Page 489 - Cote clinical veterinary advisor dogs and cats 4th

220 Cranial Cruciate Ligament Injury

○ Tibial compression test: cranial movement ○ Deracoxib (dogs) 1-2 mg/kg PO q 24h • Intra-articular injection of mesenchymal stem
of tibial tuberosity as hock is flexed (may use 3-4 mg/kg PO q 24h for first cells and/or platelet-rich plasma may decrease
VetBooks.ir ○ Medium-sized to large dogs: joint effusion ○ Meloxicam 0.1 mg/kg PO q 24h, or • For animals with end-stage osteoarthritis (rare
pain.
7 days only), or
• Lateral and craniocaudal stifle radiographs
○ Tepoxalin 10 mg/kg PO q 24h
with cruciate disease), total stifle replacement
almost always is present; degenerative
changes evident after 3 weeks
many variations exist for all of these techniques:
○ Small dogs, and cats: joint effusion may Surgical stabilization of the stifle (CrCL tear): can be considered.
be minimal; tibia often cranially displaced • Intra-articular patellar tendon, fascial, or Nutrition/Diet
relative to femur (static drawer) hamstring graft: aims to replace missing Weight control helps alleviate lameness due to
○ Growing dogs: an avulsed bone fragment CrCL’s function osteoarthritis (p. 1077).
may be seen near the CrCL insertion. • Extracapsular suture stabilization (femoral
○ Measurements such as tibial plateau slope condyle or fabella to tibia): limits cranial Behavior/Exercise
angle are made for planning when an motion and internal rotation. There are a Most dogs and cats can return to full function
osteotomy technique is chosen for repair. number of variations on this theme. after recovery from surgical treatment of cruciate
○ Caudal cruciate rupture: there may be an • TPLO and cranial closing wedge osteotomy: disease.
avulsed fragment over the caudal tibial neutralizes cranial tibial thrust by changing
plateau; tibia may be caudally displaced tibial plateau angle and transferring stress Possible Complications
relative to femur. from the absent CrCL to the intact caudal Medical management:
○ Multiple ligamentous injuries: stifle often cruciate ligament • Gastrointestinal, hepatic, renal, or other
luxated or abnormally positioned • TTA: neutralizes cranial tibial thrust by systemic reactions from NSAID therapy
making the pull of the patellar tendon • Continued lameness; progression of degenera-
Advanced or Confirmatory Testing perpendicular to the tibial plateau when tive joint disease
Occasionally, additional tests are warranted: the stifle is bearing weight Surgical management:
• Rickettsial and/or fungal titers, as indicated • Pinning or wiring to reattach ligament • Postoperative meniscal tears
by other findings (e.g., polyarthropathy, insertion can be done in young dogs with • Suture breakage, stretch, or slippage
thrombocytopenia) large avulsion fragments. • Infection
• Arthrocentesis to eliminate inflammatory • Proximal tibial epiphysiodesis: in dogs ≤ 5 • Fracture or implant failure
arthritides as causes (p. 1059) months of age, a screw can be placed across the • Progression of degenerative joint disease
• Arthroscopy or arthrotomy, the most cranial aspect of the tibial physis to progressively
common way to confirm diagnosis decrease tibial plateau angle as the dog grows. Recommended Monitoring
• Magnetic resonance imaging (see p. 1132) Treatment of meniscal injury: • Weight loss, exercise levels (rehabilitation),
• Removal of the torn portion of the meniscus and clinical signs as dictated by the patient.
TREATMENT • Medial meniscal release (has an effect • Basic laboratory monitoring of patients on
similar to meniscectomy, sometimes done NSAID therapy.
Treatment Overview prophylactically) • Radiographic monitoring of healing of
• Medical management (including physical Treatment of caudal cruciate injury: osteotomies (usually at 6-8 and 10-12 weeks
rehabilitation and weight control) has about • In almost all cases, conservative therapy after surgery) and of any repair if clinical
a 60% success rate for return to normal suffices for return to full function. signs worsen
activities; surgical management (by most • Suture or fascial imbrication can be used in
techniques) has an 85%-90% success rate. persistently lame dogs. PROGNOSIS & OUTCOME
• Surgical management usually involves inspec- Treatment of multiple ligamentous injury:
tion (and debridement or release if necessary) • Debride torn menisci. • Long-term function for patients that have
of menisci, combined with a stabilization • Extracapsular sutures to replace function of undergone a reconstructive procedure is good.
technique. Stabilization techniques involve caudal cruciate, medial (occasionally lateral) Published assessments of most techniques in
creation of a prosthetic ligament to mimic collateral, and cranial cruciate ligaments the past 25 years describe improvement in
the function of the CrCL or a change (usually • In cats, a transarticular pin can be used to 80%-90% of dogs after surgery, regardless
by osteotomy) in the geometry of the stifle stabilize the stifle for 10-21 days, after which of methodology.
so there is minimal cranial tibial translation the pin is removed, and fibrosis holds things • Prognosis after surgery is not affected by
when the limb is bearing weight. in place. whether meniscectomy has been necessary
• Success rates are similar for prosthetic or by degree of osteoarthritis evident on
ligament and osteotomy (tibial plateau Chronic Treatment preoperative radiographs.
leveling osteotomy [TPLO], tibial tuberosity • Management includes the same treatments as • The majority of dogs with caudal cruciate
advancement [TTA], triple tibial osteotomy in acute cases, but long-term medical man- ligament tears return to full function with
[TTO]) repairs. Return to full weight bearing agement of osteoarthritis may be required. medical therapy.
is usually faster with osteotomy techniques. Success rates are similar for surgical treatment • Prognosis for surgically treated multiple
Cats and small dogs are most commonly of acute and chronic cranial cruciate injuries, ligamentous injury is similarly good; about
treated with prosthetic ligament techniques. with or without meniscal tears. 80% of animals return to previous level of
○ NSAIDs as listed previously performance.
Acute General Treatment ○ Physical rehabilitation • Postoperative rehabilitation is critical for full
Medical management: ○ Disease-modifying osteoarthritis agents recovery.
• Physical rehabilitation may be helpful:
○ Controlled leash walks ■ Polysulfated glycosaminoglycan 5 mg/ PEARLS & CONSIDERATIONS
○ Sit-to-stand exercises kg IM once weekly × 4-6 weeks, or
○ Swimming, water treadmill work ■ Pentosan polysulfate 3 mg/kg SQ once Comments
• Nonsteroidal antiinflammatory drugs weekly, or • Bilateral lameness may be difficult to recog-
(NSAIDs): ■ Oral formulations (glucosamine, nize and is often confused with neurologic
○ Carprofen (dogs) 2 mg/kg PO q 12h, or chondroitin sulfate, avocado soy unsa- disease.
○ Robenacoxib 1-2 mg/kg PO q 24h (up ponifiables): according to formulation/ • Injury of the contralateral cranial cruciate
to 6 days’ use for cats), or labeled instructions ligament occurs in 40%-50% of canine
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