t +44 (0) TTA Rapid

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1 t +44 () TTA Rapid Veterinary Instrumentation Broadfi eld Road, Sheffi eld, United Kingdom S8 XL t +44 () f +44 () info@vetinst.com 1

2 TTA RAPID (Patented) 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 Rita Leibinger Medical and Dr Yves Samoy, University of Ghent, TTA Rapid is one of the newer developments in both implant technology and technique. 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 times as many infectious units for an implant associated infection to develop when compared to stainless steel. The Implants 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 post-operative management are indicated. 2

3 TTA Rapid Technique Advancement Calculations Calculation of the advancement is performed using the surgeon s technique of choice classic TTA, common tangent, etc. Using the TTA Rapid template provided, a visual check is performed to confirm cage selection. The template is adjusted so that one of the lines extending proximally from the cage represents the chosen line of the osteotomy. The template is positioned so that the top of the cage sits approximately 3mm below the proximal extent of the tibia along this line and that the Maquet hole marker on the template just touches the cranial cortex. The calculated advancement and the thickness of the cranial cortex in the region of the simulated Maquet hole are recorded for later use. Note that each cage width requires a unique osteotomy length. The final length of implant is determined intra-operatively. The approach is through a medial skin incision. Opening the Osteotomy This is a critical part of the procedure, and should be performed slowly and carefully allowing the bone time to adjust. This will make hinge failure unlikely. Start with the smallest Spreader inserted as shown in the most proximal section of the osteotomy The handle is rotated downwards to minimise forces on the fragment, gently. A second Spreader can be used to maintain displacement but should NEVER be used to advance displacement as a hinge fracture will result. Work up through the Spacers until the correct advancement is achieved. Details of this part of the procedure should be viewed on the video either online or from the free DVD. Using the L-Shaped Saw Guide With the limb placed lateral side down, a 2.5mm pin is placed vertically through the joint capsule at, or just cranial to the Tubercle of Gerdy so as to be just touching the proximal tibia. The L-shaped saw guide is dropped over the Gerdy pin using the hole in the vertical arm of the saw guide that corresponds to the advancement. 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. The cage ears should be contoured slightly up on the tibia side, slightly down on the cranial (crista tibiae) side. Elevate the periosteum in the cage area, and insert the cage into the osteotomy. The thumb-pin is placed through the hole in the horizontal arm of the saw guide corresponding to the thickness of the cranial cortex (as measured from the preoperative radiographs). Typically this is around 3mm for a smaller dog and around 5mm for a large dog. The guide is pushed caudally at its distal extent so that the thumb pin sits firmly against the cranial cortex. The guide should be positioned so that the slot is vertical to the operating table. Positioning flat against the medial cortex results in an oblique osteotomy. A saw is driven along the saw-guide creating the osteotomy. Cut the cranioproximal trans-cortex last to hold the osteotomy open until the cut is almost completed. The osteotomy terminates in the distal hole of the sawguide slot. Opening the osteotomy and fitting the cage are undertaken as described. 3 Fitting the Cage TTA RAPID STEP BY STEP GUIDE BRTTARAP Step by Step Guide to TTA Rapid 2.4mm Screws are used in the cage. The screws are directed to avoid the articular surfaces and the osteotomy. Start with the most cranial proximal screw, then the most distal caudal. Screw orientation is medio-proximal to latero-distal in the tibial crest mimicking the angle of the forks in the original TTA. The tibial screws are placed cranio-medio-proximal to caudo-latero-distal. Remove all forceps and re-tighten all screws.

4 TTA Rapid Starter Kit Instrument and selected implant set, supplied in basket type containers with dedicated racks. Implant set contains commonly used sizes as listed below. TTA Rapid Conversion Kit Kit contains: New L Shaped Saw Guide Drill Guide Pin TTA Rapid Lever-Spreader Double-ended 3mm and 9mm TTA Rapid Lever-Spreader Double-ended 6mm and 12mm TTA RAPID CONVERSION KIT TTARNEWMIN TTA Rapid Conversion Kit - New Technique TTA Rapid Screw Rack The Kit contains: Instrument Tray - Complete with new L-Shaped Saw guide. Implant Tray containing 6mm x 16mm Cage x 1 7.5mm x 16mm Cage x 1 7.5mm x 19mm Cage x 1 9mm x 19mm Cage x 1 9mm x 22mm Cage x 1.5mm x 22mm Cage x 1.5mm x 25mm Cage x 1 12mm x 22mm Cage x 1 (8 cages in total) Screws 1 x 8mm 4 x 22mm 2 x 34mm 2 x mm 4 x 24mm 2 x 36mm 4 x 12mm 4 x 14mm 4 x 16mm 4 x 26mm 4 x 28mm 4 x 3mm 2 x 38mm 1 x 4mm (54 Screws in total) TTA Rapid Screw Rack designed for holding TTA Rapid Standard 2.4mm Titanium Screws from 6mm to 4mm in length or TTA Rapid Petite 2.mm Titamiun Screws from 6mm in length. 4 x mm 4 x 32mm Please note supplied empty. 2 x 2.5ml Nanopaste Starter Kit price is discounted by over % compared to component price. TTA RAPID STARTER KIT TTARNEWSTARTKIT TTA Rapid Starter Kit TTA RAPID SCREW RACK TTAR23624 TTA Rapid Screw Rack - Standard for 2.4mm Screws for 6-4mm in length TTAR155 TTA Rapid Screw Rack - Petite for 2.mm Screws for 6mm to mm in length TTA RAPID PREMIUM INSTRUMENT AND IMPLANT KIT TTARNEWPREMALL TTA Rapid Premium Instrument and Implant Kit TTARNEWPREMIMP TTA Rapid Premium Implant Kit TTARNEWPREMINST TTA Rapid Premium Instrument Kit TTA RAPID INSTRUMENT AND IMPLANT TRAYS TTAR1325/A TTA Rapid Implant Tray Supplied Empty TTAR1325/A TTA Rapid Instrument TraySupplied Empty. TTA Rapid Accessories TTA RAPID ACCESSORIES TTAR144 TTA Rapid K Wire Single Trochar Tip 1.2mm x mm TTAR14415 TTA Rapid K Wire Single Trochar Tip 1.5mm x mm TTAR14425 TTA Rapid K Wire Single Trochar Tip 2.5mm x mm TTAR TTA Rapid 1.8mm Drill Bit Round Shaft TTAR1488 TTA Rapid 2.mm Drill Bit Round Shaft TTAR14883 TTA Rapid 3.mm Drill Bit Round Shaft TTAR Twist Drill 1.8mm AO 14/ 3mm AO Shaft TTAR14881 Twist Drill 2.mm AO AO Shaft TTAR14813 Twist Drill 3.mm AO 1/ 85mm AO Shaft 4

5 TTA Rapid Implants TTA Rapid Cages - Standard For use with 2.4mm TTA Rapid Screws. New sizes available - 18 TTA RAPID CAGES TITANIUM TTAR38 TTA Rapid Cage 3/8 Titanium TTAR3 TTA Rapid Cage 3/ Titanium TTAR313 TTA Rapid Cage 3/13 Titanium TTAR316 TTA Rapid Cage 3/16 Titanium TTAR459 TTA Rapid Cage 4.5/9 Titanium TTAR4512 TTA Rapid Cage 4.5/12 Titanium TTAR4515 TTA Rapid Cage 4.5/15 Titanium TTAR4518 TTA Rapid Cage 4.5/18 Titanium TTAR613 TTA Rapid Cage 6/13 Titanium TTAR616 TTA Rapid Cage 6/16 Titanium TTAR619 TTA Rapid Cage 6/19 Titanium TTAR622 TTA Rapid Cage 6/22 Titanium TTAR7513 TTA Rapid Cage 7.5/13 Titanium TTAR7516 TTA Rapid Cage 7.5/16 Titanium TTAR7519 TTA Rapid Cage 7.5/19 Titanium TTAR7522 TTA Rapid Cage 7.5/22 Titanium TTAR916 TTA Rapid Cage 9/16 Titanium TTAR919 TTA Rapid Cage 9/19 Titanium TTAR922 TTA Rapid Cage 9/22 Titanium TTAR925 TTA Rapid Cage 9/25 Titanium TTAR516 TTA Rapid Cage.5/16 Titanium TTAR519 TTA Rapid Cage.5/19 Titanium TTAR522 TTA Rapid Cage.5/22 Titanium TTAR525 TTA Rapid Cage.5/25 Titanium TTAR1219 TTA Rapid Cage 12/19 Titanium TTAR1222 TTA Rapid Cage 12/22 Titanium TTAR1225 TTA Rapid Cage 12/25 Titanium TTAR1228 TTA Rapid Cage 12/28 Titanium TTAR13519 TTA Rapid Cage 13.5/19 Titanium TTAR13522 TTA Rapid Cage 13.5/22 Titanium TTAR13525 TTA Rapid Cage 13.5/25 Titanium TTAR13528 TTA Rapid Cage 13.5/28 Titanium TTAR1519 TTA Rapid Cage 15/19 Titanium TTAR1522 TTA Rapid Cage 15/22 Titanium TTAR1525 TTA Rapid Cage 15/25 Titanium TTAR1528 TTA Rapid Cage 15/28 Titanium TTA Rapid 2.4mm Titanium Screws - 2.mm Hex Head TTA RAPID SCREWS 2.4MM TITANIUM WITH 2.MM HEX HEAD TTARSC246 TTARSC248 TTARSC24 TTARSC2412 TTARSC2414 TTARSC2416 TTARSC2418 TTARSC24 TTARSC2422 TTARSC2424 TTARSC2426 TTARSC2428 TTARSC243 TTARSC2432 TTARSC2434 TTARSC2436 TTARSC2438 TTARSC244 TTA Rapid 2.4mm Screw Titanium 6mm TTA Rapid 2.4mm Screw Titanium 8mm TTA Rapid 2.4mm Screw Titanium mm TTA Rapid 2.4mm Screw Titanium 12mm TTA Rapid 2.4mm Screw Titanium 14mm TTA Rapid 2.4mm Screw Titanium 16mm TTA Rapid 2.4mm Screw Titanium 18mm TTA Rapid 2.4mm Screw Titanium mm TTA Rapid 2.4mm Screw Titanium 22mm TTA Rapid 2.4mm Screw Titanium 24mm TTA Rapid 2.4mm Screw Titanium 26mm TTA Rapid 2.4mm Screw Titanium 28mm TTA Rapid 2.4mm Screw Titanium 3mm TTA Rapid 2.4mm Screw Titanium 32mm TTA Rapid 2.4mm Screw Titanium 34mm TTA Rapid 2.4mm Screw Titanium 36mm TTA Rapid 2.4mm Screw Titanium 38mm TTA Rapid 2.4mm Screw Titanium 4mm NanoPaste Bone Substitutes TTA Rapid Acetate Template - TTA Rapid Rev.6-d 9, ,5 15 Hydroxyapetite paste. 2.5ml is adequate for cages up to.5mm. To completely fill the osteotomy and lattice of larger cages, a 5ml size is also available. NANOPASTE 7,5 6 4, for 2. screw PAS2.5 PAS5 NanoPaste Syringe 2.5ml NanoPaste Syringe 5ml TTA RAPID ACETATE TTARACE TTA Rapid Acetate 5

6 TTA Rapid Petite Petite is aimed at smaller patients such as cats and smaller dogs, where 3mm advancement is sufficient but 2.4 screws in the tibial tubercle are not appropriate. Petite uses 2mm screws, and has dedicated instrumentation including saw guide. Note the saw guide only accepts thin blades. TTA Rapid Cages - Petite Rapid Luxation Plating System LUXATION P L A T I N G S Y S T E M Patella Luxation Plate - Titanium For use with 2.mm TTA Rapid Screws. TTA RAPID CAGES PETITE TITANIUM TTAR13238 TTA Rapid Cage Titanium 3/8 TTAR1323 TTA Rapid Cage Titanium 3/ TTAR TTA Rapid Cage Titanium 3/13 Correction of a patella luxation without TTA operation. This technique is suitable for dogs which do not have a cruciate ligament rupture but suffer from a patella luxation. TTA Rapid Screws 2.mm Titanium - Hex Head TTA RAPID SCREWS 2.MM TITANIUM WITH 1.5MM HEX HEAD TTARSC6 TTA Rapid 2.mm Screw Titanium 6mm TTARSC8 TTA Rapid 2.mm Screw Titanium 8mm TTARSC TTA Rapid 2.mm Screw Titanium mm TTARSC12 TTA Rapid 2.mm Screw Titanium 12mm TTARSC14 TTA Rapid 2.mm Screw Titanium 14mm TTARSC16 TTA Rapid 2.mm Screw Titanium 16mm TTARSC18 TTA Rapid 2.mm Screw Titanium 18mm TTARSC TTA Rapid 2.mm Screw Titanium mm TTA Rapid Petite Drill Sleeve Guide Used to position pilot holes for 2.mm screws. TTA RAPID PETITE DRILL SLEEVE GUIDE TTAR TTA Rapid Petite Drill Sleeve Guide TTARDRIVER TTA Rapid 2.mm Screwdriver, Insert and Sleeve TTA Rapid Petite Depth Gauge TTA RAPID PETITE DEPTH GAUGE TTAR16415 TTA Rapid Petite Depth Gauge for 2.mm Screws TTA Rapid L-Shaped Petite Saw Guide Using the modified technique without a Maquet hole, this guide is used for the TTA Rapid Petite system for advancements of 3mm. TTA RAPID L-SHAPED PETITE SAW GUIDE TTAR13244 TTA Rapid L-shaped Petite Saw Guide PATELLA LUXATION PLATE - TITANIUM Hole 1.5mm Height With Gliding Holes For 2.4mm Screws Hole 1mm Height With Gliding Holes For 2.4mm Screws Hole 1mm Height With Gliding Holes For 2.mm Screws 6

7 TTA Rapid Tibial Tappet & Patellar Luxation Spacers TTA Rapid Tibial Tappet Patellar Luxation in combination with TTA Rapid Especially but not only with small dogs patella luxation issues can come along with a cranial cruciate ligament rupture. Even lower grade patella luxation can become more severe with a torn cruciate ligament. The rotational stability which is provided by the cruciate ligament does not exist any longer. This may result in a luxating patella which did not show any clinical signs before CCL rupture. With the new Rita Leibinger patella spacers the patella luxation can be corrected when a cruciate ligament repair surgery has do be done anyways. With the new Tibia Tappet the tibia tuberosity can easily be transposed after the TTA Rapid cage is inserted into the open partial osteotomy. The Patella Spacers can then easily be placed between the screw holes of the cage and the bone. Cage and Spacer can be fixed with the 2.4mm TTA Rapid screws. Identical to the TTA Rapid Cage also the Patella Spacers are made of purest Titanium for best biocompatibility. The Tappet is to simplify the transposition of the tibia tuberosity and easy application of the patella luxation spacers. For further information please contact Rita Leibinger (info@leibinger-medical.com) or contact our Vet Tech Gurus on or info@vetinst.com TTA Rapid Patellar Luxation Spacers Function The Tappet is put into either the cranial or caudal screw holes (top and centre screw hole for the 3-hole cages for size 9 and up) of the TTA Rapid cage depending if there is a medial or lateral patella luxation. Then the tappet can be rotated, it fixates itself in the screw holes of the cage and transposes the tibia crest to the medial or lateral side. The scale (in mm) on the top of the instruments shows exactly how far tibia crest is transposed. Then the spacer will be placed between the cage and the bone and after this the tappet can be removed. Spacer for 2 hole cage (left shown) & Spacers for 3 hole cages (right shown) TTA RAPID PATELLAR LUXATION SPACERS TTAR13282L TTA Rapid Patellar Luxation Spacer 2 Holes 2mm Height Left TTAR13282R TTA Rapid Patellar Luxation Spacer 2 Holes 2mm Height Right TTAR13283L TTA Rapid Patellar Luxation Spacer 2 Holes 3mm Height Left TTAR13283R TTA Rapid Patellar Luxation Spacer 2 Holes 3mm Height Right TTAR13284L TTA Rapid Patellar Luxation Spacer 2 Holes 4mm Height Left TTAR13284R TTA Rapid Patellar Luxation Spacer 2 Holes 4mm Height Right TTAR13282L TTA Rapid Patellar Luxation Spacer 3 Holes 2mm Height Left TTAR13282R TTA Rapid Patellar Luxation Spacer 3 Holes 2mm Height Right TTAR13284L TTA Rapid Patellar Luxation Spacer 3 Holes 4mm Height Left TTAR13284R TTA Rapid Patellar Luxation Spacer 3 Holes 4mm Height Right TTAR13286L TTA Rapid Patellar Luxation Spacer 3 Holes 6mm Height Left TTAR13286R TTA Rapid Patellar Luxation Spacer 3 Holes 6mm Height Right TTA RAPID TIBIAL TAPPET TTAR13247 TTA Rapid Tibial Tappet 7

8 TTA Rapid Bending Iron TTA Rapid Universal Spreader This is used for contouring the cage ears for accurate placement and is common to the original and modified techniques. The use of other devices to create this contour is likely to result in damage to the cage ears. TTA RAPID BENDING IRON Permits incremental opening of the osteotomy in a very controlled manner. 16mm length. TTAR1324 TTA Rapid Bending Iron TTA RAPID UNIVERSAL SPREADER TTA Rapid L-Shaped Saw Guide TTAR TTA Rapid Universal Spreader L shaped saw guide for the TTA Rapid technique. TTA RAPID L-SHAPED SAW GUIDE TTAR13244 TTA Rapid L-shaped Saw Guide TTAR13243 TTA Rapid Drill Guide Pin TTAR13244 TTA Rapid L-shaped Petite Saw Guide TTA Rapid Lever Spreader These are used to open the osteotomy incrementally to the required width. Available in two double-ended sizes. The spreaders measure 1mm wider than their stated size to permit insertion of a cage beneath them. TTA RAPID LEVER SPREADER TTAR TTAR TTAR TTA Rapid Lever Spreader Double-ended 3mm & 9mm Broad TTA Rapid Lever Spreader Double-ended 6mm & 12mm Broad TTA Rapid Lever Spreader Double-ended13.5mm & 15mm Broad 8

9 TTA Rapid Screwdriver Handle AO Coupling TTA Rapid Cage Holding Forceps - Angled Used to remove cages from implant trays. A high quality modular screw-driver with a familiar coupling and rotating base-cap. TTA RAPID CAGE HOLDING FORCEPS - ANGLED TTAR TTA Rapid Cage Holding Forceps - Angled - 16mm Long TTA RAPID SCREWDRIVER HANDLE - AO COUPLING TTAR3863 TTA Rapid Screwdriver Handle - AO Coupling TTA Rapid Drill Sleeve Guide for 2.4mm Screws TTA Rapid Screwdriver Inserts Used for accurate positioning of pilot holes for 2.4mm screws. TTA RAPID SCREWDRIVER INSERTS TTA RAPID DRILL SLEEVE GUIDE FOR 2.4MM SCREWS & 2.MM MAQUET HOLE TTAR3424 TTA Rapid Screwdriver Insert for 2.4mm Hex Screws AO Fitting mm Long TTAR TTA Rapid Drill Sleeve Guide for 2.4mm Screws TTAR TTA Rapid Screw Holding Sleeve for 2.4mm Hex Screws TTA Rapid Depth Gauges TTA RAPID DEPTH GAUGES TTAR TTAR16415 TTA Rapid Depth Gauge for 2.4mm Screws 15mm Long - reads to 4mm TTA Rapid Petite Depth Gauge for 2.mm Screws 9

10 Additional useful instruments for TTA Rapid Plate Holding/ Drill Guide Forceps Adjustable Bone Saw Useful for completing/ squaring off the osteotomy, this saw comes complete with five, fine chrome plated blades. Blade length is adjustable from 4mm to mm. Handle length13mm. Blade length 155mm. ADJUSTABLE BONE SAW Adjustable Bone Saw c/w 5 Fine Blades Used to snug the TTA Rapid cage ears against the medial cortex prior to drilling pilot holes. PLATE HOLDING/ DRILL GUIDE FORCEPS /2. Plate Holding/ Drill Guide Forceps 14mm Long Petite TTA Rapid /2.7 Plate Holding/ Drill Guide Forceps 145mm Long Standard TTA Rapid Reduction Forceps with Spinlock REDUCTION FORCEPS WITH SPINLOCK 13 Very Large Fragment Forceps with Spinlock 215mm Long 1245SL Large Fragment Forceps with Spinlock 18mm Long NP8 ISSUE 1 FEB 18 Veterinary Instrumentation Broadfield Road, Sheffield, United Kingdom S8 XL t +44 () f +44 () info@vetinst.com