Joop Hopmans, Small animal orthopedic surgeon. Wednesday, April 24, 13

Transcription

1 Joop Hopmans, Small animal orthopedic surgeon 1

2 Cranial Cruciate Trauma What to do????? TightRope OTT TPLO MMT FHT MRIT TTA TCC TTO TTArap TTA-2 2

3 The biggest ones TPLO TTA TTO TCC 3

4 Why changing/modifying? TPLO = good concept of Barney and Theresa Slocum lifting caudal part tibiaplateau > stress on the caudal menisci creating sometimes a patella alta (at least in my hands) = less stability massive surgery, creating a lot of surgical soft tissue damage as well. You ve to dissect al lot of tissue. high complication rate (short and longterm) long rehab period 4

5 TTA staying away from the caudal part of the tibia plateau less patella alta forks vs different shapes of tuberositas tibiae still a lot of implants needed great concept faster rehab 5

6 TTO not cutting all the blood supply with the osteotomy no patella alta, but patella coming down in the trochlear groove = better stability no damage to the retropatellair cartilage (suspected, but not histopathology proved) intact cranial and caudal tibia cortices small adaptations possible in cases of concomitant MPL 6

7 TCC (Tibia Crest Cage 2005) no fork/plate offered to Synthes 2005 cage without fork and screws > resembles current TTA-rapid idea asked for spikes to get the TCC screwless preserving pers anserinus 7

8 The first thoughts... 8

9 Concept of TCC (Tibial Crest Cage) Combination of TTA and TTO the best of both worlds" from TTA: cages, screws, Ti, opener, common tangent from TTO: wedgies, saw guide, freer osteotomy length depends on cage size distal screw(s) to reduce torsional stress and fracture 9

10 Concept of TCC (Tibial Crest Cage) 800 cases with overall 2.5 % short time 2nd Sx > almost al cases without a distal screw. (Trial and error!) LMI in less than 1.8 % of the cases 2nd stifle in 4.3% of the cases (being the most of them American Bulldogs, Cane Corso and Dogue de Bordeaux) Spikes on the cage to take the forces... 10

11 Goals of therapy towards TTA-2 - Minimal invasive - Less morbidity - Rapid healing - Minimum of complications (< 1%) - Future without restrictions 11

12 Common Tangent 12

13 Opening wedge With patience 13

14 1th with hydroxyapatite with tricalciumphosphate 14

15 40 days after sx 15

16 Tricky distal point? 16

17 Event which healed without intervention 17

18 Slobodan s drawings 18

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20 Different shapes of osteotomies Different length of the cages With/without screw 20

21 Bone ingrowth 21

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25 Post OP 25

26 At home 1th day after surgery 26

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29 Dear Chris, I m sorry for the delay, but we re not in a crisis. Busy as usual. As a small animal orthopaedic surgeon, licensed to use TPLO, TTO and TTA procedures, I m performing about stifle (cruciate, menisci) surgeries each year. Still looking for better, easier methods, I m investigating other -less invasive- alternatives. I m starting using it as well in medial patellar luxations in f.i. English and French Bulldog s, Podenco s The outcomes seems to be promising! (Especially with sufficient trochlear depth, but after performing a trochlear sulcopastic as well. Not if a lateral crest transplant is necessary). Today I never perform TPLO anymore, for the following reason: 1. The point of turning the tibial plateau is lying in the proximal-distal tibia. Performing the TPLO procedure in this way, the most distal part of the tibia is more lifted as desired and giving pressure on the caudal parts of the menisci. Ideal the axis point to place the saw should be at this ultimate proximal-distal point of the tibia, but is technical not possible (no stable fixation in the periost!) 2. The edge of lifting the tibia in such a way, gives pressure on the popliteal muscle en giving postoperative pain, sometimes (lowgrade) long-time pain. I ve three wishes/requests to you: 1th Tibial plateau adaptation techniques (TTO, TTA and TPLO) In performing a TTO (Warrick/Veterinary Instrumentation) I m not happy with the plate configuration: Most of the time the lateral collateral had to be drilled and is laying underneath the plate. I ve been remodelling a Slocum Delta TPLO plate (left <-> right). In doing this, the lateral collateral can be missed all the time. The straight side of the Delta plate is lying at the level of the tibial crest osteotomy. My request is to construct a 3.5 plate with locking/combination holes, pre-bent and of a length of about 65 mm (today VI is manufacturing 55/57 mm and 77/79 mm plates). With a 65 mm it s possible to serve al dogs between 25 and 60 kg. Above and under these weights we need smaller/greater ones (the small can be less heavy, to make it less bulky). I prefer to use only 3.5 (locking) screws in all plates. As an attachment you find a standard procedure and one with a delta plate (Despite of the proximal DCP holes, who didn t fit as they are TPLO designed) 2 nd 29