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J Vet Clin 2022; 39(3): 100-106

https://doi.org/10.17555/jvc.2022.39.3.100

Published online June 30, 2022

Influence of Plate Design on the Accuracy of Tibial Alignment after Center of Rotation of Angulation-Based Leveling Osteotomy in Toy-Breed Dogs

Jae-Hong Han , Hae-Beom Lee , Jae-Min Jeong , Young-Jin Jeon , Yoon-Ho Roh

College of Veterinary Medicine, Chungnam National University, Daejeon 34134, Korea

Correspondence to:*royoonseok@gmail.com

Jae-Hong Han and Hae-Beom Lee contributed equally to this work.

Received: December 13, 2021; Revised: March 30, 2022; Accepted: April 25, 2022

Copyright © The Korean Society of Veterinary Clinics.

The center of rotation of angulation-based leveling osteotomy (CBLO) has been introduced for the stabilization of cranial cruciate ligament rupture (CCLR) in small-breed dogs. This technique can be applied to the tibia without damaging its tuberosity. Although different designs of CBLO plates are available, tibial plateau leveling osteotomy (TPLO) plates have been still used for stabilization during CBLO. To the best of our knowledge, no studies have reported the effects of TPLO plates on the postoperative limb alignment after CBLO. Therefore, the present study (January 2020 to February 2021) aimed to compare the postoperative outcomes (postoperative tibial plateau angle [TPA] and tibial alignment) in patients receiving CBLO and TPLO plates during CBLO. Paired stifle joints (n = 16) were obtained from eight toy-breed cadaver dogs (mean weight, 4.4 kg) that underwent CBLO. The joints were randomly assigned to receive the CBLO (CBLO group) or TPLO plates (TPLO group). Pre-and postoperative radiographs were obtained, and the dissected tibiae were evaluated. The following postoperative parameters were compared to evaluate the surgical outcome: TPA, osteotomy location, mechanical medial proximal tibia angle, inter-segment gap, and tibial plateau translation. No significant differences were found in the postoperative alignment between the two groups. Therefore, TPLO plates may be considered as a viable alternative in toy-breed dogs undergoing CBLO.

Keywords: center of rotation of angulation-based leveling osteotomy, cranial cruciate ligament rupture, tibial plateau leveling osteotomy, plate, dog.

Cranial cruciate ligament rupture (CCLR) is one of the most common causes of hindlimb lameness in toy-breed dogs, which leads to stifle instability due to the cranial tibial thrust generated during weight-bearing (24,30). This is seen in cases with progressive degeneration of the stifle joint, stifle arthritis, or stifle instability (24,30). Surgical techniques including proximal tibial osteotomies, such as tibial closing wedge osteotomy, tibial plateau leveling osteotomy (TPLO), and center of rotation of angulation-based leveling osteotomy (CBLO) have been used in small-breed dogs to neutralize the cranial tibial thrust and restore joint function (21,24,25,32). Recently, several studies have reported favorable outcomes and improved limb function after proximal tibial osteotomy in small-breed dogs (11,15,21,23).

CBLO modifies the proximal tibial procurvatum of dogs based on the center of rotation of angulation (CORA) methodology, leading to a decrease in the tibial plateau angle (TPA, 9°-12°) and cranial tibial thrust (18,27). Although TPLO is the most common surgical procedure for CCLR in veterinary medicine, CBLO (2010) is universally accepted for treating CCLR in small-breed dogs (15,18,23). In small and toy-breed dogs, CBLO has several advantages over other techniques (11,21,27). First, CBLO preserves the proximal epiphysis for plate application. Second, it prevents the iatrogenic fracture of the tibial tuberosity in cases with narrow tuberosity (after TPLO). Third, as the axis of correction (proximal tibial epiphysis) is centered on the tibial shaft (CORA) there is no risk of secondary translation of segments (15). Fourth, CBLO can be applied to juvenile patients. Fifth, the non-articular osteotomy line leads to faster recovery as compared to patients undergoing TPLO (8,10).

Stabilization with bone plates and headless screws is recommended to increase the stability and improve the postoperative healing after CBLO (11,21). One of the complications of TPLO is the tibial plateau angle (TPA) shift that increases the TPA due to implant instability and contracture of the quadriceps muscle (11). It has been reported that the type and position of plates could influence the postoperative bone alignment and, consequently, the surgical outcome and postoperative bone healing (2,4,12,21,29). Recently, pre-contoured CBLO plates have been developed to achieve greater stability of the segments during fixation (20). In addition, In the case of concurrent medial patellar luxation (MPL) and CCLR in small and toy-breed dogs, a combination including tibial tuberosity transposition, trochoplasty, and soft tissue reconstruction is needed to treat all problems at once. However, several studies still report using TPLO plates for tibial stabilization after CBLO because there is a lack of clear evidence for plate stabilization in the tibia except for TPLO plates (11,21,23).

This study aimed to compare the postoperative alignment and TPA to determine the ideal plate for bony stabilization during CBLO in toy-breed dogs. We hypothesized that there would be no differences in the postoperative TPA and bony alignment between the CBLO and TPLO plates.

Specimens

Sixteen stifle joints obtained from eight toy-breed cadaver dogs (age, 1-10 years) were included. Radiographs did not reveal any joint abnormalities. The cadavers were stored at –20°C and thawed at room temperature for 24 h, prior to surgery. The tibiae were divided into the TPLO and CBLO groups, based on the fixation plates (Fig. 1).

Figure 1.Precontoured center of rotation of angulation (CORA) based leveling osteotomy (CBLO) locking compression plate (A). Tibial plateau leveling osteotomy locking compression plate (B).

Surgical planning

Preoperative mediolateral and craniocaudal radiographs were obtained (6). TPA, mechanical medial proximal tibial angle (mMPTA), and osteotomy location were assessed using a radiographic software program (ViewRex3®, TechHeim Co. Ltd., Seoul, Korea) (6). CBLO was planned on preoperative mediolateral radiographs (Fig. 2). The proximal joint orientation line (JOL), and the proximal (through the anterior slope of the tibial eminence, 81° to JOL) and distal mid-diaphyseal lines (from Gerdy’s tubercle to the midpoint of the medullary cavity at the distal tibial crest) were drawn. The angle formed by the intersection of the proximal and distal mid-diaphyseal lines was the anatomic CORA of the tibia. The intended centroid of osteotomy (ICO) was located along the transverse bisecting line (tBL) on the anatomic CORA (21). In some cases, the ICO was located distal to tBL to preserve sufficient bone stock for fixation of the proximal segments. The proximal segment rotation was determined to achieve a postsurgical TPA of 9° (21).

Figure 2.Preoperative mediolateral radiographs for center of rotation of angulation (CORA)- based leveling osteotomy (CBLO) planning. Measurement of the tibial plateau angle (TPA) (A); Preoperative planning for CBLO (B). The proximal joint reference line (PJL), and the distal mid-diaphyseal line that bisects the diaphysis at the distal tibial crest and exits the Gerdy’s tubercle were drawn. The proximal mid-diaphyseal line bisects PJL at 81°. The CORA lies at the intersection of the proximal and distal mid-diaphyseal lines. The intended centroid of osteotomy (ICO) was located distal to the transverse bisecting line (tBL).

Surgical procedure

Surgical procedures were carried out (Han) in the way of previous studies (1,3,21,22). Cranial cruciate ligaments wereas resected using the (No. 11 blades) during arthrotomy. The 8 mm and 10 mm saw blades were used during TPLO. Each dog received the CBLO (It has been designed to preserve the tibiae tuberosity, which might make the tibial tuberosity transposition possible by doing CBLO at one time) and TPLO plates (Mini TPLO system, DePuy Synthes Vet, Solothurn, Switzerland) (Fig. 1). The legs receiving the TPLO and CBLO plates (2.0 mm, 6-hole) were randomly selected (1,3,21).

Postoperative measurements

TPA, mMPTA, and osteotomy location

The osteotomy locations and pre-and postoperative mMPTA and TPA were assessed on the craniocaudal radiographic images (1,14). The ICO was located on the anatomic CORA along the tBL. The actual center of osteotomy (ACO) was the center of the circle drawn along the osteotomy line of the kproximal segment. R1 (ICO to the point of insertion of the patellar ligament in the tibial tuberosity, T point) and R2 (ICO to the most caudal aspect of the tibial plateau, C point) were measured on preoperative radiographs. Circles with radii R1 and R2 were drawn on postoperative radiographs at points T and C, respectively. The point of intersection of the circles closest to the ACO, was the ICO. The distance between ICO and ACO was the distance of eccentricity (DOE) (Fig. 3) (3,5).

Figure 3.Postoperative radiograph for assessing segment alignment. Mediolateral radiograph of the stifle joint with TPLO plate indicating the distance of eccentricity (DOE). DOE is the distance between the intended centroid of osteotomy (ICO) and the actual center of osteotomy (ACO). R1, radius of the circle from ICO to the tibial tuberosity; R2, radius of the circle from ICO to the most caudal aspect of the tibial plateau; T, tibial tuberosity.

Gap and translation between segments

The tibiae were dissected to measure the inter-segment gaps and translations using calipers. The inter-segment gaps were measured at the largest widths on the medial and lateral aspects (Fig. 4). The proximal segment translations were measured at the level of the osteotomies. The translation distance was the displacement of the proximal cortex in relation to the distal abaxial edge of the lateral cortex on the caudal aspect. Positive and negative values were assigned to lateral and medial translations, respectively (30).

Figure 4.Measurements of the dissected tibiae of the CBLO (A-C) and TPLO groups (D-F). The gaps between the proximal and distal segments were measured on the lateral (A, D) and medial (B, E) aspects. The tibial segment translations were measured at the level of the osteotomies using calipers (C, F). CBLO, CORA-based leveling osteotomy; CORA, center of rotation of angulation; TPLO, tibial plateau leveling osteotomy.

Statistical analysis

Data were documented on a spreadsheet and stored as a file in Microsoft Excel (Microsoft Corp., Seattle, Wash, USA). The data were expressed as mean values ± SD. The normality of data was verified using the Shapiro-Wilk test. Paired Mann-Whitney test was used to compared the outcomes between the 2 groups. The statistical significance was set at p < 0.05. Statistical analyses were performed using SPSS (Statistical Package for the Social Sciences) for windows (version 22.0; IBM Corp, Armonk, New York, USA).

Specimens

Sixteen tibiae from 8 toy-breed cadaver dogs were examined (January 2020 to February 2021). The mean weight of the cadavers was 4.1 ± 1.2 kg (range, 3.1-6.9) and no limbs were excluded on the basis of weight (>7 kg). The following breeds were included in the study: Maltese (3); Poodle (2); Pomeranian (2); and Mongrel (1). Of the eight dogs, two were males and six were females. The 8 mm and 10 mm TPLO blades were selected for six and two pairs of tibiae, respectively.

TPA and mMPTA

The mean preoperative TPA values for the CBLO and TPLO groups were 26.38 ± 2.6° and 26.45 ± 1.7°, respectively. The mean postoperative TPA values for the CBLO and TPLO groups were 8.4 ± 1.7° and 8.6 ± 2.1°, respectively. The mean postoperative mMPTA values for the CBLO and TPLO groups were 95.65° and 95.80°, respectively. No significant differences were found in the postoperative TPA (p = 0.84) and mMPTA (p = 0.93) values between the two groups (Table 1).

Table 1 Descriptive data for the CBLO and TPLO groups (mean ± SD)

ParametersCBLO groupTPLO groupp value
Pre-TPA (degree)26.4 ± 2.626.5 ± 1.70.946
Post-TPA (degree)8.4 ± 1.78.6 ± 2.10.837
Pre-mMPTA (degree)95.0 ± 2.794.9 ± 2.10.690
Post-mMPTA (degree)95.7 ± 3.795.8 ± 3.30.932
DOE (mm)1.4 ± 0.81.6 ± 0.60.747
Translation (mm)1.2 ± 0.61.1 ± 0.60.713
Lateral gap (mm)0.7 ± 0.60.5 ± 0.50.610
Medial gap (mm)0.6 ± 0.60.9 ± 0.60.468

CBLO, center of rotation of angulation (CORA)- based leveling osteotomy; DOE, distance of eccentricity; mMPTA, mechanical medial proximal tibial angle; TPA, tibial plateau angle; TPLO, tibial plateau leveling osteotomy.



Osteotomy location, gap, and tibial plateau translation

The mean DOE values for the CBLO and TPLO groups were 1.4 ± 0.8 mm and 1.6 ± 0.6 mm, respectively (Table 1). No significant differences were seen in the osteotomy locations between the two groups (p = 0.75). The mean lateral gaps between the proximal and distal segments were 0.7 mm and 0.5 mm for the CBLO and TPLO groups, respectively. The mean medial gaps for the CBLO and TPLO groups were 0.6 mm and 0.8 mm, respectively. There were no significant differences in the lateral (p = 0.61) and medial gaps (p = 0.47) between the proximal and distal segments. The mean translations of the tibial plateaus for the CBLO and TPLO groups were 1.2 ± 0.6 mm and 1.1 ± 0.6 mm, respectively. No significant differences were seen in the mean translations between the two groups (p = 0.81) (Table 1).

This study aimed to compare the postoperative tibial alignment in toy-breed dogs receiving CBLO and TPLO plates during CBLO. In this study, the plate design did not affect the postoperative alignment, TPA, mMPTA, osteotomy location, inter-segment gap, and tibial plateau translation. Both plates were closely adapted on the medial surfaces of the tibiae without additional contouring. These results are consistent with previous reports on the use of TPLO plates in CBLO (15,21,23).

It is well-known that the accuracy of osteotomy affects the postoperative alignment of the bony segments and the surgical outcomes (9,28,31). Studies conducted on the osteotomy locations in TPLO reported that distal deviations of the osteotomy centers may increase the TPA after the osteotomies (13,16). In this study, no significant differences were seen in the mean DOE (p = 0.75) and postoperative TPA (p = 0.84) values between the two groups. These results indicate that the planned postoperative TPA values were achieved due to the accuracy of the osteotomies. Consistent with the results of the previous studies, caudodistal deviations of ACOs were observed in our study (26). A possible reason is a shift in the osteotomy lines, either due to the influence of the jigs or due to modifications by the surgeon to ensure adequate bone stock for the plates (16,26). However, no significant differences were seen in the deviations of ACOs between the two groups.

Consistent with previous reports, the lateral translations of tibial plateaus were observed in our study (17,30). The lateral translations of the proximal tibial segments were 1.2 ± 0.6 mm and 1.4 mm ± 0.6 mm in the CBLO and TPLO groups, respectively. However, no significant differences were seen in the lateral translations between the two groups (p = 0.81). It is believed that lateral translations occurred during fixation as both plates had dynamic compression plate holes in the distal segments (22). There are several reasons for the translation of the bony segments. First, only the medial sides of the tibiae were accessible to the surgeons. Second, during fixation the forces were transmitted from the medial to the lateral side. Third, the distal segments were translated medially during the insertion of screws in the proximal holes of the distal segments, while the proximal segments were locked with plates and locking screws (30). Despite the translation of bony segments, no significant differences were found between the pre- and postoperative mMPTA values. In addition, there were no significant differences in the postoperative mMPTA values between the two groups. The gaps between the proximal and distal segments were measured to assess the postoperative stability, and the accuracy of bony reductions due to axial compression between the bony segments and plates. Postoperative TPA shift is a complication during the healing period, leading to restoration of lameness due to instability of the bony segments (11). There were no significant differences in the medial and lateral gaps between the two groups, suggesting that the TPLO plates did not significantly influence the inter-segment gaps after CBLO. Several studies report that precontoured plating systems could help achieve correct limb alignment and accurate reduction of the bony fragments, as translations and gaps may occur during plate fixation (7,19). These results indicate that TPLO precontoured plate design has no significant effects on the postoperative alignment after CBLO.

This study had several limitations. First, the small sample size may be responsible for the type II errors during inter-group comparisons. Second, since this was an ex-vivo study it may not accurately predict the in-vivo performance of the plates. Third, the mechanical properties (construct stiffness) and plate designs, which may influence the postoperative stability were not considered. However, the primary purpose of this study was to compare the applicability between CBLO and TPLO plates.

In this study, no significant differences were seen in the surgical outcomes in dogs receiving CBLO and TPLO plates during CBLO. Therefore, TPLO plates are a viable alternative in toy-breed dogs undergoing CBLO. Further in-vivo studies with long-term follow-ups, that consider the mechanical properties of plates and varying clinical conditions, are needed to substantiate the results our study.

All procedures were approved by the Chungnam National University Animal Care and Use Committee. Eleven adult toy-breed dog cadavers were obtained from an animal shelter. The animals had been euthanized for reasons unrelated to this study.

This study was supported by the research fund of Chungnam National University.

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Article

Original Article

J Vet Clin 2022; 39(3): 100-106

Published online June 30, 2022 https://doi.org/10.17555/jvc.2022.39.3.100

Copyright © The Korean Society of Veterinary Clinics.

Influence of Plate Design on the Accuracy of Tibial Alignment after Center of Rotation of Angulation-Based Leveling Osteotomy in Toy-Breed Dogs

Jae-Hong Han , Hae-Beom Lee , Jae-Min Jeong , Young-Jin Jeon , Yoon-Ho Roh

College of Veterinary Medicine, Chungnam National University, Daejeon 34134, Korea

Correspondence to:*royoonseok@gmail.com

Jae-Hong Han and Hae-Beom Lee contributed equally to this work.

Received: December 13, 2021; Revised: March 30, 2022; Accepted: April 25, 2022

This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The center of rotation of angulation-based leveling osteotomy (CBLO) has been introduced for the stabilization of cranial cruciate ligament rupture (CCLR) in small-breed dogs. This technique can be applied to the tibia without damaging its tuberosity. Although different designs of CBLO plates are available, tibial plateau leveling osteotomy (TPLO) plates have been still used for stabilization during CBLO. To the best of our knowledge, no studies have reported the effects of TPLO plates on the postoperative limb alignment after CBLO. Therefore, the present study (January 2020 to February 2021) aimed to compare the postoperative outcomes (postoperative tibial plateau angle [TPA] and tibial alignment) in patients receiving CBLO and TPLO plates during CBLO. Paired stifle joints (n = 16) were obtained from eight toy-breed cadaver dogs (mean weight, 4.4 kg) that underwent CBLO. The joints were randomly assigned to receive the CBLO (CBLO group) or TPLO plates (TPLO group). Pre-and postoperative radiographs were obtained, and the dissected tibiae were evaluated. The following postoperative parameters were compared to evaluate the surgical outcome: TPA, osteotomy location, mechanical medial proximal tibia angle, inter-segment gap, and tibial plateau translation. No significant differences were found in the postoperative alignment between the two groups. Therefore, TPLO plates may be considered as a viable alternative in toy-breed dogs undergoing CBLO.

Keywords: center of rotation of angulation-based leveling osteotomy, cranial cruciate ligament rupture, tibial plateau leveling osteotomy, plate, dog.

Introduction

Cranial cruciate ligament rupture (CCLR) is one of the most common causes of hindlimb lameness in toy-breed dogs, which leads to stifle instability due to the cranial tibial thrust generated during weight-bearing (24,30). This is seen in cases with progressive degeneration of the stifle joint, stifle arthritis, or stifle instability (24,30). Surgical techniques including proximal tibial osteotomies, such as tibial closing wedge osteotomy, tibial plateau leveling osteotomy (TPLO), and center of rotation of angulation-based leveling osteotomy (CBLO) have been used in small-breed dogs to neutralize the cranial tibial thrust and restore joint function (21,24,25,32). Recently, several studies have reported favorable outcomes and improved limb function after proximal tibial osteotomy in small-breed dogs (11,15,21,23).

CBLO modifies the proximal tibial procurvatum of dogs based on the center of rotation of angulation (CORA) methodology, leading to a decrease in the tibial plateau angle (TPA, 9°-12°) and cranial tibial thrust (18,27). Although TPLO is the most common surgical procedure for CCLR in veterinary medicine, CBLO (2010) is universally accepted for treating CCLR in small-breed dogs (15,18,23). In small and toy-breed dogs, CBLO has several advantages over other techniques (11,21,27). First, CBLO preserves the proximal epiphysis for plate application. Second, it prevents the iatrogenic fracture of the tibial tuberosity in cases with narrow tuberosity (after TPLO). Third, as the axis of correction (proximal tibial epiphysis) is centered on the tibial shaft (CORA) there is no risk of secondary translation of segments (15). Fourth, CBLO can be applied to juvenile patients. Fifth, the non-articular osteotomy line leads to faster recovery as compared to patients undergoing TPLO (8,10).

Stabilization with bone plates and headless screws is recommended to increase the stability and improve the postoperative healing after CBLO (11,21). One of the complications of TPLO is the tibial plateau angle (TPA) shift that increases the TPA due to implant instability and contracture of the quadriceps muscle (11). It has been reported that the type and position of plates could influence the postoperative bone alignment and, consequently, the surgical outcome and postoperative bone healing (2,4,12,21,29). Recently, pre-contoured CBLO plates have been developed to achieve greater stability of the segments during fixation (20). In addition, In the case of concurrent medial patellar luxation (MPL) and CCLR in small and toy-breed dogs, a combination including tibial tuberosity transposition, trochoplasty, and soft tissue reconstruction is needed to treat all problems at once. However, several studies still report using TPLO plates for tibial stabilization after CBLO because there is a lack of clear evidence for plate stabilization in the tibia except for TPLO plates (11,21,23).

This study aimed to compare the postoperative alignment and TPA to determine the ideal plate for bony stabilization during CBLO in toy-breed dogs. We hypothesized that there would be no differences in the postoperative TPA and bony alignment between the CBLO and TPLO plates.

Materials and Methods

Specimens

Sixteen stifle joints obtained from eight toy-breed cadaver dogs (age, 1-10 years) were included. Radiographs did not reveal any joint abnormalities. The cadavers were stored at –20°C and thawed at room temperature for 24 h, prior to surgery. The tibiae were divided into the TPLO and CBLO groups, based on the fixation plates (Fig. 1).

Figure 1. Precontoured center of rotation of angulation (CORA) based leveling osteotomy (CBLO) locking compression plate (A). Tibial plateau leveling osteotomy locking compression plate (B).

Surgical planning

Preoperative mediolateral and craniocaudal radiographs were obtained (6). TPA, mechanical medial proximal tibial angle (mMPTA), and osteotomy location were assessed using a radiographic software program (ViewRex3®, TechHeim Co. Ltd., Seoul, Korea) (6). CBLO was planned on preoperative mediolateral radiographs (Fig. 2). The proximal joint orientation line (JOL), and the proximal (through the anterior slope of the tibial eminence, 81° to JOL) and distal mid-diaphyseal lines (from Gerdy’s tubercle to the midpoint of the medullary cavity at the distal tibial crest) were drawn. The angle formed by the intersection of the proximal and distal mid-diaphyseal lines was the anatomic CORA of the tibia. The intended centroid of osteotomy (ICO) was located along the transverse bisecting line (tBL) on the anatomic CORA (21). In some cases, the ICO was located distal to tBL to preserve sufficient bone stock for fixation of the proximal segments. The proximal segment rotation was determined to achieve a postsurgical TPA of 9° (21).

Figure 2. Preoperative mediolateral radiographs for center of rotation of angulation (CORA)- based leveling osteotomy (CBLO) planning. Measurement of the tibial plateau angle (TPA) (A); Preoperative planning for CBLO (B). The proximal joint reference line (PJL), and the distal mid-diaphyseal line that bisects the diaphysis at the distal tibial crest and exits the Gerdy’s tubercle were drawn. The proximal mid-diaphyseal line bisects PJL at 81°. The CORA lies at the intersection of the proximal and distal mid-diaphyseal lines. The intended centroid of osteotomy (ICO) was located distal to the transverse bisecting line (tBL).

Surgical procedure

Surgical procedures were carried out (Han) in the way of previous studies (1,3,21,22). Cranial cruciate ligaments wereas resected using the (No. 11 blades) during arthrotomy. The 8 mm and 10 mm saw blades were used during TPLO. Each dog received the CBLO (It has been designed to preserve the tibiae tuberosity, which might make the tibial tuberosity transposition possible by doing CBLO at one time) and TPLO plates (Mini TPLO system, DePuy Synthes Vet, Solothurn, Switzerland) (Fig. 1). The legs receiving the TPLO and CBLO plates (2.0 mm, 6-hole) were randomly selected (1,3,21).

Postoperative measurements

TPA, mMPTA, and osteotomy location

The osteotomy locations and pre-and postoperative mMPTA and TPA were assessed on the craniocaudal radiographic images (1,14). The ICO was located on the anatomic CORA along the tBL. The actual center of osteotomy (ACO) was the center of the circle drawn along the osteotomy line of the kproximal segment. R1 (ICO to the point of insertion of the patellar ligament in the tibial tuberosity, T point) and R2 (ICO to the most caudal aspect of the tibial plateau, C point) were measured on preoperative radiographs. Circles with radii R1 and R2 were drawn on postoperative radiographs at points T and C, respectively. The point of intersection of the circles closest to the ACO, was the ICO. The distance between ICO and ACO was the distance of eccentricity (DOE) (Fig. 3) (3,5).

Figure 3. Postoperative radiograph for assessing segment alignment. Mediolateral radiograph of the stifle joint with TPLO plate indicating the distance of eccentricity (DOE). DOE is the distance between the intended centroid of osteotomy (ICO) and the actual center of osteotomy (ACO). R1, radius of the circle from ICO to the tibial tuberosity; R2, radius of the circle from ICO to the most caudal aspect of the tibial plateau; T, tibial tuberosity.

Gap and translation between segments

The tibiae were dissected to measure the inter-segment gaps and translations using calipers. The inter-segment gaps were measured at the largest widths on the medial and lateral aspects (Fig. 4). The proximal segment translations were measured at the level of the osteotomies. The translation distance was the displacement of the proximal cortex in relation to the distal abaxial edge of the lateral cortex on the caudal aspect. Positive and negative values were assigned to lateral and medial translations, respectively (30).

Figure 4. Measurements of the dissected tibiae of the CBLO (A-C) and TPLO groups (D-F). The gaps between the proximal and distal segments were measured on the lateral (A, D) and medial (B, E) aspects. The tibial segment translations were measured at the level of the osteotomies using calipers (C, F). CBLO, CORA-based leveling osteotomy; CORA, center of rotation of angulation; TPLO, tibial plateau leveling osteotomy.

Statistical analysis

Data were documented on a spreadsheet and stored as a file in Microsoft Excel (Microsoft Corp., Seattle, Wash, USA). The data were expressed as mean values ± SD. The normality of data was verified using the Shapiro-Wilk test. Paired Mann-Whitney test was used to compared the outcomes between the 2 groups. The statistical significance was set at p < 0.05. Statistical analyses were performed using SPSS (Statistical Package for the Social Sciences) for windows (version 22.0; IBM Corp, Armonk, New York, USA).

Results

Specimens

Sixteen tibiae from 8 toy-breed cadaver dogs were examined (January 2020 to February 2021). The mean weight of the cadavers was 4.1 ± 1.2 kg (range, 3.1-6.9) and no limbs were excluded on the basis of weight (>7 kg). The following breeds were included in the study: Maltese (3); Poodle (2); Pomeranian (2); and Mongrel (1). Of the eight dogs, two were males and six were females. The 8 mm and 10 mm TPLO blades were selected for six and two pairs of tibiae, respectively.

TPA and mMPTA

The mean preoperative TPA values for the CBLO and TPLO groups were 26.38 ± 2.6° and 26.45 ± 1.7°, respectively. The mean postoperative TPA values for the CBLO and TPLO groups were 8.4 ± 1.7° and 8.6 ± 2.1°, respectively. The mean postoperative mMPTA values for the CBLO and TPLO groups were 95.65° and 95.80°, respectively. No significant differences were found in the postoperative TPA (p = 0.84) and mMPTA (p = 0.93) values between the two groups (Table 1).

Table 1 . Descriptive data for the CBLO and TPLO groups (mean ± SD).

ParametersCBLO groupTPLO groupp value
Pre-TPA (degree)26.4 ± 2.626.5 ± 1.70.946
Post-TPA (degree)8.4 ± 1.78.6 ± 2.10.837
Pre-mMPTA (degree)95.0 ± 2.794.9 ± 2.10.690
Post-mMPTA (degree)95.7 ± 3.795.8 ± 3.30.932
DOE (mm)1.4 ± 0.81.6 ± 0.60.747
Translation (mm)1.2 ± 0.61.1 ± 0.60.713
Lateral gap (mm)0.7 ± 0.60.5 ± 0.50.610
Medial gap (mm)0.6 ± 0.60.9 ± 0.60.468

CBLO, center of rotation of angulation (CORA)- based leveling osteotomy; DOE, distance of eccentricity; mMPTA, mechanical medial proximal tibial angle; TPA, tibial plateau angle; TPLO, tibial plateau leveling osteotomy..



Osteotomy location, gap, and tibial plateau translation

The mean DOE values for the CBLO and TPLO groups were 1.4 ± 0.8 mm and 1.6 ± 0.6 mm, respectively (Table 1). No significant differences were seen in the osteotomy locations between the two groups (p = 0.75). The mean lateral gaps between the proximal and distal segments were 0.7 mm and 0.5 mm for the CBLO and TPLO groups, respectively. The mean medial gaps for the CBLO and TPLO groups were 0.6 mm and 0.8 mm, respectively. There were no significant differences in the lateral (p = 0.61) and medial gaps (p = 0.47) between the proximal and distal segments. The mean translations of the tibial plateaus for the CBLO and TPLO groups were 1.2 ± 0.6 mm and 1.1 ± 0.6 mm, respectively. No significant differences were seen in the mean translations between the two groups (p = 0.81) (Table 1).

Discussion

This study aimed to compare the postoperative tibial alignment in toy-breed dogs receiving CBLO and TPLO plates during CBLO. In this study, the plate design did not affect the postoperative alignment, TPA, mMPTA, osteotomy location, inter-segment gap, and tibial plateau translation. Both plates were closely adapted on the medial surfaces of the tibiae without additional contouring. These results are consistent with previous reports on the use of TPLO plates in CBLO (15,21,23).

It is well-known that the accuracy of osteotomy affects the postoperative alignment of the bony segments and the surgical outcomes (9,28,31). Studies conducted on the osteotomy locations in TPLO reported that distal deviations of the osteotomy centers may increase the TPA after the osteotomies (13,16). In this study, no significant differences were seen in the mean DOE (p = 0.75) and postoperative TPA (p = 0.84) values between the two groups. These results indicate that the planned postoperative TPA values were achieved due to the accuracy of the osteotomies. Consistent with the results of the previous studies, caudodistal deviations of ACOs were observed in our study (26). A possible reason is a shift in the osteotomy lines, either due to the influence of the jigs or due to modifications by the surgeon to ensure adequate bone stock for the plates (16,26). However, no significant differences were seen in the deviations of ACOs between the two groups.

Consistent with previous reports, the lateral translations of tibial plateaus were observed in our study (17,30). The lateral translations of the proximal tibial segments were 1.2 ± 0.6 mm and 1.4 mm ± 0.6 mm in the CBLO and TPLO groups, respectively. However, no significant differences were seen in the lateral translations between the two groups (p = 0.81). It is believed that lateral translations occurred during fixation as both plates had dynamic compression plate holes in the distal segments (22). There are several reasons for the translation of the bony segments. First, only the medial sides of the tibiae were accessible to the surgeons. Second, during fixation the forces were transmitted from the medial to the lateral side. Third, the distal segments were translated medially during the insertion of screws in the proximal holes of the distal segments, while the proximal segments were locked with plates and locking screws (30). Despite the translation of bony segments, no significant differences were found between the pre- and postoperative mMPTA values. In addition, there were no significant differences in the postoperative mMPTA values between the two groups. The gaps between the proximal and distal segments were measured to assess the postoperative stability, and the accuracy of bony reductions due to axial compression between the bony segments and plates. Postoperative TPA shift is a complication during the healing period, leading to restoration of lameness due to instability of the bony segments (11). There were no significant differences in the medial and lateral gaps between the two groups, suggesting that the TPLO plates did not significantly influence the inter-segment gaps after CBLO. Several studies report that precontoured plating systems could help achieve correct limb alignment and accurate reduction of the bony fragments, as translations and gaps may occur during plate fixation (7,19). These results indicate that TPLO precontoured plate design has no significant effects on the postoperative alignment after CBLO.

This study had several limitations. First, the small sample size may be responsible for the type II errors during inter-group comparisons. Second, since this was an ex-vivo study it may not accurately predict the in-vivo performance of the plates. Third, the mechanical properties (construct stiffness) and plate designs, which may influence the postoperative stability were not considered. However, the primary purpose of this study was to compare the applicability between CBLO and TPLO plates.

In this study, no significant differences were seen in the surgical outcomes in dogs receiving CBLO and TPLO plates during CBLO. Therefore, TPLO plates are a viable alternative in toy-breed dogs undergoing CBLO. Further in-vivo studies with long-term follow-ups, that consider the mechanical properties of plates and varying clinical conditions, are needed to substantiate the results our study.

Ethics Approval

All procedures were approved by the Chungnam National University Animal Care and Use Committee. Eleven adult toy-breed dog cadavers were obtained from an animal shelter. The animals had been euthanized for reasons unrelated to this study.

Acknowledgements

This study was supported by the research fund of Chungnam National University.

Conflicts of Interest

The authors have no conflicting interests.

Fig 1.

Figure 1.Precontoured center of rotation of angulation (CORA) based leveling osteotomy (CBLO) locking compression plate (A). Tibial plateau leveling osteotomy locking compression plate (B).
Journal of Veterinary Clinics 2022; 39: 100-106https://doi.org/10.17555/jvc.2022.39.3.100

Fig 2.

Figure 2.Preoperative mediolateral radiographs for center of rotation of angulation (CORA)- based leveling osteotomy (CBLO) planning. Measurement of the tibial plateau angle (TPA) (A); Preoperative planning for CBLO (B). The proximal joint reference line (PJL), and the distal mid-diaphyseal line that bisects the diaphysis at the distal tibial crest and exits the Gerdy’s tubercle were drawn. The proximal mid-diaphyseal line bisects PJL at 81°. The CORA lies at the intersection of the proximal and distal mid-diaphyseal lines. The intended centroid of osteotomy (ICO) was located distal to the transverse bisecting line (tBL).
Journal of Veterinary Clinics 2022; 39: 100-106https://doi.org/10.17555/jvc.2022.39.3.100

Fig 3.

Figure 3.Postoperative radiograph for assessing segment alignment. Mediolateral radiograph of the stifle joint with TPLO plate indicating the distance of eccentricity (DOE). DOE is the distance between the intended centroid of osteotomy (ICO) and the actual center of osteotomy (ACO). R1, radius of the circle from ICO to the tibial tuberosity; R2, radius of the circle from ICO to the most caudal aspect of the tibial plateau; T, tibial tuberosity.
Journal of Veterinary Clinics 2022; 39: 100-106https://doi.org/10.17555/jvc.2022.39.3.100

Fig 4.

Figure 4.Measurements of the dissected tibiae of the CBLO (A-C) and TPLO groups (D-F). The gaps between the proximal and distal segments were measured on the lateral (A, D) and medial (B, E) aspects. The tibial segment translations were measured at the level of the osteotomies using calipers (C, F). CBLO, CORA-based leveling osteotomy; CORA, center of rotation of angulation; TPLO, tibial plateau leveling osteotomy.
Journal of Veterinary Clinics 2022; 39: 100-106https://doi.org/10.17555/jvc.2022.39.3.100

Table 1 Descriptive data for the CBLO and TPLO groups (mean ± SD)

ParametersCBLO groupTPLO groupp value
Pre-TPA (degree)26.4 ± 2.626.5 ± 1.70.946
Post-TPA (degree)8.4 ± 1.78.6 ± 2.10.837
Pre-mMPTA (degree)95.0 ± 2.794.9 ± 2.10.690
Post-mMPTA (degree)95.7 ± 3.795.8 ± 3.30.932
DOE (mm)1.4 ± 0.81.6 ± 0.60.747
Translation (mm)1.2 ± 0.61.1 ± 0.60.713
Lateral gap (mm)0.7 ± 0.60.5 ± 0.50.610
Medial gap (mm)0.6 ± 0.60.9 ± 0.60.468

CBLO, center of rotation of angulation (CORA)- based leveling osteotomy; DOE, distance of eccentricity; mMPTA, mechanical medial proximal tibial angle; TPA, tibial plateau angle; TPLO, tibial plateau leveling osteotomy.


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Vol.39 No.4 August, 2022

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