OrthoFoam MMP Wedge For Canine Cruciate Disease

OrthoFoam MMP Wedge
For Canine Cruciate Disease
User Guide
OrthoFoam MMP Wedge
User Guide
History
Rationale for technical development
In the early 1960’s a human orthopaedic surgeon named Maquet working
The perfect technique needs no further development. Consequently, if
in Liege, Belgium described a tibial tuberosity advancement (TTA)
a surgical technique is worthy of development, it is necessary first to
procedure for the treatment of knee joint arthritis [1]. Human knee OA is
define and describe shortcomings of the technique, as it exists. These
a significant cause of pain and disability that is associated with loss of
shortcomings become design and development targets.
articular cartilage between the patella and femur. Maquet argued that
advancing the tibial tuberosity would reduce patello-femoral pressure
The Slocum TPLO arrived as a relatively well-developed and engineered
and therefore reduce the pain and disability. The procedure appears to
technique and subsequent modifications or developments have been
have been successful but complications – typically due to fixation failure
relatively modest in nature comprising minor modifications to surgical
[2] – were not uncommon and the permanent and obvious disfigurement
technique or changes to implant design. TPLO offers up few obvious
of the patient’s knee was another drawback.
areas for improvement.
Notwithstanding these limitations, Maquet’s procedure gained some
TTA has some theoretical advantages when compared with TPLO.
popularity and it is the subject of several subsequent reports in the
Notably, the long (weight bearing) axis of the tibia, which is cut in TPLO,
human literature, summarised by Rappoport and colleagues (1992) [ ].
is preserved in TTA. Additionally, the work of Kim, Pozzi and colleagues
Throughout the seventies and eighties several papers were published
[7] showed that following TTA the stifle appears to retain a more normal
that discussed the biomechanical consequences of TTA and noted that
femoro-tibial contact pattern.
3
advancing the tibial tuberosity had potentially significant mechanical
effects on the function of other key anatomy around the knee, notably
However, TTA remains an extremely complex and technically demanding
Mendes and colleagues (1987) [4].
surgical procedure. Complications are not uncommon and reflecting
the original Maquet experience, these often relate to fixation failure
During the 1980s and early 1990s the concept of managing cranial
– such complications are typically very serious requiring additional
cruciate ligament (CCL) failure in the dog using osteotomies to alter
major surgery and a downwardly revised prognosis [8]. Fixation of the
the mechanics of the stifle joint appeared. The two pioneers of this
advanced tibial tuberosity is tenuous and relies on a multi-component
work in dogs were Barclay Slocum and Slobodan Tepic who developed
cage, plate and bone-screw device along with grafting procedures
the tibial plateau levelling osteotomy (TPLO) and the tibial tuberosity
to fill the considerable surgical dead space. The TTA procedure is
advancement (TTA) respectively. It is not clear to what extent the work of
limited to dogs requiring a relatively modest advancement (< approx
Slocum and Tepic on the canine stifle was influenced by the much earlier
15mm) and this appears to be an implant-imposed limitation. A lengthy
endeavours of Maquet working on the human knee.
convalescence is required and this, too, appears to be dictated more by
the limitations of the fixation system than due to any specific physiologic
Relatively quickly, TPLO became established as the most popular
factors.
technique chosen by specialist veterinary orthopaedic surgeons when
treating dogs with CCL failure [5]. Many tens of thousands of dogs have
been treated using TPLO but since its more recent inception, TTA has
There is some confusion about how the amount of advancement is
become at least as popular. However, both TPLO and TTA are technically
calculated. A lateral radiograph of the affected stifle in 135 degrees
demanding surgical techniques and not surprisingly, the literature shows
of extension as the most commonly used starting point. However,
that complications, many of which are major, are not uncommon with
considerable variation in distal femoral morphology exists and there
either technique [6].
does not appear to be a universally agreed method of determining the
femoral long axis and thereby establishing a reproducible radiographic
datum. Furthermore, the work of Echteparaborde and colleagues (2011)
[9] shows that the currently widely practiced technique of measuring
2
required advancement along the tibial plateau results in consistently
fixation and enables bone augmentation. The availability of titanium
low estimations and the error can become quite substantial when
foam for use as an orthopaedic implant – licensed for veterinary use
dealing with steep tibial plateau angles. Finally, one major supplier of
under the name “Orthofoam” - was recognised as the key component to
TTA hardware implies that such complex estimation is unnecessary,
developing a simplified, robust TTA procedure.
suggesting that small dogs get small advancements, medium size
dogs get bigger advancements and the biggest dogs get the biggest
Porous metals were proposed for implant fixation in the late 60’s as a
advancements [10]. There appeared to be considerable potential to
solution to problems encountered with methacrylate-based bone cement
review the estimating procedure to improve accuracy and precision.
[11,12,13]. These materials have been extensively studied since then and
are now used routinely in various orthopaedic surgical procedures. The
rough surface finish of the porous material provides the friction with
Design and development targets
surrounding tissues and promotes the initial fixation of the implant. The
biological fixation is achieved after surgery through bone ingrowth into
the porosity of the material. This biological fixation creates excellent
Simplify the surgical technique
implant-bone adhesion strengths [14] and secures the long term stability
•
Instrumentation
of the implants. Many studies provided evidence of the efficiency of
•
Fixation
biologic fixation with porous metals [15]. The fixation and stability are
•
Bone grafting/void-filling
made possible only if the material structure, composition and properties
are carefully adapted for the application [16].
Shorten the convalescence
•
Robust fixation system
Important research and development activities were conducted to
•
“Less invasive” surgical technique
develop materials with optimum structure and properties for implant
fixation and bone augmentation. The National Research Council of
Improve scope for advancement
Canada has recently developed a process to produce highly porous
•
titanium foams with open porosity [17]. The process can be used to
Enhanced stability/security of fixation
produce porous implants with structure adapted for bone reconstruction
Define a reproducible technique for estimation of
and augmentation. The properties of this material and its biological
required advancement
behaviour have been reported in different studies [18,19, 20, 21, 22, 23, 24].
The foam is biocompatible and possesses mechanical properties
which make it suitable for implantation in load bearing situations. The
interconnected porosity permits rapid bone ingrowth and provides
The development of a simple, robust method of advancing and fixing
fixation to surrounding bone [25].
the tibial tuberosity was recognised as key to making any significant
improvement to existing TTA techniques. The existing system, though
Orthomed in conjunction with the IVOA began work with the National
complex and costly is well engineered and effective. Given the technical
Research Council of Canada in 2008 which has resulted in the first
challenges of a relatively small tibial tuberosity fragment; considerable
application of OrthoFoam in the MMP (Modified Maquet Procedure)
traction; an inevitable bone void etc this system could not obviously be
wedge for canine cruciate disease.
significantly improved by evolution.
Improvement has been made possible by the development of new
implants and materials (i.e. titanium foam). The new foam wedge defines
the degree of advancement of the tibial tuberosity while the open
structure of the titanium foam allows bone ingrowth, promotes bone
Version: 1.1 | Date: October 2011 | Author: Malcolm G. Ness
3
OrthoFoam MMP Wedge
User Guide
The Modified Maquet Procedure (MMP)
Fig. 1
The Modified Maquet Procedure – so named to acknowledge the
instigator of these operations – uses a wedge shaped implant of
Orthofoam which both defines the degree of advancement of the
tibial tuberosity and fixes the bone in its new place. The work of
Echteparaborde and colleagues (2010) [26] demonstrated the importance
of retaining a soft tissue bridge distally to effectively replace the complex
plate-screw fixation described for conventional TTA and confirmed
the benefit of a hole at the distal end of the osteotomy to control crack
propagation. The creation of the osteotomy is facilitated by the use of
a saw guide that ensures a cut of correct length precisely positioned to
ensure an adequately “thick” tibial tuberosity fragment while locating the
end of the osteotomy appropriately close to the cranial tibial cortex. The
Orthofoam wedge can be manufactured in a range of sizes and provides
Above is a backscattered scanning electron microscope image
a robust fixation with impressive early stability. The open porous
of a cross section through the 5mm porous Ti core of an implant
structure encourages early in-growth of bone and removes the need
harvested at 12 weeks. There is abundant bone within the pores
to place graft/ bone substitute or similar. Initial stabilisation is achieved
of the implant (seen in the image as grey colour), attesting to
using a simple and inexpensive K wire and tension band because of the
the suitability of the material for bone ingrowth fixation. This is
material properties of the Orthofoam, the precision of the instrumented
particularly impressive considering the initial 3mm gap between
osteotomy, the preservation of soft tissues and the high coefficient of
the porous implant and surrounding host bone. In this SEM
friction between Orthofoam and bone, stability is predictable.
image the Ti is white in colour and the void space is black. The
gap has been filled with a demineralized bone matrix compound
The MMP procedure capitalises on the known advantages of TTA.
– this no doubt helped bone healing within the gap itself but
However, the MMP technique is rapid, relatively simple, reproducible
does not in itself account for all the bone formation within the
and robust so most of the limitations of conventional TTA have been
depths of the implant pores.
eliminated. Furthermore, the development and rationalisation of a
method for estimating the required tuberosity advancement offers
L.Lim, J.D.Bobyn, K.M.Bobyn, L.P.Lefebvre, M.Tanzer,
increased precision and reproducibility.
Demineralized Bone Matrix Around Porous Implants
Promotes Rapid Gap Healing and Bone Ingrowth, AAOS
2011 Annual Meeting, USA, (Otto Aufranc Award).
Orthofoam MMP Wedge
Fig. 2 -
Method for estimating required tibial tuberosity
advancement
The desired end point of MMP surgery is a patella tendon angle
of 90 degrees to the tibial plateau with the stifle in 135 degrees of
extension. Although initially derived from theoretical considerations and
mathematical modelling, informed to some degree by kinetic studies, the
work of Apelt, Kowaleski and Boudrieau (2007) [27] provides supporting
evidence for this method albeit from in vitro study. Clinical reports of
excellent outcome following TTA surgery in many thousands of clinical
cases provides further evidence that this 90 degree end-point is, at the
4
very least, an acceptable working hypothesis.
There has been debate about how best to estimate the tibial plateau
angle. The method described by Slocum (1993)[28] has stood the test of
time and more recently a method involving common tangents has found
some favour. De Rooster and Van Bree (1999) [29] reported a degree of
radiographically apparent tibio-femoral subluxation associated with
CCL failure and the common tangent modification (which has not been
shown to be measurably better than the Slocum method) depends to
some extent upon the spatial relationship between the tibia and the
femur. Because this spatial relationship inevitably changes with failure
of the CCL these techniques must, therefore, be flawed. Similarly, it is
nearly impossible to collect a radiograph with exact joint angulation and
the variable morphology of the distal femur makes accurate appraisal of
the stifle joint angle rather subjective. The requirement to measure from
a radiograph featuring the stifle in 135 degrees of extension inevitably
introduces unacceptable and uncontrollable variation.
Given this degree of anatomical and radiographic variability, it seems
logical that a tibial osteotomy should be derived from datum points
exclusively on the tibia.
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OrthoFoam MMP Wedge
User Guide
Method to establish advancement for use with MMP wedge
01
Draw a line (A-B) along the tibial plateau extending
caudally and cranially.
02
Locate the intercondylar eminence on the tibia.
03
Locate the mid-point of the intercondylar eminence on
B
A
the tibial plateau line (C).
04
Draw a line (C-D) from this point to the centre of the
tibial tarsal bone – the long axis of the tibia.
C
B
A
D
6
05
Draw a line (C-E) such that the angle DCE = 135
degrees.
E
06
Locate point F, which is the most cranial part of the
tibial tuberosity where the straight patella ligament
135º
C
A
inserts.
B
F
D
07
Draw a line (F-G) such that F-G is parallel with C-E.
08
Locate point H where F-G crosses A-B.
G E
H
135º
C
A
B
F
D
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OrthoFoam MMP Wedge
User Guide
09
I
a right angle.
G E
135º
J
C
H
A
Draw a line F-I to cross A-B at point J such that FJA is
B
F
D
10
I
G E
L
135º
J
A
C
H
B
F
D
8
Draw a line F-L through F and perpendicular to C-D.
11
I
Draw a line through H and parallel to I-F which
intersects F-L at M.
G E
L
135º
J
C
H
A
F
B
M
D
12
I
Measure the distance F-M. This is the amount of
advancement (Wedge Size) required to give a patella
G E
tendon angle of 90 degrees.
L
135º
J
A
C
H
F
B
M
D
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OrthoFoam MMP Wedge
User Guide
MMP Surgical Technique
01
The affected limb is clipped and prepared for aseptic
surgery from just distal to the hip down to the hock
joint. The patient is placed in dorsal recumbency and
the limb draped to allow flexion and extension both of
the stifle joint and of the hock.
This shows the ‘surgeons eye view’ looking at the
cranio-medial aspect of a left pelvic limb with the stifle
towards the upper, right corner of the picture.
03
The limb is positioned such that the greater trochanter
of the femur, the lateral aspect of the distal femur
at the stifle, the lateral malleolus of the hock and
the lateral aspect of the paw are all in contact with
the tabletop while maintaining approximately ninety
degrees of stifle flexion. This standard reference
position establishes the saggital plane of the limb
parallel to the tabletop.
10
03
A skin incision is made on the medial aspect starting
proximally at the level of the mid-point of the straight
patellar ligament and extending distally for eight to ten
centimeters.
04
Avoid any further dissection.
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OrthoFoam MMP Wedge
User Guide
05
The incision is developed at the proximal end
only: a short, medial, parapatellar joint capsule
incision is made less than two centimeters long and
approximately five millimeters behind the straight
patellar ligament. The caudally angled, cartilage
covered surface of the proximal tibia adjacent to the
insertion of the straight patellar ligament is identified.
Avoid excessive dissection.
06
An instrument (in this case a closed pair of
Metzenbaum scissors) is pushed firmly behind the
straight patella ligament to puncture the lateral joint
capsule. The limb is held in the standard reference
position and the instrument is driven perpendicular
to the tabletop. This step is intended to facilitate the
subsequent placement of the saw-guide locating pin.
12
07
The proximal (long) pin of the MMP saw guide is
placed behind the straight patellar ligament such
that the proximal pin contacts the angled, cartilagecovered surface of the proximal tibia. The diameter of
the distal (short) pin can be selected between 3 and
6 mm. The diameter of this pin controls the position
of the osteotomy and therefore thickness of the tibial
tuberosity fragment. For most cases the smaller (3 or
4 mm) pin will be appropriate.
08
Inspect the anticipated size of the tibial tuberosity
fragment and modify through varying guide position
and distal pin diameter. The MMP saw guide is
fixed using the short 3.5mm drill, which is advanced
through both tibial cortices. Prior to drilling, the limb
is returned to the standard reference position, ‘see
step 2 above’ and the drill is placed perpendicular to
the tabletop. The chuck is removed leaving the drill in
place thereby fixing the MMP saw-guide in place.
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OrthoFoam MMP Wedge
User Guide
09
The osteotomy is made: a saw blade with a thickness
of approximately 0.7mm should be used. The MMP
saw-guide and the geometry of the MMP wedge is
designed around a saw cut of this size.
10
On completion of the osteotomy, the 3.5mm drill bit is
removed.
14
11
The MMP saw-guide is removed.
12
A bony bridge between the distal end of the saw slot
and the 3.5mm drill hole persists. This is identified
and cleared of any overlying fascia. Avoid excessive
dissection – it is essential that all soft tissue distal to
the end of the osteotomy is preserved untouched.
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OrthoFoam MMP Wedge
User Guide
13
Removing the small bony bridge using the same
oscillating saw completes the osteotomy.
NB the bone of the tibial tuberosity is hard so
copious irrigation should be used. Irrigation
was not used in this cadaver series to ensure
image quality.
14
A pair of small pointed reduction forceps is placed
across the proximal end of the osteotomised
tibial tuberosity. Gentle traction confirms that the
osteotomy has been completed successfully.
Occassionally, further use of the bone saw will be
required to complete the osteotomy proximally and
in that case the saw guide must be replaced. An
important function of the saw guide is to protect the
straight patella ligament and other, intra-articular
structures from iatrogenic damage.
16
15
The smallest trial wedge is offered up to the
osteotomy – the small pointed reduction forceps
facilitate this process.
16
Increasingly large trial wedges are placed until the
desired size is reached.
17
OrthoFoam MMP Wedge
User Guide
17
The distal tip of the wedge should lie within 1mm
of the 3.5mm drill hole and the medial aspect of the
wedge should lie on, or slightly proud, of the medial
tibial cortex. The proximal end of the wedge will lie
below the proximal extremity of the tibial tuberosity.
18
Ensure that there is no tendency for soft tissue to be
“dragged” in between the trial wedge and the bone.
18
19
Larger trial wedges are placed and evaluated
sequentially.
20
The final trial wedge is placed - in this case 12mm.
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OrthoFoam MMP Wedge
User Guide
21
The appropriate Orthofoam MMP wedge is loaded
into MMP insertion device and placed exactly as
predicted by the trial wedge.
22
Positioning of the wedge is reviewed: the distal tip of
the wedge should lie within 1mm of the 3.5mm drill
hole and the medial aspect of the wedge should lie
on, or slightly proud, of the medial tibial cortex. The
proximal end of the wedge will lie below the proximal
extremity of the tibial tuberosity. Check that there is no
soft-tissue entrapment.
20
23
The butterfly drill-guide is placed onto the MMP
insertion device. Two butterfly drill-guides are
provided, identical but for the length of the locating
pins. Cases with a thinner tibial tuberosity and a
significant medial buttress will need the short-pinned
guide while the butterfly drill-guide with the longer
pins will be appropriate in most cases.
24
A 1.5mm drill bit is used to make a hole through the
tibial tuberosity only. The butterfly drill-guide will line
up this drilling with the hole in the Orthofoam wedge.
Avoid drilling beyond the wedge – specifically, do not
drill the tibial diaphysis.
21
OrthoFoam MMP Wedge
User Guide
25
A 1.6mm Kirschner wire (size critical) is placed
through the butterfly drill guide and advanced until
firmly seated in, but not penetrating, the caudal tibial
cortex.
26
The butterfly drill-guide is removed by gently sliding it
back off the K-wire.
22
27
The MMP insertion device is removed by unscrewing
the handle a few turns before gently lifting the hooked
head up and over the Orthofoam wedge.
28
Preparing the holes for the figure of eight wire. Start
the proximal hole as shown using a 1.5mm drill bit:
locate the starting point approximately two thirds of
the distance between the K wire and the end of the
osteotomy and start the hole very close to the edge
of the osteotomy. Drill no more than half a millimeter
deep in this direction.
23
OrthoFoam MMP Wedge
User Guide
29
As soon as possible, re-direct the drill at an angle
between thirty and forty five degrees to the vertical
and continue drilling such that the hole exits the
lateral aspect of the tibia close to its cranial extremity.
Avoid any dissection – it is essential that the soft
tissues in this region are preserved untouched.
30
Patients up to 25kg (55lb)
A second 1.5mm drill hole is started. Its centre should
be approximately ten millimeters from the centre of
the 3.5mm hole at the distal end of the osteotomy. Its
position should be such that the tension-band wire
will act at approximately forty five degrees to the tibial
long axis.
Medio-lateral radiograph
showing the desired
location of the tension
band wire.
24
31
A length of orthopaedic wire, 1.0 (minimum) – 1.2mm
diameter (size critical) is pushed from medial to lateral.
Avoid all dissection – the wire will find a path through
the soft tissues without the need to do any dissection
whatsoever. Preservation of the distal soft tissue
bridge is essential.
32
A second short length of orthopaedic wire, 1.0
(minimum) – 1.2mm in diameter (size critical) is
passed through the distal hole in similar fashion.
Again, it is important that all dissection is avoided.
The size of orthopaedic wire is rather larger than
many surgeons will be used to selecting for similar
applications. However, the magnitude and direction of
forces acting here after advancing the tibial tuberosity
requires that a substantial wire tension band is used.
25
OrthoFoam MMP Wedge
User Guide
33
The figure of eight pattern is laid in routine fashion and
great care is taken to ensure that the twists are made
evenly and neatly.
34
Two symmetrical twists are needed to provide even
tightening of this relatively thick wire. Each “arm” of
the figure eight is tightened in turn to maintain even
tension.
26
35
The wire should end up “snug” rather than very
tight – the aim is to prevent creep and not to apply
compression.
36
The twists are cut to length and bent over to lie flush
with the underlying structures.
27
OrthoFoam MMP Wedge
User Guide
37
Patients over 25kg
A 2.7mm hole is started in the position shown in box
30. It’s position should be such that the tension-band
wire will act at approximately forty five degrees to
the tibial long axis. The large hole acts as the distal
anchor point for both orthopaedic wires as shown in
the radiograph.
4 Week Follow UP
Courtesy of Dr Duncan Midgley, BVMS, CertSAO,
MRCVS, Rutland House Referrals, UK.
38
The K-wire is cut leaving approximately 10mm
protruding.
28
39
The protruding K-wire is bent medially to a right angle
using the MMP K-wire bender.
40
The bent K-wire is rotated to lie against the craniomedial aspect of the tibial tuberosity.
29
OrthoFoam MMP Wedge
User Guide
41
The soft-tissues are closed using a single simple
continuous suture of 3metric or similar before the skin
is closed using a single continuous suture of 2 or 3
metric monofilament nylon or similar.
42
Bandages and complex dressings are unnecessary
– the wound is protected using two or three rolled
sterile gauze swabs (sponges) held in place with
three simple interrupted sutures of 2 or 3 metric
monofilament nylon or similar.
30
After-care information for clients
short leash walks – 5-10 minutes six or eight times daily is a good
starting point. It is important that the operated knee joint is returned to
Your pet’s cranial cruciate ligament failure has been treated surgically
use as quickly as possible - concentrate on walking relatively slowly as
using the Modified Maquet Procedure (MMP). The operation is based
this will encourage the patient to use the leg. Ideally, your dog should go
on a technique developed almost 50 years ago for use in human knees
outside ON A LEASH to toilet during the first two weeks after surgery.
by Dr Maquet, a Belgian orthopaedic surgeon. The operation works
Do not swim the dog.
by redirecting the force generated by the large quadriceps muscles to
No other exercise is recommended for the first 14 days - it is important
compensate for the failed cruciate ligament. This is achieved by cutting
to not let your pet loose to run freely in the house, particularly up and
free, and moving forward, the part of the tibia (the tibial tuberosity)
down stairs.
attached to the quadriceps muscle. The bone cut is called an osteotomy
and the osteotomy is stabilised using a modern orthopaedic implant
material called Orthofoam. The porous titanium Orthofoam promotes
Third and fourth weeks
remarkably rapid bone ingrowth and healing and this is key to the
reduced convalescence and minimal pain seen with MMP surgery.
The amount of activity can now be gradually increased but it is essential
that the patient is not allowed off the leash until after the 4 week X-ray
Successful recovery after knee surgery, no matter which procedure has
check.
been used, requires a period of controlled activity. Compared to other
Leash walks can be longer and faster though take care to ensure that the
procedures, MMP causes less discomfort and while a comfortable, pain-
patient continues to use the operated limb confidently at every step.
free patient is obviously a good thing, many dogs are tempted to use
the operated leg too much, too soon. No matter how comfortable and
confident your pet is feeling in the days after their MMP operation, it is
Fifth and sixth weeks
absolutely essential that running, jumping, and general “rough
and tumble” with other pets is avoided for the first 6 weeks or
Check X rays are scheduled for the end of week four and these should
so. The bone must be given time to heal adequately and too much strain
confirm that the osteotomy is healing well. Bear in mind that although
placed on the osteotomy too early can result in stress fracture or implant
bone healing and remodelling will be progressing nicely, full strength will
failure and while this is rarely catastrophic, the ensuing complication may
not be established for several more weeks.
be painful and will certainly delay the recovery.
At this stage, the patient will be capable of frequent lengthy (30 minutes
or more) leash walks and we will soon be introducing some free running
activity. The key to success is a programme of gradually increasing
First and second weeks
activity. At first, the patient can be allowed off the leash towards the end
of the last walk of the day – choose a quiet area with a good surface – a
Your dog will have a short course of antibiotics and a longer course of
short cut grassy park is ideal - without dogs or other distractions that
a non-steroidal anti-inflammatory drug (NSAID). Treatment with NSAIDs
might encourage your pet to do too much too soon. Five minutes is
will usually continue for at least six weeks while the osteotomy heals.
enough for the first day off the leash. Subsequently, the amount of free
running play and exercise can be increased gradually back towards
Bandages are not used following MMP because it is important that your
normal pre-injury levels. Most dogs will be capable of full, unrestricted
pet is able to flex and extend the operated knee freely right from day
athletic activity within 12 weeks of their MMP operation. Some residual
one. A gauze pad is sutured over the skin incision to protect the wound.
low grade stiffness and lameness may still be seen at twelve weeks
The pad can be removed after five days or so and the skin sutures are
but this will resolve completely over the subsequent month or two as
removed a fortnight after surgery.
the patient regains full fitness and the osteotomy completes its healing
process.
During the first 14 days, your pet should be encouraged to take frequent
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OrthoFoam MMP Wedge
User Guide
References
1
Maquet P, Advancement of the tibial tuberosity. Clin Orth 1976;
11
115:225
2
Bessette-GC; Hunter-RE, The Maquet procedure – A retrospective
Hirshhom HS, McBeath AA, Dustoor MR, Porous titanium surgical
implant materials. J BioMed Mater. 1971 2:49.
12
review. Clin-Ortho. 1988 Jul(232): 159:67
Petersen CD, Miles JS, Sotomons C et al, Union between bone and
implants of open pore ceramic and stainless steel: a histologic study.
J Bone Joint Surg. 1969; 51A 805.
3
Rappoport LH et al, The Maquet osteotomy. Orth Clin of North Am
No.4 1992; 645:656
13
Cameron HU, Pilliar RM, McNab I, The effect of movement on the
bonding of porous metal to bone. J Biomed Mater Res., 1973; 7(4)
4
Mendes DG, Soudry M, Iusim M, Clinical assessment of Maquet
301:11.
tibial tuberosity advancement. Clin Ortho. 1987 (222) 228:38
14
5
Bobyn, J. D., Pilliar, R. M., Cameron, H. U., Weatherly, G. C., and
Leighton RL, Preferred method of repair of cranial cruciate ligament
Kent, G. M, The effect of porous surface configuration on the tensile
rupture in dogs: a survey of ACVS diplomates specializing in canine
strength of fixation of implants by bone ingrowth. Clin Orthop. 1980;
orthopedics. American College of Veterinary Surgery. Vet Surg. 1999;
291:298.
28(3):19
15
6
Lafaver S, Miller NA, Stubbs WP, Taylor RA, Boudrieau RJ, Tibial
M.Spector, Historical Review of Porous-Coated Implants,
J.Arthroplasty, Volume 2, Issue 2, 1987; 163:177.
tuberosity advancement for stabilization of the canine cranial
cruciate ligament-deficient stifle joint: surgical technique, early
16
results, and complications in 101 dogs. Vet Surg. 2007;36(6) 573:86
Bobyn, J. D., Pilliar, R. M., Cameron, H. U., and Weatherly, G. C, The
optimum pore size for the fixation of porous-surfaced metal implants
by the ingrowth of bone. Clin Ortho. 1980; 263:270.
7
Kim SE, Pozzi A, et al, Effect of tibial tuberosity advancement on
femero-tibial contact mechanics and stifle kinematics. Vet Surg.
17
US 6,660,224, WO 03/015963
18
Wazen R, Lefebvre LP, Baril E, Nanci A, Initial evaluation of bone
2009; 38 (1)33:39
8
Lafaver S, Miller NA, Stubbs WP, Taylor RA, Boudrieau RJ, Tibial
ingrowth into a novel porous titanium coating, J.Biomedical Mat.
tuberosity advancement for stabilization of the canine cranial
Res.-Part B; 2010, 94 (1), 64:71.
cruciate ligament-deficient stifle joint: surgical technique, early
results, and complications in 101 dogs. Vet Surg. 2007;36(6) 573:86
19
Lim L, Bobyn JD, Lefebvre LP, Tanzer M, Efficacy of Bone Graft
Substitute Materials for Gap Healing Around Porous Titanium
9
Echteparaborde S, Mills J, Busoni V, Brunel L, Balligand M,
Implants, 57th Annual Meeting of the Orthopaedic Research Society,
Theoretical discrepancy between cage size and efficient tibial
Long Beach, California, USA, January 13-16, 2011.
tuberosity advancement in dogs treated for cranial cruciate ligament
rupture. VCOT. 2011: 24(1) 27:31
20
Baril E, Lefebvre LP, Hacking A, Direct Visualization and
Quantification of Bone Growth Into Porous Titanium Implants
10
Veterinary Instrumentation Catalogue 2010.
using Microtomography, Journal of Material Science: Materials in
Medicine, 2011 (online).
32
21
Lefebvre LP, Baril E, Bureau MN, Effect of Oxygen Content on
the Static and Cyclic Deformation of Titanium Foams, J.Mat.Sci.:
Materials in Medicine, Volume 20, Number 11 / November, 2009;
2223:2233.
22
Lefebvre LP, Baril E, Effect of oxygen concentration and distribution
on the compression properties on titanium foams, Advanced
Engineering Materials. 2008; 10 (9) 868:876.
23
St-Pierre JP, Gauthier M, Lefebvre LP, Tabrizian M, “Threedimensional growth of differentiating MC3T3-E1 pre-osteoblasts
on porous titanium scaffolds”, Biomaterials, 2005; vol.26, no.35,
7319:7328.
24
Menini R, Dion MJ, So V, Gauthier M, Lefebvre LP, “Surface and
Corrosion Electrochemical Characterization of Titanium Foams for
Implant Applications” J.Elect. Chem. Soc., 153, (1), 2006, B13:B21.
25
http://www.youtube.com/watch?v=hdscnna5r1Q
26
Echteparaborde S, Barthelemy N, Mills J, Pascon F, Ragetly GR,
Balligand M, Mechanical testing of a modified stabilisation method
for tibial tuberosity advancement. VCOT. 6/2010; 400:405
27
Apelt D, Kowaleski MP, Boudrieau RJ, Effect of tibial tuberosity
advancement on cranial tibial subluxation in canine cranial cruciatedeficient stifle joints: an in vitro experimental study. Vet Surg 2007;
36(2) 170:77
28
Slocum B, Slocum TD, Tibial plateau levelling osteotomy for repair
of cranial cruciate ligament rupture in the canine. Vet Clin North Am
Anim Pract. 1993; 23 777:795
29
De Rooster H, Van Bree H, Radiographic measurement of
craniocaudal instability in stifle joints of clinically normal dogs and
dogs with injury of a cranial cruciate ligament. Am J Vet Res 1999;
60(12) 1567:70
33
OrthoFoam MMP Wedge
User Guide
Notes
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35
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