Management of Bilateral Patellar Luxation in an Alpaca

Gustavo A. Abuja, LV, Michael P. Kowaleski, DVM, Diplomate ACVS & ECVS,
and Jos M. GarcaLpez, VMD, Diplomate ACVS
Department of Clinical Sciences, Tufts University, Cummings School of Veterinary Medicine, North Grafton, Massachusetts

Corresponding Author
Dr. Jose M. GarciaLopez, VMD, Diplomate
ACVS, Department of Clinical Sciences,
Tufts University, Cummings School of
Veterinary Medicine, 200 Westboro Road,
North Grafton, MA 01536.
Email: jose.garcia-lopez@tufts.edu
Submitted May 2011
Accepted November 2011
DOI:10.1111/j.1532-950X.2014.12118.x
Objective: To report surgical management bilateral lateral patellar luxation in a mature
alpaca using a combination of trochlear wedge recession (TWR), tibial tuberosity
transposition (TTT), and joint capsule imbrication.
Study Design: Clinical case report.
Animals: 9yearold castrated male Alpaca.
Methods: Bilateral, grade III/IV, lateral patellar luxation was identied by palpation,
lameness examination and conrmed with radiography and ultrasonography. Surgical
procedures were staged, with the left stie treated rst. Bilateral TWR, TTT, and joint
capsule imbrication were performed. Outcome was assessed by radiography and follow
up lameness examinations.
Results: An immediate improvement in weight bearing occurred after surgery of the
left hind limb. Five months after initial surgery, right hind limb patella luxation was
corrected. After surgery on the 2nd limb, the alpaca had progressive improvement in
weight bearing during hospitalization. At 12 months, there were no signs of lameness
and the alpaca had resumed normal activities.
Conclusions: For bilateral lateral patellar luxation, a combination of TWR, TTT, and
joint capsule imbrication resulted in excellent longterm outcome.

Both medial and lateral patellar luxations have been reported in
South American camelids. Congenital luxations have been
reported in crias.1,2 and acquired luxations usually follow a
traumatic incident that ruptures the medial or lateral retinacula
during packing accidents or ghts with herd mates.1,2 Similar
to the dog, camelids have a single patellar ligament and the
stie joint has 1 compartment with broad medial and lateral
patellar retinacula that help to keep the patella within the
trochlear groove.1
In South American camelids, lateral luxation appears to be
more common than medial luxation.13 Treatment depends on
the underlying cause and whether there are concomitant
abnormalities. Reported repair techniques in South American
camelids include abrasion trochleoplasty,4 retinacular imbri-
cation and release,1,4 tibial tuberosity transposition (TTT)1,3
and trochlear block recession.5
In adult dogs, trochlear wedge recession (TWR) and
trochlear block recession are the most commonly used
techniques for Trochleoplasty.6,7 Other corrective techni-
ques used for patellar luxation are TTT, capsular/retinacular
release, capsular/retinacular imbrication, antirotational
suture placement, and correction of angular limb deformities
if present.6,7
Our purpose is describe successful repair of bilateral
patellar luxation in an adult alpaca using TWR, TTT, and joint
capsule imbrication.
CLINICAL REPORT
History
A 9yearold, 75 kg alpaca castrated male was examined because
of a history of severe, progressive, life long, left pelvic limb
lameness that had worsened 2 weeks before admission. There was
no known history of trauma. Before admission, treatment with
unixin meglumine (1.1 mg/kg twice daily) had been attempted.
Radiographs of the left stie performed by the referring
veterinarian were consistent with lateral patellar luxation. Because
of the continued lameness despite management with nonsteroidal
antiinammatory medications and the persistent abducted
position of the limb while in sternal recumbency, the alpaca
had been referred for further evaluation and treatment.
Clinical Findings
On admission, severe left pelvic limb and moderate right pelvic
limb lameness were evident at a walk. There was marked
lordosis of the thoracic and lumbar spine and severe left pelvic
limb and crural muscle atrophy. Grade III/IV bilateral lateral
patellar luxation and moderate femoropatellar joint effusion
were identied by palpation and visual assessment. Pain was
elicited when the stie joint was extended. No crepitus was
appreciated during palpation or manipulation of the joint.

Veterinary Surgery 43 (2014) 459464 Copyright 2014 by The American College of Veterinary Surgeons 459
Bilateral Patellar Luxation in an Alpaca Abuja, Kowaleski, and GarcaLpez

The alpaca was sedated with diazepam (0.5 mg/kg
intravenously [IV]) and butorphanol (0.05 mg/kg intramuscu-
larly [IM]) to obtain recumbent lateral, craniocaudal, and
exed dorsoproximaldorsodistal stie radiographs (Fig 1).
Radiographs conrmed the presence of lateral displacement of
both patellas and a more proximal location (patella alta). A
welldened (10 mm
10 mm) fragment was identied cranial
and proximal to the trochlear groove. Mild to moderate
periarticular new bone formation was present in the apex, base
of the patella, and the lateral tibial plateau. Radiographic
evaluation of the right stie revealed mineralized fragments
and moderate periarticular new bone formation. Both sties
also revealed collapse of the lateral femorotibial and widening
of the medial femorotibial joint spaces.
On ultrasonographic examination, a 2nd fragment (4 mm

3 mm) lateral to the lateral trochlear ridge was identied in
the left stie. The left trochlear groove had an angle of 163 and
the right was 149. The articular cartilage over the femoral
trochlear ridges had normal thickness, except for a small defect
at the level of the lateral aspect of the lateral ridge. The patellar
and medial collateral ligaments appeared within normal limits.
On the lateral aspect of the joint the fused peroneus tertius and
long digital extensor tendon (that provide lateral support to the
joint) appeared within normal limits. Both menisci had
heterogeneous echogenicity and a moderate amount of well
dened periarticular new bone formation was present at the
level of both tibial condyles. Examination of the right stie
conrmed patellar luxation and mineralized fragments, with no
other abnormal ndings.
Based on the clinical ndings and longstanding history, a
recommendation was made to manage patella luxation
by performing a TWR, TTT, and joint capsule imbrication
bilaterally.
Surgical Procedure
Before surgery, no abnormalities were identied on a complete
blood count and serum biochemical prole. Food was withheld
for 12 hours and water for 6 hours. Ceftiofur (4.4 mg/kg IV)
and unixin meglumine (1.1 mg/kg IV) were administered
preoperatively.
Anesthesia was induced with a combination of ketamine
hydrochloride (2.2 mg/kg IV) and diazepam (0.5 mg/kg IV)
and maintained with isourane and oxygen in a semiclosed
system. The alpaca was positioned and maintained in
dorsal recumbency with a conformable positioning device
(VacuPositioner1, Shoreline RTM) and the left stie was
clipped, prepared, and draped for aseptic surgery. Using a
craniolateral approach, an 18cm curvilinear skin incision was
made extending from 8cm proximal to the patella to 6cm
distal to the tibial tuberosity. The incision was extended with
sharp dissection to perform a fasciotomy of the biceps femoris

Figure 1 Preoperative lateromedial (A), caudocranial (B), and exed dorsoproximaldorsodistal (C) radiographic views of the left stie and
corresponding views of the right stie (DF). There are osteochondral fragments in the femoropatellar joint and mild to moderate periarticular new bone
formation in the apex, base of the patella and the lateral tibial plateau with collapse of the lateral femorotibial joint space and widening of the medial joint
space. The patella is luxated laterally and located in a more proximal position (patella alta).

460 Veterinary Surgery 43 (2014) 459464 Copyright 2014 by The American College of Veterinary Surgeons
Abuja, Kowaleski, and GarcaLpez Bilateral Patellar Luxation in an Alpaca

and to incise the femoropatellar joint capsule. The entire joint Immediately after surgery the alpaca was bearing full weight on
was inspected and the lateral trochlear ridge was found to be the operated limb. Four months later the right pelvic limb was
less prominent than the medial. Moderate dystrophic minerali- operated in the same fashion.
zation of the joint capsule was noted. The rest of the articular
structures were considered within normal limits.
Using a hand saw (Precision Razor Saw x235, XActoTM, Postoperative Care
Precision Razor Saw x235, XActoTM, Elmers Products, Inc., The alpaca was administered ceftiofur (4.4 mg/kg IV) twice
Columbus, OH), a TWR was performed by creating 2 daily for 7 days and unixin meglumine (1.1 mg/kg IV) twice
convergent cuts from abaxial to axial therefore creating a V daily for 6 days. Butorphanol tartrate (0.05 mg/kg IV) was
shaped wedge of bone and articular cartilage. The wedge was administered every 6 hours for 3 days to provide additional
then placed in sterile saline (0.9% NaCl) solution. The resulting multimodal analgesia.
defect in the femoral trochlea was widened by creating a 3 Followup orthogonal radiographs were performed the
4 mm thick V shaped osteochondral wedge, by performing day after surgery and 1 week later (Fig 2), which conrmed
two 3 to 4mm thick additional cuts on either side. This 2nd that the patella was centered in the trochlear groove, and that
piece of bone was discarded and then the original articular the implants were well positioned. The alpaca was weight
wedge was replaced in a recessed position. The wedge was bearing and ambulating well throughout the postoperative
secured in place with two 0.062in. Kwires placed perpendic- period.
ular to the long axis of the femur, across the femoral trochlear The owners were instructed at discharge to keep the alpaca
ridges, and including the wedge. conned in a stall for 1 month until recheck examination. The
An arthrotomy on either side of the patellar ligament to bandages were kept in place until staple removal and changed
the level of the tibial tuberosity was performed; thereafter a every other day. The skin staples were removed 2 weeks after
combination of sharp and blunt dissection was used to elevate surgery.
the origin of the cranial tibial muscle off the curvature of the
tibial tuberosity, allowing for access to the tuberosity. An
oscillating saw (Synthes, West Chester, PA) was used to
perform an osteotomy of the tibial tuberosity with the intact
attachment of the patellar ligament that was then transposed
further distally and medially and nally secured in place with
two 5/6400 Kwires and a 16 g stainless steel tension band
wire. During the relocation of the tibial tuberosity the limb
was kept in extension to relax the extensor mechanism. The
relocation of the patella in a more distal position was aimed at
treating the patella alta. A 10 hole 3.5mm locking
compression plate (LCP; Synthes) was contoured to the
cranial border of the tibia, and was secured in place with
seven 3.5mm locking screws (3 placed in the tibial
tuberosity) and three 3.5mm cortical screws. The stie
was then exed and extended to assess the stability of the
patella within the trochlear groove of the femur and proper
realignment of the quadriceps mechanism.
The parapatellar tissues were released laterally and
imbricated medially by continuing the incision in the cranio-
lateral aspect of the stie through the fascia lata, the fascia of
the vastus lateralis muscle and the lateral patellar retinaculum.
The medial joint capsule was imbricated by suturing the fascia
of the sartorius, vastus medialis, and the medial femoropatellar
joint capsule retinaculum with 1 polydioxanone in a vest over
pants pattern; these sutures were oversewn with 1 polydiox-
anone in a simple continuous pattern. After lateral release and
medial imbrication the stie was exed and extended
repeatedly to conrm stability of the patella. The subcutaneous
tissues were closed with 20 poliglecaprone in a simple
continuous pattern and the skin with stainless steel staples. A
sterile pressure bandage using a nonadhesive dressing, sterile
gauze, elastic nonadhesive tape and elastic adhesive tape was Figure 2 Left lateromedial (A), left caudocranial (B), right lateromedial
placed. (C), and right caudocranial (D) radiographic views after surgical
The alpaca recovered uneventfully from anesthesia and treatment. Note the presence of the LCP and 2 Kwires in the proximal
was able to stand without assistance shortly after surgery. tibia. The trochlear wedge is stabilized with 2 Kwires.

Veterinary Surgery 43 (2014) 459464 Copyright 2014 by The American College of Veterinary Surgeons 461
Bilateral Patellar Luxation in an Alpaca
Outcome
One month after left pelvic limb surgery, the alpaca was
readmitted for reevaluation. On physical examination, no
lameness was noted on the left pelvic limb, and moderate right
hind limb lameness was evident at a walk. Radiographs of the
left stie, including lateromedial, craniocaudal, and oblique
views, conrmed normal patellar position, with no evidence of
patellar luxation. The owner was instructed to start hand
walking exercise once daily for 5 minutes and increasing the
walking exercise by 5 minutes every week until a maximum of
30 minutes of hand walk daily. Two months after surgery the
alpaca was allowed turnout in small paddock.
Four months postoperatively the alpaca was readmitted
again for surgery of the right pelvic limb. The same
perioperative antibiotics, antiinammatory drugs and anes-
thetic protocols were used, as well as the rehabilitation
protocol. One month after the 2nd surgery, radiographs
conrmed the correct location of both patellas (Fig 3).
On followup conversation at 24 months after the 2nd
surgery, the owner reported that the alpaca had remained sound
and has resumed a normal routine of life.
DISCUSSION
Patellar luxation is a frequently recognized developmental or
acquired condition in dogs.79 It has also been recognized,
Figure 3 Right lateromedial (A), right caudocranial (B), left lateromedial
(C), and left caudocranial (D) radiographic views 3 (right) and 4 (left)
months postoperatively.
462 Veterinary Surgery 43 (2014) 459464 Copyright 2014 by The American College of Veterinary Surgeons
Abuja, Kowaleski, and GarcaLpez
although not as frequently, in South American camelids.1,2 In
camelids, stability of the patella in the trochlear groove is
maintained by the patellar ligament, the medial and lateral
retinacular tissue, tendinous insertions on the patella, and the
shape of the trochlear groove. Any disruption or malformation
of these structures can lead to patellar luxation.1
Patellar luxations are graded from I to IV, with grade I
being least severe. In dogs, surgical treatment of many grade
II/IV luxations, and most grade III or IV/IV patellar luxations is
recommended because continued luxation can result in
considerable stie discomfort, dysfunction and osteoarthrosis.
Castration of llamas younger than a year has been postulated
to be a predisposing factor for patellar luxation, because castration
at an early age may predispose to a more upright conformation
that can result in patellar luxation after a traumatic event.1,2
Barrington et al. cautioned that abnormalities of conformation
have been observed in llamas castrated at a young age.2 Llamas
continue to grow until long bone growth reaches a plateau at
1824 months of age. Male hormones inuence physeal closure
and early castration may alter this inuence. Thus, early castration
may cause a prolonged period of long bone growth and result in a
more upright conformation because of joint hyperextension,
which may predispose the llama to early onset osteoarthritis or
patellar luxation.1,2 Age at castration of the alpaca we report was
unknown; therefore, a potential association between early
castration and upright conformation that could predispose to
patellar luxation could not be made.
Surgical repair of patellar luxation requires the re
alignment of the extensor mechanism and stabilization of the
patella in the trochlear groove of the femur. Extensor re
alignment can be achieved by TTT or rotation of the tibia at the
stie joint. In dogs, TTT resulted in a lower frequency of major
complications and patellar reluxation when compared with
imbrication and capsular/retinacular release.10
Retinacular/capsular release techniques are aimed at
reducing the tension in the soft tissues on the side of the
patellar luxation. In dogs, release techniques, resulted in a
higher frequency of major complications (dened as those
requiring a 2nd surgery) but did not increase the frequency of
reluxation, perhaps because the loss of integrity of the
retinaculum and joint capsule caused by the release procedure
can result in reduced soft tissue support of the quadriceps
mechanism and patella.10 In dogs, the combination of capsular/
retinacular imbrication with TTT resulted in a reduced
frequency of major complications but did not signicantly
affect the risk of patellar relaxation.10
Femoral trochleoplasty deepens the trochlear groove, thus
increasing patellar stability and resulted in lower frequency of
patellar relaxation in one study.10 Trochleoplasty techniques
include abrasion trochleoplasty, trochlear chondroplasty,
trochlear block recession and TWR.79 All these techniques
are aimed at deepening the femoral trochlea in an attempt
to stabilize the femoropatellar joint. The simplest method
for deepening the femoral trochlea is to remove the articular
cartilage. The resulting tissue has been shown to be irregular
when examined with scanning electron microscopy and weaker
than hyaline articular cartilage.7,9 In a canine cadaver model,
trochlear block recession provided increased patellar articular
Abuja, Kowaleski, and GarcaLpez
contact with the recessed proximal trochlea, greater resistance
to patellar luxation in an extended joint position and increased
proximal patellar depth within the trochlea when compared to
TWR.11 Those authors concluded that this technique may
prove to be benecial in preventing future degenerative joint
disease11; however, this has not been proven clinically.
Fracture of the lateral trochlear ridge has been reported as a
complication after surgical stabilization of a medial patellar
luxation using a trochlear block recession (TBR) and TTT12 in a
dog. The authors suggested that this complication may have not
happened had a TWR been performed, as the remaining
trochlear ridges are considerably thicker with this technique. In
our alpaca, we elected to perform a TWR, because in our clinical
experience with dogs, this technique results in a consistent depth
of the trochlear groove and is technically easier.
Many authors have reported good results after surgical
treatment of patellar luxation in dogs.1316 In general, the
prognosis can be considered good for luxations up to and
including grade III, with a successful treatment outcome in >90%
of cases.16 In dogs, the risks of patellar reluxation and of other
major complications that require revision surgery are 8% and
13%, respectively.10 A higher frequency of major complications
associated with higher body weight has also been reported.10,16
Van Hoogmoed and colleagues1 described the treatment of
patellar luxation in 7 llamas by TTT and capsular imbrication.
More recently Furman and colleagues described TBR in
association with medial imbrication for a traumatic patellar
luxation.5 TTT has been reported to fail in adult llamas1; 6 of
7 cases had recurrence of patellar luxation. Two animals
were treated with TTT but luxation recurred in both and the
other 5 llamas had imbrications and release procedures that
resulted in recurrence of luxation in 4. When a TTT technique
was used, the tibial tuberosity was stabilized in the new
position only with two 5/6400 Steinmann pins and 18 g wire in a
gure of 8 pattern. In that report, the failure of the TTT was
related in some cases to implant failure.3
In all previous reports,1,3 the tibial tuberosity was stabilized
with Steinmann pins or cortical screws and in adults with the
addition of a stainless steel tension band wire. To minimize the
risk of implant failure we opted for a combination of Kwires
with a tension band wire, reinforced with an LCP. The Kwires
with the tension band were used initially as a temporary method
of xation until the plate was secured; however, we decided to
leave them in place, although after applying the plate they could
have been removed without compromising the stability. It has
been suggested that although the anatomy of the camelids and
dogs are similar, a more upright conformation and different
biomechanics, associated with a greater body weight may
contribute to a poor success rate in South American camelids.1
Because the screws are locked into the plate, the LCP system
provides angular stability at the platescrew interface. The limited
contact locking plates have been termed internal xators and
have the biological advantage of external xators and employ the
principles of dynamic osteosynthesis with internal placement of
the implant.17 Alternatively, other options of xation, such as the
use of DCP or LCDCP plates, could have been chosen instead of
the LCP. Use of this method of xation was elected in our alpaca
based on recent availability of the implants and the anticipated
Veterinary Surgery 43 (2014) 459464 Copyright 2014 by The American College of Veterinary Surgeons
Bilateral Patellar Luxation in an Alpaca
increased biomechanical needs derived from the anatomic
conformation of South American camelids, and previous reports
of unsuccessful treatment and implant failure.
Migration of the autograft has been reported after TWR in
dogs;13 therefore, we opted for xation of the wedge by means
of implantation of 2 Kwires across the femoral trochlea,
including the osteochondral wedge. Based on the chronicity of
patellar luxation, age of this alpaca, and the bilateral nature of
the condition, we decided to address each abnormality present
in the joint, by performing all 3 procedures, to maximize the
chances of a satisfactory outcome.
It has been proposed that a sling for recovery is crucial to
obtain a successful outcome.1 Sling recovery avoids compli-
cations associated with full limb cast or application of a
SchroederThomas splint. In our case, sling training was
attempted before surgery, but the alpaca remained uncoopera-
tive despite successive efforts. Fortunately, the alpaca was able
to ambulate comfortably on the operated leg immediately after
surgery and a full limb bandage was adequate to keep the
surgical incisions clean. The increased stability achieved with
the use of LCP in addition to the Kwires and wire may have
been instrumental in avoiding the need of a sling recovery. The
fact that the alpaca had lived for a long period with the luxation
may have been advantageous as it had developed compensato-
ry strategies to rise and ambulate.
The degree of collapse of the lateral femorotibial joints
space detected during radiographic examination may be
attributed to the fact that all radiographs were performed
under general anesthesia; therefore, this collapse may be
overestimated by the position of the limbs during radiographs.
The ligamentous structures that contribute to the stabilization
of the joint were examined with ultrasonography and found
within normal limits, an during surgery the joint was stable.
The trochlear groove angle, sulcus angle or trochlear angle
is formed by a line tangential to the lateral slope of the trochlea
and a line tangential to the medial slope, the vertex of this angle
corresponds to the groove of the trochlea. We are unaware of
normal values for camelids. In an ultrasonographic study,
Nietosvaara found that the angle of the cartilaginous sulcus
was between 134 and 155 in normal children, and in
those with patellar dislocations, the cartilaginous sulcus angle
was consistently wider (154195).18 In our alpaca, we
measured the trochlear angle using the technique described
by Nietosvaara et al., and we used it for the purpose of
documenting the difference between both legs and to serve for
future comparison with trochlear angles in normal alpacas.
We concluded that a combination of TWR, TTT, and joint
capsule imbrication, addressing each abnormality present in
the joint, resulted in successful surgical treatment of a bilateral
lateral patellar luxation in an alpaca and allowed for early
return to function, which is especially important when dealing
with bilateral conditions.
DISCLOSURE
The authors report no nancial or other conicts related to this
report.
463
Bilateral Patellar Luxation in an Alpaca
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