Cruciate ligament injury

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Patella and intra-articular osteophytes evident in a grade 3 CCL rupture in a dog[1]
Intraoperative view of the CCL ligament in a dog[2]

Cranial cruciate ligament (CCL) injury is a common orthopedic injury in dogs and a leading cause of acute lameness and chronic osteoarthritis of the canine knee[3].

This condition can occur in any breed of dog but is commonly reported in the middle-aged Labrador Retriever, Rottweiler, Golden Retriever and Boxer breeds. Rottweilers often present with bilateral CCL disease[4].

The canine cranial cruciate ligament is attached to the medial surface of the lateral femoral condyle and the craniomedial surface of the tibial plateau[5]. It consists of twisted collagenous fascicles and fiber bundles and has two attachment zones and consequently is divided into craniomedial and craniolateral components. The CCL is critical for craniocaudal stability of the stifle joint[6], acting to restrict cranial translation of the tibia on the femur and resist overextension and inward rotation.

The leading cause of cranial cruciate ligament rupture is joint instability and pre-existing degenerative changes, leading to weakened tensile strength. Joint instability usually occurs as a result of congenital joint malformations such as unusually flat tibeal plateau angle and greater femoral anteversion angle[7].

Rupture is usually triggered acutely or chronically by traumatic torsion forces causing ligament tearing or teasing, but should be viewed as an end-point in a progressive disease[8]. Meniscal tears also arise in conjunction with rupture of the CCL, with up to 80% of dogs with CCL rupture affected[9].

Once ruptured, the torn CCL retracts and does not heal, leading to increased internal rotation, and hyperextension. This leads to abnormal movement, consequent cartilage damage and synovitis due to infiltration of the joint with inflammatory agents such as glycoaminoglycans and matrix metalloproteases[10]. Untreated animals will show some degenerative change in the affected joint within a few weeks and can have severe degenerative changes within a few months[11].

Over time, chondrodysplasia and arthritis ensue, leading eventually to osteoarthritis, even following corrective surgical intervention[12].

Pre-existing causes of stifle degeneration include:

Clinically affected dogs present with lameness of the affected Schindler, often acutely sore after exercise. Pain, muscle quivering and reluctance to have the stifle extended are typical signs. Under sedation or general anesthesia, an anterior draw can be elicited, which is usually diagnostic.

Arthroscopic examination or arthrotomy are required for definitive diagnosis[14].

A differential diagnosis would include hip dysplasia and tibial tuberosity avulsion.

Radiographic examination usually reveals varying degrees of joint effusion, periarticular fibrosis, synovitis[15] and joint effusion[16].

Treatment may employ medical management through use of palliative anti-inflammatory medication (e.g. carprofen[17], meloxicam), restricted exercise and weight loss programs, particularly in older patients.

Surgical intervention is usually recommended in order to restore leg function and minimize progress arthritic changes within the joint. A number of procedures have been used, including:

  • Extracapsular techniques
- Capsular fascial imbrication[18]
- Modified D' Angelis method
- Biceps femoris muscle transposition (small breeds)[19]
- Extra-articular prosthetic stabilization[20]
  • Intracapsular techniques
- Fibular head transposition
- Cranial closing wedge ostectomy[21]
- Tibial tuberosity advancement[22]
- Tibial plateau leveling osteotomy - good post-operative outcome in most patients[23], although meniscal tears, swelling and infection can complicate recovery[24]
- Triple tibial osteotomy

With intracapsular repair methods, partial medial meniscectomy may help to avoid repeated surgery and progression of osteoarthritis in the affected joint[25].

The prognosis is good following surgical repair of CCL rupture, but regardless of method employed, postoperative stifle osteoarthritis is likely to ensue due to secondary joint and cartilage damage.

In dogs with a predisposition to bilateral CCL rupture, treatment with arthroscopic lavage, intra-articular hyaluronic acid, platelet-rich plasma[26] or oral doxycycline (thought to minimize metalloproteinase production[27]) does not significantly influence contralateral CCL survival[28].

Very rare reports of post-operative neoplasia have been reported such as osteosarcoma, presumably due to chronic inflammation at the site[29][30].

References

  1. Pet Wiki
  2. Dogs Life
  3. El-Hadi M et al (2012) Expression of interleukin-8 and intercellular cell adhesion molecule-1 in the synovial membrane and cranial cruciate ligament of dogs after rupture of the ligament. Can J Vet Res 76(1):8-15
  4. Guthrie JW et al (2012) Effect of signalment on the presentation of canine patients suffering from cranial cruciate ligament disease. J Small Anim Pract 53(5):273-277
  5. de Bruin T et al (2005) Interleukin-8 mRNA expression in synovial fluid of canine stifle joints with osteoarthritis. Vet Immunol Immunopathol 108:387–397
  6. de Rooster H et al (2006) Morphologic and functional features of the canine cruciate ligaments. Vet Surg 35:769–780
  7. Ragetly CA et al (2012) Kinetic and kinematic analysis of the right hind limb during trotting on a treadmill in Labrador Retrievers presumed predisposed or not predisposed to cranial cruciate ligament disease. Am J Vet Res 73(8):1171-1177
  8. Doom M et al (2008) Immunopathological mechanisms in dogs with rupture of the cranial cruciate ligament. Vet Immunol Immunopathol 125:143–161
  9. Metelman LA et al (1995) An evaluation of 3 different cranial cruciate ligament surgical stabilization procedures as they relate to postoperative meniscal injuries: a retrospective study of 665 stifles. Vet Comp Orthop Traumatol 8(2):118-123
  10. Hamburg JP et al (2009) GATA-3 protects against severe joint inflammation and bone erosion and reduces differentiation of Th17 cells during experimental arthritis. Arthritis Rheum 60:750–759
  11. Conzemius MG et al (2005) Effect of surgical technique on limb function after surgery for rupture of the cranial cruciate ligament in dogs. J Am Vet Med Assoc 226:232–236
  12. Vasseur PB & Berry CR (1992) Progression of stifle osteoarthrosis following reconstruction of the cranial cruciate ligament in 21 dogs. J Am Anim Hosp Assoc 28:129–136
  13. Fitzpatrick N et al (2012) Osteochondral autograft transfer for the treatment of osteochondritis dissecans of the medial femoral condyle in dogs. Vet Comp Orthop Traumatol 25(2):135-143
  14. Plesman R et al (2012) Detection of meniscal tears by arthroscopy and arthrotomy in dogs with cranial cruciate ligament rupture. A retrospective, cohort study. Vet Comp Orthop Traumatol Nov 14
  15. Bleedorn JA et al (2011) Synovitis in dogs with stable stifle joints and incipient cranial cruciate ligament rupture: a cross-sectional study. Vet Surg 40(5):531-543
  16. Harasen G (2003) Canine cranial cruciate ligament rupture in profile. Can Vet J 44:845–846
  17. Gordon-Evans WJ et al (2011) Effect of the use of carprofen in dogs undergoing intense rehabilitation after lateral fabellar suture stabilization. J Am Vet Med Assoc 239(1):75-80
  18. Böddeker J et al (2012) Computer-assisted gait analysis of the dog: comparison of two surgical techniques for the ruptured cranial cruciate ligament. Vet Comp Orthop Traumatol 25(1):11-21
  19. Tamburro R et al (2012) Biceps femoris muscle transposition for treatment of cranial cruciate ligament rupture in small breed dogs. J Vet Sci 13(1):93-98
  20. Tonks CA et al (2011) A review of extra-articular prosthetic stabilization of the cranial cruciate ligament-deficient stifle. Vet Comp Orthop Traumatol 24(3):167-177
  21. Wallace AM et al (2011) Modification of the cranial closing wedge ostectomy technique for the treatment of canine cruciate disease. Description and comparison with standard technique. Vet Comp Orthop Traumatol 24(6):457-462
  22. Skinner OT et al (2012) In vivo femorotibial subluxation during weight-bearing and clinical outcome following tibial tuberosity advancement for cranial cruciate ligament insufficiency in dogs. Vet J Sep 15
  23. Nelson SA et al (2012) Long-Term Functional Outcome of Tibial Plateau Leveling Osteotomy Versus Extracapsular Repair in a Heterogeneous Population of Dogs. Vet Surg Nov 15
  24. Wolf RE et al (2012) Surgical and postoperative complications associated with tibial tuberosity advancement for cranial cruciate ligament rupture in dogs: 458 cases (2007-2009). J Am Vet Med Assoc 240(12):1481-1487
  25. Imholt KM et al (2011) Lameness and osteoarthritis development following Tibial Plateau Leveling Osteotomy (TPLO) and potential prognostic predictors. A long-term retrospective study. Tierarztl Prax Ausg K Kleintiere Heimtiere 39(5):323-335
  26. Xie X et al (2013) Platelet-rich plasma enhances autograft revascularization and reinnervation in a dog model of anterior cruciate ligament reconstruction. J Surg Res Jan 31
  27. Rabillard M et al (2012) Matrix metalloproteinase activity in stifle synovial fluid of cranial cruciate ligament deficient dogs and effect of postoperative doxycycline treatment. Vet J 193(1):271-273
  28. Muir P et al (2011) Contralateral cruciate survival in dogs with unilateral non-contact cranial cruciate ligament rupture. PLoS One 6(10):e25331
  29. Atherton MJ & Arthurs G (2012) Osteosarcoma of the tibia 6 years after tibial plateau leveling osteotomy. J Am Anim Hosp Assoc 48(3):188-193
  30. Dunn AL et al (2012) Osteosarcoma at the site of titanium orthopaedic implants in a dog. Aust Vet J 90(1-2):39-43
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