pISSN 1598-298X / eISSN 2384-0749J Vet Clin 34(1) : 7-12 (2017)http://dx.doi.org/10.17555/jvc.2017.02.34.1.7
7
Triple Tibial Osteotomy (TTO) for Treatment of
Cranial Cruciate Ligament Rupture in Small Breed Dogs
Tae-Hwan Kim, Subin Hong, Heesup Moon, Jeong-In Shin,
Yun-Sul Jang, Hyeonjong Choi, In-Geun Kim and Jae-hoon Lee1
Institute of Animal Medicine, College of Veterinary Medicine, Gyeongsang National University, Jinju 52828, Korea
(Received: November 23, 2016 / Accepted: February 14, 2017)
Abstract : Twelve dogs weighing less than 10 kg underwent unilateral TTO to stabilize the stifle joint with cranialcruciate ligament rupture. Surgical findings, intra-operative and post-operative complications were recorded.Radiographic examinations were performed for 8 weeks following surgery. Postoperative outcome was evaluated usinga visual analogue lameness scoring system. Mean preoperative PTA (the angle created by the intersection of the tibialplateau extrapolation line and the patellar tendon) was 103.8 degrees. Mean tibial wedge angle was 16.6 degrees. Meanpostoperative PTA was 92.1 degrees. Intraoperatively, fracture through the caudal tibial cortex occurred in all dogs,through the distal tibial crest cortex in 2 dogs, through the lateral tibial cortex in 2 dogs and through the fibula in1 dog. Four-week postoperative radiographs demonstrated evidence of progressive bone union at osteotomy site andcomplete unions were identified at 8 week in 10 dogs. All dogs were healed in 11 weeks. Most of dogs revealedweak lameness in 4 weeks and normal ambulation in 8 weeks postoperatively except for only one dog returned in11 weeks. Despite frequent minor complication, it appears that the TTO is an alternative procedure for managementof cranial cruciate ligament rupture in small breed dogs.
Key words : cranial cruciate ligament, triple tibial osteotomy, complication, small breed, dog.
Introduction
Proximal tibial osteotomy techniques for treatment of
CCLR recently have gained popularity. There are two alter-
nate concepts about how dynamic stabilization should be
attained with proximal tibial osteotomy. The first concept
was suggested by Slocum and Devine (24). This concept was
that the joint reaction force in the stifle during weight bear-
ing was nearly parallel to functional the long axis of the tibia.
Because of the caudo-distally sloping tibial plateau, the shear
forces in the stifle joint accountable for CTT would have a
relationship with the angle formed between the tibial plateau
and functional long axis of the tibia. They suggested that
CTT would be removed from CCL ruptured joint by reduc-
ing the tibial plateau angle (TPA) so that it was perpendicu-
lar to the functional long axis of the tibia. The surgery
techniques to accomplish this purpose were the cranial tibial
wedge osteotomy (CTWO) (25) and the tibial plateau level-
ing osteotomy (TPLO) (26). The second concept is founded
on a biomechanical model suggested by Tepic et al. This
concept was developed from study in human being that the
joint force generated in weight bearing is parallel to patellar
tendon (17). It was therefore suggested that elimination CTT
during weight bearing would be achieved by performing a
tibial tuberosity advancement (TTA), so that the patellar ten-
don was perpendicular to the tibial plateau (10).
The triple tibial osteotomy (TTO) combines three osteoto-
mies made in the proximal tibia to create a partial tibial
wedge osteotomy caudal to a partial tibial crest osteotomy.
This procedure partially levels the tibial plateau while advan-
cing the tibial tuberosity and patella tendon in an attempt to
neutralize femorotibial shearing forces across the stifle (5).
Proposed advantages of TTO over other proximal tibial
osteotomies include the need for less radical angular changes
of the tibia than would be indicated in procedure’s that solely
level the tibial plateau or advance the tibia tuberosity, mini-
mal change to the femorotibial articulating surfaces, minimal
need for specialized implants or surgical equipment and no
loss of tibial length (5,13).
There is no information in the work on the surgical find-
ings, complications and outcome associated with the TTO in
small breed dogs. The purposes of this study are to docu-
ment the surgical findings and complications of TTO for the
treatment of cranial cruciate ligament disruption in small
breed dogs.
Materials and Methods
This study was conducted under approval of ethical com-
mittee of Gyeong-sang national university laboratory animal
center (Approval number: GNU-150402-D0016). The twelve
dogs weighed less than 10 kg, and had a normal ambulation
on physical examination. The medical data was noted for
breed, age, sex, weight, affected limb and meniscal tear.
1Corresponding author.E-mail : [email protected]
8 Tae-Hwan Kim et al.
Twelve dogs had unilateral TTO procedures. The mean body-
weight of dogs was 6.25 kg (range 4.6 kg to 8.6 kg). The
mean age of the dogs was 3.4 years (range 2 years to 7
years). There were seven entire females, five entire males.
The dogs had been fasted for about 12 hours before the
operation. They were premedicated with medetomidine (0.2
mg/kg, administered subcutaneously (SC), Domitor®; Pfizer,
NY, USA) together with acepromazine (0.05 mg/kg, SC,
Sedaject®; Samu Median, Seoul, Korea) and atropine (0.04
mg/kg, SC, Atropine®, Jeil Pham., Daegu, Korea). Cefazolin
(25 mg/kg, SC, Hankook Korus Pharm Co, Seoul, Korea)
was used as a prophylactic antibiotic. After placement of a
catheter in the cephalic vein, general anesthesia was induced
with etomidate (2 mg/kg, administered intravenously (IV),
Etomidate-®Lipuro; B. Braun Melsungen AG, Germany)
titrated to effect and administered to effect preceding tra-
cheal intubation. Anesthesia was maintained with isoflurane
(TerrellTM, Piramal Critical Care, USA) in 100 percent oxy-
gen via endotracheal intubation in a circle rebreathing sys-
tem. Normal saline was administered at 10 mL/kg/hour through
the cephalic vein during the whole procedure. The dog’s
heart rate, body temperature, percutaneous blood oxygen sat-
uration (SpO2) and end tidal CO2 (Et CO2) was monitored
during anesthesia. A circulating water blanket (Medi-Therm®,
Gaymar, NY, USA) with 38~39oC was used to maintain body
temperature.
CCLR modeling preceded the TTO procedure. On the pre-
operative radiograph, the TPA was defined according to the
conventional method (3,20). The patellar tendon, the patellar
tendon angle (PTA) and the correction angle (CA) were
defined as previously described (5,8,23). Pre-operative radio-
graphic calculations were as follows (Fig 1). Tibial plateau
(TP) was defined by estimating the position of the surface of
the medial tibial condyle, which was slightly convex in
shape. The location of the tibial plateau was determined by
identifying the cranial and caudal points and drawing a line
between them. The cranial most point of the medial tibial
condyle was visible as a small discrete step. The caudal point
was the point of insertion of the caudal cruciate ligament-the
apex of popliteal notch was a useful point of reference. A
line marking the cranial edge of the straight patellar liga-
ment (PL) was drawn. Position a straight-edge cranial to the
stifle and slide it caudally until it first touches points on the
patella and tibial crest. The distance between theses points
was the PL length. The tibial crest osteotomy (TCO) was
drawn with exactly the length of PL. The TCO was made
parallel to the axis of the tibial shaft and was usually parallel
to the cranial aspect of the tibial crest. A line was created by
drawing a line perpendicular to TP starting from the proxi-
mal end of PL. the correction angle (CA) was angle between
PL and the line. The angle of the tibial wedge osteotomy was
calculated according to the currently recommended formula;
wedge angle (WA) = 0.6 X CA + 7.3o (22). The central axis
of the wedge was located exactly halfway along the TCO. It
was drawn in the central axis of the wedge as a line extend-
ing caudally and perpendicularly from the TCO line at its
mid-point.
Surgery was performed as described by Bruce et al (5)
with the minor modifications that no meniscal release proce-
dures were performed (Fig 2). The dog was positioned in lat-
eral recumbency with the affected leg down and parallel to
the operating table, which was to explore the medial aspect
of the stifle joint. Carprofen (2.2 mg/kg, PO, twice daily,
Carprofen®, Zoetis, USA), cefadroxil (25 mg/kg, PO, bid,
Cefaxil®; Koruspharm, Jecheon, Korea) and famotidine (0.5
mg/kg, PO, bid, Famotidine®; NELSON, Korea) were given
for 7 days.
Radiographs were taken immediately following surgery, 2,
4 and 8 weeks postoperatively. On the postoperative radio-
graphs, the TPA and patellar tendon angle (PTA) were mea-
sured (3,20). The intended wedge angle was substracted from
the preoperative TPA to give the anticipated postoperative
TPA. The difference between the anticipated and the achieved
postoperative TPA was calculated. On radiographic examina-
tion following surgery, major complications were defined as
those that required further surgery or treatment. Other com-
plications were considered to be minor.
Visual lameness of the dogs was evaluated at stance, walk
and trot in preoperative TTO surgery, 4 weeks and 8 weeks.
Visual lameness was graded using a modified scoring sys-
tem (12): 0 = no detectable lameness (clinically sound); 2 =
barely detectable lameness; 4 = mild lameness; 6 = moderate
lameness; 8 = severe lameness (carries limb when trotting);
10 = non-weight bearing (could not be more lame).
The visual lameness score was measured in preoperative
TTO surgery, 4 weeks and 8 weeks. Statistical analysis was
Fig 1. Preoperative surgical plan for the TTO surgery. CA is the
correction angle formed between the patellar tendon and a line
originating at the cranial-most aspect of the patella and perpen-
dicular to the tibial plateau. PTA is the angle created by the
intersection of the tibial plateau extraspolation line and the
patella tendon. TPA is tibial plateau angle. PT is patellar tendon.
TWO is tibial wedge osteotomy. TCO is tibial crest osteotomy.
The dotted line bisects and is perpendeicular to the TCO.
Triple Tibial Osteotomy (TTO) for Treatment of Cranial Cruciate Ligament Rupture in Small Breed Dogs 9
performed using SPSS 21.0 (SPSS Inc, Chicago, Ill, USA).
A repeated measure ANOVA (RM-ANOVA) was used to
investigate the change from preoperative lameness. P-value
less than 0.05 was considered to be statistically significant.
The results expressed with a means ± standard deviation (S.D).
Results
The TTO surgery was performed on 4 left- stifle joints and
8 right-stifle joint. The duration of lameness before TTO sur-
gery was 1 ± 0.5 weeks. All dogs had no gross pathological
changes observed in the medial meniscus on arthrotomy.
On the preoperative and the immediate postoperative ra-
diographs, The TPA, PTA, and others were measured (Table
1). The mean preoperative stifle joint extension angle was
130.1 ± 3.7o. The mean preoperative PTA was 103.8 ± 4.8o and
the mean preoperative TPA was 25.7 ± 7.1o. The mean in-
tended WA was 16.6 ± 1.7o.
On postoperative radiographs, the postoperative TPA was
different from the anticipated TPA by 9.1 ± 6.6o. The mean
postoperative PTA was 92.1 ± 2.1o and the mean postopera-
tive TPA was 11.0 ± 5.4o.
In ten TTO procedures (83%), incomplete osteotomy of
the tibial crest had been achieved with an intact segment of
the cranial tibial cortex preserved at the distal end of tibia
crest following tuberosity advancement. The ten closed
wedge osteotomies were stabilized with 2.0 mm tibial pla-
teau leveling osteotomy (TPLO) plate (Veterinary Instrumen-
tation, Henry schein®, Shefield, UK). In two dogs, the closed
wedge osteotomies were stabilized with 2.4 mm TPLO plate
Fig 2. TTO procedure; Three linear (TCO line and WA line) osteotomy. A. The TCO was completed with an oscillating saw (the TCO
proximal end should terminate within the non-articular part of the proximal tibia, caudal to the patellar ligament insertion and cranial
to the cranial edge of the meniscus). B. A saw blade was used to cut a full thickness wedge from the proximal tibia and was orientated
slightly caudally to cut the caudal and caudo-lateral parts of the lateral tibia. C. The tibia wedge was closed. The plate was then fixed
to the bone using cortical screws.
Table 1. Radiographic measurements (degree)
Pre EA Pre PTA Pre TPA CA WA (mm) WA PO PTA PO TPAAnt PO
PTA
PO TPA
-Ant PO TPA
1 130.3 105.0 41.0 16.2 3.0 17.0 90.7 14.9 24.0 −9.1
2 126 98.3 30.8 12.6 6.0 14.9 89.5 17.7 15.9 1.8
3 132.7 104.0 23.5 16.8 2.0 17.4 96.5 6.0 6.1 −0.1
4 134.9 103.0 27.0 15.2 4.0 16.4 92.6 11.6 10.6 1.0
5 137.4 105.5 21.0 16.2 4.0 17.0 93.3 7.9 4.0 3.9
6 132.0 98.5 13.4 12.6 2.6 14.9 91.6 6.0 −1.5 7.5
7 125.0 108.7 28.0 18.6 5.0 18.5 89.7 16.8 9.5 7.3
8 127.0 99.0 27.0 12.1 3.0 14.6 90.4 19.5 12.4 7.1
9 129.0 114.5 31.0 21.6 2.6 20.3 95.4 12.8 10.7 2.1
10 128.0 99.6 18.0 12.4 8.0 14.7 91.0 2.0 3.3 −1.3
11 131.0 107.0 26.0 17.0 2.0 17.5 92.0 9.0 8.5 0.5
12 128.3 103.0 22.0 15.1 3.0 16.4 92.0 8.0 5.6 2.4
Mean ± SD 130.1 ± 3.7 103.8 ± 4.8 25.7 ± 7.1 15.5 ± 2.9 3.8 ± 1.8 16.6 ± 1.7 92.1 ± 2.1 11.0 ± 5.4 9.1 ± 6.6 1.9 ± 4.6
Pre; Preoperative, PO; postoperative, EA; Angle of stifle joint, Ant; Anticipated, TPA; Tibial Plateau Angle, CA; Correction Angle, WA;Wedge Angle PTA; Patellar Tendon Angle
10 Tae-Hwan Kim et al.
(Veterinary Instrumentation, Henry schein®, Shefield, UK).
Supplementary implants were applied in the two procedures
with fracturing of the tibial crest osteotomy at the distal end
of tibia crest. These additional implants were a cerclage wire.
Four different complications were detected intra-operatively
(Fig 3). Meaningfully, in all dogs, the caudal cortex of the
tibia fractured during the TTO procedure (Fig 3A). In two
dogs, fracture through the distal end of the tibial crest osteot-
omy occurred during the procedure, requiring a cerclage wire
(Fig 3 B). Proximal fibular fracture was occurred in only one
dog (Fig 3 C). In two dogs, tibial lateral cortex defect was
occurred (Fig 3 D).
We define a major complication as an undesirable develop-
ment that required further diagnostic investigation or surgi-
cal treatment. Follow-up examinations were performed for 8
weeks after TTO procedure. Post-operative major complica-
tion did not occurred in 8 weeks. Minor complications
including bruising and swelling occurred in five dogs (41%).
The dogs were healed in 2 weeks uneventfully.
Four weeks postoperative radiographs demonstrated evi-
dence of progressive bone union at the osteotomy site and
fractured sites in all dogs. Eight weeks postoperative radio-
graphs demonstrated radiographic union in 10 dogs (83%). In
consequence, all dogs healed in 11 weeks (100%).
The visual lameness score varied from 6 to 9 before TTO
surgery. Ten dogs (83%) revealed weak lameness (grade 2 of
10) in 4 weeks and normal ambulation in 8 weeks postoper-
atively except for only one dog returned in 11 weeks.
Discussion
TTO surgery is used to change the biomechanics of the sti-
fle to overcome CTT in dogs with CCLR. The TTO is prox-
imal tibial osteotomy procedure incorporating features of the
TPLO procedure and TTA procedures. The purpose of the
TTO procedure is to reduce the PTA to 90o. The mean post-
operative PTA achieved of 92.1o, compares favorably with
94.1o achieved by Bruce et al (5), with the 93.5o achieved by
Renwick et al (22) and also with the 95.5o achieved using the
TTA technique (10). Although the postoperative mean PTA is
almost 90o, the TTO technique failed to achieve the aim of
the PTA 90o. Thus, dynamic stability of the stifle cannot be
assured. The mean wedge angle removed during the surgical
procedures was 16.6o. This angle was slightly larger than the
mean wedge angle previously reported by Bruce et al (5) of
11.5o, by Renwick et al (22) of 15.9o and by Moles and oth-
ers (16) of 13.6o. The most likely examination for the differ-
ences is resulted from variations in stifle joint flexion angles
on preoperative wedge angle formula (16). The radiographic
protocol for TTO demands the stifle to be positioned medio-
laterally at flexion angle of 135o in order to determine the
amount of tibial tuberosity advancement involved to ensure
PTA 90o (5). This positioning is difficult to be achieved accu-
rately. The difficulty provides a potential cause of error in
determining the exact wedge osteotomy angles demanded
preoperatively and postoperative assessment of the tibial pla-
teau to patella tendon angles achieved (11). This source of
inaccuracy is similar for the TTA procedure and is compara-
ble to the previously reported inter-observer variability in
measuring tibial plateau slopes of up to 6o (6).
Bruce et al concluded that measurement of the TPA is not
needed when performing the TTO (18). However, Renwick
and others suggested that measurement of the TPA is neces-
sary to avoid over-correction of the TPA and also to identify
cases that may not be ideal candidates for the technique (9).
In this study, the preoperative mean TPA was 25.7 ± 7.1o and
the postoperative mean TPA was 11.0 ± 5.4o. A subgroup of
dogs was identified with below average TPAs and relative
large CAs. In this subgroup (dog no.5, 6 and 10), advancing
the tibial tuberosity to the recommended position using the
TTO procedure may have resulted in a less than 5o TPA. In
vitro studies of the TPLO where the TPA is reduced have
shown loading of the caudal cruciate ligament when the TPA
is 6o or less (21,29). And an in vitro study of TTA where the
TPA was unchanged showed caudal tibial translation when
the PTA was less than 90o (1). Because there are no in vitro
studies to assess the effect of combined TTA and TPA reduc-
tion, it is logical idea that when using the TTO, if the TPA is
reduced to less than 5o, the effect of increased loading of cau-
dal cruciate ligament is likely to be at least equal to if not
greater than the loading created at the same angle in perform-
ing a TPLO (22). Thus in these three dogs (dog no. 5, 6, 10),
we reduced the TPA to 5o, as recommended for the TPLO
method (1).
The combined osteometer and saw guide is too big to
Fig 3. Intra-operative complications. A. In all dogs, the caudal
cortex of the tibia fractured during the TTO procedure. B. In two
dogs (No. 2 and 3 dogs), fracture through the distal end of the
tibial crest osteotomy occurred during the procedure, requiring a
cerclage wire. C. Proximal fibular fracture was occurred in only
one dog (No. 6 dog). D. In two dogs (No. 1 and 11 dogs), tibial
lateral cortex defect was occurred.
Triple Tibial Osteotomy (TTO) for Treatment of Cranial Cruciate Ligament Rupture in Small Breed Dogs 11
apply on small breed dogs. So the wedge osteotomy angle was
converted into length. The difference between the antici-
pated and the achieved postoperative TPA was 1.9 ± 4.6o,
which was the similar result achieved by Renwick et al (9).
Fracture through the caudal tibial cortex occurred in all
dogs. The tibial wedge osteotomy should be gradually closed
by applying upward pressure on the foot. The resultant action
served to gradually close the gap between wedge osteoto-
mies but at the same time keeping the caudal tibial cortex
intact (18). It has been hypothesized that the caudal tibial
fracture occurred because the tibial wedge osteotomy was
rapidly closed. Different types of tibial tuberosity fractures or
avulsions have previously been reported with TPLO, TTA
and TTO (4,5,22). Only 17% of stifles (dog no.1 and 3) in
our study, fracture of tibial crest from the distal flexion point
appeared. The two dogs had larger CA than the average angle.
Age related brittleness of the bone and increased advance-
ment of the tibial tuberosity associated with large closing-
wedge osteotomies may account for this tibia fracture (15). It
is recommended that the use of additional implants in the tib-
ial crest segment during TTO only if intraoperative fracture
occurs at the tibial crest flexion hole (28). Moles et al recom-
mend stabilization using K-wire and a tension band wire
(22). In our study, cerclage wire was placed to stabilize the
fractured bone, maintained for 8 weeks postoperatively. Fib-
ular fracture has been recorded as a complication with other
tibial plateau levelling technique (7,19,27). This complica-
tion was not regarded clinically significant in our study and it
was left without treatment. In addition, it would be consider
delayed bone healing of osteotomy sites as a potential com-
plication. It also needed careful applications of angle of the
osteotomies, because of the individual variation of shape and
small size of the tibia in small breed dogs.
The visual lameness score ranged from grade 6 to 9 before
TTO procedure. Ten dogs (83%) had a grade 2 of 10 in 4
weeks. And normal ambulation in 8 weeks postoperatively
except for only one dog which was returned in 11 weeks. In
other studies, lameness score was 2.4 of 5 at 6 weeks postop-
eratively and still was same score (2.1 of 5) at 7-10months
after ECR (14). And dogs had a 2 of 5 lameness score at 8
weeks after TPLO (2). Our result showed faster recovery
than other procedures on visual lameness score.
There are limitations in this study. Significant point is the
lack of any in vitro or kinetic studies on the TTO. For exam-
ple, it is unidentified how a less than 0o TPA affects stifle
joint shear force when the PTA is 90o. Or does a change in
PTA of only 2o induce a stable stifle if the pre-operative PTA
is 92o. Further retrospective or prospective studies are required
to document long-term complications and clinical outcomes
for TTO.
TTO surgery, like TPLO and TTA, is used to change the
biomechanics of the stifle to overcome cranial tibial thrust in
dogs suffering from cranial cruciate ligament disruption. Our
outcomes for TTO procedure in small breed dogs are similar
to those previously reported for large breed dogs. Despite
frequent minor complication, it appears that the TTO is an
alternative procedure for management of CCLR in small
breed dogs.
References
1. Apelt D, Kowaleski MP, Boudrieau RJ. Effect of tibial
tuberosity advancement on cranial tibial subluxation in canine
cranial cruciate deficient stifle joints: an in vitro experi-
mental study. Vet Surg 2007; 36: 170-177.
2. Ballagas AJ, Montgomery RD, Henderson RA, Gillette R.
Pre and postoperative force plate analysis of dogs with
experimentally transected cranial cruciate ligaments treated
using tibial plateau leveling osteotomy. Vet Surg 2004; 33:
187-190.
3. Baroni E, Matthias RR, Marcellin-Little DJ, Vezzoni A,
Stebbins ME. Comparison of radiographic assessments of
the tibial plateau slope in dogs. Am J Vet Res 2003; 64:
586-589.
4. Bergh MS, Rajala SP, Johnson KA. Risk factors for tibial
tuberosity fracture after tibial plateau leveling osteotomy in
dogs. Vet Surg 2008; 37: 374-382.
5. Bruce W, Rose A, Tuke S, Robins G. Evaluation of the
triple tibial osteotomy. A new technique for the management
of the canine cruciate-deficient stifle. Vet Comp Orthop
Traumatol 2007; 20: 159-168.
6. Caylor KB, Zumpano CA, Evans LM, Moore RW. Intra-
and interobserver measurement variability of tibial plateau
slope from lateral radiographs in dogs. J Am Anim Hosp
Assoc 2001; 37: 263-268.
7. Corr S, Brown C. A comparison of outcomes following
tibial plateau levelling osteotomy and cranial tibial wedge
osteotomy procedures. Vet Comp Orthop Traumatol 2007;
20: 312-319.
8. Dennler R, Kipfer NM, Tepic S, Hassig M, Montavon PM.
Inclination of the patellar ligament in relation to flexion
angle in stifle joints of dogs without degenerative joint
disease. Am J Vet Res 2006; 67: 1849-1854.
9. Guenego L, Zahra A, Madelenat A, Gautier R, Marcellin-
Little D, Hulse D. Cranial cruciate ligament rupture in large
and giant dogs-A retrospective evaluation of a modified
lateral extracapsular stabilization. Vet Comp Orthop Traumatol
2007; 20: 43-50.
10. Hoffmann D, Miller J, Ober C, Lanz O, Martin R, Shires
P. Tibial tuberosity advancement in 65 canine stifles. Vet
Comp Orthop Traumatol 2006; 19: 219-227.
11. Hong YJ, Jang SU, Jung IS. Cranial tibial wedge osteot-
omy for treatment of canine cranial cruciate ligament injury
in dogs with over 15 kg. Proceedings of the Korean Society
of Veterinary Clinics. Seoul: Korean Society of Veterinary
Clinics, 2007: 106.
12. Impellizeri JA, Tetrick MA, Muir P. Effect of weight reduc-
tion on clinical signs of lameness in dogs with hip osteo-
arthritis. J Am Vet Med Assoc 2000; 216: 1089-1091.
13. Kim SE, Pozzi A, Kowaleski MP, Lewis DD. Tibial osteot-
omies for cranial cruciate ligament insufficiency in dogs.
Vet Surg 2008; 37: 111-125.
14. Kunkel KA, Basinger RR, Suber JT, Gerard PD. Evaluation
of a transcondylar toggle system for stabilization of the
cranial cruciate deficient stifle in small dogs and cats. Vet
Surg 2009; 38: 975-982.
15. Lee SJ, Seong Y, Jeong W, Jang K. Two Case of Bilateral
Cranial cruciate ligament rupture corrected tibial wedge
osteotomy. Proceedings of the Korean Society of Veterinary
Clinics. Daejeon: Korean Society of Veterinary Clinics, 2008:
177.
16. Moles A, Hill T, Glyde M. Triple tibial osteotomy for
treatment of the canine cranial cruciate ligament-deficient
12 Tae-Hwan Kim et al.
stifle joint. Vet Comp Orthop Traumatol 2009; 22: 473-478.
17. Nisell R, Németh G, Ohlsén H. Joint forces in extension of
the knee: analysis of a mechanical model. Acta Ortho-
paedica 1986; 57: 41-46.
18. Pozzi A, Litsky A, Field J, Apelt D, Meadows C, Johnson
K. Pressure distributions on the medial tibial plateau after
medial meniscal surgery and tibial plateau levelling osteotomy
in dogs. Vet Comp Orthop Traumatol 2008; 21: 8-14.
19. Priddy NH, Tomlinson JL, Dodam JR, Hornbostel JE.
Complications with and owner assessment of the outcome
of tibial plateau leveling osteotomy for treatment of cranial
cruciate ligament rupture in dogs: 193 cases (1997-2001). J
Am Vet Med Assoc 2003; 222: 1726-1732.
20. Reif U, Dejardin LM, Probst CW, DeCamp CE, Flo GL,
Johnson AL. Influence of limb positioning and measure-
ment method on the magnitude of the tibial plateau angle.
Vet Surg 2004; 33: 368-375.
21. Reif U, Hulse DA, Hauptman JG. Effect of tibial plateau
leveling on stability of the canine cranial cruciate-deficient
stifle joint: an in vitro study. Vet Surg 2002; 31: 147-154.
22. Renwick A, McKee W, Emmerson T, House A. Preliminary
experiences of the triple tibial osteotomy procedure: tibial
morphology and complications. J Small Anim Prac 2009;
50: 212-221.
23. Schwandt CS, Bohorquez-Vanelli A, Tepic S, Hassig M,
Dennler R, Vezzoni A, Montavon PM. Angle between the
patellar ligament and tibial plateau in dogs with partial
rupture of the cranial cruciate ligament. Am J Vet Res
2006; 67: 1855-1860.
24. Slocum B, Devine T. Cranial tibial thrust: a primary force in
the canine stifle. J Am Vet Med Assoc 1983; 183: 456-459.
25. Slocum B, Devine T. Cranial tibial wedge osteotomy: a
technique for eliminating cranial tibial thrust in cranial
cruciate ligament repair. J Am Vet Med Assoc 1984; 184:
564-569.
26. Slocum B, Slocum TD. Tibial plateau leveling osteotomy
for repair of cranial cruciate ligament rupture in the canine.
Vet Clin Am Small Anim Pra 1993; 23: 777-795.
27. Stauffer KD, Tuttle TA, Elkins A, Wehrenberg AP, Character
BJ. Complications associated with 696 tibial plateau leveling
osteotomies (2001-2003). J Am Vet Med Assoc 2006; 42: 44-
50.
28. Tashman S, Anderst W. In-vivo measurement of dynamic
joint motion using high speed biplane radiography and CT:
application to canine ACL deficiency. J Biomech Eng 2003;
125: 238-245.
29. Warzee CC, Dejardin LM, Arnoczky SP, Perry RL. Effect
of tibial plateau leveling on cranial and caudal tibial thrusts
in canine cranial cruciate-deficient stifles: An in vitro ex-
perimental study. Vet Surg 2001; 30: 278-286.