Clinical Communication
Distal tibial tuberosity translation
using TTA implants for the
treatment of patella alta in large
breed dogs
Surgical technique and clinical outcome
L. C. Pugliese1; F. S. Pike2; S. W. Aiken2
1TheOhio State University College of Veterinary Medicine, Columbus, OH, USA; 2Veterinary Specialty Hospital of San
Diego, San Diego, CA, USA
Keywords
Patellar luxation, patella alta, tibial tuberos-
ity advancement, TTA, large breed dogs
Summary
Introduction: Medial patellar luxation fre-
quently occurs in dogs resulting in lameness
with increasing incidence in large breed
dogs. Patella alta has been defined as a pa-
tellar ligament length to patellar length ratio
that is greater than two and may predispose
to patellar luxation.
Objective: To describe the surgical tech-
nique for stabilization of the distal trans-
lation of the tibial tuberosity using tibial
tuberosity advancement plates and the clini-
cal outcomes with follow-up for clinical cases
of dogs.
Methods: Dogs that were presented with
the complaint of patellar luxation and that
were concurrently diagnosed with patella
alta and were greater than 20 kg in body
weight underwent surgery using a tibial
Correspondence to:
Lauren C. Pugliese, DVM
The Ohio State University
College of Veterinary Medicine
601 Vernon L Tharp Street
Columbus, OH 43210
United States
Phone: +1 614 292 3551
Fax: +1 614 292 1454
E-mail: lpugliesedvm@gmail.com
© Schattauer 2015
tuberosity advancement plate to stabilize the
osteotomy. Radiographic assessment of A:PL
distance (the ratio of the proximal aspect of
the patella to the femoral condyle [A] to the
patellar length [PL]), L:P ratio (ratio of the
length of the patellar ligament to the diagon-
al length of the patella), and owner assess-
ment were obtained.
Results: Eleven stifles in nine dogs under-
went surgical correction with a mean preop-
erative L:P ratio of 2.47. There were no com-
plications and the lameness resolved clini-
cally. The mean A:PL ratios preoperatively
(2.6 ± 0.22) and postoperatively (2.1 ± 0.25)
were significantly different (p = 0.0003). All
owners were satisfied with the outcome and
all dogs had a resolution of lameness with no
recurrence of patellar luxation.
Clinical significance: Stabilization of distal
translation of the tibial tuberosity using tibial
tuberosity advancement implants to correct
patella alta in large breed dogs was feasible
and resulted in good clinical outcome.
Vet Comp Orthop Traumatol 2015; 28: 274–281
http://dx.doi.org/10.3415/VCOT-14-05-0075
Received: May 20, 2014
Accepted: March 13, 2015
Epub ahead of print: April 22, 2015
274
Introduction
The incidence of patellar luxation in large
Downloaded by: University of Utrecht. Copyrighted material.
breed dogs is increasing (1-4). Tradition-
ally, this developmental orthopaedic dis-
ease has been more commonly recognized
in small breed dogs with medial luxations
while large breed dogs have lateral lu-
xations (5). Studies at various institutions
have found an increased incidence of patel-
lar luxation, as well as medial luxation
being more common in both large and
small breed dogs (1-4).
The determination of patella alta in
dogs can be performed using the Insall-
Salvati method, which was originally devel-
oped for human orthopaedics (6, 7). It is
suspected that patella alta contributes to
patellar luxation as the patella moves proxi-
mal to the trochlear ridge and therefore has
the potential to track outside of the troch-
lear groove (8). However, proximal tibial
and distal femoral conformation may also
contribute to patellar luxation in dogs (9,
10). The complete biomechanical alter-
ations that occur with patella alta in the
dog are not yet fully understood. In hu-
mans, changes in the patellofemoral con-
tact mechanics predispose knees with pa-
tella alta to chondromalacia, patellar pain,
osteoarthritis, and painful luxation (11).
Surgical correction for patellar luxation
may need to consider these abnormalities.
Consequently, the recognition of patella
alta and a surgical correction that addresses
the proximal position of the patella is
required for successful surgical outcome.
Radiographic identification of patella
alta relies upon measurements of the patel-
Vet Comp Orthop Traumatol 4/2015
275 L. C. Pugliese et al.: Correction of patella alta using TTA implants

la and the patellar ligament length to accu- dogs with medial or lateral patellar lu- scribe the surgical technique of using
rately assess the vertical position of the pa- xations and preoperatively recognized TTA implants for distal tibial tuberosity
tella. The vertical position of the patella can patella alta that underwent distal tibial transposition in large breed dogs with
be defined using a lateral radiograph and is transpositions stabilized using a TTA patella luxations, the clinical outcome,
determined by the ratio of the length of the plate. The aim of our study was to de- and owner assessment of outcome.
patellar ligament to the diagonal length of
the patella (L:P) (6, 8). Mostafa and col-
leagues reported that a longer patellar liga-
ment (PLL) to patella length (PL) ratio was
associated with medial patellar luxation,
and lateral patellar luxations were associ-
ated with patella baja (10). Additionally,
the ratio of the proximal aspect of the pa-
tella to the femoral condyle (A) to the pa-
tellar length (PL) can be evaluated in the
craniocaudal radiographic view to deter-
mine the presence of variations in patellar
height. A ratio of patellar ligament length
to patellar length greater than 1.97

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(2.03–2.06) and an A:PL ratio of greater
than 2.03 is consistent with the definition
of patella alta (6, 8, 10).
The surgical treatment options for pa-
tella alta in dogs would include distal tibial
tuberosity transposition as described for
the same condition in humans (8, 10, 12).
Generalized surgical correction options are
described in the veterinary literature. Segal
and Shani were the first to describe distal
transposition of the tibial tuberosity in pre-
dominantly small breed dogs affected with
medial patellar luxation with no reported
complications (13). In a report by Yeadon
and colleagues, tibial tuberosity transposi-
tion and translation laterally and distally
were performed with tibial tuberosity ad-
vancement (TTA) to address cranial cru- A B
ciate ligament deficient stifles with concur-
rent medial patellar luxation (14).
Complications using a pin and tension
band repair can occur. Failure, loosening,
or migration of the implants, avulsion or
fracture of the tibial tuberosity, patellar
ligament rupture, and fracture of the
tibia and fibula have been reported (15,
16). Management of tibial tuberosity
avulsion or fracture can be challenging,
but successful techniques have been de- Figure 1
scribed (17, 18). These can lead to cata- Preoperative radio-
graphs showing the
strophic failures and ongoing lameness.
A) craniocaudal view,
Use of an implant that disperses forces B) mediolateral view,
over a larger area may help to reduce the C) extended medio-
potential of the complications, particu- lateral view, and
larly in a large breed dog. Our study D) determination of C D
evaluated clinical cases of large breed L:P ratio.

Vet Comp Orthop Traumatol 4/2015 © Schattauer 2015

L. C. Pugliese et al.: Correction of patella alta using TTA implants
Materials and methods
Medium to large breed dogs weighing
greater than 20 kg that were presented to the
Veterinary Specialty Hospital of San Diego
between October 1, 2007 and December 31,
2012 and diagnosed with patellar luxation
were considered for inclusion in this study.
After review of the medical records and case
logs of the surgeons, dogs were excluded if
cranial tibial thrust or tibial drawer consist-
ent with a cranial cruciate ligament rupture
was present. Radiographs were obtained of
each dog as part of the preoperative plan-
ning, without knowledge of the presence of
patella alta. Radiographic views obtained in-
cluded standard medial to lateral tibial pla-
teau levelling osteotomy views of the stifle,
cranial caudal views of the stifle including
the entire tibia, and extended medial to lat-
eral views of the stifle. If a radiographic di-
agnosis of patella alta was made, the dog was
included in the study. Patella alta was diag-
nosed if either the patella on stifle extended
lateral radiographs was proximal to the
trochlear groove or if the ratio of the patella
length to patellar ligament length was
greater than two (5).
Prior to surgery, routine haematology
and biochemical profile analyses were per-
formed on all dogs. Radiographs obtained
under sedation were used for diagnosis and
to appropriately plan for surgery. To deter-
mine the translation distance for the tibial
tuberosity, calibrated radiographs were
used to measure the translation distance to
move the patella into the centre of the
trochlear groove. This distance in milli-
metres was then used to move the tibial
tuberosity distally during surgical correc-
tion (▶ Figure 1).
The anaesthesia protocol was similar for
all dogs. Hydromorphonea was adminis-
tered (0.05 mg/kg IV once) approximately
15–30 minutes prior to induction of anaes-
thesia. Induction of anaesthesia was
achieved using diazepama (0.3 mg/kg IV)
and propofolb (4 mg/kg IV once, given to
effect) and maintained using isofluranec in
a Hospira Inc, Lake Forest, IL, USA
b PropoFlo: Abbott Animal Health, Abbott Park, IL,
USA
c IsoFlo®: Abbott Animal Health, Abbott Park, IL,
USA
© Schattauer 2015
Figure 2 Image of 90 degree flexed stifle and
hock lateral stifle with patella alta measurements
of a five-month-old Great Pyrenees dog. The ratio
was 2.4.
oxygen. Cefazolina (22 mg/kg IV) was ad-
ministered 15–30 minutes prior to initial
skin incision.
A medial or lateral parapatellar ap-
proach to the stifle was made with a medial
or lateral arthrotomy for assessment of the
cruciate ligaments and the menisci. The
choice between a lateral or medial ap-
proach was based upon surgeon prefer-
ence. The cranial cruciate ligament was
examined and an intercondylar notchplasty
was performed if there was evidence of de-
generative changes in the intercondylar
notch resulting in impingement of the
cranial cruciate ligament (19, 20). The
trochlear groove and condylar ridges, as
well as the cartilage surface of the patella
were assessed for evidence of abnormal
cartilage wear. Evaluation of eburnation of
the patellar cartilage and cartilage wear of
276
the condylar ridges was performed. If the
trochlear groove was noted to be shallow, a
trochlear block recession was performed in
a routine fashion using a sagittal sawd,
osteotome, and a mallet (21). The cancel-
lous bed was deepened using a power
rasperd or a manual rasp, osteotome, and
mallet. Any bone remnants were used as an
autogenous bone graft. The trochlear block
was replaced and noted to be stable.
Preparation of the medial aspect of the
proximal tibia was performed for TTA as
previously described (22). A TTA drill
guide was placed as described for the TTA
and five holes were drilled with a 2.0 mm
drill bit using the provided drill guide. A
partial osteotomy of the tibial crest was
made using a sagittal saw. An appropriately
sized TTA platee was applied to the tibial
Downloaded by: University of Utrecht. Copyrighted material.
crest with the corresponding fork as de-
scribed for a TTA (22, 23). The osteotomy
was completed using the sagittal saw. The
tibial crest and the cranial aspect of the
tibia were contoured using a Surgairtome
drillf if needed and the tibial crest was
transposed distally the prescribed
measured distance. Lateral or medial trans-
lation of the tibial crest was also performed
if necessary for proper alignment of the pa-
tellar ligament along the long axis of the
tibia. Distally, the TTA plate was secured
with 3.5 mm screws as described in the
TTA technique. The screw-holding loop
portion of the cage was removed as a separ-
ate piece from the cage and secured with
two 2.4 mm screws proximal to the fork
(▶ Figure 2). This was performed to pro-
vide additional points of fixation for the
proximal segment.
All patients were hospitalized for 24–48
hours postoperatively. Postoperative pain
management in hospital included epidural
morphineg anaesthesia (0.2 mg/kg preserv-
ative free morphine) and administration of
hydromorphone (0.05 mg/kg IV q8 hours
as needed). Patients were discharged with
instructions to owners to administer oral
d TPS Microcutting system: Stryker MedSurg Group,
Kalamazoo, MI, USA
e Kyon Veterinary Surgery Products, Boston, MA,
USA
f Hall Surgairtome Two® High Speed Drill: Conmed,
Centennial, CO, USA
g Duramorph®: Hospira Inc, Lake Forest, IL, USA
Vet Comp Orthop Traumatol 4/2015
277 L. C. Pugliese et al.: Correction of patella alta using TTA implants

tramadolh (2–5 mg/kg PO q8h) for 10 days

and carprofeni (2.2 mg/kg PO q12h) for
five days starting 48 hours after surgery, or
meloxicamj (0.1 mg/kg PO q24) for five
days starting 48 hours after surgery. A fent-
anyl patchk (2–4 mcg/kg) was also applied
for five days. Examinations were perform-
ed at two weeks for suture removal and at
eight weeks for follow-up radiographs
(▶ Figure 3).
Radiographic measurement of the L:P
ratio was made preoperatively as pre-
viously described (5, 7). Measurement on
the cranial caudal radiograph of the patella
position, patellar height (PL), and distance
from the femoral condyles (A distance),
was made both preoperatively and postop-
eratively as previously described (10).
Owner assessment was obtained via tele-

Downloaded by: University of Utrecht. Copyrighted material.

phone at least three months postoper-
atively. Owners were questioned as to the
success or failure of the procedure, their
appreciation for their pet’s performance,
and whether any concerns existed.
Statistical analysisl was performed using
a paired t-test for comparison of the pre-
and postoperative A:PL ratio. A signifi-
cance level of p <0.05 was used.

Results
Nine dogs with eleven affected stifles were
included. Mean body weight was 33.5 kg
(range: 20.3-54.5 kg) and mean age was
19.5 months (range: 10–42 months).
Breeds affected included Golden Retriever,
Boxer, Chesapeake Bay Retriever, Great
Pyrenees, Labrador Retriever, and mixed
breed dogs. There were six female spayed
dogs and three male neutered dogs
(▶ Table 1).
All dogs were presented for lameness
evaluation ranging in severity from mild to
non-weight bearing. All dogs had a grade 3
or 4 patellar luxation. Six of 11 stifles had
h Tramadol HCl: Amneal Pharmaceutical, Bridge-
water, NJ, USA
i Zoetis Animal Health, Florham Park, NJ, USA
j Metacam: Boehringer Ingelheim, Ridgefield, CT,
USA
k Duragesic®: Janssen Pharmaceuticals, Titusville, NJ,
USA
l SPSS for Windows, version 21: IBM, Armonk, NY,
USA
A B
Figure 3 Postoperative orthogonal radiographs showing A) implant placement and B) distal trans-
lation of the tibial tuberosity.
both medial and lateral patellar luxation stifles also had block recession trochleo-
(bidirectional luxation) as the patella dis- plasty performed at the time of surgery.
engaged from the trochlear ridges proxim- Mean surgery time was 105 minutes (range:
ally. No dog underwent evaluation for dis- 90-120 minutes). Lateral imbrication of the
tal femoral varus as a contributing factor to fascia was performed in one case. The tibial
patellar luxation. tuberosity was translated distally in all cases,
The mean preoperative L:P ratio was 2.5 with medial translation addionally in one
(range: 2.1–2.833) and the postoperative L:P case and lateral translation in four cases
ratio was 2 (range: 1.3–2.5). The mean (▶Figure 2). A notchoplasty was performed
translation distance of the tibial tuberosity in two cases. For the two cases with bilateral
was 14 mm (range: 9 –20 mm). The mean patella alta, the two surgical procedures were
A:PL ratio preoperatively (2.6 ± 0.22) and staged to allow for complete healing of the
postoperatively (2.1 ± 0.25) were signifi- previous tibia before surgical correction of
cantly different (p = 0.0003). Nine of the 11 the contralateral side.

Vet Comp Orthop Traumatol 4/2015 © Schattauer 2015

L. C. Pugliese et al.: Correction of patella alta using TTA implants 278

There were no intra-operative, perioper-
ative, or postoperative complications noted.
All osteotomies healed within eight weeks of
surgery. Patellar ligament thickening was
noted in all cases on the eight week follow-
up radiographs. Implant position remained
unchanged at the follow-up for all patients.
All dogs returned to full weight-bearing
function. There was no recurrence of lu-
xation noted for any case at both suture re-
moval and eight week follow-up radio-
graphs. No clinical complications were
documented and surgeon-assessed patellar
stability was restored with this corrective
technique. Client satisfaction with outcome
was available for six of nine cases by phone
conversation at least three months postoper-
atively and was reported to be excellent in all
cases, with an owner-perceived return to
normal function and comfort.
Discussion
This technique using TTA implants to se-
cure the distal translation of the tibial tube-
rosity for correction of patella alta in large
breed dogs had good to excellent outcomes
in all dogs with resolution of lameness and
correction of patellar luxation. All clients
were satisfied with the outcome. There
were no complications associated with sur-
gery.
About half of the dogs (55%) exhibited
lameness associated with bi-directional lu-
xation preoperatively meaning that in ex-
tension, the patella could be luxated both
medially and laterally. This finding sug-
gests that the primary mechanism for pa-

Table 1 Summary table for the clinical findings and surgical procedures performed for each patient.

Patient Signalment Direction of Stifle affected Distance distally Block recession Lateral fascial Surgical
luxation translated (mm) trochleoplasty imbrication translation
(preop) performed performed medial or lateral

Downloaded by: University of Utrecht. Copyrighted material.

1 14 months Both R 11 No No None
Female spayed
Mixed
2L 10 months Lateral L 15 Yes No Lateral
Male neutered
Boxer
2R 16 months Lateral R 15 Yes No Lateral
Male neutered
Boxer
3 21 months Both R 9 Yes No None
Female spayed
Golden Retriever
4L 17 months Both L 20 Yes No None
Female spayed
Great Pyrenees
4R 21 months Both R 20 Yes No None
Female spayed
Great Pyrenees
5 15 months Lateral R 16 Yes No Lateral
Female spayed
Chesapeake Bay
Retriever
6 55 months Lateral L 10 Yes Yes Lateral
Female spayed
Border Collie mix
7 13 months Both L 15 Yes No None
Male neutered
Ridgeback mix
8 33 months Both L 11.5 Yes No None
Female spayed
Labrador Retriever
9 12 months Medial L 10.5 No No Medial
Male neutered
Golden Retriever

Preop: preoperatively; R: right; L: left.

© Schattauer 2015 Vet Comp Orthop Traumatol 4/2015

279
tellar instability was the proximal position
of the patella relative to the trochlear
groove rather than trochlear groove depth
or quadriceps mechanism alignment. This
differs from previous reports that suggest
that patella alta is consistent with medial
patellar luxation (10, 13).
The TTA implant acts as a tension band
to counteract the pull of the quadriceps
against the tibial tuberosity. The goal was to
avoid complications with tibial tuberosity
fracture or avulsion that may occur when
large diameter pins are used to secure the
tibial tuberosity, thus creating a focal stress
riser. The idea behind using the TTA plate
was to distribute stresses throughout the ti-
bial crest. The TTA plate has been shown
to spread the force over the span of the
cranial aspect of the plate (24). There is a
more even distribution of stress around the
fork pins along the length of the tuberosity
(24). Additionally, greater support of a lat-
eralized and advanced tibial tuberosity has
been noted with a TTA plate when com-
pared with a pin and tension band wire
(25).
The titanium construction of the TTA
implants also provides a biologically inert
material with a similar modulus of elastic-
ity as bone. Titanium is stronger and light-
er in weight compared to stainless steel im-
plants. It has a large resistance to repeated
loads which makes it ideal for this appli-
cation. The implants allow for multiple
points of fixation of the tibial tuberosity,
which provides sufficient re-attachment
stabilization for large breed dogs without
being high profile or bulky along the medi-
al aspect of the proximal tibia. Securing the
plate with the fork and screws theoretically
helps to ameliorate the complication of pin
migration or tension band wire failure that
may occur with the traditional internal fix-
ation recommendation, avoiding the com-
plications of implant failure when a pin and
tension band fixation is used. Placement of
the plate along the medial aspect also
avoids interference with the patellar liga-
ment and eliminates the risk of patellar
ligament transection.
Standard radiographic views of the stifle
can be used to assess vertical patella posi-
tion. The modified Insall-Salvati ratio de-
veloped for dogs by Johnson and colleagues
was evaluated over the stifle angles for nor-
Vet Comp Orthop Traumatol 4/2015
L. C. Pugliese et al.: Correction of patella alta using TTA implants
mal range-of-motion at the walk and trot
in dogs (6). This method assumes that the
patellar ligament does not stretch and that
the length is fixed (6). The stifle angles
tested and validated by others ranged from
75 to 148 degrees of flexion (6). However,
Mostafa and colleagues evaluated a larger
number of stifles and found that there was
a curvilinear relationship between the L:P
ratio (termed PLL:PL in that study) and the
stifle angle for dogs (10). The L:P ratio did
remain constant over stifle angles between
70–110 degrees, and the maximal value
was obtained at a stifle angle of 90 degrees
(10). In our clinical cases, standard tibial
plateau levelling osteotomy type radio-
graphic films were obtained with a stifle
flexed to 90 degrees with a tarsal angle also
of 90 degrees on the mediolateral projec-
tion, as well as a straight craniocaudal view
of the stifle (26). This falls within both pre-
viously evaluated published data for evalu-
ation of L:P and correlates with the maxi-
mal value of 90 degrees. Therefore, this
radiographic positioning is recommended
for accurate assessment of vertical patellar
position.
One previous study evaluating latero-
distal transposition of the tibial tuberosity
for correction of medial patellar luxation
with an alta component made intra-oper-
ative assessments of patellar height (13). In
that study, the authors did not feel that
planning the distance for correction could
be made preoperatively. In our group of
dogs, recognition of patella alta on preop-
erative radiographs allowed for proper sur-
gical planning and implant selection to be
made. This can be evidenced by the
measurement of the A:PL distance to help
to assess the vertical patellar position
relative to the condyles. This will help to
guide the distance of the displacement that
should be calculated for the distal trans-
lation of the tibial tuberosity. Intra-oper-
ative modifications and assessment remain
important to assess the stability of the pa-
tella within the trochlear groove.
In the study by Mostafa and colleagues,
an A:PL ratio of >2.03 was consistent with
patella alta. All of the dogs in our study had
an A:PL ratio greater than the 2.03 re-
ported by Mostafa et al preoperatively.
Postoperatively, while the ratio was signifi-
cantly different when compared with the
preoperative ratio, seven out of nine dogs
still had an A:PL ratio greater than 2.03. As
there was no evidence of return of patellar
luxation, this suggests that improving the
tracking by capturing the patella within the
trochlear groove proximally, quadriceps
alignment, and depth of the trochlear
groove will allow for the patella to function
normally throughout the range-of-motion
of the stifle.
The incidence of patella alta as a con-
tributing factor to patellar luxation in dogs
is currently unknown. In a recent study, the
A:PL ratio was not shown to be signifi-
cantly different between groups that relu-
xated and those that did not postoper-
atively (16). Similar to this study, dogs in
our study had patella alta as determined by
the A:PL ratio both pre- and postoper-
Downloaded by: University of Utrecht. Copyrighted material.
atively (16).
A variety of breeds were represented
within this small case population. Labrador
Retriever and male dogs have been re-
ported to be overrepresented with MPL in
a number of studies (1, 2, 4, 15). Although
the dogs in our study were less than two
years old, with such a small cohort, it is not
appropriate to draw any conclusions about
age or breed disposition.
In this study, all dogs had the tibial tube-
rosity translated distally, but only five out
of 11 stifles had concurrent correction of a
medial or lateral translation. Nine of the
dogs had concurrent trochleoplasty con-
sistent with findings of a previous study
that deepening of the groove is an impor-
tant feature of correction for patellar lu-
xation (16). Whether surgical repair with-
out distal tibial translation for patellar lu-
xation would be successful in these cases is
unknown, but presumably the patella
would be able to continue luxating from
the trochlear groove even if the quadriceps
mechanism was properly aligned. How-
ever, two stifles had distal translation of the
tibial tuberosity without a groove deepen-
ing trochleoplasty. Evaluation of a larger
number of dogs with patella alta will help
to elucidate the undergoing anatomical ab-
normalities that contribute to patellar lu-
xation with evaluation of patellar height
being an important component of this
evaluation.
Patellar luxation correction often in-
cludes multiple procedures to address im-
© Schattauer 2015
L. C. Pugliese et al.: Correction of patella alta using TTA implants
provement of the quadriceps mechanism
alignment and improve the stability of the
patella. In addition to medial or lateral
translation, distal translation of the patella
may be necessary in order to allow for the
trochlear ridges to capture the patella.
Given the degree of patella alta present in
these clinical cases with the patella com-
pletely proximal to the trochlear ridges on
an extended radiograph in some cases, it
was determined that deepening the troch-
lear groove and medial or lateral trans-
lation of the tibial tuberosity, as appropri-
ate, would be insufficient to correct the pa-
tellar luxation. In addition, alignment of
the quadriceps mechanism alone would
have been insufficient to address the clini-
cal problem of a bi-directionally luxating
patella. It is unknown whether block reces-
sion trochleoplasty alone to deepen the
groove would have been sufficient to cor-
rect patellar luxation for these dogs.
In humans, patellofemoral pain can af-
fect up to 30% of physically active people
and is one of the most common disorders
of the knee (27). Chondromalacia and sub-
luxation of the patella, which reflect abnor-
malities in patellofemoral function, have a
suspected relationship to abnormalities in
patellar position (7). Patella alta has been
recognized in people to contribute to knee
pain (28). Patella alta changes the patellofe-
moral contact forces, creates malalignment
of this joint, and causes increased patellofe-
moral joint stress that may lead to damage
of the underlying cartilage and bone (27,
28). Patients with patella alta had a higher
incidence of osteoarthritis (28). The clini-
cal importance and changes in patellofe-
moral joint mechanics that occur second-
ary to patella alta are not yet completely
understood. However, the human medical
experience dictates that correction to mini-
mize knee pain and improve patellofemoral
function may be applicable in canine pa-
tients.
Although the insertion of the patellar
ligament was widened compared to the
preoperative radiographic films, no direct
measurements were obtained. Patellar liga-
ment thickening has been previously re-
ported as a finding after tibial plateau level-
ling osteotomy (29, 30). The alterations in
the patellar ligament thickness may be due
to changes in the biomechanics of the pa-
© Schattauer 2015
tellar ligament as it travels to the tibial
tuberosity (29). The distal translation of the
insertion of the patellar ligament alters the
path of the forces as well as exposes the pa-
tellar ligament to the osteotomized surface
on the cranial aspect of the tibia. This pas-
sage of the patellar ligament over the osteo-
tomized surface of the cranial aspect of the
tibia may create an angulation of the liga-
ment which would alter the forces acting
on the ligament fibres. Concurrent ad-
vancement of the tibial tuberosity may help
to protect the patellar ligament as it travels
over the proximal tibia (13).
A major limitation of this study was the
lack of control group and more standard-
ization of the surgical techniques applied.
More objective measures of outcome in-
cluding gait analysis within a larger study
population size may be needed to further
assess this technique against other possible
surgical corrections. Biomechanical testing
of this implant construction compared
with traditional pin and tension band fix-
ation may also be warranted.
Conclusions
Distal tibial tuberosity translation provided
a good outcome for large breed dogs that
had patellar luxation with patella alta. No
complications were experienced using TTA
implants, but further study is warranted to
assess the role of patellar placement within
the trochlea, the mechanical stability of the
implant systems, and objective measures of
outcome for this technique.
Acknowledgements
The authors would like to thank Kathy
Welte for her assistance in providing the
images for this publication. A poster ab-
stract of this study was presented at the
2009 ACVS Veterinary Symposium, “The
Surgical Summit” (Washington, D.C., USA;
Oct. 6-10, 2009), and at the 40th Annual
Conference of the Veterinary Orthopedic
Society (Canyons Resort, Utah, USA;
March 9-16).
Conflict of interest
Author F. S. Pike is a paid consultant for
Securos, however reports no conflict of in-
280
terest regarding this study. There are no
other conflicts of interests to report for the
authors.
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