ttp://www.bsava.

com PAPER

Management of concurrent patellar

luxation and cranial cruciate ligament
rupture using modified tibial plateau
levelling
OBJECTIVES: To evaluate a novel surgery aimed at managing concur- and Langley-Hobbs 2006). Surgical man-
agement options for dogs with clinical
rent medial patellar luxation (MPL) and cranial cruciate ligament MPL disease include soft tissue proce-
(CCL) ruptures in dogs weighing more than 30 kg. dures, including lateral imbrication of the
fascia lata, stifle joint derotational sutures,
METHODS: Tibial plateau levelling osteotomy (TPLO) and femoral cranial sartorius muscle release and hard
trochleopasty were performed. The principal tibial fragment was tissue procedures, such as wedge or block
trochleoplasty, and tibial crest transposition
laterally translated by 3 to 6 mm and was externally and abaxially (Roy and others 1992, Johnson and others
rotated to create a wedge measuring 1·5 to 2·5 mm at the medial 2001, Johnson and others 2002, Arthurs
and Langley-Hobbs, 2006). Several of
and cranial aspect and 1 to 3 mm at the medial and distal aspect these procedures are routinely combined to
of the tibial plateau fragment. The fragments were stabilised with a address MPL in dogs. Trochleoplasty and
tibial crest transposition have been recom-
narrow TPLO plate. mended in large breed dogs to reduce the
RESULTS: Thirteen surgeries were performed in 12 dogs with a mean likelihood of recurrence of MPL (Gibbons
and others 2006). However, complication
weight of 39·8 kg. The mean postoperative tibial plateau slope rates of 18% to 29% have been reported
was 8·1°. Additional surgery was required in two cases, one due in large breed dogs (Arthurs and Langley-
Hobbs 2006, Gibbons and others 2006).
to failure of fixation and another due to screw breakage. The mean Osteotomies of the femur or tibia have
lameness score was 3·5 (out of 5) before surgery, 0·7 after 8 to 12 been advocated to manage angular and
rotational deformities of the femur and
weeks, and 0·3 at final follow-up. Median follow-up was 1115 days tibia, including varus deformities of the
(range, 270 to 2040 days). No patella luxated after surgery. femur and internal rotation of the tibia
(Swiderski and Palmer 2007, Roch and
CLINICAL SIGNIFICANCE: MPL and CCL ruptures may be successfully Gemmill 2008). CCL ruptures occur in
managed by performing a TPLO and simultaneously altering the rela- dogs of all sizes. They are managed with
intracapsular or extracapsular stabiliza-
tionship of the principal and tibial plateau fragments during surgery. tion techniques. Surgical alterations of the
tibial plateau, such as tibial plateau level-
ling osteotomy (TPLO), are now popular
ANKE LANGENBACH AND DENIS J. MARCELLIN- INTRODUCTION when addressing CCL ruptures in large
LITTLE*
and giant dog breeds (Slocum and Slo-
Journal of Small Animal Practice (2010) Cranial cruciate ligament (CCL) ruptures cum 1993, Kim and others 2008). When
51, 97–103 and medial patellar luxations (MPL) are MPL and CCL ruptures occur concur-
DOI: 10.1111/j.1748-5827.2009.00854.x common causes of hind limb lameness in rently, both conditions must be addressed
Accepted: 1 September 2009; Published dogs and may occur concurrently (DeAn- to regain normal stifle joint function. This
online: 11 January 2010
gelis and Hohn 1970, Hayes and others may be achieved using staged surgical pro-
1994, Aragon and Budsberg 2005, Pow- cedures (that is, TPLO followed by MPL
ers and others 2005). MPL is considered a management several weeks later) or by
predisposing factor for CCL rupture (Wil- combining several surgical procedures in
Veterinary Surgical Center, Vienna, VA 22180, USA
lauer and Vasseur 1987). MPL is primarily a single event. During the TPLO proce-
*Department of Clinical Sciences, College of Vet- found in small and toy breeds (dogs weigh- dure, the curved cut of the tibial plateau
erinary Medicine, North Carolina State University,
Raleigh, NC 27606, USA ing <20 kg) but large breeds (weighing preserves the tibial crest. If a tibial crest
>20 kg) represent 9% to 35% of all MPL transposition is required, an additional
Presented in part at the ACVS Symposium,
Chicago, IL (October 2007) and the ECVS Annual patients (Prister 1972, Remedios and oth- osteotomy is necessary which requires
Scientific meeting, Basel, Switzerland (July 2008). ers 1992, Johnson and others 2002, Arthurs additional fixation and may decrease

Journal of Small Animal Practice • Vol 51 • February 2010 • © 2010 British Small Animal Veterinary Association 97

the stability of the proximal portion of
the tibia and lead to tibial crest avulsion
(Priddy and others 2003, Kergosien and
others 2004). To reduce patient morbidity
and accelerate postoperative recuperation,
it would be advantageous to combine the
management of MPL and CCL ruptures
without increasing the invasiveness of the
surgical procedure. We proposed that we
could manage CCL ruptures and MPL by
displacing the osteotomised tibial plateau
in relation to the principal tibial fragment
during TPLO, mimicking a tibial crest
transposition and realigning the quad-
riceps mechanism. The purpose of this
study was to prospectively evaluate the
combined MPL and CCL stabilisation in
large breed dogs.
MATERIAL AND METHODS
Dogs were included in this study if they
were presented for hind leg lameness, had
cranial cruciate ligament ruptures and
MPL, weighed more than 30 kg, and were
seen at the Veterinary Surgical Center in
Vienna, Virginia (USA) between January
2001 and December 2006. Twenty-five
dogs undergoing TPLO in our hospital
were randomly selected as case controls to
compare the age of patients at the time of
surgery in both groups.
Clinical evaluation
All dogs had a physical, orthopaedic,
and radiographic evaluation. Preopera-
tive complete blood count and chemistry
were performed on all dogs. Lameness
was graded subjectively as described by
Impellizeri (2000). A numerical rating
scale (NRS) with 5 levels of lameness
severity was utilized per the following:
0 = no detectable lameness at a walk or
trot, no detectable lateral weight shift at
a stance; 1 = no detectable lameness at a
walk or trot and minor lateral weight shift
at a stance; 2 = lameness at a walk or trot
without hip hike; 3 = lameness at a walk or
trot with hip hike; 4 = non-weight bearing
at a trot; 5 = non-weight bearing at stance
or walk. MPL was graded by Putman’s
grading system with grades 1 to 4 (Single-
ton 1969). Written consent was obtained
from all clients.
98
A. Langenbach & D. J. Marcellin-Little
Radiographic evaluation
Mediolateral stifle radiographs were pro-
duced with the stifle and hock held at 90°
allowing for both joints in the radiographic
projection. The radiographic beam was
centred on the stifle. A craniocaudal pro-
jection was produced also, including hock
and stifle in the exposure. The beam was
centred on the stifle.
Preoperative radiographs were produced
immediately before surgery, postopera-
tive radiographs immediately following.
These radiographs were produced with
the patients anaesthetised. Radiographs
were produced in the same manner at
four and eight weeks post surgery and at
other reevaluations, but under sedation.
The tibial plateau slope (TPS) was mea-
sured on preoperative and postoperative
radiographs using the method proposed
by Slocum (Baroni and others 2003). The
orientation of the femoral trochlea in rela-
tion to the distal portion of the femoral
shaft as seen on craniocaudal radiographs
was measured.
Surgery
Inhalation anaesthesia was performed
after endotracheal intubation using iso-
flurane as an anaesthetic agent. Epidural
analgesia was administered preoperatively
in four patients at L7/S1 using a combina-
tion of bupivicaine (Marcaine (5 mg/ml),
Hospira, Inc., Lake Forest, IL) (1 ml/4·5
kg) and morphine (Morphine Sulfate
(15 mg/ml), Baxter Healthcare Corpora-
tion, Deerfield, IL) (0·11 mg/kg) deliv-
ered through a 0·9-mm diameter, 6-cm
long diamond point spinal needle. The
remaining nine procedures the patients
received a 3-ml intra-articular injection of
bupivicaine (5 mg/ml) with epinephrine
(Marcaine with epinephrine (5 mg/ml
and 0·0091 mg/ml), Hospira, Inc., Lake
Forest, IL) (0·0091 mg/ml). All patients
received an intravenous dose of cefazolin
(Cefazolin (reconstituted to 100 mg/ml),
Watson Laboratories, Inc., Corona, CA)
(22 mg/kg IV) that was repeated at 90-
minute intervals when necessary. The
durations of surgery and anaesthesia were
recorded.
A craniomedial approach to the stifle
was performed, followed by complete stifle
joint exploratory arthrotomy. A ruptured
CCL and MPL were confirmed in all cases
Journal of Small Animal Practice • Vol 51 • February 2010 • © 2010 British Small Animal Veterinary Association
and remnants of the CCL were removed.
In cases where a meniscal tear was pres-
ent the torn portions were removed, while
in cases where the meniscus was intact a
meniscal release was performed. A wedge
resection trochleoplasty and a cranial sar-
torius muscle release were performed. The
TPLO procedure followed (Slocum and
Slocum 1993). The jig was removed after
completion of the curved cut. The surgeon
and an assistant levelled the tibial plateau
to the desired level and aligned the quad-
riceps mechanism by performing three
alignment alterations beyond plateau lev-
elling. With the patella reduced and facing
cranially, the principal tibial fragment was
externally rotated along its long axis until
torsion between the patella and the tibial
tubercle was eliminated (first alteration).
This created a 1·5- to 2·5-mm gap between
the medial and cranial aspect of the oste-
otomised tibial plateau fragment and the
tibial crest on the principal tibial fragment
(Fig 1). Gaps were measured intraopera-
tively using a sterile ruler. The bow-legged
appearance (genu varum) was addressed
by aligning the femoral shaft, patella,
tibial tubercle, tibial shaft and hock. This
was done by laterally translating the tibial
crest in relation to the osteotomised tibial
plateau fragment by 3 to 6 mm (second
alteration) and by abaxially rotating the
distal portion of the tibia to create a 1- to
3-mm wide gap between the medial and
distal aspect of the osteotomised tibial pla-
teau fragment and the principal tibial frag-
ment (third alteration). There was no gap
between the cranial or distal aspect of the
osteotomised tibial plateau fragment and
the principal tibia fragment on the lateral
aspect of the tibia. The displacement of the
principal tibial fragment in relation to the
tibial plateau fragment resulted in a lateral
transposition of the tibial crest (Fig 2) and
realigned the mechanical axis of the pel-
vic limb. A stainless steel bar was used to
confirm the alignment of the femur and
tibia. The tibial plateau was secured with a
1·55-mm-diameter Kirschner wire passed
from the proximo-lateral tibial crest to the
caudal central tibial plateau. The patella
was checked for stability. Plate contour-
ing for this procedure differed from typi-
cal TPLO procedures. Bending irons were
used to create an approximately 30° angle
between the third and fourth screws and
 Modified tibial plateau levelling

tablet), Novartis Animal Health US, Inc.,

Greensboro, NC) (1 to 2 mg/kg PO q
24 hours), two patients were admin-
istered tramadol hydrochloride (Tra-
madol Hydrochloride (50 mg tablet),
Caraco Pharmaceutical Laboratories, Ltd.,
Detroit, MI) (2 mg/kg PO q 12 hours) in
addition to deracoxib, and two separate
patients were administered Acepromazine
Maleate (25 mg tablet, Boehringer Ingel-
heim Vetmedica, Inc., St. Joseph, MO) (1
to 2 mg/kg PO q 12 hours) for sedation.
Patients were discharged to owners the day
after surgery.

Follow-up evaluation
Patients’ follow-up included a 7- to 10-day
reevaluation and suture removal, 4- and
8- to 12-week reevaluation with radiog-
raphy of the stifle. An additional reevalu-
ation with radiographs was performed in
12 of 13 patients more than six months
after surgery and a phone interview was
conducted with the owner and referring
veterinarian of the remaining patient.
Outcome was considered excellent if no
lameness was present, good if grade 1 or
FIG 1. Front view of the stifle joint of a dog with MPL and CCL rupture before (A) and after realign-
2, fair if grade 3 and poor if grade 4 or 5
ment (B). Genu varum is initially present. The tibial plateau fragment is tilted forward to decrease lameness was present at final reevaluation.
the TPS (arrow). The alignment of the quadriceps is improved by rotating the principal tibial frag-
ment externally (in relation to the osteotomised tibial plateau fragment), by laterally translating
the principal tibial fragment and by displacing its distal portion abaxially (arrow). This displacement
creates an open wedge on the medial aspect of the tibia between the cranial aspect of the osteot- RESULTS
omised tibial plateau and the tibial crest and between the distal aspect of the osteotomised tibial
plateau and the tibial shaft
Twelve consecutive client-owned dogs:
three Labrador retrievers, three Labrador
medially twisting the cranial aspect of IVX Animal Health, Inc., St. Joseph, MO) retriever mixed, two golden retrievers, two
the proximal portion of the plate (Fig 3). (0·02 mg/kg) given ½ intramuscularly and greater Swiss mountain dogs, one Dalma-
The contoured TPLO plate was applied ½ intravenously and in four, a constant tian and one husky mixed were included
and secured with six screws: three distal rate infusion of morphine (3 ml/kg/hour in this study. One dog was operated bilat-
cortical and three proximal cancellous IV for 8 hours) was administered. The erally with staged procedures. These pro-
screws. The Kirschner wire was removed. CRIs were reduced sequentially by 50% cedures were considered as independent
The stifle was checked for patella stabil- at each of 8, 12 and 16 hours. Oral anti- procedures in this report. The mean age
ity, quadriceps alignment and absence of biotics and analgesics were provided the at surgery was 3·6 years (median age, 2
cranial tibial thrust. The area was lavaged morning following surgery. Nine patients years; range, 1 to 10 years). By compari-
followed by a multi-layer closure using were administered cephalexin (Cephalexin son, the mean age of control dogs under-
monofilament absorbable (PDS, Ethicon, (250 mg and 500 mg capsules), Ranbaxy going TPLO in our hospital was 5·5 years.
Inc., Somerville, NJ) and non-absorbable Pharmaceuticals, Inc., Jacksonville, FL) There were nine male neutered dogs and
(Ethilon, Ethicon, Inc., Somerville, NJ) (22 mg/kg PO q 12 hours) and four three female spayed dogs in the study. The
sutures. The stifle joint was iced following patients were administered cefpodox- mean weight was 39·8 kg (range, 30·3 to
surgery and then bandaged with a modi- ime proxetil (Simplicef (200 mg tablet), 49 kg). The mean preoperative lameness
fied Robert Jones bandage. The bandage Pharmacia & Upjohn Company division grade was 3·5 out of 5 (range, 2 to 5). The
was removed the following morning and of Pfizer, Inc., New York, NY) (5 mg/kg mean preoperative TPS was 26° (range, 20
the stifle was iced again. Analgesia was PO q 24 hours) for a seven-day antibiotic to 34°). The mean orientation of the fem-
provided in eight patients with morphine course. Ten patients were administered oral trochlea in relation to the distal por-
(0·44 mg/kg) combined with aceproma- the non-steroidal anti-inflammatory drug tion of the femoral shaft was 9° of varus
zine (Acepromazine Maleate (10 mg/ml), (NSAID) deracoxib (Deramaxx (100 mg (range, 5 to 12° of varus).

Journal of Small Animal Practice • Vol 51 • February 2010 • © 2010 British Small Animal Veterinary Association 99
 A. Langenbach & D. J. Marcellin-Little

FIG 3. Artist rendering based on left plates used

to perform a standard TPLO procedure (A) and
for the combined management of patellar luxa-
FIG 2. Craniocaudal radiograph of the stifle joint of a 1·5-year-old neutered male Labrador Retriever tion and CCL rupture described in this report
with a grade 3 MPL and CCL injury before (A) and immediately after simultaneous management of (B). The plate used for conventional TPLO is
the stifle joint instability and patellar luxation (B) using a modified tibial plateau levelling procedure. contoured to the surface of the medial aspect
The patella is luxated and the tibial crest is on the medial aspect of the tibia on the preoperative of the proximal portion of the tibia, forming
radiograph. The patella is reduced and the tibial crest is centred on the postoperative radiograph approximately a 20° angle. The plate used to
stabilize the tibia of the dogs in this study has
an increased concavity in its proximal portion,
forming approximately a 30° angle. The cranial
MPL was present in all dogs with six on one stifle but one dog had MPL/TPLO aspect of its proximal portion is medially
grade 2 and seven grade 3 MPL. All stifles surgery on both stifles, nine months apart. twisted
had complete CCL ruptures as deter- Eight dogs had only MPL on the contra-
mined by physical examination and con- lateral leg. Five of these eight patients had Bayer HealthCare LLC, Shawnee Mission,
firmed during stifle surgery. One surgeon standard MPL surgery on the opposite KS) (5 mg/kg PO q 12 hours) and amoxicil-
(AL) performed all surgeries. The mean leg. Three had no surgery on the opposite lin trihydrate/clavulanate postassium (Cla-
(±sd) durations of surgery and anaesthe- leg, despite existing MPL during the study vamox (375 mg tablet), GlaxoSmithKline,
sia were 69 ± 17 minutes and 122 ± 34 period. Three dogs had CCL on the other Research Triangle Park, NC) (12·5 mg/kg
minutes, respectively. All dogs received side and two received a TPLO surgery and PO q 12 hours), as well as septic arthritis
a single narrow 3·5 mm plate from one one a standard extracapsular repair. that was treated with amikacin (Amikacin
of three sources: nine Slocum plates Eleven of 12 dogs were alive at the end sulfate (50 mg/ml), Phoenix Pharmaceu-
(3·5 mm TPLO plate 224TL3.5-R/L of the study period. The mean postopera- tical, Inc., St. Joseph, MO) (10 mg/kg
or 225TL3.5-R/L, Slocum Enterprises, tive lameness score was 0·7 out of 5 (range, IV q 24 hours), ampicillin (Ampicillin
Eugene, OR), three Veterinary Orthope- 0 to 2) 8 to 12 weeks after surgery and was (reconstituted to 250 mg/ml), American
dic Implants plates (3·5 mm TPLO plate, 0·3 out of 5 (range, 0 to 2) at long-term Pharmaceutical Partners, East Schaum-
Veterinary Orthopedic Implants, South reevaluation. There was no recurrence of burg, IL) (10 mg/kg IVq 8 hours) and
Burlington, VT), and one Securos plate MPL. ceftriaxone (Ceftriaxone sodium (recon-
(3·5 mm TPLO plate 9107401010R or One dog weighing 49 kg fell down a stituted to 350 mg/ml), Roche Labora-
91077401011L, Securos, Fiskdale, MA) flight of stairs chasing a cat two weeks after tories, Inc., Nutley, NJ) (25 mg/kg IM q
were used. The mean postoperative TPS surgery. He broke all proximal screws, 24 hours). He recovered and improved his
was 8·1° (range, 2 to 14°). The median fractured his fibular head and reluxated grade 5 lameness to grade 3 at eight weeks
time to follow-up was 1115 days (range, his patella. A second procedure with stabi- and grade 2 at three months post surgery.
270 to 2040 days). The mean TPS at the lisation of the tibial plateau using a TPLO The external fixator was removed 56 days
time of reevaluation was 9·8° (range, 2 to plate and bilateral external fixation device later and plate and screws were removed
15°). was necessary. He developed a postopera- at 251 days post the initial TPLO with
Although all dogs had bilateral stifle tive wound infection that was treated with MPL surgery. He was reevaluated for a
disease, 11 dogs had MPL/TPLO surgery enrofloxacin (136 mg Enrofloxacin tablets, right forelimb lameness and elbow pain at

100 Journal of Small Animal Practice • Vol 51 • February 2010 • © 2010 British Small Animal Veterinary Association

suture removal, 261 days post surgery. No
pelvic limb lameness was present at that
time. He was euthanatised 605 days post
surgery after acute onset tetraparesis, neck
pain, and anorexia.
Another dog had plate and screws
removed at day 293 because of a mild
pain response to palpation. All but a por-
tion of the broken most proximal screw
were removed. That screw fragment was
removed 591 days after surgery because
of potential interference with the lateral
collateral ligament. Two patients had inci-
sional complications and healing occurred
uneventfully.
DISCUSSION
Our results show that MPL and CCL rup-
ture correction using a modified TPLO
procedure and trochlear wedge resection
may be performed successfully in large
dogs with grade 2 or grade 3 MPL. The
outcome assessment methods in this study
were limited to joint palpation and visual
assessment of lameness. Lameness was
addressed with a subjective numerical
scale. The use of a force plate would have
increased the objectivity of our outcome
assessments (Waxman and others 2008),
but was unavailable in our practice. Sub-
jectively, this procedure is not more tech-
nically challenging than either procedure
alone and may be performed without
major technical difficulty. This proce-
dure appears technically simpler than the
combination of a TPLO with a transpo-
sition of the tibial crest and it does not
require two osteotomies and the creation
of a small crest fragment that could avulse
in the postoperative period. The proce-
dure requires simultaneous alignment of
the quadriceps mechanism and rotation
of the tibial plateau. This is achieved by
moving the principal tibial fragment later-
ally and abaxially while rotating it exter-
nally. The successful realignment of the
tibia leaves an open wedge, medially. As
a consequence, the plate used to stabilise
the proximal portion of the tibia is used
in buttress fashion. The specific mechani-
cal consequences of this form of fixation
have not been assessed experimentally.
Buttress fixation of bone fragments is less
stable than fragment apposition using
Journal of Small Animal Practice • Vol 51 • February 2010 • © 2010 British Small Animal Veterinary Association
Modified tibial plateau levelling
interfragmentary compression (Hulse and
Hyman 1991, Prayson and others 2001,
Marcellin-Little and others 2008). Few
reports have compared the complication
rate after fixation of bone fragments with
buttress or compressive fixation. In one
randomised study of unstable trochanteric
fractures in 233 people, failure of fixation
occurred after 9% of buttress fixations
and after 19% of compressive fixations
(Buciuto and others 1998). The acute
failure of fixation and screw breakage seen
in the two cases in this report may have
resulted from the fact that buttress fixa-
tion was used. However, the low incidence
of mechanical failures for the patients and
the absence of tibial plateau fragment “roll
back” in this report suggest that the stabil-
ity of buttress fixation is acceptable. Even
though all patients in this report received
a single narrow plate, a broad plate or sec-
ond plate could be added to the fixation to
lower the likelihood of mechanical failure.
Three different narrow plates were used in
this report. The first nine cases received
original TPLO plates (3·5 mm TPLO
plate 224TL3.5-R/L or 225TL3.5-R/L,
Slocum Enterprises, Eugene, Oregon).
Because of concerns regarding the material
properties of these plates (Boudrieau and
others 2006), plates from two other man-
ufacturers were used in four cases. While
we felt that the overall alignment of the
operated limb was improved in all cases,
we did not objectively evaluate the impact
of the surgical procedure on the shape of
the pelvic limb when dogs were stand-
ing or using goniometry, radiography or
computed tomography. Such assessments
would be necessary to assess the impact of
this procedure on the mechanical axis of
the pelvic limb.
Mean postoperative TPS (8°) was
slightly larger that the proposed TPS of 5°
(Slocum and Slocum 1993). One patient
in this report was undercorrected (14°)
because of the perceived difficulties and
risk of fibular fracture during correction.
This patient was free of lameness at reeval-
uation. In vitro studies demonstrate that
cranial tibial thrust is neutralised at 6·5°
(Warzee and others 2001, Reif and others
2002). In one report, good outcomes after
TPLO were present in dogs with postop-
erative TPS ranging from 0 to 14° (Robin-
son and others 2006).
All dogs in this study had mild to mod-
erate varus angulation of their femoral
trochlea in relation to the femoral shaft
(genu varum), as seen on their craniocau-
dal radiographs and from their bow-legged
stance. Because the mean (±sd) femoral
varus angulation of the dogs in this report
(9 ± 2°) was similar to the angulation
measured in nine mixed breed dogs free of
orthopaedic problems in a previous report
(9 ± 2°)(Dudley and others 2006), it is not
possible to ascertain whether the dogs in
this report had true deformities of the dis-
tal portion of the femur and whether these
potential femoral deformities impacted
the development of patellar luxations and
CCL ruptures. None of the dogs managed
during the study period had grade 4 MPL.
While the surgical procedure described in
this report could possibly be performed
in dogs with grade 4 MPL, the presence
of more severe angular and rotational
femoral and tibial deformities may require
additional corrective procedures, such as a
distal femoral osteotomy (Swiderski and
Palmer 2007, Roch and Gemmill 2008).
The patients in this report had a mean
age of 3·6 years. They represented approxi-
mately 3% of TPLO patients in our hospi-
tal. They were in average two years younger
than the control dogs undergoing TPLO.
They were also younger than dogs undergo-
ing TPLO in other reports, who had a mean
age of 4·7, 5·0 and 6·2 years (Pacchiana
and others 2003, Priddy and others 2003,
Stauffer and others 2006). The younger
age of the dogs in our report may be due
to the fact MPL is a developmental con-
dition likely to affect young patients and,
if MPL predisposes dogs to CCL rupture,
then such rupture is more likely to occur
in a younger population of dogs than that
suffering from CCL rupture alone.
The 12 patients in this report had bilat-
eral stifle disease. Eight patients (67%) had
bilateral MPL. The reported rate of bilat-
eral MPL is approximately 50% (Alam
and others 2007). Our rate was higher,
possibly because of the long-term pro-
spective nature of this study. Four patients
(33%) had bilateral CCL rupture. This
is in agreement with the reported rate of
bilateral CCL rupture (Doverspike and
others 1993).
A jig is used to prevent malalignment in
normal hind legs during TPLO procedure
101

(Slocum and Slocum 1993). It also acts as
a guide during TPLO performed on dogs
with CCL rupture and internal torsion of
the tibia, varus or valgus tibial deformities.
In our study, we felt that complete quad-
riceps alignment was not possible with the
jig in place and we decided to perform
the correction without the jig. While the
absence of a jig could lead to iatrogenic
axial or rotational malalignment, the very
focus of this procedure was on realigning
the tibia. We felt that the good long-term
clinical outcome supported our realign-
ment method. Using preoperative CT
planning or intraoperative fluoroscopic
image intensification could increase
the precision of this tibial realignment
method. TPLO performed without a jig
did not appear to lead to axial or rota-
tional malalignment in two recent reports
(Bell and Ness 2007, Schmerbach and
others 2007).
The reported complication rate of
TPLO has ranged from 19% to 28%
(Pacchiana and others 2003, Priddy and
others 2003, Stauffer and others 2006).
The reported complication rate after
MPL surgery in large breed dogs has been
reported to be 29%, with 10% of patients
having major complications such as patel-
lar reluxation or implant failure (Gibbons
and others 2006). The heaviest dog in
our study had implant failure and patel-
lar reluxation due to a traumatic event.
This complication occurred during a fall
that resulted in fibular fracture, fracture
of the top three screws and reluxation of
the patella. An additional surgical proce-
dure was required to stabilise the stifle.
The patient recovered and improved to a
grade 2 lameness, three months after sur-
gery. Proper client compliance with con-
finement is important after surgery. The
use of a broad plate or the addition of a
second plate could lower the likelihood of
such mechanical failure in patients placing
large loads on their operated legs in the
early postoperative period. We now use
broad plates on patients weighing more
than 41 kg with tibiae that can accommo-
date the larger plate.
One patient was referred for poor prog-
ress after extracapsular stabilisation of a
CCL-deficient stifle joint. This patient
also had an MPL. While MPL was not
diagnosed in that patient before the origi-
102
A. Langenbach & D. J. Marcellin-Little
nal surgery, it is likely that the MPL was
developmental and did not result from
the extracapsular stabilisation because of
the distal portion of the femur had a varus
angulation and because the wound closure
of the fascia lata was intact when evaluated
during the second surgery. It is possible,
however, that MPL was secondary to the
CCL stabilisation in that dog. MPL has
been reported to result from CCL stabili-
sation (Arthurs and Langley-Hobbs 2007).
In that report including 32 patients, MPL
after CCL stabilisation was considered
challenging and a variety of management
methods were used. The reluxation rates
ranged from 35% to 100% and were lower
with tibial crest transposition, sulcoplasty
and tibial realignment. The overall suc-
cess rate was 79%. We cannot conclude
whether the procedure evaluated in this
report would be appropriate to manage
patients with failed CCL stabilisation and
MPL.
We conclude from this report that MPL
and CCL ruptures may be simultaneously
managed in large dogs by externally rotat-
ing, by laterally translating and by abaxi-
ally displacing the principal portion of
the tibia during the TPLO procedure.
The geometric and mechanical features of
this corrective surgery could be optimised
using in vitro experiments.
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