TTA Rapid Overview TTA RAPID. The Implants

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3 TTA Rapid Overview TTA RAPID Tibial Tuberosity Advancement (TTA) as a technique for the surgical management of cranial cruciate ligament insufficiency has gained increasing acceptance and popularity in recent years. As we learn more, efforts are being made to simplify the technique, to make it more user friendly and overcome some of the pitfalls of the original technique. Developed in collaboration with Dr. Yves Samoy, University of Ghent, TTA Rapid is one of the newer developments in both implant technology and technique. The Implants Once the full structure has been created, the cages are separated from the powder and various chemical and other finishing processes are performed to leave the cages in their final, implantable state. Through this process, shapes can be created that would either be impossible to produce using more conventional technologies or cost prohibitive. In the case of TTA Rapid, a very porous honeycomb titanium lattice with a modulus similar to that of cancellous bone is generated permitting very rapid bony ingrowth to occur. Titanium is also very biocompatible, MRI compatible and typically needs to be inoculated with 10 times as many infectious units for an implant associated infection to develop when compared to stainless steel. The manufacture of TTA Rapid cages has only been made possible with advances in materials and manufacturing technology. The cages are made by an additive manufacturing (AM) 3D printing process known as selective laser sintering (SLS). The process is interesting to watch. Although other materials can be used in the process, TTA Rapid cages start life as a very fine, commercially pure titanium powder. A very thin layer of titanium powder is deposited on the working bed of the SLS machine and a modified print head carrying a high intensity laser is used to selectively melt the powder to bond (sinter) regions together. As further layers of powder are applied and the laser sintering process repeated, a solid three dimensional structure begins to form within the sand-pit of metal powder. Electron beam melting (EBM) is a similar procedure that uses an electron beam instead of a laser. The lattice found in the TTA Rapid cages is bound on 4 sides by an anatomically shaped, rigid shell of the same material with one side carrying lugs with screw holes in them. With the lattice, cage and screw lugs being one piece, the cages are very stable in situ. The constructs are so stable that auxiliary implants such as plates, wires, forks and staples are rarely indicated. This has a number of benefits: Reduced morbidity and biological cost that may be associated with the dissection and placement of additional implants. Reduced potential for cold conduction with superficially sited metallic implants. Fewer additional holes created in the tibial diaphysis which may contribute to crack propagation and failure of the tibial shaft. Metals of different electro-potentials are avoided in the same construct. Theoretically this reduces the potential for galvanic corrosion to occur (all components are titanium). Simplified inventory management. Potential time savings in the placement of implants. Caution: TTA Rapid patients are often subjectively more comfortable in their early post-operative recovery than many patients undergoing other osteotomy surgeries. TTA Rapid still involves a major osteotomy and both appropriate patient selection and appropriate client education for postoperative management are indicated. 6

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5 Patella Luxation & TTA Repeat these steps until the required displacement is reached. 3. The depth of the osteotomy is measured with a drill depth gauge at the proximal extent of the osteotomy. This measurement is rounded up to select the correct cage length. d. Aftercare 1. Casting/bandaging is generally not required. 2. A light dressing can be applied for 3 to 5 days. 3. NSAIDs are provided for 3 to 4 weeks. 4. With HA paste, clinical union can generally be anticipated within 6 weeks. c. Fixating the cage 1. The ears of the cage need to be bent using the bending stick. Ears on the caudal side (tibia) should point slightly upwards, while the ears on the cranial side (crista tibiae) should be tilted slightly downwards. Slight under-bending of the caudal ears and slight over-bending of the cranial ears will help compress the osteotomy against the cage. 2. Elevate the periostium from the bone in the region where the cage will be fixed. 3. Insert the cage into the osteotomy. Use bone Forceps to make sure the ears of the cage are in close contact with the bone. 4. Once the cage is in place, check if the height of the cage is correct. This can be done by palpating the proximal tibia with the tip of a small mosquito clamp. You should feel about 3mm of bone above the top of the cage. More bone means a more distal placement of the cage and thus subsequently a more cranial displacement of the tibial tuberosity. 5. Large bone Forceps can be used to give extra compression on the cage. This step is not essential if the distal cortex is still intact, but will result in a better bone contact with the cage mm screws are inserted into the cage. Start with the most cranial, most proximal screw. The orientation of the screws should be medio-proximal to latero-distal (similar as the orientation of the fork in a standard TTA).The second screw is the caudo-proximal screw. The orientation of this screw is cranio-medio-proximal to caudo-laterodistal ( Away from the joint, away from the osteotomy site ). The rest of the screws are placed in the same fashion starting with the most proximal screws. Once all screws are inserted, remove the bone Forceps and re-tighten all screws. 7. Insertion of Hydroxy-Apatite paste inside and underneath the cage will accelerate healing of the osteotomy. Close the fascia where possible. 8. Close the wound in a routine fashion. Y. Samoy, DVM, PhD and P. Verleyen, DVM Department of Medical Imaging and Small Animal Orthopedics Faculty of Veterinary Medicine, Ghent University TTA and Patella Luxation (TTTA) Dr. Hugo Schmökel When a dog suffers from a cranial cruciate ligament rupture with a simultaneous patellar luxation, this can be addressed with a modified TTA Rapid procedure. Prior to the TTA Rapid surgery itself, it should be determined if the dog would benefit from a trochleoplasty. If so, this should be performed before the actual TTA Rapid procedure(1). The osteotomy used for the TTA Rapid procedure can also be used to achieve a medial or lateral tibial tuberosity transposition (TTT), depending on the kind of patellar luxation. The further described procedure focuses on a lateralization of the crest, needed for the correction of a medial patellar luxation After performing the osteotomy, the appropriate cage is inserted into the osteotomy and all of the caudal screws are inserted in the tibia (Figure 1). Take care to choose a cage that has a bigger medio-lateral length than measured after the osteotomy, as both cortices of the transposed crest need to be supported! Usually, the longest cage is advised. Consecutively, the tibial crest is slightly advanced, so that itcan be moved laterally (Fig 2 and 3). Be very careful performing this and restrict the advancement to the absolute minimum to avoid crest avulsion. Ideally, the advancement is given above 8

6 the cage. Once the desired position is reached, a bone holding Forceps (or a small Kirschner wire) can be used as described above to keep the position, until a corresponding washer is placed between the crista tibiae and the ears of the cage (Figure 4). If the transposition is sufficient to prevent dislocation of the patella, the remaining screws are inserted and the operation finished as described (Figure 5 and 6). In case of a a lateral luxation, the tibial crest is shifted medially in a similar manner after fixating the cranial part of the cage in the tibial crest. More Information Please visit our website and read the latest studies, find additional videos, surgery instructions, special surgeries and much more Samoy Y, Verhoeven G, Bosmans T, Van der Vekens E, de Bakker E, Verleyen P, et al. TTA Rapid: Description of the Technique and Short Term Clinical Trial Results of the First 50 Cases. Vet Surg. 2014:n/a-n/a. Studies about TTA RAPID TTA Rapid: Description of the Technique and Short Term Clinical Trial Results of the First 50 Cases Ghent University, Faculty of Veterinary Medicine, Department of Veterinary Medical Imaging and Small Animal Orthopaedics Yves Samoy1, DVM, PhD, Geert Verhoeven1, DVM, PhD, Diplomate ECVS, Tim Bosmans2, DVM, PhD, Elke Van der Vekens1, DVM, Diplomate ECVDI, Evelien de Bakker1, DVM, PhD, Piet Verleyen1, DVM and Bernadette Van Ryssen1, Prof, DVM, PhD Vet Surg 2014 Tibial tuberosity advancement in smallbreed dogs using TTA Rapid implants. Complications and outcome Evidensia Strömsholm Small Animal Referral Hospital, Sweden Dyall B A R, DVM, Spec SWE. Schmökel H, DVM, DECVS, PHD 2016 TTA Rapid in the treatment of the canine cruciate deficient stifle: short- and mediumterm outcome Postoperative infection with a multiresistant Staphylococcus aureus (MRSA) in a Bernese mountain dog with a rupture of the cranial cruciate ligament Ghent University, Faculty of Veterinary Medicine, Department of Veterinary Medical Imaging and Small Animal Orthopaedics 1F. Vandael, 1E. de Bakker, 2D. Paepe, 1L.Mosselmans, 1Y. Samoy, 1G. Verhoeven, 1B. Van Ryssen Flemish Veterinary Journal, 2015, 84 TTA Rapid: an interesting alternative operation method of an injured cranial crucial ligament Lecznica Weterynaryjna Arwet w Wieliczce lek. wet. Rafał Korta WETERYNARIA W PRAKTYCE 2014 TTA Rapid for treatment of cranial cruciate ligament injuries in dogs. Clinical results 50 cases. Kydd and Kydd Veterinary Health Centre, Wimbledon David M Kydd BVetMed CertVR CertSAO MRCVS Orthopaedic News from Kydd & Kydd 2014 S. J. Butterworth & D. M. Kydd, Weighbridge Referral Centre & Kydd & Kydd Vets Journal of Small Animal Practice

7 TTA Rapid Sets TTA RAPID Instrument Kit Sterilization Container blue (image) green TTA RAPID Premium Set The Premium Set contains two cages of each size and 5 pieces of each 2.4mm screw length Image: Premium Kit & Instruments Kit 10

8 TTA RAPID Starter Split Set The Starter Split Set contains one cage of each size and 5 pieces of each 2.4mm screw length TTA RAPID Starter Set II The Starter Set II contains two cages of the most used sizes and 5 pieces of each 2.4mm screw length TTA RAPID Starter Set I The Starter Set I contains one cage of the most used sizes and 5 pieces of each 2.4mm screw length

9 TTA Rapid Implants Patella Luxation Spacers TTA RAPID Implants TTA RAPID Cages Titanium Patella Luxation Spacers Product Code Size (mm) Color /08 (for 2.0 screws) /10 (for 2.0 screws) /13 (for 2.0 screws) / / / / / / / / / / / / / / / / / / / / / / / / / / /28 Product Code Specifications for cages L 2 mm height, 2 holes, left 3-7,5 mm R 2 mm height, 2 holes, right 3-7,5 mm L 3 mm height, 2 holes, left 3-7,5 mm R 3 mm height, 2 holes, right 3-7,5 mm L 4 mm height, 2 holes, left 3-7,5 mm R 4 mm height, 2 holes, right 3-7,5 mm L 2 mm height, 3 holes, left 9-15 mm R 2 mm height, 3 holes, right 9-15 mm L 4 mm height, 3 holes, left 9-15 mm R 4 mm height, 3 holes, right 9-15 mm L 6 mm height, 3 holes, left 9-15 mm R 6 mm height, 3 holes, right 9-15 mm 12

10 Screw Rack Screws (self-tapping, TTA Rapid) Self-tapping Screws Hex Head Standard (2.4 mm) Petite (2.0 mm) Head diameter 4.0 mm 4.0 mm Thread diameter 2.4 mm 2.0 mm Core diameter 1.7 mm 1.4 mm Thread pitch 1.0 mm 0.6 mm Color Screw Rack for 2.4 mm screws for 2.0 mm screws Standard Product Code Petite Product Code Length (mm)

11 TTA Rapid Spreader TTA Rapid Saw Guides TTA Rapid Bending Iron TTA RAPID Spreader with tensioning and fixation screw, 16 cm TTA RAPID Lever-Spreader mm & 9 mm mm & 12 mm mm & 15 mm TTA RAPID Saw Guide for cage size 6-15 mm for cage size mm TTA RAPID Saw Guide Pin Ø 1.0mm TTA RAPID Bending Iron 120 mm

12 Holding Sleeves Drill Guide Screwdriver Handles Screwdriver AO-Handle Standard 2.4 mm size, AO QC sterilizable up to 134 C Petite 2.0 mm size, AO QC Holding sleeve Standard 2.4 mm Petite 2.0 mm Standard Petite Screw Driver Shaft Standard 2.4 mm Petite 2.0 mm Plate Holding Forceps 160 mm Kirschner Wires, single Trokar mm x 100 mm mm x 100 mm Drill Guide Standard 1.8/ Petite 1.1/1.5 15

13 Twist Drills TTA Depth Gauge Patella Luxation Tibia Tappet Boneholding Forceps Tibia Tappet For incorporation of Patella Luxation Spacers Twist Drill Ø 1.8 mm (standard), AO QC Ø 1.8 mm (standard), straight shank Ø 1.5 mm (petite), AO QC Ø 1.5 mm petite, straight shank TTA Depth Gauge Standard 2.4 mm Petite 2.0 mm Boneholding Forceps 21,5 cm - with spin lock

14 Saw Blades Sawblades - Samoy Rapid-Cut extreme cutting precision optimum performance protection against wear titanium nitride* *Titanium Nitride (TiN) is one of the hardest and toughest materials in the medical field. TiN coated Saw-Blades last up to 5 times longer. Colibri 50x20mm Aesculap 42x15mm Linvatec-Hall 35x12mm AO/Synthes 27x10mm TERRIER Standard Length x Width x Cutting Thickness 50x20x0.8mm 42x15x0.8mm 35x12x0.8mm 27x10x0.8mm Colibri Aesculap Linvatec-Hall AO/Synthes x16x0.7mm 40x12x0.7mm TERRIER Petite Prod. Code Specifications Colibri x11x0.6mm Aesculap x10x0.7mm Linvatec-Hall x9.4x0.65mm AO/Synthes x10x0.6mm 17

15 Stifle Surgery Set Basic Stifle Surgery Set Product Code Description Basic Stifle Surgery Set (Complete) Willinger Bone Curettes Double Ended, 13,5 cm, 5 1/4" SENN Retractor, double-ended, sharp STIFLE Distractor, small, 14cm, spinlock STIFLE, Distractor, min. spread 8mm, max. 30mm Hartmann Meniscal Cup Forceps, Shaft length 12 cm Hartmann Meniscal Grasping Forceps, Shaft length 12 cm, 1 x 2 Teeth HOHMANN, mini bone lever, 6mm, 16cm Hook Knife SMILIE Meniscotome, 5,0 mm Hook Probe 4,0mm WALLACE, Knee Retractor, 14cm HALSTED-MOSQUITO Normal straight, 1:2 Teeth, 10 cm/ 4" Implant-Sterilisation Container, Gold lid, 330x145x105 mm 18