Complications of tibial plateau levelling osteotomy in dogs

The tibial plateau levelling osteotomy (TPLO) is one of the most common surgical procedures used to treat cranial cruciate ligament disease in dogs. Complications occurring during or after TPLO can range in severity from swelling and bruising to fracture and osteomyelitis. Ten to 34% of TPLO surgical procedures are reported to experience a complication and approximately two to four percent require revision surgery to address a complication. Although the risk factors for many complications have not been fully assessed, the best available evidence suggests that complications of TPLO can be reduced with increased surgeon experience, careful surgical planning, and accurate execution of the surgical procedure. Identification of known or suspected risk factors and intra-operative technical errors allow subsequent action to be taken that is aimed at decreasing postoperative morbidity. There is a need for prospective studies with consistent data reporting in order to fully reveal the incidence risk factors for complications associated with TPLO.     

Effect of medial meniscal release on tibial translation after tibial plateau leveling osteotomy

OBJECTIVE: To evaluate the biomechanical effects of medial meniscal release (MMR) and medial, caudal pole hemimeniscectomy (MCH) on joint stability in the cranial cruciate ligament (CCL)-deficient canine stifle before and after tibial plateau leveling osteotomy (TPLO). STUDY DESIGN: Experimental study. ANIMALS: Thirty-one dogs. METHODS: In experiment 1, 16 pairs of normal hindlimbs randomly assigned to an intact or transected CCL group were studied to determine the magnitude of tibial translation after MMR and MCH under 20% body weight load using radiographic imaging of radio-opaque markers. In experiment 2, 15 pairs of CCL-deficient hindlimbs were randomly assigned to a TPLO or sham TPLO group. The remainder of the experiment was performed as described for experiment 1. The effect of CCL transection, MMR, MCH and TPLO were analyzed using 2-way repeated measures ANOVA; P<.05 was considered significant. RESULTS: We found a greater effect of MMR on tibial translation in transected CCL stifles than in intact stifles (P=.0016). We found no further effect of MCH after MMR (P>.05). We found a greater effect of MMR in sham TPLO than TPLO stifles (P=.0013) but no further effect of MCH after MMR (P>.05). CONCLUSIONS: By resisting tibial translation the medial meniscus might be at greater risk of tearing in CCL-deficient stifles. TPLO may spare the medial meniscus by neutralizing the tibial thrust and eliminating the wedge effect of the medial meniscus. CLINICAL RELEVANCE: MMR may not be indicated in the CCL-deficient stifle stabilized by TPLO.     

Kinematic gait analysis of the hind limb after tibial plateau levelling osteotomy and cranial tibial wedge osteotomy in ten dogs

This study identifies and compares the kinematic gait changes occurring in tibial plateau levelling osteotomy (TPLO) and cranial tibial wedge osteotomy (CTWO) limbs after transection of the cranial cruciate ligament (CrCL). Ten, healthy, adult beagle dogs were assigned to TPLO (five dogs) and CTWO (five dogs) groups. Hind limb kinematics were assessed, while dogs were trotted at speeds ranging from 2.0 to 2.3 m/s. The animals were evaluated preoperatively (prior to TPLO and CTWO surgery) and at both 8 and 12 weeks after surgery. Two-dimensional evaluation was synchronized to obtain the three-dimensional coordinates using the APAS motion analysis software. Gait patterns were assessed by measuring stifle, tibiotarsal joint angles and stifle joints angular velocity. Stifle and tibiotarsal joint functions were not affected by TPLO surgery, but stifle and tibiotarsal joint angles were changed, following CTWO surgery, compared with their preoperative values. The angular velocity patterns of CTWO were characterized by increased stifle joint extension velocity from the middle to end swing phase and decrease in the peak velocities (flexion) during swing phase. None of these changes was observed in the stance phase after the CTWO surgery. These kinematic results showed that dogs that underwent a CTWO procedure were more likely to have significantly hyperextended gait patterns of the swing phase postoperatively than the dogs that had a TPLO procedure for repair of a ruptured CrCL.     

A retrospective comparison of two analgesic strategies after uncomplicated tibial plateau levelling osteotomy in dogs

Objective

To compare the efficacy and side effects of postoperative methadone administered according to pain score (PS) or every 4 hours (Q4), after unilateral uncomplicated tibial plateau levelling osteotomy (TPLO) in dogs in which a peripheral nerve block (PNB) was administered.

Change in tibial plateau angle after tibial plateau leveling osteotomy in dogs

OBJECTIVE: To determine the change in tibial plateau angle (TPA) during healing after tibial plateau leveling osteotomy (TPLO) performed for cranial cruciate ligament insufficiency in dogs and to examine factors that may be associated with the change. STUDY DESIGN: Retrospective study. STUDY POPULATION: One hundred and forty-nine canine stifles after TPLO procedure. METHODS: Records of dogs that had TPLO were reviewed. Patient age, weight, sex, breed, pre- and postoperative TPA, recheck TPA, time to recheck, type of implant used, and radiographic evidence of healing were analyzed. RESULTS: Mean time to recheck evaluation was 46 days (range, 28-65 days). Mean difference between immediate postoperative and recheck TPA measurements was 1.5 degrees (range, -3 to 9 degrees). Recheck TPA was a significantly greater (numerically higher) than immediate postoperative TPA (P<.0001). There was no significant effect of patient weight, type of plate used, or healing status of the osteotomy at the time of recheck. No correlation between pre- or postoperative TPA angles and change in TPA angle was detected. CONCLUSIONS: TPA changes during osteotomy healing after TPLO, but factors influencing this change were not identified. CLINICAL RELEVANCE: TPA may increase during healing after TPLO despite apparently adequate osteotomy fixation. The clinical relevance of this increase is unknown but is likely minimal.     

Opioid requirements after locoregional anaesthesia in dogs undergoing tibial plateau levelling osteotomy: a pilot study

ObjectiveTo determine the intraoperative and early postoperative opioid requirement after ultrasound-guided sciatic and/or femoral nerve block or epidural anaesthesia in dogs undergoing tibial plateau levelling osteotomy (TPLO).Study designProspective, masked, pilot, randomized, clinical trial.AnimalsA total of 40 client-owned dogs undergoing TPLO.MethodsEach dog was randomly assigned to group SF (combined sciatic and femoral nerve block), group S (sciatic nerve block), group F (femoral nerve block) or group E (epidural anaesthesia). A total of 0.3 mL kg^–1 of ropivacaine 0.5% was administered to each nerve or in the epidural space. Intraoperatively, fentanyl (2 μg kg^–1) was administered intravenously when heart rate, mean arterial pressure or respiratory rate increased by >30% compared with baseline values. Postoperatively, a visual analogue scale (VAS) and a modified German version of the French pain scale (4AVet) were used to assess pain every 30 minutes for 150 minutes and again once the morning after surgery. Methadone (0.1 mg kg^–1) was administered intravenously if the VAS was ≥ 4 cm [maximal value 10 cm; median (interquartile range)] or the composite pain score was ≥5 [maximal value 15; median (interquartile range)]. Significance was defined as p ≤ 0.05.ResultsGroups SF and E required less total intraoperative and early postoperative opioid doses compared with groups S and F (p = 0.031). No dogs in group SF had a block failure or required postoperative methadone. A reduced methadone requirement was found in group SF compared with all the other groups up to 150 minutes after recovery (p = 0.041).Conclusions and clinical relevanceCombined sciatic and femoral nerve block and epidural anaesthesia lead to less cumulative consumption of perioperative opioids than single nerve blockade. Sciatic or femoral nerve block alone might be insufficient to control nociception and early postoperative pain in dogs undergoing TPLO.     

A comparison of outcomes following tibial plateau levelling osteotomy and cranial tibial wedge osteotomy procedures.

The objective of this study was to determine whether clinical outcomes were superior and complication rates were lower in dogs that had had a cranial cruciate ligament rupture treated by tibial plateau levelling osteotomy (TPLO), compared to those dogs that had been treated using the original cranial tibial wedge osteotomy (CTWO) procedure. Thirty-seven client-owned dogs with cranial cruciate ligament rupture were included in the study: 19 dogs underwent a TPLO procedure, and 18 dogs underwent a CTWO procedure. The study was retrospective, with the data being obtained from medical records and a review of radiographs. The long-term outcome was assessed by means of an owner questionnaire using a visual analogue scale. For the majority of factors that were reviewed, there was not a significant difference in outcome between the dogs that had a TPLO or those that had undergone a CTWO. All of the dogs showed a rapid return to weight bearing after surgery, and at the six week re-examination, the majority of the dogs did not have any pain on stifle palpation. They displayed a good stifle range of motion and significantly lower lameness scores than those prior to surgery. The complication rates did not differ between the procedures, however, within this small sample of dogs, complications following a CTWO were more likely to require revision surgery.     

Risk factors for tibial tuberosity fracture after tibial plateau leveling osteotomy in dogs

Objective— To evaluate factors that predispose to tibial tuberosity (TT) fracture after tibial plateau leveling osteotomy (TPLO) in dogs.
Study Design— Retrospective study.
Animals— Dogs (n=182) with cranial cruciate ligament (CCL) rupture undergoing 213 TPLO surgeries.
Methods— Medical records and radiographs of 2 groups of dogs that had TPLO surgery (2000–2001, 2004–2005) were evaluated to determine the effect of operative technique and surgeon experience on TT fracture.
Results— TT fracture was diagnosed in 8 dogs (9 TPLO, 4.2% of surgical procedures). Four fractures occurred after unilateral TPLO in 167 dogs (2.4%), 4 fractures occurred after simultaneous bilateral TPLO in 5 dogs (40%), and 1 fracture occurred after staged bilateral TPLO in 36 dogs (2.8%). Simultaneous bilateral TPLO resulted in a 12.4 times higher odds of TT fracture versus unilateral TPLO ( P =.046). The mean absolute thickness of the TT after TPLO was less in dogs sustaining TT fractures (7.2 ± 2.2 mm) than those that did not (10.8 ± 2.7 mm, P <.0001). The odds of fracture decreased by 37% when the absolute TT width postosteotomy increased by 1 mm ( P <.0001). An increase in tibial plateau angle at follow-up versus immediately postoperative was associated with TT fracture ( P =.025). Surgeon experience was not associated with TT fracture.
Conclusion— A combination of surgical decision-making and surgical technique play a role in the occurrence of TT fracture after TPLO. Simultaneous bilateral TPLO was associated with a high percentage of TT fracture.
Clinical Relevance— Careful planning of osteotomy positioning is advised while performing TPLO surgery.     

Femoral and sciatic nerve blockade of the pelvic limb with and without obturator nerve block for tibial plateau levelling osteotomy surgery in dogs

ObjectiveTo determine the effect of blocking the obturator nerve in addition to performing femoral nerve and sciatic nerve blocks on intraoperative nociception in dogs undergoing unilateral tibial plateau levelling osteotomy (TPLO) surgery.Study designProspective, blinded, randomized, placebo-controlled, clinical comparison.AnimalsA total of 88 client-owned dogs undergoing unilateral TPLO surgery (100 procedures).MethodsDogs were randomly assigned to either group FSO (femoral, sciatic and obturator nerve blocks) [n = 50; ropivacaine 0.75% (0.75 mg kg^–1)] or group FSP (femoral, sciatic and placebo) [n = 50; ropivacaine 0.75% (0.75 mg kg^–1) femoral and sciatic nerve blocks plus saline solution 0.9% (0.1 mL kg^–1) as a placebo injection around the obturator nerve]. The anaesthetic protocol was standardized. Data collection included intraoperative cardiopulmonary variables and opioid consumption. Rescue analgesia consisted of an intravenous bolus of fentanyl (2 μg kg^–1) and was administered when a change in cardiopulmonary variables (20% increase in mean arterial pressure or heart rate) was attributed to a sympathetic stimulus. Data were analysed using generalized linear mixed models, cross tables and multivariable binary logistic regression. Results were expressed as adjusted odds ratios with 95% confidence intervals and Wald p values (α = 0.05).ResultsThere were no clinically relevant differences between groups in intraoperative cardiopulmonary variables and need for rescue analgesia. The requirement for rescue analgesia was significantly higher in dogs with a body weight >34 kg.Conclusions and clinical relevanceAnaesthesia of the obturator nerve in addition to the femoral and sciatic nerves was not associated with clinically significant differences in cardiopulmonary variables or a reduced need for rescue analgesia. Therefore, the clinical benefit of an additional obturator nerve block for intraoperative antinociception in dogs undergoing unilateral TPLO surgery using the described anaesthetic regimen is low.     

Effects of perineural dexmedetomidine combined with ropivacaine on postoperative methadone requirements in dogs after tibial plateau levelling osteotomy: a two-centre study

ObjectiveTo evaluate the efficacy of a perineural injection of dexmedetomidine combined with ropivacaine for reducing postoperative methadone requirements in dogs after tibial plateau levelling osteotomy (TPLO).Study designA prospective, clinical, randomized and blinded trial.AnimalsA total of 58 client-owned dogs.MethodsUltrasound-guided midfemoral sciatic and inguinal femoral nerve blocks with ropivacaine (1 mg kg^–1 per nerve block) combined with either dexmedetomidine (0.5 μg kg^–1 per nerve block; group DEX) or the same volume of saline (group CON) were performed in dogs undergoing TPLO. Pain was assessed 30 minutes, 2 hours and then every 4 hours for 24 hours after surgery with a validated pain scale (4AVet). Meloxicam (0.15 mg kg^–1) was administered intravenously (IV) at recovery. Rescue methadone (0.2 mg kg^–1 IV) was administered if a score ≥ 6 (maximal score 18) was recorded and the number of postoperative doses was analysed by Fisher exact tests. The study was performed in parallel at a Veterinary Teaching Hospital (VTH) and a private Veterinary Referral Centre (VRC).ResultsDogs received a total of 22 and 31 postoperative doses of methadone in groups DEX (14 doses at VRC, eight doses at VTH) and CON (28 doses at VRC, three doses at VTH), respectively. Overall, there was no difference in the postoperative rescue analgesia requirements between groups (p = 0.244). At the VRC, dogs received less methadone (p = 0.026) in group DEX compared with group CON, whereas at the VTH, there was no difference between groups (p = 0.216).Conclusions and clinical relevancePerineural dexmedetomidine combined with ropivacaine did not reduce postoperative methadone requirements in dogs after TPLO, but results may differ from one centre to another. This discrepancy might be linked to variations in clinical practices and questions the validity of results obtained from single-centre randomized controlled trials but applied to different clinical settings.     

Peripheral nerve block versus systemic analgesia in dogs undergoing tibial plateau levelling osteotomy: Analgesic efficacy and pharmacoeconomics comparison

ObjectiveTo compare the perioperative effects and pharmacoeconomics of peripheral nerve blocks (PNBs) versus fentanyl target-controlled infusion (fTCI) in dogs undergoing tibial plateau levelling osteotomy (TPLO).Study designRandomized clinical study.AnimalsA total of 39 dogs undergoing unilateral TPLO.MethodsAfter acepromazine and methadone, anaesthesia was induced with propofol and maintained with isoflurane. Dogs were allocated to group fTCI [target plasma concentration (TPC) 1 ng mL^–1] or group PNB (nerve stimulator-guided femoral-sciatic block using 0.2 and 0.1 mL kg^–1 of levobupivacaine 0.5%, respectively). If nociceptive response occurred, isoflurane was increased by 0.1%, and TPC was increased by 0.5 ng mL^–1 in group fTCI; a fentanyl bolus (1 μg kg^–1) was administered in group PNB. During the first 24 postoperative hours, methadone (0.2 mg kg^–1) was administered intramuscularly according to the Short Form Glasgow Composite Pain Scale, or if pain was equal to 5/24 or 4/20 for two consecutive assessments, or if the dog was non-weight bearing. The area under the curve (AUC) of pain scores, cumulative postoperative methadone requirement, food intake and pharmacoeconomic implications were calculated.ResultsIncidence of bradycardia (p = 0.025), nociceptive response to surgery (p = 0.041) and AUC of pain scores (p < 0.0001) were greater in group fTCI. Postoperatively, 16/19 (84.2%) and eight/20 (40%) dogs in groups fTCI and PNB, respectively, were given at least one dose of methadone (p = 0.0079). Food intake was greater in group PNB (p = 0.049). Although total cost was not different (p = 0.083), PNB was more cost-effective in dogs weighing >15 kg.Conclusions and clinical relevanceCompared with group fTCI, incidence of bradycardia, nociceptive response to surgery, postoperative pain scores, cumulative methadone requirement were lower, and food intake was greater in group PNB, with an economic advantage in dogs weighing >15 kg.     

Effect of meniscal release on rate of subsequent meniscal tears and owner-assessed outcome in dogs with cruciate disease treated with tibial plateau leveling osteotomy

OBJECTIVE: To determine and compare rates of meniscal tears after tibial plateau leveling osteotomy (TPLO) among 3 groups of dogs based on treatment method: arthrotomy with meniscal release (openR), arthrotomy without meniscal release (openNR), arthroscopy without meniscal release (scopeNR), and compare long term owner-assessed outcomes for the same groups. STUDY DESIGN: Retrospective cohort study. SAMPLE POPULATION: Stifles (n=254) of dogs that had TPLO. METHODS: The three groups were compared for significant (P<.05) differences in rate of subsequent tears using a chi(2) test. Odds ratios for likelihood of subsequent meniscal tears were determined. Data for signalment, outcome, time to peak function, and time to subsequent tear were compared for significant differences using ANOVA, t-test, or rank sum test. RESULTS: Subsequent meniscal tears were diagnosed in 16 cases (6.3%). Of dogs with subsequent meniscal tears, 9 had openNR, 4 had openR, and 3 had scopeNR; the proportion of subsequent meniscal tears was significantly different (P=.035) among groups. Odds ratio indicated that subsequent meniscal tear was 3.8 times more likely to occur for openNR than openR or scopeNR. No significant differences among groups were noted for measures of outcome. CONCLUSIONS: Meniscal release did not reduce the rate of subsequent meniscal tears when compared with cases treated arthroscopically or when compared with all cases combined, but may be advantageous when meniscal pathology cannot be comprehensively assessed in the cranial cruciate deficient stifle. Meniscal release had no effects on owner-assessed outcome as determined in this study. CLINICAL RELEVANCE: The low rates of subsequent meniscal tears in conjunction with the relatively high and equivocal levels of owner-assessed outcome and time to peak function for all 3 treatment groups suggest that any of these surgical management strategies can be considered acceptable. We suggest that a meniscal release be performed when complete and thorough exploration of the joint and meniscus cannot be, or are not, performed.