Revista Electrónica:
Depósito Legal: ppi 201502ZU4665 / / ISSN electrónico: 2477-944X
Revista Impresa:
Depósito Legal: pp 199102ZU46 / ISSN 0798-2259
MARACAIBO, ESTADO ZULIA, VENEZUELA
Vol. XXX (2) 2020
UNIVERSIDAD DEL ZULIA
REVISTA CIENTÍFICA
FACULTAD DE CIENCIAS VETERINARIAS
DIVISIÓN DE INVESTIGACIÓN
59
Revista Cientíca, FVC-LUZ / Vol. XXX, N° 2, 59 - 64, 2020
THE EFFECT OF TIBIAL TUBEROSITY ADVENCEMENT (TTA)
ON CAUDAL CRUCIATE LIGAMENT (CACL) RIGIDITY IN
CANINE STIFLE JOINT UNDER CRANIAL FEMORAL DRAWER.
COMPARISON BETWEEN INTACT, CRANIAL CRUCIATE LIGAMENT-
DEFICIENT (CRCL-DEFICIENT) AND TTA KNEE: AN IAN IN-VITRO
EXPERIMENTAL STUDY.
EFECTO DEL AVANCE DE LA TUBEROSIDAD TIBIAL (ATT) SOBRE LA RIGIDEZ DEL
LIGAMENTO CRUZADO CAUDAL EN ARTICULACIÓN DE RODILLA CANINA BAJO FUERZA
FEMORAL CRANIAL. COMPARACIÓN ENTRE RODILLA INTACTA, CON ROTURA DE
LIGAMENTO CRUZADO CRANIAL Y CON LA ATT: ESTUDIO EXPERIMENTAL IN-VITRO
Marta Musté-Rodríguez and Elsa Pérez-Guindal*
Department of Strength of Materials and Engineering Structures, “Universidad Politécnica de Cataluña” (EPSEVG-UPC), Avda. Víctor
Balaguer, 08800 Vilanova i la Geltrú (Barcelona), Spain. Tel 938967725. Fax 938967700
*Corresponding author: +34 93 8967725 / +34 650497463, elsa.perez@upc.edu
ABSTRACT
The tibial tuberosity advancement (TTA) is a surgical technique
used to repair cranial cruciate ligament-decient (CrCL-decient)
canine knees. The aim of this study was to assess the eect of TTA
on caudal cruciate ligament (CaCL) under femoral anterior force,
in a 135° joint extension angle; and the role of CaCL in an CrCL-
decient knee. Five fresh cadaveric adult canine stie joints were
tested in an apparatus in which muscle forces were simulated.
Each knee was tested in three dierent conditions: intact, CrCL-
decient knee and with TTA surgery. Shear force (Newtons, N)
and CaCL deformation (millimetres, mm) were measured using
sensors and the ligament rigidity (force divided by deformation,
N/mm) was calculated and compared between the three knees.
The mean rigiditiy values increased from intact knee, 104.4 N/mm
(SD 3.6), to CrCL-decient knee, 136.5 N/mm (SD 7.5). However,
the rigidity was even greater when applying the TTA, 257.2 N/
mm (SD 21.1). Since, stress on the CaCL in CrCL-decient knees
was greater than in intact knees, the ligament assumed a more
important role. On the other hand, the TTA technique generates
an overload on the CaCL until rigidity exceeds its load-bearing
capacity. Although the in-vitro models are far from reality, these
ndings suggest the need to further study the eects of TTA on
the CaCL.
Key words: Caudal cruciate ligament; cranial cruciate liga
m e n t - d e c i e n t ; c a n i n e s t i e j o i n t ; o r t h o p a e d i c
plates; tibial tuberosity advancement
RESUMEN
El avance de la tuberosidad tibial (ATT) es una técnica quirúrgi-
ca usada para reparar la lesion de Ligamento Cruzado Craneal
(LCCr) en la rodilla canina. El objetivo de este estudio fue de-
terminar el efecto de la ATT sobre el ligamento cruzado caudal
(LCCa) con el efecto de una fuerza femoral cranial, en un ángulo
de extension de la articulación de 135º; y el rol del LCCa en rodil-
las con lesion de LCCr. Cinco articulaciones cadavéricas de ro-
dilla canina se sometieron a pruebas en una bancada, en la cual
se simularon las fuerzas musculares. Cada rodilla fué ensayada
en tres condiciones diferentes: rodilla intacta, rodilla con rotura
de LCCr, y rodilla operada con la ATT. Se midieron con sensores
la fuerza cortante (Newtons, N), la deformación del LCCa (mili-
metros, mm) y se calculó la rigidez del ligamento (fuerza dividida
por deformación, N/mm) y se comparó entre las tres rodillas. Los
valores promedios de la rigidez se incrementaron desde la rodilla
intacta, con 104,4, N/mm (DS 3,6), a la rodilla con lesion de LCCr,
con 136,5 N/mm (DS 7,5). Sin embargo, la rigidez aun fué mayor
cuando se aplicó la ATT, con 257,2 N/mm (SD 21,1). Debido a
que el estrés en el LCCa fué mayor en las rodillas con lesion de
LCCr que en rodillas intactas, el ligamento asumió un rol más
importante. Por otro lado, la técnica de la ATT genera una sobre
carga al LCCa hasta alcanzar una rigidez por encima de su ca-
pacidad. Sin embargo, los modelos in-vitro siguen estando lejos
de la realidad, por lo que estos hallazgos sugieren la necesidad
de más estudios de los efectos del ATT sobre el LCCa.
Palabras clave: L i g a m e n t o c r u z a d o c a u d a l ; l i g a m e n t o c r u z a d o
c r a n i a l d e c i e n t e ; a r t i c u l a c i ó n d e r o d i l l a c a n i n a ;
prótesis ortopédicas; avance de la
tuberosidadtibial
Recibido: 15/01/2020 Aceptado: 22/04/2020
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Efecto del avance de la tuberosidad tibial (att) / Muslé,M and Perez,E.
INTRODUCTION
Anterior displacement of the tibial tubercle was recommended
in humans to reduce pressure and pain in the patelofemoral joint
in patients with osteoarthritis [15]. Tibial tuberosity advancement
(TTA) that was presented in 2002 [17,25] is performed with the
premise that it increases the eciency of the extensor mechanism
and decreases quadriceps activation. This technique is adopted
in veterinary surgery to neutralize dynamically cranial shear
forces in cranial cruciate ligament-decient (CrCL-decient)
knees lengthening the lever arm of the quadriceps during canine
(Canis lupus familiaris) gait [2,5]. The tibiofemoral shear force
is directed forward when the knee is extended and backwards
when exed and is zero when the patellar tendon angle (PTA)
is 90° [19]. If the tuberosity is advanced to the point where the
PTA angle is 90° or less in the extended position, the shear force
will be neutral or caudally directed. Dierent studies using in vitro
models support the theoretical foundations of TTA that measure
the cranial tibial thrust (CTT) [1, 8, 12, 16], however, warn that
TTA may caudally displace the tibia at 135° of extension, which
would cause an excessive load on the caudal cruciate ligament
(CaCL) [1, 4, 8, 12]. A nite element simulation model of the forces
in the human knee showed that tibial tubercle elevation caused
that the CaCL was beginning to tense at lower exion angles [24],
i.e., TTA technique causes an overload on the CaCL from the
knee extended position. Although CaCL has a function during gait
cycle and, in an CrCL-decient knee, plays an important role in
the extended position, it has received much less attention than
the CrCL. Whilst cranial translation in intact and CrCL-decient
knees has been studied, the behaviour of the CaCL submitted
to caudal displacement with CrCL-decient knees and tuberosity
advancement has not. (redaccion)
This study analizes the stress on CaCL under tibial caudal
translation in canine stie joints in dierent conditions: intact,
CrCL-decient and with TTA. After comparing the results, the eect
of TTA surgery on CaCL will be assessed. Five unconstrained
canine stie joints were tested In vitro in a 135° extension angle.
CaCL deformation (in millimeters, mm) was measured using
a displacement sensor and a tension load cell measured the
tibiofemoral shear force (in Newtons, N). Then, the linear rigidity
of the ligament was calculated by means of the linear slope of the
resulting load-deformation curve (rigidity is the relation between
load and deformation, N/mm). The greater the ligament rigidity,
the more tense the ligament is working, and the more stress on it.
MATERIALS AND METHODS
The knee specimens were xed to a testing bench designed
and constructed in the laboratory. The caudal displacement of the
tibia relative to the femur is simulated in experimental trials by
applying a cranial displacement of the femur on a xed tibia (FIG.
1). Due to the relative motion that exists between femur and tibia,
the cranial femoral displacement on a xed tibia is equivalent to
the caudal displacement of the tibia on a xed femur. The distal
end of the tibia-bula of each specimen was introduced in a con-
tainer with a high mechanical strength composite to ensure their
embedding. To simulate the position during canine gait, the tibia
was bent 30 degrees forward.
An orice was drilled on the femoral condyles, and a 150 mm
horizontal bar with M5 metric threaded was introduced to transmit
a shear force on the condyles in order to simulate the movement
of the femur relative to the tibia (FIGS. 1 and 2), i.e., the shear
force. An u-shaped steel sheet adaptor was xed on the metal
bar. The force sensor
1
was connected to that steel adaptor, which
in turn, was connected to metal wire. The metal wire transmit-
ted the shear force through a pulley (FIG. 1). Two inductive dis-
placement sensors of femur motion were placed on the femur bar,
which weren’t used in this study.
FIGURE 1. TESTING BENCH WITH SPECIMEN, MUSCULA-
TURE SIMULATORS, MEASURING DEVICES AND APPLIED
FORCE SYSTEM
FIGURE 2. FORCE APPLICATION SYSTEMS. A BAR
TRANSMITS A SHEAR FORCE ON THE CONDYLES IN
ORDER TO SIMULATE THE MOVEMENT OF THE FEMUR
RELATIVE TO THE TIBIA. TWO THIN PLASTIC CORDS
ANCHORED TO THE SUPRACONDYLAR TUBEROSITIES OF
THE FEMUR RECREATED THE FLEXOR MUSCLES
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Revista Cientíca, FVC-LUZ / Vol. XXX, N° 2, 59 - 64, 2020
Specimen preparation
Five fresh cadaveric right canine knees from adult dogs be-
tween 25 to 35 kilograms (kg) of body weight were used for this
study, each of them was tested three times. The specimens were
obtained from canine cadavers that were sacriced by others pa-
thologies with their owner’s consent. The bones were disarticulat-
ed at the hip joint (articulatio coxae), preserving the femoral head,
and the tibia was sectioned distally, on its distal third. All soft
tissues were removed except for the patella and patellar tendon
and the quadriceps muscle, the stie joint capsule, the collateral
ligaments and the sesamoid bones of the gastrocnemius muscle.
The specimens were frozen
2
at -18 °C until it was time to perform
the trials.
The mid-stance phase of canine gait when CTT occurs is at
135º [6, 10, 21]. Muscle forces of the canine hind limb during this
phase at 135° were simulated in accordance with a mathematical
model [22]. A variable force spring attached to the proximal end
of the femur and the top of the patella was used to play the role
of the extensor muscle. The force of the quadriceps tendon was,
according to Shahar and Bank-Sills [22], approximately equal to
48,5% of the animal’s weight. The spring was pre-stressed with
a force corresponding to 48% of the dog’s weight. The spring
force helded the limb in extension and an upper stop limited the
angle of the limb. To recreate the exor muscles, mostly attached
to the Achilles tendon, it was used a constant weight provided
by thin plastic cords that were anchored to the supracondylar
tuberosities of the femur with two 3.5 mm threaded screws, and
run parallel to the tibia towards the heel. According to Shahar and
Bank-Sills [22], the total strength of the muscles that is attached
to the calcaneal tendon was 29.09% of the dog’s weight (FIGS.
1 and 2). Since the trials were performed on specimens free of
muscles and tissues a reduction factor was applied to quadriceps
and Achilles tendon force.
Specimen preparation with the TTA system
A longitudinal osteotomy was performed from the proximal cra-
nial portion of the tibia, at the extensor sulcus level, to the distal
area of the tibial crest, where a 3.5 mm orice was made, as de-
scribed in the TTA technique by Montavon et al. [18]. To perform
the TTA, the tibial cranial fragment was progressively advanced,
and a 9 mm box introduced and anchored in position with a 2 mm
cortical screw. The plate was xed with 2 mm cortical screws in its
cranial portion and 2.7 mm screws in its caudal portion.
Measuring systems
The devices measuring tibiofemoral shear force and CaCL de-
formation were electromechanical transducers. The force sensor
was a tension load cell
3
. And the displacement sensor was an in-
ductive sensor, Linear Variable Dierential Transformer (LVDT)
4
,
which measured the CaCL deformation in millimetres. The super-
cial CaCL was exposed in the back of the knee, and the DVRT
for displacement was securely sutured to the ligament.
The two sensors were connected to a multiplexer
5
to treat and
amplify the signal. The multiplexer captured the analogue inputs
from the measuring devices in reading channels, which used the
Wheatstone bridge as a connection circuit. A data acquisition
card converted the analogue signal into a digital signal, which
was treated by a software designed using the Laboratory Virtu-
al Instrument Engineering Workbench (LabView)
6
Management
Program. This program was responsible for the reading manage-
ment of all channels on the acquisition card, and for displaying
and saving all the generated data in les.
Each of the ve specimens were tested three times and
the values corresponding to the applied force and the CaCL
deformation were recorded for the three cases: intact knee, CrCL-
decient knee, and after applying the TTA technique with surgical
instruments in the laboratory. In order to produce a standard force
versus deformation curve that could be used for biomechanical
comparison, all the tests were performed with repeated loads and
a constant rate of loading, thus minimizing side eects.
Statistical analysis
One way analysis of variance, ANOVA calculated with an excel
sheet, with ve specimens, was used to compare changes in
ligament rigidity between intact knee, CrCL-decient and TTA
surgery. The condence limits were 95%. Signicant dierences
between three groups was observed (P < 0.001). Normality of
residuals was met by all values on the displacements, and
variability of residuals were similar in the three groups (assumption
of homoscedasticity); there were no residuals outliers.
RESULTS AND DISCUSSION
The shear force and CaCL deformation curves are shown in a
gure in which specimen 4 is represented in dierent conditions:
intact, CrCL-decient and TTA knee (FIG. 3). All the specimens
had similar behaviors. Because the high sensitivity sensors mea-
surements, large amounts of data per second were gathered and
highly accurate curves were developed
.
FIGURE 3. FORCE-STRAIN CURVE IN INTACT, CrCL-
DEFICIENT AND TTA KNEE IN 135º EXTENSION, IN A
CAUDAL DISPLACEMENT OF THE TIBIA (KNEE 4). The
linear regression of the linear part of the curves are shown
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Efecto del avance de la tuberosidad tibial (att) / Muslé,M and Perez,E.
The rigidity of each ligament was calculated in the linear re-
gion of the graphs by divinding the shear force, in Newtons, by
CaCL deformation in millimetres (N/mm), i.e., the rigidity is the
slope of the linear regression. The linear ligament rigidity calcu-
lation of ve specimens for each type of knee is summarized in a
Table (TABLE I).
TABLE I
DATA ON LIGAMENT LINEAR RIGIDITY (N/mm) IN CADAVER
KNEES (n=5) IN 135° EXTENSION. ANOVA ANALYSIS
Intact Knee
R-sq
1
CrCL
decient
R-sq
1
TTA
R-sq
1
knee 1 100.2 0.99 125.6 0.99 231.3 0.98
knee 2 106.1 0.99 143.3 0.99 261.5 0.98
knee 3 108.9 0.99 140.4 0.99 245.8 0.99
knee 4 105.6 0.99 138.2 0.98 270.3 0.99
knee 5 101.1 0.99 135.1 0.99 276.9 0.97
Mean 104.4 136.5 257.2
Standard
Deviation
(SD) 3.6 7,5 18.1
P = 0.000
; R-sq =
96.81%
¹R-sq of the linear regression
All curves of the ligaments showed the same behaviour pattern
with a nonlinear and a linear phase (FIG. 3). In the initial nonlinear
part of the curves wavy collagen bres are not maximally stretched
[20]. In the linear region, the CaCL is tensed and wavy collagen
bres that compose it, are maximally stretched.
The CaCL deformation in intact knees curves were increasing
uniformly, and the average ligament rigiditiy was 104.4 N/mm
(SD 3.6) (TABLE I). Only the CrCL linear stiness is reported in
a ligament tensile test with Femur-CrCL-Tibia system [26]. The
stiness was 265 N/mm at an extension angle of 150°; and, in a
test with a cranial movement of the tibia, the stiness obtained
was 224.6 N/mm [26]. In the intact knee the mean value of 104.4
N/mm, far below 224.6 N/mm, indicates less CaCL deformation,
and that the ligament was working below its load-bearing capacity
due to the involvement of other stabilizers - collateral ligaments,
menisci and cartilage.
Instead, CaCL linear rigidity increased in CrCL-decient knees
in response to the shear force, and the values ranged from 125.6
to 143.3 N/mm (SD 7.5) (FIG. 3 and TABLE I). The CrCL consists
of a cranio-medial band and a caudo-lateral band, so it acts in
both directions. When the CrCL is missing, the force in the CaCL
increases. A biomechanical model of the canine knee during gait
found that when the CrCL was sectioned, the CaCL tensed for
most of the gait cycle, reaching a magnitude equal to 11% of body
weight [23].
On the other hand, the ligament deformation in CrCL-decient
knees greatly increased versus the intact knee, and rigidity only
did so by a 24.7% on average. So, CrCL-decient curves show
that there is no direct correlation between the increase in CaCL
deformation and the rigidity. This could be explained because
the total CaCL deformation can vary, as it can be found initially
relaxed or taut depending on whether the knee is intact, CrCL-
decient or operated. In the absence of the CrCL, the tibia adopts
a more cranial position, since the CrCL is the primary restraint to
tibial anterior translation [3], so a CrCL injury causes an anterior
shift. DeFrate measured approximately 3 mm translation [7]. This
distance is travelled by the CaCL in the caudal movement of the
tibia, so the curves show a longer deformation.
Rigidity values for kness with TTA surgery were higher still, with
257.2 N/mm (SD 18.1) on average, similar to that value obtained
in a ligament tensile test of 265 N/mm [26]. This high value means
that the ligament was very taut and was oering resistance being
deformed. Because the linear region is not entirely linear for
heterogeneous natural materials, stiness increases in the last
stretch before the beginning of the bres rupture [20]. It appears
that the TTA led the ligament to this limit, above the physiological
range. Since this high value in a TTA surgery knee is reached
repeatedly while walking, bres might rupture.
TTA varies the position of the patellar tendon to neutralize the
CTT or make it caudal during walking. The high CaCL rigidity
shows that tibial advancement promotes a caudal force at
135°, which is absorbed mainly by CaCL during walking. Apelt
also observed a caudal displacement of the tibia when the
advancement was higher than 10 mm [1]. Shirazi’s nite element
model of the human knee showed that tibial tubercle elevation in
full extension reduces the force on the CrCL from 143 N without
advancement to 32 N with a 2.5 centimetre advancement [24].
Therefore, if TTA stops the CTT in extension, this implies greater
caudal forces in any other exion position, where they occur
naturally. Shirazi’s model shows that the CaCL begins to tense
only at a exion of 20°, and at a exion of 40° the force goes
from 0 without advancement to 100 N with 2.5 cm advancement.
However, the caudal shift in direction of the tibia of a healthy knee
happens from an angle of 60° [9, 13, 14]. In this canine study the
CaCL is tensed from extension position.
On the other hand, the behaviour of the CaCL was somewhat
dierent from the intact and CrCL-decient knees. At the
beginning of the curve the ligament was deformed by applying
little force, but the distance travelled was smaller than in the
CrCL-decient (FIG. 3). This eect can be explained because
the drawer between the advanced portion of the tuberosity
and the tibia tends to displace the latter in the caudal direction.
This would imply a permanent pre-tension on the CaCL and a
change in the relative position between the joint surfaces. This
could have consequences in the normal knee kinematic patterns.
Several studies warn that an increase in caudal tibial translation
and external rotation is accompanied by an increase in contact
pressure in the patellofemoral joint [11, 14, 24].
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Revista Cientíca, FVC-LUZ / Vol. XXX, N° 2, 59 - 64, 2020
CONCLUSIONS
CaCL takes a leading role in the caudal movements in CrCL-
decient knees from the extended position. The TTA surgery in
canine CrCL-decient knees causes an unstable behaviour and
an overload on the CaCL. Based on mean values of TABLE
I, CaCL rigidity under anterior femoral force in a 135° angle
extension, increases with TTA 246.4% versus the intact knee, and
188.4% versus CrCL-decient. Current results further emphasize
the need for an integral view of the entire joint in management of
disorders. However, experimental models have large limitations
to simulate actual conditions within the joint. To reach conclusive
results on the eects of TTA on the CaCL, long-term follow-up
clinical studies are needed.
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Vol, XXX, N
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2 2020
Esta revista fue editada en formato digital y publicada en
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