Cruciate Ligament Surgery- TPLO / TTA / TTO / LFS
Cruciate ligament surgery
TPLO / TTA / TTO / LFS
Tibial Plateau Leveling Osteotomy TPLO & Tibial Tuberosity Advancement (TTA) for cruciate ligament rupture.
Cranial or anterior cruciate ligament (CCL) rupture is the most common cause of hind limb lameness in dogs.
There are various surgical techniques available to replace the action of the cruciate ligaments. Traditionally these surgeries most often involved the placement of artificial ligaments along the outside of the knee joint. (DeAngelis 1970; Flo 1975). However, there are newer surgical techniques available including Tibial Plateau Leveling Osteotomy (TPLO), Tibial Tuberosity Advancement (TTA) or Triple Tibial Osteotomy (TTO) that are especially beneficial for medium to larger, more athletic dogs.
Most experienced orthopaedic surgeons and referral centres believe Tibial plateau levelling osteotomy TPLO, Tibial Tuberosity Advancement (TTA) or Triple Tibial Osteotomy (TTO) surgical methods have significant advantages over the traditional extracapsular methods particularly in medium, large and giant breeds.
These include less development of post operative arthritis (DJD), greater likelihood of return to normal athletic or working activity, better range of movement and more rapid recovery.
All cases are carefully assessed to determine the most suitable surgical method of surgeryfor each case. Each case has conscious examinations and also under sedation along with pre-op radiographs and assessments of conformation and plateau angles.
Following this a decision to perform either TPLO/TTA/TTO or in some cases CWO is made.
We find similar results and outcomes between the methods of TPLO/ plate TTA and TTO. Outcome is more affected by the experience of the surgeon with these methods than the differences between the techniques.
All the above the methods are available with the most frequently performed being TPLO and plate TTA.
Pre and post op TTA surgery. We utilise the plate TTA method designed by Tepic and have found it to have produced very pleasing & consistent results with extremely low complications in over 100 operated limbs, many having bilateral surgery, either at the time or returning if the opposite cruciate ligament ruptures, for surgery on the opposite leg months or years later.
Concurent Cruciate ligament rupture and patellar luxation
A modification of the TTA method is successful to aid with correction of medial patellar luxation which occurs in the same knee (stifle) joint as a ruptured cruciate ligamant, avoiding having to have 2 separate surgical procedures.
This modification permits simultaneous advancement and transposition of the tibial tuberosity- Tibial Tuberosity Transposition and Advancement (TTTA). The placement of a sized spacer and contouring of the TTA plate permits this modification, as seen in this West Highland Terrier at surgery.
Cruciate ligamant surgery -modified TTA method for concurrent patellar luxation- TTTA
The function of the cruciate ligament is to prevent forward movement of the tibia and provide stability in the stifle (Knee joint). Instability can lead to further damage within the joint– in particular to the medial meniscus. Tibial plateau levelling osteotomy TPLO or Triple Tibial Osteotomy (TTO) surgery aim to level the tibial plateau to prevent the tibia (shin bone) moving forward when the dog is weight bearing so producing a stable action through the stifle (knee joint) in dogs which have a complete or partial cruciate ligament rupture.
Tibial plateau levelling osteotomy TPLO procedures
Slocum designed a Tibial plateau levelling osteotomy TPLO surgical procedure to level the tibial plateau to 6 degrees. Many dogs have tibial slopes of 15 to 30 degrees and some have slopes of up to 45 degrees.
Cruciate ligamant surgery
Portion of excised torn medial meniscus at time of cruciate surgery
Following bilateral TTA cruciate surgery and hip replacement
Triple Tibial Osteotomy (TTO) procedure for TPLO
Dr. Warwick Bruce, a specialist surgeon, Sydney, Australia has brought principles from both TPLO & TTA methods and designed the procedure called Triple Tibial Osteotomy (TTO) which may be more stable & produces less radical angular changes than the Tibial plateau levelling osteotomy TPLO. (Bruce et al, 2007).
In the operation of triple tibial osteotomy (TTO) we perform a TPLO at an exact geometric point so that when the bone is rotated this simultaneously advances the tibial crest- similar to the Tibial Tuberosity Advancement TTA method.
The site is packed with bone graft harvested from the closing wedge osteotomy and then a Tibial plateau levelling osteotomy TPLO plate and screws secure the tibia.
TTO is performed in our clinic in the largest of cases- especially over 65kg utilising double plating in the very large 80kg dogs for increased strength and stability.
Post op double plate TTO surgery in 80kg St Bernard with Bilateral cruciate rupture and bilateral staged TTO surgery.
Follow up review radiograph showing healing of the osteotomy and surgical site
Intraoperative view of double plating TTO in giant dog breed
In all tibial plateau levelling osteotomy TPLO, TTA & LFS methods post operative rehabilitation is helpful to assist in the building up of the musculature surrounding the stifle (knee) joint in order to speed the recovery process and return to activity.