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Cranial Cruciate Ligament Rupture

What you need to know:

Before you get started you must understand:

"How you help your dog recover from surgery is as important as the surgery itself."

Dr. James St.Clair

Normal Anatomy:

The normal canine stifle “knee” has all the same parts that your knee has:

• Femur
• Tibia
• Joint Capsule
• Joint Fluid
• Medial and Lateral Meniscus
• Cranial and Caudal Cruciate Ligaments
• Medial and Lateral Colateral Ligaments
• Transverse Ligament
• All surrouning Muscles and Tendons

From this list alone you can tell that it is a very complicated structure. Yet there is one HUGE difference between the two knees.  Think about how you stand on your legs as opposed to your dog!  Your force is vertical, straight down, which is not the case for your dog. Dogs knees are always positioned at an angle, a degree of flexion, and therefore every time your dog puts weight on their back legs, there is tension on the cranial cruciate ligament.

Predisposing Factors:

There are a number of potential underlying reasons for this injury.  Here is a list of a few:

• The anatomy of dogs!!! Remember the angle of the dog kneeOverweightExisting Hip Dysplasia (We recommend to have you dogs hip X-rayed at the time of knee surgery)Lack of regular exercise  =  “weekend warrior syndrome” = injuryPreviously partially torn ligamentDegeneration with age
• Accident

Reasons for Injury:

It is important to first determine one of two things:

• Was it a Sudden (Acute) Injury?

  Meaning you observe your dog suddenly holding the leg up and they appear in real pain.  Sometimes you will even hear them yelp and then immediately hold the injured leg up tight against the body.

  OR

• Has your dog had intermittent lameness with that leg over time?

  Many times dogs will injure the ligament gradually over time, referred to as a partial tear.  The majority of these dogs will eventually rupture the ligament.

Remember: This is an injury of hyperextension or internal rotation of the knee. Most of the time its because you dog exploded after something in the backyard. Right?

Such things as:

• Sudden explosion after a squirrel, cat, other dog.
• Sudden fast turn
• Jumping, Jumping, Jumping

Understanding in Simple Terms:

             

Imagine a wagon cart tied with a rope to a tree at the top of a hill.  The only thing stopping the wagon from rolling down the hill is the rope.  Now think about that rope.  If someone were to cut the rope with one quick slice of a knife, the wagon cart would quickly go flying down the hill.  This is the same as a “full tear” of the cranial cruciate ligament. 

Now go back to the image of the rope and think of how many individual fibers make up that rope in its entirety.  If that same person instead of using a really sharp knife used a butter knife of cut the rope, it would take a lot longer to cut through.  Eventually there will come a point in weakening the rope that simply the weight of the wagon cart is enough to snap the rope and off the cart goes down the hill.  This is the same as a “partial tear” of the cranial cruciate ligament. 

In the canine knee the hill represents what is referred to as the tibial plateau.  It is on this surface that the femur and tibia communicate.  Due to the angle of this slope once the cranial cruciate ligament is ruptured the femur slides down the slope, therefore creating instability, inflammation and pain.

 

Signs of Injury:

Complete CCL tear:

• Sudden non-weight bearing on the injured leg
• Many times they will really “hike” the leg up tight against the body
• Crying and yelping

Partial CCL tear:

• Intermittent lameness, comes and goes
• Occasional toe touching
• Definite increase in lameness after exercise
• Muscle loss over time in the injured leg

Diagnosis:

Diagnosis of ligament rupture should be split into two categories:

Non-Sedated Evaluation:

• It is important for your veterinarian to see your dog walking ie. Gate analysis.  Most of the time at this point your dog will either be not using the leg at all or just toe touching, but it is still important to evaluate.
• Another very good evaluation tool is asking your dog to sit.  Dogs that have injury to their cruciate ligament will always sit improperly with their knee off to the side and in slight flexion. 

 

Sedated Evaluation:

             

• The majority of the time it is necessary to sedate your dog for complete evaluation of the CCL ligament. It it is really important for them and the muscles surrounding/supporting the knee to be relax.  This way the joint can be properly evaluated. Remember this is a very complex joint, in which a number of different problems can arise.  There are number of very sensitive manipulations that your veterinarian will perform. 

• Crainal Tibial Trust “Drawer Sign”
• Using four designated points on the femur and tibia your veterinarian will attempt to slide the tibia forward.
• Tibial Tuberocity Advancement
• With the knee in slight flexion your veterinarian will flex the hock and therefore evaluate forward movement of the tibia in the area of the knee.
• X-rays of the knees for arthritic evaluation
• X-rays of the hips for potential underlying dysplasia

Surgery:

There are a number of differnent surgeries options avaliable to stabilize your dogs knee, therefore it is best to discuss with your veterinarian the right surgery for you and your dog.

Here is a list of the 3 most common surgeries:

• Tibial Plateau Leveling Osteotomy (TPLO)
• Extracapsular Lateral Suture Repair
• Tibial Tuberocity Advancement (TTA)

Tibial Plateau Leveling Osteotomy:

During the surgery the surgeon will visibly look inside your dogs “knee” joint in order to evaluate the degree of the cranial cruciate damage, the integrity of the meniscus and the degree of cartilage damage or arthiritis. At this time the remnants of the ruptured ligament are removed and many times the damaged section of meniscus is removed as well.  Once the joint capsule is closed the surgery on the tibia begins.

What makes the TPLO unique is that using a special curved saw, the surgeon will make a complete cut through the top part of the tibial bone.  This cut is then rotated so that the once "sloped" tibial plateau is now esentially flat.  Once the proper placement is accomplised a metal plate and screws are placed on the outside of bone to hold it in place. See image below.

 This image is property of Slocum Enterprises,Inc.

Important

It is important to remember that this is now a broken bone and therefore the healing process should be treated as such. This biggest problem owners have after surgery is restricting their dog properly and saftely to allow the bone to callus and heal properly.

Extracapsular Lateral Suture Repair

(Lateral Fabellar Technique)

To this day, this is still the most common technique performed for surgical repair of the cranial cruciate ligament rupture. 

During the surgery the surgeon will visibly look inside your dogs “knee” joint in order to evaluate the degree of the cranial cruciate damage, the integrity of the meniscus and the degree of cartilage damage or arthiritis. At this time the remnants of the ruptured ligament are removed and many times the damaged section of meniscus is removed as well. Often times the surgeon will also perform what is referred to as a menical release to prevent future tearing of the meniscus.

With the extracapsular repair, using a curved needle, a heavy nylon suture is passed round the lateral fabellar bone. The fabellar bone, also known as a sesamoid bone, is defined as a small nodular bone embedded in a tendon or joint capsule. This serves as an anchor.  A hole is then drilled thru the tibial tuberocity, serving as the second anchor and the nylon suture is passed through.   The two ends are then held together with a clip and the incision is closed.

Over a six to eight week period of time, fibrosis scar tissue forms around the false ligament and the joint which overtime helps to stablize the joint.

Tibial Tuberocity Advancement (TTA)

This is the newest of the three surgical procedures performed. It was developed at the University of Zurich by Dr. Slobodan and is demead to be a less invasive alternative to the TPLO. The mechanics of this surgery works by changing the insertion of the patellar ligament cranially therefore changing the geometry and physics of the joint.  Like the TPLO this surgery alters the dynamics in which forces stabilize the joint without having a cranial cruciate ligament.

 

 

 

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