Aragosa, Federica (2023) New generation TTAT, comparison of preoperative planning methods in terms of reliability and effectiveness in vivo and ex vivo. [Tesi di dottorato]

Anteprima

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Abstract

Rupture of the cranial cruciate ligament (rCCL) in dogs is a disease with a mainly degenerative etiopathogenesis; in contrast, in human medicine a predominantly traumatic aetiology is recorded. The cranial cruciate ligament (CrCL) primarily limits cranial translation of the tibia in relation to the femur (cranial drawer) and hyperextension. The CrCL and caudal cruciate ligaments twist themselves to limit internal rotation, but both ligaments play a minor role in limiting external rotation. Internal rotation and cranial translation of the tibia on the femur support functional changes and degenerative changes in the joint. Several surgical techniques have been developed to restore joint stability and slow down secondary joint degeneration. Tibial tuberosity advancement (TTA) is one of the biomechanical corrective techniques of choice for the treatment of this pathology. New-generation tibial tuberosity advancement techniques (TTAT) use the same principles of traditional TTA but without a complete osteotomy of the tibial tuberosity (Aragosa et al., 2022; Pillard et al., 2016). For TTAT, the advancement is achieved through the use of spacers (cage or wedge). Determining the extent of advancement of the tibial tuberosity is a fundamental step of traditional TTA and of TTAT. In Chapter 2, different surgical techniques for the treatment of canine rCCL were analysed in dogs, aiming to critically review the available literature, focusing on preoperative planning, surgical procedure, follow-up, and complications of rCCL treated by TTAT. Three bibliographic databases (PubMed, Google Scholar, and Scopus) were used for a board research and included studies were evaluated using five GRADE recommendations according to Grading of Recommendations Assessment, Development and Evaluation and Joanna Briggs Institute Critical Appraisal Checklists were applied to the studies included. Data regarding preoperative planning (a measure of advancement), meniscal disease (meniscectomy, meniscal release, and late meniscal tears), and postoperative patellar tendon angle were recorded. Time frame, outcome, and complications were classified according to Cook's guidelines. Of the 471 reports yielded, only 30 met the inclusion criteria. The common tangent method was the most commonly reported measurement technique for preoperative planning. The 40.21% of knee joints had a meniscal tear at surgery, while 4.28% suffered late meniscal tears. Short-, mid- and long-term follow-up showed full/acceptable function in > 90% of cases. For all new-generation techniques, minor complications were reported in 33.5% of cases and major complications in 10.67%. Compared with traditional TTA, new-generation TTAT was found to be effective in the treatment of cranial cruciate ligament failure, showing a lower rate of late meniscal injury but a higher rate of minor complications. The goal of preoperative planning is to determine the amount of advancement required to achieve a postoperative patellar tendon angle (PTA) of 90° and to select the optimal wedge size to achieve this target. In Chapter 3, radiographic methods for determining the advancement distance for the tibial tuberosity were investigated in terms of comparison and interobserver reliability. Among the methods developed, we decided to include the common tangent method (CT) (Dennler et al., 2006), the tibial anatomy-based method (TAM) (Ness, 2016), and the Bielecki method (BF) (Bielecki et al., 2014). As transparent overlays, conventional and correction methods have been extensively investigated and their poor reliability has already been confirmed (Cadmus et al., 2014; Etchepareborde, Mills, et al., 2011; Pillard et al., 2016), we did not analyse these methods further. For all techniques, radiographs were taken in mediolateral projection with the knee joint flexed at 135°. Three observers with different degree of experience independently evaluated and scored the degree of OA for each stifle, as previously described (Mager, 2000; Matis, 2005; Wessely et al., 2017) and performed measurements of the amount of advancement of the tibial tuberosity using CT, TAM, and BF on 33 stifles. According to the results, the overall score for OA in mediolateral view was influenced by the experience of the observers, which does not confirm a previous study (Wessely et al., 2017). However, osteophytosis does not seem to affect the identification of anatomical landmarks, as shown by several studies (Millet et al., 2013; Reif et al., 2004; Ritter et al., 2007). Regarding the measurement methods used to assess advancement, poor interobserver reliability was found for CT and BF, while only a slight moderate interobserver agreement was found for TAM. This is inconsistent with data collected by Bielecki and colleagues (Bielecki et al., 2014). Moreover, measurements from CT and TAM were overlapping, as previously confirmed (Butterworth & Kydd, 2017; Samoy et al., 2015). Conversely, BF showed no agreement with the other methods included in the present study, with a significantly higher mean rank, probably due to its correction formula (Bielecki et al., 2014). According to the results of this chapter, TAM had better interobserver reliability and was easier to perform according to the observers. In Chapter 4, the efficacy of CT and TAM to calculate the amount of advancement to achieve the target PTA of 90° after MMP was examined. Twenty knee joints of adult medium-sized breeds, dead for reasons unrelated to this study, were randomly assigned to the two measurement procedures (CT and TAM), respectively. Radiographs in mediolateral projection were used to measure the amount of advancement of the tibial tuberosity, and the size of the wedge was accordingly selected. For all stifles MMP was performed by a board-certified surgeon, and a custom-made wedge corresponding to the one commercially available was inserted into the osteotomy. A postoperative radiographic mediolateral view allowed measurement of postoperative PTA and evaluation of wedge position. This is the first report of the validity of CT for selecting the correct wedge to achieve the desired advancement, while previous evidences exist on TAM (Kapler et al., 2015). Most measurement methods have been developed and tested for traditional TTA (Dennler et al., 2006; Etchepareborde, Brunel, et al., 2011; Montavon et al., 2002), which is characterised by a different direction of advancement than TTAT. The values of advancement obtained with TAM and CT were not significantly different, confirming the results obtained in Chapter 3. The 60% of measurements obtained with CT were often lower than 5.3 mm, so we had to increase the wedge size significantly to reach the commercially available one. For this reason, a statistical difference was found between the measurements made with CT and the selected wedges. On the contrary, the selection of wedges with TAM proved to be easier. The postoperative PTA did not differ between groups, but only TAM provided the measure of the advancement of the tibial tuberosity closest to the real one to obtain a resultant mean PTA of 90°. On the other hand, 80% of the knee joints in both groups had a postoperative PTA of 90° ± 5, which is currently considered to stabilize the stifle joint. The position of the wedge in relation to the osteotomy did not differ between the studied groups, but a mean distance of 12 mm was observed between the line passing through the insertion of the distal patellar tendon (PT) and the proximal edge of the wedge. This could affect the true advancement achieved by MMP (Butterworth & Kydd, 2017) and lead to under-advancement, which has been frequently reported for TTA (Jin et al., 2019; Kapler et al., 2015; Meeson et al., 2018). In our opinion, TAM is easier to apply because it provides advancement values that are generally consistent with commercially available wedges and provides the correct measurement to achieve a postoperative PTA of 90°. On the other hand, the measurement of the required advancement distance for the tibial tuberosity can be influenced by several factors, both preoperatively and intraoperatively: method of PTA measurement, tibial plateau angle (TPA), method of advancement measurement, limb positioning, anatomical factors, concomitant pathological conditions or spacer position (Etchepareborde, Mills, et al., 2011; Meeson et al., 2018; Millet et al., 2013; Pillard et al., 2016). This has been confirmed by several studies on discrepancies between measured values on radiographs and values obtained in vivo (Millet et al., 2013; Pillard et al., 2016; Skinner et al., 2013). For this reason, we have described in Chapter 5 our current efforts to find an intraoperative method to measure the desired advancement until a PTA of 90° is achieved.

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