Tibial Tuberosity Advancement

TTA

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Surgical repair of cranial cruciate deficiency is one of the most common small animal orthopedic procedures, due not only to the high incidence of the problem, but also to the clinical success of recent surgical techniques.

KYON launched TTA for cranial cruciate deficiency in dogs in early 2004, following three years of clinical testing.  Slobodan Tepic, Dr. Sci., Dipl. Ing., and Prof. Pierre M. Montavon, Head of Small Animal Surgery at the School of Veterinary Medicine, University of Zurich, have developed  TTA to allow neutralization of cranial tibial thrust without compromising joint congruency. This technique was a major departure from conventional practice. Since 2004, KYON’s TTA procedure has been used in over 100,000 cases by more than 1,000 surgeons and has become an important addition to the canine cranial cruciate repair armamentarium. read publications on Tibial Tuberosity Advancement>>

TECHNICAL FEATURES:
• Sound biomechanical rationale
• Simplified surgical procedure
• Unique implants designed specifically for TTA
• Superb biocompatibility of titanium
• Broad range of sizes available
BIOLOGICAL BENEFITS:
• TTA neutralizes cranial tibial thrust in cranial cruciate deficient stifles.
• Stability is achieved without compromising joint congruency.
• TTA decreases internal joint reactions including retro-patellar pressure.
• TTA is less invasive than other geometry modifying techniques.
• TTA reduces morbidity and post-surgical complications while accelerating recovery.

The rapid acceptance of TTA has motivated several other companies to offer similar implants. KYON has neither collaborated with nor endorsed any of the competitors in the manufacture, promotion or sale of their TTA systems. KYON Veterinary Surgical Products is the only authorized distributor of KYON products in the United States.

Indications

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Hind Limb Lameness

One of the most common causes of hind limb lameness in the dog is Cranial Cruciate Ligament (CrCL) rupture. The CrCL, the equivalent of the anterior cruciate ligament (ACL) in humans, and the Caudal Cruciate Ligament (CaCL) sit inside the stifle (knee) joint and prevent the proximal tibia from sliding back and forth with respect to the distal femur. At the top of the tibia is the tibial plateau, a condylar, cartilage covered surface that supports the weight coming from the femur. The plateau is convex as are the condyles of the femur and in weight bearing, the tendency of the femur is to slide down the tibial plateau pushing the top of the tibia forward (cranial tibial translation). The CrCL stops this downward slide, occurring in locomotion for millions of cycles per year. This repetitive biomechanical stress on the ligament often leads to fraying and eventual tear or rupture of the CrCL. Rupture is a major cause of Degenerative Joint Disease (DJD).

Signs of CrCL Rupture:

  • Sudden lameness on one rear limb to a degree that weight can not be borne.
  • A history of mild lameness in the same limb that seems to come and go before this sudden worsening of symptoms.

Consequences of CrCL Rupture:

  • Ligament deterioration releases a combination of inflammatory factors from the ligament.
  • Increasing instability and inflammation of the joint from the weakened ligament causes arthritis to develop quickly within the joint.
  • Every time the pet bears weight on the affected leg, the femur slides down the tibial plateau with nothing to halt its movement. This sliding action damages a cartilage seal in the joint called the meniscus. Once the meniscus is torn, arthritic change accelerates and perceived pain worsens.
  • Weight bearing studies, using force plate testing, have shown that dogs with a damaged CrCL bear only 20-30% of the normal amount of weight on the affected leg. As a result, the weight is shifted to the other rear leg placing even more stress on that limb’s CrCL and increasing the possibility of damage to that stifle. Rupture of the CrCL in both stifles is common.

read more about CrCL rupture>> (recommended for veterinary professionals)
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Dog Knee Surgery Treatment Options:

Veterinarians have been using many treatment options to minimize deterioration of the stifle in dogs with CrCL damage.  These range from very conservative treatment, prescribing pain management drugs, to aggressive surgical treatment, cutting bone to alter joint biomechanics, with other less invasive surgical procedures in between.  Although pain management drugs may help the dog feel better and cope with a bad knee, they do not alter the progression of disease.

Many surgical suture techniques have been developed.  Newer procedures use very strong braided materials to hold the tibia in place relative to the femur.  Suture techniques may have positive short term outcomes followed by the development of joint fibrosis that can increase stability, but progression of arthrosis is commonly observed, especially in young and active medium or larger dogs.

The first, broadly accepted, orthopedic procedure to correct knee geometry was the Tibial Plateau Leveling Osteotomy (TPLO) of Dr. Barclay Slocum.  A curved cut, bisecting the proximal end (top) of the tibia, separates the tibial plateau from the rest of the bone.  The plateau is rotated, removing the natural slope of the plateau.  A custom shaped metal plate is used to secure the plateau segment back to the tibia with screws.

TPLO has been a successful dog knee surgery, with about 20 years of history.  It is a complex procedure that can lead to major complications if not performed correctly.
For a detailed comparison of TTA and TPLO see>> Boudrieau RJ, – Tibial Plateau Leveling Osteotomy or Tibial Tuberosity Advancement? Vet Surg 38:1-22, 2009.

Other corrective procedures include Closing Wedge Osteotomy (CWO), Triple Tibial Osteotomy (TTO), Tibial Wedge Osteotomy (TWO), and Fibular Head Transposition.

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Principles

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The TTA technique was developed on the basis of several observations and simple biomechanical analysis of the canine knee joint:

  • Total joint force in the stifle is approximately parallel to the patellar ligament (a point of departure from Slocum, who maintained that it was parallel to the functional axis of the tibia);
  • If the angle between the patellar ligament and the common-tangent at the tibio-femoral point of contact, call it alpha, is 90 deg, neither of the cruciates is loaded;
  • In the canine stifle, alpha is 90 deg at 110 deg of flexion – call this a cross-over flexion point; in full extension ( ~135° stifle angle) alpha is approx. 105 deg; in full flexion it is approx. 80 deg;
  • With the stifle in extension with respect to the cross-over point, the load is on the cranial cruciate ligament; with the stifle flexed past the cross-over point, the load is on the caudal cruciate ligament;
  • With the cranial cruciate ligament gone, the stifle can be stabilized by shifting the cross-over point to the full extension;
  • This can be done by either TPLO (turning the plateau), or by TTA (advancing the patellar ligament).

EXECUTION:

The TTA involves an osteotomy of the non-weight bearing portion of the tibia. The patellar ligament is aligned perpendicularly to the common tangent of the femorotibial joint, eliminating cranial tibial thrust. This new alignment eliminates the need for the CrCL and results in a stable joint.

  • The required advancement of the patellar ligament insertion at the tibial tuberosity is measured from a radiograph of the stifle in extension;
  • With a frontal plane osteotomy, the tibial tuberosity is advanced and held in position by:

(1) A cage transferring the compression component of the patellar ligament force from the tuberosity to the proximal tibia;
(2) A tension band plate transferring the patellar ligament force to the proximal diaphysis of the tibia;

  • The open osteotomy, distal to the cage, is grafted with autologous cancellous bone or other graft material such as allograft or hydroxyapatite (HA) to accelerate healing.

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TTA vs. TPLO

Since its clinical introduction, TTA has been mostly compared with the Tibial Plateau Leveling Osteotomy (TPLO). The January 2009 issue of Veterinary Surgery gives the most in-depth comparison of the two techniques in a review article: Boudrieau, RJ – Tibial Plateau Leveling Osteotomy or Tibial Tuberosity Advancement? Vet Surg 38: 1-22, 2009.
Some of the key differences are:

  • TTA moves the joint force to meet the tibial plateau; TPLO moves the plateau to meet the joint force.
  • TPLO increases internal joint forces; TTA reduces them by lengthening the “lever arm” to the patellar tendon.
  • TTA does not change the geometry of the joint;
  • By logical extension, but without clinical evidence at this time, TTA may reduce the development of osteoarthritis[1][2];
  • TTA is less invasive, surgically simpler (but not simple);
  • Angular corrections are not possible with TTA, but TTA is less prone to unintended angulations.
  • TTA restores femorotibial contact patterns similar to those obtained before CrCL transections, while TPLO does not.
  • TTA takes into account the stabilizing force of the quadriceps muscle which is ignored in the TPLO biomechanical rationale.

Advancement of the patellar ligament insertion point on the tibia increases the lever arm of the dominant active force at the stifle, leading to a general reduction of all reaction forces, including those between the patella, femur, and the tibia.

In contrast, TPLO causes a cranial shift of the femur, i.e. closer to the insertion point of the patellar ligament. This shift reduces the lever arm and thus increased force is required to extend the leg. Inflammation of the patellar ligament, frequently seen in TPLO, may be an indication of an increased force required to keep the joint balanced. Increased patellar ligament force, increases joint reaction forces and elevates the risk of cartilage degeneration. In view of these arguments and the apparent lack of patellar ligament inflammation in TTA, progression of joint disease may be slower than reported in TPLO.[2]

A more obvious, though generally overlooked, difference is that TPLO intervention places the stifle into increased flexion by the amount of the plateau rotation, i.e. by some 20 degrees. Joint congruity at near full flexion must be compromised, not the least in the region of the caudal meniscus. Whether the meniscus is released at surgery, as instructed by Slocum, or through the wear and tear of its use, reduced fluid sealing function is bound to lead to cartilage degradation.

TTA does not effect joint congruency. However, it does increase the loading of the caudal cruciate, although to a lesser extent than TPLO. This is partially offset by general reduction of internal joint reactions due to the now longer patellar ligament lever arm.

On balance, TTA is expected to provide a further improvement in long-term joint function, although to date there is no definitive data proving this.

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Notes:
[1] – Boudrieau, RJ – Tibial Plateau Leveling Osteotomy or Tibial Tuberosity Advancement?
VetSurg 38: 1-22, 2009 (p.8)
[2] – Kim SE et al. – Effect of Tibial Tuberosity Advancement on Femorotibial Contact Mechanics and Stifle Kinematics
Vet Surg 38: 33-39, 2009

Experience

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Over the course of two years, starting in December 2001, some 150 clinical procedures were performed, mostly at the University of Zurich, to refine the surgical approach and the implant design.  Trial and error in the first year was followed by a more focused development phase in the second year.  Controlled clinical release of the TTA system was initiated in early 2004.

Clinical experience with several hundred cases during the first nine months of 2004, by 50 surgeons in the United States, Europe and Japan demonstrated reduced complexity and morbidity of the procedure in comparison to TPLO.

Early complication rates were manageable.  In most cases, complications were related to technical errors, such as incorrect placement of the implants and inaccurate location and/or orientation of the osteotomy.

By the end of 2004, TTA was fully released into clinical use.  By 2009, over 50,000 cases have been performed by more than 700 surgeons world wide.  While positive reports on the technique and short-term clinical outcomes are encouraging, the most important benefits and advantages of TTA are expected in long-term trouble-free performance.

TTA-2

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Surgical repair of cranial cruciate deficiency is one of the most common small animal orthopedic procedures, due to the high incidence of the problem and the clinical success of recent surgical techniques.

In early 2004, following three years of clinical testing, KYON launched the original Tibial Tuberosity Advancement (TTA) procedure for cranial cruciate deficiency in dogs. Slobodan Tepic, Dr. Sci., Dipl. Ing., and Prof. Pierre M. Montavon, Head of Small Animal Surgery at the School of Veterinary Medicine, University of Zurich, invented and developed TTA to allow neutralization of cranial tibial thrust without compromising joint congruency. At the time, this technique was a major departure from conventional practice. KYON’s TTA procedure has been performed in >100,000 procedures by more than 1,000 surgeons.

Throughout the last decade of clinical experience, KYON continued to refine and improve TTA preoperative planning, surgical technique, implants and instruments. In 2012, KYON in collaboration with Dr. Joop Hopmans began in vitro testing and, soon after, safety and efficacy testing to explore the next step in the TTA evolution, TTA-2*. TTA-2 consists of an incomplete osteotomy, performed with a novel hinged saw guide and a new cage, designed to transfer shear and compression forces. The simplified surgical technique preserves the periosteum on the medial aspect of the tibial tuberosity, eliminates stress risers created by the plate, fork, and screws, shortens the surgery time, and reduces the implant inventory. TTA-2 implants are packaged sterile for surgical convenience. In vitro and in vivo studies have demonstrated that the saw guide and surgical planning for its use, combined with the use of the Fine Touch Osteotomy Spreader minimizes the risk of intraoperative or early postoperative fracture of the tuberosity.

With 2 years of clinical experience and over a decades’ experience in the basic mechanical and biological principles behind tibial tuberosity advancement as a geometry modifying procedure, TTA-2 was made commercially available in spring 2014. TTA-2 has the potential to reduce iatrogenic trauma, reduce the risk of infection, accelerate the incorporation of the implant into the bone and shorten the surgery time, thus providing surgeons and their patients with tangible benefits.

TTA-2 involves an incomplete osteotomy of the non-weight bearing portion of the tibia. The patellar ligament is aligned perpendicular to the common tangent of the femorotibial joint, eliminating cranial tibial thrust. This alignment takes the load off the CrCL even in full extension and results in a stable joint.

  • The required advancement of the patellar ligament insertion at the tibial tuberosity is measured from a radiograph of the stifle in extension
  • An incomplete frontal plane osteotomy is performed using the TTA-2 hinged sawguide
  • The osteotomy gap is opened slowly and the tibial tuberosity is advanced and held in position by a cage implant, transferring the compression component of the patellar ligament force from the tuberosity to the proximal tibia

*patent pending

TECHNICAL FEATURES:
• Sound biomechanical rationale
• Broad patient range, toy to giant breeds
• Shorter operating time
• Titanium-aluminum-niobium alloy for supreme biocompatibility and reduced risk of infection
• Less invasive than other geometry modifying techniques including standard TTA
• Biocer® coating facilitates rapid bone integration with reduced risk of aseptic loosening
• Reduced implant and instrument inventory
BIOLOGICAL BENEFITS:
• Reduces damage to vascular supply
• Increases resistance to infection
• Accelerated healing
• Simplified surgical procedure
• Neutralizes cranial tibial thrust in cranial cruciate deficient stifles
• Achieves stability without compromising joint congruency
• Decreased internal joint reactions including retro-patellar pressure
• Reduces morbidity and post-surgical complications while accelerating recovery

The Tibial Tuberosity Advancement 2 (TTA-2) procedure was invented and developed by KYON, through iteration during clinical testing, to best meet the exacting demands of the procedure and surgical convenience, with optimal selection of materials and manufacturing techniques for precision, durability, and maintenance. KYON products are manufactured in Switzerland with proprietary processes that produce superior products to those made by conventional manufacturing.

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Reports

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Calvo I1, Aisa J, Chase D, Garcia-Fernandez P, San Roman F, Bennett D.
Tibial tuberosity fracture as a complication of tibial tuberosity advancement.
Vet Comp Orthop Traumatol. 2014;27(2):148-54. doi: 10.3415/VCOT-13-06-0071. Epub 2014 Jan 20.
1University of Glasgow, School of Veterinary Medicine, Small Animal Hospital, Bearsden Road, Bearsden, G61 1QH Glasgow, Scotland, United Kingdom, ignacio.calvo@glasgow.ac.uk.

Cadmus J1, Palmer RH, Duncan C.
The Effect of Preoperative Planning Method on Recommended Tibial Tuberosity Advancement Cage Size.
Vet Surg. 2014 Jan 10. doi: 10.1111/j.1532-950X.2014.12126.x.
1Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado.

MacDonald TL1S, Allen DA, Monteith GJ.
Clinical assessment following tibial tuberosity advancement in 28 stifles at 6 months and 1 year after surgery.
Can Vet J. 2013 Mar;54(3):249-54.
1Small Animal Surgery Department, VCA Mission Animal Referral and Emergency Center, Mission, Kansas 66202, USA. Tamaramacd@gmail.com

Proot JL1, Corr SA.
Clinical audit for the tibial tuberosity advancement procedure: establishing the learning curve and monitoring ongoing performance for the tibial tuberosity advancement procedure using the cumulative summation technique.
Vet Comp Orthop Traumatol. 2013;26(4):280-4. doi: 10.3415/VCOT-12-04-0052. Epub 2013 Mar 22.
1Calder Vets Ltd, Dewsbury, West-Yorkshire, United Kingdom. caldervets@me.com

Skinner OT1, Kim SE, Lewis DD, Pozzi A.
In vivo femorotibial subluxation during weight-bearing and clinical outcome following tibial tuberosity advancement for cranial cruciate ligament insufficiency in dogs.
Vet J. 2013 Apr;196(1):86-91. doi: 10.1016/j.tvjl.2012.08.003. Epub 2012 Sep 16.
1Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL, USA.

Hirshenson MS1, Krotscheck U, Thompson MS, Knapp-Hoch HM, Jay-Silva AR, McConkey M, Bliss SP, Todhunter R, Mohammed HO.
Evaluation of complications and short-term outcome after unilateral or single-session bilateral tibial tuberosity advancement for cranial cruciate rupture in dogs.
Vet Comp Orthop Traumatol. 2012;25(5):402-9. doi: 10.3415/VCOT-11-12-0175. Epub 2012 Jun 13.
1Department of Clinical Science, Cornell University, Ithaca, NY 14853, USA.

Wolf RE1, Scavelli TD, Hoelzler MG, Fulcher RP, Bastian RP.
Surgical and postoperative complications associated with tibial tuberosity advancement for cranial cruciate ligament rupture in dogs: 458 cases (2007-2009).
J Am Vet Med Assoc. 2012 Jun 15;240(12):1481-7. doi: 10.2460/javma.240.12.1481.
1Garden State Veterinary Specialists, 1 Pine St, Tinton Falls, NJ 07753, USA. rewolf@gmail.com

Guerrero TG1, Pozzi A, Dunbar N, Kipfer N, Haessig M, Beth Horodyski M, Montavon PM.
Effect of tibial tuberosity advancement on the contact mechanics and the alignment of the patellofemoral and femorotibial joints.
Vet Surg. 2011 Oct;40(7):839-48. doi: 10.1111/j.1532-950X.2011.00866.x. Epub 2011 Aug 16.
1Clinic for Small Animal Surgery, Vetsuisse-Faculty University of Zurich, Zurich, Switzerland. tguerrero@sgu.edu

Butler JR1, Syrcle JA, McLaughlin RM, Elder SH.
The effect of tibial tuberosity advancement and meniscal release on kinematics of the cranial cruciate ligament-deficient stifle during early, middle, and late stance.
Vet Comp Orthop Traumatol. 2011;24(5):342-9. doi: 10.3415/VCOT-10-08-0122. Epub 2011 Jul 21.
1College of Veterinary Medicine, Mississippi State University, Mississippi State, MS 39762, USA. rbutler@cvm.msstate.edu

Steinberg EJ1, Prata RG, Palazzini K, Brown DC.
Tibial tuberosity advancement for treatment of CrCL injury: complications and owner satisfaction.
J Am Anim Hosp Assoc. 2011 Jul-Aug;47(4):250-7. doi: 10.5326/JAAHA-MS-5574. Epub 2011 Jun 14.
1Valley Central Veterinary Referral Center, Allentown, PA, USA. ezrajs@yahoo.com

Bush MA1, Bowlt K, Gines JA, Owen MR.
Effect of use of different landmark methods on determining stifle angle and on calculated tibial tuberosity advancement.
Vet Comp Orthop Traumatol. 2011;24(3):205-10. doi: 10.3415/VCOT-10-07-0104. Epub 2011 Mar 3.
1Department of Clinical Veterianry Medicine, University of Bristol, Langford, North Somerset, UK. mark.bush@scvetspecialists.co.uk

Hoffmann DE1, Kowaleski MP, Johnson KA, Evans RB, Boudrieau RJ.
Ex vivo biomechanical evaluation of the canine cranial cruciate ligament-deficient stifle with varying angles of stifle joint flexion and axial loads after tibial tuberosity advancement.
Vet Surg. 2011 Apr;40(3):311-20. doi: 10.1111/j.1532-950X.2011.00807.x. Epub 2011 Mar 1.
1Department of Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA.

Guerrero TG1, Makara MA, Katiofsky K, Fluckiger MA, Morgan JP, Haessig M, Montavon PM.
Comparison of healing of the osteotomy gap after tibial tuberosity advancement with and without use of an autogenous cancellous bone graft.
Vet Surg. 2011 Jan;40(1):27-33. doi: 10.1111/j.1532-950X.2010.00772.x. Epub 2010 Dec 23.
1Department of Small Animal Surgery, University of Zurich, Zurich, Switzerland. tguerrero@vetclinics.uzh.ch

Etchepareborde S1, Mills J, Busoni V, Brunel L, Balligand M.
Theoretical discrepancy between cage size and efficient tibial tuberosity advancement in dogs treated for cranial cruciate ligament rupture.
Vet Comp Orthop Traumatol. 2011;24(1):27-31. doi: 10.3415/VCOT-10-01-0013. Epub 2010 Nov 19.
1School of Veterinary Medicine, University of Liège-Department of Clinical Sciences, Liège, Belgium. sebetche@yahoo.com

Dymond NL1, Goldsmid SE, Simpson DJ.
Tibial tuberosity advancement in 92 canine stifles: initial results, clinical outcome and owner evaluation.
Aust Vet J. 2010 Oct;88(10):381-5. doi: 10.1111/j.1751-0813.2010.00627.x.
1Animal Referral Hospital, South Strathfield, New South Wales, Australia. nickdymond@hotmail.com

Etchepareborde S1, Barthelemy N, Mills J, Pascon F, Ragetly GR, Balligand M.
Mechanical testing of a modified stabilisation method for tibial tuberosity advancement.
Vet Comp Orthop Traumatol. 2010;23(6):400-5. doi: 10.3415/VCOT-09-08-0088. Epub 2010 Sep 9.
1Department of Clinical Sciences, School of Veterinary Medicine, University of Liège, Belgium. sebetche@yahoo.com

Yeadon R1, Fitzpatrick N, Kowaleski MP.
Tibial tuberosity transposition-advancement for treatment of medial patellar luxation and concomitant cranial cruciate ligament disease in the dog. Surgical technique, radiographic and clinical outcomes.
Vet Comp Orthop Traumatol. 2011;24(1):18-26. doi: 10.3415/VCOT-10-01-0015. Epub 2010 Sep 9.
1Fitzpatrick Referrals, Halfway Lane, Eashing, Surrey, GU7 2QQ, United Kingdom. r.yeadon@vet.gla.ac.uk

Kim SE1, Pozzi A, Banks SA, Conrad BP, Lewis DD.
Effect of cranial cruciate ligament deficiency, tibial plateau leveling osteotomy, and tibial tuberosity advancement on contact mechanics and alignment of the stifle in flexion.
Vet Surg. 2010 Apr;39(3):363-70. doi: 10.1111/j.1532-950X.2010.00655.x.
1Departments of Small Animal Clinical Sciences, Mechanical and Aerospace Engineering, and Orthopedics and Rehabilitation, University of Florida, Gainesville, FL 32610, USA.

Kim SE1, Pozzi A, Banks SA, Conrad BP, Lewis DD.
Effect of tibial tuberosity advancement on femorotibial contact mechanics and stifle kinematics.
Vet Surg. 2009 Jan;38(1):33-9. doi: 10.1111/j.1532-950X.2008.00471.x.
1Departments of Small Animal Clinical Sciences, Mechanical and Aerospace Engineering, and Orthopedics and Rehabilitation, University of Florida, Gainesville, FL 32610, USA.

Boudrieau RJ.
Tibial plateau leveling osteotomy or tibial tuberosity advancement?
Vet Surg. 2009 Jan;38(1):1-22. doi: 10.1111/j.1532-950X.2008.00439.x.
Department of Clinical Sciences, Cummings School of Veterinary Medicine at Tufts University, 200 Westboro Road, North Grafton, MA 01536, USA. randy.boudrieau@tufts.edu

Inauen R1, Koch D, Bass M, Haessig M.
Tibial tuberosity conformation as a risk factor for cranial cruciate ligament rupture in the dog.
Vet Comp Orthop Traumatol. 2009;22(1):16-20.
1Koch & Bass Referral Practice for Small Animal Surgery, Basadingerstrasse 26, 8253 Diessenhofen, Switzerland. info@kochbass.ch

Kim SE1, Pozzi A, Banks SA, Conrad BP, Lewis DD.
Effect of tibial tuberosity advancement on femorotibial contact mechanics and stifle kinematics.
Vet Surg. 2009 Jan;38(1):33-9. doi: 10.1111/j.1532-950X.2008.00471.x
1Departments of Small Animal Clinical Sciences, Mechanical and Aerospace Engineering, and Orthopedics and Rehabilitation, University of Florida, Gainesville, FL 32610, USA.

Kipfer NM1, Tepic S, Damur DM, Guerrero T, Hässig M, Montavon PM.
Effect of tibial tuberosity advancement on femorotibial shear in cranial cruciate-deficient stifles. An in vitro study.
Vet Comp Orthop Traumatol. 2008;21(5):385-90.
1Clinic for Small Animal Surgery, Vetsuisse Faculty University of Zurich, Winterthurerstrasse 260, CH-8057 Zurich, Switzerland. nkipfer@vetclinics.unizh.ch

Kim SE1, Pozzi A, Kowaleski MP, Lewis DD.
Tibial osteotomies for cranial cruciate ligament insufficiency in dogs.
Vet Surg. 2008 Feb;37(2):111-25. doi: 10.1111/j.1532-950X.2007.00361.x.
1Department of Small Animal Clinical Sciences, University of Florida, Gainesville, FL 32610, USA.

Burns CG1, Boudrieau RJ.
Modified tibial tuberosity advancement procedure with tuberosity advancement in excess of 12 mm in four large breed dogs with cranial cruciate ligament-deficient joints.
Vet Comp Orthop Traumatol. 2008;21(3):250-5.
1Department of Clinical Sciences, Cummings School of Veterinary Medicine at Tufts University, North Grafton, MA 01536, USA. randy.boudrieau@tufts.edu

Voss K1, Damur DM, Guerrero T, Haessig M, Montavon PM.
Force plate gait analysis to assess limb function after tibial tuberosity advancement in dogs with cranial cruciate ligament disease.
Vet Comp Orthop Traumatol. 2008;21(3):243-9.
1Clinic for Small Animal Surgery, Vetsuisse Faculty University of Zurich, Zurich, Switzerland. kvoss@vetclinics.uzh.ch

Guerrero TG1, Geyer H, Hässig M, Montavon PM.
Effect of conformation of the distal portion of the femur and proximal portion of the tibia on the pathogenesis of cranial cruciate ligament disease in dogs.
Am J Vet Res. 2007 Dec;68(12):1332-7.
1Clinic for Small Animal Surgery, Vetsuisse Faculty, University of Zurich, Winterthurerstrasse 260, CH-8057 Zurich, Switzerland.

Lafaver S1, Miller NA, Stubbs WP, Taylor RA, Boudrieau RJ.
Tibial tuberosity advancement for stabilization of the canine cranial cruciate ligament-deficient stifle joint: surgical technique, early results, and complications in 101 dogs.
Vet Surg. 2007 Aug;36(6):573-86.
1Alameda East Veterinary Hospital, Denver, CO, USA.

Miller JM1, Shires PK, Lanz OI, Martin RA, Grant JW.
Effect of 9 mm tibial tuberosity advancement on cranial tibial translation in the canine cranial cruciate ligament-deficient stifle.
Vet Surg. 2007 Jun;36(4):335-40.
1Virginia-Maryland Regional College of Veterinary Medicine, Blacksburg, VA 24060, USA. millerj@vt.edu

Apelt D1, Kowaleski MP, Boudrieau RJ.
Effect of tibial tuberosity advancement on cranial tibial subluxation in canine cranial cruciate-deficient stifle joints: an in vitro experimental study.
Vet Surg. 2007 Feb;36(2):170-7.
1College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA.

Dennler R1, Kipfer NM, Tepic S, Hassig M, Montavon PM.
Inclination of the patellar ligament in relation to flexion angle in stifle joints of dogs without degenerative joint disease.
Am J Vet Res. 2006 Nov;67(11):1849-54.
1Tierklinik Dennler AG, Poststrasse 2, 8910 Affoltern am Albis, Switzerland.

Schwandt CS1, Bohorquez-Vanelli A, Tepic S, Hassig M, Dennler R, Vezzoni A, Montavon PM.
Angle between the patellar ligament and tibial plateau in dogs with partial rupture of the cranial cruciate ligament.
Am J Vet Res. 2006 Nov;67(11):1855-60.
1Clinic for Small Animal Surgery, Vetsuisse Faculty, University of Zurich, 8057 Zurich, Switzerland.

Stein S1, Schmoekel H.
Short-term and eight to 12 months results of a tibial tuberosity advancement as treatment of canine cranial cruciate ligament damage.
J Small Anim Pract. 2008 Aug;49(8):398-404. doi: 10.1111/j.1748-5827.2008.00592.x. Epub 2008 Jul 10.
1Great Western Referrals, Shrivenham Road, Swindon SN1 2NR, UK.

Surgeons

The following database, contains contact information for surgeons who use KYON TTA implants and instruments.

Please contact main@kyon.us to update contact information.

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