Cruciate ligament injury
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.
The canine cranial cruciate ligament is attached to the medial surface of the lateral femoral condyle and the craniomedial surface of the tibial plateau. 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, 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.
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. Meniscal tears also arise in conjunction with rupture of the CCL, with up to 80% of dogs with CCL rupture affected.
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. 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.
Pre-existing causes of stifle degeneration include:
- Immune-mediated arthritis
- Osteochondritis dissecans
- Patella luxation
- Pes varus
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.
Treatment may employ medical management through use of palliative anti-inflammatory medication (e.g. carprofen, 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
- - Modified D' Angelis method
- - Biceps femoris muscle transposition (small breeds)
- - Extra-articular prosthetic stabilization
- Intracapsular techniques
- - Fibular head transposition
- - Cranial closing wedge ostectomy
- - Tibial tuberosity advancement
- - Tibial plateau leveling osteotomy - good post-operative outcome in most patients, although meniscal tears, swelling and infection can complicate recovery
- - Triple tibial osteotomy
With intracapsular repair methods, partial medial meniscectomy may help to avoid repeated surgery and progression of osteoarthritis in the affected joint.
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 or oral doxycycline (thought to minimize metalloproteinase production) does not significantly influence contralateral CCL survival.
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