide dynamic cranio-
other tibial osteotomy techniques. caudal stifle stability during the stance phase of gait by
Although dynamic stabilization of CrCL-deficient sti- reducing the slope of the tibial plateau. Proposed by
fles is receiving considerable attention, reports document- Slocum in 1993, TPLO involves performing a radial
ing clinical outcomes after CTWO are sparse. In a osteotomy of the proximal tibia with subsequent rotation
preliminary study of the CTWO involving 17 dogs, Slo- of the proximal segment to enable precise manipulation
cum and Devine reported rapid return to function and of the tibial plateau slope.19 Based on the radius of the
clinical union of the osteotomy for most dogs by 6 weeks osteotomy and the preoperative TPA, the exact amount
after surgery.18 All 9 dogs evaluated at 12 months after of rotation of the proximal segment is calculated to
surgery had limb function that was subjectively consid- achieve a postoperative angle of 51.54 The procedure is
ered indistinguishable from normal. Radiographic evi- performed by a medial approach to the proximal tibia.54
dence of OA did not progress in any of the stifles; A biradial saw blade is used to create a crescent-shaped
however, objective, quantitative assessment of stifle OA osteotomy; compression of the osteotomy results in com-
was not performed. The dogs also had semitendinosus, plete congruency, as the inner and outer edges of the saw
gracilis, and biceps femoris muscle advancement to re- blade are of the same diameter.54 A custom-jig that is
duce laxity, confounding the assessment of the CTWO applied medially maintains alignment of the bone
procedure. In a retrospective analysis of 91 dogs treated segments while allowing for rotation of the proximal
with CTWO, 86% of the dogs were considered to have segment.54 The osteotomy should be centered over the
good-to-excellent limb function based on the results of a intercondylar tubercles to ensure accurate rotation and
client survey and physical examination.25 Two case series maintain enough bone in the proximal segment for ad-
reported the results of CTWO in small breeds dogs with equate purchase during internal fixation of the osteotomy
proximal tibial deformities.49,50 Subjective lameness grad- (Fig 4).54 Imprecise positioning of the osteotomy may
ing or owner satisfaction was used to gauge the efficacy of result in an inaccurate tibial plateau leveling and com-
the procedure. All dogs (13 overall) in both studies had plications such as angular and rotational deformities, and
good-to-excellent limb function within 6 weeks after sur- tibial tuberosity fracture.55–57
gery, and maintained good limb use with an average Biomechanical studies have demonstrated that after
follow-up of 1 year. In 1 of these reports, CTWO was tibial plateau rotation, the tibiofemoral shear force shifts
combined with lateral suture stabilization, making it from cranial to caudal when the limb is loaded.42,43 Thus,
difficult to ascertain the efficacy of CTWO alone in this it has been postulated that joint stability is dependent on
group of dogs.50 the CaCL neutralizing caudal tibial translation after
Reported complications have been principally associated TPLO.42 The recommended postoperative TPA was de-
with failure of fixation and nonunion.18,25,49,50,53 In a direct fined as 0 and 51 when the procedure was first described
clinical comparison of TPLO and CTWO, the second-sur- in 1993 and in the TPLO licensing course, respective-
gery rate for CTWO was 11.9%, nearly twice the second- ly.18,54 Despite these specific guidelines, the optimal TPA
surgery rate for TPLO (4.5%).51 Of the 12 dogs requiring is still a contentious subject. In vitro studies demonstrate
surgical revision after CTWO, 9 were considered to have that cranial tibial thrust is effectively neutralized at a
catastrophic tibial fractures requiring multiple plating.51 mean angle of 6.51.42,43 Three-dimensional computer
CTWO has the advantage of not requiring patented modeling of the canine stifle, on the other hand, found
specialized equipment.53 Other advantages include the that rotation to 51 only marginally decreased the tensile
ability to address exceedingly steep tibial plateau slopes, force acting on the CrCL.58 Both in vitro analyses and
as well as tibial varus and torsion. Because CTWO causes theoretical modeling, however, can fail to reliably predict
distal displacement of the patellar tendon insertion, the clinical outcome.59 Limitations associated with cadaver
procedure may be used to treat concurrent patella alta.20 experiments include the difficulty of replicating naturally
Disadvantages include: variability in postoperative TPAs, occurring disease and the inability to simulate all the
potential for creating patella baja and limb shorten- muscular forces acting on the joint. Inaccuracies of com-
ing.20,49,50 Also, inducing longitudinal tibial axis shift puter modeling can arise from multiple assumptions, such
may result in esthetically undesirable craniocaudal an- as disregarding muscular compensation, and simplifying
116 TIBIAL OSTEOTOMIES FOR CRANIAL CRUCIATE LIGAMENT INSUFFICIENCY IN DOGS
been evaluated in the literature, and many of these studies developing meniscal injuries after TPLO because passive
were documenting initial experience with this technique. joint stability is not restored.19 The caudal pole of the
The overall complication rate is reportedly 26–34%, with medial meniscus acts as a wedge between the femoral and
tibial tuberosity fracture, implant failure, patellar ten- the tibial condyles and may become crushed during cra-
donitis, subsequent meniscal tear after TPLO and infec- nial tibial translation.34 TPLO places the stifle joint in a
tion reported most frequently.57,68–72 Whereas most are greater angle of flexion during weight bearing, which
implant or fracture-related complications, others have might result in excessive loading of the caudal pole of the
been attributed to abnormal stifle biomechanics induced medial meniscus.28 Slocum and others have advocated
by TPLO.57,68–72 Tibial tuberosity fracture occurs in 3– complete radial transection of the medial meniscus,
7% of TPLO cases.68–70 Most of these fractures are non- termed meniscal release, to allow caudal displacement
or minimally displaced and do not require surgical inter- of the caudal pole of the medial meniscus during cranial
vention.57 Fracture of the tibial tuberosity may be caused tibial translation, thereby preventing subsequent meniscal
by a stress riser effect at the site of Kirschner wire place- tears.19,68 In vitro studies have, however, shown that
ment used to maintain the rotation of the tibial plateau meniscal release impairs load transmission and stability
segment, or at the narrow isthmus of the tibial tuberosity of the stifle.34,75 The adverse consequences of releasing
created by a cranially positioned osteotomy.68,69 Thermal the meniscus were corroborated by a radiographic study
necrosis, vascular compromise secondary to soft tissue demonstrating greater progression of OA in dogs that
dissection, increased strain in the patellar tendon after had meniscal release.76 Furthermore, there is no evidence
TPLO and large rotations of the tibia plateau segment to suggest that meniscal release eliminates the risk of
have also been cited as potential predisposing fac- subsequent meniscal tears.77 A recent retrospective study
tors.20,57,68 A retrospective analysis by Kergiosen et al57 reported a 3.5% incidence of subsequent meniscal injury
identified age, weight, single session bilateral TPLO sur- in stifles that underwent arthrotomy with meniscal
gery and tibial tuberosity width as potential risk factors release.77 Meniscal release did not reduce the rate of
for tibial tuberosity fractures. Prophylactic pin and ten- subsequent meniscal tearing when compared with cases
sion bands have been used in an attempt to decrease the treated arthroscopically without meniscal release.77
risk of tibial tuberosity fractures.62 Whereas traditionally, stifle arthrotomy has been con-
Patellar tendonitis is also common, and may cause sidered as an accurate method for assessing the menisci,78
lameness within the first 2 months after TPLO.68,69,71,72 the data suggest that lack of identification of meniscal
Clinical signs are usually self-limiting. Patellar tendon tears at the time of TPLO may play an important role in
thickening, visible on radiographs or by ultrasonography, the development of recurrent lameness because of men-
is most commonly noted distally.72 Possible causes in- iscal pathology.77 Indeed, a recent cadaver study found
clude trauma to the patellar tendon sustained during that meniscal examination by arthrotomy had significant-
surgery because of excessive retraction, or thermal dam- ly lower sensitivity and specificity than arthroscopy for
age associated with saw blade contact.71,72 Histopatho- diagnosing meniscal tears.79 When meniscal pathology
logic changes in the tendon are noninflammatory and cannot be comprehensively assessed in the CrCL-deficient
similar to those identified in humans with patellar tendon stifle, releasing the medial meniscus is advocated to de-
strain, hence excessive loading of patellar tendon second- crease the incidence of subsequent meniscal tears.77,79 If
ary to altered biomechanics after TPLO has also been the medial meniscus is thoroughly evaluated at the time of
implicated as a possible underlying cause.55,71 Rotation TPLO, and cranial tibial thrust is effectively neutralized,
of the tibial plateau segment may result in a decreased meniscal release may not be warranted.77,79
moment arm if the distance between the patellar tendon The decision to release an intact meniscus remains
insertion and instant center of rotation of the stifle is controversial, and the issue is further complicated by the
reduced; in turn, greater forces in the quadriceps mech- apparent nominal impact meniscal release has on limb
anism may be required to generate the same extensor function.77 Further studies are necessary to determine the
moment about the stifle.55,71 This theory is corroborated long-term effects of meniscal release on joint function. It
by findings from a radiographic study by Mattern et al72, is important to note that although meniscal release is
where lower postoperative TPAs (o61) were associated most commonly referenced to TPLO, performing a men-
with more severe ultrasonographic changes in the patellar iscal release is not restricted to this procedure because
tendon. passive joint laxity is a consistent feature of all tibial
Recurrent lameness after TPLO may indicate subse- osteotomy techniques.
quent meniscal injuries. Although meniscal tears occur- CaCL injury is cited as a potential complication after
ring after stabilization of CrCL-deficient stifles have been TPLO.19 Because TPLO is postulated to induce caudal
reported as a complication associated with several pro- tibial thrust, over-rotation increases strain on the CaCL.42
cedures,73,74 it is proposed that there is a high risk of Whereas increased strain has been demonstrated in
118 TIBIAL OSTEOTOMIES FOR CRANIAL CRUCIATE LIGAMENT INSUFFICIENCY IN DOGS
tuberosity in a cranial position. The width of the cage, quently modified. Excessive postoperative activity has also
available in 3, 6, 9, and 12 mm sizes, is determined by resulted in complete implant failure.26 Partial CaCL rup-
measurements made from preoperative lateral pelvic limb ture diagnosed 4 months after surgery in 1 dog was attrib-
radiographs with the stifle at 1351 extension.24 A ten- uted to excessive advancement of the tibial tuberosity.92
sion-band bone plate is applied to the medial aspect of Indeed, in the cadaver study by Apelt et al88, caudal tibial
the tibia, and autogenous or allogenic bone graft is placed translation was found to occur when the tibial tuberosity
in the resulting defect to accelerate bone union.24 was advanced beyond the defined angle required to neu-
Theoretical reduction of tibiofemoral shear forces by tralize cranial tibial thrust, presumably placing excessive
advancing the insertion of the patellar tendon has been strain on the CaCL. Postoperative meniscal injuries were
substantiated in both cadaver and computer-modeling frequent in 1 study, occurring in 7 of 24 cases that had
studies.88–90 Maquet’s procedure in human patients in- intact medial menisci at surgery.93 It is difficult to ascertain
volves anterior advancement of the tibial tuberosity, whether this was an accurate reflection of the true prev-
which is advocated for treatment of patellofemoral alence of late meniscal injury associated with the TTA, if
pain.91 In a cadaver study of Maquet’s procedure, the meniscal lesions were the result of unfavorable biomechan-
magnitude of tibiofemoral forces in a direction tangential ics, if meniscal lesions were missed at the primary surgery,
to the joint surfaces consistently decreased after incre- or if meniscal lesions were caused by insufficient advance-
mental advancement, provided the knee angle was at ment of the tibial tuberosity after TTA.
near-to-full extension.90 Similarly, finite element analysis From a biomechanical perspective, TTA may have 2
of the human knee found that, at near full extension, an- principal advantages over TPLO. TTA preserves the nat-
terior cruciate ligament and tibiofemoral contact forces ural tibiofemoral articulation because the tibial plateau is
substantially decreased after advancement of the tibial tu- not repositioned. In doing so, and provided that the TTA
berosity.89 A recent in vitro study performed in canine is equally as effective as the TPLO in neutralizing cranial
cadaver pelvic limbs also demonstrated neutralization of tibial thrust, natural load transmission across the stifle
tibiofemoral shear forces by advancing the tibial tubero- (and menisci) is less likely to be altered. TTA also in-
sity, where the mean patellar tendon-to-tibial plateau angle creases the extensor moment arm of the stifle and thus the
required to eliminate cranial tibial thrust was 90 91.88 mechanical advantage of the patellar tendon, thereby
Clinical outcomes after TTA are currently document- theoretically reducing the forces acting along the patellar
ed in a small number of preliminary reports only 2 of tendon.28 TPLO, on the other hand, appears to increase
which are still in abstract form.24,92,93 In a prospective the strain on the extensor mechanisms of the stifle, re-
clinical trial of 40 CrCL-deficient stifles treated with sulting in clinically relevant complications.55,71 At this
TTA, mean peak vertical force was 32% of body weight stage, these potentially advantageous features of TTA are
preoperatively, and doubled to 64% of body weight at a purely speculative, and future biomechanical analyses will
final examination performed between 4 and 12 months hopefully provide information that allows objective com-
after surgery.92 This was still significantly lower than a parisons between TTA and TPLO.
mean peak vertical force of 74% in clinically normal Purported advantages of TTA include being less in-
dogs, although the results are comparable with the find- vasive and technically less demanding than other tibial
ings in a similar study evaluating pelvic limb function osteotomies, an ability to effectively treat concurrent pa-
before and after TPLO.92 In a retrospective report, 38 of tellar luxation,94 short operative time, and low postop-
40 owners (95%) were satisfied with the long-term out- erative morbidity.92 Disadvantages include the potential
come of TTA, and the author’s clinical impression was to cause iatrogenic patellar luxation, requirement for
that the postoperative recovery with this technique was specialized implants, and potentially high rate of late
very rapid.93 Hoffman et al26, found that, with a median meniscal injuries. Because the technique is a new proce-
follow-up of 24 weeks, owners assessed the overall out- dure, the true benefits and complications are yet to be
come of the procedure good to excellent in 90% of cases. substantiated by sufficient clinical or biomechanical data.
These initial results appear promising; however, accurate
assessment of outcome after TTA is not currently pos-
sible because of a lack of reported clinical studies. OTHER TIBIAL OSTEOTOMY TECHNIQUES
Reported complications associated with TTA include
implant failure, tibial tuberosity fracture, medial patellar Several other tibial plateau leveling techniques have
luxation, CaCL injury because of excessive advancement, been described. Whereas information regarding these
and subsequent meniscal injury.26,92,93 Implant failure, procedures is limited, each procedure presents unique
reported to occur in 1–5% of operated limbs, was attrib- methods developed to circumvent certain limitations of
uted to either technical error or earlier implant designs that conventional tibial osteotomies described above, and may
were considered too weak; the implants have been subse- gain further attention in the future.
120 TIBIAL OSTEOTOMIES FOR CRANIAL CRUCIATE LIGAMENT INSUFFICIENCY IN DOGS
PTIO
CONCLUSIONS
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