Triple tibial osteotomy

Last updated February 07, 2020

The triple tibial osteotomy is a surgical procedure used to treat dogs that have completely or partially ruptured the cranial cruciate ligament in one or both of their stifles.^[1] The cranial cruciate ligament connects the femur with the tibia, which functions to stabilise the canine stifle joint from the forces put on it during exercise and weight bearing.^[2]

Stifle joint in dog

The stifle joint relies solely upon soft tissue structures for its integrity; thus it differs from an elbow or a hip joint that have a lot of parallel joint surfaces and an interlocking structure to the joints that give them inherent stability and an almost vacuum effect that keeps the joint surfaces together.

Along with the cranial cruciate ligament, the other soft tissue structures stabilising the stifle are the caudal cruciate ligament and the two menisci, all of which are intra-articular (within the joint), and the two collateral ligaments (external to the joint). Muscle tone through the quadriceps, hamstring and calf muscles play a significant role in the forces acting on the joint.

Cranial cruciate ligament

The cranial cruciate ligament is composed of two bands, a craniomedial band and a caudolateral band. It functions to stop cranial (anterior) movement of the tibia with respect to the femur, hyperextension of the stifle joint and internal rotation of the tibia. The cranial cruciate ligament is thought to be able to resist a force equivalent to four times the weight of the dog before it ruptures, but often the ligament is weakened by arthritis that is present in the joint. Arthritis infers inflammation of the joint; in this condition there is the production of a joint fluid that is less viscous and therefore less able to absorb shock than normal fluid. Joint fluid's other role is to provide nutrition to the cartilage and the cruciate ligaments. The situation is a little like a chicken-and-egg scenario: it is usually accepted that the cranial cruciate ligament ruptures because arthritis has caused the ligament to weaken because of poor joint fluid characteristics, but what causes the arthritis in the first place – a partial cruciate tear?

The situation is dissimilar to that seen in human athletes where overextension of the joint stretches the cranial cruciate ligament to failure, and replacement of the ligament with a fascial prosthesis has a good prognosis for return to full function.

Menisci

The menisci are the other intra-articular structures that help to stabilise the joint and help to distribute load evenly across the surfaces; these are crescent-shaped discs of cartilage facing each other from side to side across the joint. They are thicker at the outside and with a thin inner aspect and they also have nerve fibres that help to tell the brain how much load is getting transmitted through the joint. The medial (inside) meniscus is often damaged with a long-standing cruciate ligament rupture because it is firmly attached to the tibia and gets crushed during abnormal cranial movement of the tibia. The lateral (outside) meniscus is more firmly attached to the femur and does not get crushed.

Surgical rationale

The triple tibial osteotomy was developed by a New Zealand veterinary orthopaedic specialist, Dr. Warrick Bruce, while he was working in Adelaide, South Australia. By changing the geometry of the forces of gravity and muscle contractions that act on the stifle during weight-bearing, it aims to neutralise the shear force that causes the cranial movement of the tibia with respect to the femur.

This shear force develops because the canine tibial plateau – the weight-bearing aspect of the joint – is sloped caudally (downwards towards the back of the joint) and there is an acute angle between the tibial plateau slope and the patellar ligament. In the triple tibial osteotomy procedure, the tibia has three osteotomies (cuts into the bone with a bone saw) performed upon it with the aim of realigning the tibial plateau slope so that it ultimately becomes aligned at right angles to the patellar ligament instead of sloping backwards.^[3] By achieving this, shear forces within the joint are neutralised and the joint is stable as the dog weight-bears.

The joint is not stable, however, when it is physically manipulated by attempting to move the tibia cranially. This contrasts with previous methods of cranial cruciate ligament repair which aimed to provide stability to the joint by replacing the ligament either with a fascial graft within the joint, or using a prosthesis made of nylon placed externally from the lateral fabella to a hole drilled in the tibial crest.

The triple tibial osteotomy has been developed as a hybrid of two previously available orthopaedic procedures, the tibial tuberosity advancement and the tibial plateau leveling osteotomy. The tibial tuberosity advancement neutralises shear force within the stifle by advancing the tibial tuberosity until the tibial plateau is at right angles to the patellar ligament. The tibial plateau leveling osteotomy neutralises shear force by rotating the tibial plateau so that it is approximately horizontal with respect to the long axis of the tibia. The triple tibial osteotomy combines both of these procedures and as such less radical changes than either are required.

Surgical technique

The triple tibial osteotomy involves removing a horizontal small wedge of bone (average 16 degrees) halfway along a vertical osteotomy in the tibial tuberosity. Firstly by removing the wedge of bone, the tibial plateau is levelled. Secondly as the horizontal defect created by removing the wedge is closed down, the tibial tuberosity is itself advanced by several millimetres. This compares with an average of 20 degrees plateau levelling required for the tibial plateau leveling osteotomy and 9-12mm of tibial tuberosity advancement with the tibial tuberosity advancement.

Return to normal function is rapid, with most dogs having good use of the leg and a normal appearing gait within 3–4 months; long-term progression of arthritis is minimal.

Alternative procedures

Related Research Articles

In humans and other primates, the knee joins the thigh with the leg and consists of two joints: one between the femur and tibia, and one between the femur and patella. It is the largest joint in the human body. The knee is a modified hinge joint, which permits flexion and extension as well as slight internal and external rotation. The knee is vulnerable to injury and to the development of osteoarthritis.

The tibia, also known as the shinbone or shankbone, is the larger, stronger, and anterior (frontal) of the two bones in the leg below the knee in vertebrates, and it connects the knee with the ankle bones. The tibia is found on the medial side of the leg next to the fibula and closer to the median plane or centre-line. The tibia is connected to the fibula by the interosseous membrane of the leg, forming a type of fibrous joint called a syndesmosis with very little movement. The tibia is named for the flute tibia. It is the second largest bone in the human body next to the femur. The leg bones are the strongest long bones as they support the rest of the body.

An osteotomy is a surgical operation whereby a bone is cut to shorten or lengthen it or to change its alignment. It is sometimes performed to correct a hallux valgus, or to straighten a bone that has healed crookedly following a fracture. It is also used to correct a coxa vara, genu valgum, and genu varum. The operation is done under a general anaesthetic.

The posterior cruciate ligament is one of the four major ligaments of the knee. It connects the posterior intercondylar area of the tibia to the medial condyle of the femur. This configuration allows the PCL to resist forces pushing the tibia posteriorly relative to the femur.

The anterior cruciate ligament (ACL) is one of a pair of cruciate ligaments in the human knee. The 2 ligaments are also called cruciform ligaments, as they are arranged in a crossed formation. In the quadruped stifle joint, based on its anatomical position, it is also referred to as the cranial cruciate ligament. The term cruciate translates to cross. This name is fitting because the ACL crosses the posterior cruciate ligament to form an “X”. It is composed of strong fibrous material and assists in controlling excessive motion. This is done by limiting mobility of the joint. The anterior cruciate ligament is one of the four main ligaments of the knee, providing 85% of the restraining force to anterior tibial displacement at 30 degrees and 90 degrees of knee flexion. The ACL is the most injured ligament of the four located in the knee.

A luxating patella, or trick knee in layman's terms, is a condition in which the patella, or kneecap, dislocates or moves out of its normal location.

The medial meniscus is a fibrocartilage semicircular band that spans the knee joint medially, located between the medial condyle of the femur and the medial condyle of the tibia. It is also referred to as the internal semilunar fibrocartilage. The medial meniscus has more of a crescent shape while the lateral meniscus is more circular. The anterior aspects of both menisci are connected by the transverse ligament. It is a common site of injury, especially if the knee is twisted.

The knee examination, in medicine and physiotherapy, is performed as part of a physical examination, or when a patient presents with knee pain or a history that suggests a pathology of the knee joint.

The stifle joint is a complex joint in the hind limbs of quadruped mammals such as the sheep, horse or dog. It is the equivalent of the human knee and is often the largest synovial joint in the animal's body. The stifle joint joins three bones: the femur, patella, and tibia. The joint consists of three smaller ones: the femoropatellar joint, medial femorotibial joint, and lateral femorotibial joint.

Lower extremity of femur lower end of the thigh bone in human and other animals

The lower extremity of femur is the lower end of the thigh bone in human and other animals, closer to the knee. It is larger than the upper extremity of femur, is somewhat cuboid in form, but its transverse diameter is greater than its antero-posterior; it consists of two oblong eminences known as the condyles.

Cruciate ligaments are pairs of ligaments arranged like a letter X. They occur in several joints of the body, such as the knee joint and the atlanto-axial joint. In a fashion similar to the cords in a toy Jacob's ladder, the crossed ligaments stabilize the joint while allowing a very large range of motion.

The patellar ligament is the distal portion of the common tendon of the quadriceps femoris, which is continued from the patella to the tibial tuberosity. It is also sometimes called the patellar tendon as it is a continuation of the quadriceps tendon.

TPLO, or tibial-plateau-leveling osteotomy, is a surgery performed on dogs to stabilize the stifle joint after ruptures of the cranial cruciate ligament.

The unhappy triad, also known as a blown knee among other names, is an injury to the anterior cruciate ligament, medial collateral ligament, and meniscus. Analysis during the 1990s indicated that this 'classic' O'Donoghue triad is actually an unusual clinical entity among athletes with knee injuries. Some authors mistakenly believe that in this type of injury, "combined anterior cruciate and medial collateral ligament disruptions that were incurred during athletic endeavors" always present with concomitant medial meniscus injury. However, the 1990 analysis showed that lateral meniscus tears are more common than medial meniscus tears in conjunction with sprains of the ACL.

The knee bursae are the fluid-filled sacs and synovial pockets that surround and sometimes communicate with the knee joint cavity. The bursae are thin-walled, and filled with synovial fluid. They represent the weak point of the joint, but also provide enlargements to the joint space. They can be grouped into either communicating and non-communicating bursae or, after their location – frontal, lateral, or medial.

The coronary ligaments of the knee are portions of the joint capsule which connect the inferior edges of the fibrocartilaginous menisci to the periphery of the tibial plateaus.

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Tightrope CCL is a veterinary orthopedic surgical method developed to provide a minimally invasive procedure for extracapsular stabilization of the canine cranial cruciate ligament-deficient stifle joint. The cranial cruciate ligament (CrCL) stabilizes the dog knee much like the anterior cruciate ligament (ACL) does in humans.

$Tibial plateau fracture$

A tibial plateau fracture is a break of the upper part of the tibia (shinbone) that involves the knee joint. Symptoms include pain, swelling, and a decreased ability to move the knee. People are generally unable to walk. Complication may include injury to the artery or nerve, arthritis, and compartment syndrome.

Simitri Stable in Stride is a three part modular surgical implant used during surgery performed on dogs to stabilize the stifle joint (knee) after rupture of the cranial cruciate ligament (CrCL) which is analogous to the anterior cruciate ligament (ACL) in humans.

References

↑ Karen M. Tobias; Spencer A. Johnston (26 December 2013). Veterinary Surgery: Small Animal: 2-Volume Set. Elsevier Health Sciences. pp. 967–. ISBN 978-0-323-26337-5.
↑ Darryl Millis; David Levine (30 March 2014). Canine Rehabilitation and Physical Therapy. Elsevier Health Sciences. pp. 568–. ISBN 978-1-4557-7580-4.
↑ Etienne Cote (9 December 2014). Clinical Veterinary Advisor: Dogs and Cats. Elsevier Health Sciences. pp. 159–. ISBN 978-0-323-24074-1.

Vet Comp Orthop Traumatol. 2007;20(3):159-68.

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[TobiasJohnston2013-1] Karen M. Tobias; Spencer A. Johnston (26 December 2013). Veterinary Surgery: Small Animal: 2-Volume Set. Elsevier Health Sciences. pp. 967–. ISBN 978-0-323-26337-5.

[MillisLevine2014-2] Darryl Millis; David Levine (30 March 2014). Canine Rehabilitation and Physical Therapy. Elsevier Health Sciences. pp. 568–. ISBN 978-1-4557-7580-4.

[Cote2014-3] Etienne Cote (9 December 2014). Clinical Veterinary Advisor: Dogs and Cats. Elsevier Health Sciences. pp. 159–. ISBN 978-0-323-24074-1.