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:
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 patient 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:
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 radius has to be selected so that it creates a radial cut starting behind the tibial tuberosity and ending in the caudal tibia.
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:
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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