TPLO vs TTA
What is Fake and What is Fact?
Cranial
1992 - 2016
üI used several different techniques ‣ DeAngelis 1970 extracapsular synthetic suture ‣ Flo 1975, fabella-tibia extracapsular imbrication ‣ Arnoczky 1979 over the top patellar tendon ‣ Gambardella 1981 extracapsular fishing line ‣ Smith 1984 filbular head transposition ‣ Olmstead 1993, extracapsular stainless steel wire üOutcome
‣ Unpredictable
‣ Several times disappointing
Cranial
1992 - 2000
üRottweiler 3 yrs, 42 kg, 3 mo. p.o.
Fishing line 100 lb
1992 - 2000
üNewfoundland 4 yrs, 45 kg, 2 mo. p.o. üLabrador 3 yrs, 35 kg, 5 mo. p.o.
1992 - 1996
üRottweiler 5 yrs, 38 kg, 1 yr. p.o. üNewfoundland 7 yrs, 45 kg, 3 yrs. p.o.
1992 - 1996
1992 - 2000
üSlocum B. Slocum TD: Cranial Tibial Wedge Osteotomy: a technique for eliminating cranial tibial thrust in cranial cruciate ligament repair. JAVMA 1984
üSlocum B. Slocum TD: Cranial Tibial Thrust: a primary force in the canine stifle. JAVMA 1983
“Crazy, cutting a bone to fix a ligament!”
1992 - 1996
üSlocum B. Slocum TD: Tibial Plateau Levelling Osteotomy for repair of cranial cruciate ligament rupture in the canine. Vet Clin North Am 1993
üSlocum B. ACVS San Francisco 1996: meet the forces, do not oppose to them
October 1997, Gainesville, Florida üBarclay Slocum and Theresa Devine Slocum
üFirst TPLO wet-lab in a University setting
üAttended by 18 curious and interested european veterinary specialists
December 2006 - Slobodan visits VT üSlobodan Tepic
üTibial Tuberosity Advancement ü2001 theory (Maquet 1976, Nisell 1985) ü2002 - 2004 experimental
ü2004 clinical TPLO
TTA üTPLO moves the plateau to meet the forces
üTTA moves the forces to meet the plateau S. Tepic, 2001 Nisell, 1985
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Stifle joint w/o CrCL
• TPLO moves the plateau to meet the force
• TTA moves the force to meet the plateau
• TPLO increases joint force • TTA decreases joint force • TPLO disrupts congruency • TPLO second-order effects ?
meniscus ? medial-lateral femoral/tibial condyles ?
May 2004 - December 2013
üTTA vs TPLO, case selection:
‣Narrow proximal tibia, to increase the lever arm
‣Moderate tibial plateau slope
‣< 25°
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Am J Vet Res. 1977 Nov;38(11):1807-14.
The cruciate ligaments of the canine stifle: an anatomical and functional analysis. Arnoczky SP, Marshall JL.
Abstract
Fifty canine stifles were used to study the anatomy and function of the cruciate ligaments...
“Internal rotation of the tibia on the femur was limited
by the cruciate ligaments as they twisted on one
another.”
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• external rotator: biceps, (q’s)
• internal rotators: popliteus, semitendinosus, gracilis, semimembranos
• all but popliteus strongly affected by extension • CrCL limits internal rotation
• popliteus tensions CrCL, hence counters tibia thrust
• TPLO technique weakens popliteus • lat. suture is ill-conditioned
Rotators and Cruciates
üTTA vs TPLO, case selection: ‣Narrow proximal tibia, to
increase the lever arm ‣Moderate tibial plateau slope ‣< 25°
‣No malalignment
Momb, Labrador F, 6 yrs.
TTA Long Term Follow Up
üMomb, Labrador F, 6 yrs., bilateral TTA, FU 3 yrs.
Early Experience TTA üPersistent cranial tibial subluxation
üCaudal bone spur of tibial plateau
üUndercorrection?
Jack Russel, M, 4 y, 2 yr FU extracapsular fix. Lara, Boxer, F, 4yrs., TTA FU 1 yr.
Newfoundland, M., 5 yrs. 65 kg, 1 yr. p.o.
FU 2 mo after TPLO
TPA 27° 12 mm cage
üPlanning of the Advancement: ‣Pitfalls due to cranial tibial
subluxation
üPlanning of the Advancement:
‣Pitfalls due to tibial tuberosity morphology and patella tendon insertion
üEffective Advancement: ‣Influenced by cage position
üEffective Advancement:
‣attempts to improve planning
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This investigation revealed that the TTA method is a suitable treatment for CrCL rupture, because it tends to establish a situation closer to that seen in non-affected dogs. Furthermore, the breeding from dogs that have a rTTW of more than 0.9 may lessen the risk of sustaining a CrCL rupture.
üEasier planning üStraightforward surgical
technique
üRepeatability intra and inter operators
üConsistent outcome üPredictable clinical results üVersatility
üLimb alignment üPatellar luxation - TPLO/TTA üLow complication rate TPLO Planning
üMeniscal Damage - Very important
Nico, Boxer M, 4 yrs. 36 kg, Medial Meniscal Damage, FU 5 mo.
üEasier planning üNot influenced by cranial tibial subluxation TPA 19° D1 D2 TPLO üEasier planning
üNot influenced by cranial tibial subluxation
üStandard correction
TPA 25° TPA 5°
TPLO Planning
üEasier planning
üNot influenced by cranial tibial subluxation
üStandard correction üEasily reported in surgery TPLO Planning
TPLO PLATE FROM KYON
Labrador, M, 4 yrs, 32 kg
üStraightforward surgical technique üJig and alignment
üRepeatability
üConsistency
üSame surgical execution
TPLO and TTA
üRepeatability üConsistency üConsistent outcome TPLO vs TTA
üPredictable clinical results - TTA
FU 2 mo. Lucky, Dogue de Bordeaux, M, 4 yr., 55 kg
TPLO vs TTA
üPredictable clinical results üClient satisfaction
üField champion winning again!
Dila, German Shorthaired Pointer, F, 5 yr., 18 kg FU 5 mo.
TTA FU 1 mo.
TTA Procedure üOlmo, Labrador M, 3 yrs.,
Left CCL
üPredictable clinical results
üLong term FUs Mongrel F, 3 yrs. 23 kg FU 5 yrs.
üVersatility
‣Any dog size and weight
Jack, JRT, M, 6 yr., 7 kg FU 2 mo.
Why I now prefer TPLO vs TTA
üVersatility
‣Any dog size and weight
Nelson, St. Bernard, M, 4 yr., 75 kg, Left complete, Right partial
üVersatility
‣Any dog size and weight
Nelson, St. Bernard, M, 4 yr., 75 kg, Left complete, Right partial FU 4 mo. Right FU 2 mo. Left Why I now prefer TPLO vs TTA
üVersatility
‣Pathologic tibial plateau slope Lapo, Drahthaar M, 3 yrs., 33 kg TPLO+CCWO
TPA 42° pre op TPA 7° post-op
üVersatility
‣Surgical revisions of failed treatments
Bichon frisé, M, 9 yrs. 4.3 kg, failed extracapsular stabilization
üVersatility
‣Surgical revisions of failed treatments
Amabel, Newfoundland M, 1.5 yrs. 66 kg, failed extracapsular wire stabilization FU 3 a.
üVersatility
‣Surgical revisions of failed treatments
Rolly, Labrador M, 2 yrs. 34 kg, failed fibular head transposition. FU 6 mo.
R R - TCT
üVersatility
‣ Surgical revisions of failed treatments
Rolly, Labrador M, 2 yrs. 34 kg, failed fibular head transposition. FU 6 mo. R
FU 2 a. R
R R
Black, Rottweiler, F, 3 yrs. 36 kg üLimb alignment
‣Tibial torsion
Pivot shift
Black, Rottweiler, F, 3 yrs. 36 kg üLimb alignment
‣Tibial torsion
Pivot shift
Black, Rottweiler, F, 3 yrs. 36 kg üLimb alignment
‣Tibial torsion
Black, Rottweiler, F, 3 yrs. 36 kg üLimb alignment
Black, Rottweiler, F, 3 yrs. 36 kg üLimb alignment ‣Tibial torsion üLimb alignment ‣Tibial ALD ‣Double cut Rocky, GSD, M, 3 yrs. 34 kg Rocky, GSD, M, 3 yrs. 34 kg üLimb alignment ‣Tibial ALD ‣Double cut Rocky, GSD, M, 3 yrs. 34 kg üLimb alignment ‣Tibial ALD ‣Double cut Rocky, GSD, M, 3 yrs. 34 kg üLimb alignment ‣Tibial ALD ‣Double cut Rocky, GSD, M, 3 yrs. 34 kg üLimb alignment ‣Tibial ALD ‣Double cut mMPTA 99° mMPTA 91° TPA 7°
Lady, Yorkshire, F, 11 yrs, 5 kg üPatellar luxation
‣Lateral shift of TT for MPL ‣External torsion of TT fro MPL
üLow incidence of complications
‣Subsequent meniscal lesion requiring surgical revision
‣Meniscal release performed regularly except in early partial? 8 cases among 2432
üLow incidence of complications ‣Implant removal
Prevention: Strict asepsis No skin contact
üLow incidence of complications
‣Tibia fractures
•Requiring surgical revision: ‣TT fx: 1 case
Rottweiler, M., 5 yrs.
üNo pes anserinus suture complications üLow incidence of complications after TPLO and TTA
‣ 2.4% Conclusions
üConsistent outcome and client satisfaction üTTA - Sagital Plane, Not torsional Plane
Correction
üTPLO - Sagital and Torsional Plane Correction
üBe careful! Lots of articles are misleading
