TPLO etc

1. DIVISION OF
DIVISION OF VETERINARY SURGERY
VETERINARY SURGERY AND
AND
RADIOLOGY
RADIOLOGY
MANAGEMENT OF RUPTURED
CRUCIATE LIGAMENT IN DOGS
Submitted to- Dr. Mehraj u din dar

2. • Cruciate ligaments are a major part of the canine
knee.
• "Rupture of the anterior cruciate ligament is the
most common injury in the stifle joint of the dog.”
most common injury in the stifle joint of the dog.”
• Peak incidence : 2 – 10 years
• Painful and immobilizing injury..
• Cruciate ligament rupture, especially cranial
cruciate ligament rupture, has long been a
clinical problem observed in veterinary practice.

3. • It consist of two joints
• FEMORO-PATELLAR ARTICULATION
• FEMORO-TIBIALARTICULATION

5. 1a: Caudolateral
Bundle Of CrCL
1b: Craniomedial
Bundle Of CrCL
2: CaCL
3: Medial Meniscus
4: Lateral Meniscus
5: Long Digital
Extensor tendon
6: Medial Humeral
Condyle
7: Tibial Tuberosity

6. 1: CrCL
2: CaCL
3: medial meniscus
4: intermeniscal ligament
5: medial collateral ligament
6: lateral meniscus
7: meniscofemoral
7: meniscofemoral
ligament
8: popliteal tendon
9: tendon of the long digital
extensor
10: infrapatellar fat pad
11: patellar tendon;
12: patella

8. • Origin : medial side of the lateral femoral condyle
• Insertion : cranial intercondyloid area of the tibia
• The CrCL is narrowest in its mid - region and fans out
proximally and distally
• In dogs, the CrCL has a craniomedial and a caudolateral
• In dogs, the CrCL has a craniomedial and a caudolateral
component containing bundles of longitudinally orientated
collagen fibers
• The craniomedial component is tight in both flexion and
extension, whereas the caudolateral component is only
tight in extension(CL slack –flexion)
Cr-medial …main wt bearing

10. • Origin : a fossa on the ventral aspect of the lateral side of
the medial femoral condyle.
• Insertion : medial aspect of the popliteal notch of the tibia
• Slightly longer and broader than the cranial cruciate
ligament.
• Lies medial to and crosses the cranial cruciate
ligament
• Rupture of CaCL is rare as compared to the CrCL

11. CrCL
prevent cranial
displacement
Limit excessive
internal rotation of
the tibia on the femur
by twisting on the
CaCL
prevent
hyperextension
CaCL
limits excessive
internal rotation
of the tibia on the
femur.
prevent caudal
displacement

12. PREDISPOSING
FACTORS
Breed
Conformation
Anatomy
Trauma
FACTORS
Conformation
Obese
Hyperactive
dogs
Degenerative cruciate
lesion

13.  ANATOMYCrCL is under a tremendous
mechanical stress even during relatively
sedentary activities.
 Conformation intercondylar notch narrow
more injury
 ……..this tear is often the result of subtle,
slow degeneration that has been taking place
slow degeneration that has been taking place
within the ligament rather than the result of
trauma to an otherwise healthy ligament.
This is why approximately half of the dogs
that have a cruciate ligament problem in one
knee will, at some future time, develop a
similar problem in the other knee.

14. Magnetic resonance
imaging
Tibial compression test
Drawer sign
test
Arthrotomy
Ultrasonography
Stress radiography
Arthroscopy

15.  First, in the diagnosis phase special emphasis must
 be placed on thoroughly evaluating the ACL using the
 drawer test and the tibial compression test. It is known
 that muscle action can falsify this test in excessively
 nervous animals. Therefore, prior calming or even general
 anaesthesia might be needed to allow the surgeon
 to neutralise these active forces which are so decisive in
 this diagnosis phase.
 A meticulous medical history can provide a very high
 A meticulous medical history can provide a very high
 percentage of the information needed to diagnose
 partial ruptures.This abnormality must be suspected
 in animals with subtle lameness of the pelvic limb that
 does not completely prevent the activity of the limb but
 does always appear after exercise and disappear with
 rest. It must always be checked by means of an arthro
 Tomy or arthroscopy prior to aTPLO.

17. Slight extension
Hock joint flex

18. Tibial Plateau Leveling Osteotomy (TPLO)
TREATMENT
Tibial Tuberosity Advancement (TTA)

20. Stifle braces assist in the
management of dogs with CCL
injury, not being managed by
surgery.
This can prevent the instability in
the stifle that occurs during weight
bearing ,but can only be worn
during daytime, so restrict exercise
overnight.

21. •Extra-capsular suture stabilization (also called “Ex-
Cap suture”, “lateral fabellar suture stabilization”
and the “fishing line technique”)
•This is a traditional surgical treatment that has been
performed for many years.
•The concept of this procedure is to replace the
function of an incompetent cranial cruciate ligament
function of an incompetent cranial cruciate ligament
with a heavy monofilament nylon suture (a specific
brand of fishing line is typically used) placed along a
similar orientation to the original cruciate ligament,
but outside of the joint (the actual ligament is inside
the joint).
• The suture needs to stabilize the tibia (“shin-bone”)
relative to the femur (“thigh bone”), while allowing
normal knee movement, until organized scar tissue can
form and assume the stabilizing role.

22. Tibial tuberosity—hole
driven…suture around
lateral fabella and then
around tibial
tuberosity…..tighten the
Traditi
onal
metho
d
monof
ilame
nt
nylon
tuberosity…..tighten the
suture
nylon
suture

23. • Tibial Plateau Leveling Osteotomy(tplo)
• Tibial Tuberosity Advancement (tta)

24. • First described by Slocum and Slocum (1993)
• The dynamic stability imparted to the CrCL - deficient
stifle via TPLO is achieved by performing a radial
osteotomy of the proximal tibia and rotating the proximal
segment to decrease the tibial plateau angle.
segment to decrease the tibial plateau angle.
TPA ….angle between
PATELLATENDON and
TIBIAL PLAETUAE
•The forward movement is prevented by changing angle of top of tibia
calledTibial plateau by saw which is used to cut tibia .Top of tibia is rotated
so that it is perpendicular to the axis of tibia (shaft)……reduce slope …more
stiff …extended
•Plate and screw used to hold tibial plateau in new position
•The loss ofTibial pleatue slope means that when the dog bears WT.
-backward movement of the femur down the slope is prevented.

26. B

27. B

28. • TPLO results in increased strain on the CaCL ligament; therefore,
patients with a compromised CaCL are not candidates for the
procedure

29. The saw must be perpendicular to the
longitudinal axis of the tibia and perpendicular
to the
medial cortex.
Partial-thickness osteotomy.

30. Image of a oscillating saw, this
one with the blade inserted,
which works in a semi rotating
fashion
Depending on the preoperative lateral X-ray,
Depending on the preoperative lateral X-ray,
the angle of the tibial plateau is measured and
correction tables are used to decide upon the
distance of rotation of theTPLO fragment to
achieve the desired degree of rotation of the
tibial plateau in the postoperative period.
At this time the cortices on both sides of the
osteotomy are marked with two stitches that
distance apart.

31. Postoperative care
Following surgery, animals must remain at rest with supervised exercise until X-ray
evidence of ossification is obtained.
After four weeks, the patient undergoes another radiological examination. At this time,
the owner tends to report that it is difficult to keep the animal at rest, and this is a
favorable sign. It may even be necessary to prescribe sedatives to keep the animal at
rest.
After eight weeks, another radiological examination is performed.
After eight weeks, another radiological examination is performed.
After 12weeks, the animal walks normally and it is difficult to tell which limb has
undergone surgery

32. Postoperative evaluation of the stifle joint
Five main criteria to evaluate the success of aTPLO
1.The animal must be fully capable of flexing the stifle joint
2. Complete muscle development of the affected limb occurs
simultaneously with normal use of this limb.
3. Absence of inflammation in the stifle joint, which should
completely resolve within three months of the operation.
4. Cessation of osteoarthritis progress, which must be
evaluated on X-ray.
5. Complete return to normal activity 12 to 16 weeks after surgery.

33. • The overall postoperative complication rate of TPLO has
been reported to vary from 18% to 28%.
• Higher complication rates have been found in dogs
undergoing simultaneous bilateral TPLO.
• Examples of complications include hemorrhage, incision
• Examples of complications include hemorrhage, incision
site issues, patellar tendon enlargement, fractures
involving the fibula or tibia, subsequent meniscal injury,
and implant failures.
• Dogs with preoperative TPA of ≥ 35 ° have a higher
incidence of postoperative complications.

35. • Advancement of the tibial tuberosity was first described
by Maquet
• Montavon and Tepic proposed that a similar situation
existed in the dog, and that tibial tuberosity advancement
(TTA) would neutralize cranial tibiofemoral shear force in
(TTA) would neutralize cranial tibiofemoral shear force in
a cranial cruciate ligament (CrCL) - deficient stifle joint in
the dog.
• TTA did not change the geometry of the joint, and the
pressure distributions essentially remained unchanged,
there may be less development of osteoarthritis
over time.

36. TTA
In normal joint < between femur and tibia is >90(TP slope and
patellar tendon)
Quadriceps tries to pull tibia forward when it contracts(via patella
tendon)
When the Crcl is ruptured this forward movement is not resisted.
However this can be prevented by moving tibial tuberosity forward.
A GUIDE is used to drill holes in tibial tuberosity
FORK drill guide holes –t.tuberosity fixed____proximal ---
anchor pegs left there mark for osteotomy
CAGES--
A GUIDE is used to drill holes in tibial tuberosity
The tuberosity is cut then with oscillating saw
Tuberosity cut moved forward and held in position with a plate
Metal spacer placed at top of gap to prevent tuberosity moving
back.
Advancement of the tibial tuberosity makes the <between
tibial plate and patella tendon less than 90.(natural > =90)
So now when the quadriceps muscle contracts it forces the
tibia backwards into a normal position thus forward
movement of tibia is prevented

37. All implants used are made of pure titanium
Determination of the tibial plateau and
point of insertion of the patellar ligament
Detail of the calculation of the advancement
needed on an X-ray of the stifle e joint in
mediolateral projection. In this case a 9mm
advancement is required.

38. Detail of the special drill guide used to create the holes of
Detail of the special drill guide used to create the holes of
the forks over the tibial tuberosity .
Detail of theTTA template

40. Patients that undergoTTA do not require hospitalization; however, hospitalization is
recommended to optimally monitor their vital signs and postoperative pain during the first
24hours.
A Robert Jones bandage is placed for 24 to 48hours.
The patient is provided with non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics
to treat inflammation and pain.
Analgesics are to be administered during the first 24hours, and NSAIDs are to be administered
Postoperative care
Analgesics are to be administered during the first 24hours, and NSAIDs are to be administered
for five to 10days following surgery.
The first radiological examination is performed six to eight weeks after surgery to confirm
that healing of the Osteotomy has occurred (If it has not then the examination is repeated
every four weeks until it is confirmed.
Healing is not complete after six weeks, but it is generally sufficient to provide suitable
stability.
If the radiological examination confirms that healing is progressing properly then walks are
lengthened up to normal.

42. Thank you