Management of ruptured cruciate ligament in dogs

DIVISION OF VETERINARY SURGERY AND RADIOLOGY

MANAGEMENT OF RUPTURED CRUCIATE LIGAMENT IN DOGS

KAMIL MALIK©snakewrangler47

INTRODUCTION • Over the last 30 years, veterinarians have

become increasingly aware about the typical clinical features of the cruciate rupture arthropathy in dogs with relation to stifle arthritis

• Advances in diagnostic techniques

helped to more thoroughly

determine the extent of cruciate

ligament disruption during

patient evaluation.©snakewrangler4

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INTRODUCTION

• Cruciate ligaments are a major part of the canine knee.

• "Rupture of the anterior cruciate ligament is the most common injury in the stifle joint of the dog.” Stone et al,. (1980)

• Peak incidence : 2 – 10 years• Painful and immobilizing injury. • Must be addressed for the sake of your

dog.• Cruciate ligament rupture, especially

cranial cruciate ligament rupture, has long been a clinical problem observed in veterinary practice.

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HISTORY • First described by CARLIN in 1926,• In1952 , PAATSAMA, in his classic treatise on

ligament injuries of the canine stifle.• Finally brought the clinical manifestations and

surgical treatment of cruciate ligament rupture in the dog into focus.

• In the 30 years following that work, the diagnosis and surgical treatment of ruptured cruciate ligaments in the dog have received more attention in the veterinary orthopedic literature than any other musculoskeletal problem, with the possible exception of hip dysplasia.

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ANATOMY OF STIFLE JOINT • It consist of two joints

•FEMORO-PATELLAR ARTICULATION•FEMORO-TIBIAL ARTICULATION

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Anatomical structures

1a: Caudolateral Bundle Of CrCL

1b: Craniomedial Bundle Of CrCL

2: CaCL

3: Medial Meniscus

4: Lateral Meniscus

5: Long Digital Extensor tendon

6: Medial Humeral Condyle

7: Tibial Tuberosity©snakewrangler47

Cruciate ligaments 1: CrCL

2: CaCL3: medial meniscus

4: intermeniscal ligament

5: medial collateral ligament

6: lateral meniscus

7: meniscofemoral ligament

8: popliteal tendon

9: tendon of the long digital extensor

10: infrapatellar fat pad

11: patellar tendon;

12: patella©snakewrangler47

Anatomical structures

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CRANIAL CRUCIATE LIGAMENT (CrCL)• Origin : medial side of the lateral femoral condyle • Insertion : cranial intercondyloid area of the tibia• The CrCL is narrowest in its mid - region and fans

out proximally and distally• In dogs, the CrCL has a craniomedial and a

caudolateral component containing bundles of longitudinally orientated collagen fibers (Heffron & Campbell 1978 ). The craniomedial component is taut in both flexion and extension, whereas the caudolateral component is only taut in extension (Arnoczky & Marshall 1977 ).

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Anatomical details

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CAUDAL CRUCIATE LIGAMENT (CaCL).

• Origin : a fossa on the ventral aspect of the lateral

side of the medial femoral condyle.

• Insertion : medial aspect of the popliteal notch of

the tibia

• Slightly longer and broader than the cranial

cruciate ligament.

• Lies medial to and crosses the cranial cruciate

ligament

• Rupture of CaCL is rare as compared to the CrCL©snakewrangler4

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FUNCTIONS

CrCL

CaCL

prevent cranial displacement

limits excessive internal rotation of the tibia on the femur.

Limit excessive internal rotation of the tibia on the femur by twisting on the CaCL

prevent caudal displacement

prevent hyperextension

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MECHANISM OF INJURY

Hyperextension.

Sudden rotation of the stifle with the joint in 20° to 50° of flexion

Excessive forces during extremes motion will result in damage to the ligaments.

Stifle dislocation

Cranio-caudal trauma to tibia

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PREDISPOSING

FACTORS

Hyperactive dogs

Obese

Anatomy

Breed

Conformation

Trauma

Degenerative cruciate lesion ©snakewrangler4

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PATHOLOGY OF THE CRUCIATE INSUFFICIENT JOINT

instability of the stifle joint

pain and lameness

progressive degenrative changes

periarticular osteophyte formation, capsular thickening, and meniscal degeneration

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DIAGNOSIS OF CRUCIATE LIGAMENT INJURY

Magnetic resonance imaging

Arthrotomy

UltrasonographyStress radiography

Arthroscopy

Tibial compression test

Drawer sign test

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DRAWER SIGN TEST

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TIBIAL COMPRESSION TEST

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ULTRASONOGRAPHY

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ARTHROSCOPY

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STRESS RADIOGRAPHY

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ARTHROTOMY

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MAGNETIC RESONANCE IMAGING

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TREATMENT• CONSERVATIVE

• EXTRA-ARTICULAR TECHNIQUES

• INTRA-ARTICULAR TECHNIQUES

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CRUCIATE BRACE

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DOG WEARING CRUCIATE BRACE

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EXTRA-ARTICULAR TECHNIQUES• Stabilize joint by altering (tightening) extra-

articular structures by:

CAPSULAR (FASCIAL) IMBRICATION

(PEARSON)

LATERAL RETINACULAR IMBRICATION

(DeANGELIS)

MODIFICATION OF THE LATERAL

RETINACULAR -IMBRICATION TECHNIQUE

(FLO)

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CAPSULAR (FASCIAL) IMBRICATION (PEARSON)©snakewrangler4

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LATERAL RETINACULAR IMBRICATION (DeANGELIS)©snakewrangler4

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MODIFICATION OF THE LATERAL RETINACULAR IMBRICATION TECHNIQUE (FLO)

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INTRA- ARTICULAR TECHNIQUES

FASCIA LATA (PAATSAMA)

PATELLAR TENDON TECHNIQUE (DUELAND)

THE OVER-THE-TOP TECHNIQUE (ARNOCZKY)

SYNTHETIC CRUCIATE LIGAMENTS

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CAUDAL CRUCIATE LIGAMENT REPAIR• Femoral avulsion injuries of the caudal cruciate

ligament can be treated primarily by reattaching the avulsed portion of bone.

• Extra-articular imbrication of capsular tissues has been used to treat cases of caudal cruciate ligament rupture in smaller animals

• Imbrication sutures are placed on the lateral and medial aspects of the joint in a craniocaudal direction from the proximal aspect of the patella to the proximal caudal aspect of the tibia

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TIBIAL PLATEAU LEVELING OSTEOTOMY(TPLO)• First described by Slocum and Slocum (1993)• The dynamic stability imparted to the CrCL -

deficient stifle via TPLO is achieved by performing a radial osteotomy of the proximal tibia and rotating the proximal segment to decrease the tibial plateau angle.

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• TPLO results in increased strain on the CaCL ligament; therefore, patients with a compromised CaCL are not candidates for the procedure

• TPLO IMPLANT SELECTION• Synthes TPLO plate(locking type) were found to be

significantly stiffer than Slocum TPLO plate• Use of locking bone screws causes significantly

less translational movement of the proximal tibial segment toward the bone plate compared with use of conventional bone screws in an identical plate

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COMPLICATIONS• The overall postoperative complication rate of

TPLO has been reported to vary from 18% to 28%.• Higher complication rates have been found in

dogs undergoing simultaneous bilateral TPLO. (Priddy et al. 2003 ).

• Examples of complications include hemorrhage, incision site issues, patellar tendon enlargement, fractures involving the fibula or tibia, subsequent meniscal injury, and implant failures.

• Dogs with preoperative TPA of ≥ 35 ° have a higher incidence of postoperative complications.

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Tibial Tuberosity Advancement• Advancement of the tibial tuberosity was first

described by Maquet• Montavon and Tepic proposed that a similar

situation existed in the dog, and that tibial tuberosity advancement (TTA) would neutralize cranial tibiofemoral shear force in a cranial cruciate ligament (CrCL) - deficient stifle joint in the dog.

• TTA did not change the geometry of the joint, and the pressure distributions essentially remained unchanged, there may be less development of osteoarthritis over time. (Kim et al. 2009)

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Management of ruptured cruciate ligament in dogs

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