Veterinary Surgery 37:111125, 2008

INVITED REVIEW

Tibial Osteotomies for Cranial Cruciate Ligament Insufciency in Dogs

STANLEY E. KIM,
BVSc,

ANTONIO POZZI, DMV, MS, Diplomate ACVS, MICHAEL P. KOWALESKI, and DANIEL D. LEWIS, DVM, Diplomate ACVS

DVM, Diplomate ACVS,

ObjectiveTo review the biomechanical considerations, experimental investigations, and clinical data pertaining to tibial osteotomy procedures for treatment of cranial cruciate ligament (CrCL) insufciency in dogs. Study DesignLiterature review. MethodsLiterature search through Pub Med, Veterinary Information Network, Commonwealth Agricultural Bureau Abstracts, and conference proceedings abstracts (November 1977 to March 2007). ResultsReported tibial osteotomy procedures attempt to eliminate sagittal instability (cranial tibial thrust) in CrCL-decient sties by altering the conformation of the proximal tibia. Functional stability can be achieved by decreasing the tibial plateau slope (cranial tibial closing wedge osteotomy [CTWO], tibial plateau leveling osteotomy [TPLO], combined TPLO and CTWO, proximal intraarticular osteotomy, chevron wedge osteotomy), altering the alignment of the patellar tendon (tibial tuberosity advancement), or both (triple tibial osteotomy). Clinical reports assessing the efcacy of these procedures frequently use subjective outcome measures, and the periods of follow-up evaluation are highly variable. Satisfactory results have been reported in most (475%) dogs irrespective of the type of tibial osteotomy procedure. ConclusionsCurrently available data does not allow accurate comparisons between different tibial osteotomy procedures, or with traditional methods of stabilizing the CrCL-decient stie. Carefully designed long-term clinical studies and further biomechanical analyses are required to determine the optimal osteotomy technique, and whether these procedures are superior to other stabilization methods. Clinical RelevanceLimb function in dogs with CrCL insufciency can be improved using the currently described tibial osteotomy techniques. r Copyright 2008 by The American College of Veterinary Surgeons

INTRODUCTION RANIAL CRUCIATE ligament (CrCL) insufciency is one of the most common causes of lameness in dogs.1 Rupture of the CrCL can be caused entirely by trauma; however, in most dogs rupture is a consequence of mid-substance, progressive, pathologic fatigue.2 Subsequent instability invariably leads to

development of progressive stie osteoarthritis (OA) and often results in secondary meniscal damage. This debilitating condition commonly affects young adult large breed dogs and frequently affects both sties within a year of the initial diagnosis.3 The economic impact of treating dogs with CrCL insufciency in the United States has been estimated in 2003 at just over $1 billion.4

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.u.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

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Treatment of CrCL insufciency aims to resolve lameness caused by joint instability and provide good longterm function of the affected hindlimb. Conservative management of dogs weighing o15 kg typically results in acceptable limb function, with reported success rates ranging from 84% to 90%.5,6 Surgical intervention is, however, recommended for most dogs with CrCL insufciency to reestablish joint stability, mitigate secondary degenerative joint disease, and address any concurrent meniscal injury.6,7 Over the past 50 years, a plethora of surgical techniques have been reported for treatment of this condition. This evolution of surgical procedures reects the controversy about optimal management of CrCL insufciency, and to date, no one procedure has consistently demonstrated superior clinical efcacy. Traditional surgical techniques attempt to impart stability using an autogenous, allogenic, or synthetic structure placed within or about the stie that mimics the function of the normal CrCL. Extraarticular techniques use periarticular heavy gauge suture or wires,8,9 or the transposition of soft tissues10 to reduce stie laxity, whereas intraarticular techniques attempt to anatomically reconstruct the CrCL using autogenous tissues,11 allografts,12 or synthetic materials.13 Most authors cite good to excellent limb function in most of dogs that have had extra- or intraarticular procedures.14,15 Yet despite these reported satisfactory results, traditional methods are generally considered to yield suboptimal long-term outcomes, as these techniques fail to consistently maintain stability, arrest the progression of OA, and prevent late meniscal damage.9,16,17 As surgical techniques continue to evolve, the focus has shifted to the concept of creating dynamic stability in the CrCL-decient stie by altering bone geometry. In 1984, Slocum described the cranial tibial wedge osteotomy (CTWO), a surgical procedure that attempts to eliminate cranial subluxation of the tibia during weightbearing by reducing the caudally directed slope of the tibial plateau.18 By establishing dynamic stability of the CrCL-decient stie, passive restraint against laxity is not required. Recognition that stabilization could be achieved in this manner led to the development of several proximal tibial osteotomy procedures, such as tibial plateau leveling osteotomy (TPLO)19; combined TPLO/CTWO20; proximal tibial intraarticular osteotomy (PTIO)21; triple tibial osteotomy (TTO)22; and chevron wedge osteotomy (CVWO).23 The more recently described tibial tuberosity advancement (TTA) procedure attempts to dynamically neutralize craniocaudal instability by altering the relative alignment of the patellar tendon to the tibial plateau.24 Although there are few studies evaluating long-term functional outcomes of any of these tibial osteotomy techniques, most have been associated with favorable clinical results.1822,2426

Our purpose was to review the biomechanical considerations, experimental investigations, and clinical data pertaining to tibial osteotomy procedures for treating CrCL insufciency in dogs.

CrCL BIOMECHANICS Because of the high prevalence of CrCL insufciency, and because CrCL transection in dogs is frequently used as an experimental model to induce OA,27 the structure and function of the CrCL has been extensively investigated.2832 Cadaveric experiments, in vivo kinematic analyses and theoretical models have contributed to understanding of CrCL biomechanics and subsequently lead to the development of tibial osteotomy techniques. Using a cadaver model, Arnoczky and Marshall demonstrated that the CrCL contributes to passive restraint specically limiting cranial translation of the tibia relative to the femur, excessive internal rotation of the tibia, and hyperextension of the stie.29 Other structures that provide passive restraint of the canine stie include the caudal cruciate ligament (CaCL), the collateral ligaments, and menisci.29,33,34 The loss of a passive supporting structure about a joint may increase laxity, but does not necessarily result in clinically relevant instability.35 During in vivo activity, joints are subject to other important dynamic restraint mechanisms, such as those produced by muscular force.35 For instance, electromyographic studies have shown that humans with anterior cruciate ligament rupture can inhibit anterior tibial translation by increasing hamstring tone and decreasing quadriceps activity.36 Further, the magnitude of forces applied to a joint to demonstrate and quantify joint laxity in vitro may be considerably different than the physiologic loads that are sustained in vivo. Therefore, results of cadaver experiments such as those reported by Arnoczky and Marshall do not fully dene whether or not the CrCL is a primary stabilizer of the canine stie. Kinematic studies in dogs, using stereo radiophotogrammetry and/or instrumented spatial linkage, were able to conrm that CrCL transection results in substantial cranial tibial subluxation during the stance phase of gait.30,31 These ndings demonstrate that muscular forces are unable to compensate for the loss of restraint provided by the CrCL. In all but 1 dog, cranial tibial translation did not occur during the swing phase of gait. Thus, the authors concluded that the stability of the stie during the stance phase of gait is dependent on the CrCL, whereas stability during the swing phase of gait is not dependent on the integrity of the CrCL. These observations are in agreement with ndings from a study in goats that measured dynamic CrCL strain in vivo, where maximum CrCL force occurred in early stance phase, and

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dropped to zero during the swing phase of gait.37 Conversely, neither kinematic study found signicant differences in peak internal rotation magnitude between CrCLdecient dogs and normal dogs,30,31 suggesting that either the CrCL is a secondary stabilizer against internal tibial rotation, or that nominal internal tibial torques are generated while walking. In the clinical setting, diagnosis of complete CrCL rupture is made by detection of craniocaudal joint laxity, which can be elicited by applying a cranially directed load on the proximal tibia. The cranial drawer test can be considered a static clinical test and is analogous to the cadaver experiment performed by Arnoczky and Marshall, because eliciting cranial drawer relies on displacement of a bone in the direction of an applied force.35 Dynamic tests, on the other hand, aim to mimic the forces and dynamic instabilities that normally occur during weight bearing.35 The tibial compression test, described by Henderson and Milton38 in 1978, attempts to replicate a weight-bearing force on the limb by exing the hock. With the stie at a standing angle, the tension generated in the gastrocnemius muscle creates strong caudodistal traction of the femur and consequently a cranioproximal shear force on the tibia.38 This force is normally counteracted by the CrCL, so cranioproximal translation of the tibia will result if the CrCL is ruptured. The tibiofemoral shear force that occurs during weightbearing was termed cranial tibial thrust by Slocum in 1983.32 Slocum also presented a theoretical model that proposed the magnitude of cranial tibial thrust was dependent on the degree of the caudodistally directed slope of the tibial plateau.32 Quantication of the tibial plateau slope, the tibial plateau angle (TPA), is dened by the angle formed between the slope of the medial tibial condyle and the perpendicular to the longitudinal axis of the tibia.18 Reported mean TPAs in clinically normal dogs range from 18 to 241.3941 According to Slocum, the compressive forces of weight-bearing, assumed to be parallel to the axis of the tibia, can be resolved into a cranially directed component (the cranial tibial thrust) responsible for cranial tibial translation, and a joint compressive force (Fig 1).32 A correlation between tibial plateau slope and anterior or cranial tibial thrust has been conrmed in human and animal in vitro models.4244 It is, however, important to note that there is no denitive evidence substantiating that dogs with higher than average TPAs are at greater risk for developing CrCL insufciency.39,40 More recent biomechanical theories argue that the tibia is not axially loaded as proposed by Slocum. Rather, Tepic suggests that the total tibiofemoral joint forces in vivo are directed parallel to the patellar tendon.28,45 Cranial tibial thrust, according to this model, is then depen-

Fig 1. Slocum theorized that, during weight bearing, the joint reaction force (magenta arrow) is approximately parallel the longitudinal axis of the tibia. In the CrCL-decient stie (A), the joint reaction force can be resolved into a cranially directed tibiofemoral shear component (parallel to tibial plateau) and a joint compressive force (perpendicular to tibial plateau). By leveling the tibial plateau (B), the joint reaction force is perpendicular to the tibial plateau, thus can only be resolved into a joint compressive force; cranial tibial thrust is eliminated. CrCL, cranial cruciate ligament.

dent on the angle between the tibial plateau and the patellar tendon (Fig 2).28 This model also predicts that cranial tibial translation should not occur when a CrCLdecient stie is exed beyond 901.28 Based on the predominant craniocaudal instability generated by CrCL transection in vivo; it is reasonable to conclude that neutralization of cranial tibial thrust is likely the most important function of the CrCL.30 Accordingly, current tibial osteotomy techniques primarily aim to address the sagittal plane instability that occurs as a result of weight-bearing. Because these procedures do not provide a passive restraint against internal tibial rotation, excessive internal tibial rotation may still occur (e.g. during certain vigorous activities that involve pivoting on the pelvic limb), and rotational instability may potentially contribute to the subsequent development of OA and meniscal injury. CTWO CTWO was the rst reported procedure that attempted to eliminate cranial tibial thrust by reducing TPA.18 Initially recommended as an adjunct to procedures that impart passive stabilization (such as fascial imbrication), CTWO involves leveling the TPA by resecting a cranially

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TIBIAL OSTEOTOMIES FOR CRANIAL CRUCIATE LIGAMENT INSUFFICIENCY IN DOGS

Fig 2. An alternate theory, proposed by Tepic, suggests that the joint reaction force (magenta arrow) is approximately parallel to the patellar tendon, not the tibial long axis. In the CrCL-decient stie (A), the joint reaction force can be resolved into a cranially directed tibiofemoral shear component and a joint compressive force (yellow arrows). By advancing the tibial tuberosity cranially, the patellar tendon is perpendicular to the tibial plateau during stance phase of gait (B). The joint reaction force, therefore, becomes perpendicular to the tibial plateau during weight bearing, thus can only be resolved into a joint compressive force; cranial tibial thrust is eliminated. CrCL, cranial cruciate ligament.

Fig 3. Position of the osteotomies and postoperative illustration of cranial tibial wedge ostectomy.

based wedge of bone from the proximal tibia, apposing the margins of the ostectomy site, then stabilizing the 2 bone segments with a medially applied bone plate using AO-ASIF principles (Fig 3). The ostectomy is performed as proximally as feasible while preserving a large enough proximal bone segment to allow for xation with at least 3 screws in each segment.46 Recent biomechanical studies suggest that to achieve a postoperative TPA of 51, and thereby neutralize cranial tibial thrust, the angle of the wedge to be excised should equal the measured preoperative TPA.47 Intuitively, it would seem that a wedge angle equal to the TPA would result in a postoperative TPA of 01. Performing a CTWO, however, induces tibial longitudinal axis shift, which is responsible for inadequate leveling of the tibial plateau slope.46,48 After CTWO, the proximal landmark for dening the tibial longitudinal axis of the tibia, the intercondylar tubercles, is shifted cranially.46,48 To compensate for this change in position, over-rotation of the tibial plateau is necessary to achieve the expected TPA of 51. The postoperative TPA will be larger than anticipated if calculations do not account for the shift of the longitudinal axis of the tibia.46

Wide discrepancies in the postoperative TPAs have been reported after CTWO.18,49,50 For instance, within a single case series reported by Macias et al49, postoperative TPAs ranged from 7 to 211. Difculty in attaining the target TPA may be attributed to variability in size and position of the ostectomy, and tibial longitudinal axis shift.46 Resecting a wedge equal to the TPA, performing the ostectomy as proximal as practical, and aligning the cranial cortices is recommended to improve the accuracy of the procedure.46,47 Intraoperative calculation of the wedge angle should be precise and methodical to further minimize variability in the postoperative TPA. A trigonometric method,20 or a sterilized template of the desired wedge made from radiographic lm can be used for this purpose. CTWO may be indicated in dogs with certain types of proximal tibial conformation. Although no causal relationship between a high TPA and CrCL insufciency has been established, abnormally steep tibial plateau slopes have been implicated as the underlying cause of CrCL rupture in several case series.20,4951 Exceedingly steep tibial plateau slopes secondary to alterations in proximal tibial physeal growth may be most amenable to treatment with a CTWO.52 Osmond et al52, attempted to characterize anomalies of the proximal portion of the tibia by correlating the morphometry of the proximal tibia in clinical CrCL insufciency cases with computer-generated models that mimicked different tibial morphologies.

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The authors identied a subset of CrCL-decient dogs with steep TPAs attributed to proximal shaft deformities, and theorized that the tibia would assume a more anatomically correct alignment after CTWO, as the procedure tilts the distal portion of the tibial shaft in relation to the proximal portion.52 In our experience (A.P.), correction of substantial proximal tibial varus or torsion are also more easily addressed by CTWO compared with other tibial osteotomy techniques. Although dynamic stabilization of CrCL-decient sties is receiving considerable attention, reports documenting clinical outcomes after CTWO are sparse. In a preliminary study of the CTWO involving 17 dogs, Slocum and Devine reported rapid return to function and clinical union of the osteotomy for most dogs by 6 weeks after surgery.18 All 9 dogs evaluated at 12 months after surgery had limb function that was subjectively considered indistinguishable from normal. Radiographic evidence of OA did not progress in any of the sties; however, objective, quantitative assessment of stie OA was not performed. The dogs also had semitendinosus, gracilis, and biceps femoris muscle advancement to reduce laxity, confounding the assessment of the CTWO procedure. In a retrospective analysis of 91 dogs treated with CTWO, 86% of the dogs were considered to have good-to-excellent limb function based on the results of a client survey and physical examination.25 Two case series reported the results of CTWO in small breeds dogs with proximal tibial deformities.49,50 Subjective lameness grading or owner satisfaction was used to gauge the efcacy of the procedure. All dogs (13 overall) in both studies had good-to-excellent limb function within 6 weeks after surgery, and maintained good limb use with an average follow-up of 1 year. In 1 of these reports, CTWO was combined with lateral suture stabilization, making it difcult to ascertain the efcacy of CTWO alone in this group of dogs.50 Reported complications have been principally associated with failure of xation and nonunion.18,25,49,50,53 In a direct clinical comparison of TPLO and CTWO, the second-surgery rate for CTWO was 11.9%, nearly twice the secondsurgery rate for TPLO (4.5%).51 Of the 12 dogs requiring surgical revision after CTWO, 9 were considered to have catastrophic tibial fractures requiring multiple plating.51 CTWO has the advantage of not requiring patented specialized equipment.53 Other advantages include the ability to address exceedingly steep tibial plateau slopes, as well as tibial varus and torsion. Because CTWO causes distal displacement of the patellar tendon insertion, the procedure may be used to treat concurrent patella alta.20 Disadvantages include: variability in postoperative TPAs, potential for creating patella baja and limb shortening.20,49,50 Also, inducing longitudinal tibial axis shift may result in esthetically undesirable craniocaudal an-

gulation of the tibia.20 With the growing recognition of proximal tibial angular limb deformities inducing steep TPAs, CTWO may gain wider acceptance in the treatment of CrCL insufciency. TPLO Like CTWO, TPLO aims to provide dynamic craniocaudal stie stability during the stance phase of gait by reducing the slope of the tibial plateau. Proposed by Slocum in 1993, TPLO involves performing a radial osteotomy of the proximal tibia with subsequent rotation of the proximal segment to enable precise manipulation of the tibial plateau slope.19 Based on the radius of the osteotomy and the preoperative TPA, the exact amount of rotation of the proximal segment is calculated to achieve a postoperative angle of 51.54 The procedure is performed by a medial approach to the proximal tibia.54 A biradial saw blade is used to create a crescent-shaped osteotomy; compression of the osteotomy results in complete congruency, as the inner and outer edges of the saw blade are of the same diameter.54 A custom-jig that is applied medially maintains alignment of the bone segments while allowing for rotation of the proximal segment.54 The osteotomy should be centered over the intercondylar tubercles to ensure accurate rotation and maintain enough bone in the proximal segment for adequate purchase during internal xation of the osteotomy (Fig 4).54 Imprecise positioning of the osteotomy may result in an inaccurate tibial plateau leveling and complications such as angular and rotational deformities, and tibial tuberosity fracture.5557 Biomechanical studies have demonstrated that after tibial plateau rotation, the tibiofemoral shear force shifts from cranial to caudal when the limb is loaded.42,43 Thus, it has been postulated that joint stability is dependent on the CaCL neutralizing caudal tibial translation after TPLO.42 The recommended postoperative TPA was dened as 0 and 51 when the procedure was rst described in 1993 and in the TPLO licensing course, respectively.18,54 Despite these specic guidelines, the optimal TPA is still a contentious subject. In vitro studies demonstrate that cranial tibial thrust is effectively neutralized at a mean angle of 6.51.42,43 Three-dimensional computer modeling of the canine stie, on the other hand, found that rotation to 51 only marginally decreased the tensile force acting on the CrCL.58 Both in vitro analyses and theoretical modeling, however, can fail to reliably predict clinical outcome.59 Limitations associated with cadaver experiments include the difculty of replicating naturally occurring disease and the inability to simulate all the muscular forces acting on the joint. Inaccuracies of computer modeling can arise from multiple assumptions, such as disregarding muscular compensation, and simplifying

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Fig 4. Position of the osteotomy and postoperative illustration of tibial plateau leveling osteotomy.

joint geometry. Data from in vitro and computer-modeling investigations should be interpreted and applied to clinical cases with caution because of these limitations. In a clinical study by Robinson et al60, there was no statistically signicant relationship between TPA and ground reaction forces after TPLO, where the postoperative TPAs were between 0 and 141. Satisfactory results of under-rotated sties, which were indistinguishable from the outcome of dogs that had optimal postoperative TPAs, may be indicative of complete elimination of cranial tibial thrust in vivo over a wide range of angles. Optimal TPAs may vary between breeds, or indeed between individual dogs. Chronically affected sties may not require as much rotation as sties with acute rupture, because periarticular brosis can contribute substantially to joint stability.7 Alternatively, the presence of residual cranial tibial thrust after TPLO may not result in lameness.19 Precise in vivo kinematic analyses are required to identify the optimal TPA and further understand the biomechanics of the TPLO. Results for dogs treated with TPLO have so far been encouraging, although there are no studies documenting objective data with follow-up 417 months (mean).60 Subjective evaluation of limb function suggests earlier return to weight-bearing after TPLO when compared with the intra- and extracapsular forms of stabilization.61 Beyond the initial recovery period, however, convincing proof that the TPLO results in superior limb function

currently does not exist. In Slocums original study, which included 394 dogs, outcomes at follow-up evaluations 46 months after surgery were reported as excellent for 73%, good for 21%, and fair for 3%.19 Another study with a follow-up ranging from 6 months to 4 years reported that 93% of owners were satised with the outcome after TPLO, which is similar to the proportion of owner satisfaction after other techniques.57 Good to excellent long-term function, based on owner evaluation, has also been reported in most dogs (25 cases, 50 sties) treated with single-session bilateral TPLOs.62 In an in vivo experiment by Ballagas et al63, experimentally induced CrCL-decient pelvic limbs were treated with TPLO and evaluated with force plate analysis preoperatively, at 8 and 18 weeks after surgery. By 18 weeks, peak vertical force and vertical impulse were not signicantly different when compared with preoperative values, although a subjective mild lameness was still evident in 4 of 6 dogs. Conzemius et al64 in a prospective clinical study in Labrador Retrievers with CrCL insufciency compared limb function after lateral suture stabilization, intracapsular stabilization, and TPLO using force platform gait analysis. Contrary to the conclusions drawn by some studies that evaluated outcomes subjectively, these investigators found no difference in ground reaction forces or peak vertical impulse between TPLO and lateral suture stabilization treated dogs at 2 and 6 months after surgery. Moreover, only 10.9% of TPLOtreated dogs obtained comparable limb function to clinically normal dogs compared with 14.9% of dogs with lateral suture stabilization and 15% of dogs with intracapsular stabilization evaluated in the same study. There are several reports that have investigated the progression of stie OA after TPLO. A prospective radiographic study of 40 dogs showed a signicant overall increase in mean osteophyte scores 6 months after TPLO.65 Interestingly, progression of osteophytosis was not evident in most (57.5%) of dogs, and radiographic parameters of OA were improved in 2 dogs.65 A comparison of long-term radiographic changes after TPLO and lateral suture stabilization revealed that whereas TPLO did not prevent progression of OA, rate of progression was $ 3-fold less than sties that had lateral suture stabilization.66 Studies assessing the efcacy of TPLO based on radiographic OA assessment should be interpreted with caution, as soft tissue (e.g. cartilage, synovium, menisci, periarticular tissues) changes are not readily identiable with this imaging modality, and 1 study has shown that radiographic OA changes in the stie are not predictive of limb function.67 Numerous intra- and postoperative complications have been reported in dogs undergoing TPLO. The relative high frequency of complications reported for TPLO may be because of the large number of cases that have

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been evaluated in the literature, and many of these studies were documenting initial experience with this technique. The overall complication rate is reportedly 2634%, with tibial tuberosity fracture, implant failure, patellar tendonitis, subsequent meniscal tear after TPLO and infection reported most frequently.57,6872 Whereas most are implant or fracture-related complications, others have been attributed to abnormal stie biomechanics induced by TPLO.57,6872 Tibial tuberosity fracture occurs in 3 7% of TPLO cases.6870 Most of these fractures are nonor minimally displaced and do not require surgical intervention.57 Fracture of the tibial tuberosity may be caused by a stress riser effect at the site of Kirschner wire placement used to maintain the rotation of the tibial plateau segment, or at the narrow isthmus of the tibial tuberosity created by a cranially positioned osteotomy.68,69 Thermal necrosis, vascular compromise secondary to soft tissue dissection, increased strain in the patellar tendon after TPLO and large rotations of the tibia plateau segment have also been cited as potential predisposing factors.20,57,68 A retrospective analysis by Kergiosen et al57 identied age, weight, single session bilateral TPLO surgery and tibial tuberosity width as potential risk factors for tibial tuberosity fractures. Prophylactic pin and tension bands have been used in an attempt to decrease the risk of tibial tuberosity fractures.62 Patellar tendonitis is also common, and may cause lameness within the rst 2 months after TPLO.68,69,71,72 Clinical signs are usually self-limiting. Patellar tendon thickening, visible on radiographs or by ultrasonography, is most commonly noted distally.72 Possible causes include trauma to the patellar tendon sustained during surgery because of excessive retraction, or thermal damage associated with saw blade contact.71,72 Histopathologic changes in the tendon are noninammatory and similar to those identied in humans with patellar tendon strain, hence excessive loading of patellar tendon secondary to altered biomechanics after TPLO has also been implicated as a possible underlying cause.55,71 Rotation of the tibial plateau segment may result in a decreased moment arm if the distance between the patellar tendon insertion and instant center of rotation of the stie is reduced; in turn, greater forces in the quadriceps mechanism may be required to generate the same extensor moment about the stie.55,71 This theory is corroborated by ndings from a radiographic study by Mattern et al72, where lower postoperative TPAs (o61) were associated with more severe ultrasonographic changes in the patellar tendon. Recurrent lameness after TPLO may indicate subsequent meniscal injuries. Although meniscal tears occurring after stabilization of CrCL-decient sties have been reported as a complication associated with several procedures,73,74 it is proposed that there is a high risk of

developing meniscal injuries after TPLO because passive joint stability is not restored.19 The caudal pole of the medial meniscus acts as a wedge between the femoral and the tibial condyles and may become crushed during cranial tibial translation.34 TPLO places the stie joint in a greater angle of exion during weight bearing, which might result in excessive loading of the caudal pole of the medial meniscus.28 Slocum and others have advocated complete radial transection of the medial meniscus, termed meniscal release, to allow caudal displacement of the caudal pole of the medial meniscus during cranial tibial translation, thereby preventing subsequent meniscal tears.19,68 In vitro studies have, however, shown that meniscal release impairs load transmission and stability of the stie.34,75 The adverse consequences of releasing the meniscus were corroborated by a radiographic study demonstrating greater progression of OA in dogs that had meniscal release.76 Furthermore, there is no evidence to suggest that meniscal release eliminates the risk of subsequent meniscal tears.77 A recent retrospective study reported a 3.5% incidence of subsequent meniscal injury in sties that underwent arthrotomy with meniscal release.77 Meniscal release did not reduce the rate of subsequent meniscal tearing when compared with cases treated arthroscopically without meniscal release.77 Whereas traditionally, stie arthrotomy has been considered as an accurate method for assessing the menisci,78 the data suggest that lack of identication of meniscal tears at the time of TPLO may play an important role in the development of recurrent lameness because of meniscal pathology.77 Indeed, a recent cadaver study found that meniscal examination by arthrotomy had signicantly lower sensitivity and specicity than arthroscopy for diagnosing meniscal tears.79 When meniscal pathology cannot be comprehensively assessed in the CrCL-decient stie, releasing the medial meniscus is advocated to decrease the incidence of subsequent meniscal tears.77,79 If the medial meniscus is thoroughly evaluated at the time of TPLO, and cranial tibial thrust is effectively neutralized, meniscal release may not be warranted.77,79 The decision to release an intact meniscus remains controversial, and the issue is further complicated by the apparent nominal impact meniscal release has on limb function.77 Further studies are necessary to determine the long-term effects of meniscal release on joint function. It is important to note that although meniscal release is most commonly referenced to TPLO, performing a meniscal release is not restricted to this procedure because passive joint laxity is a consistent feature of all tibial osteotomy techniques. CaCL injury is cited as a potential complication after TPLO.19 Because TPLO is postulated to induce caudal tibial thrust, over-rotation increases strain on the CaCL.42 Whereas increased strain has been demonstrated in

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cadaver studies,42 clinical cases with postoperative lameness denitively attributed to CaCL strain or rupture have not been reported, even in cases where TPAs have been as low as 71.68 Neoplasia developing at the TPLO surgical site has been documented; however, a direct causal relationship has not been proven.80 Boudrieau et al80 recently described a dog with an histiocytic sarcoma involving the proximal portion of the tibia 5 years after TPLO. Visual, microscopic, chemical and metallographic analysis of the TPLO plate retrieved from this dog revealed corrosion; poor resistance to corrosion was attributed to the casting manufacturing process of the implant. Implant corrosion was implicated as a potential cause of tumor development, and 3 additional dogs were identied that had previously undergone TPLO and developed osseous neoplasia of the proximal tibia. These ndings prompted further investigations; metallurgic analyses of both new and previously implanted Slocum TPLO plates revealed these plates had unusual surface irregularities and porosity.81,82 Aluminum and silicon residua and inclusions, which were thought to have originated from the cast moulds, were also identied.81 Conicting results exist regarding corrosion of retrieved implants.8183 Although investigations have focused on corrosion as a potential cause for neoplasia, other causative factors that are not specic to the Slocum TPLO plate, such as the osteotomy itself, have not been eliminated. Moreover, TPLO is almost exclusively recommended to a population of dogs that are at risk for developing primary osseous neoplasia, of which the proximal tibia is a common site of occurrence.84 Further work is warranted to determine whether the TPLO procedure, or the specic implants used, increase the risk of tumor development. Infection, manifesting as septic arthritis, osteomyelitis, or supercial wound infection is reported with a rate of 37%, which is greater than the infection rate previously reported for other clean surgical procedures.6870,85 Septic arthritis is considered one of the most serious complications encountered after TPLO.68 The cause of higher infection rate after TPLO is likely multifactorial. Infection after open reduction and internal xation of proximal tibial fractures in human patients is attributed to poor soft tissue coverage and blood supply.86 Poor soft tissue coverage of the surgical site may play a role in migration of bacteria through the surgical wound from the external environment.86 Extensive soft tissue dissection around the proximal tibia, poor tissue handling, prolonged surgical time, surface plate characteristics87, and thermal necrosis at the osteotomy site may also contribute to infection. TPLO is currently the most common tibial osteotomy performed, and widely regarded by many veterinary surgeons as the best surgical option for CrCL insufciency in

Fig 5. Position of the osteotomy and postoperative illustration of tibial tuberosity advancement.

medium to large breed dogs.64 Advantages include geometric precision, maintenance of the original position of the tibial tuberosity and patellofemoral joint.20 Disadvantages include the technical difculty and complications of the surgical procedure, including iatrogenic angular and torsional deformities, as well as the potential adverse affects on stie biomechanics.56,57,69,70,72 TTA TTA, rst described by Montavon et al24 in 2002, attempts to dynamically stabilize the CrCL-decient stie without leveling the tibial plateau. As previously discussed, theoretical models of the stie predict that the total joint forces are approximately parallel to the patellar tendon.28 Thus, if the patellar tendon is oriented perpendicular to the tibial plateau, there is no shear component of the total joint force. During the stance phase of gait, where the stie angle is 1351 of extension, the angle between the patellar tendon and the tibial plateau is approximately 1051.45 Accordingly, reducing this angle to 901 should stabilize the CrCL-decient stie (Fig 2). This anatomic conformation can be achieved by performing a TTA (Fig 5). The procedure involves making a longitudinal osteotomy subjacent to the tibial tuberosity. An appropriately sized spacer-cage is implanted at the proximal extent of the osteotomy to secure the tibial

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tuberosity in a cranial position. The width of the cage, available in 3, 6, 9, and 12 mm sizes, is determined by measurements made from preoperative lateral pelvic limb radiographs with the stie at $ 1351 extension.24 A tension-band bone plate is applied to the medial aspect of the tibia, and autogenous or allogenic bone graft is placed in the resulting defect to accelerate bone union.24 Theoretical reduction of tibiofemoral shear forces by advancing the insertion of the patellar tendon has been substantiated in both cadaver and computer-modeling studies.8890 Maquets procedure in human patients involves anterior advancement of the tibial tuberosity, which is advocated for treatment of patellofemoral pain.91 In a cadaver study of Maquets procedure, the magnitude of tibiofemoral forces in a direction tangential to the joint surfaces consistently decreased after incremental advancement, provided the knee angle was at near-to-full extension.90 Similarly, nite element analysis of the human knee found that, at near full extension, anterior cruciate ligament and tibiofemoral contact forces substantially decreased after advancement of the tibial tuberosity.89 A recent in vitro study performed in canine cadaver pelvic limbs also demonstrated neutralization of tibiofemoral shear forces by advancing the tibial tuberosity, where the mean patellar tendon-to-tibial plateau angle required to eliminate cranial tibial thrust was 90 91.88 Clinical outcomes after TTA are currently documented in a small number of preliminary reports only 2 of which are still in abstract form.24,92,93 In a prospective clinical trial of 40 CrCL-decient sties treated with TTA, mean peak vertical force was 32% of body weight preoperatively, and doubled to 64% of body weight at a nal examination performed between 4 and 12 months after surgery.92 This was still signicantly lower than a mean peak vertical force of 74% in clinically normal dogs, although the results are comparable with the ndings in a similar study evaluating pelvic limb function before and after TPLO.92 In a retrospective report, 38 of 40 owners (95%) were satised with the long-term outcome of TTA, and the authors clinical impression was that the postoperative recovery with this technique was very rapid.93 Hoffman et al26, found that, with a median follow-up of 24 weeks, owners assessed the overall outcome of the procedure good to excellent in 90% of cases. These initial results appear promising; however, accurate assessment of outcome after TTA is not currently possible because of a lack of reported clinical studies. Reported complications associated with TTA include implant failure, tibial tuberosity fracture, medial patellar luxation, CaCL injury because of excessive advancement, and subsequent meniscal injury.26,92,93 Implant failure, reported to occur in 15% of operated limbs, was attributed to either technical error or earlier implant designs that were considered too weak; the implants have been subse-

quently modied. Excessive postoperative activity has also resulted in complete implant failure.26 Partial CaCL rupture diagnosed 4 months after surgery in 1 dog was attributed to excessive advancement of the tibial tuberosity.92 Indeed, in the cadaver study by Apelt et al88, caudal tibial translation was found to occur when the tibial tuberosity was advanced beyond the dened angle required to neutralize cranial tibial thrust, presumably placing excessive strain on the CaCL. Postoperative meniscal injuries were frequent in 1 study, occurring in 7 of 24 cases that had intact medial menisci at surgery.93 It is difcult to ascertain whether this was an accurate reection of the true prevalence of late meniscal injury associated with the TTA, if meniscal lesions were the result of unfavorable biomechanics, if meniscal lesions were missed at the primary surgery, or if meniscal lesions were caused by insufcient advancement of the tibial tuberosity after TTA. From a biomechanical perspective, TTA may have 2 principal advantages over TPLO. TTA preserves the natural tibiofemoral articulation because the tibial plateau is not repositioned. In doing so, and provided that the TTA is equally as effective as the TPLO in neutralizing cranial tibial thrust, natural load transmission across the stie (and menisci) is less likely to be altered. TTA also increases the extensor moment arm of the stie and thus the mechanical advantage of the patellar tendon, thereby theoretically reducing the forces acting along the patellar tendon.28 TPLO, on the other hand, appears to increase the strain on the extensor mechanisms of the stie, resulting in clinically relevant complications.55,71 At this stage, these potentially advantageous features of TTA are purely speculative, and future biomechanical analyses will hopefully provide information that allows objective comparisons between TTA and TPLO. Purported advantages of TTA include being less invasive and technically less demanding than other tibial osteotomies, an ability to effectively treat concurrent patellar luxation,94 short operative time, and low postoperative morbidity.92 Disadvantages include the potential to cause iatrogenic patellar luxation, requirement for specialized implants, and potentially high rate of late meniscal injuries. Because the technique is a new procedure, the true benets and complications are yet to be substantiated by sufcient clinical or biomechanical data.

OTHER TIBIAL OSTEOTOMY TECHNIQUES Several other tibial plateau leveling techniques have been described. Whereas information regarding these procedures is limited, each procedure presents unique methods developed to circumvent certain limitations of conventional tibial osteotomies described above, and may gain further attention in the future.

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of cases. Most notably, implant failure necessitating a second procedure occurred in more than 1 in 4 cases, and mean time to complete radiographic healing was prolonged at 18 weeks. CrCL insufciency in dogs with exceedingly large TPAs remains a challenging orthopedic problem, and despite a high complication rate, combination TPLO/ CTWO may be one of few surgical procedures resulting in an acceptable outcome. Dogs with excessive TPAs may also have concurrent pelvic limb conformational abnormalities,51 and proponents of combining TPLO with CTWO suggest many of these conditions can be addressed with this technique.20 It is arguably the most technically demanding procedure of all described tibial osteotomies and should thus be performed by only experienced veterinary orthopedic surgeons. PTIO PTIO is another tibial plateau leveling technique that involves making a wedge ostectomy with the base of the wedge located between the bursa of the patellar tendon and the cranial aspect of the menisci (Fig 7).21,95 A biaxial approach is required: tibial osteotomies are performed from the medial surface; laterally the craniolateral crus muscles area is elevated off the proximal tibia and a bula ostectomy is made to facilitate reduction of the ostectomy site. Both medial and lateral arthrotomies are recom-

Fig 6. Position of the osteotomies and postoperative illustration of tibial plateau leveling osteotomy and cranial tibial wedge ostectomy.

Combination Closing Wedge Osteotomy and TPLO Combination TPLO and CTWO is primarily used to treat CrCL-decient sties with excessive TPAs (4341).20 Reducing TPA by using both methods concurrently is purported to diminish the risk of complications encountered when either procedure is performed alone, such as patella baja and tibial tuberosity fracture.20 The magnitude of rotation and wedge angle is determined by standardizing 1 measurement (e.g. wedge angle 101), then calculating the remainder of tibial plateau leveling with the other measurement (e.g. tibial plateau rotation TPA5wedge angle) to achieve a postoperative TPA of 51. The radial osteotomy is positioned in the same location as a standard TPLO, and the cranially based closing wedge ostectomy is placed such that the apex is at the caudal cortical margin of the TPLO. Extensive rigid internal xation using interfragmentary Kirschner wires, tension-band wire, and single or double plating is required to stabilize all 3 bone segments (Fig 6). In a clinical series of 15 dogs with excessive TPAs, a mean postoperative TPA of 81 was achieved with combination TPLO/CTWO.20 At a mean nal follow-up of 23 weeks, no lameness was observed in 73%, only a mild lameness was noted in the remaining 27%, and all owners were satised with the overall outcome. Postoperative complications were, however, common, occurring in 78%

Fig 7. Position of the osteotomies and postoperative illustration of proximal tibial intraarticular osteotomy.

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mended to inspect the stie and excise the infrapatellar fat pad for adequate visualization during the procedure. The angle of the wedge to be excised is determined from preoperative radiographs, but descriptions of calculating this angle are vague. The margins of the osteotomies are reduced with reduction forceps and stabilization is achieved with screws inserted in lag fashion craniocaudally, with or without augmentation using a medially positioned 6-hole plate applied in buttress fashion. The medial and lateral fascia may be imbricated to reduce passive instability. In the original description of this procedure, 75 of 87 dogs (86%) were considered to have a sound gait at follow-up assessments 4 months postoperatively, but 7 dogs (8%) were still moderately lame.21 Slightly better outcomes were reported by Jerram et al95, where lameness was not apparent in 54 of 57 (95%) operated limbs when examined 6 months after surgery. The remaining 3 (5%) operated limbs had intermittent, mild, weight-bearing lameness with exercise.95 Although the overall proportion of dogs with satisfactory results is comparable with other tibial osteotomy procedures, multiple complications may preclude PTIO from gaining wide acceptance.21 A high rate of subsequent meniscal injuries has been observed. Of 57 sties with an intact medial meniscus, subsequent meniscal injury requiring surgical intervention occurred in 10 sties (17.5%).21 Induced tibial valgus deformity was observed in both reports, occurring in 312% of operated limbs. Other reported complications included long digital extensor trauma or brosis, requiring a second surgery and intensive physical therapy, supercial peroneal nerve injury, laceration of the cranial tibial artery, tibial fracture, osteomyelitis, and implant failure.21,95 The main advantage of PTIO is that it can be performed without need for specialized surgical equipment.21,95 Disadvantages include long operative time, apparent necessity for medial meniscal release, and occurrence of complications, such as valgus deformities and long digital extensor tendon injury that often require surgical revision. The requirement for extensive arthrotomies is unfavorable when compared with other techniques, as studies have demonstrated acceleration of OA when a full arthrotomy is performed.96,97 At present, PTIO cannot be advocated as a valid alternative to TPLO. Chevron Wedge Tibial Osteotomy A cranially based tibial wedge ostectomy can be performed using chevron kerfs.23 The rationale behind using more complex osteotomies stems from the perception that opposed V-shaped osteotomy surfaces resist craniocaudal shear and torsional forces better than conventional linear osteotomies (Fig 8).23 Planning of CVWO is similar to CTWO: tibial longitudinal axis shift should be taken into consideration when calculating the wedge an-

Fig 8. Position of the osteotomies and postoperative illustration of chevron wedge osteotomy.

gle, the osteotomies should be positioned as proximally as possible, and the ostectomy site is stabilized with a medially applied bone plate. Accurate execution of the osteotomies may be facilitated with the use of a saw-blade guide jig, and stability of the construct can be enhanced by use of a cranially placed screw inserted in lag fashion, directed caudad and proximad. Clinical outcomes of CVWO for treatment of CrCL insufciency in dogs have not been reported, and thus the complication rate is unknown. In an in vitro geometric study of 5 different tibial osteotomy techniques,23 CVWO induced the greatest amount of tibial valgus deformity, and postoperative valgus has also been observed anecdotally in clinical cases (Denis J. Marcellin-Little, 2007, personal communication). Because of the paucity of information available, it is uncertain whether CVWO has any clinically relevant benet over other tibial plateau leveling procedures. TTO TTO, like TTA, is a procedure that aims to result in a proximal tibial conformation so that the patellar tendon is oriented perpendicular to the tibial plateau when the stie is at a weight-bearing angle.22 First, a partial frontal plane osteotomy of the tibial tuberosity is made, leaving the distal cortex intact. A partial wedge ostectomy, with a

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operative patellar tendon-to-TPA when using the recommended calculations, and questionable protective effects against medial meniscal injury. CONCLUSIONS By addressing the cranially directed shear force leading to cranioproximal tibial translation that occurs during weight-bearing, tibial osteotomy techniques have been clinically successful in improving pelvic limb function in dogs with CrCL insufciency. Despite their popularity, differences in long-term outcome between tibial osteotomies and traditional methods of repair are not apparent.64 As highlighted in a recent metaanalysis evaluating surgical procedures used in dogs with CrCL insufciency, this may reect the lack of objective clinical data reported.98 Likewise, the current body of information is insufcient to validate 1 tibial osteotomy technique over another. Individual and interbreed differences in morphology, kinematics and kinetics may also inuence the nal outcome after surgery, and some osteotomy procedures may be more suitable than others in certain breeds of dogs or tibial conformations. Specic indications for each individual technique remain to be determined. Concerns common to all tibial osteotomies for treating CrCL insufciency include the sparing effect on the meniscus, the progression of OA after surgery and the correlation between clinical outcome and postoperative TPA or patellar tendon-to-tibial plateau angle. Future clinical studies need to adopt reliable, validated and standardized outcome measures to permit fair and direct comparisons between the various techniques. The problems encountered in the surgical management of CrCL insufciency are undoubtedly a reection of the complexity of the structure and function of the stie joint. Future studies should not only focus on the clinical results of different surgical procedures; a clearer understanding of the biomechanics of the canine stie and the etiopathogenesis of the disease is also required to determine whether tibial osteotomy techniques are superior to other treatment modalities for managing CrCL insufciency in dogs. ACKNOWLEDGMENTS
The authors thank Drs. Jimi L. Cook, Denis J. MarcellinLittle, Warwick J. Bruce, and Randy J. Boudrieau for their contributions. The assistance of Tim Vojt in producing the gures is gratefully acknowledged.

Fig 9. Position of the osteotomies and postoperative illustration of triple tibial osteotomy.

wedge angle equal to two-thirds of angle between the patellar tendon and a line perpendicular to the tibial plateau slope, is then performed caudal to the tibial tuberosity osteotomy. Specialized TTO instrumentation is commercially available to facilitate accurate positioning of the osteotomies. Reduction of the wedge ostectomy site simultaneously reduces the tibial plateau slope and shifts the tibial tuberosity in a cranial direction (Fig 9). Application of a 3.5 mm T-plate is recommended to stabilize the wedge ostectomy site. In a prospective clinical study of TTO in 64 dogs with a mean follow-up of 15 months, no lameness was observed in most dogs at nal examination.22 Signicant increases in thigh circumference and stie range of motion were also noted. All owners assessed their dog as being normal or near normal for all physical activities except sitting (2% mildly abnormal) and standing (4% mildly abnormal). Complications were encountered in 36% of cases, including tibial tuberosity fractures, infection, and subsequent meniscal injury. The most common complication was intraoperative tibial tuberosity fracture necessitating tension-band wire xation, which occurred in 23% of dogs. Proposed advantages of TTO include minimal change to the orientation of the tibiofemoral articulating surfaces, a relatively small osteotomy gap caudal to the tibial tuberosity, no loss of limb length, and low technical difculty when the appropriate instrumentation is used. Potential disadvantages include variability of the post-

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