Abstract
The objective of this retrospective study was to determine the complications of the first 30 tibial tuberosity advancement rapid (TTA-rapid) and 30 modified circular tibial tuberosity advancement (mcTTA) procedures performed by our team, and to compare the results with the findings reported in the literature. Our research was based on 30 procedures in each group. All dogs were client-owned. Data were collected only for the study of cases that had a minimum follow-up period of 3 months. Intraoperative (IO) and postoperative (PO) complications were assessed, with the latter divided into two subgroups: major and minor. Results obtained for the TTA-rapid group: IO complications 23.3% (7/30), major PO complications 13.3% (4/30), minor PO complications 16.7% (5/30). Results of the mcTTA group: IO complications 0% (0/30), major PO complications 3.3% (1/30), minor PO complications 20% (6/30). Comparing the complication rates, we found that there was a significant difference between the two groups in the occurrence of IO complications (P = 0.01054); however, there was no significant difference in the incidence of major (P = 0.3533) and minor (P > 0.9999) PO complications between groups. Our results are consistent with the findings reported in the literature and suggest that both techniques are efficient and carry a relatively low complication rate.
Introduction
Cranial cruciate ligament rupture in the stifle joint is the most common cause of hindlimb lameness in dogs (Lampmann et al., 2003; Nutt et al., 2015). The treatment of this condition is one of the most discussed topics of small animal orthopaedics today. In recent decades, various surgical techniques based on the concept of altering the biomechanics of the stifle joint have been developed. One of these techniques is tibial tuberosity advancement (TTA), which was described in 2002 (Montavon et al., 2002). From the original TTA, numerous modified surgical techniques based on the same biomechanical principle but less demanding in terms of instrumentation have been developed. The key of the concept is to realign the patellar tendon angle (PTA) to 90°, as viewed in the 135-degree-flexed position of the stifle joint (Montavon et al., 2002; Apelt et al., 2007).
Our study focuses on TTA-rapid and circular tibial tuberosity advancement (cTTA), both belonging to this group of advanced techniques. TTA-rapid was first described in 2015 (Samoy et al., 2015). The authors of the study have developed specialised implants and a toolkit for TTA-rapid. The original paper contains a description of the technique and short-term outcomes of the first 50 procedures (Samoy et al., 2015). The tibial tuberosity and the tibial crest remain attached to the tibial shaft through a thin cortical hinge at the distal part of the tibial crest after the TTA-rapid procedure, unlike in the original TTA procedure where they are osteotomised completely (Fig. 1).
TTA-rapid procedure performed on canine tibia
Citation: Acta Veterinaria Hungarica 70, 4; 10.1556/004.2022.00033
The cTTA technique was described in 2010, when the first 89 cases were reported (Petazzoni, 2010). The tibial tuberosity and the tibial crest are osteotomised completely from the tibia during the procedure and then rotated in a cranial and proximal direction (Fig. 2).
cTTA procedure performed on canine tibia
Citation: Acta Veterinaria Hungarica 70, 4; 10.1556/004.2022.00033
A substantial number of publications are available on the complications of the original TTA technique. One of the largest studies has examined the complications of 1,613 TTA surgeries (Costa et al., 2017). Complications have been documented in 13.4% of the cases. Complications considered major are as follows: surgical site infection, late meniscal injury, implant failure, postoperative patellar luxation and various types of tibial fractures in the postoperative period. Less data are available on the complications of TTA-rapid (Samoy et al., 2015; Butterworth and Kydd, 2017; Arican et al., 2017; Dyall and Schmökel, 2017; Roydev and Goranov, 2021). To the best of our knowledge, only the original article (Petazzoni, 2010) and another publication reviewing our own first 16 cases (Ipolyi et al., 2015) report the complications of cTTA.
Further surgical techniques similar to TTA-rapid have also been developed from TTA, where the tibial tuberosity and tibial crest remain in contact with the tibial shaft. One of these is the modified Maquet technique (MMT), described in 2011 (Etchepareborde et al., 2011). Another is the tibial tuberosity advancement technique with cranial implant fixation (TTA-CF) described in 2018 (Zhalniarovich et al., 2018). Recently, a systematic review has been published about the modified versions of the TTA method, which analyses the outcomes and complication rates of each method (Aragosa et al., 2022).
We began to use TTA-rapid and a modified cTTA (mcTTA) technique, where the locking plate system used in the original technique was modified by our team, at the Department and Clinic of Small Animal Surgery and Ophthalmology, University of Veterinary Medicine Budapest, and the present paper reports the experience with, and the complications of, the first 30 cases of each technique, together with a comparison of the complication rates.
Materials and methods
Data collection
Data were collected from the database of the Small Animal Clinic of the University of Veterinary Medicine Budapest (Doki for Vets). Results of the first 30 TTA-rapid and the first 30 cTTA surgeries were used. Breed, body weight, sex and the limb operated on were recorded. Inclusion criteria included a follow-up period of at least 3 months.
Radiographic imaging
X-ray images in two projections (mediolateral and caudocranial) were taken pre- and postoperatively. On the preoperative images preoperative planning was performed and other unrelated conditions were ruled out. For preoperative planning, a mediolateral X-ray image of the stifle taken in a 135-degree-flexed position of the joint was used. On the postoperative images the position of the implants and the degree of correction were assessed.
Anaesthetic protocol
The anaesthetic protocol was the same for both types of surgeries. During preparation an intravenous catheter was inserted. The following drugs were applied intravenously for premedication: 5 μg bwkg−1 fentanyl (Fentanyl-Richter 50 μg mL−1 injection), 0.5 mg bwkg−1 ketamine (Calypsol 500 mg 10 mL−1 injection). All patients received intravenous perioperative cefazolin (Cefazolin Sandoz 1 g powder for injection) in a dose of 22 mg bwkg−1 30 min before induction. Five mg bwkg−1 propofol (Propofol 1% or 2% MCT/LCT Fresenius Emulsion) was used for induction and 0.3 mg bwkg−1 morphine (Morphium-hydrochloricum Teva 10 mg mL−1 injection) was applied intramuscularly preoperatively for prolonged analgesia. After induction, an endotracheal tube was inserted. General anaesthesia was maintained with a mixture of sevoflurane (Sevorane) and oxygen. A constant rate infusion of ketamine and fentanyl (12 mL Fentanyl-Richter 50 μg mL−1 injection and 1.2 mL Calypsol 500 mg 10 mL−1 injection in 500 mL saline solution) was administered at a 3 mL bwkg−1 h−1 rate using an Infusomat® (B. Braun Medical Ltd., Gyöngyös, Hungary). During the surgeries saline or Ringer's solution was administered at a rate of 10 mL bwkg−1 h−1.
TTA-rapid group
Preoperative planning and the surgery were performed according to the original description of the procedure (Samoy et al., 2015), using the TTA-rapid toolkit (Rita Leibinger GmbH & Co. KG, Mühlheim an der Donau, Germany). The implants used were manufactured by Rita Leibinger Medical and Scinova Ltd. (Eger, Hungary). All surgeries were performed by the same primary orthopaedic surgeon (TI).
During the preoperative planning, the optimal degree of correction was calculated using both the common tangent and tibial plateau slope methods (Cadmus et al., 2014). The adequate implant size was selected considering both results.
The procedures were executed adhering to the original paper (Samoy et al., 2015) except for a few modifications: ‘cleaning-up’ was either performed through a microarthrotomy incision or by arthroscopy, depending on the case. Where the menisci were normal, meniscal release was not performed. At the end of the surgery, hydroxyapatite paste was not used in the osteotomy gap. Figure 3 shows an immediate postoperative X-ray study of a patient from the TTA-rapid group.
Postoperative mediolateral X-ray image of a TTA-rapid surgery
Citation: Acta Veterinaria Hungarica 70, 4; 10.1556/004.2022.00033
Modified-cTTA (mcTTA) group
For preoperative planning, the same method was used as in the TTA-rapid group. Unlike TTA-rapid, cTTA includes a dome-shaped osteotomy of the tibial tuberosity and tibial crest using a TPLO (Tibial Plateau Levelling Osteotomy) saw blade. Although the original paper does not go into details about the method of calculating the optimal position of the saw blade during the procedure (Petazzoni, 2010), an X-ray image is included in the article in which it is marked that the thinnest part of the tibial shaft after osteotomy should be at least 60% of the original width. Preoperative planning was performed with regard to this rule. In order to select the saw blade of the most fitting size, a circle was drawn to represent the blade during the preoperative planning.
All procedures were performed by the same orthopaedic surgeon (TI) in accordance with the original description (Petazzoni, 2010). ‘Cleaning-up’ was performed through a microarthrotomy incision in all cases. Meniscal release was not performed where the menisci were judged normal. Although the use of the Fixin system had been described in the original paper, a significant modification was done by our team applying another type of locking plate (SOP; String of Pearls, Medimetal Ltd., Eger, Hungary) with 2.7-mm cortical screws (Scinova Ltd.). Figure 4 shows an immediate postoperative image of an mcTTA performed by our team.
Postoperative mediolateral X-ray image of a modified cTTA procedure
Citation: Acta Veterinaria Hungarica 70, 4; 10.1556/004.2022.00033
Complications
Intraoperative and postoperative complications were recorded, with the latter divided in two subgroups: major and minor. Complications considered major were those that required revision surgery. Any complication outside of these categories was considered minor (Costa et al., 2017). Surgical follow-up was at least 3 months.
Postoperative treatment
The postoperative treatment protocol was the same for both patient groups. The surgical wound was covered with sterile gauze and Omnifix (Hartmann) tape, then a modified Robert-Jones bandage was applied. Both were removed 2 days postoperatively. Sutures were removed on the 10th day after surgery. During the two-week postoperative period, the use of an Elizabethan collar was recommended. In the first 7–10 days, meloxicam (0.1 mg bwkg−1) was administered orally by the owner and a chondroprotective was prescribed for a course of at least one month (Synoquin EFA tablets). Postoperative antibiotics were not prescribed. Strict exercise restriction was recommended for 8 weeks. Veterinary examination was performed at the time of suture removal and 3 months postoperatively unless a complaint dictated a visit.
Statistical analysis
Fisher exact test was used to compare complication rates. Other factors such as age, body weight, sex and breed were not considered here, as the two groups had similar mean values of these variables.
Results
TTA-rapid group
TTA-rapid was performed on 30 stifle joints in 29 dogs. One dog had TTA-rapid of both stifle joints within 3 months. There were 14 male, 6 female, 3 neutered male and 6 spayed female dogs. Fifteen right and 15 left stifle joints were operated on. The mean age of the patients was 5.2 ± 2.83 years and the mean body weight was 34.4 ± 10.98 kg. The breeds were 5 mixed breeds, 3 Staffordshire Terriers, 2 Hungarian Vizslas, 2 German Shepherds, 2 Labrador Retrievers, 2 Bernese Mountain Dogs, 2 Boxers, 2 Dogue de Bordeaux, 2 Giant Schnauzers, 1 Border Collie, 1 Tibetan Terrier, 1 Sarplaninac, 1 American Bully, 1 American Bulldog, 1 Doberman and 1 Bullmastiff.
The extent of injury to the cranial crucial ligament (i.e. partial or complete rupture) was not specified in this group. However, the condition of the menisci was always noted. The menisci were intact in 19 cases (63.3%), while the caudal horn of the medial meniscus was injured in 11 cases (36.7%). Lateral meniscal injury was not encountered.
In TTA-rapid surgeries, two cage sizes were used: nine 6-mm and twenty-one 9-mm cages as dictated by the preoperative planning.
Intraoperative complications occurred in 7 cases (23.3%), where the tibial crest fractured off the shaft of the tibia at the distal cortical hinge (tibial crest fracture or detachment). In one case (3.3%) the fracture was then stabilised with an additional Kirschner wire (K-wire).
Major postoperative complications occurred in 4 cases (13.4%). In 2 patients (6.7%) a postoperative tibial shaft fracture was diagnosed. One of these cases was the patient with the intraoperative complication (tibial crest fracture) treated with an additional K-wire. The fracture presented two weeks postoperatively (Fig. 5). The two cases of tibial shaft fractures were similar, where transverse fractures occurred at the level of the Maquet hole. Both fractures were reoperated and treated with plate osteosynthesis. In the case presented in Fig. 5, cerclage wire and a K-wire were also used for additional fixation. Both cases healed subsequently without any further complication. In 2 other cases (6.7%) late meniscal injury occurred. In a revision surgery, the injured portions of the meniscus were removed in both cases.
A. Immediate postoperative mediolateral X-ray image of a TTA-rapid procedure. B. Transverse tibial fracture two weeks postoperatively. C. Immediate postoperative X-ray image following revision surgery. The fracture was fixed with a string of pearls (SOP) plate, cerclage wire and a Kirschner wire
Citation: Acta Veterinaria Hungarica 70, 4; 10.1556/004.2022.00033
Minor postoperative complications were noted in 5 cases (16.7%). In 2 cases (6.7%) implant failure was found, both due to broken cortical screws. In these cases revision surgery was not necessary. These two cases coincide with the two patients with late meniscal injury and one of them also had an intraoperative tibial crest fracture. In one out of the five cases (3.3%), severe lameness of the operated leg developed one month postoperatively, which resolved after a one-week course of an NSAID (meloxicam, 0.1 mg bwkg−1). In another case (3.3%), swelling of the surgical site presented in the second postoperative week. Two-plane radiographs of the operated limb did not reveal any abnormality. No antibiotics were administered, and the swelling resolved two days later. In the fifth case, the patient started to lick the surgical site three months after surgery and a wound developed. This was treated topically and with an Elizabethan collar, resulting in complete remission and no relapse within the follow-up period. The complication rates are shown in Table 1.
Complication rates in the TTA-rapid and mcTTA groups
| TTA-Rapid (N = 30) | MCTTA (N = 30) | |
| Intraoperative complications | 7 (23.3%) | 0 (0%) |
| Fracture of the tibial crest | 7 (23.3%) | 0 (0%) |
| Major postoperative complications | 4 (13.4%) | 1 (3.3%) |
| Fracture of the tibia | 2 (6.7%) | 0 (0%) |
| Late meniscal injury | 2 (6.7%) | 1 (3.3%) |
| Minor postoperative complications | 5 (16.7%) | 6 (20.0%) |
mcTTA group
A total of 30 mcTTA procedures were performed in 27 dogs. Three dogs had surgeries on both hindlimbs six months apart. There were 8 male, 9 female, 3 neutered male and 7 spayed female dogs. Fourteen right and 16 left stifle joints were operated on. The mean age of the patients was 4.77 ± 2.38 years. The mean body weight was 32.17 ± 11.84 kg. The following breeds were treated: 5 mixed breed dogs, 4 Staffordshire Terriers, 3 Cane Corso dogs, 3 Beagles, 2 Middle East Shepherds, 1 French Bulldog, 1 American Bulldog, 1 English Bulldog, 1 Bernese Mountain Dog, 1 Boxer, 1 Doberman, 1 Labrador Retriever, 1 Hungarian Vizsla and 1 Dogo Argentino.
In 23 cases (76.7%) the cranial cruciate ligament was completely ruptured, while in 7 cases (23.3%) the rupture was partial. The menisci were intact in 13 cases (43.4%). The caudal horn of the medial meniscus was injured in 15 cases (50%), and the lateral meniscus was injured in one case (3.3%). In one dog (3.3%) the condition of the menisci was not recorded.
Intraoperative complications did not occur in this group.
A major postoperative complication was encountered in one case (3.3%). Three months postoperatively a late meniscal injury developed. The injured portion of the meniscus was removed by microarthrotomy during a revision surgery.
Minor postoperative complications were observed in 6 cases (20%). In one case (3.3%) a seroma developed at the surgical site within the first 14 days. A microbiological sample was collected and submitted, but no microorganisms could be cultured and the seroma resolved without treatment. In one case (3.3%) the surgical wound was licked by the patient. After topical treatment with povidone iodine (Betadine solution, Egis, Budapest, Hungary) and application of an Elizabethan collar the problem resolved. The same patient also developed a mild lameness of the operated limb after suture removal. The patient responded well to physiotherapy and its condition quickly improved. At the 3-month postoperative examination radiography was performed routinely and an almost completely healed tibial fracture was observed with callus formation and without any dislocation (Fig. 6). In a total of 3 cases (10%) mild lameness developed in the postoperative period. In one case (3.3%) this occurred in the first, while in two cases (6.7%) in the second month. These patients were sent to physiotherapy and all improved. In one case (3.3%) a discharge was observed at the surgical site within the second postoperative month. A microbiological sample was collected and Staphylococcus pseudintermedius was cultured. As the strain was susceptible to amoxicillin and clavulanic acid, the patient was treated for one week and the discharge discontinued. The complication rates are summarised in Table 1.
Three months postoperative X-ray images of a mcTTA group patient with a healed tibial shaft fracture
Citation: Acta Veterinaria Hungarica 70, 4; 10.1556/004.2022.00033
Comparison of the complication rates of TTA-rapid and mcTTA
Based on the results of the Fisher exact test, the intraoperative complication rates were significantly higher in the TTA-rapid than in the mcTTA group (P = 0.0105). However, no significant difference was found between the two groups in terms of the incidence of major postoperative complications (P = 0.3533). Also, there was no significant difference between the groups in the number of minor postoperative complications either (P > 0.9999) (Table 2).
Comparison of the TTA-rapid and modified cTTA procedures in terms of complication rates
| Intraoperative complications | Major postoperative complications | Minor postoperative complications | |
| TTA-RAPID (N = 30) | 7/30 | 4/30 | 5/30 |
| MCTTA (N =30) | 0/30 | 1/30 | 6/30 |
| P Value | P = 0.0105 | P = 0.3533 | P > 0.9999 |
Discussion
The TTA-rapid and cTTA techniques are further developed versions of the original TTA procedure (Montavon et al., 2002). The purpose of designing these modified techniques was to reduce the complexity and costs of tibial tuberosity advancement (Petazzoni, 2010; Samoy et al., 2015). The original TTA method has been studied extensively. However, the TTA-rapid and cTTA techniques have barely been mentioned in the literature.
Studies about the original TTA technique have reported a total complication rate of 19–59% (Hoffmann et al., 2006; Lafaver et al., 2007; Stein and Schmoekel, 2008; Wolf et al., 2012). Major complication rates have been between 11.4 and 14% (Lafaver et al., 2007; Stein and Schmoekel, 2008; Wolf et al., 2012; Costa et al., 2017). The largest study examining major complications was based on a caseload of 1,613 dogs, where TTA surgeries resulted in a 13.4% major complication rate (Costa et al., 2017).
Our results showed a mean age of 5.2 ± 2.83 years in the TTA-rapid group, which is similar to what has been described in other studies. The mean body weight was 34.4 ± 10.98 kg, which is slightly higher than in other studies (Samoy et al., 2015; Butterworth and Kydd, 2017).
The original paper about TTA-rapid has described a 34% total complication rate based on the results of 50 cases (Samoy et al., 2015). A smaller study of 10 cases has reported a 40% total complication rate (Roydev and Goranov, 2021). Another study has reported a 42.6% total complication rate based on 17 cases (Arican et al., 2017). In one study, TTA-rapid has exclusively been performed in dogs under 15 kg of body weight. Forty-eight surgeries have resulted in a total complication rate of 25% (Dyall and Schmökel, 2017). The major postoperative complication rate reported by these studies was between 4 and 17.6%, whereas the minor postoperative complication rate between 2.1 and 30% (Samoy et al., 2015; Butterworth and Kydd, 2017; Arican et al., 2017; Dyall and Schmökel, 2017; Roydev and Goranov, 2021). In our study, the overall complication rate was 53.3% in the TTA-rapid group. Although our complication rates were somewhat higher than those presented in other studies, the major postoperative complication rate (13.3%) and the minor postoperative complication rate (16.7%) were both within the range reported in the literature. Nevertheless, our intraoperative complication rate (23.3%) was slightly higher than that reported in the literature. The results of the TTA-rapid group as compared with the literature findings are presented in Table 3.
A comparison of TTA-rapid complication rates between the literature and our study
| Samoy et al. (2015) | Butterworth and Kydd (2017) | Arican et al. (2017) | Dyall and Schmökel (2017) | Roydev and Goranov (2021) | Our study | |
| Total number of cases | 50 | 152 | 17 | 48 | 10 | 30 |
| Intraoperative complications | 6 (12%) | 3 (2%) | No exact information | 4 (8.3%) | 1 (10%) | 7 (23.3%) |
| Major postoperative complications | 2 (4%) | 11 (7%) | 4 (17.6%) | 7 (14.6%) | 1 (10%) | 4 (13.3%) |
| Minor postoperative complications | 15 (30%) | No exact information | No exact information | 1 (2.1%) | 2 (20%) | 5 (16.7%) |
Results are highlighted with bold font.
Studies with the MMT have reported complication rates similar to those obtained in the TTA-rapid studies. In one study of a total of 174 cases, tibial crest detachment (fracture) occurred in 6 cases (3.4%). In the same study, tibial fracture as a complication was reported to be 14.2% (21/148). However, this number may have been higher as re-evaluation X-ray images were only available in 148 out of the 174 cases (Lefebvre et al., 2018). These numbers are similar to our findings. Another MMT study has reported higher complication rates. After 84 procedures, the intraoperative complication rate was 31%, with the major postoperative complication rate being 40.5% and the minor postoperative complication rate 10.7% (Ramirez et al., 2015).
The mean age in the mcTTA group was 4.77 ± 2.38 years. This is almost the same as in the TTA-rapid group and also matches with the findings of the single existing study about cTTA where the mean age was 5.5 years (Petazzoni, 2010). The mean body weight was 32.17 ± 2.38 kg and this also coincides with the mean body weight of the TTA-rapid group and also with that reported in the original paper by Petazzoni where it was 32 kg (Petazzoni, 2010).
The original description reported 9 complications in a total of 89 cases (10%). However, these were all major postoperative complications requiring surgical revision. In 2 cases tibial shaft fracture, in 1 case tibial crest and tibial shaft fractures occurred. In the other 6 cases, fractures occurred around the implants: in 5 cases around the screws, and in one case around a K-wire (Petazzoni, 2010). In the case of our mcTTA, the major postoperative complication rate was 3.3%, i.e. one out of 30 cases, which was a late meniscal injury but not a fracture. In our series of surgeries only one tibial fracture occurred and was considered a minor complication as it was only revealed retrospectively at 3 months after the surgery and did not require any treatment. In our cases there were no fractures around the implants. In the original study the Fixin locking plate system (Intrauma S.p.A., Rivoli TO, Italy) was used (Petazzoni, 2010), whereas in our study string of pearls (SOP) plates with cortical screws (Medimetal Ltd., Scinova Ltd.) were applied. Implant failure may present differently with different implant constructs. This calls for further biomechanical studies on a larger number of cases. In 2014, a preliminary study was presented at a Bioengineering Conference aiming to design and test plates and screws optimal for cTTA, but until the writing of the present paper no further communication has been released about the final results (Wright et al., 2014).
Based on our results, we can conclude that there is a significant difference between TTA-rapid and mcTTA in the intraoperative complication rates (P = 0.0105). In the TTA-rapid group this is 7/30 (23.3%) while in the mcTTA group 0/30 (0%). This is most likely due to the difference in the osteotomy techniques. All intraoperative complications in the TTA-rapid group were fractures of the tibial crest following osteotomy, and this kind of complication could not have occurred in the mcTTA group, as there the entire tibial crest is osteotomised.
There was no significant difference between our study groups in the major postoperative complication rates (P = 0.3533). However, in the TTA-rapid group tibial shaft fracture requiring revision surgery occurred in a total of two cases (6.7%), while in the mcTTA group there was not a single case like this. Further studies would be necessary to examine if there is any difference between the two techniques in this regard. Postoperative meniscal injures occurred in two cases (6.7%) in the TTA-rapid group and in one case in mcTTA group (3.3%). For TTA-rapid this is similar to that found in the literature, as other studies have reported a 5.9% (9/152) (Butterworth and Kydd, 2017) and a 4.2% (2/48) (Dyall and Schmökel, 2017) rate of late meniscal injury. No data are available in the literature regarding cTTA and late complications. Further long-term follow-up studies are warranted.
There was no significant difference between the two groups in the rate of minor postoperative complications, which was 16.7% in the TTA-rapid group and 20% in the mcTTA group (P > 0.9999).
The limitations of this study are its retrospective nature and small sample size. Long-term follow-up studies with both methods are necessary. Studies aimed at exploring the interaction between complication rates and factors such as age, body weight and sex are also warranted.
We can conclude that there is a statistically significant difference between the two techniques in the rate of intraoperative complications. Complication rates in our study were consistent with the findings reported in the literature. Complication rates are low with either technique, and both can be recommended safely for use in the clinical practice.
Ethical statement
The last author, Tibor Németh is a member of the Editorial Board.
Acknowledgement
The study was conducted at and financed by the Department of Small Animal Surgery and Ophthalmology of the University of Veterinary Medicine Budapest, Hungary.
References
Apelt, A., Kowaleski, M. P. and Boudrieau, R. J. (2007): Effect of tibial tuberosity advancement on cranial tibial subluxation in canine cranial cruciate-deficient stifle joints: an in vitro experimental study. Vet. Surg. 36, 170–177.
Aragosa, F., Caterino, C., Della Valle, G. and Fatone, G. (2022): Tibial tuberosity advancement techniques (TTAT): a systematic review. Animals 12 ,2114.
Arican, M., Parlak, K. and Sahin H. (2017): Evaluation and application of the TTA-rapid method in dogs with cranial cruciate ligament rupture. Acta Vet. Beograd 67 ,238–253.
Butterworth, S. J. and Kydd, D. M (2017): TTA-rapid in the treatment of the canine cruciate deficient stifle: short- and medium-term outcome. JSAP 58 ,35–41.
Cadmus, J., Palmer, R. H. and Duncan, C. (2014): The effect of preoperative planning method on recommended tibial tuberosity advancement cage size. Vet. Surg. 43 ,995–1000.
Costa, M., Craig, D., Cambridge, T., Sebestyén, P., Su, Y. and Fahie M. A. (2017): Major complications of tibial tuberosity advancement in 1613 dogs. Vet. Surg. 46 ,494–500.
Dyall, B. and Schmökel, H. (2017): Tibial tuberosity advancement in small-breed dogs using TTA Rapid implants: complications and outcome. JSAP 58 ,314–322.
Etchepareborde, S., Brunel, L., Bollen, G. and Balligand, M. (2011): Preliminary experience of a modified Maquet technique for repair of cranial cruciate ligament rupture in dogs. Vet. Comp. Orthop. Traumatol. 24 ,223–227.
Hoffmann, D. E., Miller, J. M., Ober, C. P., Lanz, O. I., Martin, R. A. and Shires, P. K. (2006): Tibial tuberosity advancement in 65 canine stifles. Vet. Comp. Orthop. Traumatol. 19 ,219–227.
Ipolyi, T., Zólyomi, D., Szalay, F., Diószegi, Z., Molnár, P., Dunay, M. P., Simon, Cs. and Németh, T. (2015): cTTA: a new treatment method for cranial cruciate ligament rupture in dogs, part 2: surgical technique [in Hungarian, with English abstract]. Magy. Allatorvosok 10 ,595–602.
Lafaver, S., Miller, N. A., Stubbs, W. P., Taylor, R. A. and Boudrieau, R. J. (2007): Tibial tuberosity advancement for stabilization of the canine cranial cruciate ligament-deficient stifle joint: surgical technique, early results, and complications in 101 dogs. Vet. Surg. 36 ,573–586.
Lampmann, T. J., Lund, E. M. and Lipowitz, A. J. (2003): Cranial cruciate disease: current status of diagnosis, surgery and risk for disease. Vet. Comp. Orthop. Traumatol. 16 ,122–126.
Lefebvre, M. D., Broux, O. R., Barthélémy, N. P., Hamon, M., Moyse, E. V., Bouvy, B. M. and Balligand, M. H. (2018): Risk factors for tibial damage associated with the modified Maquet technique in 174 stifles. Vet. Surg. 47 ,30–35.
Montavon, P. M., Damur, D. M. and Tepic, S. (2002): Advancement of the tibial tuberosity for the treatment of the cranial cruciate deficient stifle. Proceedings of the 1st World Orthopaedic Veterinary Congress. September 5 to 8, 2002, Munich, Germany. p. 152.
Nutt, A. E., Garcia-Fernandez, P., San Roman, F., Parkin, T. and Calvo, I. (2015): Risk factors for tibial tuberosity fracture after tibial tuberosity advancement in dogs. Vet. Comp. Orthop. Traumatol. 28 ,116–123.
Petazzoni, M. (2010): cTTA (circular tibial tuberosity advancement). Proceedings of the World Veterinary Orthopedic Congress, Bologna, Italy. pp. 295–296.
Ramirez, J., Barthélémy, N., Noël, S., Claeys, S., Etchepareborde, S., Farnir, F. and Balligand, M. (2015): Complications and outcome of a new modified Maquet technique for treatment of cranial cruciate ligament rupture in 82 dogs. Vet. Comp. Orthop. Traumatol. 28 ,339–346.
Roydev, R. and Goranov, N. (2021): Long-term clinical and goniometric follow-Up of TTA rapid surgery in dogs with cranial cruciate ligament rupture. Acta Vet. Eurasia 47 ,154–160.
Samoy, Y., Verhoeven, G., Bosmans, T., Van der Vekens, E., de Bakker, E., Verleyen, P. and Van Ryssen, B. (2015): TTA Rapid: description of the technique and short term clinical trial results of the first 50 cases. Vet. Surg. 44, 474–484.
Stein, S. and Schmoekel, H. (2008): Short-term and eight to 12 months results of tibial tuberosity advancement as treatment of canine cranial cruciate ligament damage. JSAP 49 ,398–404.
Wolf, R. E., Scavelli, T. D., Hoelzler, M. G., Fulcher, R. P. and Bastian, R. P. (2012): Surgical and postoperative complications associated with tibial tuberosity advancement for cranial cruciate ligament rupture in dogs: 458 cases (2007–2009). JAVMA 240 ,1481–1487.
Wright, K., Newell, K. and Durand, O. (2014): Canine stifle stabilization system: for a circular tibial tuberosity advancement (cTTA) procedure. 40th Annual Northeast Bioengineering Conference (NEBEC), 2014, pp. 1–2.
Zhalniarovich, Y., Mieszkowska, M., Przyborowska-Zhalniarovich, P., Głodek, J., Sobolewski, A., Waluś, G. and Adamiak, Z. (2018): A novel tibial tuberosity advancement technique with cranial implant fixation (TTA CF): a pilot study in sheep. BMC Vet. Res. 14 ,231.
