Cranial closing wedge ostectomies for management of canine cranial cruciate ligament insufficiency: Comparison and geometric modelling of errors.

Variants of the cranial closing wedge ostectomy (CCWO) may be used to manage cranial cruciate ligament deficient stifles by reduction of the tibial plateau angle (TPA). Concerns have been raised about predictability of achieving target TPA, limb shortening, axis shift, and distalization of the tibial tuberosity. Landmarks derived from tibial radiographs (n = 50) by 5 observers, along with outlines of the cranial and caudal proximal tibial cortices, were used to simulate six CCWO variants. Tested variants were Slocum-type (n = 2), modified (n = 2), isosceles, and anatomical-mechanical axis (AMA)-based CCWO. Observer specific landmarks were used to model pre- and postoperative errors in TPA measurement. Mean landmarks were used to compare key outcome variables between the variants, as well as modelling errors in positioning the wedge apex. Variants differed markedly in TPA, axis shift, mechanical axis length changes, and tibial tuberosity distalization, with more proximally positioned wedges performing better than distally positioned wedges. Errors in TPA identification appeared partially self-correcting due to altered axis shifts. Craniocaudal shifts in wedge apex position had the most severe effects on outcome variables, especially in shorter tibiae with greater initial TPA values. Recent CCWO variants are likely to achieve a satisfactory postoperative TPA with limited axis shift. The AMA-based CCWO technique appears to influence MA length and tibial tuberosity position the least, and apart from the effect on TPA where no advantage could be discerned, it appeared more robust in the face of wedge apex positioning errors than the other techniques.

Diagnosis of medial meniscal lesions in the canine stifle using multidetector computed tomographic positive-contrast arthrography.

OBJECTIVE: To assess diagnostic value and clinical utility of multidetector computed tomographic positive contrast arthrography (CTA) for meniscal lesions in dogs. STUDY DESIGN: Prospective case series. STUDY POPULATION: Client-owned dogs (n = 55) with cranial cruciate ligament injuries. METHODS: Sedated dogs underwent CTA using a 16-slice scanner, and subsequently received mini-medial arthrotomy for meniscal assessment. Scans were anonymized, randomized, and reviewed twice for meniscal lesions by three independent observers with varying experience. Results were compared with surgical findings. Reproducibility and repeatability were assessed with kappa statistics, intraobserver changes in diagnosis by McNemar's test, and interobserver differences using Cochran's Q test. Test performance was calculated using sensitivity, specificity, proportion correctly identified, and positive and negative predictive values and likelihood ratios. RESULTS: Analysis was based on 52 scans from 44 dogs. Sensitivity for identifying meniscal lesions was 0.62-1.00 and specificity was 0.70-0.96. Intraobserver agreement was 0.50-0.78, and interobserver agreement was 0.47-0.83. There was a significant change between readings one and two for the least experienced observers (p < .05). The sum of sensitivity and specificity exceeded 1.5 for both readings and all observers. CONCLUSION: Diagnostic performance was suitable for identifying meniscal lesions. An effect of experience and learning was seen in this study.

Objective and owner-reported outcomes after modified cranial closing wedge ostectomy: a case series.

Immediate and longer-term outcomes of a cranial closing wedge ostectomy variant for management of canine cranial cruciate ligament disease were assessed in this single-center retrospective consecutive study. Records and radiographs were retrieved and assessed by three independent observers to evaluate tibial plateau angle, anatomical-mechanical axis angle, tibial tuberosity distalization, and mechanical axis length before and after surgery. Kinetic gait analysis and owner questionnaires were used to assess clinical outcomes. Seventeen stifles from fifteen dogs were evaluated radiographically. Mean error from target tibial plateau angle was 0.4 degrees. Anatomical-mechanical axis angles reduced from mean 2.9 degrees preoperatively to mean - 0.9 degrees postoperatively. Tibial tuberosity distalization was mean 5.0% of mechanical axis length, and mean reduction in mechanical axis length was 0.1%. Increased tibial plateau angles were noted in 8/17 stifles, with a mean of 9.6 degrees at short-term follow-up. Major complications were observed in 9/17 stifles. Long term follow-up (mean 832 days) was obtained with gait analysis in 8/15 dogs and with questionnaire in 11/15. Most dogs (9/11) were weakly to moderately affected by osteoarthritis symptoms. All values for peak vertical force and vertical impulse normalized to body weight exceeded local lower reference limits for normal dogs, indicating acceptable limb use. Satisfactory immediate and long-term clinical outcomes appear to be possible with this technique, but the high incidence of shorter-term complications may caution against the technique or the fixation and management described here.

Effect of center of rotation of angulation-based leveling osteotomy on ex vivo stifle joint stability following cranial cruciate ligament transection and medial meniscal release with and without a hamstring load.

OBJECTIVE: To evaluate the effect of center of rotation of angulation (CORA)-based leveling osteotomy (CBLO) and hamstring load on stifle stability following cranial cruciate ligament transection (CCLx) and medial meniscal release (MMR). STUDY DESIGN: Ex vivo experimental study. SAMPLE POPULATION: Cadaver hind limb preparations (n = 7). METHODS: After instrumentation, constant quadriceps and gastrocnemius loads with an optional hamstring load in a 3:1:0.6 ratio were applied, and stifles were extended from fully flexed using an electrical motor during fluoroscopic recording. The recording process was repeated after each of CCLx, MMR and CBLO and the extracted landmark coordinates were used for calculation of cranial tibial translation (CTT) and patellar ligament angle (PTA). RESULTS: Mean initial tibial plateau angle was 28.1°: post-CBLO the mean was 9.7°. Cranial tibial translation developed from 50° and 75° with CCLx and MMR respectively (p < .04, < .02) without hamstring loading. Hamstring loading mitigated CTT due to CCLx and delayed CTT until 120° for MMR (P < .02) in this model. CBLO prevented CTT, except at 140° without hamstring loading (P = .01). Similar results were seen for PTA, but CBLO curves were parallel to and lower than intact values at all tested angles (P < .04), consistent with induced effective joint flexion. CONCLUSION: CBLO to a target tibial plateau angle of 10° largely eliminated CTT induced by CCLx and MMR. Hamstring loads of 20% quadriceps load improved stifle stability in this model. IMPACT: Stifle stability following CBLO appears to be multifactorial and depends on meniscal integrity, joint angle, and hamstring strength.

Quantifying the variability between multiple multiplanar reconstructions of computed tomography scans.

BACKGROUND: Multiplanar reconstructions of computed tomography (CT) scans can alleviate issues with bone or joint positioning during scan acquisition. The repeatability of these reconstructions is dependent on human operators applying reconstruction criteria, and therefore is subject to error, which could affect measurement reliability for angular or spatial measurements made for orthopaedic surgery. We describe a method for quantifying inter-reconstruction variability numerically and graphically using metadata from the CT header to find vectors describing reconstruction axis alignment. The approach is demonstrated using 3 sets of computed tomographic reconstructions of 24 vulpine femorotibial joints. RESULTS: Vectors describing axis alignments permitted identification and subsequent analysis of deviations from optimal alignment between reconstruction sets. For the worked example, alignment deviations equivalent to femoral abduction/adduction were nearly twice those for extension/flexion, and simulation of the effects of these deviations on measurements closely matched published data. CONCLUSIONS: The method presented here is straightforward and permits numerical and graphical analysis of reconstruction variability. Reconstruction alignment variability should be considered before adopting new reconstruction criteria for clinical use, and evaluated whenever there is suspicion that reconstruction variability could unduly influence subsequent measurements. These evaluations may help drive improvements in reconstruction criteria. The methods described here could also be employed for comparing patient positioning between scans and between different scan modalities.

Modelling the Effects of Cranial Cruciate Ligament Transection, Medial Meniscal Release and Triple Tibial Osteotomy on Stability of the Canine Stifle Joint.

OBJECTIVE: The aim of this study was to evaluate the ex vivo effects of sequential cranial cruciate ligament transection (CCLx), medial meniscal release (MMR) and triple tibial osteotomy (TTO) on canine stifle stability compared with the intact state, across a wide range of joint angles. STUDY DESIGN: Nine right hind limb preparations were instrumented to provide constant quadriceps and gastrocnemius loads in a 3:1 ratio, and extended from full flexion during fluoroscopic recording. Recordings were repeated after each of CCLx, MMR and TTO. Fluoroscopic landmarks were used to calculate tibial subluxation and patellar ligament angle. RESULTS: Medial meniscal release resulted in additional cranial tibial subluxation compared with CCLx. Triple tibial osteotomy restored stifle stability up to a joint angle of 125 degrees. The presence of the crossover angle could be inferred from the patellar ligament angle and subluxation curves. CONCLUSION: Our results suggest that in the cranial cruciate ligament-deficient stifle, the crossover angle at which loading shifts between the caudal and cranial cruciate ligaments is dependent on both loading and integrity of the medial meniscus. Triple tibial osteotomy improves stifle stability over a wide range of joint angles under a quadricep to gastrocnemius loading ratio of 3:1 by converting cranial tibial thrust to caudal tibial thrust, due to TTO increasing the amount of joint extension required to reach the crossover angle.

Stifle Joint Rotational Variation in Extended Stifles in Healthy Dogs Undergoing Computed Tomography Examinations.

OBJECTIVES: The aim of this study was to evaluate stifle joint rotational stability in response to body position and repositioning in dogs undergoing computed tomography (CT). MATERIALS AND METHODS: Nine dogs (18 stifles) with no history or clinical signs of stifle injury undergoing CT examinations for other reasons were included in the study. Dogs were positioned in alternating dorsal and sternal recumbency with the pelvic limbs extended caudally and unrestrained, for a total of four examinations. Scans included the entire tibia and distal femur. Using defined landmarks on the tibia and femur, stifle joint rotational angles were measured from multiplanar reconstructions made by two independent observers, and repositioning effects and intra- and interobserver agreement evaluated. RESULTS: Repositioning produced repeatable stifle joint rotational angles (pooled within-subject standard deviations of 0.9° and 1.4°) and intraobserver repeatability was good (within-subject standard deviations 1.4°), but interobserver agreement was poor. Dorsal and sternal positioning produced equivalent results. CLINICAL SIGNIFICANCE: The results indicate that little rotation occurs in the healthy extended canine stifle joint during positioning for CT and support CT as a method for assessing limb alignment around the stifle joint, provided that the limb distal to the femorotibial joint is unrestrained. Clinically, it is likely that measured changes in rotational angles across (and distant to) the stifle joint are real, rather than being due to rotation artefact during imaging.

Approximations to the Tibial Distal Anatomical Axis in the Sagittal Plane.

OBJECTIVE: The aim of this study was to compare approximations to the tibial distal anatomical axis (DAA) with regression lines for the symmetric axis of the tibia, and to identify an optimal approximation for surgical planning of osteotomies for the management of canine cruciate ligament deficiency. STUDY DESIGN: Prospective radiographic study of 20 canine tibiae. Using curve-fitting and the symmetric axis technique, the true anatomical axis was identified for each tibia. Regression lines were calculated for the distal 67% and distal 50% subsections of this axis. Angular deviations between these lines and DAA approximations were calculated and compared with to find the closest approximations. RESULTS: The DAA approximations based on the distal 50% rather than the distal 67% of the tibia had smaller maximal deviations from the true axis. Landmarks at 50% and 75% of tibial length exhibited greater deviations than those at 50% and 95% or 100%. CONCLUSION: The DAA landmarks should be restricted to the distal half of the tibia. Use of a distal landmark either just proximal to the distal metaphyseal flare of the tibia or at the mid-point of the distal articular surface is to be preferred. In this way, the DAA will better reflect the true anatomical axis of the distal tibia.

Femoral rotation unpredictably affects radiographic anatomical lateral distal femoral angle measurements.

OBJECTIVE: To describe the effects of internal and external femoral rotation on radiographic measurements of the anatomical lateral distal femoral angle (a-LDFA) using two methods for defining the anatomical proximal femoral axis (a-PFA). METHODS: Digital radiographs were obtained of 14 right femora at five degree intervals from 10° external rotation to 10° internal rotation. Using freely available software, a-LDFA measurements were made using two different a-PFA by a single observer on one occasion. RESULTS: Mean a-LDFA was significantly greater at 10° external rotation than at any other rotation. The response of individual femora to rotation was unpredictable, although fairly stable within ±5° of zero rotation. Mean a-LDFA for the two a-PFA methods differed by 1.5°, but were otherwise similarly affected by femoral rotation. CLINICAL SIGNIFICANCE: If zero femoral elevation can be achieved for radiography, a-LDFA measurements do not vary much with mild femoral rotation (±5°). Outside of this range, a-LDFA varies unpredictably with femoral rotation.

Radiographic, ultrasonographic, and anatomic assessment of femoral trochlea morphology in red foxes (Vulpes vulpes).

OBJECTIVE: To compare repeatability and equivalency of measures of femoral trochlea depth and trochlear angle in red foxes (Vulpes vulpes) determined by use of radiography, ultrasonography, and digital photography of cadaver limbs. SAMPLE: 24 pelvic limbs from 12 red fox cadavers. PROCEDURES: Cranioproximal-craniodistal oblique (skyline) and lateromedial radiographic views of the stifle joint and ultrasonographic images at 5 locations along the femoral trochlea were used in the study. Spacing of the 5 locations was determined on the basis of patellar position with the stifle joint at various caudal angles ranging from 96° to maximal extension (approx 170°). Ultrasonographic measurements were compared with those obtained at matched locations on photographs of anatomic preparations. Trochlear depth was assessed with all 3 image formats, and trochlear angle (measured between the trochlear ridges and sulcus) was assessed on radiographs and ultrasonographic images. Patellar thickness was measured on radiographs. Values obtained were compared by means of ANOVA, modified Bland-Altman plots, and repeatability testing. RESULTS: Depth measurement repeatability was considered good for all modalities. Small but significant differences between mean ultrasonographic trochlear depth and anatomic (photographic) measurements were found at 3 locations; 95% limits of agreement for paired anatomic and ultrasonographic measurements were wide. The ratio of trochlear depth to radiographic patellar thickness was approximately 30% for all modalities. Trochlear angle measurements were more variable than trochlear depth measurements, especially in the distal aspect of the trochlea. CONCLUSIONS AND CLINICAL RELEVANCE: Paired anatomic and ultrasonographic measurements did not appear equivalent in this study, possibly attributable to imprecise probe location, which could limit quantitative use of ultrasonography in assessing proximal trochlear depth in a clinical setting.

Measurement repeatability of tibial tuberosity-trochlear groove offset distance in red fox (Vulpes vulpes) cadavers.

OBJECTIVE: To describe CT image reconstruction criteria for measurement of the tibial tuberosity-trochlear groove (TT-TG) offset distance, evaluate intra- and inter-reconstruction repeatability, and identify key sources of error in the measurement technique, as determined in vulpine hind limbs. ANIMALS: 12 red fox (Vulpes vulpes) cadavers. PROCEDURES: CT images of each hind limb in intact cadavers were obtained; at 1-week intervals, 3 reconstructions were performed that were based on 1 plane passing through the centers of the femoral head and medial condyle and parallel to the caudal femoral condyles, 1 plane aligned with the femoral trochlea, and a third orthogonal plane. Randomized and anonymized reconstructions were assessed for TT-TG offset distance with a single-image technique by 1 observer, and inter-reconstruction repeatability and intra- and inter-reconstruction measurement repeatability were assessed via the repeatability coefficient and intraclass correlation coefficient. RESULTS: Multiplanar reconstructions of hind limb images were repeatedly made to within a few degrees of each other. Intra- and inter-reconstruction repeatability for TT-TG offset distance measurement was good. Repeatability was most affected by accurate identification of the tibial tuberosity and femoral trochlea landmarks. CONCLUSIONS AND CLINICAL RELEVANCE: Results obtained from vulpine hind limb CT images indicated that reconstructions can be made with a high degree of repeatability when based on strictly defined and applied criteria. The TT-TG offset distance has potential as an objective assessment of alignment of the distal portion of the quadriceps mechanism; its use as an aid in case selection for corrective femoral osteotomy among dogs with medial patellar luxation warrants investigation.

Five patellar proximodistal positioning indices compared in clinically normal Greenland sled dogs.

Patellar luxation in large-breed dogs is associated with abnormal proximodistal patellar positioning. Using a clinically normal population of Greenland sled dogs, measurement reliability and the effect of limb position were compared for five patellar proximodistal positioning indices based on the Insall-Salvati (IS), modified Insall-Salvati (mIS), de Carvalho (dC), patellotrochlear (PT) and Blackburne-Peel (BP) indices. Indices were measured at one knee angle in 44 dogs and two knee angles in 10 dogs. Index susceptibility to error was modelled for different errors in knee angle estimation. Two reported techniques for determining knee angle were compared in a fox hind limb model. Indices dC and PT were significantly affected by knee angle (P<0.001). Error susceptibility was the lowest for IS and the greatest for PT. Intra- and inter-observer agreements were moderate to substantial for all indices. Measurement precision was good for all indices except BP. Patellar ligament laxity significantly affected IS, mIS, dC and BP (P<0.05). Knee angle measurements were technique dependent, with a bias of 9° to 13° and limits of agreement of ±5°. All five indices were reliable, but precision varied. For pre- and post-operative comparison, dC showed less error susceptibility than PT and better precision than BP. An ideal index for clinical use remains to be defined; the best option is dC, although with limitations. The method of knee angle measurement must be defined prior to index measurement and comparison of index values. Index values may vary with species and/or body size.

Comparison of reliability of five patellar position indices at various stifle joint angles in pelvic limbs obtained from cadavers of red foxes (Vulpes vulpes).

OBJECTIVE: To compare 5 patellar position indices at various stifle joint angles in cadavers of red foxes, determine measurement reliability, and assess the suitability of these indices for clinical use. SAMPLE: Pelvic limbs from cadavers of 12 red foxes (Vulpes vulpes). PROCEDURES: Patellar position in each limb at 7 stifle joint angles (30° to 148°) was assessed by use of the Insall-Salvati (IS), modified Insall-Salvati (mIS), de Carvalho (dC), patellotrochlear (PT), and Blackburne-Peel (BP) indices. RESULTS: Values for all indices varied significantly on the basis of joint angle, but for IS and mIS indices, this was minor and nonsignificant between 52° and 130° and between 52° and 148°, respectively. The dC index increased linearly, and PT and BP indices varied polynomially with increases in stifle joint angle. Stifle joint angles measured from radiographs agreed well with the goniometrically set stifle joint angles up to approximately 100° and diverged thereafter. Intraobserver and interobserver agreement was substantial for all indices, and IS index was the most precise. CONCLUSIONS AND CLINICAL RELEVANCE: IS and mIS index values were effectively independent of stifle joint angle, in contrast to dC, PT, and BP indices. The BP index varied nonsignificantly across a range of joint angles. To maximize angular accuracy, radiographs should not be obtained at joint angles > 100°. Although dC, PT, and BP indices appeared to be suitable for preoperative and postoperative evaluation of patellar position, BP index appeared to have the most promise for determination of patellar position in clinical applications.

The quadriceps angle: reliability and accuracy in a fox (Vulpes vulpes) pelvic limb model.

OBJECTIVES: To evaluate the effect of measurement technique and limb positioning on quadriceps (Q) angle measurement, intra- and interobserver reliability, potential sources of error, and the effect of Q angle variation. STUDY DESIGN: Cadaveric radiographic study and computer modeling. ANIMALS: Pelvic limbs from red foxes (Vulpes vulpes). METHODS: Q angles were measured on hip dysplasia (HD) and whole limb (WL) view radiographs of each limb between the acetabular rim, mid-point (Q1: patellar center, Q2: femoral trochlea), and tibial tuberosity. Errors of 0.5-2.0 mm at measurement landmarks alone and in combination were modeled to identify the effect on Q angle. The effect of measured Q angles on the medial force exerted on the patella (F(MEDIAL)) was calculated. RESULTS: The HD position yielded significantly (P < .001) more medial Q angles than the WL position. No significant difference was observed between Q1 and Q2, but Bland-Altman plots indicated they were not equivalent. Intra- and interobserver agreement was substantial. Q2 errors were inherently greater than Q1: the mid-point and tibial tuberosity are the most important sources of Q angle variability. Increasing Q angles significantly increased the exerted F(MEDIAL) (P < .0001, gradient 1.7%). CONCLUSIONS: Measurements are reliable, but Q2 is more prone to error than Q1, and the 2 measurement techniques are not interchangeable. Positional errors must be kept below 1.3 mm (Q1) or 0.8 mm (Q2).

Modulation of the intramedullary pressure responses by calcium dobesilate in a rabbit knee model of osteoarthritis.

BACKGROUND AND PURPOSE: The presence of bone marrow edema in patients with osteoarthritis is associated with pain and disease progression. Management of bone edema with the synthetic prostacyclin iloprost may be complicated by side effects. Calcium dobesilate, a treatment for chronic venous disease, shares some pharmacological actions with iloprost but appears to be better tolerated. Anecdotal reports have suggested that calcium dobesilate may be useful for medical management of osteoarthritis, possibly by reducing bone marrow edema, and this study was performed to investigate possible benefits of treatment. METHODS: The effects of a 6-week period of oral calcium dobesilate administration on tibial intramedullary pressure dynamics and physical joint characteristics were evaluated in 20 rabbits with unilaterally induced knee osteoarthritis that were randomly allocated to either a treatment group or a placebo control group. Treatment or placebo started 8 weeks after induction of osteoarthritis, and was followed by a 4-week washout period. RESULTS: Calcium dobesilate did not affect joint thickness or range of motion, nor individual pressure measurements, compared to placebo. Pressure ranges in the operated limb were greater than in the intact limb after 8 weeks, and approached those of the intact limb after 6 weeks of treatment with calcium dobesilate but not with placebo. Inter-limb differences were lower (p = 0.02) in the dobesilate group following the washout period. INTERPRETATION: Calcium dobesilate had a detectable effect on pressure dynamics in the subchondral bone of osteoarthritic joints in this model. The significance of these effects for pain and function should be established.