Triple tibial osteotomy

Introduction

• The triple tibial osteotomy (TTO) is a surgical procedure designed to stabilize the cranial cruciate ligament (CrCL) deficient stifle by reducing the tibial plateau slope to an angle perpendicular to the patellar ligament. Three cuts are made in the proximal tibia to create a partial wedge ostectomy caudal to a partial tibial crest osteotomy . The tibial plateau is made perpendicular to the patellar ligament by rotating the proximal tibial fragment to close the wedge ostectomy and simultaneously advancing the tibial tuberosity. This negates the cranial thrust generated during load bearing.
  This technique should not be attempted by veterinarians without appropriate specialist training.

Uses

• To neutralize instability in canine CrCL-deficient stifle joints .

Advantages

• According to proponents, TTO provides a rapid recovery with good to excellent outcomes reported for dogs of all sizes with cruciate ligament disease.
• Postopertive morbidity, complications and progression of osteoarthritis following surgery appears to be similar to other tibial osteotomy techniques.
• Utilizes readily available implants.
• The procedure results in less radical angular changes.
• TTO can be easily adapted to correct other concomitant deformities such as: genu varum, genu valgum , increased tibial plateau slope angle, tibial torsion deformity and patellar luxation .

Disadvantages

• Limited independent verification of technique by surgeons in academia or practice.
• Numerous techniques for repair of CrCL injury have been described during the past 50 years; uniform success rates of 80-90% have been published for many of these procedures. Initial reports for TTO are similar.
• Complications can be more severe than for more conventional repair techniques.

Requirements

Materials required

Ideal equipment

• Routine for joint surgery.
• Specific TTO instrumentation.

Other requirements

• Sterile equipment:
  • Oscillating saw.
  • Drill.
  • Veterinary Instrumentation TPLO plate.
  • Screws and instruments for their placement, eg depth gauge +/- taps.
  • Bone holding and reduction forceps.

Sequelae

Complications

• Post-operative meniscal injury.
• Osteomyelitis .

Prognosis

• Good - excellent.

Reasons for treatment failure

• Technical errors in surgery.
• Premature, excessive limb usage.

Sources

Publications

• Recent references from PubMed.
• Renwick A I C , McKee W M, Emmerson T D & House A K (2009) Preliminary experiences of the triple tibial osteotomy procedure: tibial morphology and complications. JSAP 50 , 212-221 PubMed.
• Bruce W J, Rose A, Tuke J & Robins G M (2007) Evaluation of the triple tibial osteotomy. A new technique for the management of the canine cruciate-deficient stifle. Veterinary Comparative Orthopaedics and Traumatology 20 , 159-168PubMed.