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Triple Tibial Osteotomy (TTO) for Treatment of Cranial Cruciate Ligament Rupture in Small Breed Dogs

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Triple Tibial Osteotomy (TTO) for Treatment of Cranial Cruciate Ligament Rupture in Small Breed Dogs pISSN 1598-298X / eISSN 2384-0749 J Vet Clin 34(1) : 7-12 (2017) http://dx.doi.org/10.17555/jvc.2017.02.34.1.7 Triple Tibial Osteotomy (TTO) for Treatment of Cranial Cruciate Ligament Rupture in Small Breed Dogs Tae-Hwan Kim, Subin Hong, Heesup Moon, Jeong-In Shin, Yun-Sul Jang, Hyeonjong Choi, In-Geun Kim and Jae-hoon Lee1 Institute of Animal Medicine, College of Veterinary Medicine, Gyeongsang National University, Jinju 52828, Korea (Received: November 23, 2016 / Accepted: February 14, 2017) Abstract : Twelve dogs weighing less than 10 kg underwent unilateral TTO to stabilize the stifle joint with cranial cruciate ligament rupture. Surgical findings, intra-operative and post-operative complications were recorded. Radiographic examinations were performed for 8 weeks following surgery. Postoperative outcome was evaluated using a visual analogue lameness scoring system. Mean preoperative PTA (the angle created by the intersection of the tibial plateau extrapolation line and the patellar tendon) was 103.8 degrees. Mean tibial wedge angle was 16.6 degrees. Mean postoperative PTA was 92.1 degrees. Intraoperatively, fracture through the caudal tibial cortex occurred in all dogs, through the distal tibial crest cortex in 2 dogs, through the lateral tibial cortex in 2 dogs and through the fibula in 1 dog. Four-week postoperative radiographs demonstrated evidence of progressive bone union at osteotomy site and complete unions were identified at 8 week in 10 dogs. All dogs were healed in 11 weeks. Most of dogs revealed weak lameness in 4 weeks and normal ambulation in 8 weeks postoperatively except for only one dog returned in 11 weeks. Despite frequent minor complication, it appears that the TTO is an alternative procedure for management of cranial cruciate ligament rupture in small breed dogs. Key words : cranial cruciate ligament, triple tibial osteotomy, complication, small breed, dog. Introduction don was perpendicular to the tibial plateau (10). The triple tibial osteotomy (TTO) combines three osteoto- Proximal tibial osteotomy techniques for treatment of mies made in the proximal tibia to create a partial tibial CCLR recently have gained popularity. There are two alter- wedge osteotomy caudal to a partial tibial crest osteotomy. nate concepts about how dynamic stabilization should be This procedure partially levels the tibial plateau while advan- attained with proximal tibial osteotomy. The first concept cing the tibial tuberosity and patella tendon in an attempt to was suggested by Slocum and Devine (24). This concept was neutralize femorotibial shearing forces across the stifle (5). that the joint reaction force in the stifle during weight bear- Proposed advantages of TTO over other proximal tibial ing was nearly parallel to functional the long axis of the tibia. osteotomies include the need for less radical angular changes Because of the caudo-distally sloping tibial plateau, the shear of the tibia than would be indicated in procedure’s that solely forces in the stifle joint accountable for CTT would have a level the tibial plateau or advance the tibia tuberosity, mini- relationship with the angle formed between the tibial plateau mal change to the femorotibial articulating surfaces, minimal and functional long axis of the tibia. They suggested that need for specialized implants or surgical equipment and no CTT would be removed from CCL ruptured joint by reduc- loss of tibial length (5,13). ing the tibial plateau angle (TPA) so that it was perpendicu- There is no information in the work on the surgical find- lar to the functional long axis of the tibia. The surgery ings, complications and outcome associated with the TTO in techniques to accomplish this purpose were the cranial tibial small breed dogs. The purposes of this study are to docu- wedge osteotomy (CTWO) (25) and the tibial plateau level- ment the surgical findings and complications of TTO for the ing osteotomy (TPLO) (26). The second concept is founded treatment of cranial cruciate ligament disruption in small on a biomechanical model suggested by Tepic et al. This breed dogs. concept was developed from study in human being that the joint force generated in weight bearing is parallel to patellar Materials and Methods tendon (17). It was therefore suggested that elimination CTT during weight bearing would be achieved by performing a This study was conducted under approval of ethical com- tibial tuberosity advancement (TTA), so that the patellar ten- mittee of Gyeong-sang national university laboratory animal center (Approval number: GNU-150402-D0016). The twelve dogs weighed less than 10 kg, and had a normal ambulation 1Corresponding author. on physical examination. The medical data was noted for E-mail : [email protected] breed, age, sex, weight, affected limb and meniscal tear. 7 8 Tae-Hwan Kim et al. Twelve dogs had unilateral TTO procedures. The mean body- operative radiograph, the TPA was defined according to the weight of dogs was 6.25 kg (range 4.6 kg to 8.6 kg). The conventional method (3,20). The patellar tendon, the patellar mean age of the dogs was 3.4 years (range 2 years to 7 tendon angle (PTA) and the correction angle (CA) were years). There were seven entire females, five entire males. defined as previously described (5,8,23). Pre-operative radio- The dogs had been fasted for about 12 hours before the graphic calculations were as follows (Fig 1). Tibial plateau operation. They were premedicated with medetomidine (0.2 (TP) was defined by estimating the position of the surface of mg/kg, administered subcutaneously (SC), Domitor®; Pfizer, the medial tibial condyle, which was slightly convex in NY, USA) together with acepromazine (0.05 mg/kg, SC, shape. The location of the tibial plateau was determined by Sedaject®; Samu Median, Seoul, Korea) and atropine (0.04 identifying the cranial and caudal points and drawing a line mg/kg, SC, Atropine®, Jeil Pham., Daegu, Korea). Cefazolin between them. The cranial most point of the medial tibial (25 mg/kg, SC, Hankook Korus Pharm Co, Seoul, Korea) condyle was visible as a small discrete step. The caudal point was used as a prophylactic antibiotic. After placement of a was the point of insertion of the caudal cruciate ligament-the catheter in the cephalic vein, general anesthesia was induced apex of popliteal notch was a useful point of reference. A with etomidate (2 mg/kg, administered intravenously (IV), line marking the cranial edge of the straight patellar liga- Etomidate-®Lipuro; B. Braun Melsungen AG, Germany) ment (PL) was drawn. Position a straight-edge cranial to the titrated to effect and administered to effect preceding tra- stifle and slide it caudally until it first touches points on the cheal intubation. Anesthesia was maintained with isoflurane patella and tibial crest. The distance between theses points (TerrellTM, Piramal Critical Care, USA) in 100 percent oxy- was the PL length. The tibial crest osteotomy (TCO) was gen via endotracheal intubation in a circle rebreathing sys- drawn with exactly the length of PL. The TCO was made tem. Normal saline was administered at 10 mL/kg/hour through parallel to the axis of the tibial shaft and was usually parallel the cephalic vein during the whole procedure. The dog’s to the cranial aspect of the tibial crest. A line was created by heart rate, body temperature, percutaneous blood oxygen sat- drawing a line perpendicular to TP starting from the proxi- uration (SpO2) and end tidal CO2 (Et CO2) was monitored mal end of PL. the correction angle (CA) was angle between during anesthesia. A circulating water blanket (Medi-Therm®, PL and the line. The angle of the tibial wedge osteotomy was Gaymar, NY, USA) with 38~39oC was used to maintain body calculated according to the currently recommended formula; temperature. wedge angle (WA) = 0.6 X CA + 7.3o (22). The central axis CCLR modeling preceded the TTO procedure. On the pre- of the wedge was located exactly halfway along the TCO. It was drawn in the central axis of the wedge as a line extend- ing caudally and perpendicularly from the TCO line at its mid-point. Surgery was performed as described by Bruce et al (5) with the minor modifications that no meniscal release proce- dures were performed (Fig 2). The dog was positioned in lat- eral recumbency with the affected leg down and parallel to the operating table, which was to explore the medial aspect of the stifle joint. Carprofen (2.2 mg/kg, PO, twice daily, Carprofen®, Zoetis, USA), cefadroxil (25 mg/kg, PO, bid, Cefaxil®; Koruspharm, Jecheon, Korea) and famotidine (0.5 mg/kg, PO, bid, Famotidine®; NELSON, Korea) were given for 7 days. Radiographs were taken immediately following surgery, 2, 4 and 8 weeks postoperatively. On the postoperative radio- graphs, the TPA and patellar tendon angle (PTA) were mea- sured (3,20). The intended wedge angle was substracted from the preoperative TPA to give the anticipated postoperative TPA. The difference between the anticipated and the achieved postoperative TPA was calculated. On radiographic examina- tion following surgery, major complications were defined as those that required further surgery or treatment. Other com- plications were considered to be minor. Visual lameness of the dogs was evaluated at stance, walk Fig 1. Preoperative surgical plan for the TTO surgery. CA is the and trot in preoperative TTO surgery, 4 weeks and 8 weeks. correction angle formed between the patellar tendon and a line Visual lameness was graded using a modified scoring sys- originating at the cranial-most aspect of the patella and perpen- tem (12): 0 = no detectable lameness (clinically sound); 2 = dicular to the tibial plateau. PTA is the angle created by the barely detectable lameness; 4 = mild lameness; 6 = moderate intersection of the tibial plateau extraspolation line and the lameness; 8 = severe lameness (carries limb when trotting); patella tendon.
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