The development of TTA (Tibial Tuberosity Advancement) and the subsequent refinement into the TTA RAPID® Technique marks significant progress in veterinary orthopedic surgery, particularly in addressing cranial cruciate ligament (CCL) injuries in dogs.
Early Challenges in CCL Treatment
Prior to the development of TTA, treating CCL ruptures in dogs posed significant challenges. Common surgical techniques like extracapsular repair were effective but had limitations. Extracapsular techniques may not fully address the underlying biomechanical changes in the knee joint associated with CCL ruptures. They rely on external support rather than restoring the normal function of the ligament, and may be less effective in larger, more active dogs due to the increased forces placed on the knee joint.
TPLO (Tibial Plateau Leveling Osteotomy) - Dr. Slocum (Oregon, USA)
TPLO was pioneered by Dr. Barclay Slocum, an American veterinary surgeon, in the late 1980s. Dr. Slocum recognized the limitations of traditional surgical methods for treating CCL injuries, such as extracapsular repair, particularly in large and active dogs.
The TPLO procedure is based on altering the biomechanics of the stifle joint to stabilize it in the absence of a functional CCL. Instead of repairing or replacing the ligament, TPLO aims to change the angle of the tibial plateau to eliminate cranial tibial thrust, the abnormal forward movement of the tibia relative to the femur seen in CCL-deficient joints. The procedure involves making a curved cut (osteotomy) in the proximal portion of the tibia, rotating the tibial plateau to a more perpendicular position relative to the femur, and stabilizing it with a plate and screws.
Here is a video showing how TPLO works →
Following the grant of the procedure's patent to Dr. Slocum in 1991, veterinary surgeons were required to seek permission or obtain a license to perform the technique. While the expiration of the patent in 2011 facilitated broader adoption of the TPLO procedure within the veterinary community, the initial 20-year restriction potentially spurred the development of alternative techniques for addressing CCL ruptures, such as the TTA1.
OrthoFoam MMP by Orthomed Technology GmbH (Langenfeld | Germany)
OrthoFoam MMP (Modified Maquet Procedure) by Orthomed is a variation of the original Maquet Procedure, which was was initially developed as a surgical treatment for human anterior cruciate ligament (ACL) injuries. Dr. Jean-Marie Maquet introduced the technique in the 1980s, which involved stabilizing the knee joint by advancing the tibial tuberosity and fixing it in place with screws or pins.
Recognizing the potential of the Maquet Procedure for treating CCL injuries in dogs, veterinary surgeons adapted it for veterinary use, making modifications to accommodate the anatomical differences between human and canine knees.
OrthoFoam MMP is one of such modification and was developed to address the limitations of other surgical techniques for treating CCL injuries in dogs, such as extracapsular repair or traditional TPLO. One of the distinguishing features of OrthoFoam MMP is the use of a foam implant to support the advancement of the tibial tuberosity. This implant provides structural support while promoting bone ingrowth and stabilization through its porous structure, which resembles a sponge or foam-like consistency. This porous architecture allows for the infiltration of bone cells and blood vessels, promoting osseointegration.
TTA Standard – Dr. Tepic & Prof. Montavon (Zurich | Switzerland)
The story of TTA begins with Dr. Slobodan Tepic and Professor Pierre Montavon at the School of Veterinary Medicine, University of Zurich in Switzerland. In the late 1990s, Slobodan Tepic and Pierre Montavon recognized the limitations of traditional techniques like TPLO, which involved extensive manipulation of the knee joint and lengthy recovery periods. They hypothesized that by altering the biomechanics of the stifle joint, particularly by changing the angle of the patellar ligament, it might be possible to stabilize the joint without relying on the CCL.
The TTA technique involves advancing the tibial tuberosity cranially, thereby reducing the forces that cause the femur, the thigh bone, to slip backward when the CCL is ruptured. Using a combination of implants, typically a bone plate and a cage, the tibia is secured in its new position. The procedure involved a cage with two ears for screw fixation. An additional plate was fixed by an auxiliary fork. This fork was hammered through the plate into the bone.
This concept marked a departure from traditional methods that focused on repairing or replacing the CCL itself and their pioneering work revolutionized the treatment of this common orthopedic condition in canines.
Dr. Tepic later founded KYON in 1999. In 2005, TTA was released for clinical use and has quickly gained acceptance among veterinarians due to its several advantages over traditional methods.
TTA RAPID® by Rita Leibinger Medical & Dr. Samoy (Tuttlingen | Germany)
Developed in collaboration with Dr. Yves Samoy of the University of Ghent, TTA RAPID® represents the latest advancement in the field of Tibial Tuberosity Advancement (TTA) techniques, building upon the foundation of the original TTA method. It amalgamates the most advantageous features from other Tibial Plateau leveling procedures, including Triple Tibial Osteotomy (TTO), Modified Maquet Technique (MMT), and MMP™. 2
Unlike conventional TTA, TTA RAPID® streamlines the surgical process, eliminating the need for plates, forks, pins, or wires. This approach significantly reduces the extent of dissection and soft tissue injury. The entirety of the surgery focuses on the proximal cranial tibia, an easily accessible area. Advancement of the tibial tuberosity is facilitated by the multi-screwed TTA RAPID® Cage, designed to offer immediate stability and facilitate bone ingrowth.
Manufactured using cutting-edge laser manufacturing techniques, TTA RAPID® Cages are crafted from the purest medical-grade titanium. This material is renowned for its biocompatibility, ensuring compatibility with the body's natural processes. The advanced laser manufacturing process allows for the creation of a complex internal architecture with open pores, resembling cancellous bone. Integrated screw hole lugs enhance stability, while the availability of cages in standard widths and lengths ensures versatility in surgical applications.
These properties collectively contribute to high fixation stability, expedited bone growth facilitated by the sponge-like construction, and a reduced risk of infections. TTA RAPID® thus represents a significant advancement in orthopedic surgery, offering improved outcomes and a minimally invasive approach to CCL repair in dogs.
TTA RAPID® offers exceptional flexibility, a notable improvement over previous techniques. Historically, surgeons had to adjust their approach based on a dog's weight and size. Standard TTA was effective for dogs under 30kg, while TPLO was preferred for those over 20kg. With TTA RAPID®, however, implants are versatile enough to accommodate dogs ranging from 5kg to 90kg. Additionally, RITA LEIBINGER offers GIANT cages specifically designed for heavier dogs, ensuring that TTA RAPID® can be successfully applied across a wide range of canine patients.
Here is a short video showing the TTA RAPID® Technique→