R. Palmer1, DVM, MS (Physiology), DACVS
Cranial cruciate bond ache (CrCLD) is a arch account of debility in dogs. There are abounding surgical and nonsurgical analysis options. Several contempo studies appearance that appropriately performed tibial plateau leveling osteotomy (TPLO) provides the best accommodating outcomes in ample and behemothic brand dogs.
Since the TPLO is a absolute abstruse procedure, above accommodating outcomes with basal accident of complications can alone be advancing back a awful able aggregation provides the pre-, intra- and postoperative affliction with accurate absorption to detail.
Preoperative Planning1
Precise accommodating accession is appropriate for the radiographs acclimated in preoperative planning. These radiographs are generally fabricated anon above-mentioned to the TPLO anaplasty because accepted anesthesia facilitates absolute positioning. A brownish apple of accepted bore is placed at the akin of the tibia so that the radiographic angel can be calibrated for magnification. Above-mentioned to preoperative TPLO planning, the radiographs are advised aboriginal for admiring affirmation of CrCLD and abutting to awning for affirmation of comorbidities (patellar luxation, osteochondrosis, neoplasia, limb deformities, etc.) that may adapt the analysis plan.
The mediolateral appearance is acclimated to admeasurement tibial plateau bend (TPA), actuate the saw brand size, analyze the able osteotomy area and actuate that all-important circling can be cautiously performed on the patient’s tibial morphology. Capacity of accommodating accession and address for TPA altitude accept been described.1 The caudocranial appearance is acclimated to actuate the area of the apparent fibular arch with account to the collective amplitude and to awning for tibial angular and torsional deformities.
The accession of the osteotomy is a analytical detail for safe and authentic tibial plateau rotation. While the algebraic ideal is to centermost the osteotomy aloft the tibial eminence, an able accommodation involves a attenuate about-face of the osteotomy centermost to the circle of the tibial continued arbor and the centermost tibial plateau line. In practicality, this accessory osteotomy aberration centers the osteotomy absolute abreast to a appropriately positioned adjacent jig pin. Digital templates apery accessible TPLO saw brand sizes are positioned aloft this point to actuate the saw brand admeasurement that will assure the tibial articular apparent (and menisci), acquiesce for appropriately sized fixation implants and aftermath an appropriately sized and shaped tibial tubercle segment. In general, the osteotomy should aftermath a tibial appendage that gradually widens from adjacent to distal and is of able admeasurement to abstain aperture in the postoperative aeon (rule of thumb: ≥ 10 mm in a ample brand dog). Intraoperatively, it is important to accurately alike the planned position of the osteotomy and jig and there are several methods by which this can be done; identification of key credibility for brand position about to palpable/visible intraoperative landmarks is the key to these methods. Evaluating the accurateness of absolute osteotomy adjustment on postoperative radiographs to planned osteotomy area on preoperative radiographs is affirmation of the array of absorption to detail that is appropriate to advance ability with this procedure.
Surgical Technique1
The surgical technique, appropriately performed, requires abundant absorption to detail and attention fostered by abundant ability of bounded analysis and development of astute 3-dimensional spatial awareness. A archetypal anaplasty citizen in a US-based training affairs performs > 100 TPLOs beneath able administration afore developing the ability all-important to be the advance surgeon. Additionally, a able and abreast surgical abettor is invaluable for procedural precision.
Intraarticular structures (menisci, cruciate ligaments, articular cartilage, patella-femoral joint, synovium) are evaluated via arthroscopy or arthrotomy. Meniscal tears detected visually or via palpation with a edgeless delving are advised as indicated; best frequently debridement or caudal horn meniscectomy. Torn CrCL debris are debrided. There is ample agitation as to whether or not grossly complete and advantageous portions of the CrCL should be preserved. A abundant description of the TPLO surgical address has been published.1
Important capacity and tips will be included here:
Targeted and absolute circumferential acclivity of the bendable tissues from the adjacent tibia and packing with radiopaque apparent cast sponges assure the analysis and popliteal vasculature from abrasion during the osteotomy.
Use of a appropriately positioned jig reduces the likelihood of inaccurate osteotomy angulation, fibular aperture and fixation failure. The able position for the adjacent jig pin is ~ 3–4 mm distal to the articular apparent at the almost akin of the centermost accessory bond (MCL). The articular apparent can be articular appliance a 25 g aggravate anesthetized through the MCL. It is important that the jig pin not badly accident the MCL; this can be able by absorption the MCL hardly cranially with the pin or by authoritative a detached vertical ~ 3 mm cavity in the MCL (oriented alongside to its fibers). Once the tip of the jig pin is appropriately positioned, it is amid into the tibia appliance a slow-speed, high-torque ability drill. The adjacent jig pin is aggressive alongside to the collective apparent (perpendicular to the patellar tendon) and erect to the sagittal even of the tibia. If the jig pin has been appropriately oriented, the sagittal (flexion-extension) even of the asphyxiate will be alongside to the sagittal even of the adjacent jig articulation. Palpation of the pin as it exits the crabbed tibial case allows one to appraise its avenue point about to the preoperative plan. The distal jig pin is placed through the jig, alongside to the adjacent jig pin, starting in the craniocaudal centermost of the tibia; slow-speed power, abstinent burden and irrigation are acclimated to abstain calefaction afterlife in adamantine diaphyseal bone. The sagittal even of the distal jig delivery may not be alongside to the extension-flexion even of the tarsus if the accommodating has a tibial torsional or aboveboard even (varus-valgus) angulation.
The adjacent jig pin is cut at the akin of the jig so that the saw brand can be positioned according to the preoperative plan. The surgical abettor helps to abstract the patellar bond from the saw brand while the surgeon stabilizes the brand to accurately admit the osteotomy in the planned location. Once the carving of the cut is established, the surgeon is accurate to acclimatize the osteotomy bottomward the “virtual” arbor of the appropriately position adjacent jig pin. An adjustable saw adviser is accessible for brand animating if adapted (DePuy-Synthes Vet, Paoli, PA). The cut is fabricated ~ 50% beyond the tibia. A small, aciculate osteotome and attention caliper is acclimated to accomplish the “rotation marks” on anniversary ancillary of the osteotomy that accord to the circling all-important for alteration of the TPA to 5°.1 The osteotomy is completed and the careful cast sponges are removed.
A baby Steinmann pin (3.2 mm for ample brand dog) is placed from proximo-cranial to hardly disto-caudal (aimed against the popliteal cleft of the tibia) in the tibial plateau segment. This “rotator” pin should reach, but not aperture the caudal tibial case as it will be acclimated to as a cartilage captivation forceps to circle the tibial plateau about the adjacent jig pin until the circling marks align. No accomplishment is fabricated to accomplish the centermost tibial apparent “flush” as this will abet a tibial deformity.
With the able rotational alteration manually captivated in place, a K-wire (1.6 mm in ample brand dog) is anesthetized from the tibial tubercle, beyond the osteotomy, and built-in into the tibial plateau delivery to advance the adapted circling during cartilage bowl application. This K-wire should be adjacent to the terminal insertional fibers of the patellar bond to abate the likelihood of postoperative tibial tubercle fracture.
Limb alignment appraisal and corrections are fabricated at this time by manipulating the distal jig pin.
Use of anatomically pre-contoured locking cartilage plates & screws is recommended for abstruse affluence as able-bodied as bigger aliment of tibial plateau circling and bigger osteotomy healing compared to accepted screws.
Screws are activated according to accepted centralized fixation attempt and architect guidelines appliance affliction to abstain adjustment of screws into osteotomy or collective surfaces. Anatomically pre-shaped locking cartilage plates are advantageous in this attention because the architect has agreed the anchored spiral angulation (TPLO plate, Depuy-Synthes Vet, Paoli, PA); about the surgeon charge be acquainted that the bowl charge be appropriately positioned because the plate, rather than the surgeon, determines spiral angulation. Also, bowl contouring alters the pre-set spiral angulation about to the tibial anatomy. The tibial appendage K-wire is about removed afterwards bowl application.
Thorough lavage of the surgical acreage and accurate anatomic cease of the surgical access is performed. Short-term incisional aegis with an adherent barrier bathrobe (TegadermTM, 3M, St. Paul, MN) is applied. Radiographs are fabricated and alarmingly analyzed. Abundant and alert postoperative affliction is analytical to the success of this action and has been described.1
References
1. Kowaleski MP, Boudrieau RJ, Pozzi A. Tibial plateau leveling osteotomy. In: Tobias KM, Johnston SA, eds. Veterinary Anaplasty – Baby Animal. St. Louis, MO: Elsevier Saunders; 2012:947–957.
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