Veterinary Colleagues

So many different techniques are advocated for the management of cruciate disease it can sometimes be overwhelming. At VetFix we keep things simple and stick to techniques that have been widely reported in peer reviewed literature to offer the best outcome with minimal complication rates.

Decision making and planning are critical for each individual case. No one option is suitable for all patients or all clients.

Tibial tuberosity advancement, to provide a patella ligament-tibial plateau angle of 90o, neutralizes tibiofemoral shear force. In the CCL deficient stifle this eliminates cranial tibial thrust on weight bearing. I favour the use of titanium implants due to improved biocompatibility and fatigue strength and use the Securos XGen forkless system.

A good to excellent outcome can be expected in more than 90% of cases. Regardless of technique, late meniscal tears can be expected in 5-10% of dogs and post-operative infection in around 5% of cases.

TPLO, CCWO and TTA are dynamic cranial cruciate ligament repair techniques with the lateral suture extracapsular repair a static system. The TPLO procedure is essentially a radial osteotomy of the proximal tibia intended to neutralize cranial tibial thrust by reduction of the tibial plateau angle. At VetFix we stabilize this rotation with a locking TPLO plate. This provides an angle stable construct with robust fixation. Selection of TPLO or CCWO versus TTA continues to be surgeon preference. However, recent evidence does suggest long-term outcome may be improved with the TPLO technique. I have written an article summarizing recent advances in cruciate surgery – Read full article here

Regardless of technique, late meniscal tears can be expected in 5-10% of dogs and post-operative infection in around 5% of cases.

Tibial plateau angles of greater than 30o can preclude sufficient advancement of the tibial tuberosity for successful TTA. This can be seen in small breed dogs such as the West Highland White Terrier. In some other terrier breeds insufficient tibial tuberosity space makes placement of the TTA plate difficult. In these cases CCWO can be extremely useful. I favour use of a small TPLO locking plate or delta plate for this procedure.

Regardless of technique, late meniscal tears can be expected in 5-10% of dogs and post-operative infection in around 5% of cases.

The lateral suture system (LSS) is a static CCL repair technique. In a prospective clinical study, Conzemius et al, 2005, found the LSS and TPLO surgery superior to the intracapsular technique. The quasi-isometric points around the stifle are described though true isometric placement is not possible. There have been many improvements in the LSS. I favour LigaFiba manufactured by VI for my lateral sutures. It has superior tensile strength and resistance to cyclic elongation. I do not like the plastic button that comes with the kit and use a titanium button. A good to excellent outcome can be expected in more than 90% of cases.

Regardless of technique, late meniscal tears can be expected in 5-10% of dogs and post-operative infection in around 5% of cases.

VetFix have the equipment and implants to manage both simple and complex fracture repairs. We try to work with local practitioners to provide an option that works for both the pet and the owner. As well as a full range of the standard dynamic compression plating (DCP) systems we also use the Securos polyaxial (PAX) locking plate system. Locking plates can be extremely useful for a variety of fracture types but in particular in regions where plate contouring can be difficult and time consuming.

With my clinical experience at the PDSA, I also try to offer cost sensitive solution for some fractures. In some cases, fractures are beyond what we can manage at VetFix and tertiary referral for further diagnostic imaging or surgery with a specialist is necessary.

Tibial tuberosity advancement, to provide a patella ligament-tibial plateau angle of 90o, neutralizes tibiofemoral shear force. In the CCL deficient stifle this eliminates cranial tibial thrust on weight bearing. I favour the use of titanium implants due to improved biocompatibility and fatigue strength and use the Securos XGen forkless system.

A good to excellent outcome can be expected in more than 90% of cases. Regardless of technique, late meniscal tears can be expected in 5-10% of dogs and post-operative infection in around 5% of cases.

TPLO, CCWO and TTA are dynamic cranial cruciate ligament repair techniques with the lateral suture extracapsular repair a static system. The TPLO procedure is essentially a radial osteotomy of the proximal tibia intended to neutralize cranial tibial thrust by reduction of the tibial plateau angle. At VetFix we stabilize this rotation with a locking TPLO plate. This provides an angle stable construct with robust fixation. Selection of TPLO or CCWO versus TTA continues to be surgeon preference. However, recent evidence does suggest long-term outcome may be improved with the TPLO technique. I have written an article summarizing recent advances in cruciate surgery – Read full article here

Regardless of technique, late meniscal tears can be expected in 5-10% of dogs and post-operative infection in around 5% of cases.

Tibial plateau angles of greater than 30o can preclude sufficient advancement of the tibial tuberosity for successful TTA. This can be seen in small breed dogs such as the West Highland White Terrier. In some other terrier breeds insufficient tibial tuberosity space makes placement of the TTA plate difficult. In these cases CCWO can be extremely useful. I favour use of a small TPLO locking plate or delta plate for this procedure.

Regardless of technique, late meniscal tears can be expected in 5-10% of dogs and post-operative infection in around 5% of cases.

The lateral suture system (LSS) is a static CCL repair technique. In a prospective clinical study, Conzemius et al, 2005, found the LSS and TPLO surgery superior to the intracapsular technique. The quasi-isometric points around the stifle are described though true isometric placement is not possible. There have been many improvements in the LSS. I favour LigaFiba manufactured by VI for my lateral sutures. It has superior tensile strength and resistance to cyclic elongation. I do not like the plastic button that comes with the kit and use a titanium button. A good to excellent outcome can be expected in more than 90% of cases.

Regardless of technique, late meniscal tears can be expected in 5-10% of dogs and post-operative infection in around 5% of cases.

Decision making is critical to ensure individualized treatment is provided for each patient. The degree of skeletal deformity, associated pain and the potential for progression of osteoarthritis help dictate when surgical management is appropriate. We will always offer advice on when conservative management might be preferred over surgical intervention. At VetFix we tend to avoid trochleoplasty unless essential. That is to say we often perform a tibial tuberosity transposition (TTT) without a trochlear wedge recession unless the patella is still unstable following TTT. This approach minimizes disruption of the articular cartilage unless necessary.

We perform a clinical audit of outcomes to ensure we continue to provide the best possible treatment for our patients.

This is the grading system described by Singleton, 1969, for medial patellar luxation:

Grade 1

The patella can be luxated medially with the stifle in full extension. There is no crepitus noted during stifle range of motion and bony deformity is absent. Clinical signs are typically not present.

Grade 2

Spontaneous luxation occurs. Clinical signs of a nonpainful, “skipping” type of lameness are often seen. Mild deformities develop, consisting of internal rotation of the tibia and abduction of the hock. This condition may progress to a grade 3 luxation as progressive cartilage erosion on the patellar and trochlear surfaces occur, and/or cranial cruciate disease occurs.

Grade 3

Patella is luxated permanently but can be reduced manually. More severe bony deformities are present including marked internal tibial rotation and an S-shaped curve of the distal femur and proximal tibia. A shallow trochlear groove may be palpable. The client often complains of an abnormal, “crouched” gait rather than intermittent lameness, because the dog often uses the leg in a semiflexed, internally rotated position. The condition is often bilateral.

Grade 4

This is a severe condition with permanent, nonreducible luxation of the patella. The tibia is rotated from 60 degress to 90 degrees relative to the saggital plane. If not corrected early in life, severe bony and ligamentous deformities develop making surgical correction more challenging.

TPLO, CCWO and TTA are dynamic cranial cruciate ligament repair techniques with the lateral suture extracapsular repair a static system. The TPLO procedure is essentially a radial osteotomy of the proximal tibia intended to neutralize cranial tibial thrust by reduction of the tibial plateau angle. At VetFix we stabilize this rotation with a locking TPLO plate. This provides an angle stable construct with robust fixation. Selection of TPLO or CCWO versus TTA continues to be surgeon preference. However, recent evidence does suggest long-term outcome may be improved with the TPLO technique. I have written an article summarizing recent advances in cruciate surgery – Read full article here

Regardless of technique, late meniscal tears can be expected in 5-10% of dogs and post-operative infection in around 5% of cases.

Tibial plateau angles of greater than 30o can preclude sufficient advancement of the tibial tuberosity for successful TTA. This can be seen in small breed dogs such as the West Highland White Terrier. In some other terrier breeds insufficient tibial tuberosity space makes placement of the TTA plate difficult. In these cases CCWO can be extremely useful. I favour use of a small TPLO locking plate or delta plate for this procedure.

Regardless of technique, late meniscal tears can be expected in 5-10% of dogs and post-operative infection in around 5% of cases.

The lateral suture system (LSS) is a static CCL repair technique. In a prospective clinical study, Conzemius et al, 2005, found the LSS and TPLO surgery superior to the intracapsular technique. The quasi-isometric points around the stifle are described though true isometric placement is not possible. There have been many improvements in the LSS. I favour LigaFiba manufactured by VI for my lateral sutures. It has superior tensile strength and resistance to cyclic elongation. I do not like the plastic button that comes with the kit and use a titanium button. A good to excellent outcome can be expected in more than 90% of cases.

Regardless of technique, late meniscal tears can be expected in 5-10% of dogs and post-operative infection in around 5% of cases.

Hip luxation can be a common problem in small animal practice. With vehicular trauma, forces are thought to transfer through the femur driving the femoral head dorsally over the acetabular rim often tearing important joint stabilisers. Craniodorsal luxation is common.

Closed reduction and external stabilisation using an Ehmer sling has been reported as the initial treatment of choice with success rates of 50% to 60%. At VetFix we are not advocates of Ehmer slings and have seen severe complications associated with their use. If closed reduction is successful cage rest is preferred. If unstable following initial reduction, surgical treatment is often necessary. A success rate of 70-80% is reported following the open reduction and surgical stabilization of failed closed reduction cases.

The wide variety of options for open reduction can be broadly separated into intra-articular and extra-articular stabilization. The Iliofemoral suture is an extra-articular technique and offers the advantage of avoiding articular cartilage damage that could occur with placement of a transarticular pin or toggle. VetFix favour the iliofemoral suture when the hip is stable following reduction and internal rotation of the limb during surgery ie a congruent joint.

With transarticular pinning a Steinmann pin is inserted through the femoral head and neck and acetabulum to provide temporary joint stability. This is an intra-articular stabilization technique and poses a risk of articular cartilage damage. It is however a very useful technique with an overall 80% success rate reported in dogs. Heavier dogs and those with hip dysplasia carry a worse prognosis for successful open reduction.

Total hip replacement is advocated for recurrent cases of hip luxation or severe cases of hip dysplasia. VetFix can offer advice on possible THR candidates and assist with tertiary referral. Dogs often do extremely well with a THR and it is well worth considering before a femoral head and neck ostectomy (FHNO) is performed.

Femoral head and neck ostectomy (FHNO) should be considered if open reduction techniques are unsuccessful or if severe articular damage is present and THR is not an option for the client. In cats FHNO typically leads to full return to function though there is a strong argument for avoiding this if possible ie attempt open reduction first.

Hagrid 30 days following FHNO for a slipped capital femoral physis:

Performing a successful FHNO requires a good approach. A well positioned Langenbek retractor can aid visualization of the appropriate cut line. An oscillating saw is best used for the osteotomy. Pain management and immediate physiotherapy are important in the immediate postoperative period to encourage early weight-bearing and preservation of range of motion.

At VetFix we are always keen to hear of any orthopaedic cases you may have. Often we can arrange to perform a full orthopaedic examination or review radiographs. This can be a critical part of any lameness workup. In addition we offer advice on the medical management of osteoarthritis. Angular limb deformities often benefit from a CT scan and again we can advise on when best to take this extremely useful step.

The wide variety of options for open reduction can be broadly separated into intra-articular and extra-articular stabilization. The Iliofemoral suture is an extra-articular technique and offers the advantage of avoiding articular cartilage damage that could occur with placement of a transarticular pin or toggle. VetFix favour the iliofemoral suture when the hip is stable following reduction and internal rotation of the limb during surgery ie a congruent joint.

With transarticular pinning a Steinmann pin is inserted through the femoral head and neck and acetabulum to provide temporary joint stability. This is an intra-articular stabilization technique and poses a risk of articular cartilage damage. It is however a very useful technique with an overall 80% success rate reported in dogs. Heavier dogs and those with hip dysplasia carry a worse prognosis for successful open reduction.

Total hip replacement is advocated for recurrent cases of hip luxation or severe cases of hip dysplasia. VetFix can offer advice on possible THR candidates and assist with tertiary referral. Dogs often do extremely well with a THR and it is well worth considering before a femoral head and neck ostectomy (FHNO) is performed.

Femoral head and neck ostectomy (FHNO) should be considered if open reduction techniques are unsuccessful or if severe articular damage is present and THR is not an option for the client. In cats FHNO typically leads to full return to function though there is a strong argument for avoiding this if possible ie attempt open reduction first.

Hagrid 30 days following FHNO for a slipped capital femoral physis:

Performing a successful FHNO requires a good approach. A well positioned Langenbek retractor can aid visualization of the appropriate cut line. An oscillating saw is best used for the osteotomy. Pain management and immediate physiotherapy are important in the immediate postoperative period to encourage early weight-bearing and preservation of range of motion.