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TPLO Surgical Technique

This step-by-step guide details the management of a cruciate deficient stifle using the TPLO Technique. 

Overview

IMPORTANT REMINDER: We strongly advise attending one of the TPLO workshops to acquire the necessary skills for performing TPLO surgery independently. This article is designed to provide an overview of the technique and to merely offer guidance.

Pre-Operative Assessment and Planning

TPLO Surgery

Tibial Plateau Leveling Osteotomy (TPLO) is a widely recognized surgical technique and is a globally popular choice for addressing cruciate ligament tears in dogs and cats. This procedure involves precisely cutting, rotating, and securing the tibial plateau at a different angle, effectively redistributing forces within the knee joint to alleviate strain on the compromised ligaments.

Indications

TPLO surgery is applicable for treating Cranial Cruciate Ligament (CrCL) injuries across all sizes of dogs. The decision regarding surgical intervention involves multiple factors, including the availability of equipment, surgical expertise, economic considerations, as well as biological and biomechanical factors. Notably, TPLO may be especially relevant for the following patients:
  • Patients with high Tibial Plateau Angle (TPA): As a very steep TPA would require a too wide of an advancement when using the TTA procedure, it may be more difficult to neutralize tibiofemoral shear force.
  • Active Dogs: Working and agility dogs may benefit the most from this procedure in allowing them to return to pre-injury function. (Nanda, et al., 2019)
It is important to note that each case is unique, and the decision to proceed with TPLO surgery should be based on a thorough evaluation, considering factors such as the dog's age, size, overall health, activity level, severity of CrCL injury, and owner's preferences and expectations.

Radiographic Planning: Positioning

Improving the outcomes of TPLO surgeries relies heavily on consistent and repeatable measurements of the tibial plateau angle (TPA) and the ease of landmark identification during preoperative planning (Headrick et al., 2007).  By ensuring proper positioning of the limb, accurate radiographs with consistent appearance of anatomic landmarks can be obtained for TPLO preoperative planning, allowing for precise measurement of the TPA.
Orthogonal radiographs are taken with the stifle positioned at 90 degrees and the tarsus at 90 degrees for the lateral projection. The AP projection must have the stifle and tarsus included for the attending surgeon to assess limb alignment. The dog/cat is best sedated for radiographs to assure optimal positioning. Magnification must be accounted for with a measuring device.
Here's a general guideline for positioning:
  • Lateral Recumbency: Position the patient in lateral recumbency, ensuring the contralateral limb is extended forward and the knee (stifle) and ankle (tarsus) joints of the limb being X-rayed are flexed to a 90° angle. Place the contralateral (opposite) hindlimb just in front of the limb being radiographed.
  • Maintain Limb Position: Limb positioners or tape can be used to mantain the position, so that a handler will not be necessary.
  • Alignment: Ensure that the femur and tibia are parallel to the table and at the same height. This alignment may be achieved by using a foam wedge under the stifle, hip, or tarsus.
  • Center the X-ray beam precisely over the stifle joint with collimation to capture the entire length of the tibia, preventing any distortion that could affect the assessment of Tibial Plateau Angle (TPA) landmarks.
  • Calibration: To facilitate image calibration, include an object of known size, such as a calibration ball, positioned at the same height and in close proximity to the knee joint.
It is important to note that any internal or external rotation of the tibia can affect how the tibial plateau appears on the X-ray, which in turn impacts the measurement of the tibial plateau angle by about 1 degree. This rotation can occur due to incorrect positioning of the affected limb or failure to center the X-ray beam accurately over the stifle joint.

Determining the Tibial Plateau Angle (TPA)

A - Draw a line from the intercondylar eminence or tibial eminence proximally to the center of the tarsal joint or talocrural joint distally. This line is the weight bearing axis / mechanical tibial axis / functional axis.

B - Draw a second line across the slope of the medial tibial condyle. This is the tibial plateau line. The cranial and caudal points of this line should be equally distant from the intercondylar eminence.

C - Draw a line perpendicular to the weight bearing axis or functional axis, Line A.

The TPA is the angle between Line C, the line perpendicular to the weight bearing axis, and Line B, the tibal plateau slope.

Most digital systems have software that will calculate the tibial plateau angle.
Accurate TPA measurement is the most critical factor in preoperative planning for TPLO. Excessive rotation may lead to postoperative caudal cruciate ligament rupture, while inadequate rotation can result in an unstable stifle joint due to insufficient reduction of cranial tibial thrust (Reif et al., 2002; Shahar & Milgram, 2006; Slocum & Devine, 1984; Zachos et al., 2002). 

Determining Saw Blade Radius 

Considering the patient's weight and bone size, a suitable curved saw blade is chosen, ranging from 9mm to 33mm in radius (see our range of saw blades). The saw blade is positioned so that the radial pivot point is centered on the eminences of the tibia (centered about the most proximal point of the tibial functional axis).

Through mathematical calculations and the use of a TPLO rotation chart, the proximal aspect of the tibia is rotated to achieve a neutral slope (leveling osteotomy). The goal is to achieve a postoperative tibial plateau angle of 4-6 degrees, effectively neutralizing abnormal shear forces resulting from cruciate ligament deficiency and restoring biomechanical stability.

What you will need

Essential Instruments

X-Ray Calibration Ball

For radiographic calibration, it is recommended to position an object of known dimensions near the targeted joint or bone, ideally using an X-Ray Calibration Ball. While image calibration does not alter Tibial Plateau Angle (TPA) measurement, since the angle remains consistent regardless of image size, it enables the radiographs to be utilized for surgical planning in addition to diagnostic purposes.

Product Code

Description 

100-2000-25

X-Ray Calibration Ball, 25mm diameter

TPLO Saw Blade

The RITA LEIBINGER TPLO Saw Blades are coated with Titanium Nitride (TiN), one of the hardest and toughest materials in the medical field.

Product Code

Width (in mm)

102-2100-09

09

102-2100-12

12

102-2100-15

15

102-2100-18

18

102-2100-21

21

102-2100-24

24

102-2100-27

27

102-2100-30

30

102-2100-33

33

TPLO / CBLO Essential Instruments

Here are just some of the instruments. Please visit our shop or ask for our catalog to see all instrument size variants and details.

Product Code

Description

247-0103-00

Screwdriver Handle, silicone, compact, approved for 2.0/2.4 TPLO

128-2735-10

Screwdriver Shaft Star Drive T10

148-0081-25

Drill Bit, 2.5 mm diameter

128-2418-24

Compression Drill Guide for 2.4mm screws and 1.8mm drills

164-2735-60

Depth Gauge for 2.7/3.5 mm screws

164-1520-20

Depth Gauge for 2.0/2.4 mm screws

128-4355-00

TPLO Jig for 2.7 mm

128-4354-00

TPLO Jig for 2.0 / 2.4 mm

17-3105-08

Castroviejo, Caliper

164-2000-00

164-2400-00

164-2700-00

164-3500-00

Locking Drill Guide for 2.0 mm screws

Locking Drill Guide for 2.4 mm screws 

Locking Drill Guide for 2.7 mm screws

Locking Drill Guide for 3.5 mm screws

TPLO / CBLO Instrument Set and Screw Racks

The LeiLOX TPLO / CBLO Instrument Set contains the essential instruments that you would need to perform a TPLO or CBLO surgery. Screw Racks are also available to facilitate easy access to screws during surgery, and help maintain efficiency and organization in the operating room.

Product Code

Set Description

142-0100-01

TPLO / CBLO Instrument Set

150-0520-00

150-0524-00

150-0527-00

150-0535-00

150-4027-00

150-4035-00

Screw Rack for 2.0 mm screws

Screw Rack for 2.4 mm screws

Screw Rack for 2.7 mm screws

Screw Rack for 3.5 mm screws

Screw Rack for 2.7 mm screws, extended

Screw Rack for 3.5 mm screws, extended

LeiLOX TPLO Stainless Steel and Titanium Implants

Our LeiLOX TPLO Systems are suitable for small to giant breed dogs. 
Featuring multiaxial locking screws that can be locked in a 90° angle with a 12° deviation in any direction, it allows you to angle the screws away from vital structures. Two precisely designed compression holes enable a very tight compression of the osteotomy, which supports bone healing.

LeiLOX TPLO - Patient Weight Guide

Weight Range

LeiLOX TPLO Implant Size

less than 10 kg

2.0 mm 

8 to 18 kg

2.4 mm

15 to 30 kg

2.7 mm

25 to 40 kg

3.5 mm

more than 35 kg

3.5 mm broad

IMPORTANT NOTE: The table above only serves as a guide and the weight ranges are merely suggestions. It is up to the veterinarian to assess and determine the correct implant size, material type, and configuration to use for his patient, as well as its application and the technique to be employed.

TPLO Surgery Protocol

A step-by-step guide

The following describes the TPLO procedure with the aid of a TPLO Jig. The Jig was developed to maintain a fixed plane orientation of the tibial segments during rotation and can aid in the perpendicular alignment of the osteotomy.

1. Using the TPLO Jig

1.1
The joint surface is marked with a needle. About 3 to 4 mm below is the insertion point of the proximal pin for the TPLO Jig.
1.2
The proximal pin is inserted in a 90° angle to the joint surface.
1.3
The distal pin is placed. Take care to not tilt the jig. The pins must be parallel to each other, and absolutely perpendicular to to the jig.

2. Making the osteotomy and rotating the bone fragment

2.1
Using a radial oscillating saw, perform a partial osteotomy, making sure that the cut is parallel to the pins and perpendicular to the jig.
2.2
The cut is made approximately half-way (1/2) or a third (1/3) of the way through the bone. Then, measure and make the following markings for the rotation as determined during pre-op planning:
  • Position the first mark on the proximal bone fragment adjacent to the edge of the osteotomy, ensuring it is situated cranially to the midpoint of the osteotomy.
  • A second mark is then made on the distal bone fragment at the designated distance from the first mark, as determined by the TPLO Rotation Chart during preoperative planning. 
2.3
Complete the cut and rotate the proximal bone fragment to align the two markings. Once the correct rotation has been achieved, stabilize the osteotomy by placing a K-Wire across the tibial tuberosity.

3. Placing the TPLO Plate

Place the TPLO Plate (see our TPLO Implants), securing it in place with K-Wires. The screws are inserted in the following (recommended) sequence:
Insert standard cortical screws 1 and then 2 into the compression holes. Do not tighten.
Insert locking screws 3, 4, and then 5 into the plate head and tighten.
The jig may only be removed when at least 2 screws have already been fixed into the plate head.
Remove K-Wires and tighten screws 1 and 2 for a strong compression.
Insert locking screw 6 and tighten.
Check tightness of all screws. Close the wound using standard techniques.
(Note: It is crucial to properly close the periosteum and soft tissue layers to safeguard the plate site. Ensure not to overlook the closure of the incision made for the distal jig pin.)

4. Post-Surgery Care

4.1
Routine advice includes 7 days strict exercise restriction to toileting purposes only.
4.2
Controlled exercise on a lead or harnesss up to 6 weeks post-operatively.
4.3
Hydrotherapy may be recommended.

Questions?

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LeiLOX TPLO

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