GENERAL PRACTITIONER CERTIFICATE PROGRAMME IN SMALL SURGERY

TIBIAL PLATEAU LEVELING OSTEOTOMY

WORDS: 2,353

PRESENTED BY:
M.V.Z. ESP. CERTSAS. SERGIO GARCIA
 CONTENT

INTRODUCTION .............................................................................................................. 4
HISTORY ......................................................................................................................... 5
PHYSICAL EXAM: ........................................................................................................... 5
PROBLEM LIST AND DIFFERENTIAL DIAGNOSIS ....................................................... 6
DIAGNOSTIC TECHNIQUES .......................................................................................... 6
DIAGNOSIS ..................................................................................................................... 8
TREATMENT: ................................................................................................................ 12
SURGERY ANATOMY ............................................................................................... 12
SURGICAL PLANNING: ............................................................................................. 13
ANESTHESIA PROTOCOL: ....................................................................................... 15
SURGICAL TECNIQUE: ............................................................................................. 15
POST-SURGICAL TREATMENT: .............................................................................. 17
PROGRESS AND OUTCOME ....................................................................................... 18
DISCUSSION ................................................................................................................. 19
REFERENCES: .............................................................................................................. 19

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SUMMARY/ ABSTRACT

The cranial cruciate ligament rupture (CCL) is one of the most common orthopedic
conditions affecting the hind limb in dogs. The pain and lameness tend to recur easily
even with only minimal activity.
Animals with an acute complete tear are usually restless during examination of the knee
joint, but feel none or mild pain. It may be difficult to cause instability due to the patient
restlessness and the resulting muscle contraction. The joint effusion can be palpated
adjacent to the patellar tendon. It is easier to obtain a positive tibial compression test than
a positive drawer test.
Patients with chronic tear may have muscle atrophy in the thigh and crepitus is evident
when the knee is extended and flexed.

The tibial plateau leveling osteotomy (TPLO) is the most recommended surgery.

When the CCL ruptures, there is instability in the joint, and every time a step is taken, the
tibia moves abnormally in relation to the femur. When examining the knee, manipulation
of the joint to test for this instability is what provides a diagnosis of a ruptured CCL.

Almost any dog is a candidate to perform the TPLO surgery on.

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INTRODUCTION

The knee or stifle is a complex joint composed of distal femur and proximal tibia, patella
and small bean-shaped bone fabella. The medial and lateral menisci cushion the bones,
and ligaments hold the structures in position and enable the joint to function properly
(Aithal, Kinjavdekar, and Pawde, 2023).

The cranial and caudal cruciate ligaments are two important stabilizing ligaments that
cross over one another inside the knee joint. Cranial cruciate ligament injures are one of
the most commonly seen orthopedic problems (Aithal, Kinjavdekar, and Pawde, 2023).

The cranial cruciate ligament is divided into craniomedial and caudolateral bands, which
different insertion points on the plateau. The CCL functions primarily to limit cranial
translation of the tibia relative to the femur. CCL failure can result from degenerative and
traumatic causes. The categories are interrelated, because ligaments weakened by
degeneration are more susceptible to trauma (Fossum, 2019).

Degeneration of the ligament is associated with aging (especially in large-breed dogs),

degeneration of the ligament has also been associated with an increased TPA. An
increased TPA has been theorized to place chronic excessive loads on the CCL leading
to eventual mechanical failure. With ligament degeneration, even repetitive normal
activities can cause progressive rupturing or the ligament (Fossum, 2019).

Partial rupture generally procedes to complete ligament rupture with time. CCL injury with
stifle instability is part of a cascade of events that include progressive osteoarthritis and
medial meniscus injury. This instability results in synovitis, articular cartilage
degeneration, periarticular osteophyte development, and capsular fibrosis. Progressive
osteoarthritis occurs after CCL rupture regardless of the treatment method (Fossum,
2019).

Surgical management, however, is typically recommended to address joint instability,

mitigate the progression of osteoarthritis, and address concurrent meniscal pathology

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(Townsend, Kim, and Tinga, 2018). The TPLO has been advocated as a better treatment
for cruciate rupture in the dog, based largely on a randomized controlled clinical trial
published in 2013 (Gordon-Evans et al., 2013).

Several studies have shown that dogs treated by TPLO recover faster and have better
function and slower progression of osteoarthritis than those treated by other stabilization
procedures (Heidorn et al., 2018).

HISTORY

Fiona
Lab mix, 6 Years old, Female, 64 lbs.

Fiona is one of three dogs at home, she always plays with her siblings, she is a really
active dog. Unfortunately, she was affected 3 weeks ago by right pelvic limb, grade 4
(Severe, predominately weight-bearing lameness). The first visit was in a different vet
clinic in town. She was on Carprofen 100 MG 1+½ Tablets by mouth once a day for 10
days and Gabapentin 100MG: 1+½ Tablets by mouth every 8 hours for 10 days. The first
10 days she was looking okay, more active, without pain and no limping. After those 10
days of medication she was looking the same like on the first day. She comes to us for a
second opinion, with grade 4 of lameness, eating okay, moderate pain, with history of up-
to-date vaccinations.

PHYSICAL EXAM:

Body Temperature: 100.9 ⁰F

Heart rate:125 bpm
Respiratory rate: 30 bpm
Blood Pressure: 128/112
Mucous Membrane assessment (MM): Pink, normal.

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Capillary refill time (CTR): <2 Normal.
Ears: Normal
Lymph nodes: Normal
Pulse: Normal
Skin turgor test: Normal
Body condition: 5/9 ideal
Abdomen: Normal
Eyes: Normal
Skin: Normal

PROBLEM LIST AND DIFFERENTIAL DIAGNOSIS

PROBLEM LIST
1. Grade 4 of lameness.
2. Moderate pain

DIFFERENTIAL DIAGNOSIS
1. Mild joint sprains or muscle strains
2. Patellar luxation
3. Caudal cruciate ligament injury
4. Primary meniscal injury
5. Long digital extensor tendon avulsion
6. Primary or secondary arthritis
7. Immune mediated arthritis

DIAGNOSTIC TECHNIQUES

Clinical presentation (Signalment, history), physical examination findings (cranial drawer

test, tibial compression test, diagnostic imaging, laboratory findings).

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Physical examination findings, animals with actue complete tears often are
apprenhensive during examination of the stifle joint, which results in muscle contraction
and the instability can be difficult to elicit. Joint effusion may be palpable adjecent to the
patellar tendon. A positive tibial compression test may be easier to elicit than a positive
drawer test. Patients with chronic tears may have thigh muscle atrophy and crepitus may
be evident when stifle is flexed and extended. When the joint is extended from a flexed
position, a clicking or popping may be heard and felt, this is commonly aossociated with
a meniscal tear (Fossum, 2019).

Fig. 1 Positioning of the hands and fingers for the cranial drawer test for diagnosis of
cruciate ligament rupture.
Fig. 2: The hand grasping the tibia pushes the tibia cranially to test for instability and pain
(Koch, et al., 2020).

Fig. 3: Positioning of the hands and fingers for the tibial compression test for diagnosis of
cranial cruciate ligament rupture; the tarsal and stifle joints are placed in extension, then
the tarsal joint is flexed.

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Fig. 4: Tibial compression test: if the cranial cruciate ligament ruptured, the proximal part
of the tibia moves cranially when the tarsal joint is flexed.
(Koch, et al., 2020).

Radiographic examination of the knee is justified in all cases of suspected cranial cruciate
ligament injury to verify osteoarthritis of the knee, as well as to rule out other disorders
such as fractures or bone cancer (Johnston and Tobias, 2017).
The stifle is often used to study the progression of canine degenerative joint disease. The
initial stages are asymptomatic, and radiographs usually result normal. The first change
is mild nonsuppurative synovitis, accompanied by increased synovial mass. Focal
articular cartilage degeneration follows. Osteophyte formation commences as early as 3
days after cranial cruciate ligament transection and can be seen radiographically at the
margins of the femoral trochlea as early as 2 weeks after onset of stifle instability. Initially,
osteophytes consist of cartilage, and they do not become visible radiographically until
they are mineralized. The proximal and distal ends of the trochlear ridges are the sites of
earliest osteophyte formation in the stifle joint, but changes occur later on the lateral and
medial femoral condylar surfaces and tibial condyles (Thrall, 2013). Arthroscopy,
ultrasound and magnetic resonance imaging can also be used for the diagnosis of
ruptured cranial cruciate ligament.

DIAGNOSIS

In Fiona's case, an orthopedic evaluation and radiography were performed under

sedation, where the diagnosis of cranial cruciate ligament rupture was confirmed by a
positive drawer test, crepitus of the knee in flexion and extension, a positive tibial
compression test, in addition to radiographic changes of osteoarthritis and synovial
effusion. Blood work was performed too.

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Fig. 5: Medio-Lateral x-ray of Fiona, Before surgery.

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Ap. 1: Fiona’s Hematology.

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Ap. 2: Fiona’s Chemistry.
Blood work unremarkable.

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TREATMENT:

Conservative treatment is unsuccessful, especially in large breed dogs.

Surgical therapy is the best option, and it is divided into intracapsular and extracapsular
reconstruction techniques, corrective osteotomy or primary repair with augmentation, but
in this case the surgery selected was a tibial plateau leveling osteotomy (TPLO). This
technique changes the mechanics of the stifle to achieve stabilization by active constraint
of the joint. Tibial plateau leveling osteotomy is an effective procedure for dogs with a
complete or partial tear of the cranial cruciate ligament and, in this case, it was the
selected technique because many surgeons prefer tibial plateau leveling osteotomy for
treating larger, active dogs in which long term rehabilitation and postoperative control are
difficult (Fossum, 2019), and current evidence indicates that TPLO is favorable with
respect to certain complications, compared to TTA (Wemmers et al., 2022).

SURGERY ANATOMY

It is important to know the origin and insertion of the normal ligamentous structures and
menisci of the knee joint if arthroscopic examination or surgery is going to be performed
to repair the cranial cruciate ligament injury. The tendon of the extensor digitalis longus
muscle originates in the extensor fossa of the lateral condyle of the femur, and is located
directly below the incision for the lateral arthrotomy (Fossum, 2019).

The main joint of the knee is the femorotibial, between the voluminous, roller-shaped
condyles of the femur and the flattened ones of the tibia, this joint is the one that mostly
supports the weight of the animal. Congruence between the articular surfaces of the
femur and the tibial condyles is improved by the interposition of the medial and lateral
menisci (Johnston and Tobias, 2017).

The capsule of the knee joint forms three freely communicating sacs, one in the medial
femorotibial joint, another in the lateral joint, and the third between the patella and the

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femur. The femorotibial sacs are divided into two, the femoromeniscal and the
tibiomeniscal, by the menisci (Johnston and Tobias, 2017).

The menisci are C-shaped discs of fibrocartilage located between the condyles of the
femur and tibia. The crescent shape and approximately triangular cross section of the
menisci adapt to the femoral and tibial joint surfaces and improve joint congruity. The
peripheral edge of each meniscus is thick, convex and attached to the inside of the joint
capsule, while the inner part tapers to form a thin free edge (Johnston and Tobias, 2017).

SURGICAL PLANNING:

The first step for a tibial plateau leveling osteotomy is do a correct radiography study to
plan the surgery. The first image is a mediolateral X ray from Fiona and the others images
are part of surgical planning.

Fig. 6: Fiona’s X-rays from the V pop planning.

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Calibrate the image in V Pop or another app for orthopeadic planning. On the mediolateral
X ray connect with a line the center of the trochlea of the talus with the center of the
intercondylar eminence of the tibial plateau. Then do a second line to estimate the tibial
plateau. And the intersect of these two lines gives you an angle. Substract the angle
obtained from 90 and the result will be the tibial plateau angle. For the selection of the
osteotomy blade is necessary do a measure from the tibial tuberosity to the caudal part
of the tibia and then divide this measure by four, this measure will be the mark number
two (D2).

The degree of rotation is determinate by the selected osteotomy blade and the tibial
plateau angle. After do the rotation select the correct plate.

Table. 1: Rotational charts for tibial plateau leveling osteotomy (Fossum, 2019).
Fig. 7: Surgical planning from Fiona’s TPLO.

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ANESTHESIA PROTOCOL:

The patient was sedated with dexmedetomidin 5mcg/kg, buprenorphine 10mcg/kg,

ketamine 0.5mg/kg, as induction agent we used propofol 2mg/kg, and maintenance with
isoflorane. Epidural anesthesia with lidocaine 0.2mg/kg was performed in the lumbosacral
region.

SURGICAL TECNIQUE:

The first step prior to the tibial plateau leveling osteotomy is do an arthrotomy for a joint
examination. The menisci are important intra-articular structures. They function in load
transmission and energy absorption, help provide rotational and varus-valgus stability,
lubricate the joint, and render joint surfaces congruent. Isolated meniscal injures are
uncommon dogs, although isolate meniscal tears involving the midbody of the lateral
meniscus occasionally occur during a fall when the leg is twisted. Most meniscal tears
causing lameness in dogs occur in conjunction with cranial cruciate ligament ruptures.
These tears usually involve the caudal body of the medial meniscus because the
craniocaudal instability associated with cranial cruciate ligament rupture displaces the
medial femoral condyle caudally during stifle joint flexion (Fossum, 2019). That is why,
prior to a tibial plateau leveling osteotomy, and arthrotomy must be performed to evaluate
the menisci.
The arthrotomy is performed in dorsal recumbency, the limb is prepared for aseptic
surgery, we prefer the hanging leg position because it facilitates manipulation of the limb
during surgery. A medial access to the stifle is used to visualization of the medial meniscus
and examination of the joint surfaces. In this case, Fionna did not have a meniscus injury,
so the tibial plateau leveling osteotomy was performed.

When the patient in decubitus right is prepared for aseptic surgery again, make a medial
incision (we used the same incision for both procedures) at the level of the proximal tibia,
above the tibial plateau and continue it distally.

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With the electrocautery incise the subcutaneous and reflect the muscle sartorious
caudally to visualize the medial collateral ligament and the caudal aspect of the proximal
tibia. Then make the marks for the osteotomy, for this use a caliper and take as a
reference the tibial tuberosity to make the first and the second marks. Identify the center
of the joint and insert a needle, this will be the reference for the third mark. Make the three
marks with an electrocautery.

Use the correct blade to do the partial osteotomy (about half) following the reference
marks. Then use the caliper for measure the rotation, put two marks with the
electrocautery and then with an osteotome and an orthopedic mallet.

Complete the osteotomy and with a reduction forceps do the rotation, the rotation marks
are aligned and fixed with a pin. The pin is inserted just in the insertion of the patellar
tendon and it should come out in the caudal tibial to stabilize the osteotomy. And using a
compression forceps the fragments are compressed.

Then is the moment to put the plate, in this case the plate selected according to the
planning was an osteocertus TPLO plate large short with 3.5mm screws. Use a surgical
drill to 3.5mm screws and put the first screw (cortical screw not fully tightened). Then put
the second screw in the proximal fragment (compression screw), remove the pin and
complete the tightening of the cortical screw. The rest of the screws are placed to finish
the surgery. The subcutaneous tissue and the skin are closed with absorbable sutures
(The following images are not from Fiona’s surgery).

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Fig. 8: Pictures from TPLO surgery on the hospital.

POST-SURGICAL TREATMENT:

Cephalexin 25mg/kg q12hrs, for 10-12 days. Orally.

Carprofen 4.4mg/kg q24hrs, for 10 days. Orally.
Gabapentin 5-10mg/kg q12hrs, for 20 days. Orally.
Bedinvetmab 0.5-1mg/kg (Librela solution for injection; Zoetis) once a month.
Subcutaneously.
Chondroprotectors, Pro Plan Veterinary Diets Joint Mobility JM food, absolute rest and a
physiotherapy plan are indicated for the patient to accelerate her recovery.

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PROGRESS AND OUTCOME

Control x-rays are performed immediately after surgery, The patient remains hospitalized
from 1 to 3 nights. If she does not present complications such as uncontrolled pain or
signs of infection, she is sent home with instructions for complete rest. An appointment is
made after 30 to 45 days to perform control x-rays.

Fig. 9: Fiona’s X-rays after the TPLO surgery.

In this case, Fiona attended her check-up 40 days later and x-rays were repeated. During
this visit, her owners reported that the patient is walking without complications, she has
no lameness and the wound looks perfect, she does not have pain or another problem.
The x-rays show correct ossification, without periosteal reaction or other alterations.

Fig. 10: Fiona’s X-rays 6 weeks after the TPLO Surgery.

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DISCUSSION

In addition to patient size, owner expectations of performance are also important. The
TPLO offers the best prognosis to return to full athletic function. Active and agile dogs
may benefit the most from this procedure in allowing them to return to pre-injury function.
A study of agility dogs demonstrated a good prognosis of returning to competition
following TPLO surgery. Many of these dogs can vary in size and having a procedure that
best optimizes outcome that is universally applicable is crucial to handlers and owners of
dogs with specific function.

REFERENCES:

1. Aithal, H. P., Pal, A., Kinjavdekar, P., and Pawde, A. M. (2023). Textbook of
Veterinary Orthopaedic Surgery. Springer Nature.
2. Fossum, T. W. (2019). Small animal surgery (5th ed.). Mosby.
3. Gordon-Evans, W.J. et al. (2013) Comparison of Lateral Fabellar Suture and Tibial
Plateau Leveling Osteotomy Techniques for Treatment of Dogs with Cranial
Cruciate Ligament Disease. Journal of the American Veterinary Medical
Association, 243 (5), pp. http://dx.doi.org/10.2460/javma.243.5.675

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4. Heidorn, S. N., Canapp, S. O., Zink, C. M., Leasure, C. S., & Carr, B. J. (2018).
Rate of return to agility competition for dogs with cranial cruciate ligament tears
treated with tibial plateau leveling osteotomy. Javma-journal Of The American
VeterinaryMedicalAssociation, 253(11),14391444. https://doi.org/10.2460/javma.
253.11.1439
5. Johnston, S. A., and Tobias, K. M. (2017). Veterinary surgery: Small Animal (2nd
ed.). Saunders.
6. Koch, D., Fischer, M. S., Dobenecker, B., Andikfar, A., & Lauströer, J.
(2020). Diagnosing canine lameness. https://doi.org/10.1055/b-007-170978
7. Thrall, D. E. (2013). Textbook of Veterinary Diagnostic Radiology (6.a ed.).
Elsevier.
8. Townsend, S., Kim, S. E., and Tinga, S. (2018). Tibial plateau morphology in dogs
with cranial cruciate ligament insufficiency. Veterinary Surgery, 47(8), 1009-
1015. https://doi.org/10.1111/vsu.12953
9. Wemmers, A. C., Charalambous, M., Harms, O., & Volk, H. A. (2022). Surgical
treatment of cranial cruciate ligament disease in dogs using Tibial Plateau Leveling
Osteotomy or Tibial Tuberosity Advancement–A systematic review with a meta-
analytic approach. Frontiers In Veterinary
Science, 9. https://doi.org/10.3389/fvets.2022.1004637

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