Management of ruptured cruciate ligament in dogs

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it deals with the management of the ruptured cruciate ligaments in canines , i have gathered the information right from the predisposing factors , mechanism of injury , various diagnostic tests , and at last the treatment with old as well as latest techniques , all the pics that i have collected are from net , and few from books by pete muir and nunamaker ,

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  • The cruciate ligaments of the stifle joint are the cranial cruciate ligament (CrCL) and the caudal cruciate ligament (CaCL). These ligaments are two strong, rounded bands . The CrCL is lateral and the CaCL is medial. They cross each other like the limbs of an X. The CrCL and CaCL remain distinct throughout and each has its own partial synovial sheath. Relative to the femur, the CrCL keeps the tibia from slipping forward and the CaCL keeps the tibia from slipping backward.
  • . 1 This is probably due to the fact that, with the exception of caudal displacement of the tibia, the caudal cruciate ligament is protected from extremes of motion by other joint structures.2 sometimes only on arthrotomy it is diagnosed that there is a ruptured caudal ligament , 3Experimentally, transection of the CaCL does not cause an obvious lameness and only leads to mild internal rotation of the tibia relative to the femur4Rupture of the CaCL often involves avulsion fracture of an attachment site and affected dogs usually have a history of trauma and may haveother complicating injuries
  • . In this position the cruciate ligaments begin to twist on each other and on themselves to limit the normal internal rotation of the tibia on the femur. With excessive internal rotation of the tibia, the cranial cruciate ligament becomes wound very tightly and is subject to trauma from the lateral femoral condyle as it rotates against it. This may cause the cranial cruciate ligament to rupture in its midportion or, in the case of younger animals, to avulse a portion of its bony attachment .Another mechanism of injury to the cranial cruciate ligament is hyperextension. The cranial cruciate ligament is the primary check against hyperextension of the stifle. Therefore, as the stifle is hyperextended, the cranial cruciate ligament is the first structure to be subject to injury
  • While acute cruciate ligament rupture due to trauma does occur, it is thought that the majority of cruciate lesions are a result of chronic degenerative changes within the ligaments themselves. Patellar luxation is a common problem that contributes to excessive stress on the cranial cruciate ligament owing to the fact that the stifle lacks the proper support of the quadriceps muscles and patellar ligament. In obese animals these stresses are increased and the possibility of degenerative joint changes is greater. As joint changes develop, the cruciate ligaments undergo alteration in their microstructure. Collagen fibrin become hyalinized, and the tensile strength of the ligament is reduced, making the ligament more susceptible to damage from minimal trauma. These changes also have been associated with the aging process and may explain the fact that the majority of cruciate injuries are seen in dogs over 4 years of age
  • In this maneuver the examiner grasps the metatarsus with one hand and places the palm of the hand over the cranial aspect of the distal femur and patella, extending the forefinger down over the tibial tuberosity. By flexing the hock, the reciprocal tightening effect of the gastrocnemius muscle acts to compress the tibia and the femur. If the cranial cruciate ligament is not intact, the tibial tuberosity will be felt to slide cranially. Tibial compression stress radiography is a valuableasset in the diagnosis of canine stifl e instabilitybecause of CrCL rupture. It is a useful techniqueto prove (or disprove) a tentative diagnosis ofCrCL damage, especially when there is a lack ofcranial drawer sign on clinical examination. Nofalse positive results were obtained. Tibial compressionstress radiography is able to detectcomplete or partial tears of the CrCL. It is aneasy and reliable technique that does not requireexpensive equipment or a high level of technicalproficiency.
  • Arthroscopic - assisted surgical techniques reduce postoperative pain and shorten the length of hospital stay and the time required for return to functionArthroscopic management of CrCL rupture reduces short - term postoperative morbidity compared to traditional arthrotomy technique A magnified view of anatomic structures of the stifle allows more accurate diagnosis and precise treatment of pathological conditionsArthroscopy of the stifle is commonly used to evaluate and treat CrCL tears, meniscal tears, osteochondrosis, osteochondral fragments, intraarticular foreign bodies, and septic arthritis.
  • A radiograph shows the spatial relationship between the bones at the joint level.On a neutral view of a normal canine stifle in 90 ° of flexion, the perpendicular on the femoral axis that runs just cranial to the fabellae, will be almost tangential to the caudal projection of the lateral tibial condyleThis particular sign is called “ Cazieux - positive, ” and always indicates a ruptured CrCL
  • It is the golden standard for diagnosing the cruciate ligament rupture,Traditional arthrotomy can be performed by a medial or lateral Para patellar approach depending on the surgeon ’ s preferenceSome surgeons prefer a medial parapatellar approach because they claim to have an improved view and better access to the medial meniscusA lateral arthrotomy may be best if a lateral extracapsular prosthetic CrCL is to be placed due to the need to have exposure to the caudolateral aspect of the joint
  • MRI recognition of joint lesions is based on alterations of signal intensity (SI) and morphologic changes.The combination of the joint capsule and synovial membrane is seen as a low SI structure on MR images.
  • Basically, the surgical procedures for cruciate ligament repair can be divided into the intraarticular and the extra-articular techniques. The intra-articular techniques use either an autogenous or a synthetic graft to actually replace the cruciate ligament) while the extra-articular techniques stabilize the joint by altering (tightening) extra-articular structures.(Before the individual techniques for cruciate ligament repair are discussed, it should be noted that in all cases of cruciate ligament repair, the joint should be opened by lateral or medial arthrotomy and inspected thoroughly for additional pathology. The remnants of the ruptured ligament should be removed and the joint irrigated thoroughly with lactated Ringer's or saline solution. If the joint has been unstable for a while, marginal osteophytes will be present along the margin of the femoral trochlea.(28) These osteophytes may be removed by sharp dissection with a scalpel blade if they appear too proliferative,It should be noted that in all cases of cruciate ligament repair, the joint should be opened by lateral or medial arthrotomy and inspected thoroughly for additional pathology. The remnants of the ruptured ligament should be removed and the joint irrigated thoroughly with lactated Ringer's or saline solution. If the joint has been unstable for a while, marginal osteophytes will be present along the margin of the femoral trochlea. These osteophytes may be removed by sharp dissection with a scalpel blade if they appear too proliferative
  • Management of ruptured cruciate ligament in dogs

    1. 1. DIVISION OF VETERINARY SURGERY AND RADIOLOGY MANAGEMENT OF RUPTURED CRUCIATE LIGAMENT IN DOGS ©snakewrangler47 KAMIL MALIK
    2. 2. • 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. ©snakewrangler47
    3. 3. ©snakewrangler47 • 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.
    4. 4. ©snakewrangler47 • 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.
    5. 5. ©snakewrangler47 • It consist of two joints • FEMORO-PATELLAR ARTICULATION • FEMORO-TIBIAL ARTICULATION
    6. 6. 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 ©snakewrangler47 7: Tibial Tuberosity
    7. 7. 1: CrCL 2: CaCL 3: 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
    8. 8. ©snakewrangler47
    9. 9. • 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 ). ©snakewrangler47
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    11. 11. • 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 ©snakewrangler47
    12. 12. prevent cranial displacement prevent hyperextension limits excessive internal rotation of the tibia on the femur. ©snakewrangler47 CrC L CaC L Limit excessive internal rotation of the tibia on the femur by twisting on the CaCL prevent caudal displacement
    13. 13. Excessive forces during extremes motion will result in damage to the ligaments. Sudden rotation of the stifle with the joint in 20° to 50° of flexion Hyperextension. Cranio-caudal trauma to tibia ©snakewrangler47 Stifle dislocation
    14. 14. Breed Anatomy Trauma PREDISPOSI NG FACTORS Conformation Obese Hyperactive dogs Degenerative cruciate lesion ©snakewrangler47
    15. 15. ©snakewrangler47 instabilit y of the stifle joint pain and lamene ss progressiv e degenrativ e changes periarticular osteophyte formation, capsular thickening, and meniscal degeneratio n
    16. 16. Drawer sign test Tibial compression test Magnetic resonance imaging Arthroscopy Ultrasonography Stress radiography Arthrotomy ©snakewrangler47
    17. 17. ©snakewrangler47
    18. 18. ©snakewrangler47
    19. 19. ©snakewrangler47
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    24. 24. • CONSERVATIVE • EXTRA-ARTICULAR TECHNIQUES • INTRA-ARTICULAR TECHNIQUES ©snakewrangler47
    25. 25. ©snakewrangler47
    26. 26. ©snakewrangler47
    27. 27. • 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) ©snakewrangler47
    28. 28. ©snakewrangler47
    29. 29. ©snakewrangler47
    30. 30. ©snakewrangler47
    31. 31.  FASCIA LATA (PAATSAMA)  PATELLAR TENDON TECHNIQUE (DUELAND)  THE OVER-THE-TOP TECHNIQUE (ARNOCZKY)  SYNTHETIC CRUCIATE LIGAMENTS ©snakewrangler47
    32. 32. ©snakewrangler47
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    34. 34. ©snakewrangler47
    35. 35. • 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 ©snakewrangler47
    36. 36. • Tibial Plateau Leveling Osteotomy(tplo) • Tibial Tuberosity Advancement (tta) ©snakewrangler47
    37. 37. • 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. ©snakewrangler47
    38. 38. ©snakewrangler47
    39. 39. ©snakewrangler47
    40. 40. • 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 ©snakewrangler47
    41. 41. • 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. ©snakewrangler47
    42. 42. • 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) ©snakewrangler47
    43. 43. ©snakewrangler47
    44. 44. ©snakewrangler47
    45. 45. ©snakewrangler47
    46. 46. Thank you

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