Canine CCL injury: Diagnosis and surgical decision making (Proceedings) - Veterinary Healthcare
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Canine CCL injury: Diagnosis and surgical decision making (Proceedings)


CVC IN BALTIMORE PROCEEDINGS


Some dogs present with a mild, chronic lameness. These dogs may have no cranial drawer sign, but exhibit discomfort when tested for drawer or when the stifle is placed in hyperextension. They may have a partial CrCL rupture, with minimal effusion and no osteoarthritis visible on radiographs.

Less commonly, dogs may present acutely non-ambulatory, or with difficulty rising, or with shifting leg lameness. These dogs often have bilateral CrCL rupture, but may present with a variety of previous diagnoses, including spinal cord disease and hip dysplasia. When assisted to walk, they may have a very short-strided gait, mimicking dogs with lower motor neuron dysfunction due to lumbosacral spinal cord disease. A full neurologic exam, paying close attention to proprioception and spinal reflexes is needed to rule out neurologic disease. To make things more challenging, these patients sometimes DO have concurrent hip dysplasia/DJD and lumbosacral disease. Even with concurrent diseases, a good orthopedic exam can evaluate CrCL status with confidence.

Physical Examination

Most cases of CrCL rupture can be diagnosed by a complete physical exam. After obtaining a thorough history from the client, observe the dog at a walk and a trot in a straight line. Non-weightbearing lameness is not a challenging observation to make, but more subtle lameness can become apparent with gait analysis. Dogs with a CrCL injury and a subtle lameness may exhibit a shortened stride and a somewhat extended stifle. The normal limb will appear to land harder on the ground. Pay attention to how the dog sits. A dog with a CrCL injury often will not sit with its legs squarely beneath it, due to the stress placed on the CrCL in this position. Instead, the dog may sit with the leg extended and out to the side. Some clinicians refer to this as "the positive sit test".

Begin the physical exam with the dog standing and an assistant gently restraining the dog. This allows palpation and comparison of both hindlimbs, with the dog in a relatively relaxed position. Begin proximally, palpating the thigh muscles to assess atrophy. Continue distally, sliding the patella and patellar ligament between the thumb and index finger. The medial and lateral edges of the patellar ligament should palpate sharply. Indistinct margins indicate possible joint effusion distending the cranial joint capsule. Continue distally, palpating the medial aspect of the stifle for medial buttress, or periarticular fibrosis, a response to stifle instability. Medial buttress may be felt with or without concurrent cranial drawer.

After palpation, examine the dog in lateral recumbency on an exam table or the floor. Proceed to the good leg first, to allow the dog to relax and get an idea of what baseline responses are for the individual dog. The limb should be examined from the toes to the hip. When the stifle is reached, begin by flexing and extending the joint to assess range of motion, crepitus, or clicking noise. Patients may have diminished range of motion due to fibrosis, pain, or effusion. Crepitus can be consistent with degenerative joint disease (osteoarthritis). A palpable or audible click may indicate a meniscal tear.

Next, test cranial drawer by placing the thumb and index finger of one hand on the lateral fabella and patella, respectively. Place the other thumb and index finger on the fibular head and tibial tuberosity. Hold the patella/fabella firmly, while moving the tibia caudally and cranially. Except for puppies, which may have a small amount of motion, any amount of cranial drawer motion is abnormal. The cranial drawer test should be done with the leg in flexion and extension, to test both parts of the CrCL. If no drawer is palpated, but CrCL injury is still suspected, cranial drawer should be re-evaluated under sedation. Dogs with ACL injury may not exhibit cranial drawer either because they are resisting your palpation with their leg muscles, they have significant periarticular fibrosis which has stabilized the stifle, or they have a partial tear and the remaining intact ligament resists gross displacement. Remember that the craniomedial band is under tension both during flexion and extension. Thus a tear in the caudolateral part may not be appreciated with a drawer test. However, these dogs often are painful when cranial drawer is attempted, or on hyperextension of the stifle. They may also exhibit stifle effusion and buttress. In cases of suspected partial tears, an MRI, or arthroscopy/arthrotomy may be needed to confirm diagnosis of CrCL injury.

Radiographs

Even in cases where a clear diagnosis of CrCL rupture can be made in the exam room, radiographic examination of the joint is indicated. Radiographs are used to rule out concurrent diseases such as neoplasia and OCD. They are used to evaluate the degree of secondary signs of CrCL rupture, primarily: joint effusion with infrafatellar fat pad displacement, caudal joint capsule displacement, and degenerative joint disease (DJD) noted on the patella, trochlear ridges, and tibial plateau. The degree of DJD may be an indicator of prognosis, as dogs with minor degenerative changes probably have a better prognosis for long-term function than do those with advanced osteoarthritis. In cases without positive cranial drawer, these secondary signs give support to a diagnosis of CrCL rupture.

Treatment Options

While very light dogs (<15lbs) may do well with medical management, heavier dogs have a significantly faster and more complete return to function with surgery. The goal of surgery is stabilization of the joint and thus minimization of DJD progression, as well as management of meniscal injury.

A variety of repair methods have been described for treatment of CrCL insufficiency. They can be divided into static repairs, which attempt to replace the function of the CrCL, and dynamic repairs, which alter joint biomechanics to absolve the need for a functioning CrCL. Static repairs include intracapsular grafting techniques, extracapsular lateral suture techniques and fibular head advancement. These techniques stabilize the joint through static neutralization of cranial drawer without alteration of stifle joint anatomy. Dynamic repairs include tibial plateau leveling osteotomy (TPLO) and tibial tuberosity advancement (TTA). These techniques provide dynamic stability to the stifle joint by altering tibial plateau angle and the insertion point of the patellar ligament. Neutralization of cranial tibial thrust by TPLO has been shown to provide stability to the CrCL deficient stifle by generation of caudal tibial thrust and increased stress on the caudal cruciate ligament during mid stance phase of the gait. The TTA neutralizes the contribution of the quadriceps muscle to cranial tibial thrust and also results in generation of caudal tibial thrust at certain points of the stance phase. Good results, often with maintenance of full range of motion and normal activity levels can be achieved with any of the above techniques. In a study comparing force plate analysis of dogs undergoing 3 different techniques for stabilization of CrCL deficient stifles, lateral suture technique and TPLO were found to result in similar clinical results.


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Source: CVC IN BALTIMORE PROCEEDINGS,
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