Tibial Tuberosity Advancement 239(A) (B)Figure 28.11 Lateral radiographs of the stifle of 41.8-kg Golden Retriever after treatment with TTA-2. (A) Immediate
postoperative lateral radiograph. The saw guide was placed with four Kirschner wires to temporarily anchor it in position
to guide the osteotomy; three of the four holes are visible (small white arrows). An intraoperative bridge fracture at the
distal end of the tibial tuberosity occurred at the time of the tibial advancement. Note that it is no longer recommended
to use the adjacent K-wire hole as the location for a restraining suture. As a result of this fracture, three K-wires (0.062")
and an 18-gauge tension-band wire were placed proximally. The tension-band wire also passes through a hole used to
temporarily secure the saw guide. (B) The dog fractured the tibial diaphysis one day postoperatively when rising. This
shaft fracture originated at the site of the bridge fracture due to the stress-riser at this level. Recommendations for TTA-2
are evolving and have been recently updated. Currently, the saw cut is longer, with the length based on cage width/size,
and applied with a revised saw guide. The tuberosity should be advanced slowly, using gradual steps to prevent any
acute stress at the distal end of the tuberosity. The restraining suture at the distal end of the osteotomy is no longer used.
Similarly, a distal screw placed cranio-caudal below the cage is also no longer recommended. A proximal staple is
currently recommended (placed medially) to span the cage at its proximal extent to help neutralize torsional forces. All
of these measures are designed to avoid the bridge fracture at the distal end of the tibial tuberosity at the termination of
the osteotomy. (See alsohttp://www.kyon.ch/current-products/tibial-tuberosity-advancement-tta/tta-2-development-
technique). Complications of the second-generation techniques are not unique to the TTA-2. All of the
second-generation techniques continue to evolve. Images provided courtesy of Dr Robert Botte.
transection or injury of the tendon of origin of
the long digital extensor, and delayed union or
non-union of the gap, often because no graft or
osteoconductive filler material was used.
Outcome and complications with
second-generation cage-only TTA
Second-generation TTA procedures eliminate
plate fixation. These methods propose a novel
cage and alternate osteotomy, but few results
have been published. All of the complications
noted previously with the first-generation tech-
niques are a concern with second-generation
TTA. Some technical issues have been resolved
with use of a saw guide, but this approach
also introduces other potential problems. The
most obvious concern is the complication
of tibial fractures at the distal end of the
osteotomy (Figure 28.11) (Etcheparebordeet al.
2011; Brunelet al. 2013; Barthel ́emy ́ et al. 2014;