TUGAS MATA KULIAH

ILMU BEDAH KHUSUS VETERINER

JUDUL
TEKNIK OPERASI LUKSASI PATELLA

SAIDATUL SHOLEHA 1409005024

KUSUMANING ARUMSARI WIMBAVITRATI 1409005030

INGGRID MADANI 1409005040

ENDAH RAHMAWATI 1409005044

NOVI KUSTIANI RAHAYU 1409005059

LABORATORIUM BEDAH VETERINER

FAKULTAS KEDOKTERAN HEWAN
UNIVERSITAS UDAYANA
TAHUN 2017

i
 RINGKASAN

Luxatio patella adalah suatu keadaan dimana patella (tempurung lutut)

seekor anjing bergeser dari tempatnya (lekukan trochlea dari tulang
paha/femur). Perkembangan penyakitnya dapat menjadi penyakit sendi
degeneratif, terjadi nyeri dan kepincangan. Keadaan luksasi patella baru
diketahui pada waktu anjing sudah berumur 3-4 bulan. Kasus luxatio patella
dapat dikelompokkan menjadi 2, yaitu: kasus luxatio patella ke arah medial
(dalam) dan kasus luxatio patella ke arah lateral (luar). Faktor keturunan
merupakan salah satu penyebab terjadinya kasus luxatio patella, faktor lainnya
ialah coxo-femoral displasia, cacat kongenital (lengkungan tulang femur
bagian bawah, displasia tuberositas tulang tibia bagian medial, kelainan
bentuk trochlea yang datar/cembung), dan trauma. Diagnosa dapat diketahui
dari anamnesa, gejala klinis, maupun foto rontgen dari kaki belakang dengan
view craniocaudal dan mediolateral. Metode yang umum digunakan untuk
menyembuhkan kucing atau anjing dari Luksasi Patella yaitu dengan cara
Pembedahan (Operasi).

Kata Kunci : Luksasi Patella, Insisi, Suture

ii
 SUMMARY

Luxatio patella is a condition where the patella (shell of the knee) of a dog
shifts from its place (the trochlea curve of the femur / thigh bone). The development
of the disease can be degenerative joint disease, pain and lameness occur. The
condition of patella's laceration is known when the dog is 3-4 months old. Cases of
luxatio patella can be grouped into 2, namely: the case of luxatio patella to the medial
(in) and the case of luxatio patella to the lateral (outer). Hereditary factors are one of
the causes of the case of luxatio patella, other factors are coxo-femoral dysplasia,
congenital disfigurement (lower femur bone arch, medial tibial dysplastic tubercular
dysfunction, convex trochlea deformity), and trauma. Diagnosis can be determined
from anamnesis, clinical symptoms, as well as x-rays of the hind legs with
craniocaudal and mediolateral views. The common method used to cure a cat or dog
from Luxatio Patella is by way of Surgery (Operation).

Keywords: Lukeasi Patella, Incisions, Suture

iii
 KATA PENGANTAR

Puji syukur penulis panjatkan kehadirat Tuhan Yang Maha Esa atas berkah dan
rahmat-Nya sehingga penyusunan paper ini dapat diselesaikan tepat pada waktunya.
Judul paper ini adalah “Teknik Operasi Luksasi Patella”
Makalah ini dibuat sebagai salah satu pedoman dalam pelajaran Mata Kuliah
“Ilmu Bedah Khusus Veteriner”. Melalui penulisan paper ini, diharapkan mahasiswa
mengetahui dan lebih mengerti mengenai pembahasan dari paper ini.
Terimakasih penulis sampaikan kepada seluruh dosen matakuliah Ilmu Bedah
Khusus Veteriner yang telah membimbing dan memberikan kuliah demi lancarnya
terselesaikannya tugas paper ini.
Segala kritik dan saran sangat penulis harapkan demi perbaikan penulisan paper
ini. Demikianlah tugas ini penulis susun. Penulis berharap semoga bermanfaat, dan
dapat memenuhi tugas matakuliah Ilmu Bedah Veteriner. Akhir kata, tidak lupa
penulis ucapkan terima kasih.

Denpasar, 07 Desember 2017

Penulis

iv
 DAFTAR ISI

HALAMAN JUDUL ........................................................................................... i

RINGKASAN ...................................................................................................... ii
SUMMARY ......................................................................................................... iii
KATA PENGANTAR ......................................................................................... iv
DAFTAR ISI ........................................................................................................ v
DAFTAR GAMBAR ........................................................................................... vi
DAFTAR LAMPIRAN ....................................................................................... vii
BAB I. PENDAHULUAN
1.1 Latar Belakang ......................................................................................... 1
1.2 Rumusan Masalah .................................................................................... 2
BAB II. TUJUAN DAN MANFAAT TULISAN
2.1 Tujuan Tulisan ......................................................................................... 3
2.2 Manfaat Tulisan ....................................................................................... 3
BAB III. TINJAUAN PUSTAKA ...................................................................... 4
BAB IV. PEMBAHASAN................................................................................... 8
BAB V. SIMPULAN DAN SARAN
5.1 Simpulan.................................................................................................... 21
DAFTAR PUSTAKA
LAMPIRAN-LAMPIRAN

v
 DAFTAR GAMBAR

Gambar 1. Patella normal dan luxatio patella......................................................... 5

Gambar 2. Normal patella and Luxating Patella………………………………..... 6
Gambar 3. Gambaran intraoperative…………………………………................... 10
Gambar 4. Rongeurs Forceps…………………………………………….............. 12
Gambar 5. Peninggian tulang rawan pada chondroplasty trochlear pada anak
anjing..................................................................................................... 12
Gambar 6. Metode Operasi untuk Memperdalam Lekukan Trochlea.................... 14
Gambar 7. Gambaran intraoperatif pada teknik Trochleoplasty block recession

setelah elevasi trochlear pada luksasi patella Grade IV dan osteoarthritis

berat...................................................................................................... 16

Gambar 8. Alignment antara patella (P), ligamentum patela (PL) dan tuberositas
tibialis (TT) dengan patella di trochlea................................................. 17
Gambar 9. Gambaran radiografi lateral dan posteroanterior pasca operasi .......... 18
Gambar 10. Gambaran radiologis lateral dan tampilan radiografi……………..... 19
Gambar 11. Gambaran radiografi medio lateral dan tampilan radiografi……...... 20

vi
 DAFTAR LAMPIRAN

Jurnal 1. Management of medial patellar luxation in dogs: what you need to know

Jurnal 2. PATELLAR LUXATION - A STEP BY STEP GUIDE

Jurnal 3. Canine patellar luxation part 2: treatments and outcomes

vii
 BAB I
PENDAHULUAN

1.1 Latar Belakang

Anjing adalah salah satu hewan peliharaan yang hingga kini
menduduki urutan pertama sebagai hewan peliharaan yang paling banyak
diminati masyarakat, baik masyarakat Indonesia maupun mancanegara. Di
jaman millenial ini, anjing memiliki berbagai macam manfaat bagi
kelangsungan hajat hidup manusia seperti berburu, menjaga ladang, menjaga
rumah, melacak, serta untuk memenuhi kepuasan pemilik.
Meningkatnya minat masyarakat akan pemeliharaan anjing seharusnya
sejajar dengan tingkat kesadaran hak hidup hewan sebagaimana mestinya.
Sehingga, untuk memperhatikan tingkat kesejahteraan anjing, timbul banyak
organisasi sebagai media pemerhati anjing. Seperti halnya di Bali, masyarakat
seakan tidak bisa jauh dari anjing. Terdapat sekitar 500.000-600.000 ekor
anjing di Bali.
Namun, disamping itu anjing paling sering terkena penyakit tulang
salah satunya yaitu luksasi patella. Luxatio patella adalah suatu keadaan
dimana patella (tempurung lutut) seekor anjing bergeser dari tempatnya
(lekukan trochlea dari tulang paha/femur).
Luksasi patella merupakan suatu gangguan ortopedi yang paling
umum ditemukan pada anjing ras kecil dan sedang seperti Chihuahua,
Pomeranian, Poodle, Pekingese, Yorkshire terrier, Pug, dan Chow chow.
Luksasi patella pada perkembangannya dapat menjadi penyakit sendi
degeneratif, terjadi nyeri dan kepincangan. Luxatio patella kadang-kadang
juga ditemukan pada ras besar seperti German Shepherd. Anjing ras besar
cenderung memiliki lebih sedikit masalah genetic mengenai kneecap atau
patella dibandingkan dengan anjing ras kecil, karena anjing ras besar memiliki
type trochlear groove yang lebih dalam.

1
1.2 Rumusan Masalah
Dari pembahasan latar belakang diatas, maka didapatkan beberapa
rumusan masalah, yaitu sebagai berikut :
1. Apa saja yang perlu dipersiapkan dalam pra-operasi luksasi patella pada
hewan?
2. Bagaimana metode dan teknik operasi luksasi patella pada hewan?
3. Bagaimana tindakan pasca operasi luksasi patella pada hewan?

2
 BAB II
TUJUAN DAN MANFAAT TULISAN

2.1 Tujuan Tulisan

Berdasarkan latar belakang dan rumusan masalah di atas, adapun tujuan
penulisan dari paper ini adalah sebagai berikut :
1. Secara nalar, penulis dan pembaca mengetahui dan memahami teknik pra
operasi, teknik operasi, dan pasca operasi luksasi patella pada hewan.
2. Memberikan informasi dan pemahaman pada pembaca mengenai luksasi
patella pada hewan.
3. Memenuhi syarat tugas kelompok pada mata kuliah Ilmu Bedah Khusus
Veteriner.

2.2 Manfaat Tulisan

Berdasarkan tujuan diatas adapun manfaat yang diperoleh dari penulisan
paper ini adalah sebagai berikut :
1. Manfaat teoritis : Mahasiswa atau pembaca mampu memahami dan
mengetahui secara mendalam tentang teknik operasi
luksasi patella pada hewan.
2. Manfaat empiris : Melalui kajian materi dari paper ini, diharapkan
mahasiswa mampu untuk menangani dan menguasai
teknik operasi luksasi patella pada hewan dan
mengaplikasikan ilmunya di lapangan.

3
 BAB III

TINJAUAN PUSTAKA

3.1 Definisi Luksasi

Banyak para ahli yang menyebutkan pengertian dari luksasi atau
dislokasi sendi, yaitu adalah seperti berikut. Luksasi atau dislokasi sendi
adalah tergesernya permukaan tulang yang membentuk persendian terhadap
tulang lain (Sjamsuhidajat,2011. Buku Ajar lImu Bedah, edisi 3,Halaman
1046). Luksasi atau dislokasi sendi adalah suatu keadaan dimana permukaan
sendi tulang yang membentuk sendi tak lagi dalam hubungan anatomis
(Brunner & Suddart, 2002, KMB, edisi 8, vol 3,Halaman 2355). Luksasi atau
dislokasi sendi adalah menggambarkan individu yang mengalami atau
beresiko tinggi untuk mengalami perubahan posisi tulang dari posisinya pada
sendi. (Carpenito, 2000, edisi 6, Halaman 1118). Luksasi atau dislokasi sendi
adalah fragmen frakrtur saling terpisah dan menimbulkan deformitas
(Kowalak, 2011, Buku Ajar Patofisiologi, Halaman 404). Luksasi atau
dislokasi sendi adalah deviasi hubungan normal antara rawan yang satu
dengan rawan yang lainnya sudah tidak menyinggung satu dengan lainnya
(Price & Wilson, 2006, edisi 6, vol 2, Halaman1368 ).

3.2 Definisi Luksasi Patella

Luxatio patella adalah suatu keadaan dimana patella (tempurung lutut)
seekor anjing bergeser dari tempatnya (lekukan trochlea dari tulang
paha/femur). Kasus luxatio patella ini sering ditemukan pada anjing-anjing ras
kecil dan sedang seperti Chihuahua, Pomeranian, Poodle, Pekingese,
Yorkshire terrier, Pug, dan Chow chow. Luxatio patella kadang-kadang juga
ditemukan pada ras besar seperti German Shepherd. Anjing ras besar
cenderung memiliki lebih sedikit masalah genetic mengenai kneecap atau

4
patella dibandingkan dengan anjing ras kecil, karena anjing ras besar memiliki
type trochlear groove yang lebih dalam.
Sebenarnya tanda-tanda akan terjadinya luxatio patella sudah dapat
dideteksi sejak lahir, akan tetapi keadaan ini kebanyakan baru diketahui pada
waktu anjing sudah berumur 3-4 bulan. Kasus luxatio patella dapat
dikelompokkan menjadi 2, yaitu: kasus luxatio patella ke arah medial (dalam)
dan kasus luxatio patella ke arah lateral (luar).

Gambar 1: patella normal dan luxatio patella.

A.Gambaran skematis patella normal (kiri) dan luxatio patella (kanan) 1.
B.Gambaran radiologi patella normal (patella kiri) dan medial luxatio patella
(patella kanan).

5
 Gambar 2. Normal patella and Luxating Patella

Menurut catatan rekam medik salah satu praktisi hewan kecil yaitu
drh. C Koesharyono, kasus luxatio patella ke arah medial lebih banyak (75%)
daripada kasus luxatio patella ke arah lateral (25%). Kasus pada anjing betina
ras kecil lebih banyak dibanding kasus pada anjing jantan ras kecil. Faktor
keturunan merupakan salah satu penyebab terjadinya kasus luxatio patella,
faktor lainnya ialah coxo-femoral displasia, cacat kongenital (lengkungan
tulang femur bagian bawah, displasia tuberositas tulang tibia bagian medial,
kelainan bentuk trochlea yang datar/cembung), dan trauma.
Penelitian yang pernah dilakukan pada 70 ekor anjing ras besar yang
menderita luxatio patella, ternyata 45 ekor adalah anjing jantan, dan 25 ekor
anjing betina, 35 ekor diantaranya adalah penderita luxatio bilateral. Pada
anjing-anjing ras kecil, kasus luxatio patella sering ditemukan pada anjing
umur 5-8 tahun. Luxatio patella yang bergeser ke arah lateral (luar) sering
ditemukan pada ras besar seperti: Great Dane, Saint Bernard, dan Irish
Wolfhound .

6
3.3 Gejala Klinis dan Diagnosa Luksasi Patella
Luxatio patella adalah kondisi ortopedi umum pada anjing dan mudah
untuk didiagnosa. Kondisi ini sering terjadi pada anjing ras kecil namun tidak
dapat dipungkiri juga bahwa anjing ras besar serta kucing juga dapat
mengalami luksasi patella dan gejala klinis yang ditimbulkan pun sama.
Untuk diagnosa dapat diketahui dari anamnesa, gejala klinis, maupun foto
rontgen dari kaki belakang dengan view craniocaudal dan mediolateral. Klien
datang dengan keluhan anjingnya sesekali mengangkat salah satu kaki
belakangnya pada waktu berjalan atau berlari serta sesekali kaki belakangnya
akan terlihat gemetar dan biasanya anjing juga akan meluruskan kakinya
terlebih dahulu sebelum digunakan untuk berjalan . Setelah itu anjing berjalan
normal kembali. Dari pemeriksaan klinis dengan palpasi di daerah lutut pada
kaki yang pincang terasa adanya pergeseran patella dari lekukan trochlea yang
disebut dengan trochlear groove. Arah bergesernya patella dapat dirasakan ke
arah medial (dalam) atau ke arah lateral (luar). Pemeriksaan klinis tersebut
dapat diperkuat dengan membuat foto rontgen dari kaki yang diduga
bermasalah. Hasil foto rontgen tersebut dapat menunjukkan berapa derajad
patella bergeser dari tempatnya. Bergesernya patella berkisar antara 30⁰-60⁰
dari tempatnya. Beberapa kasus dapat bergeser hingga 90⁰ (gambar 1.B) dan
satu kasus pernah ditemukan dengan pergeseran 180⁰ (anjing Pomeranian).

7
 BAB IV

PEMBAHASAN

4.1 Pra-Operasi
4.1.1 Persiapan alat dan obat
Berikut ini persiapan alat dan obat yang digunakan dalam
operasi luksasi patella pada hewan :
1. Bak instrument steril
2. Surgery drape
3. Kain kasa steril atau spons
4. Blade dan scalpel
5. Alat bedah mayor
6. Pin
7. Bone plate
8. Screw
9. External fixating rods & clamps.
10. Electric drill / bor tulang
11. Benang non absorbable dan absorbable
12. Alcohol
13. Yodium tincture
14. Anastesi
15. Antibiotic
16. Anti inflamasi
4.1.2 Persiapan ruang operasi
Persiapan ruang operasi meliputi ruang operasi harus bersih,
lantai dan meja operasi hendaknya dibersihkan dan didesinfeksi, ruang
operasi hendaknya memiliki penerangan yang cukup.

8
 4.1.3 Persiapan operator
Operator prosedur operasi, dapat memprediksi hal-hal yang
akan terjadi selama operasi, dapat memperkirakan hasil operasi,
mencuci tangan atau personal hygiene, serta harus siap fisik, mental,
tenang dan terampil
4.1.4 Persiapan pasien
Hewan yang hendak melakukan operasi fraktur sebaiknya
dilakukan terlebih dahulu pengecekan anamnesa, pemeriksaan fisik,
pemeriksaan laboratorium dan tentunya pemeriksaan radiografi. Bila
kondisi hewan dinyatakan normal atau sehat maka hewan dapat
dilakukan operasi. Namun, sebelum operasi, hewan terlebih dahulu
dipuasakan selama 12 jam.
Setelah itu dilakukan premedikasi dengan pemberian atropine
sulfat (0,02 – 0,04 ml/kgBB secara IM) dan di anestesi dengan
pemberian ketamine (ml/kgBB secara IM) dan xylazine (ml/kgBB
secara IM). Dan dilakukan maintenance dengan anestesi inhalasi
seperti isoflurane atau sevoflurane (2% - 3%).
Hewan diposisikan lateral atau dorsal recumbency, tergantung
pada preferensi dokter hewan dan daerah yang akan dioperasi
dibersihkan terlebih dahulu meliputi pencukuran rambut serta
pemberian yodium tincture kemudian dipasangi kain drape pada site
operasi.

4.2 Teknik Operasi

Inti dari penanganan luksasio patella adalah mengembalikan patella ke
posisi yang benar dan mempertahankan patella tetap pada tempatnya. Hal ini
dapat dilakukan dengan memindahkan patella dan ligamennya pada posisi
yang benar yaitu pada lekukan trochlea. Pada kasus-kasus tertentu dimana
lekukan trochlea berbentuk datar/cembung maka lekukan trochlea tersebut
perlu diperdalam (dibuat bentuk cekung) terlebih dahulu dengan

9
menggunakan scalpel dan kuret tulang. Menurut Arthus, 2006, yang dikutip
dari Veterinary Ireland Journal Volume 4 No. 12 bahwa inti proses
pembedahan MPL (Medial Patella Luxation) didasarkan pada pengembalian
mekanisme paha depan dan stabilisasi patela dalam trochlear os femur.
Berbagai teknik berbasis soft tissue dan osseous bisa digunakan untuk
mengembalikan fungsi patella kembai ke keadaan normal. Kombinasi
berbagai teknik biasanya digunakan dalam kasus yang sama untuk
memperbaiki MPL. Teknik soft tissue cenderung menyebabkan kegagalan
dan teknik osseus meminimalkan risiko reluxation pasca operasi (Arthurs et
al, 2006). Keputusan tentang teknik mana yang digunakan didasarkan pada
temuan radiografi (yaitu, deformitas tulang, perpindahan medial tuberositas
tibialis) dan evaluasi intraoperatif (yaitu kedalaman trochlea femoralis,
perpindahan medial tuberositas tibialis, dan keselarasan mekanisme paha
depan).
Arthrotomy lateral dilakukan pada MPL untuk mengeksplorasi sendi,
terutama CCL (Cranial Cruciate Luxation) dan tulang rawan artikular dari
aspek kaudal patela dan punggung trochlear medial (Gambar 1a dan 1b).
Dalam satu penelitian ditemukan bahwa dua anjing dengan luksasi patela
mengalami erosi kartilago, terutama anjing yang lebih berat dengan luksasi
patella Grade IV (Daems dkk, 2009).

10
 Gambar 3: (a) Gambaran intraoperatif erosi ringan di punggungan
trochlear medial pada seekor anjing yang mengalami MPL (panah hitam) ; (b)
gambaran intraoperatif pada MPL grade 4 dengan erosi parah (panah hitam)
dan alur trochlear yang dangkal (panah putih)

A. TEKNIK OSSEOUS
1. Trochleaplasty
Tujuan dari teknik ini adalah untuk memodifikasi bentuk alur
trochlear, membuat kedalaman dan lebar yang cukup sekitar 50 persen
sehingga patela menonjol di atas lengkungan trochlear. Selain teknik yang
dijelaskan di bawah ini, ada referensi baru yang telah dilaporkan, seperti:
rotating dome trochleoplasty (Gillick et al, 2007), median ridge elevation
wedge trochleoplasty (Fujii et al, 2013), rotasi trochlea femoralis (Pinna et
al, 2008), dan RidgeStop atau patellar groove replacement (PGR) pada
kasus OA tingkat lanjut.

2. Trochlear Sulcoplasty
Teknik ini adalah yang paling sederhana. Tulang rawan artikular dan
beberapa milimeter tulang subchondral dilepas dengan rongeurs forceps.
Teknik ini menghasilkan hilangnya lapisan tulang rawan hial trofeo
femoralis; Meskipun teknik ini berhasil pada anjing kecil, tapi teknik ini
menunjukkan atrofi otot paha depan femoris, krepitasi yang jelas, erosi
tulang rawan patella yang parah sejak empat minggu setelah operasi dan
kembali berfungsi lebih lambat dibandingkan dengan teknik lainnya.
Meskipun trochlea yang lebih dalam ditutupi fibrokartil, pengisian defek
lebih tidak dapat diprediksi.

11
 Gambar 4. Rongeurs Forceps
3. Trochlear Chondroplasty
Teknik 'cartage flap' ini hanya berguna pada anak anjing sampai usia
enam bulan, tulang rawan menjadi lebih tipis dan lebih melekat pada
tulang subchondral, sehingga sulit diseksi flap. Sebuah flap tulang rawan
persegi panjang diangkat, tulang subchondral dikeluarkan dari bawahnya,
dan flap dikembalikan ke alur yang dalam (lihat Gambar 7).

Gambar 5. Peninggian tulang rawan pada chondroplasty trochlear

pada anak anjing

4. Trochlear Wedge Recession

Pada kasus-kasus tertentu dimana lekukan trochlea berbentuk
datar/cembung, maka lekukan trochlea tersebut perlu diperdalam (dibuat
bentuk cekung) terlebih dahulu dengan menggunakan scalpel dan kuret

12
tulang (seperti terlihat pada gambar 4). Hal yang harus dilakukan yaitu
dengan incisi trochlear berbentuk V.

4A 4B

4C 4D

13
 4E 4F

Gambar 6. Metode Operasi untuk Memperdalam Lekukan Trochlea

Keterangan Gambar :

 3A & 3B: Dibuat sayatan pada tulang rawan trcohlea dengan pola “V”
 3C : Sayatan dikuakkan
 3D : Tulang dikerok menggunakan kuret untuk memperdalam
lekuk trochlea
 3E : Sayatan dikembalikan lagi ke posisi semula (sudah terlihat adanya
lekukan pada trochlea)
 3F: Dilakukan jahitan/fixasi ligamentum patella dengan ligamentum
collateral bagian lateral.
Setelah patella dapat dikembalikan ke tempatnya maka segera
dilakukan fiksasi dengan jalan menjahit ligamentum patella dengan tulang
fabella bagian lateral dengan membentuk angka 8 (eight-suture pattern)
menggunakan benang PGA nomor 2.0 atau 1.0 untuk anjing besar.
Tingkat keberhasilan metode ini di atas 75%. Setelah operasi, disarankan
kepada pemilik untuk membatasi pergerakan anjing tersebut dengan
mengandangkan anjing selama 2 minggu.

14
5. Trochlear Block Resession
Sisi-sisi potongan yang dilepas sejajar. Dengan menggunakan
kekuatan atau gergaji manual, dua sayatan paralel pada tulang rawan dan
tulang dibuat cukup jauh terpisah untuk mengakomodasi lebar patela,
memastikan bahwa peninggian trochlear dipertahankan (biasanya hanya
beraksi ke puncak trochlear). Ukuran osteotome atau daya gergaji yang
memadai digunakan untuk membuat potongan dari proksimal ke asal
ligamen caudal cruciatum, yang menghubungkan potongan lateral yang
sebelumnya dibuat, ke aspek proksimal trochlea. Perhatian yang besar
harus dilakukan untuk mencegah terjatuh dan terkontaminasi, atau
membuat rekahan blok yang longgar. Segmen tulang dan tulang rawan ini
diangkat dan dibungkus dengan bloody spons sementara tulang trabekular
dikeluarkan dari tulang paha untuk berhenti di blok. Sebagai alternatif,
aspek proksimal dari blok tersebut mungkin tetap terpasang dan dibalik
secara proksimal untuk memungkinkan resesi trochlea.
Potongan lateral dapat diperdalam 2-3 mm dan lapisan tulang
cancellous lainnya dilepas dengan osteotome (lihat Gambar 5). Blok ini
kemudian ditekan kembali ke dalam tulang paha tersembunyi dan cangkok
cancellous yang dimasukkan ke dalam celah di sisi blok jika perlu untuk
mencegah goyah (lihat Gambar 6). Dalam sebuah studi oleh Johnson dkk
(2001) ditemukan bahwa resesi blok troflear meningkatkan kedalaman
patela proksimal dan kontak artikular patela dengan troflea proksimal
yang tersembunyi, ia menambahkan persentase luas area troflear yang
lebih besar, dan menghasilkan ketahanan yang lebih besar terhadap
kemewahan patela. dalam posisi diperpanjang dibandingkan dengan resesi
trochlear wedge. Penulis secara rutin melakukan teknik resesi trochlear
block.

15
 Gambar 7. Gambaran intraoperatif pada teknik Trochleoplasty block
recession setelah elevasi trochlear pada luksasi patella Grade IV dan
osteoarthritis berat

6. Tibial Tuberosity Transposition

Teknik ini memperbaiki garis abnormal pada ligamentum patela di
MPL, yang membentang dari proximolateral ke distomedial (lihat Gambar
10). Kelekatan yang tepat dari tendon patella diidentifikasi dengan palpasi.
Periosteum pada aspek medial tibia ditorehkan di sepanjang garis
osteotomy yang diusulkan dan otot tibialis cranialis ditinggikan secara
lateral. Osteotomi dimulai pada titik tengah antara aspek tengkorak
dataran tibialis dan penyisipan tendon patella, dan meluas sampai ke sisi
distal dari puncak tibialis. Osteotomi dilakukan dengan gergaji manual
atau berosilasi sampai ke tingkat distal tibial crest.

16
 Gambar 8. Alignment antara patella (P), ligamentum patela (PL) dan
tuberositas tibialis (TT) dengan patella di trochlea. Perhatikan posisi
medial TT dan penyimpangan medial ligamentum patella meskipun ada
pengurangan patela;

Kemudian tuberositas dialihkan secara lateral untuk mencapai penataan

kembali. Evaluasi terhadap keselarasan antara otot paha depan, patella,
ligamen patella dan tuberositas tibialis. Gunakan penggaris atau sesuatu yang
panjang dan rata untuk memastikan strukturnya rata. Dua kawat Kirschner
dengan ukuran yang memadai ditempatkan untuk memperbaiki tuberositas
tibialis pada posisi baru, mengikuti arah yang agak distal dan caudomedial
(lihat Gambar 11a dan 11b).

17
 Gambar 9: (a) Gambaran radiografi lateral pasca operasi setelah
trochleoplasty reseptor blok dan transferensi tuberositas tibialis lateral pada
anjing dengan MPL. Periostium dalam aspek distal tuberositas tibialis telah
diperbaiki, jadi band belum diterapkan; (b) Gambaran radiograf
posteroanterior postoperatif dari stigma yang sama.

Dokter bedah harus memastikan bahwa kawat Kirschener ditempatkan

secara proksimal sampai pada titik penyisipan ligamentum patela, untuk
mengurangi risiko patah tulang. Pada anjing kecil, jika periostium distal telah
membaik, tidak perlu memasang band lagi. Pada anjing yang lebih besar dan
sangat aktif, atau jika tuberositas tibialis telah ditransistorkan secara distal,
band dipasang untuk menahan gangguan dari ligamentum patela. Lubang
tulang distal dibor dan sedikit ke kaudal sampai ke bagian distal osteotomy,
dan kawat ortopedi ditempatkan melalui lubang dan di sekitar pin dengan
eight suture pattern untuk menciptakan kawat tension-band stabil. Fiksasi ini
secara efektif menahan distraktif mekanisme quadriceps (lihat Gambar 12a
dan 12b). Radiografi diperoleh pasca operasi dan enam sampai delapan
minggu pasca operasi untuk menilai penyembuhan tulang dan memverifikasi
kestabilan implan.

18
 Gambar 10. (a) (a) Gambaran radiologis lateral pasca operasi setelah
trochleoplasty block recession dan transposisi tuberositas tibialis lateral pada
anjing dengan MPL. Periostium dalam aspek distal tuberositas tibialis belum
diawetkan, jadi band tension telah diterapkan; (b) Tampilan radiografi
posteroanterior post operatif dari sisi yang sama.

7. Distal Femoral or Proximal Tibial Corrective Osteotomy

Teknik ini digunakan pada kasus dengan varus femoral / tibialis yang
serius dan / atau deformitas torsi. Hal ini terkait dengan tingkat
kekambuhan yang sangat rendah dalam kasus ini. Beberapa teknik telah
dijelaskan, termasuk ostektomi penutupan lateral femoralis lateral,
osteotomi wedge femoralis medial, osteotomy detorsional untuk
mengatasi torsi tulang yang terisolasi, dan osteotomi radial; fiksasi pelat
adalah metode fiksasi yang disukai dan banyak digunakan (Gambar 13a
dan 13b). Pengukuran pra-operasi yang akurat harus dilakukan untuk
memastikan lokasi osteotomi dan besarnya angulasi femoralis dan torsi.

19
 Gambar 11. (a) Gambaran radiografi medio lateral post operatif pada
anjing dengan Grade 4 MPL dan rotasi internal tibialis proksimal yang
parah. Sebuah trochleoplasty reseptor blok dan osteotomy derotasional
tibialis proksimal telah dilakukan. Jahitan antirotika telah diterapkan; (b)
Tampilan radiografi postero anterior pasca operasi dari stigma yang sama.

B. TEKNIK SOFT TISSUES

Teknik ini digunakan setelah rekonstruksi tulang dan tidak pernah
digunakan sebagai perbaikan utama kecuali untuk luksasi patela yang
traumatis, atau sebagai tahap pertama dari perbaikan dua tahap pada pasien
yang belum dewasa. Dalam MPL teknik ini didasarkan pada pelepasan
jaringan pada sisi medial patella dan imbrikasi jaringan laring pada sisi lateral.
Dalam MPL, pelepasan retinakular medial (retinakular mengacu pada fasia
dan jaringan fibrosa lainnya yang membantu menjaga patela di tempat) dan
kapsulotomi dilakukan; jaringan medial dilepaskan dengan melakukan
sayatan pada aspek medial dari ikatan tibialis ligamentum patela, berlanjut
secara proksimal, medial ke patella sampai semua ketegangan pada patela
lepas. Insisi biasanya dibiarkan terbuka. Imbrikasi jaringan lunak sisi lateral
juga digunakan untuk menstabilkan patella. Kapsul sendi dan jaringan fasia
dapat disimulasikan dengan horizontal mattress suture pattern menggunakan
monofilament absorable.

20
C. TEKNIK ANTIROTATIONAL
Koreksi awal rotasi tibial pada hewan yang belum dewasa dapat
menyebabkan mitigasi keparahan, atau koreksi deformitas selama
pertumbuhan. Namun, pada hewan dewasa, teknik ini mungkin tidak cukup
untuk memperbaiki MPL sendiri, kecuali teknik konkuren lainnya diterapkan.
Menempatkan non absorbable suture (misalnya nylon leader line)) dari fabella
lateral ke puncak tibialis yang menghasilkan rotasi eksternal tibia.

4.3 Pasca Operasi

Setelah dilakukan pembedahan, disarankan kepada pemilik untuk
membatasi pergerakan berlebihan anjing tersebut selama 3 minggu kedepan.
Gunakan E-collar untuk mencegah anjing menjilat atau merusak bekas
jahitan. Latihan biasanya terbatas untuk jalan-jalan tali selama 6 sampai 14
minggu tergantung pada prosedur yang dilakukan dan faktor yang
mempengaruhi kapasitas penyembuhan dari hewan peliharaan. Pemberian
obat nyeri dapat diresepkan selama seminggu setelah operasi. Pemberikan
kompres dingin ke lutut (5-10 menit sehari) juga bisa diberikan untuk
membantu mengurangi peradangan. Radiografi dapat diulang secara berkala
untuk memantau penyembuhan tulang.

21
 BAB V

SIMPULAN DAN SARAN

5.1 Simpulan
Luxatio patella adalah suatu keadaan dimana patella (tempurung lutut)
seekor anjing bergeser dari tempatnya (lekukan trochlea dari tulang
paha/femur). Dimana perkembangan penyakitnya dapat menjadi penyakit
sendi degeneratif, terjadi nyeri dan kepincangan.
Tanda-tanda terjadinya luxatio patella sudah dapat dideteksi sejak
lahir, akan tetapi keadaan baru diketahui pada waktu anjing sudah berumur 3-
4 bulan. Kasus luxatio patella dapat dikelompokkan menjadi 2, yaitu: kasus
luxatio patella ke arah medial (dalam) dan kasus luxatio patella ke arah lateral
(luar).
Faktor keturunan merupakan salah satu penyebab terjadinya kasus
luxatio patella, faktor lainnya ialah coxo-femoral displasia, cacat kongenital
(lengkungan tulang femur bagian bawah, displasia tuberositas tulang tibia
bagian medial, kelainan bentuk trochlea yang datar/cembung), dan trauma.

22
 DAFTAR PUSTAKA

Koesharyono, C. 2008. Luxatio patella pada anjing dan penanganannya.

http://anjingkita.com/artikel/5864/luxatio-patella-pada-anjing-dan-penanganannya
(Diunduh pada tanggal 30 November 2017).

Anonimous. Dog Patella Luxation http://www.sydneyanimalhospitals.com.au/dog-

patella-luxation (Diunduh pada tanggal 30 November 2017).

Patellar Luxations. 2017. ACVS Americans College of Veterinary Surgeons. Sitasi :

https://www.acvs.org/small-animal/patellar-luxations diakses pada tanggal 2
November 2017 pukul 21:09
Koesharyono. 2008. Luxatio Patella pada Anjing dan Penanganannya. 2008. Sitasi :
http://anjingkita.com/artikel/5864/luxatio-patella-pada-anjing-dan-
penanganannya diakses pada tanggal 2 November 2017 Pukul 20:59
Perez, P. Management of medial patellar luxation in dogs (Continuing Education).
Veterinary Ireland Journal Volume 4 Number 12
Fauron, A., Perry, K. 2016. Canine patellar luxation part 2: treatments and outcomes.
Vet Times
Sambodo W. S. 2012. Patela Luksasi. http://pus-
keswan.blogspot.co.id/2012/10/patela-luksasi.html. Diakses pada tanggal 04
Desember 2017

23
CONTINUING EDUCATION
Management of medial patellar luxation
in dogs: what you need to know
Pablo Pérez LdoVet MRCVS, Waggin’ Tails Chelsea Veterinary Clinic, London, UK, and Pilar Lafuente DVM
PhD DACVS-SA DECVS CCRT MRCVS, Diplomate American College of Veterinary Sports Medicine and
Rehabilitation, Queen Mother Hospital for Animals, Royal Veterinary College, Hatfield, UK
An overview of the causes, diagnosis and treatment of one of the most
common orthopaedic diseases seen in general practice
INTRODUCTION
The patella is an ossification in the tendon of insertion
of the quadriceps femoris muscle. It works along with the
femoral trochlea as a pulley, redirecting the line of action of
the quadriceps tendon. For the patella to be stable and to
move in the most efficient direction, axial alignment of the
extensor apparatus with the underlying skeletal elements
is necessary. The extensor apparatus is composed of the
quadriceps femoris muscle, which originates in the ventral
aspect of the ilium and the proximal femur. It converges on
the patella, and continues as the patellar ligament, which
finally attaches to the tibial tuberosity. Other periarticular
elements, such as joint capsule and femoropatellar
ligaments, also increase the stability of the femoropatellar
articulation.
Medial patellar luxation (MPL) is one of the most common
diseases affecting the canine stifle. Although it can be
seen in large-breed dogs, including Labradors, small-
breed dogs are more commonly affected, with Yorkshire
Terriers and poodles over-represented. It is also remarkable
that MPL is more common than lateral patellar luxation
(LPL), representing 75-80 per cent of cases and reaching
up to 98 per cent in small breeds, according to some
research. Bilateral MPL affects 20-25 per cent of all MPL
cases, but some authors increase this percentage up to
50-65 per cent. Regarding large breeds, although MPL
is more frequent as well, the percentage of LPL in these
breeds is higher than in small-breed dogs. In terms of sex
predisposition for MPL, small-breed females and large-
breed males are more affected. In cats, MPL is also more
common than LPL.
AETIOLOGY AND PATHOGENESIS
MPL can be traumatic or ‘congenital’, with congenital being
most common. Strictly speaking, MPL is a developmental
disorder, since the vast majority of cases develop this
disease as a result of the skeletal deformities that are
present at birth. As a result, breeding is not advisable in
affected dogs.
Although the underlying cause of MPL is not entirely
understood, some investigations suggest coxa vara
(decreased angle of inclination of the femoral neck) and
diminished anteversion angle (relative retroversion) are
the main causes. The typical deformities of MPL include:
634 Veterinary Ireland Journal I Volume 4 Number 12
Figure 1: Alignment of quadriceps
mechanism with underlying
skeletal elements in a normal dog
and in a dog with MPL.
malalignment of the quadriceps femoris muscle, coxa vara,
femoral varus, genu varum, shallow trochlear groove with
poorly developed or absent trochlear ridges, hypoplasia of
the medial femoral condyle, medial displacement of the
tibial tuberosity, internal rotation of the tibia, proximal tibia
varus, and internal rotation of the foot (see Figure 1).
Under normal alignment, the patella exerts pressure on
the articular cartilage of the trochlear groove during growth,
creating a groove with adequate depth and width. The
absence of this physiological pressure in MPL cases leads
to trochlear hypoplasia. Intermittent luxation and reduction
wear the medial trochlear ridge, which results in more
instability and tendency to luxation.
Shortening of the limb because of hip luxation or femoral
head excision may cause laxity of the extensor mechanism,
these animals being more prone to MPL.
It has been suggested that the quadriceps mechanism
is a secondary stabiliser of the stifle, preventing cranial
translation of the tibia. Due to this role, chronic patellar
luxation could lead to increased stress on the cranial
cruciate ligament (CCL) and eventual degeneration and
rupture. Combination of CCL rupture and MPL is a relatively
common finding, especially with increased severity of
patellar luxation (Campbell et al, 2010). Tibial tuberosity
transposition-advancement has been suggested as a
technique to resolve both conditions at the same time
(Yeadon et al, 2011). Patellar luxation has also been
reported as a complication of surgical intervention for
management of CCL rupture.

CLINICAL PRESENTATIONS
Clinical signs vary according to the grade of luxation (see
Table 1).
Table 1.
Grade 1 Commonly an incidental finding on routine physical
examinations.
The patella can be manually luxated, but it returns
to the trochlear groove immediately upon release of manual
pressure.
There is no crepitus noted during stifle range of motion, and
bony deformity is absent.
Clinical signs are typically not present.
Grade 2 Spontaneous luxation occurs with clinical signs of non-painful,
‘skipping’ type lameness.
Mild deformities develop (internal rotation of the tibia and
abduction of the hock).
May progress to grade 3 luxation as progressive cartilage
erosion on the patellar and trochlear surfaces occurs, and/or
CCL disease and rupture occurs.
Grade 3 Patella is luxated most of the time but can be reduced manually.
More severe bony deformities, including: marked
internal tibial rotation and S-shaped curve of the distal femur
and proximal tibia.
A shallow trochlear groove may be palpable when the patella is
luxated.
Lameness is related to the degree of cartilage erosion from the
articular surface of the patella and medial trochlear ridge of the
femur.
Abnormal, ‘crouched’ gait rather than intermittent lameness. The
leg is used in a semiflexed, internally rotated position.
Often bilateral.
Grade 4 Permanent and non-reducible luxation of the patella.
If not corrected early in life, severe bony and ligamentous
deformities develop, making later surgical correction more
challenging.
Severe bony deformities: tibia rotated from 60 degrees to 90
degrees relative to the sagittal plane, marked femoral varus,
proximal tibia varus, and internal tibial rotation are noted.
‘Crab-like’ posture, and usually carried by their owners rather
than walking.
DIAGNOSIS
Careful physical examination is necessary to characterise
the grade of luxation and to rule out concomitant CCL
disease or other pathologies that could cause hind-limb
lameness. Gait evaluation at a walk and a trot is performed
to evaluate overall conformation and to screen for overt
skeletal deformity, as well as to determine the degree and
character of lameness. These are important factors to take
into account when making a therapeutic plan.
Our aims during the physical examination are to assess:
• Instability in both directions
• Most frequent location of the patella
• Inability or ability to reduce the patella
• Presence or absence of crepitus
• Degree of tibial tuberosity deviation
• Limb torsion or angulation
• Range of motion
• Presence or absence of drawer movement.
Initial physical examination is performed with the patient
standing. In that way, symmetry between limbs and
CONTINUING EDUCATION
Figure 2: (a) Patella isolated between index and thumb in physiologic position;
(b) Patella isolated between index and thumb in medially luxated position while
applying internal rotation to the limb.
influence of quadriceps femoris muscle contraction during
weight bearing on the stability of the patella can be
assessed more easily, as well as to evaluate the degree
of joint effusion (more common when CCL disease is
present). In cases where the joint is quite inflamed, locating
the patella can be challenging. Following the patellar
ligament from its attachment on the tibial tuberosity can
help in these cases. Once located, the patella is isolated
between thumb and index finger of one hand, while the
other hand grasps the tibia and lifts the foot from the
floor. Flexion, extension, internal and external rotation is
applied to the stifle and at the same time manual lateral
and medial pressure is performed on the patella to identify
the direction and grade of luxation (see Figures 2a and 2b).
Muscle tension can prevent luxating the patella. In such
cases the physical examination can be performed in lateral
recumbency. To assess CCL disease, cranial drawer and
tibial thrust examination are carried out. It is also important
to assess the position of the patella within the trochlear
groove; if riding too high (patella alta) or abnormally low
(patella baja), this will need to be addressed during surgical
correction. Pain when applying caudal pressure over the
patella also needs to be evaluated. The depth of the
trochlear groove can be assessed by palpation after luxating
the patella. The alignment of the quadriceps mechanism
should be assessed with the animal in dorsal recumbency,
by visually evaluating the alignment of the quadriceps
muscle, patella, patellar ligament and tibial tuberosity, while
the hip, stifle and tarsus are kept in extension (see Figures
3a and 3b). If the animal does not co-operate, sedation is
administered to complete the orthopaedic evaluation and
radiographs are taken of the limb.
Radiographic survey helps to document luxation and
assess the degree of degenerative changes present in
the stifle joint; it is also essential to identify and qualify
skeletal abnormalities in severe cases. Careful radiographic
position is critical to avoid false positive limb deformity
on radiographs. If the luxation grade is low and skeletal
Veterinary Ireland Journal I Volume 4 Number 12 635
CONTINUING EDUCATION
Figure 3: (a) Alignment between patella (P), patellar ligament (PL) and tibial
tuberosity (TT) with the patella in the trochlea. Note the medial position of the
TT and medial deviation of the patellar ligament in spite of the reduction of the
patella; (b) Alignment between patella, patellar ligament and tibial tuberosity
with the patella medially luxated from the trochlea. Note the marked medial
direction of the patellar ligament.
Figure 4: (a) Medio-lateral radiographic view of the stifle in a dog with MPL. The
patella is reduced in the trochlea; (b) Posterio-anterior radiographic view of the
stifle of a dog with MPL. The patella is medially displaced from the trochlea.
abnormalities are mild, orthogonal radiographs views of the
stifle alone are sufficient (see Figures 4a and 4b). However,
in severe cases in which skeletal deformity is present,
orthogonal views of the femur and the tibia (from the hip
to the tarsal joint), in addition to orthogonal views of the
stifle, are necessary to characterise the deformities and
to accurately assess the joint (see Figure 5). Alternatively,
computed tomography (CT) study with 3D reconstruction of
the skeletal elements can be used to qualify deformities.
TREATMENT
In some cases, selecting between conservative treatment
and surgical treatment is clear-cut. Conservative
treatment, including rehabilitation to enhance quadriceps
636 Veterinary Ireland Journal I Volume 4 Number 12
Figure 5: Ventro-dorsal radiographic
view of the hindlimbs in a dog
with right MPL. Notice the medial
deviation of the tibial tuberosity and
genu varum.
mechanism, is warranted in grade 1 luxation cases with
no associated clinical signs. On the other hand, in grade 3
or grade 4 luxation cases, surgical treatment is warranted
early in the course of the disease.
In more complex cases where it is not easy to select
between both treatments, surgery is indicated if significant
episodes of lameness last two to three weeks or longer, if
there are three or more significant episodes of lameness
that occur in a short time frame (ie. over one month), or
if lameness is worsening. If the episode of lameness is
mild and infrequent, and the degree of osteoarthritis is
mild and non-progressive, conservative treatment may
be indicated, with re-evaluation if severity or frequency of
lameness increases. In very young patients with significant
growth potential, avoiding bony reconstructive techniques
is essential until maturity is reached, because distal
femoral or proximal tibial physis could be damaged. In
severe cases of immature patients, a two-stage repair
should be considered. In the initial stage only soft tissue
reconstruction techniques and trochlear chondroplasty are
recommended and other techniques should wait until the
patient reaches skeletal maturity.
SURGICAL TREATMENT
Surgical correction of MPL is based on realignment of the
quadriceps mechanism and stabilisation of the patella
within the trochlear groove of the femur. A variety of soft-
tissue and osseous techniques can be used to achieve
these goals. A combination of various techniques is
usually used in the same case to correct MPL. Soft tissue
techniques alone are likely to cause failure and osseous
techniques minimise the risk of post-operative reluxation
(Arthurs et al, 2006). The decision on which techniques
to use is based on the radiographic findings (ie. bone
deformities, medial displacement of the tibial tuberosity)
and intraoperative evaluation (ie. depth of femoral trochlea,
medial displacement of tibial tuberosity, alignment of
quadriceps mechanism).
A lateral arthrotomy is performed for MPL to explore the
joint, especially the CCL and the articular cartilage of the
caudal aspect of the patella and medial trochlear ridge (see

Figure 6: (a) Intraoperative view of mild erosion in the medial trochlear ridge
in a dog with MPL (black arrows); (b) Intraoperative view of a stifle with grade
4 MPL with severe erosions (black arrows) and shallow trochlear groove (white
arrow).
Figures 6a and 6b). In one study it was found that two-
thirds of dogs with patellar luxation had cartilage erosions,
especially heavier dogs and those with grade IV patellar
luxation (Daems et al, 2009) .
OSSEOUS TECHNIQUES
Trochleoplasty
The aim of these techniques is to modify the shape of the
trochlear groove, obtaining enough depth and width to allow
approximately 50 per cent of the patella to protrude above
the trochlear ridges. Besides the techniques described
below, there are new ones that have been reported, such
as: rotating dome trochleoplasty (Gillick et al, 2007), medial
ridge elevation wedge trochleoplasty (Fujii et al, 2013),
rotation of the femoral trochlea (Pinna et al, 2008), and
RidgeStop or patellar groove replacement (PGR) in advanced
OA cases.
Trochlear sulcoplasty
This is the simplest technique. The articular cartilage
and several millimetres of subchondral bone are removed
with rongeurs. This technique results in complete loss of
hyaline cartilage lining of the femoral trochlea; although it
is a successful technique in small dogs, they may show
quadriceps femoris muscle atrophy, palpable crepitus,
severe erosion of the cartilage of the patella as early as
four weeks after surgery and return to function is slower
compared with other techniques. Although the deeper
trochlea becomes covered with fibrocartilage, the filling of
the defect is more unpredictable.
Trochlear chondroplasty
This ‘cartilage flap’ technique is useful only in puppies up
to six months of age as, in mature animals, the cartilage
becomes thinner and more adherent to the subchondral
bone, making flap dissection difficult. A rectangular
cartilage flap is elevated from the groove, the subchondral
bone removed from beneath it, and the flap pressed back
into the deepened groove (see Figure 7).
CONTINUING EDUCATION
Figure 7: Elevation of the cartilage flap during trochlear chondroplasty in a
puppy.
Trochlear wedge recession
A V-shaped wedge, including the groove, is removed
from the trochlea with a saw. The resulting defect in the
trochlea is widened by another saw cut on one edge to
remove a second piece of bone. When the original bone
wedge is replaced, it is recessed into the defect, creating
a deeper groove still covered with hyaline cartilage. The
osteochondral wedge remains in place because of the net
compressive force of the patella and friction between the
cancellous surfaces of the two cut edges. The sides of the
defect become lined with fibrocartilage.
Trochlear block recession
The sides of the piece removed are parallel. Using a
power or manual saw, two parallel incisions in cartilage
and bone are made far enough apart to accommodate the
width of the patella, ensuring that the trochlear ridges are
maintained (usually just axial to the top of the trochlear
ridges). An adequate-sized osteotome or power saw is
used to make the cut from just proximal to the origin of the
caudal cruciate ligament, connecting the previously made
lateral cuts, to the proximal aspect of the trochlea. Great
care must be taken to prevent dropping and contaminating,
or fracturing the loosened block. This segment of bone and
cartilage is removed and wrapped in a bloody sponge while
trabecular bone is removed from the femur to recess the
block. Alternatively, the proximal aspect of the block may
remain attached and flipped proximally to allow recession
of the trochlea. The lateral cuts can be deepened 2-3mm
and another layer of cancellous bone removed with the
osteotome (see Figure 8). The block is then pressed back
into this recessed femur and cancellous graft packed into
the gaps at the side of the block if necessary to prevent
wobbling (see Figure 9).
In a study by Johnson et al (2001) it was found that
trochlear block recession increased proximal patellar depth
and patellar articular contact with the recessed proximal
trochlea, it recessed a larger percentage of trochlear
surface area, and resulted in a greater resistance to
Veterinary Ireland Journal I Volume 4 Number 12 637
CONTINUING EDUCATION

Figure 8: Intraoperative view of

block recession trochleoplasty after
elevation of the trochlear block in a
stifle with grade 4 MPL and severe
osteoarthritis.

Figure 10: (a) Post-operative medio-lateral radiographic view after block

recession trochleoplasty and lateral tibial tuberosity transposition in a dog
Figure 9: Intraoperative view after with MPL. The periostium in the distal aspect of the tibial tuberosity has been
replacing the trochlear block preserved, so a tension band has not been applied; (b) Post-operative postero-
removed in trochlear block recession anterior radiographic view of the same stifle.
technique in the same stifle as preserved, there is no need to place a tension band. In
Figure 8.
bigger, very active dogs, or if the tibial tuberosity has been
patellar luxation in an extended position as compared with transected distally, a tension band is placed to counteract
trochlear wedge recession. The authors routinely perform the distraction forces from the patellar ligament. A bone
the trochlear block recession technique. tunnel is drilled distal and slightly caudal to the distal extent
of the osteotomy, and orthopaedic wire is placed through
TIBIAL TUBEROSITY TRANSPOSITION the tunnel and around the pins in a figure of eight pattern to
This technique corrects the abnormal line of action of create a tension-band wire. This fixation effectively counter-
the patellar ligament in MPL, which runs oblique from acts the distractive force of the quadriceps mechanism
proximolateral to distomedial (see Figure 3a). The exact (see Figures 11a and 11b). Radiographs are obtained post-
attachment of the patella tendon is identified by palpation. operatively and six to eight weeks post-operatively to assess
The periosteum on the medial aspect of the tibia is bony healing and verify the stability of the implants.
incised along the proposed line of osteotomy and the
tibialis cranialis muscle elevated laterally. The osteotomy
starts at a point midway between the cranial aspect of
the tibial plateau and the insertion of the patella tendon,
and extends to the distal aspect of the tibial crest. The
osteotomy is performed with a manual or oscillating
saw until the distal extent of the tibial crest, preferably
leaving the distal periosteal attachment intact. Then the
tuberosity is transposed laterally to achieve realignment
with the stifle extended. Careful evaluation of the alignment
between the quadriceps muscle, patella, patellar ligament
and tibial tuberosity is performed with the dog in dorsal
recumbency. It may be helpful to apply a straight instrument
over these structures to make sure they are aligned. Two
Kirschner wires of adequate size are placed to fix the tibial
tuberosity in the new position, following a slightly distal
and caudomedial direction (see Figures 10a and 10b). The
surgeon should make sure these are placed proximal to
the point of insertion of the patellar ligament, to decrease
Figure 11: (a) Post-operative medio-lateral radiographic view after block
the risk of fractures, and that they are engaging sufficient recession trochleoplasty and lateral tibial tuberosity transposition in a dog with
bone at the level of the tibial tuberosity and the caudal MPL. The periostium in the distal aspect of the tibial tuberosity has not been
tibial cortex. In small dogs, if the distal periostium has been preserved, so a tension band has been applied; (b) Post-operative postero-
anterior radiographic view of the same stifle.

638 Veterinary Ireland Journal I Volume 4 Number 12


Figure 12: (a) Post-operative medio-lateral radiographic view of the stifle in
a dog with grade 4 MPL and severe proximal tibial internal rotation. A block
recession trochleoplasty and proximal tibial derotational osteotomy have been
performed. Antirotational sutures have been applied; (b) Post-operative postero-
anterior radiographic view of the same stifle.
DISTAL FEMORAL OR PROXIMAL TIBIAL
CORRECTIVE OSTEOTOMY
This technique is used in cases with significant femoral/
tibial varus and/or torsional deformity. It is associated with
a very low rate of recurrence in these cases.
Multiple techniques have been described, including laterally
based femoral closing wedge ostectomy, medial opening
femoral wedge osteotomy, detorsional osteotomy to address
isolated bone torsion, and radial osteotomy; plate fixation
is the preferred fixation method (see Figures 12a and 12b).
Accurate pre-operative measurement must be made to
ensure the osteotomy location and magnitude of femoral
angulation and torsion.
SOFT TISSUE TECHNIQUES
They are used after bony reconstruction and never as a
primary repair except for traumatic patellar luxation, or as
the first stage of a two-stage repair in immature patients.
In MPL these techniques are based on release of the
contracted tissues on the medial side of the patella and
imbrication of the lax tissues on the lateral side.
In MPL, medial retinacular release (retinacular refers to
the fascia and other fibrous tissues that help to keep
the patella in place) and capsulotomy are performed; the
medial tissues are released doing an incision in the medial
aspect from the tibial attachment of the patellar ligament,
continuing proximally, medial to the patella until all the
tension on the patella is relieved. The incision is usually left
open.
Imbrication of the soft tissues of the lateral side is also
used to stabilise the patella. The joint capsule and fascial
tissues can be imbricated with horizontal mattress suture
pattern using monofilament absorbable suture. If redundant
joint capsule is present, a strip of joint capsule (partial
CONTINUING EDUCATION
capsulectomy) can be removed and the edges sutured with
apposing suture patterns.
ANTIROTATIONAL TECHNIQUES
Early correction of the tibial rotation in immature animals
may lead to mitigation of the severity, or correction of
the deformity during growth. However, in mature animals
these techniques are likely insufficient to correct MPL
by themselves, unless other concurrent techniques are
applied.
Placing a non-absorbable suture (ie. nylon leader line) from
the lateral fabella to the tibial crest results in external
rotation of the tibia.
POST-OPERATIVE CARE, COMPLICATIONS,
PROGNOSIS
Post-operative orthogonal radiographs are imperative to
evaluate correction of the patellar luxation and adequate
implant placement.
Adequate post-operative analgesia is important for these
animals to start using the operated limb soon (ie. opioids,
non-steroidal anti-inflammatory drugs [NSAIDs]). Cold
packing can be used three times a day for the first 72
hours to decrease pain and inflammation, followed by warm
packing and gentle passive range-of-motion exercises two
to three times per day (after 72 hours). Activity should be
restricted to specific physical rehabilitation exercises and
lead walking for six to eight weeks; provided the patient is
progressing adequately and the osteotomies are healing,
then the animal could be gradually returned to normal
activity over a six-week period. Radiographs should be
obtained at six to eight weeks to evaluate healing of the
tibial crest transposition.
Complications include patellar reluxation, delayed union
or fixation failure at the osteotomy sites, infection,
and osteoarthritis. Cases treated with tibial tuberosity
transposition and femoral trochleoplasty techniques were
associated with lower risk of patella reluxation and major
complications. In a recent study by Cashmore et al (2014),
major complications accounted for 18.5 per cent, with
implant-associated complications being the most frequent,
followed by patellar reluxation and tibial tuberosity avulsion.
Dogs over 20kg and high-grade luxations are more prone
to post-operative complications. Gibbons et al (2006)
postulated that, in order to reduce post-operative risks in
large breed dogs, femoral trochleoplasty, tibial tuberosity
transposition and soft tissue techniques should be
performed.
Prognosis varies with the grade of luxation: excellent for
grades 1 through 3 luxation, and fair to good for grade 4
luxation. However, some cases of grade 4 luxation with
severe bone deformity, osteoarthritis, cartilage loss, muscle
atrophy, and rotational deformity of the stifle warrant a
grave to poor prognosis. Osteoarthritis progresses in spite
of surgical correction, but it is usually less severe than with
CCLR.
The study by Linney et al (2011) demonstrated that surgical
treatment of MPL without trochleoplasty have similar
Veterinary Ireland Journal I Volume 4 Number 12 639
CONTINUING EDUCATION
outcomes to those with trochleoplasty, although cases
should be carefully selected.
Recurrent luxation after surgery has been reported in up to
50 per cent of joints. However, most are grade 1 luxations
that do not affect clinical function. Most stifle joints
function well enough that lameness is not apparent during
examination, nor do clients report clinical dysfunction. Early
correction of severe deformities will undoubtedly play a
major role in ensuring good function.
REFERENCES
1. Arthurs et al. Complications associated with correlative
surgery for patellar luxation in 109 dogs. Veterinary
Surgery 2006: 35: 559-566
2. Arthurs et al. Patellar luxation as a complication
of surgical intervention for the management of
cranial cruciate ligament rupture in dogs. Veterinary
Comparative Orthopaedics and Traumatology 2007: 20:
204-210
3. Campbell CA, Horstman CL, Mason DR, Evans
RB. Severity of patellar luxation and frequency of
concomitant cranial cruciate ligament rupture in dogs:
162 cases (2004-2007). Journal of the American
Veterinary Medical Association 2010; 236: 887
4. Cashmore et al. Major complications and risk factors
associated with surgical correction of congenital medial
patellar luxation in 124 dogs. Veterinary Comparative
Orthopaedics and Traumatology 2014: 27(4): 263-70
5. Fossum TW. Small Animal Surgery. Fourth edition. St
Louis, Missouri: Elsevier. Mosby, 2013 (pp1354-1362)
6. Fujii et al. Medial ridge elevation wedge trochleoplasty
Reader Questions and Answers
1: A DOG WITH MPL IS LUXATED PERMANENTLY BUT CAN
BE RETURNED TO THE TROCHLEAR GROOVE MANUALLY.
WHICH GRADE OF PATELLAR LUXATION DOES THIS DOG
BELONG TO?
A: Grade 2
B: Grade 3
C: Grade 4
D: This dog can’t be classified.
2: WHAT WOULD BE THE TREATMENT FOR A SIX-MONTH-
OLD DOG WITH GRADE 3 MPL?
A: Conservative treatment with re-evaluation if severity or
frequency of lameness increase.
B: Surgical two-stage repair, in the initial stage only
soft tissue reconstruction techniques and trochlear
chondroplasty can be performed and other techniques
must wait until the patient reaches skeletal maturity.
C: Surgical repair using all the techniques needed (soft
tissue and osseous techniques) to achieve a perfect
correction of the MPL.
D: Surgical repair only using osseous techniques.
640 Veterinary Ireland Journal I Volume 4 Number 12
for medial patellar luxation: a clinical study in 5 dogs.
Veterinary Surgery 2013: 42: 721-726
7. Gibbons et al. Patellar luxation in 70 large breed dogs.
Journal of Small Animal Practice 2006: 47: 3-9
8. Gillick et al. Rotating dome trochleoplasty: an
experimental technique for correction of patellar
luxation using a feline model. Veterinary Comparative
Orthopaedics and Traumatology 2007: 20: 180-184
9. Johnson et al. Comparison of trochlear block recession
and trochlear wedge recession for canine patellar
luxation using a cadaver model. Veterinary Surgery
2001: 30: 140-150
10. Piermattei D, Flo G, DeCamp C. Handbook of small
animal orthopedics and fracture repair. Fourth edition.
Saunders: 2006 (pp562-580)
11. Pinna et al. Rotation of the femoral trochlea for
treatment of medial patellar luxation. Journal of Small
Animal Practice 2008: 49: 163-166
12. Tobias KM, Johnston SA (eds). Veterinary Surgery:
Small Animals. St Louis, Missouri: Elsevier. Saunders:
2012 (pp973-988)
13. William et al. Surgical treatment of medial patellar
luxation without femoral trochlea groove deepening
procedures in dogs: 91 cases (1998-2009). Journal of
the American Veterinary Medical Association 238(9):
1168-1172
14. Yeadon et al. Tibial tuberosity transposition-
advancement for treatment of medial patellar luxation
and concomitant cranial cruciate ligament disease in
the dog. Veterinary Comparative Orthopaedics and
Traumatology 2011: 24: 18-26
3: WHICH OF THESE SENTENCES IS TRUE?
A: Large breeds are more affected by MPL than small
breeds.
B: Bilateral involvement in MPL is hardly impossible.
C: Lateral patellar luxation is more frequent than MPL.
D: Small-breed females are more affected by MPL than
small-breed males.
4: RADIOGRAPHY SURVEY:
A: It is not essential, even severe dogs can be evaluated
and treated surgically without radiographs.
B: In severe cases, orthogonal radiographic views of the
stifle alone are sufficient.
C: Position is critical to avoid false positive limb
deformities.
D: Severe cases need orthogonal radiographs views
from mid-femur to mid-tibia.
ANSWERS: 1. B, 2. B, 3. D, 4. C
Allianz 2
 VETERINARY
INSTRUMENTATION
PATELLAR LUXATION - A STEP BY STEP GUIDE
Introduction
Patellar luxation is the condition where the patella luxates out
of the femoral trochlear sulcus instead of tracking up and down
within it. Most commonly the patella luxates medially but
lateral luxation also occurs. It can occur in any size or breed of
dog but is more common in small breed dogs.
Cats have a broad and flat patella and the femoral trochlear
sulcus is shallow; therefore the normal cat patella is much more
mobile mediolaterally and relatively unstable compared to dogs.
Patellar subluxation is common in cats but, clinically significant
patellar luxation is uncommon.
Patellar luxation is usually a diagnosis made from the patient
history and signalment, and by stifle manipulation and
palpation, rather than from radiographs. This is because the
luxating patella is mobile and can change position which can be
easily palpated but not necessarily appreciated on a radiograph.
Patellar luxation is graded depending on its severity and there
are many ways of doing this. The most commonly used grading
system is the Putnam / Singleton system which can be described
as:
Grade 1: The patella tracks normally but luxates with digital
pressure or manipulation of the tibia. Once manipulation
is discontinued, the patella tracks normally in the trochlear
groove. This causes minimal clinical problem with infrequent or
no clinical signs. Surgical correction is usually not indicated nor
of direct benefit to the patient.
Grade 2: The patella intermittently and spontaneously luxates
and resolves. This may be mild and infrequent to severe and
frequent, and anywhere in-between. Luxation normally happens
as the stifle is flexed, and resolves when the stifle is extended.
The typical history is of a dog with intermittent “skipping”
hindlimb lameness. Surgical correction is usually of benefit to
the patient.
particularly the more frequently patellar luxation occurs.
Grade 3: The patella is always luxated but can be returned
to the normal position in the trochlear sulcus by digital
manipulation. Once such manipulation stops, patellar luxation
recurs. This causes an abnormality of stifle function i.e. inability
to extend the stifle and associated hindlimb lameness. Surgical
correction is beneficial to the patient as it restores normal stifle
function, particularly the quadriceps ability to extend the stifle.
Grade 4: The patella is permanently luxated and cannot
be reduced to a normal position despite manipulation. This
causes permanently abnormal stifle function with lameness
and inability to extend the stifle, and can result in debilitating
lameness with a crouched pelvic limb stance and gait.
Surgical correction is of benefit. In puppies and young dogs
with severe grade 4 developmental patellar luxation, surgery
should be considered as soon as possible to prevent the
progression of skeletal deformities that may otherwise develop.
Surgical correction of grade 4 patellar luxation is challenging.
www.vetinst.com
Broadfield Road, Sheffield UK. S8 0XL
Tel: 0845 130 9596 Fax: 0845 130 8687
Overseas Tel: +44 114 258 8530 Fax: +44 114 255 4061
info@vetinst.com www.vetinst.com
NB Throughout this text for the purpose of clarity, patellar
luxation and its treatment will refer to medial patellar luxation.
For cases of lateral patellar luxation, the terminology and text is
interchangeable but references to position should be switched i.e.
medial to lateral and vice versa.
Causes of patellar luxation, and surgical solutions
Usually a combination of different factors cause patellar luxation.
For successful correction, the surgeon must make an individual
assessment of each patient and identify each factor present and
correct appropriately. The common problems are illustrated
below.
a. conformation of pelvic
limb of normal dog.
b. conformation of pelvic
limb of dog with medial
bowing (varus) of the
femur, internal rotation of
the tibia and medial tibial
tuberosity malpositioning
i.e. malalignment of the
quadriceps mechanism
relative to the femoral
trochlear sulcus, and
medial patellar luxation.
Red line indicates central
axis of the limb.
a b
1. Malalignment of the quadriceps mechanism and
trochlear sulcus. The quadriceps mechanism comprises the
quadriceps muscle with the origin of the three vastus muscles
on the proximal femur and rectus femoris on the pelvis just
cranial to the acetabulum, the patella, patellar ligament and
tibial tuberosity. The relative position of these, in particular the
patella and the trochlear sulcus is important. For normal patellar
tracking, the line-of-pull of the quadriceps mechanism and the
patella should lie directly over the femoral trochlear sulcus.
Factors that affect quadriceps alignment are: but the inclusion criteria are poorly defined. Partial parasagittal
- Bowing of the distal femur. This changes the position patellectomy may be performed in cats if patellar luxation
and alignment of the femoral trochlear sulcus relative to the cannot be constrained using traditional means. If significant
quadriceps mechanism. hip pathology is present such as hip subluxation, this may
Femoral bowing can be assessed from physical assessment, need to be addressed to successfully correct patellar traceing.
radiographs and CT images, but interpretation can be challenging However, these are demanding surgeries, and best undertaken by
and the normal range has not been well defined. experienced surgeons.
- Tibial malformation – a rotational (torsional) deformity of
the tibial tuberosity can cause malalignment of the quadriceps Surgical technique for (medial) patellar luxation
mechanism due to abnormal positioning of the tibial tuberosity
relative to the femoral trochlear sulcus. Initial approach and assessment.
- Bowing of the proximal tibia; often the proximal tibia is bowed
in the opposite direction to the distal femur. 1. Pre-operative assessment includes a full clinical examination
- Hip conformation and pathology; for example cranio-dorsal of the patient including gait assessment and orthopaedic
hip luxation causes functional foreshortening of the femur examination. Patellar stability and pelvic limb alignment should
with external rotation; this in turn causes quadriceps / femoral be assessed.
trochlear sulcus malalignment and patellar luxation can occur. ..........
2. Shallow femoral trochlear sulcus; too shallow a sulcus
or insufficiently high medial or lateral trochlear ridges can
result in inadequate constraint of the patella and subsequent
luxation. Assessment of sulcus depth and trochlear ridge height
is subjective; there is no guide that helps to differentiate normal
from abnormal.
3. Excessively tight medial soft tissues i.e. the retinaculum
and joint capsule. If the soft tissues medial to the patella are too
tight, they will constrain its movement by permanently “pulling”
it medially. It is likely that these tissues become tight as a
consequence of chronic patellar luxation, rather than causing it.
4. Loose lateral soft tissues i.e. retinaculum and joint capsule;
if these tissues are loose, then the patella is not “pulled” or
constrained laterally i.e. patellar luxation can occur. These tissues
are loose in the opposite direction to the patellar luxation, and
most likely develop as a result of patellar luxation rather than
causing it.
5. Co-existing rupture of the Cranial Cruciate Ligament.
Patellar luxation may also occur in association with cranial
cruciate ligament rupture. When the cranial cruciate ligament
ruptures, cranial and internal rotational stability of the tibia
relative to the femur is lost; this causes malpositioning of the
tibial tuberosity relative to the femoral sulcus, and quadriceps
malalignment.

The four commonly performed surgical options available to

correct patellar luxation include:
1. Femoral Trochlear sulcoplasty i.e. deepen the trochlear
sulcus to constrain the patella and prevent luxation. This is done
if the trochlear sulcus is assessed to be too shallow. 2. Take orthogonal radiographs of the stifle (Fig 1 & 2).
2. Tibial tuberosity transposition i.e. re-align the quadriceps Consider including a full caudo-cranial view of the entire
mechanism by osteotomy and re-positioning the tibial tuberosity hindlimb from hip to tarsus to assess bowing deformities of the
more laterally. This is done if malalignment of the quadriceps tibia and femur (Fig 1). The radiographs allow the diagnosis to be
mechanism and the femoral trochlear sulcus are present. confirmed, other differential diagnoses to be excluded, and pre-
3. Medial release i.e. transect the medial soft tissues (joint operative measurements made to plan the correct position of the
capsule and/or retinaculum) if they are excessively tight. This osteotomy for tibial tuberosity transposition (Figure 2).
is done if medial soft tissue tension prevents the patella from ...........
tracking in the trochlear sulcus.
4. Lateral imbrication i.e. tighten the lateral soft tissues (joint
capsule and retinaculum) to prevent patellar luxation. This is
done if the soft tissues are too loose, but it should not be relied on
to correct patellar luxation because future tissue loosening will
likely develop if quadriceps alignment or inadequate sulcus depth
persist.
Other surgical produces exist that may be used to correct patellar
luxation, but these are more demanding procedures. Corrective
osteotomies of the distal femur and/or proximal tibia may be
performed if there is significant femoral / tibia malalignment,
 Fig 3 Fig 4
3. Position the patient in dorsal recumbency (Fig 3) and prepare
a full aseptic surgical preparation of the limb with the entire
distal limb draped in (Fig 4) and the foot in a sterile impervious
dressing. This allows full access and manipulation of the limb
during surgery.
..........
Fig 5
4. Before starting the surgery, check patella position and
anatomic landmarks that will guide the surgery i.e. patella,
patellar ligament and tibial tuberosity (Fig 5).
..........
Fig 6
5. Make a lateral para-patellar skin incision over the stifle about
1cm lateral to the patella, extending from proximal to the patella
to the tibial tuberosity (Fig 6).
..........
Fig 7
6. Dissect the subcutaneous fascia until the patellar ligament and
tibial tuberosity are clearly seen (Fig 7).
..........
7. Assess the alignment of the quadriceps mechanism. Stand
at the toe of the dog and visualise the course and position of
the quadriceps mechanism. Review this whilst flexing the stifle
and internally rotating the tibia. Note whether the quadriceps
mechanism is aligned or malaligned i.e. does the patellar
ligament deviate medially, laterally or is it neutral? (Fig 3 & 4).
...........
Fig 8
8. Sharply incise the lateral retinaculum approx. 1cm lateral to
the patella. Dissect free from the underlying joint capsule. This
incision extends proximal to the patella. The joint capsule is
exposed underneath (Fig 8).
............
Fig 9
9. Sharply incise the joint capsule. This incision extends
proximal to the patella, extending slightly into distal vastus
lateralis. Use suction to aspirate synovial fluid. Luxate the patella
medially, flex the stifle and use Gelpi retractors to maintain
position (Fig 9).
10. Inspect and confirm that the cranial aspect of the cruciate
ligament is normal.
............

Fig 10
11. Assess the depth of the trochlear groove (this is subjective),
and then for articular cartilage erosions of the femoral trochlear
sulcus. Fig 10 shows full thickness cartilage erosion (circled
green) of the proximal medial trochlear ridge where the patella
has been luxating, a relatively shallow trochlea and a medial
trochlear ridge with poor height.
Fig 11
12. Remove the Gelpi retractors, retroflex the patella and assess
the articular cartilage damage on the caudal aspect of the patella.
Fig 11 shows a large full thickness articular cartilage abrasions
on the caudal aspect of this patella; this may adversely affect
prognosis.
Medial Release
Medial release is not necessary for the majority of cases. It is
necessary when the tension in the medial tissues is such that
the patella cannot be returned to the trochlear sulcus without
performing release, or if the tension is adversely influencing
patellar tracking i.e. grade 4 or severe grade 3 patellar luxation.
If medial release is to be performed, it is best performed as the
first step i.e. before femoral trochlear sulcoplasty, and certainly
before tibial tuberosity transposition.
To perform medial release, a medial approach is made to the
stifle in a similar way as described above for the lateral approach.
The incision extends far enough proximally until all excessive
soft tissue tension has been abolished. In most dogs, this means
releasing both the medial retinaculum and the joint capsule in the
region of and just proximal to the stifle. If severe, the release may
need to extend up to the proximal femur and pelvis.
Femoral Trochlear Sulcoplasty
Assess the depth of the femoral trochlear sulcus and the need for
sulcoplasty; this is a subjective decision (Fig 10). If the trochlear
sulcus is deep enough, sulcoplasty is not necessary. When
assessing whether to perform sulcoplasty or not, consider that the
detrimental effect of sulcoplasty is unavoidable cartilage damage;
this needs to be carefully balanced against the benefits. Methods
for sulcoplasty include:
1. Block Recession Sulcoplasty. In adult dogs, this is the best
option as it preserves the largest amount of articular cartilage,
it enables a larger amount of the sulcus to be deepened, and it
creates a deeper femoral trochlea proximally compared to wedge
recession sulcoplasty. However, it is also the most fiddly and
technically demanding method and requires precise surgical
technique and a modular osteotome (Fig 12) with thin, sharp
blades of different widths. It is very challenging to do this well
single-handed; a surgical assistant is necessary.
Fig 12
2. Wedge Recession Sulcoplasty. This is the next best option
as it preserves some articular cartilage, but it does not deepen
the trochlear sulcus as well as block recession sulcoplasty. It
is simpler to perform and can be done with less specialised
equipment or experience.
3. Abrasion Sulcoplasty (Rasping). A bone rasp (Fig 13) is
used to rasp the trochlear sulcus until adequate depth is achieved.
This is the least favourable option as all articular cartilage is
destroyed. This technique is not recommended unless no articular
cartilage present, which is uncommon except in revision surgery.
Inexperienced surgeons may choose to start using this technique,
particularly in very small stifles where the osteotomy techniques
above may be challenging and carry a risk of fracture of the
osteochondral graft, or even the femur if the cuts are made too
deep.
Fig 13
4. Chondroplasty. This is rarely performed as it can only be
done in very young patients, (less than 6 months); the cartilage
isn’t flexible enough in older patients. The articular cartilage
of the trochlear sulcus is sharply dissected away from the
subchondral bone and remains attached distally. The underlying
bone is deepened, then the articular cartilage is laid back in the
trochlear groove.
Block Recession Sulcoplasty Fig 16

4. Carefully remove the osteochondral block from the femoral

trochlea (Fig 16).

5. Recess the block by taking further subchondral bone away:

either from the exposed femoral subchondral bone or from the
base of the osteochondral block.
.........

Fig 17

1. Determine the width of the intended sulcoplasty by choosing

the modular osteotome blade that best fits the maximum width of
the trochlea.
Using a #11 blade, gently score the medial and lateral trochlear
ridges.

6. Re-position the osteochondral block in the graft site and

Fig 14 Fig 15 review for closeness of fit, stability, and depth of recession
achieved (Fig 17). Adjust until satisfactory and stable.

7. Remove the Gelpi retractors, return the patella to the trochlear

sulcus and assess the patella for normal tracking and medial
lateral stability.

Wedge Recession Sulcoplasty

2. Using a fine X-ACTO saw or similar, create the lateral and

medial cuts that will define the edges of the osteochondral
block. (Fig 14) Make sure the base of the cuts are flat and do not
become domed. Be careful to make the osteotomy as wide as
possible, yet leave enough lateral and trochlear ridge width that
neither is weakened.

3. Use the modular osteotome and mallet to cut the base of the
block from distal to proximal. (Figure 15) Start just cranial to the
intercondylar notch and aim for the osteochondral junction of the
trochlear groove proximally. This must be done very carefully
and with great care taken to avoid fracturing the block. A thick
osteotome will increase the chance of fracture. If the block
fractures, it can be salvaged.
............
1. Using a #11 blade, score the highest points of the medial and
lateral trochlear ridges of the femur; this identifies the cutting
points. Using an fine X-ACTO saw, create an osteochondral
wedge from the trochlear sulcus.
Fig 18
Fig 19
The lateral and medial saw cuts should be oriented to meet
just cranial to the intercondylar notch of the femur distally and
proximally at the osteochondral junction (Fig 18).
2. Carefully remove the cut wedge from the femoral trochlea
(Fig 19).
Fig 20
3. Recess the wedge by removing a further thin section of
subchondral bone; either from the exposed femoral trochlear
sulcus (Fig 20) which is best, or from the wedge itself but the
latter is more difficult and will make the wedge narrower and
lose more articular cartilage.
Fig 21
4. Replace the osteochondral wedge in the recessed femoral
sulcus and review for closeness or fit, stability, and depth of
trochlear recession achieved. Adjust until satisfactory (Fig 21).
Some surgeons prefer to remove some subchondral bone at the
base (apex) of the wedge with rongeurs; this can give a better fit
and stop the graft from rocking on the ridge of the base.
Remove the Gelpi retractors, return the patella to the trochlear
sulcus and assess the patella for stability through a full range
of physiological stifle movement, specifically flexing from full
extension with tibial internal and external rotation - these are the
positions most likely to cause luxation.
Patellar luxation should be resolved prior to soft tissue closure -
do not rely on soft tissue closure to ensure patellar stability.
Tibial Tuberosity Transposition
Assess the need for tibial tuberosity transposition; prior to
surgery, an indication will have been derived from the physical
examination, radiographs or CT scan. The dog should be in
dorsal recumbency. Stand at the foot of the dog, looking up the
pelvic limb (Fig 3 & 4). Hold the stifle in full extension. Observe
the orientation and position of the patellar ligament, patella and
tibial tuberosity whilst the stifle is extended and flexed and the
tibia is rotated internally and externally; the most likely position
for patellar luxation is flexing with internal tibial rotation. If
patellar ligament orientation is not neutral and patellar luxation
occurs, tibial tuberosity transposition is indicated.
Fig 22
As an example, (Fig 22) shows the relative positions of the
patella (reduced and luxated), the position of the tibial tuberosity
and the medial orientation of the patella, patellar ligament and
tibial tuberosity.
Tibial Tuberosity Transposition Surgery
1. Use sharp dissection (#11 blade and periosteal elevator) to
expose the medial aspect of the tibial tuberosity.
2. If necessary, sharply dissect and elevate the cranial tibial
muscle from the lateral tibial tuberosity. Ensure that the most
proximal attachments of the muscle are not severed i.e. the
muscle should only be partially elevated to minimise damage
from the saw blade, but not fully elevated
Fig 23 Fig 24
3. Using a powered oscillating saw, hand saw, bone cutters or
osteotome, perform an osteotomy of the tibial tuberosity (Fig
23). An oscillating saw gives the most controlled and precise
cut. Place a Freer elevator or Gelpi retractor under the patellar
ligament to protect it from the saw.
4. The size of tibial tuberosity and position of osteotomy is
important to minimise the chance of fracture. As a guide, the
cranio-caudal depth of the osteotomised tibial tuberosity should
be about 30% the cranio-caudal dimensions of the tibia at that
point. The osteotomy should go between the proximal tibia
and the base of the tibial tuberosity, preserving the periosteum
intact distally. Fig 24 shows pre-operative planning for size
and position of the tuberosity osteotomy; a sterile ruler can be
used during surgery to replicate the measurements and ensure
the osteotomy is in the correct position. Fig 25 shows a post-
operative radiograph with a good size of tibial tuberosity. If
the osteotomy is made in the wrong position, either the tibial
tuberosity or the tibia are at risk of fracture.
Fig 25 Fig 26
5. The tibial tuberosity should now be partially mobile (medial to
lateral) whilst the distal bone and periosteal attachments should
be intact. Using a periosteal elevator, gently and minimally
elevate the tibial tuberosity from the tibia and transpose it
laterally to a position that achieves neutral orientation of the
patellar ligament and quadriceps mechanism (Fig 26). If the
tuberosity is not readily mobile, this usually means the osteotomy
is not quite enough and needs slightly more work distally. Some
surgeons like to prepare the graft bed prior to tibial tuberosity
fixation; to do this, the ridge from the lateral edge of the parent
tibial tuberosity site is removed using rongeurs.
Fig 27 Fig 28
Fig 29 Fig30
6. Using a power drive where available, place a K-wire into the
proximal tibial tuberosity just proximal to the distal insertion
point of the patellar ligament, to immobilise the tibial tuberosity
in its new laterally transposed position (Fig 27, 28 & 29). The
K-wire should be directed slightly cranio-lateral to caudo-medial.
In bouncy or active dogs, or if the tibial tuberosity was detached
from the tibia and has insufficient inherent stability, application
of a figure-of-8 tension band is advisable; care must be taken
during placement to not damage the soft tissues, particularly the
patellar ligament. The size of K-wire should be appropriate to the
patient, and 2 K-wires may be advisable for additional security
(Fig 31 & 32). A Jacobs chuck can be used to drive the K-wires
but this is more challenging to successfully drive the wire
through the bone without slippage and wire bending.
7. Looking from the position of the dog’s foot, review the
orientation of the patellar ligament and the position of the tibial
tuberosity.
Fig 31 Fig 32
Fig 33 Fig 34
The patellar ligament should be in a neutral position; internal
and external rotation of the tibia should cause equal medial
and lateral orientation of the patellar ligament with no patellar
luxation (Fig 31 & 32) with internal and external rotation
respectively; note the changing alignment of the patellar ligament
as the tibia is rotated. Fig 33 & 34 show the patella in the correct
position.
8. Review the stability of the patella and specifically assess for Patella Luxaxtion Instrumentation
luxation. Start with the stifle in full extension and slowly flex WEDGE & BLOCK SULCOPLASTY INSTRUMENTATION
with the tibia in full internal and then external rotation as these 001380 Modular Osteotome with Seven Blades 4, 6, 8, 10, 12, 15 & 20mm
are the positions most likely to cause luxation. The patella should 001389 Modular Diamond Rasp 6mm
now be stable through a full range of normal physiological 001382 4mm Blade for Modular Osteotome
movement and should not luxate. 001383 6mm Blade for Modular Osteotome
Patellar luxation should be resolved prior to soft tissue closure - 001384 8mm Blade for Modular Osteotome
do not rely on soft tissue closure to ensure patellar stability. 001385 10mm Blade for Modular Osteotome
001386 12mm Blade for Modular Osteotome
Lateral Imbrication 001387 15mm Blade for Modular Osteotome
001388 20mm Blade for Modular Osteotome
For the majority of cases of patellar luxation, once sulcoplasty 001021 Universal Sulcoplasty Rasp 210mm Long
and tibial tuberosity transposition have been performed, the 001017 Superslim Osteotome 8mm
patella should be stable and further surgery (other than routine 001320 Mallet 300g
closure) should not be necessary. If the patella is not stable at this XACTOB/H X-Acto Saw Complete
stage, the trochlear sulcoplasty and tibial tuberosity transposition XACTOBLADE X-Acto Saw Blade - 0.3mm Cut - Non-sterile
should be critically reviewed, and revised if necessary. XACTOSTERILE X-Acto Saw Blade - 0.3mm Cut - Sterile
Performing lateral imbrication without adequate trochlear 001004 Orthopaedic Stainless Steel Hard Back Saw 0.4mm Cut
sulcoplasty or tibial tuberosity transposition is not recommended 001300 Small Curved Rongeurs 4mm Bite
and may be associated with a high failure rate and risk of patellar 142502 Micro Freidman Curved 2.2mm Bite
re-luxation.
Lateral imbrication tightens the soft tissues on the lateral aspect RASPS
of the stifle joint; the joint capsule and retinaculum can be done 001020 Trochlea Rasp (Max Diameter 11mm/ Min Diameter 5mm)
separately. Imbrication can be achieved by one of two methods: 001022 Trochlea Rasp Small (Max Diameter 8mm/ Min Diameter 3mm)
- Using Mayo scissors, resect a strip from one edge of the 001389 Modular Diamond Rasp 6mm (to fit Modular Osteotome Handle)
retinaculum and / or joint capsule. Don’t take so much tissue that 001021 Universal Sulcoplasty Rasp 210mm Long
it can’t then be sutured together. The tissue should close snugly
but without tension. Close the joint capsule and retinaculum TIBIAL CREST TRANSPOSITION INSTRUMENTATION
separately with simple interrupted appositional sutures. 001310 Small Angled Cutters 15mm Blade
- Or place modified Mayo Mattress (vest over pants) sutures 001311 Large Angled Cutters 19mm Blade 230mm Long
to close the retinaculum and / or joint capsule in an overlying 001000 Adjustable Bone Saw with 5 Blades
instead of an appositional fashion. 001001 Spare Fine Blades - Pack of 5 Chrome Plated
001221 Standard Jacobs Chuck & Handle 1/4” (6mm) Capacity
Closure 001220 Small Jacobs Chuck & Handle 5/32” (4mm) Capacity 260mm Long
001223 Small Pin/ ‘A’ Wire/ ‘K’ Wire Vice 100mm Long
Before considering the surgery complete, once again check 090054 0.8mm Arthrodesis Wire 125mm Long - Pack of 10
patellar stability through a normal physiological range of stifle 090020 0.9mm Arthrodesis Wire 125mm Long - Pack of 10
movement, particularly flexing the stifle from full extension with 090060 1.0mm Arthrodesis Wire 125mm Long - Pack of 10
tibial internal and external rotation. If patellar luxation persists, 090021 1.1mm Arthrodesis Wire 125mm Long - Pack of 10
the surgery needs to be reviewed and revised. The surgical site 090061 1.25mm Arthrodesis Wire 125mm Long - Pack of 10
should be flushed thoroughly and then closed: 090024 1.4mm Arthrodesis Wire 125mm Long - Pack of 10
- Appose and close the joint capsule incision; unless release was 090062 1.5mm Arthrodesis Wire 125mm Long - Pack of 10
performed, then not on that side. 090022 1.6mm Arthrodesis Wire 125mm Long - Pack of 10
- Appose and close the reticular incision; unless release was 090026 1.8mm Arthrodesis Wire 125mm Long - Pack of 10
performed, then not on that side. 090023 2.0mm Arthrodesis Wire 125mm Long - Pack of 10
- Appose and close the subcutaneous fascia 001360 Kirschner/ Arthrodesis Wire & Small Pin Punch 135mm
- Appose and close the skin. 001362 Kirschner & Arthrodesis Wire Bender 140mm Long
Fig 35 Fig 36 090039E K/ A Wire Storage Tube & Dispenser 125mm 0.9/ 1.1/ 1.6/ 2.0mm
090039SET Arthrodesis/ Kirschner Wire Storage Dispenser - Set of 10
001260 Wire Twister & Shear Cutter 165mm Long
001237 Implant Cutter S/Steel Compound Action 2.2mm Max 230mm Long
001238 Implant Cutter S/Steel Close Cut to 1.5mm 150mm Long
OW1010 Reel of Orthopaedic Wire 1.0mm/ 20g Diameter
OW0810 Reel of Orthopaedic Wire 0.80mm/ 21g Diameter

ORTHOPAEDIC POWER
001600 Variable Speed Orthopaedic Drill Kit
001708.134 Multi Saw Surgical Kit with TTAR/ TTO Blade
BLACKKIT VI Black Series Drill/ Saw Set
Post-operative radiographs of the stifle are taken to confirm the
patella has been returned to the trochlear sulcus, that the positions ADDITIONAL USEFUL ITEMS
of the sulcoplasty and tibial tuberosity transposition are correct 001330 Gelpi Self Retaining Retractor 120mm Spread 180mm Long
and appropriate, and that implants are in the correct position (Fig 001271 Periosteal Elevator CVD AO Type 180mm 6mm End Fibre Handle
35 & 36). Radiographs should be critically assessed for potential 7350/05 Freer Periosteal Elevator Dual Ended 5mm End 180mm Long
problems before the patient is recovered from the anaesthetic. 833305 Senn Retractor (Cats Paw)
Vet Times
The website for the veterinary profession
https://www.vettimes.co.uk

Canine patellar luxation part 2: treatments and outcomes

Author : Albane Fauron, Karen Perry

Categories : Companion animal, Vets

Date : April 18, 2016

ABSTRACT

The most important decision in cases of canine patellar luxation is whether surgical stabilisation is
required. Surgical treatment is generally not recommended for asymptomatic cases. For clinically
affected cases, conservative management is unlikely to result in significant improvement and
surgical therapy is indicated.

Corrective surgical techniques focus on realignment of the quadriceps mechanism and stabilisation
of the patella in the trochlea. Cases treated with tibial tuberosity transposition and femoral
trochleoplasty have been associated with lower risks of patellar reluxation and major complications,
and the use of these techniques should be considered in all developmental cases.

In cases where significant skeletal deformities have been identified preoperatively, or in cases that
fail to respond to conventional surgical techniques, more advanced imaging and surgery may be
required.

As discussed in part one (VT46.09), while patellar luxation (PL) is a common condition, not all
cases require surgical intervention. Of those needing stabilisation, deciding which
deformities require correction to achieve a comfortable and functional outcome is not
always straightforward.

Corrective surgical techniques used in the management of clinically affected cases focus on
realignment of the quadriceps mechanism and stabilisation of the patella in the trochlea.

The results of surgical correction vary with the severity of the anatomic abnormalities present, but if
appropriate decision-making is employed, for the majority of cases, the outcome should be
favourable.

1 / 12
Treatment
Decision-making

Figure 1. Intraoperative photograph demonstrating a trochlear wedge recession in a four-year-old

cavalier King Charles spaniel.

While selection of conservative or surgical management may appear straightforward, decision-

making with PL cases can become challenging. The decision to opt for conservative or surgical
management should not be based on the presence or grade of the luxation, but on the global
clinical picture, including the presence of pain, the type and duration of lameness and the clinical
function of the limb.

A retrospective evaluation of dogs with bilateral medial patellar luxation (MPL) that underwent
unilateral surgery documented a similar progression of degenerative joint disease (DJD) in
operated and non-operated stifles (Roy et al, 1992) and, therefore, the argument to operate on non-
clinically affected dogs in an effort to ameliorate DJD progression may not be appropriate.

Grade I cases with no associated clinical signs are typically managed conservatively. In the
asymptomatic adult dog, surgical intervention is not recommended. As noted, no evidence exists
that prophylactic surgery is beneficial (Roy et al, 1992) and should clinical signs become evident at
a later stage, these dogs still respond well to late surgical stabilisation – even if the cranial cruciate

2 / 12
ligament (CrCL) subsequently ruptures (Piermattei et al, 2006).

This issue is more contentious in immature asymptomatic animals; early surgical intervention may
be more appropriate to prevent the development of subsequent severe limb deformities and
contracture. This is especially true of large breed dogs, where intervention is recommended before
the trochlea erodes and deforms (Piermattei et al, 2006). While the majority of small dogs with
grade I luxation will never encounter lameness issues, large breed dogs are more likely to be
clinically affected (Harasen, 2006).

In cases of grade II luxation, indications for surgery are based on the severity of clinical signs.
Indications for surgical repair of a grade II luxation include significant episodes of lameness lasting
two weeks to three weeks or longer and at least three significant episodes of lameness occurring
over a short amount of time (three weeks to four weeks; Kowaleski et al, 2012).

Most cases of grade III or grade IV luxation require surgery early in the course of the disease to
address the clinical signs and mitigate progression of skeletal deformities and DJD. Severe cases
might already be associated with significant femoral varus or valgus and/or tibial deformity. In such
cases, femoral osteotomy may be necessary instead of, or in addition to, other standard
stabilisation techniques to achieve maintained reduction of the patella and realignment of the
quadriceps mechanism (Piermattei et al, 2006; Roch and Gemmill, 2008).

However, do not lose sight of the clinical presentation and, despite severe anatomical
abnormalities, some dogs with high-grade PL have good clinical function.

In their study, Gibbons et al (2006) reported two dogs with grade IV PL were managed
conservatively because they were sound or only mildly lame.

As the grade of PL increases, the surgical complexity often increases, as do the complication rates
and costs associated with surgical intervention. It is important the perceived improvement in
function that can be achieved with surgery is weighed against the risks and costs associated with
the procedure for each individual case.

Conservative management

Reasons for non-surgical management include owner reluctance to perform surgery and minimal,
or absence of, lameness. Sound dogs with PL are likely to not benefit from surgical intervention
since DJD is similarly progressive, despite the reduction of luxation (Roy et al, 1992).

As for many other orthopaedic conditions, the cornerstones of conservative management of PL are
weight management, rest, anti-inflammatory therapy, exercise modification and physical
rehabilitation. Limited data is available in the literature regarding the outcome of cases managed
conservatively and further studies are warranted to evaluate the long-term outcome of these cases

3 / 12
based on severity of lameness and grade of luxation on presentation.

In the authors’ experience, in clinically affected cases, conservative management may reduce the
frequency of clinical signs associated with PL, but is not likely to improve the grade of the luxation.
A caveat to this may be in cases with severe muscle atrophy where rehabilitation may be of
assistance.

Surgical options
Surgical treatment of PL can be subdivided into soft tissue reconstructive procedures that influence
medial or lateral patellar support depending on the direction of the luxation and bone reconstruction
procedures that improve alignment of the quadriceps mechanism (Gibbons et al, 2006; Remedios
et al, 1992; Willaeur and Vasseur, 1987).

Soft tissue procedures

Soft tissue stabilisation techniques are generally not appropriate when used in isolation for
developmental cases (Piermattei et al, 2006), as they do not correct the underlying skeletal
deformities; a high rate of recurrence can, therefore, be anticipated. This may be appropriate in
traumatic cases where no skeletal deformities are present.

Soft tissue balance can be achieved by release of contracted tissue in the direction of luxation and
imbrication of lax tissue on the opposite side. Both the retinaculum and the joint capsule can be
released (via a procedure called desmotomy) or imbricated depending on the direction of the
luxation. The retinaculum of the stifle refers to various layers of fascia that help stabilise the patella.

Depending on each individual case, a combination of capsular/retinacular release on one side of

the luxation and capsular/retinacular imbrication on the opposite side can be performed. For
example, in the case of MPL, a medial desmotomy allows the release of contracted tissue that
prevents the patella from returning into the trochlear groove. The joint capsule is typically left open.
Medial desmotomy is often performed in conjunction with lateral imbrication. The joint capsule and
fascial tissues can be tightened by a variety of aforementioned methods (Kowaleski et al, 2012).

Bone reconstruction procedures

The most common procedures to modify bone structures in the stifle are trochleoplasty techniques
and tibial tuberosity transposition.

Trochleoplasties (or sulcoplasties) aim at deepening and widening the trochlear groove to contain
the patella and prevent luxation.

Trochlear wedge recession (TWR) and trochlear block recession (TBR) are the two trochleoplasty

4 / 12
techniques most commonly used in adult dogs. In the former, a V-shaped wedge of articular
cartilage and subchondral bone is removed from the trochlea using a saw. The cut wedge is
carefully displaced from the femoral trochlea and a further thin section of the exposed subchondral
bone of the femoral sulcus is removed before the wedge is replaced in the recessed sulcus (Figure
1).

TBR follows the same principle, but instead of a V-shaped wedge, the piece of trochlea removed is
rectangular. A cadaveric study performed on 24 stifles comparing TBR and TWR, using CT and
biomechanical evaluation, showed TBR to be superior to TWR in terms of proximal patellar depth,
patellar articular contact with the recessed proximal trochlea and size of the recessed trochlear
surface. It also demonstrated TBR to result in a greater resistance to PL in an extended position
when compared with TWR (Johnson et al, 2001).

In young dogs up to 10 months old, a trochlear chondroplasty can be used to recess the articular
surface. A cartilage flap is carefully elevated, subchondral bone removed from beneath it and the
flap pressed back into the deepened sulcus (Piermattei et al, 2006).

Abrasion trochleoplasty techniques have also been described. Since TWR and TBR allow the
preservation of articular cartilage, these are less commonly used. However, in some severe cases
of PL, where the articular cartilage has already been severely damaged, they may still play a role.

For all techniques, stability and depth of the trochlear recession achieved are assessed and
adjusted until satisfactory. It has been suggested the femoral sulcus should be recessed sufficiently
so 50% of the patella is seated in the trochlear ridges (Slocum and Devine, 1985).

Tibial tuberosity transposition (TTT) is an osteotomy technique that allows realignment of the
quadriceps mechanism by repositioning the tibial tuberosity, the point of insertion of the patellar
ligament on the tibia.

5 / 12
Figure 2. Intraoperative photograph demonstrating a lateral tibial tuberosity in a four-year-old
cavalier King Charles spaniel stabilised using two Kirschner wires and a tension band wire.

The size of the osteotomised segment is important to minimise the chance of fracture; as a guide,
the craniocaudal depth of the osteotomised tibial tuberosity should be a maximum of 30% of the
craniocaudal dimensions of the tibia at that point. The distal periosteum of the osteotomised
tuberosity is typically left intact. The degree of medial or lateral transposition of the tuberosity
needed varies with each case.

Excessive and insufficient transposition can result in luxation in the opposite direction to that noted
preoperatively and recurrence of luxation in the original direction, respectively. The degree of
correction required is assessed intraoperatively and the appropriate position of the tuberosity is
generally where the entire quadriceps mechanism runs in a straight line, but, more importantly,
where the patella can no longer be luxated. The patella should be assessed for continued luxation
by putting the stifle through a full range of normal physiological movement, including internal and
external rotation, prior to soft tissue closure.

Adequate fixation of the tuberosity is important to prevent iatrogenic avulsion fractures. The
tuberosity is secured into the new location using Kirschner wires (K-wires) of an appropriate size,
with or without a tension band wire. If the distal periosteal attachment has been transected then a
tension band wire is almost certainly indicated. If this remains intact, the placement of a tension
band wire varies between surgeons.

6 / 12
In the hands of the authors, a tension band wire is used in almost all cases (Figure 2), with the
only exceptions being small breed dogs with a satisfactory distal periosteal attachment or dogs
where a substantial bony attachment has been maintained distally. Anticipated client compliance
postoperatively is important in this decision-making.

Deciding which procedure, or combination of procedures, is necessary is often not straightforward

and demands sound clinical judgement and experience. Piermattei et al (2006) proposed an
algorithmic approach be used to achieve patellar stability based on grade and direction of luxation.

When PL and CrCL rupture occur concurrently, both conditions must be addressed to regain
normal stifle function (Newman et al, 2014). Although this can be achieved using staged surgical
procedures, combining surgeries in a single event represents advantages, such as decreased
patient morbidity and decreased total postoperative recuperation time.

Surgical treatment of concomitant CrCL disease and PL during the same surgery can be achieved
using standard stabilisation techniques; for example, extra-capsular stabilisation of the CrCL with
concomitant TTT, and trochleoplasty, with or without MPL soft tissue stabilisation techniques
previously described. The placement of an extracapsular suture does not involve an osteotomy of
the tibial tuberosity and, as such, can be combined with a TTT without increasing the risk of tibial
crest avulsion (Langenbach and Marcellin-Little, 2010).

Figure 3. Preoperative mediolateral and caudocranial, and postoperative mediolateral and

caudocranial radiographs of a five-year-old golden retriever with concomitant medial patellar
luxation and cranial cruciate ligament disease stabilised using tibial tuberosity transposition and
advancement.

In the case of concomitant MPL and CrCL disease, TTT and advancement is another described
technique (Yeadon et al, 2011; Figure 3).

Modification of the tibial tuberosity advancement technique to include lateral transposition of the
tibial tuberosity, when used in conjunction with ancillary procedures, such as block recession
trochleoplasty and lateral parapatellar fascial imbrication, has been shown to be a valid treatment

7 / 12
modality for simultaneous management of MPL and CrCL pathology (Yeadon et al, 2011).

In the authors’ experiences, this technique can also be adapted to transpose the tibial tuberosity
medially in cases of lateral patellar luxation (LPL).

As mentioned in part one, while most canine femora have some degree of varus shape, the degree
of varus conformation appears to vary both within and between breeds. Failure to correct excessive
femoral varus has been proposed as a cause of postoperative recurrence of MPL in large breed
dogs (Kowaleski, 2006; Palmer, 2004; Palmer and Swiderski, 2007; Slocum and Slocum, 1998;
Slocum and Slocum, 2000).

Corrective distal femoral osteotomy (DFO) has been advocated for treatment of MPL in large breed
dogs when femoral varus more than 10° is measured from radiographs (Kowaleski, 2006; Palmer
2004; Slocum and Slocum, 2000), but this criterion was based on subjective clinical experience
rather than objective measurements using a validated method.

While a cadaveric study performed on 10 femora found it to be of adequate specificity when

radiologically assessing the need for DFO (Swiderski et al, 2008), this criterion remains
contentious. While it may be useful as a guideline, in the authors’ experiences, several other
considerations are equally important when deciding whether DFO is necessary for an individual
case.

For example, if a patient presents with grade III MPL on the left with associated clinical signs and a
femoral varus angle of 11°, but also has a femoral varus angle of 11° on the right with no
associated PL, it is unlikely the varus angle is contributing significantly enough to the
aetiopathogenesis of the MPL on the left to warrant DFO. DFO is relatively complex and costly to
owners and can have complications. Further work is needed in this area to establish more objective
selection criteria.

Where DFO is considered, the most commonly practised method is a lateral closing wedge
ostectomy stabilised using a lateral bone plate and screws.

An alternative, which may facilitate the procedure, is a medial opening wedge osteotomy stabilised
using an interlocking nail (Figure 4).

This is a complex procedure that warrants referral to a specialised facility in most instances. For
the general practitioner, the most important thing is to recognise cases warranting more specialised
imaging and treatment to avoid disappointing outcomes following more routine surgical treatment.

Prognosis and complication rates

Complications after surgical treatment of PL include patellar reluxation, patellar reluxation with

8 / 12
implant failure (loose or broken K-wires), tibial tuberosity avulsion fracture, fracture of the proximal
tibia and fibula, luxation in the opposite direction due to overcorrection and wound-related
problems, such as dehiscence, infection, implant-related discomfort and seroma formation
(Gibbons et al, 2006; Arthurs and Langley-Hobbs, 2006).

In a retrospective analysis of 109 dogs, the overall frequency of postoperative complication was
18%, with major complications requiring revision surgery occurring in 13% of cases (Arthurs and
Langley-Hobbs, 2006).

Weight appeared to play a role in overall complications and patellar reluxation was higher for dogs
weighing more than 20kg.

In another study evaluating outcome associated with surgical correction of MPL in 124 dogs, the
frequency of major complication was 18.5% (Cashmore et al, 2014).

Figure 4. Postoperative mediolateral and caudocranial views of the left femur of the same case as
seen in Figures 1 and 2 following an opening osteotomy of the distal femur, stabilised using an
interlocking nail and a tibial tuberosity transposition to correct grade III medial patellar luxation.

The successful clinical use of trochleoplasty techniques has been extensively described (Rousk,
1993; Slocum and Devine, 1985) and multiple studies have showed a lower incidence of patellar
reluxation in cases where initial surgical stabilisation included trochleoplasty. Indeed, reported
reluxation rates after surgical correction range from 6% to 8% in studies evaluating dogs receiving
a trochleoplasty as part of surgical treatment (Alam et al, 2007; Arthurs and Langley-Hobbs, 2006)
to 19.8% in dogs where a trochleoplasty was not performed (Linney et al, 2011).

9 / 12
In another retrospective analysis of 124 dogs, the incidence of patellar reluxation increased from
4.5% in cases where trochleoplasty had been performed to 23.4%t in cases without (Cashmore et
al, 2014).

TTT has been associated with lowers risks of postoperative patellar reluxation and major
complications (Arthurs and Langley-Hobbs, 2006). As this procedure is the only one routinely
performed that corrects malalignment of the quadriceps mechanism, this is perhaps not surprising.
Given cases treated with both TTT and femoral trochleoplasty have been associated with a lower
risk of patellar reluxation and major complications, the use of these techniques should be
considered in all developmental cases of PL (LaFond et al, 2002; Gibbons et al, 2006; Cashmore
et al, 2014).

Implant failure and tibial tuberosity avulsion are complications reported when performing TTT. A
study evaluating 124 dogs found tibial tuberosity avulsion to be 11.1 times less likely in dogs in
which two K-wires had been used to stabilise the transposition instead of one.

Independent to the number of K-wires used, the more caudodistally the K-wires were directed, the
higher the risk for tibial tuberosity avulsion. Along with the number of wires used and the direction
of their insertion, the use of a tension band wire might help lower the risk of tibial tuberosity
avulsion. None of the dogs in which a tension band wire was used in the study suffered tibial
tuberosity avulsion (Cashmore et al, 2014).

The results of surgical correction vary with the severity of the anatomic abnormalities. Grade II and
grade III are considered to have a favourable prognosis, whereas grade IV cases carry a poorer
prognosis (DeAngelis, 1971; Remedios et al, 1992; Willaeur and Vasseur, 1987).

While most cases can be managed successfully using a combination of the conventional surgical
techniques, such methods still fail to restore patellar stability or satisfactory limb function in a few
cases.

Persistent PL, despite appropriately performed TTT and trochleoplasty, should raise suspicions of
inadequate appreciation of an underlying skeletal deformity and subsequent inadequate selection
and application of corrective surgery (Roch and Gemmill, 2008).

Canine patellar luxation part 1: pathophysiology and diagnosis

References

Alam MR, Lee JI, Kang HS, Kim IS, Park SY, Lee KC and Kim NS (2007). Frequency and
distribution of patellar luxation in dogs: 134 cases, Vet Comp Orthop Traumatol 20(1):
59-64.
Arthurs GI and Langley-Hobbs SJ (2006). Complications associated with corrective surgery

10 / 12
for patellar luxation in 109 dogs, Vet Surg 35(6): 559-566.
Cashmore RG, Havlicek M, Perkins NR, James DR, Fearnside SM, Marchevsky AM and
Black AP (2014). Major complications and risk factors associated with surgical correction of
congenital medial patellar luxation in 124 dogs, Vet Comp Orthop Traumatol 27(4):
263-270.
DeAngelis M (1971). Patellar luxation in dogs, Vet Clin North Am Small Anim Pract 1(3):
403-415.
Gibbons SE, Macias C, Tonzing MA, Pinchbeck GL and McKee WM (2006). Patella
luxation in 70 large breed dogs, J Small Animal Pract 47(1): 3-9.
Harasen G (2006). Patellar luxation, Can Vet J 47(8): 817-818.
Johnson AL, Probst CW, Decamp CE, Rosenstein DS, Hauptman JG, Weaver BT and Kern
TL (2001). Comparison of trochlear block recession and trochlear wedge recession for
canine patellar luxation using a cadaver model, Vet Surg 30(2): 140-150.
Kowaleski MP (2006). Femoral corrective osteotomy for medial patellar luxation,
Proceedings of the ACVS Veterinary Symposium, Washington: 473-476.
Kowaleski MP, Boudrieau RJ and Pozzi A (2012). Stifle joint. In Tobias KM and Johnston
SA (eds), Veterinary Surgery Small Animal (1st edn), Elsevier Saunders, St Louis: 973-988.
LaFond E, Breur GJ and Austin CC (2002). Breed susceptibility for developmental
orthopaedic diseases in dogs, J Am Anim Hosp Assoc 38(5): 467-477.
Langenbach A and Marcellin-Little DJ (2010). Management of concurrent patellar luxation
and cranial cruciate ligament rupture using modified tibial plateau levelling, J Small Anim
Pract 51(2): 97-103.
Linney WR, Hammer DL and Shott S (2011). Surgical treatment of medial patellar luxation
without femoral groove deepening procedures in dogs: 91 cases (1998-2009), J Am Vet
Med Assoc 238(9): 1,168-1,172.
Newman M, Bertollo N, Walsh W and Voss K (2014). Tibial tuberosity transposition
advancement for lateralization of the tibial tuberosity: an ex vivo canine study, Vet Comp
Orthop Traumatol 27(4): 271-276.
Palmer R (2004). Patellar luxation in large breed dogs, Proceedings of the ACVS Veterinary
Symposium, Denver: 364-366.
Palmer R and Swiderski J (2007). Long-term outcome of distal femoral osteotomy (DFO) for
treatment of combined distal femoral varus and medial patellar luxation, Proceedings of the
34th Annual Conference of the Veterinary Orthopedic Society, Sun Valley: 49.
Piermattei DL, Flo GL and DeCamp CE (2006). The Stifle Joint. In Brinker, Piermattei and
Flo’s Handbook of Small Animal Orthopaedics and Fracture Repair (4th edn), Saunders,
Philadelphia: 562-581.
Remedios AM, Basher AW, Runyan CL and Fries CL (1992). Medial patellar luxation in 16
large dogs. A retrospective study, Vet Surg 21(1): 5-9.
Roch SP and Gemmill TJ (2008). Treatment of medial patellar luxation by femoral closing
wedge ostectomy using a distal femoral plate in four dogs, J Small Anim Pract 49(3):
152-158.
Rousk JK (1993). Canine patellar luxation, Vet Clin North Am Small Anim Pract 23(4):

11 / 12
 855-868
Roy RG, Wallace LJ, Johnston GR and Wickstrom SL (1992). A retrospective evaluation of
stifle osteoarthritis in dogs with bilateral medial patellar luxation and unilateral surgical
repair, Vet Surg 21(6): 475-479.
Swiderski JA, Radecki SV, Park RD and Palmer RH (2008). Comparison of radiographic
and anatomic femoral varus angles measurements in normal dogs, Vet Surg 37(1): 43-48.
Slocum B and Devine T (1985). Trochlear recession for the correction of luxating patella in
the dog, J Am Vet Med Assoc 186(4): 365-369.
Slocum B and Slocum TD (1998). Patellar luxation algorithm. In Bojrab M (ed), Current
Techniques in Small Animal Surgery (4th edn), Williams and Wilkins, Baltimore:
1,222-1,231.
Slocum B and Slocum TD (2000). Forum on pelvic limb alignment, Summer Conference of
the Association for Veterinary Orthopedic Research and Education, Sunriver.
Willaeur CC and Vasseur PB (1987). Clinical results of surgical correction of medial luxation
of the patella in dogs, Vet Surg 16(1): 31-36.
Yeadon R, Fitzpatrick N and Kowaleski MP (2011). Tibial tuberosity transposition-
advancement for treatment of medial patellar luxation and concomitant cranial cruciate
ligament disease in the dog, Vet Comp Orthop Traumatol 24(1): 18-36.

12 / 12
Powered by TCPDF (www.tcpdf.org)