Control of hemorrhage through the osteotomy gap during tibial plateau leveling osteotomy: 9 cases

Abstract

Objective: To describe a new technique to control intraoperative hemorrhage during tibial plateau leveling osteotomy (TPLO) and report subsequent short-term and longterm complications.Study Design: Retrospective case series.Animals: Nine dogs with arterial hemorrhage during TPLO.Methods: Medical records of dogs with hemorrhage controlled through the osteotomy gap of a TPLO were reviewed at 2 institutions over 8 years. Inclusion criteria included diagnosis of single cranial cruciate ligament rupture, intraoperative arterial hemorrhage during the radial osteotomy controlled with bipolar electrocautery or hemostatic clips placed along the cranial tibial artery through the osteotomy, complete medical records, radiographic follow-up for at least 8 weeks postoperatively, and completion of long-term follow-up questionnaire by the owner.Results: Dogs were 4.6 6 1.8 years old and weighed 36.6 6 9.7 kg. In total, 3 6 1 hemostatic clips were placed per stifle. Intraoperative hemostasis was achieved in all cases. One of the first dogs received a blood transfusion during the procedure and had a postoperative packed cell volume of 37%. The only complication consisted of fibular fracture, which was noticed on radiographs of 1 dog 8 weeks after TPLO. Conclusion:Arterial hemorrhage during the radial osteotomy of a TPLO can be controlled by occlusion of the compromised artery through distraction of the osteotomy gap. This technique was not associated with long-term complications.

Effect of stifle flexion on the position of the cranial tibial artery relative to the proximal tibia in dogs

“…[2][3][4] Excessive hemorrhage during TPLO is described as an infrequent but potentially severe intraoperative complication. [5][6][7][8] While the reported incidence is low (<2%), it is most likely underreported. Hemorrhage has been attributed to injury to the popliteal or cranial tibial vessels during caudomedial (popliteus) muscle elevation from the proximal tibia or execution of the osteotomy.…”

“…Hemorrhage has been attributed to injury to the popliteal or cranial tibial vessels during caudomedial (popliteus) muscle elevation from the proximal tibia or execution of the osteotomy. [5][6][7][8][9][10][11][12][13] Elevation of the proximal tibial musculature and packing with gauze sponges were recommended in the original description of the technique by Slocum and Slocum 13 in 1993 to prevent injury to the popliteal artery (now recognized as the cranial tibial artery). In a cadaveric study by Moles and Glyde, 9 the cranial tibial artery and its five-way vascular tree and cranial tibial vein were identified as the most likely source of hemorrhage during tibial osteotomy procedures as they course along the caudolateral aspect of the proximal tibia.…”

“…12 In a retrospective clinical study, severe intraoperative hemorrhage during TPLO was not encountered in any dog regardless of whether soft tissue elevation was performed. 10 In a clinical study, Matres-Lorenzo et al 8 described performance of the TPLO with the stifle and tarsocrural joints flexed to 90 to allow relaxation of the popliteal artery. In a cadaveric study, Pozzi et al 11 recommended performing the osteotomy with the pelvic limb held vertically and the stifle in flexion to allow the gastrocnemius muscle to relax and the cranial tibial artery to move caudally.…”

“…Tibial plateau levelling osteotomy (TPLO) is one of the most commonly performed surgical procedures to treat CCLD by neutralizing cranial tibial thrust and providing dynamic stability to the stifle joint at a standing angle 2‐4 . Excessive hemorrhage during TPLO is described as an infrequent but potentially severe intraoperative complication 5‐8 . While the reported incidence is low (<2%), it is most likely underreported.…”

Autotransfusion using a novel ultrafiltration device (Hemosep, Advancis Surgical) for the management of acute intraoperative haemorrhage in a dog

“…Intraoperative haemorrhage is rare during TPLO surgery, between 1 and 2 per cent of all reported complications 4. The need for allogenic transfusion has been reported in one case, although it was considered that the anaesthetist overestimated blood loss 5…”