Veterinary Surgery

37:111–125, 2008

INVITED REVIEW

Tibial Osteotomies for Cranial Cruciate Ligament Insufficiency in Dogs

STANLEY E. KIM, BVSc, ANTONIO POZZI, DMV, MS, Diplomate ACVS, MICHAEL P. KOWALESKI, DVM, Diplomate ACVS,
and DANIEL D. LEWIS, DVM, Diplomate ACVS

Objective—To review the biomechanical considerations, experimental investigations, and clinical

data pertaining to tibial osteotomy procedures for treatment of cranial cruciate ligament (CrCL)
insufficiency in dogs.
Study Design—Literature review.
Methods—Literature search through Pub Med, Veterinary Information Network, Commonwealth
Agricultural Bureau Abstracts, and conference proceedings abstracts (November 1977 to March
2007).
Results—Reported tibial osteotomy procedures attempt to eliminate sagittal instability (cranial
tibial thrust) in CrCL-deficient stifles by altering the conformation of the proximal tibia. Functional
stability can be achieved by decreasing the tibial plateau slope (cranial tibial closing wedge
osteotomy [CTWO], tibial plateau leveling osteotomy [TPLO], combined TPLO and CTWO,
proximal intraarticular osteotomy, chevron wedge osteotomy), altering the alignment of the patellar
tendon (tibial tuberosity advancement), or both (triple tibial osteotomy). Clinical reports assessing
the efficacy of these procedures frequently use subjective outcome measures, and the periods of
follow-up evaluation are highly variable. Satisfactory results have been reported in most (475%)
dogs irrespective of the type of tibial osteotomy procedure.
Conclusions—Currently available data does not allow accurate comparisons between different tibial
osteotomy procedures, or with traditional methods of stabilizing the CrCL-deficient stifle. Carefully
designed long-term clinical studies and further biomechanical analyses are required to determine the
optimal osteotomy technique, and whether these procedures are superior to other stabilization
methods.
Clinical Relevance—Limb function in dogs with CrCL insufficiency can be improved using the
currently described tibial osteotomy techniques.
r Copyright 2008 by The American College of Veterinary Surgeons

INTRODUCTION development of progressive stifle osteoarthritis (OA)

and often results in secondary meniscal damage.

C RANIAL CRUCIATE ligament (CrCL) insufficien-

cy is one of the most common causes of lameness
in dogs.1 Rupture of the CrCL can be caused entirely
by trauma; however, in most dogs rupture is a conse-
quence of mid-substance, progressive, pathologic fa-
tigue.2 Subsequent instability invariably leads to
This debilitating condition commonly affects young
adult large breed dogs and frequently affects both stifles
within a year of the initial diagnosis.3 The economic im-
pact of treating dogs with CrCL insufficiency in the
United States has been estimated in 2003 at just over
$1 billion.4

From the Department of Small Animal Clinical Sciences, University of Florida, Gainesville, FL; and the Department of Clinical
Sciences, Tufts Cummings School of Veterinary Medicine, North Grafton, MA.
Address reprint requests to Dr. Antonio Pozzi, Department of Small Animal Clinical Sciences, College of Veterinary Medicine,
University of Florida, Gainesville, FL 32610. E-mail: PozziA@vetmed.ufl.edu.
Submitted May 2007; Accepted November 2007
r Copyright 2008 by The American College of Veterinary Surgeons

0161-3499/08
doi:10.1111/j.1532-950X.2007.00361.x
111
112 TIBIAL OSTEOTOMIES FOR CRANIAL CRUCIATE LIGAMENT INSUFFICIENCY IN DOGS
Treatment of CrCL insufficiency aims to resolve lame-
ness caused by joint instability and provide good long-
term function of the affected hindlimb. Conservative
management of dogs weighing o15 kg typically results in
acceptable limb function, with reported success rates
ranging from 84% to 90%.5,6 Surgical intervention is,
however, recommended for most dogs with CrCL
insufficiency to reestablish joint stability, mitigate second-
ary degenerative joint disease, and address any concur-
rent meniscal injury.6,7 Over the past 50 years, a plethora
of surgical techniques have been reported for treatment
of this condition. This evolution of surgical procedures
reflects the controversy about optimal management of
CrCL insufficiency, and to date, no one pro-
cedure has consistently demonstrated superior clinical
efficacy.
Traditional surgical techniques attempt to impart sta-
bility using an autogenous, allogenic, or synthetic structure
placed within or about the stifle that mimics the function of
the normal CrCL. Extraarticular techniques use periartic-
ular heavy gauge suture or wires,8,9 or the transposition of
soft tissues10 to reduce stifle laxity, whereas intraarticular
techniques attempt to anatomically reconstruct the CrCL
using autogenous tissues,11 allografts,12 or synthetic mate-
rials.13 Most authors cite good to excellent limb function in
most of dogs that have had extra- or intraarticular proce-
dures.14,15 Yet despite these reported satisfactory results,
traditional methods are generally considered to yield sub-
optimal long-term outcomes, as these techniques fail to
consistently maintain stability, arrest the progression of
OA, and prevent late meniscal damage.9,16,17
As surgical techniques continue to evolve, the focus
has shifted to the concept of creating dynamic stability in
the CrCL-deficient stifle by altering bone geometry. In
1984, Slocum described the cranial tibial wedge osteo-
tomy (CTWO), a surgical procedure that attempts to
eliminate cranial subluxation of the tibia during weight-
bearing by reducing the caudally directed slope of the
tibial plateau.18 By establishing dynamic stability of the
CrCL-deficient stifle, passive restraint against laxity is not
required. Recognition that stabilization could be achieved
in this manner led to the development of several proximal
tibial osteotomy procedures, such as tibial plateau level-
ing osteotomy (TPLO)19; combined TPLO/CTWO20;
proximal tibial intraarticular osteotomy (PTIO)21; triple
tibial osteotomy (TTO)22; and chevron wedge osteotomy
(CVWO).23 The more recently described tibial tuberosity
advancement (TTA) procedure attempts to dynamically
neutralize craniocaudal instability by altering the relative
alignment of the patellar tendon to the tibial plateau.24
Although there are few studies evaluating long-term
functional outcomes of any of these tibial osteotomy
techniques, most have been associated with favorable
clinical results.18–22,24–26
Our purpose was to review the biomechanical consid-
erations, experimental investigations, and clinical data
pertaining to tibial osteotomy procedures for treating
CrCL insufficiency in dogs.
CrCL BIOMECHANICS
Because of the high prevalence of CrCL insufficiency,
and because CrCL transection in dogs is frequently used
as an experimental model to induce OA,27 the structure
and function of the CrCL has been extensively investi-
gated.28–32 Cadaveric experiments, in vivo kinematic an-
alyses and theoretical models have contributed to
understanding of CrCL biomechanics and subsequently
lead to the development of tibial osteotomy techniques.
Using a cadaver model, Arnoczky and Marshall dem-
onstrated that the CrCL contributes to passive restraint
specifically limiting cranial translation of the tibia relative
to the femur, excessive internal rotation of the tibia, and
hyperextension of the stifle.29 Other structures that pro-
vide passive restraint of the canine stifle include the cau-
dal cruciate ligament (CaCL), the collateral ligaments,
and menisci.29,33,34 The loss of a passive supporting
structure about a joint may increase laxity, but does not
necessarily result in clinically relevant instability.35 Dur-
ing in vivo activity, joints are subject to other important
dynamic restraint mechanisms, such as those produced
by muscular force.35 For instance, electromyographic
studies have shown that humans with anterior cruciate
ligament rupture can inhibit anterior tibial translation by
increasing hamstring tone and decreasing quadriceps ac-
tivity.36 Further, the magnitude of forces applied to a
joint to demonstrate and quantify joint laxity in vitro
may be considerably different than the physiologic loads
that are sustained in vivo. Therefore, results of cadaver
experiments such as those reported by Arnoczky and
Marshall do not fully define whether or not the CrCL is a
primary stabilizer of the canine stifle.
Kinematic studies in dogs, using stereo radio-
photogrammetry and/or instrumented spatial linkage,
were able to confirm that CrCL transection results in
substantial cranial tibial subluxation during the stance
phase of gait.30,31 These findings demonstrate that mus-
cular forces are unable to compensate for the loss of re-
straint provided by the CrCL. In all but 1 dog, cranial
tibial translation did not occur during the swing phase of
gait. Thus, the authors concluded that the stability of the
stifle during the stance phase of gait is dependent on the
CrCL, whereas stability during the swing phase of gait is
not dependent on the integrity of the CrCL. These ob-
servations are in agreement with findings from a study in
goats that measured dynamic CrCL strain in vivo, where
maximum CrCL force occurred in early stance phase, and
 KIM ET AL 113

dropped to zero during the swing phase of gait.37 Con-

versely, neither kinematic study found significant differ-
ences in peak internal rotation magnitude between CrCL-
deficient dogs and normal dogs,30,31 suggesting that either
the CrCL is a secondary stabilizer against internal tibial
rotation, or that nominal internal tibial torques are gen-
erated while walking.
In the clinical setting, diagnosis of complete CrCL
rupture is made by detection of craniocaudal joint laxity,
which can be elicited by applying a cranially directed load
on the proximal tibia. The ‘‘cranial drawer’’ test can be
considered a ‘‘static’’ clinical test and is analogous to the
cadaver experiment performed by Arnoczky and Mar-
shall, because eliciting cranial drawer relies on displace-
ment of a bone in the direction of an applied force.35
‘‘Dynamic’’ tests, on the other hand, aim to mimic the
forces and dynamic instabilities that normally occur dur-
ing weight bearing.35 The ‘‘tibial compression’’ test, de-
scribed by Henderson and Milton38 in 1978, attempts to Fig 1. Slocum theorized that, during weight bearing, the joint
replicate a weight-bearing force on the limb by flexing the reaction force (magenta arrow) is approximately parallel the
hock. With the stifle at a standing angle, the tension longitudinal axis of the tibia. In the CrCL-deficient stifle (A),
generated in the gastrocnemius muscle creates strong the joint reaction force can be resolved into a cranially directed
caudodistal traction of the femur and consequently a tibiofemoral shear component (parallel to tibial plateau) and a
cranioproximal shear force on the tibia.38 This force is joint compressive force (perpendicular to tibial plateau). By
leveling the tibial plateau (B), the joint reaction force is per-
normally counteracted by the CrCL, so cranioproximal
pendicular to the tibial plateau, thus can only be resolved into
translation of the tibia will result if the CrCL is ruptured.
a joint compressive force; cranial tibial thrust is eliminated.
The tibiofemoral shear force that occurs during weight- CrCL, cranial cruciate ligament.
bearing was termed ‘‘cranial tibial thrust’’ by Slocum in
1983.32
Slocum also presented a theoretical model that pro- dent on the angle between the tibial plateau and the
posed the magnitude of cranial tibial thrust was depen- patellar tendon (Fig 2).28 This model also predicts that
dent on the degree of the caudodistally directed slope of cranial tibial translation should not occur when a CrCL-
the tibial plateau.32 Quantification of the tibial plateau deficient stifle is flexed beyond 901.28
slope, the tibial plateau angle (TPA), is defined by the Based on the predominant craniocaudal instability
angle formed between the slope of the medial tibial con- generated by CrCL transection in vivo; it is reasonable to
dyle and the perpendicular to the longitudinal axis of the conclude that neutralization of cranial tibial thrust is
tibia.18 Reported mean TPAs in clinically normal dogs likely the most important function of the CrCL.30 Ac-
range from 18 to 241.39–41 According to Slocum, the cordingly, current tibial osteotomy techniques primarily
compressive forces of weight-bearing, assumed to be aim to address the sagittal plane instability that occurs as
parallel to the axis of the tibia, can be resolved into a a result of weight-bearing. Because these procedures do
cranially directed component (the cranial tibial thrust) not provide a passive restraint against internal tibial
responsible for cranial tibial translation, and a joint rotation, excessive internal tibial rotation may still occur
compressive force (Fig 1).32 A correlation between tibial (e.g. during certain vigorous activities that involve piv-
plateau slope and anterior or cranial tibial thrust oting on the pelvic limb), and rotational instability may
has been confirmed in human and animal in vitro potentially contribute to the subsequent development of
models.42–44 It is, however, important to note that there OA and meniscal injury.
is no definitive evidence substantiating that dogs with
higher than average TPAs are at greater risk for devel- CTWO
oping CrCL insufficiency.39,40
More recent biomechanical theories argue that the CTWO was the first reported procedure that attempt-
tibia is not axially loaded as proposed by Slocum. Rather, ed to eliminate cranial tibial thrust by reducing TPA.18
Tepic suggests that the total tibiofemoral joint forces in Initially recommended as an adjunct to procedures that
vivo are directed parallel to the patellar tendon.28,45 Cra- impart passive stabilization (such as fascial imbrication),
nial tibial thrust, according to this model, is then depen- CTWO involves leveling the TPA by resecting a cranially
114 TIBIAL OSTEOTOMIES FOR CRANIAL CRUCIATE LIGAMENT INSUFFICIENCY IN DOGS
Fig 2. An alternate theory, proposed by Tepic, suggests that
the joint reaction force (magenta arrow) is approximately par-
allel to the patellar tendon, not the tibial long axis. In the
CrCL-deficient stifle (A), the joint reaction force can be re-
solved into a cranially directed tibiofemoral shear component
and a joint compressive force (yellow arrows). By advancing
the tibial tuberosity cranially, the patellar tendon is perpen-
dicular to the tibial plateau during stance phase of gait (B). The
joint reaction force, therefore, becomes perpendicular to the
tibial plateau during weight bearing, thus can only be resolved
into a joint compressive force; cranial tibial thrust is eliminat-
ed. CrCL, cranial cruciate ligament.
based wedge of bone from the proximal tibia, apposing
the margins of the ostectomy site, then stabilizing the 2
bone segments with a medially applied bone plate using
AO-ASIF principles (Fig 3). The ostectomy is performed
as proximally as feasible while preserving a large enough
proximal bone segment to allow for fixation with at least
3 screws in each segment.46
Recent biomechanical studies suggest that to achieve a
postoperative TPA of 51, and thereby neutralize cranial
tibial thrust, the angle of the wedge to be excised should
equal the measured preoperative TPA.47 Intuitively, it
would seem that a wedge angle equal to the TPA would
result in a postoperative TPA of 01. Performing a
CTWO, however, induces tibial longitudinal axis shift,
which is responsible for inadequate leveling of the tibial
plateau slope.46,48 After CTWO, the proximal landmark
for defining the tibial longitudinal axis of the tibia, the
intercondylar tubercles, is shifted cranially.46,48 To com-
pensate for this change in position, ‘‘over-rotation’’ of the
tibial plateau is necessary to achieve the expected TPA of
51. The postoperative TPA will be larger than anticipated
if calculations do not account for the shift of the longi-
tudinal axis of the tibia.46
Fig 3. Position of the osteotomies and postoperative illustra-
tion of cranial tibial wedge ostectomy.
Wide discrepancies in the postoperative TPAs have
been reported after CTWO.18,49,50 For instance, within a
single case series reported by Macias et al49, postopera-
tive TPAs ranged from 7 to 211. Difficulty in attaining the
target TPA may be attributed to variability in size and
position of the ostectomy, and tibial longitudinal axis
shift.46 Resecting a wedge equal to the TPA, performing
the ostectomy as proximal as practical, and aligning the
cranial cortices is recommended to improve the accuracy
of the procedure.46,47 Intraoperative calculation of the
wedge angle should be precise and methodical to further
minimize variability in the postoperative TPA. A trigo-
nometric method,20 or a sterilized template of the desired
wedge made from radiographic film can be used for this
purpose.
CTWO may be indicated in dogs with certain types of
proximal tibial conformation. Although no causal rela-
tionship between a high TPA and CrCL insufficiency has
been established, abnormally steep tibial plateau slopes
have been implicated as the underlying cause of CrCL
rupture in several case series.20,49–51 Exceedingly steep
tibial plateau slopes secondary to alterations in proximal
tibial physeal growth may be most amenable to treatment
with a CTWO.52 Osmond et al52, attempted to charac-
terize anomalies of the proximal portion of the tibia by
correlating the morphometry of the proximal tibia in
clinical CrCL insufficiency cases with computer-generat-
ed models that mimicked different tibial morphologies.
 KIM ET AL
The authors identified a subset of CrCL-deficient dogs
with steep TPAs attributed to proximal shaft deformities,
and theorized that the tibia would assume a more ana-
tomically correct alignment after CTWO, as the proce-
dure tilts the distal portion of the tibial shaft in relation to
the proximal portion.52 In our experience (A.P.), correc-
tion of substantial proximal tibial varus or torsion are
also more easily addressed by CTWO compared with
other tibial osteotomy techniques.
Although dynamic stabilization of CrCL-deficient sti-
fles is receiving considerable attention, reports document-
ing clinical outcomes after CTWO are sparse. In a
preliminary study of the CTWO involving 17 dogs, Slo-
cum and Devine reported rapid return to function and
clinical union of the osteotomy for most dogs by 6 weeks
after surgery.18 All 9 dogs evaluated at 12 months after
surgery had limb function that was subjectively consid-
ered indistinguishable from normal. Radiographic evi-
dence of OA did not progress in any of the stifles;
however, objective, quantitative assessment of stifle OA
was not performed. The dogs also had semitendinosus,
gracilis, and biceps femoris muscle advancement to re-
duce laxity, confounding the assessment of the CTWO
procedure. In a retrospective analysis of 91 dogs treated
with CTWO, 86% of the dogs were considered to have
good-to-excellent limb function based on the results of a
client survey and physical examination.25 Two case series
reported the results of CTWO in small breeds dogs with
proximal tibial deformities.49,50 Subjective lameness grad-
ing or owner satisfaction was used to gauge the efficacy of
the procedure. All dogs (13 overall) in both studies had
good-to-excellent limb function within 6 weeks after sur-
gery, and maintained good limb use with an average
follow-up of 1 year. In 1 of these reports, CTWO was
combined with lateral suture stabilization, making it
difficult to ascertain the efficacy of CTWO alone in this
group of dogs.50
Reported complications have been principally associated
with failure of fixation and nonunion.18,25,49,50,53 In a direct
clinical comparison of TPLO and CTWO, the second-sur-
gery rate for CTWO was 11.9%, nearly twice the second-
surgery rate for TPLO (4.5%).51 Of the 12 dogs requiring
surgical revision after CTWO, 9 were considered to have
catastrophic tibial fractures requiring multiple plating.51
CTWO has the advantage of not requiring patented
specialized equipment.53 Other advantages include the
ability to address exceedingly steep tibial plateau slopes,
as well as tibial varus and torsion. Because CTWO causes
distal displacement of the patellar tendon insertion, the
procedure may be used to treat concurrent patella alta.20
Disadvantages include: variability in postoperative TPAs,
potential for creating patella baja and limb shorten-
ing.20,49,50 Also, inducing longitudinal tibial axis shift
may result in esthetically undesirable craniocaudal an-
115
gulation of the tibia.20 With the growing recognition of
proximal tibial angular limb deformities inducing steep
TPAs, CTWO may gain wider acceptance in the treat-
ment of CrCL insufficiency.
TPLO
Like CTWO, TPLO aims to provide dynamic cranio-
caudal stifle stability during the stance phase of gait by
reducing the slope of the tibial plateau. Proposed by
Slocum in 1993, TPLO involves performing a radial
osteotomy of the proximal tibia with subsequent rotation
of the proximal segment to enable precise manipulation
of the tibial plateau slope.19 Based on the radius of the
osteotomy and the preoperative TPA, the exact amount
of rotation of the proximal segment is calculated to
achieve a postoperative angle of 51.54 The procedure is
performed by a medial approach to the proximal tibia.54
A biradial saw blade is used to create a crescent-shaped
osteotomy; compression of the osteotomy results in com-
plete congruency, as the inner and outer edges of the saw
blade are of the same diameter.54 A custom-jig that is
applied medially maintains alignment of the bone
segments while allowing for rotation of the proximal
segment.54 The osteotomy should be centered over the
intercondylar tubercles to ensure accurate rotation and
maintain enough bone in the proximal segment for ad-
equate purchase during internal fixation of the osteotomy
(Fig 4).54 Imprecise positioning of the osteotomy may
result in an inaccurate tibial plateau leveling and com-
plications such as angular and rotational deformities, and
tibial tuberosity fracture.55–57
Biomechanical studies have demonstrated that after
tibial plateau rotation, the tibiofemoral shear force shifts
from cranial to caudal when the limb is loaded.42,43 Thus,
it has been postulated that joint stability is dependent on
the CaCL neutralizing caudal tibial translation after
TPLO.42 The recommended postoperative TPA was de-
fined as 0 and 51 when the procedure was first described
in 1993 and in the TPLO licensing course, respective-
ly.18,54 Despite these specific guidelines, the optimal TPA
is still a contentious subject. In vitro studies demonstrate
that cranial tibial thrust is effectively neutralized at a
mean angle of 6.51.42,43 Three-dimensional computer
modeling of the canine stifle, on the other hand, found
that rotation to 51 only marginally decreased the tensile
force acting on the CrCL.58 Both in vitro analyses and
theoretical modeling, however, can fail to reliably predict
clinical outcome.59 Limitations associated with cadaver
experiments include the difficulty of replicating naturally
occurring disease and the inability to simulate all the
muscular forces acting on the joint. Inaccuracies of com-
puter modeling can arise from multiple assumptions, such
as disregarding muscular compensation, and simplifying
116 TIBIAL OSTEOTOMIES FOR CRANIAL CRUCIATE LIGAMENT INSUFFICIENCY IN DOGS
Fig 4. Position of the osteotomy and postoperative illustra-
tion of tibial plateau leveling osteotomy.
joint geometry. Data from in vitro and computer-mod-
eling investigations should be interpreted and applied to
clinical cases with caution because of these limitations. In
a clinical study by Robinson et al60, there was no statis-
tically significant relationship between TPA and ground
reaction forces after TPLO, where the postoperative
TPAs were between 0 and 141. Satisfactory results of
under-rotated stifles, which were indistinguishable from
the outcome of dogs that had ‘‘optimal’’ postoperative
TPAs, may be indicative of complete elimination of cra-
nial tibial thrust in vivo over a wide range of angles.
Optimal TPAs may vary between breeds, or indeed be-
tween individual dogs. Chronically affected stifles may
not require as much rotation as stifles with acute rupture,
because periarticular fibrosis can contribute substantially
to joint stability.7 Alternatively, the presence of residual
cranial tibial thrust after TPLO may not result in lame-
ness.19 Precise in vivo kinematic analyses are required to
identify the optimal TPA and further understand the
biomechanics of the TPLO.
Results for dogs treated with TPLO have so far been
encouraging, although there are no studies documenting
objective data with follow-up 417 months (mean).60
Subjective evaluation of limb function suggests earlier
return to weight-bearing after TPLO when compared
with the intra- and extracapsular forms of stabilization.61
Beyond the initial recovery period, however, convincing
proof that the TPLO results in superior limb function
currently does not exist. In Slocum’s original study,
which included 394 dogs, outcomes at follow-up evalu-
ations 46 months after surgery were reported as excel-
lent for 73%, good for 21%, and fair for 3%.19 Another
study with a follow-up ranging from 6 months to 4 years
reported that 93% of owners were satisfied with the out-
come after TPLO, which is similar to the proportion of
owner satisfaction after other techniques.57 Good to ex-
cellent long-term function, based on owner evaluation,
has also been reported in most dogs (25 cases, 50 stifles)
treated with single-session bilateral TPLOs.62
In an in vivo experiment by Ballagas et al63, experi-
mentally induced CrCL-deficient pelvic limbs were treat-
ed with TPLO and evaluated with force plate analysis
preoperatively, at 8 and 18 weeks after surgery. By 18
weeks, peak vertical force and vertical impulse were not
significantly different when compared with preoperative
values, although a subjective mild lameness was still ev-
ident in 4 of 6 dogs. Conzemius et al64 in a prospective
clinical study in Labrador Retrievers with CrCL insuffi-
ciency compared limb function after lateral suture stabi-
lization, intracapsular stabilization, and TPLO using
force platform gait analysis. Contrary to the conclusions
drawn by some studies that evaluated outcomes subjec-
tively, these investigators found no difference in ground
reaction forces or peak vertical impulse between TPLO
and lateral suture stabilization treated dogs at 2 and 6
months after surgery. Moreover, only 10.9% of TPLO-
treated dogs obtained comparable limb function to clin-
ically normal dogs compared with 14.9% of dogs with
lateral suture stabilization and 15% of dogs with intra-
capsular stabilization evaluated in the same study.
There are several reports that have investigated the
progression of stifle OA after TPLO. A prospective ra-
diographic study of 40 dogs showed a significant overall
increase in mean osteophyte scores 6 months after
TPLO.65 Interestingly, progression of osteophytosis was
not evident in most (57.5%) of dogs, and radiographic
parameters of OA were improved in 2 dogs.65 A com-
parison of long-term radiographic changes after TPLO
and lateral suture stabilization revealed that whereas
TPLO did not prevent progression of OA, rate of pro-
gression was
3-fold less than stifles that had lateral
suture stabilization.66 Studies assessing the efficacy of
TPLO based on radiographic OA assessment should be
interpreted with caution, as soft tissue (e.g. cartilage,
synovium, menisci, periarticular tissues) changes are not
readily identifiable with this imaging modality, and 1
study has shown that radiographic OA changes in the
stifle are not predictive of limb function.67
Numerous intra- and postoperative complications
have been reported in dogs undergoing TPLO. The rel-
ative high frequency of complications reported for TPLO
may be because of the large number of cases that have
 KIM ET AL
been evaluated in the literature, and many of these studies
were documenting initial experience with this technique.
The overall complication rate is reportedly 26–34%, with
tibial tuberosity fracture, implant failure, patellar ten-
donitis, subsequent meniscal tear after TPLO and infec-
tion reported most frequently.57,68–72 Whereas most are
implant or fracture-related complications, others have
been attributed to abnormal stifle biomechanics induced
by TPLO.57,68–72 Tibial tuberosity fracture occurs in 3–
7% of TPLO cases.68–70 Most of these fractures are non-
or minimally displaced and do not require surgical inter-
vention.57 Fracture of the tibial tuberosity may be caused
by a stress riser effect at the site of Kirschner wire place-
ment used to maintain the rotation of the tibial plateau
segment, or at the narrow isthmus of the tibial tuberosity
created by a cranially positioned osteotomy.68,69 Thermal
necrosis, vascular compromise secondary to soft tissue
dissection, increased strain in the patellar tendon after
TPLO and large rotations of the tibia plateau segment
have also been cited as potential predisposing fac-
tors.20,57,68 A retrospective analysis by Kergiosen et al57
identified age, weight, single session bilateral TPLO sur-
gery and tibial tuberosity width as potential risk factors
for tibial tuberosity fractures. Prophylactic pin and ten-
sion bands have been used in an attempt to decrease the
risk of tibial tuberosity fractures.62
Patellar tendonitis is also common, and may cause
lameness within the first 2 months after TPLO.68,69,71,72
Clinical signs are usually self-limiting. Patellar tendon
thickening, visible on radiographs or by ultrasonography,
is most commonly noted distally.72 Possible causes in-
clude trauma to the patellar tendon sustained during
surgery because of excessive retraction, or thermal dam-
age associated with saw blade contact.71,72 Histopatho-
logic changes in the tendon are noninflammatory and
similar to those identified in humans with patellar tendon
strain, hence excessive loading of patellar tendon second-
ary to altered biomechanics after TPLO has also been
implicated as a possible underlying cause.55,71 Rotation
of the tibial plateau segment may result in a decreased
moment arm if the distance between the patellar tendon
insertion and instant center of rotation of the stifle is
reduced; in turn, greater forces in the quadriceps mech-
anism may be required to generate the same extensor
moment about the stifle.55,71 This theory is corroborated
by findings from a radiographic study by Mattern et al72,
where lower postoperative TPAs (o61) were associated
with more severe ultrasonographic changes in the patellar
tendon.
Recurrent lameness after TPLO may indicate subse-
quent meniscal injuries. Although meniscal tears occur-
ring after stabilization of CrCL-deficient stifles have been
reported as a complication associated with several pro-
cedures,73,74 it is proposed that there is a high risk of
117
developing meniscal injuries after TPLO because passive
joint stability is not restored.19 The caudal pole of the
medial meniscus acts as a wedge between the femoral and
the tibial condyles and may become crushed during cra-
nial tibial translation.34 TPLO places the stifle joint in a
greater angle of flexion during weight bearing, which
might result in excessive loading of the caudal pole of the
medial meniscus.28 Slocum and others have advocated
complete radial transection of the medial meniscus,
termed meniscal release, to allow caudal displacement
of the caudal pole of the medial meniscus during cranial
tibial translation, thereby preventing subsequent meniscal
tears.19,68 In vitro studies have, however, shown that
meniscal release impairs load transmission and stability
of the stifle.34,75 The adverse consequences of releasing
the meniscus were corroborated by a radiographic study
demonstrating greater progression of OA in dogs that
had meniscal release.76 Furthermore, there is no evidence
to suggest that meniscal release eliminates the risk of
subsequent meniscal tears.77 A recent retrospective study
reported a 3.5% incidence of subsequent meniscal injury
in stifles that underwent arthrotomy with meniscal
release.77 Meniscal release did not reduce the rate of
subsequent meniscal tearing when compared with cases
treated arthroscopically without meniscal release.77
Whereas traditionally, stifle arthrotomy has been con-
sidered as an accurate method for assessing the menisci,78
the data suggest that lack of identification of meniscal
tears at the time of TPLO may play an important role in
the development of recurrent lameness because of men-
iscal pathology.77 Indeed, a recent cadaver study found
that meniscal examination by arthrotomy had significant-
ly lower sensitivity and specificity than arthroscopy for
diagnosing meniscal tears.79 When meniscal pathology
cannot be comprehensively assessed in the CrCL-deficient
stifle, releasing the medial meniscus is advocated to de-
crease the incidence of subsequent meniscal tears.77,79 If
the medial meniscus is thoroughly evaluated at the time of
TPLO, and cranial tibial thrust is effectively neutralized,
meniscal release may not be warranted.77,79
The decision to release an intact meniscus remains
controversial, and the issue is further complicated by the
apparent nominal impact meniscal release has on limb
function.77 Further studies are necessary to determine the
long-term effects of meniscal release on joint function. It
is important to note that although meniscal release is
most commonly referenced to TPLO, performing a men-
iscal release is not restricted to this procedure because
passive joint laxity is a consistent feature of all tibial
osteotomy techniques.
CaCL injury is cited as a potential complication after
TPLO.19 Because TPLO is postulated to induce caudal
tibial thrust, over-rotation increases strain on the CaCL.42
Whereas increased strain has been demonstrated in
118 TIBIAL OSTEOTOMIES FOR CRANIAL CRUCIATE LIGAMENT INSUFFICIENCY IN DOGS

cadaver studies,42 clinical cases with postoperative lame-

ness definitively attributed to CaCL strain or rupture
have not been reported, even in cases where TPAs have
been as low as 71.68
Neoplasia developing at the TPLO surgical site has
been documented; however, a direct causal relationship
has not been proven.80 Boudrieau et al80 recently de-
scribed a dog with an histiocytic sarcoma involving the
proximal portion of the tibia 5 years after TPLO. Visual,
microscopic, chemical and metallographic analysis of the
TPLO plate retrieved from this dog revealed corrosion;
poor resistance to corrosion was attributed to the casting
manufacturing process of the implant. Implant corrosion
was implicated as a potential cause of tumor develop-
ment, and 3 additional dogs were identified that had
previously undergone TPLO and developed osseous ne-
oplasia of the proximal tibia. These findings prompted
further investigations; metallurgic analyses of both new
and previously implanted Slocum TPLO plates revealed
these plates had unusual surface irregularities and poros-
ity.81,82 Aluminum and silicon residua and inclusions,
which were thought to have originated from the cast
moulds, were also identified.81
Conflicting results exist regarding corrosion of retrie- Fig 5. Position of the osteotomy and postoperative illustra-
ved implants.81–83 Although investigations have focused tion of tibial tuberosity advancement.
on corrosion as a potential cause for neoplasia, other
causative factors that are not specific to the Slocum medium to large breed dogs.64 Advantages include
TPLO plate, such as the osteotomy itself, have not been geometric precision, maintenance of the original position
eliminated. Moreover, TPLO is almost exclusively rec- of the tibial tuberosity and patellofemoral joint.20 Dis-
ommended to a population of dogs that are at risk for advantages include the technical difficulty and complica-
developing primary osseous neoplasia, of which the prox- tions of the surgical procedure, including iatrogenic
imal tibia is a common site of occurrence.84 Further work angular and torsional deformities, as well as the poten-
is warranted to determine whether the TPLO procedure, tial adverse affects on stifle biomechanics.56,57,69,70,72
or the specific implants used, increase the risk of tumor
development.
Infection, manifesting as septic arthritis, osteomyelitis, TTA
or superficial wound infection is reported with a rate of
3–7%, which is greater than the infection rate previously TTA, first described by Montavon et al24 in 2002, at-
reported for other clean surgical procedures.68–70,85 Septic tempts to dynamically stabilize the CrCL-deficient stifle
arthritis is considered one of the most serious complica- without leveling the tibial plateau. As previously dis-
tions encountered after TPLO.68 The cause of higher in- cussed, theoretical models of the stifle predict that the
fection rate after TPLO is likely multifactorial. Infection total joint forces are approximately parallel to the patel-
after open reduction and internal fixation of proximal lar tendon.28 Thus, if the patellar tendon is oriented
tibial fractures in human patients is attributed to poor soft perpendicular to the tibial plateau, there is no shear
tissue coverage and blood supply.86 Poor soft tissue cov- component of the total joint force. During the stance
erage of the surgical site may play a role in migration of phase of gait, where the stifle angle is 1351 of extension,
bacteria through the surgical wound from the external the angle between the patellar tendon and the tibial pla-
environment.86 Extensive soft tissue dissection around the teau is approximately 1051.45 Accordingly, reducing this
proximal tibia, poor tissue handling, prolonged surgical angle to 901 should stabilize the CrCL-deficient stifle (Fig
time, surface plate characteristics87, and thermal necrosis 2). This anatomic conformation can be achieved by per-
at the osteotomy site may also contribute to infection. forming a TTA (Fig 5). The procedure involves making a
TPLO is currently the most common tibial osteotomy longitudinal osteotomy subjacent to the tibial tuberosity.
performed, and widely regarded by many veterinary sur- An appropriately sized spacer-cage is implanted at the
geons as the best surgical option for CrCL insufficiency in proximal extent of the osteotomy to secure the tibial
 KIM ET AL
tuberosity in a cranial position. The width of the cage,
available in 3, 6, 9, and 12 mm sizes, is determined by
measurements made from preoperative lateral pelvic limb
radiographs with the stifle at
1351 extension.24 A ten-
sion-band bone plate is applied to the medial aspect of
the tibia, and autogenous or allogenic bone graft is placed
in the resulting defect to accelerate bone union.24
Theoretical reduction of tibiofemoral shear forces by
advancing the insertion of the patellar tendon has been
substantiated in both cadaver and computer-modeling
studies.88–90 Maquet’s procedure in human patients in-
volves anterior advancement of the tibial tuberosity,
which is advocated for treatment of patellofemoral
pain.91 In a cadaver study of Maquet’s procedure, the
magnitude of tibiofemoral forces in a direction tangential
to the joint surfaces consistently decreased after incre-
mental advancement, provided the knee angle was at
near-to-full extension.90 Similarly, finite element analysis
of the human knee found that, at near full extension, an-
terior cruciate ligament and tibiofemoral contact forces
substantially decreased after advancement of the tibial tu-
berosity.89 A recent in vitro study performed in canine
cadaver pelvic limbs also demonstrated neutralization of
tibiofemoral shear forces by advancing the tibial tubero-
sity, where the mean patellar tendon-to-tibial plateau angle
required to eliminate cranial tibial thrust was 90  91.88
Clinical outcomes after TTA are currently document-
ed in a small number of preliminary reports only 2 of
which are still in abstract form.24,92,93 In a prospective
clinical trial of 40 CrCL-deficient stifles treated with
TTA, mean peak vertical force was 32% of body weight
preoperatively, and doubled to 64% of body weight at a
final examination performed between 4 and 12 months
after surgery.92 This was still significantly lower than a
mean peak vertical force of 74% in clinically normal
dogs, although the results are comparable with the find-
ings in a similar study evaluating pelvic limb function
before and after TPLO.92 In a retrospective report, 38 of
40 owners (95%) were satisfied with the long-term out-
come of TTA, and the author’s clinical impression was
that the postoperative recovery with this technique was
very rapid.93 Hoffman et al26, found that, with a median
follow-up of 24 weeks, owners assessed the overall out-
come of the procedure good to excellent in 90% of cases.
These initial results appear promising; however, accurate
assessment of outcome after TTA is not currently pos-
sible because of a lack of reported clinical studies.
Reported complications associated with TTA include
implant failure, tibial tuberosity fracture, medial patellar
luxation, CaCL injury because of excessive advancement,
and subsequent meniscal injury.26,92,93 Implant failure,
reported to occur in 1–5% of operated limbs, was attrib-
uted to either technical error or earlier implant designs that
were considered too weak; the implants have been subse-
119
quently modified. Excessive postoperative activity has also
resulted in complete implant failure.26 Partial CaCL rup-
ture diagnosed 4 months after surgery in 1 dog was attrib-
uted to excessive advancement of the tibial tuberosity.92
Indeed, in the cadaver study by Apelt et al88, caudal tibial
translation was found to occur when the tibial tuberosity
was advanced beyond the defined angle required to neu-
tralize cranial tibial thrust, presumably placing excessive
strain on the CaCL. Postoperative meniscal injuries were
frequent in 1 study, occurring in 7 of 24 cases that had
intact medial menisci at surgery.93 It is difficult to ascertain
whether this was an accurate reflection of the true prev-
alence of late meniscal injury associated with the TTA, if
meniscal lesions were the result of unfavorable biomechan-
ics, if meniscal lesions were missed at the primary surgery,
or if meniscal lesions were caused by insufficient advance-
ment of the tibial tuberosity after TTA.
From a biomechanical perspective, TTA may have 2
principal advantages over TPLO. TTA preserves the nat-
ural tibiofemoral articulation because the tibial plateau is
not repositioned. In doing so, and provided that the TTA
is equally as effective as the TPLO in neutralizing cranial
tibial thrust, natural load transmission across the stifle
(and menisci) is less likely to be altered. TTA also in-
creases the extensor moment arm of the stifle and thus the
mechanical advantage of the patellar tendon, thereby
theoretically reducing the forces acting along the patellar
tendon.28 TPLO, on the other hand, appears to increase
the strain on the extensor mechanisms of the stifle, re-
sulting in clinically relevant complications.55,71 At this
stage, these potentially advantageous features of TTA are
purely speculative, and future biomechanical analyses will
hopefully provide information that allows objective com-
parisons between TTA and TPLO.
Purported advantages of TTA include being less in-
vasive and technically less demanding than other tibial
osteotomies, an ability to effectively treat concurrent pa-
tellar luxation,94 short operative time, and low postop-
erative morbidity.92 Disadvantages include the potential
to cause iatrogenic patellar luxation, requirement for
specialized implants, and potentially high rate of late
meniscal injuries. Because the technique is a new proce-
dure, the true benefits and complications are yet to be
substantiated by sufficient clinical or biomechanical data.
OTHER TIBIAL OSTEOTOMY TECHNIQUES
Several other tibial plateau leveling techniques have
been described. Whereas information regarding these
procedures is limited, each procedure presents unique
methods developed to circumvent certain limitations of
conventional tibial osteotomies described above, and may
gain further attention in the future.
120 TIBIAL OSTEOTOMIES FOR CRANIAL CRUCIATE LIGAMENT INSUFFICIENCY IN DOGS

of cases. Most notably, implant failure necessitating a

second procedure occurred in more than 1 in 4 cases, and
mean time to complete radiographic healing was pro-
longed at 18 weeks.
CrCL insufficiency in dogs with exceedingly large
TPAs remains a challenging orthopedic problem, and
despite a high complication rate, combination TPLO/
CTWO may be one of few surgical procedures resulting
in an acceptable outcome. Dogs with excessive TPAs may
also have concurrent pelvic limb conformational abnor-
malities,51 and proponents of combining TPLO with
CTWO suggest many of these conditions can be ad-
dressed with this technique.20 It is arguably the most
technically demanding procedure of all described tibial
osteotomies and should thus be performed by only ex-
perienced veterinary orthopedic surgeons.

PTIO

PTIO is another tibial plateau leveling technique that

involves making a wedge ostectomy with the base of the
wedge located between the bursa of the patellar tendon
Fig 6. Position of the osteotomies and postoperative illustra- and the cranial aspect of the menisci (Fig 7).21,95 A biaxial
tion of tibial plateau leveling osteotomy and cranial tibial approach is required: tibial osteotomies are performed
wedge ostectomy. from the medial surface; laterally the craniolateral crus
muscles area is elevated off the proximal tibia and a fibula
ostectomy is made to facilitate reduction of the ostectomy
Combination Closing Wedge Osteotomy and TPLO site. Both medial and lateral arthrotomies are recom-
Combination TPLO and CTWO is primarily used to
treat CrCL-deficient stifles with excessive TPAs (4341).20
Reducing TPA by using both methods concurrently is
purported to diminish the risk of complications encoun-
tered when either procedure is performed alone, such as
patella baja and tibial tuberosity fracture.20 The magni-
tude of rotation and wedge angle is determined by stan-
dardizing 1 measurement (e.g. wedge angle 101), then
calculating the remainder of tibial plateau leveling
with the other measurement (e.g. tibial plateau rota-
tion ¼ TPA–5–wedge angle) to achieve a postoperative
TPA of 51. The radial osteotomy is positioned in the
same location as a standard TPLO, and the cranially
based closing wedge ostectomy is placed such that the
apex is at the caudal cortical margin of the TPLO. Ex-
tensive rigid internal fixation using interfragmentary
Kirschner wires, tension-band wire, and single or double
plating is required to stabilize all 3 bone segments (Fig 6).
In a clinical series of 15 dogs with excessive TPAs, a
mean postoperative TPA of 81 was achieved with com-
bination TPLO/CTWO.20 At a mean final follow-up of
23 weeks, no lameness was observed in 73%, only a mild
lameness was noted in the remaining 27%, and all owners
were satisfied with the overall outcome. Postoperative Fig 7. Position of the osteotomies and postoperative illustra-
complications were, however, common, occurring in 78% tion of proximal tibial intraarticular osteotomy.
 KIM ET AL 121

mended to inspect the stifle and excise the infrapatellar fat

pad for adequate visualization during the procedure. The
angle of the wedge to be excised is determined from pre-
operative radiographs, but descriptions of calculating this
angle are vague. The margins of the osteotomies are re-
duced with reduction forceps and stabilization is achieved
with screws inserted in lag fashion craniocaudally, with or
without augmentation using a medially positioned 6-hole
plate applied in buttress fashion. The medial and lateral
fascia may be imbricated to reduce passive instability.
In the original description of this procedure, 75 of 87
dogs (86%) were considered to have a sound gait at fol-
low-up assessments 4 months postoperatively, but 7 dogs
(8%) were still moderately lame.21 Slightly better out-
comes were reported by Jerram et al95, where lameness
was not apparent in 54 of 57 (95%) operated limbs when
examined 6 months after surgery. The remaining 3 (5%)
operated limbs had intermittent, mild, weight-bearing
lameness with exercise.95 Although the overall proportion
of dogs with satisfactory results is comparable with other
tibial osteotomy procedures, multiple complications may
preclude PTIO from gaining wide acceptance.21 A high
rate of subsequent meniscal injuries has been observed.
Of 57 stifles with an intact medial meniscus, subsequent
Fig 8. Position of the osteotomies and postoperative illustra-
meniscal injury requiring surgical intervention occurred tion of chevron wedge osteotomy.
in 10 stifles (17.5%).21 Induced tibial valgus deformity
was observed in both reports, occurring in 3–12% of
gle, the osteotomies should be positioned as proximally as
operated limbs. Other reported complications included
possible, and the ostectomy site is stabilized with a me-
long digital extensor trauma or fibrosis, requiring a sec-
dially applied bone plate. Accurate execution of the
ond surgery and intensive physical therapy, superficial
osteotomies may be facilitated with the use of a saw-blade
peroneal nerve injury, laceration of the cranial tibial ar-
guide jig, and stability of the construct can be enhanced
tery, tibial fracture, osteomyelitis, and implant failure.21,95
by use of a cranially placed screw inserted in lag fashion,
The main advantage of PTIO is that it can be per-
directed caudad and proximad.
formed without need for specialized surgical equip-
Clinical outcomes of CVWO for treatment of CrCL
ment.21,95 Disadvantages include long operative time,
insufficiency in dogs have not been reported, and thus the
apparent necessity for medial meniscal release, and oc-
complication rate is unknown. In an in vitro geometric
currence of complications, such as valgus deformities and
study of 5 different tibial osteotomy techniques,23 CVWO
long digital extensor tendon injury that often require sur-
induced the greatest amount of tibial valgus deformity,
gical revision. The requirement for extensive arthrotomies
and postoperative valgus has also been observed anec-
is unfavorable when compared with other techniques, as
dotally in clinical cases (Denis J. Marcellin-Little, 2007,
studies have demonstrated acceleration of OA when a full
personal communication). Because of the paucity of in-
arthrotomy is performed.96,97 At present, PTIO cannot be
formation available, it is uncertain whether CVWO has
advocated as a valid alternative to TPLO.
any clinically relevant benefit over other tibial plateau
leveling procedures.
Chevron Wedge Tibial Osteotomy

A cranially based tibial wedge ostectomy can be per- TTO

formed using chevron kerfs.23 The rationale behind using
more complex osteotomies stems from the perception
that opposed V-shaped osteotomy surfaces resist cranio-
caudal shear and torsional forces better than conven-
tional linear osteotomies (Fig 8).23 Planning of CVWO is
similar to CTWO: tibial longitudinal axis shift should be
taken into consideration when calculating the wedge an-
TTO, like TTA, is a procedure that aims to result in a
proximal tibial conformation so that the patellar tendon
is oriented perpendicular to the tibial plateau when the
stifle is at a weight-bearing angle.22 First, a partial frontal
plane osteotomy of the tibial tuberosity is made, leaving
the distal cortex intact. A partial wedge ostectomy, with a
122 TIBIAL OSTEOTOMIES FOR CRANIAL CRUCIATE LIGAMENT INSUFFICIENCY IN DOGS
Fig 9. Position of the osteotomies and postoperative illustra-
tion of triple tibial osteotomy.
wedge angle equal to two-thirds of angle between the
patellar tendon and a line perpendicular to the tibial pla-
teau slope, is then performed caudal to the tibial tubero-
sity osteotomy. Specialized TTO instrumentation is
commercially available to facilitate accurate positioning
of the osteotomies. Reduction of the wedge ostectomy
site simultaneously reduces the tibial plateau slope and
shifts the tibial tuberosity in a cranial direction (Fig 9).
Application of a 3.5 mm T-plate is recommended to sta-
bilize the wedge ostectomy site.
In a prospective clinical study of TTO in 64 dogs with a
mean follow-up of 15 months, no lameness was observed
in most dogs at final examination.22 Significant increases
in thigh circumference and stifle range of motion were also
noted. All owners assessed their dog as being normal or
near normal for all physical activities except sitting (2%
mildly abnormal) and standing (4% mildly abnormal).
Complications were encountered in 36% of cases, includ-
ing tibial tuberosity fractures, infection, and subsequent
meniscal injury. The most common complication was in-
traoperative tibial tuberosity fracture necessitating ten-
sion-band wire fixation, which occurred in 23% of dogs.
Proposed advantages of TTO include minimal change
to the orientation of the tibiofemoral articulating surfac-
es, a relatively small osteotomy gap caudal to the tibial
tuberosity, no loss of limb length, and low technical
difficulty when the appropriate instrumentation is used.
Potential disadvantages include variability of the post-
operative patellar tendon-to-TPA when using the recom-
mended calculations, and questionable protective effects
against medial meniscal injury.
CONCLUSIONS
By addressing the cranially directed shear force leading
to cranioproximal tibial translation that occurs during
weight-bearing, tibial osteotomy techniques have been
clinically successful in improving pelvic limb function in
dogs with CrCL insufficiency. Despite their popularity,
differences in long-term outcome between tibial osteo-
tomies and traditional methods of repair are not appar-
ent.64 As highlighted in a recent metaanalysis evaluating
surgical procedures used in dogs with CrCL insufficiency,
this may reflect the lack of objective clinical data report-
ed.98 Likewise, the current body of information is
insufficient to validate 1 tibial osteotomy technique over
another. Individual and interbreed differences in mor-
phology, kinematics and kinetics may also influence the
final outcome after surgery, and some osteotomy proce-
dures may be more suitable than others in certain breeds
of dogs or tibial conformations. Specific indications for
each individual technique remain to be determined. Con-
cerns common to all tibial osteotomies for treating CrCL
insufficiency include the sparing effect on the meniscus,
the progression of OA after surgery and the correlation
between clinical outcome and postoperative TPA or
patellar tendon-to-tibial plateau angle. Future clinical
studies need to adopt reliable, validated and standardized
outcome measures to permit fair and direct comparisons
between the various techniques.
The problems encountered in the surgical management
of CrCL insufficiency are undoubtedly a reflection of the
complexity of the structure and function of the stifle joint.
Future studies should not only focus on the clinical re-
sults of different surgical procedures; a clearer under-
standing of the biomechanics of the canine stifle and the
etiopathogenesis of the disease is also required to deter-
mine whether tibial osteotomy techniques are superior to
other treatment modalities for managing CrCL insuffi-
ciency in dogs.
ACKNOWLEDGMENTS
The authors thank Drs. Jimi L. Cook, Denis J. Marcellin-
Little, Warwick J. Bruce, and Randy J. Boudrieau for their
contributions. The assistance of Tim Vojt in producing the
figures is gratefully acknowledged.
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