The Cranial Cruciate Ligament - makes us cross, too!Prior to the advent of tibial osteotomy procedures, first described by the late Dr Barclay Slocum in the 1980s with the tibial wedge ostectomy (TWO), and then popularised in the 1990s with the Tibial Plateau Levelling Osteotomy (TPLO), the main aim of surgery had been - like in human surgery - to replace the cranial cruciate ligament. The term "cruciate [ligament] repair' has always been a misnomer.Despite the frequency with which dogs and cats rupture the cranial cruciate ligament, there have been few long-term objective clinical studies supporting any one technique, and with most people frustrated by various post-operative results (hence the tongue-in-check reference to "makes us cross, too"). Complicating factors are the frequency with which secondary lesions or problems are present or develop, especially meniscal tears and osteoarthritis / degenerative joint disease, as well as the conformation of the various components of the affects limb(s). The tibial osteotomy techniques change the conformation of the proximal (upper) tibia to provide function without prosthetic replacement of the ligament. These procedures to level the tibial plateau came after Read and Robins first described a deformity of ther proximal tibia in 1982 and further focused the attention on the tibial plateau angle; it's assessment, and its significance. These techniques are not necessarily better than ligament replacement with a prosthesis in dogs with normal conformation, and we are likely to see protocols and discussions about how to assess individual patients for their suitability for each of the various techniques currently advocated. The TWO and modifications of it became popular in Australia in the late 1990s (Watt, 2000). A few other techniques to level the tibial plateau have since been developed and described: * the Proximal Tibial wedge Ostectomy (PWO) developed and reported by Pierre Montavon and others, Zurich, in 1999 & 2003 (Montavon, 1999; Damur, Tepic & Montavon, 2003);
* and - with modifications by Jerram, Walker & Warman - re-presented as Proximal Tibial Intra-Articluar Osteotomy (PTIO) in a case series reported in Veterinary Surgery in 2005.
* the Triple Tibial Osteotomy (TTO) developed by Warwick Bruce & Geoff Robins (Bruce et al, 2007).
Another biomechanical variation, the Tibial Tuberosity Advancement (TTA) to position the tibial plateau perpendicular to the patella ligament, has recently been described by Tepic & Montavon (2002, 2004) and evaluated by others (Hoffman D, Miller J, Ober C, et al, 2006; Apelt, Kowalski & Boudrieau, 2007; Lafaver S, Miller NA, Stubbs WP, et al, 2007; Miller J, Shires P, Lanz, et al, 2007). References Apelt D, Kowalski M, Boudrieu R. (2007). Effect of Tibial Tuberosity Advancement on Cranial Tibial Subluxation in Canine Cranial Cruciate-Deficient Stifle Joints: An In Vitro Experimental Study. Vet Surg 36:170–177. Bruce WJ, Rose A; Tuke J, Robins GM (2007) Evaluation of the Triple Tibial Osteotomy. A new technique for the management of the canine cruciate-deficient stifle. VCOT 20: 159-68. Damur DM, Tepic S, Montavon PM. Proximal tibial osteotomy for the repair of cranial cruciatedeficient stifle joints in dogs. Vet Comp Orthop Traumatol 2003; 16: 211–216. Hoffman D, Miller J, Ober C, Lanz OI, Martin RA, Shires PK. Tibial tuberosity advancement in 65 canine stifles. Vet Comp Orthop Traumatol. 2006;19(4):219-27. Jerram RM, Walker AM, Warman CGA. Proximal tibial intra-articular ostectomy [PTIO] for treatment of canine cranial cruciate ligament injury. Vet Surg 2005; 34: 196–205. Lafaver S, Miller NA, Stubbs WP, Taylor RA, Boudrieau RJ. (2007) Tibial tuberosity advancement for stabilization of the canine cranial cruciate ligament-deficient stifle joint: surgical technique, early results, and complications in 101 dogs. Vet Surg. 2007 Aug;36(6):573-86. Miller JM, Shires P, Lanz O, Martin RA, and Grant JW (2007). Effect of 9mm Tibial Tuberosity Advancement on Cranial Tibial Translation in the Canine Cranial Cruciate Ligament-Deficient Stifle. Vet Surg. 36:335–340, 2007 Montavon PM (1999). The modification of the Slocum’s technique for the repair of cruciate ruptures. Proc 4th Euro Federation of European Companion Animal Veterinary Associations, Societa Culturale Italiana Veterinari per Animali Compagnia Congress 307–309, 1999. Montavon PM, Damur DM, Tepic S. Advancement of the tibial tuberosity for the treatment of cranial cruciate deficient canine stifle. In: ESVOT/VOS: 1st World Veterinary Orthopaedic Congress, 5th-8th September 2002, Munich, Germany. Montavon P, Damur D, Tepic S: Tibial tuberosity advancement (TTA) for the treatment of cranial cruciate disease in dogs: evidences, technique and initial clinical results, in Proceedings of the 12th ESVOT Congress Munich, Germany, Vezzoni A, Schramme J., eds. Abbiategrasso, Italy: Press Point, 2004, pp 254–255. Read RA, Robins GM. Deformity of the proximal tibia in [five] dogs. Vet Record 1982; 111: 295–298. Slocum B, Devine TD. Cranial tibial wedge osteotomy: a technique for eliminating cranial tibial thrust in cruciate ligament repair. J Am Vet Med Assoc 1984; 184: 564–569. Slocum B, Slocum TD. Tibial plateau leveling osteotomy for repair of cranial cruciate ligament rupture in the canine. Vet Clin North Am Small Anim Pract 1993; 23: 777–795.
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