Kinematic Gait Analysis of the Hind Limb after Tibial Plateau Levelling Osteotomy and Cranial Tibial Wedge Osteotomy in Ten Dogs

CLINICAL MEDICINE

Laboratory of Veterinary Surgery, College of Veterinary Medicine, Chungbuk National University, Cheongju, Korea

Kinematic Gait Analysis of the Hind Limb after Tibial Plateau Levelling Osteotomy

and Cranial Tibial Wedge Osteotomy in Ten Dogs

J. Y. Lee1, G. Kim

1, J. -H. Kim1 and S. H. Choi

1,2

Address of authors: 1Laboratory of Veterinary Surgery, College of Veterinary Medicine, Chungbuk National University,Cheong-ju 361-763, Korea; 2Corresponding author: Tel.: +82 43 261 2595; fax: +82 43 261 3320; E-mail: [email protected]

With 5 figures Received for publication March 31, 2006

Summary

This study identifies and compares the kinematic gait changes

occurring in tibial plateau levelling osteotomy (TPLO) andcranial tibial wedge osteotomy (CTWO) limbs after transec-tion of the cranial cruciate ligament (CrCL). Ten, healthy,

adult beagle dogs were assigned to TPLO (five dogs) andCTWO (five dogs) groups. Hind limb kinematics wereassessed, while dogs were trotted at speeds ranging from 2.0 to

2.3 m/s. The animals were evaluated preoperatively (prior toTPLO and CTWO surgery) and at both 8 and 12 weeks aftersurgery. Two-dimensional evaluation was synchronized toobtain the three-dimensional coordinates using the APAS

motion analysis software. Gait patterns were assessed bymeasuring stifle, tibiotarsal joint angles and stifle jointsangular velocity. Stifle and tibiotarsal joint functions were not

affected by TPLO surgery, but stifle and tibiotarsal joint angleswere changed, following CTWO surgery, compared with theirpreoperative values. The angular velocity patterns of CTWO

were characterized by increased stifle joint extension velocityfrom the middle to end swing phase and decrease in the peakvelocities (flexion) during swing phase. None of these changes

was observed in the stance phase after the CTWO surgery.These kinematic results showed that dogs that underwenta CTWO procedure were more likely to have significantlyhyperextended gait patterns of the swing phase postoperatively

than the dogs that had a TPLO procedure for repair of aruptured CrCL.

Introduction

Cranial cruciate ligament (CrCL) injury is one of the mostcommon joint diseases and causes of progressive secondary

osteoarthritis in the dog hind limb (Johnson and Johnson,1993). The CrCL is a vital stabilizer of the stifle joint, limitingcranial displacement of the tibia relative to the femur, prevent-

ing stifle hyperextension and limiting internal rotation of thetibia on the femur during stifle flexion (Arnoczky andMarshall,1977). Following acute rupture of the CrCL, the repeatedstresses can result in progressive degenerative joint disease, and

secondary osteoarthritis of the stifle (Brandt et al., 1991; Innes

et al., 2004). Although surgical management reportedly yields asatisfactory outcome in most dogs, a large number of dogs stillexhibit residual lameness (Innes et al., 2000).

Tibial plateau levelling osteotomy (TPLO; Slocum andSlocum, 1993) is a relatively new surgical treatment forthe CrCL-deficient stifle that improves functional stability(Ballagas et al., 2004). TPLO was previously demonstrated to

inhibit osteoarthritis induced by CrCL rupture and restorelimb function (Kergosien et al., 2004; Carey et al., 2005).Cranial tibial wedge osteotomy (CTWO) is a simpler version

of the TPLO technique; however, the postoperative consider-ations of this procedure are yet to be determined objectivelyand the relative efficacy of CTWO versus TPLO has not been

reported (Dejardin, 2003). CTWO procedure alters the normalrelationship of the femoropatellar joint and hyperextends thestifle joint (Dejardin, 2003). However, the frequency and

clinical relevance of stifle joint hyperextension, after CTWO,have not been objectively examined.We hypothesized that stifle and tibiotarsal joint angles

increase following CTWO (Slocum and Devine, 1984) surgery

because CTWO alters the normal relationship of the femoro-patellar joint, causing a lowered patellar position relative tothe femur, unless the stifle is hyperextended. In dogs with

CrCL rupture that are untreated, stifle and tibiotarsal anglesare reduced throughout the whole gait cycle, while tibiotarsaland coxofemoral angles are reduced at paw off compared with

the contralateral or preoperative values (Vilensky et al., 1994,1997; Hasler et al., 1998; Suter et al., 1998; Marsolais et al.,2003; Tashman et al., 2004).To investigate the possible relationship between changes in

joint loading and gait pattern, the kinematic gait changes,occurring in osteoarthritis of aCrCL-transected stifle joint, havebeen described (Vilensky et al., 1994, 1997; Hasler et al., 1998;

Suter et al., 1998; Marsolais et al., 2003; Tashman et al., 2004).Kinematic gait analysis is performed using a series of camerasand retroreflective targets placed on the dog�s skin over specific

anatomic land marks (DeCamp et al., 1993). A computermeasures the flexion and extension movements of joints and theangular variables of the dog�s gait as it passes through a testing

area. This method provides information relative to the swing

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and stance phases of a dog�s stride. In most cases, kinematic gaitanalysis is combined with force-plate analysis so that dynamicthree-dimensional characteristics of limb motion can be corre-

lated with ground-reaction force measurements. In a recentstudy, dogs that underwent TPLO surgery of a transected CrCLhad a significant decrease in peak vertical forces and vertical

impulse at 8 weeks; however, there was no significant differenceat 18 weeks (Ballagas et al., 2004). Joint kinematic data werenot collected in that study and there has been no data of gait

pattern after the TPLO and CTWO surgery.In the present study, we used frame-by-frame analysis to

characterize the kinematic gait changes of the post-TPLO andpost-CTWO stifle joint in 10 dogs that had transection of the

CrCL. The purposes of the study were to determine objectivelythe effect of surgical technique on canine gait following surgeryfor CrCL injury. In particular, we sought to answer whether

TPLO and CTWO surgery results in an abnormal gait patternin dogs with a deficient CrCL.

Materials and Methods

Animals

Ten adult beagles (body weight 12–15 kg) were trained to trot atspeeds ranging from 2.0 to 2.3 m/s by a single handler. Training

sessions were conducted four to six times a week for 6 weeks.After a training period that averaged 3 weeks (range14–30 days) dogswere assigned toTPLO (five dogs) andCTWO(five dogs) groups. They were screened by a complete orthopae-

dic physical examination and, subsequently, preoperative kine-matic gait evaluation was performed 14 days prior to surgery.The dogs were sedated with intramuscular (IM) atropine

(0.05 mg/kg) and acepromazine (0.05 mg/kg), 30 min beforeinduction. Anaesthesia was induced by administering thiopen-tal (12 mg/kg, IV) and maintained with isoflurane and oxygen.

Lactated Ringer�s solution (12 ml/kg/h, IV) was administeredduring surgery. Meloxicam (0.2 mg/kg, IM) was administeredfor analgesia before surgery. Cefazolin (22 mg/kg, IV) was

administered at the time of induction and 2 h later.The dogs were positioned in dorsal recumbency, A medial

arthrotomy was performed and the left CrCLs of the dogs wereexcised. The tibia was subluxated cranially and a meniscal

release was performed by a complete incision of the caudaltibial ligament of the medial meniscus. The joint capsule wassutured and then either TPLO or CTWO was performed by the

same person.Tibial plateau levelling osteotomy was performed using a

small jig (Slocum Enterprises, Eugene, OR, USA) that was

applied to the sagittal plane and was parallel to the straightpatellar tendon. A biradial saw blade (Slocum Enterprises) wasused to create a cylindrical cut in the proximal tibia. The

proximal fragment was rotated to achieve a planned tibialplateau angle of 5� and temporarily stabilized with an appro-priate pin. The two opposing bone fragments were secured intoposition with the TPLO plate (Slocum Enterprises).

Cranial tibial wedge osteotomy was performed using a smalljig (Slocum Enterprises) that was applied to the sagittal planeand was parallel to the straight patellar tendon. Using a

sagittal bone saw, the tibial wedge osteotomy was performedto achieve a tibial plateau angle of 5� and the tibial fragments,in the cranial aspect of the tibial crest, were temporarily

stabilized with a wire. The two portions of the osteotomy were

positioned with the CTWO plate (Veterinary Instrumentation,Sheffield, UK).

Hydromorphone (0.1 mg/kg, IM) was administered before

recovery from anaesthesia and continued every 5 h for 24 h.After 24 h, the dogs were administered cefazolin (22 mg/kg,IM), butorphanol (0.3 mg/kg, SC) twice daily for 3 days and

meloxicam (0.2 mg/kg, orally) once daily for 7 days. The dogsunderwent cage exercise for the first 3 weeks and then the levelof exercise was gradually increased from 10 to 30 min, daily,

by the third month. The protocols employed in this study wereapproved by the Animal Care Committee of ChungbukNational University, Korea.

Kinematic evaluation of gait

Data collection

Hind limb kinematics were assessed, while dogs trotted at

speeds ranging from 2.0 to 2.3 m/s. For each animal, minimumof five consecutive steps were recorded. Reflective markerswere placed on the greater trochanter, the lateral femoral

condyle, the lateral malleolus of the tibia and the base of thefifth metatarsal-phalangeal joint, for calculation of jointangles. To ensure a consistent placing of the reflective markers

in repeated testing, the skin above each bony landmark wastattooed before CrCL-transection. Markers were manuallydigitized for five consecutive steps for each animal. All markerswere placed on each dog and forward velocity was controlled

by a single handler. The average stifle, tibiotarsal joint anglesand angular velocity of stifle joint at swing and stance werecalculated for each animal. Kinematics were recorded using

two high speed video cameras (GR-DVL 9800; JVC, Japan,60Hz). The two video cameras were strategically placed alongthe walkway for synchronized collection of kinematic gait

data. A testing space (700 · 200 · 200 cm) was established onthe walkway. Eight markers were used to define a calibrationvolume within the testing space that measured100 · 100 · 100 cm. The animals were evaluated preopera-

tively as well as at 8 and 12 weeks after surgery.

Data analysis

Kinematic variables of interest included extension and flexionangles of the stifle and tibiotarsal joints. Stifle and tibiotarsal

joint angles were calculated from the positional data of thereflective markers respectively. Two-dimensional data fromeach camera were synchronized to predict the three-dimen-

sional data of each marker. A three-dimensional data calibra-tion and transformation were used to correct for imagedistortion. The three-dimensional positions of the retroreflec-tive markers were established by transforming the video

captures using APAS motion analysis software (APAS 2000;Ariel life system, USA). For data smoothing, we used a digitalfilter algorithm with the cut-off frequency selected automati-

cally by the APAS system optimization software. These datawere calculated using the respective kinematics measurements.To determine the mean angular displacement pattern for the

CrCL-deficient dogs, the displacement pattern for each dogwas divided into 5% intervals and the average angular valuefor all the dogs was calculated at each of the 21 points thatbordered the 20 intervals. The mean (±SD) patterns were

ascertained for the experimental dogs at each time-point.

580 J. Y. Lee et al.

To determine the angular velocities of the stifle joints, theraw data for angular displacement of the stifle joints weresmoothed with digital filtering procedures and the derivatives

of the smoothed displacement values were calculated. Wedigitalized 20 frames before and after each stride to obtainaccurate values for velocity at the end-points.

Statistical analysis

The five TPLO and CTWO dogs were evaluated separately.For each group, anova was performed to evaluate each of the21 time-points comprising the mean displacement velocitypatterns. If significant differences (P < 0.05) were detected,

Dunnett�s procedure for comparing a control to a set oftreatments was used to compare the measurements takenbefore and after the surgical procedures.

Results

Radiographs of the stifle joints obtained immediately post-

operatively revealed a mean tibial plateau angle of 7 ± 1� inall animals in both the TPLO and CTWO.

Joint angle

Displacement

The preoperative gait pattern showed the typical quadrupedalgait pattern. The swing phase is initiated by flexion, followedby extension as the limb prepares for paw contact. The stance

phase comprised an initial joint flexion phase associated withweight bearing, and is then followed by joint extension phasethat ends with takeoff. In the preoperative normal limbs, stifle

and tibiotarsal joint angles show a typical flexion-extensioncycle during the gait with a distinct stifle joints extension peakat the end of the stance phase.

The normalized mean displacement pattern of the stifle andtibiotarsal joints of the CTWO limbs characterized byincreased extension throughout the entire 12-week postoper-

ative period. Figures 1–4 show the average stifle and tibiotar-sal joint angles of the TPLO and the CTWO limbs at thedifferent time-points during the experimental period. Averagejoint angles in the TPLO dogs were similar to the preoperative

condition (Fig. 1); however, significant reduction in stifle andtibiotarsal joint angles at the beginning of the swing phase andstifle joint angles at the end of stance phase (P < 0.05, at

8 weeks postoperative) was observed. During the swing phase,

Pre-operative

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Fig. 1. Mean angular change patterns for the TPLO dog stifle joints. The heavy line superimposed on the postoperative curves is the meanpreoperative angular pattern. The error bars indicate the SD at each of the 21 time-points. The asterisks indicate a significant differences(P < 0.05) from the corresponding preoperative value. The abscissa for each graph is the percentage of the stride.

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Fig. 2. Mean angular displacement patterns for the CTWO dog stifle joints. The representation is identical to that in Fig. 1.

Gait Analysis after Tibea Osteotomy 581

from middle swing to paw contact, the average extension of thestifle and tibiotarsal joints of the CTWO dogs were 10–20�greater than the preoperative values (P < 0.05 at 8 and12 weeks postoperative) (Figs 2 and 4); however, there were no

significant differences in the TPLO dogs compared withpreoperative values (Figs 1 and 3). Distinct extension peakwas lost for both stifle and tibiotarsal joint angles at the

beginning of the swing phase, while this was only observed inthe stifle joint angles at the end of stance phase, 8 weeks aftersurgery (P < 0.05). At stance phase, there was no significant

difference in stifle and tibiotarsal joint angles in the CTWOand TPLO dogs compared with preoperative values. TheCTWO dogs carried their stifle and tibiotarsal joints in

approximately 10–20� more extension during swing phase.The most consistent differences, postoperatively, were anincrease in extension at paw contact and an increase inextension during the swing phase of their stifle and tibiotarsal

joints after CTWO surgery.

Velocity

At 12 weeks after surgery, positive (extension) and negative(flexion) joint velocities were characterized as the stifle joint

flexed and extended. Each value of the CTWO dogs resulted ina greater angular velocity than that of the preoperative dogs,but only two time-points showed a statistically significantdifference (P < 0.05, from 30% to 40% of the CTWO dogs

cycle) (Fig. 5). The velocity patterns during the stance phase,before and after the operations, were similar.

Discussion

Kinetic and kinematic gait analysis provides objective, quan-tifiable and reproducible information on normal and abnormal

gait in dogs (McLaughlin, 2001). Specialized gait analysistechniques enable the diagnosis of subtle lameness, betterevaluation of dogs with resolving lameness.

Flexion and extension during gait phase are a continuousand complex event. General kinematic characterizations ofcanine walk and trot have been objectively reported (DeCampet al., 1993, 1996; Hottinger et al., 1996). Many studies have

compared pre- and postoperative kinematic gait analysis indogs with CrCL rupture with those that have and have notundergone surgical treatment (DeCamp et al., 1993, 1996;

Vilensky et al., 1994, 1997; Hasler et al., 1998; Innes et al.,2000). In this study, we reported hind limb gait changes after

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Fig. 3. Mean angular displacement patterns for the TPLO dog tibiotarsal joints. The representation is identical to that in Fig. 1.

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Fig. 4. Mean angular displacement patterns for the CTWO dog tibiotarsal joints. The representation is identical to that in Fig. 1.


TPLO and CTWO surgery. Stifle and tibiotarsal angularpatterns, while trotting, were measured in the dogs before andafter surgery.

Kinematic gait analysis generates objective data on limbusage (McLaughlin, 2001). Kinetic and kinematic gait analysiscould be used to investigate limb function further (Hottinger

et al., 1996; McLaughlin, 2001). Following TPLO and CTWOsurgery, stifle and tibiotarsal joints extension at the end of thestance phase (or at the beginning of the swing phase) were

significantly reduced compared with preoperative joint angles;a result which was observed in dogs at 8 weeks after eithersurgical procedure. However, these results were no longerobserved at 12 weeks; it was presumed that the greater flexion

joint angles measured in this study might have been caused bythe postoperative surgical discomfort. At 8 and 12 weeks aftersurgery, stifle and tibiotarsal joint extension angles during the

swing phase (from middle swing to paw contact phase) wereobserved in the CTWO hind limb. Stifle and tibiotarsal jointangles were 10–20� greater during the swing phase, indicating

that all the animals carried the CTWO limb in a greaterextension than the normal preoperative limb. Our resultsconfirmed that the CTWO procedure alters the normal

relationship of femoropatellar joint and that the stifle joint ishyperextended to approximate the normal femoral–patellarrelationship. At the stance phase, a tendency towards slightlyincreased angular change was observed; however, this was not

found to be statistically significant. These results demonstratedthat, when weight loading, CTWO and TPLO procedures havean effect similar to preoperative values.

Angular velocity is a measure of the speed at which a jointangle changes. In the present study, angular velocities of thestifle joint were evaluated. The faster return to extension

velocity during the swing phase in the CTWO limbs, comparedwith TPLO limbs, indicated a faster return to the normalrelationship of the femoropatellar joint (This result indicated afaster extension change of the stifle joint during the swing

phase).In summary, the marked stifle joint extension angles at the

middle and end of the swing phase in CTWO procedures were

most notable. By end-swing, stifle joint extension angles,compared with preoperative values in CTWO procedures, were

significantly higher. These kinematic results showed that dogsthat had the CTWO procedure were more likely to have asignificantly hyperextended gait pattern in their postoperative

swing phase, while trotting, than dogs that had the TPLOprocedure for repair of a ruptured CrCL. The dogs thatunderwent the CTWO procedure had normal joint angles

during stance phase and were not different when comparedwith dogs that underwent the TPLO procedure. Althoughdifferences were observed in the swing phase of the gait, these

data indicate that there is likely to be no clinical difference inthese dogs regardless of which surgical technique is performed.Some limitations to this study include the use of small

number of dogs evaluated, and also the small size of the dogs

used in this study. Gait patterns between different sizes (larger)and different breeds of dogs may not be similar. Furtherevaluation in a different population of dogs, perhaps those at

greater risk of CrCL injury (e.g. Labrador retrievers), may bewarranted. Despite these limitations, we believe that our datademonstrate a consistent stance phase pattern that is not

different between dogs with an intact CrCL and those withdeficient CrCL repaired with either the TPLO or CTWO.

Acknowledgement

This work was supported by the Brain Korea 21 project in2006.

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Documents

Kinematic Gait Analysis of the Hind Limb after Tibial Plateau Levelling Osteotomy and Cranial Tibial Wedge Osteotomy in Ten Dogs