Orthopedic Surgery / Tibial Tuberosity Advancement (TTA)

Tibial Tuberosity Advancement (TTA) surgery is the latest advancement in canine orthopedic surgery to repair a ruptured cruciate ligament. Dr. Kelly is now offering this procedure as another option for repairing ruptured cruciate ligaments. He has been performing the TPLO in the Upper Valley since 2001.

Cruciate ligament injury is the leading cause of pelvic limb lameness in dogs. Many times the tearing of the ligament is due to an athletic injury, though the majority of patients suffer from degeneration of the ligament over time. The primary cause of degeneration is unknown, but most likely the result of several factors including genetics and conformation. One of these major factors causing the cruciate to rupture is abnormal force (shear force) due in a large part because of slope at the back of the tibial plateau (conformation/genetics). Because the slope is greater in some dogs then others, more strain is placed on the supporting ligaments, and over time they become torn or rupture completely.

The TPLO involves cutting (osteotomy) the upper portion of the tibia and rotating the tibial plateau until the slope is level to the ground surface thus eliminating the need for the ligament. Like the TPLO, the TTA also involves creating a controlled fracture to alter the geometry of the stifle joint to restore stability. It also uses surgical implants to stabilize the osteotomy until bone healing is complete. The TTA was developed at the University of Zurich by Dr. Slobodan Tepic and Professor Pierre Montavon in 2004. Through biomechanical analysis they determined that the total joint force in the stifle joint is approximately parallel to the patellar ligament. If the angle between the patellar ligament and the tibial plateau is 90 degrees, there is no shear force and the cranial and caudal cruciate ligaments are not stressed. How the two surgeries differ is that the TTA advances the tibial tuberosity cranially (forward) a pre-determined distance so that the patellar ligament and distal joint force is at 90 degrees to the tibial plateau. Advantages include less soft tissue dissection thus quicker healing, the bone is cut along a non-weight bearing portion of the tibia thus less possibility of stress fractures and potentially a more rapid return to normal function of the leg, and reportedly less implant problems though we do not see this complication with our TPLO patients at SAC. The recovery of the patient is pretty much the same as the TPLO. Extreme exercise restrictions for the first 6 weeks with a gradual increase in controlled activities. All patients regardless of having a TPLO or TTA are expected to return to 100% normal function of the stifle joint. Both procedures stabilize the stifle, restore normal function back to the stifle and minimize the production of arthritis.

1. The bone just below the knee or stifle joint is the tibia and the bone above is the femur. The top of the tibia is the tibial plateau. The patellar tendon attaches the kneecap (patella) to the tibial tuberosity.	2. During weight bearing, the femur slides down the tibial plateau. The ACL stops this downward slope, therefore, is under constant tension during weight bearing. This biomechanical problem results in ACL rupture and is directly related to the angle between the tibial plateau slope and the patellar tendon. A more perpendicular angle results in a more stable joint.
3. The TTA involves an osteotomy in the non-weight bearing portion of the tibia, just behind the tibial tuberosity. The tibial tuberosity is advanced to achieve a perpendicular relationship between the tibial plateau slope and patellar tendon. This relationship results in a stable joint.	4. The advanced tibial tuberosity is secured using titanium implants. A bone graft is packed in the open area of the osteotomy. Healing takes about 8 weeks. Implants do not require removal.

Currently 300 surgeons worldwide have utilized this procedure in approximately 25,000 cases. Dr. Kelly was trained by Dr. Slobodan, the person that developed the procedure, and feels that it will be a nice alternative for some of his patients. To be a candidate for a TTA, Dr Kelly looks at a number of factors, conformation of each patient’s knee, presence and degree of arthritis, and personality of the patient to name a few. Prior to surgery he will consult with the pet’s owner and discuss the different options available for that particular patient and develop a treatment plan.

Why SAC?
Dr. Kelly has completed intensive training in all aspects of stifle joint (knee) surgery. He has been performing the TPLO procedure since 2001, being one of the first surgeons in Vermont to offer this surgery to patients. He works closely with a highly trained staff to offer twenty-four hour care, industry leading anesthetic and surgical monitoring instrumentation, post-operative monitoring and aggressive pain management.

We know your pet is an important part of your family, and we are committed to excellence in not only the pre-surgical and surgical case management as well as constant communication after you return home and the weeks ahead to ensure the best possible outcome. Our doctors are always available, twenty-four hours a day, we never share our on-call time with other hospitals, guaranteeing that your pet will see a staff member that they have grown accustomed to.

When your pet is admitted into our hospital, he/she will be assigned a nurse which will stay with your pet throughout the stay. All of our patients are monitored throughout their stay, and all surgical cases are monitored with state of the art equipment. Our patients recover in the arms of a staff nurse, not in a cold, metal kennel. Our patients never return to their hospital ward until they are fully recovered. Since we can’t speak dog and cat language per say, we go on our own experience of human hospital stays to perfect the patients experience, ease stress, and eliminate the fright of the unknown. You can count on the staff at SAC to always put your pets comfort first.

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