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Cruciate Ligament Repair

Overview of techniques

Picture 1: Canine Stifle Joint

The Canine Stifle Joint:

 

 

The canine stifle (or knee) joint is a type of hinge joint formed at the junction between the femur (thigh bone) and the tibia (shin bone), with the patella (knee cap) at the front of the joint. The section of the tibia that articulates with the femur is called the tibial plateau (see picture1).

 

 

Picture 2: Cruciate Ligaments

 

 

This joint is supported by a number of soft tissue structures that stabilise the joint. These soft tissues include a pair of crossed ligaments within the joint itself that connect the Tibia and Femur (see picture 2). These cruciate ligaments function to stabilise the joint against forces generated by normal movement. It also acts to prevent rotational forces at the knee, and from over extension.

 

 

 

How does Cranial Cruciate Ligament rupture occur?

Cranial cruciate ligament rupture can occur in any breed of dog, with some breeds more likely to suffer than others :

  •  Labrador
  •  Rottweiler
  •  Boxer
  •  West Highland White Terrier
  •  Newfoundland

The majority of cases are caused by degeneration of the ligament over time, until it is no longer able to support the joint. Fewer cases are caused by traumatic injury to the knee such as over extension, or twisting. There may also be associated soft tissue injuries, including the meniscus, at the same time. This is a painful condition usually characterised by limping on the affected leg, often made worse by exercise or after a period of rest. Over time the continued abnormal movements in the joint lead to wearing of the cartilage, termed degenerative joint disease. It is important to recognise that in the majority of patients this disorder can occur in both legs over time.
No treatment option provides absolute cure, but the progression and extent of degenerative joint disease can be modified to provide the best outcome possible, with near normal joint function and pain free range of motion.

How is this condition diagnosed?

Diagnosis can usually be performed in the conscious patient by a thorough orthopaedic examination. In particular palpation of both stifles along with a tibial compression test and cranial drawer test are used to test the integrity of the cruciate ligament. In cases of complete rupture, these tests are often diagnostic. In situations where only partial rupture has occurred, complete diagnosis may not be made without imaging the joint. Orthogonal radiography of both stifle joints to obtain latero-medial (side on) and cranio-caudal (head on) images, to confirm the diagnosis are performed. This is also used to screen for any other concerns present at the joint. Alternatively arthroscopy/arthrotomy of the joint can be performed.

How is Cranial Cruciate Ligament Rupture Treated?
The method chosen to treat cranial cruciate ligament disease will depend on a number of factors, including the patient and methods available. They can be broadly divided into three categories:

  • Conservative management: This includes a strict rest and rehabilitation program along side anti-inflammatory drugs and weight control. No attempts are made to address the cruciate deficient stifle, and degenerative joint disease occurs fastest. Peri-articular fibrosis occurs to provide some stability to the joint, but arthritis develops quickly. Meniscal tears are also not addressed and can be a source of continued pain and lameness.
  • Stabilisation techniques: These surgical techniques aim to provide support to the joint. A number of techniques are described with differing degrees of outcome are recognised. Often a surgical implant is placed to hold the tibia and femur tightly together, sometimes internal grafts can be used as an alternative to surgical material implantation.
  • Neutralisation techniques: These procedures alter the angle of the joint to counteract the forces of normal movement. As the forces that the cruciate ligaments counteract are ‘neutralised’ this overcomes the cruciate rupture by making the ligament redundant. There are a number of neutralisation techniques described, aiming at levelling the tibial plateau or advancing the tibial crest .

During surgical treatment, the joint is entered to visualise and remove the ruptured cruciate ligament, before assessing the meniscus and treating where required.

All treatment options will require rest, exercise modification, rehabilitation, weight management, and anti-inflammatory drugs; the type and duration of each will vary.

Treatment options available at Framlingham Vets:
Here at Framlingham Vets we are able to offer treatment for cranial cruciate ligament disease. We will assess and discuss the treatment options for each individual and provide information of the methods deemed suitable.
We are especially pleased to offer Tibial Tuberosity Advancement by the ‘TTA Rapid’ surgery, having received specialist training in this advanced technique.

Tibial Tuberosity Advancement (TTA) is a type of neutralisation technique, counteracting the forces in the stifle joint by altering the angle of insertion of the patella ligament. Pre-operative radiographs are used to calculate the required advancement using a described technique. The operation is performed by making an osteotomy (cut) in the Tibia leaving the bottom section intact. This segment is then advanced and fixed in position. The TTA Rapid technique uses minimal implanted material, requiring only a 3D printed titanium cage held in place with screws. A specially designed nanopaste to promote bone healing can then be inserted into the gap, or a bone graft can be placed as an alternative.

Patients show good levels of function and comfort almost immediately, bearing weight within the first 24hours. We provide an in depth guidance sheet at discharge to aid in the recovery process, and follow up appointments at 5, 14, 28 and 56 days with radiography to assess the healing between 8 and 12 weeks post operatively.

Questions:

If you have any questions regarding cruciate ligament disease, and the procedures available please feel free to contact us.

Picture references avaliable