Cruciate disease

• What breeds are predisposed to cruciate disease?

  Rottweiler

  Labrador retriever

  Bull mastiff

  West Highland White terrier.

  Border terrier.
• What structures support the stifle?

  Internal stability of the stifle results from the cranial and caudal cruciate, the medial and lateral menisci, collateral ligaments, joint capsule and surrounding musculature (particularly the quadriceps, hamstrings and gastrocnemius).
• What is the general history of cruciate disease?

  A chronic lameness with sudden deterioration.

  An acute injury (the dog that runs down the garden after the squirrel or next doors cat).

  A chronic lameness.

  A clicking sound may be heard (the meniscal click as the meniscus folds and unfolds).

  An unexplained lameness in the hindlimb.

  Beware the bilateral case which can appear neurological.
• What is the presentation of an acute cruciate injury?

  Traumatic injury. May be accompanied by other injuries such as collateral ligament rupture as seen in the cat with the dislocated/deranged stifle.
• What is the presentation of an acute on chronic cruciate injury?

  Degenerative changes precede a more acute rupture.
• What is the presentation of chronic cruciate disease?

  Degenerative changes within the cruciate. Particularly seen in large breeds and the most common presentation.
• What are the clinical signs of cruciate disease?

  Lame and variable amounts of pain are demonstrated.

  Hold the limb from the ground when standing.

  The stifle may be swollen.

  The presence of a medial buttress (fibrous thickening on the medial aspect of the stifle), seen in more chronic cases.

  Pain on stifle flexion and pain in the acute phase on attempting cranial draw.

  Lameness is severe at first but slowly improves over the ext few weeks.
• How do you diagnose cranial cruciate disease?

  A combination of history and clinical signs.

  Typical radiographic signs of degenerative changes.

  Two definitive tests which demonstrate instabliry in the joint are the:

  • the cranial draw test
  • The tibial thrust or compression test.
• Cranial drawer and tibial compression tests - overview

  Pain can make the assessment of the stifle instability difficult.

  Tension or nervousness in the dog is also detrimental.

  In the chronic case the periarticular fibrosis may reduce the degree of instability appreciated.

  Cats may dislike being restrained on their side.

  Sedation or GA makes assessment much easier.
• What are the radiographic signs of cruciate disease?

  Although degenerative changes are not diagnostic of cruciate disease they are highly suggestive.

  First radiographic signs are joint effusion with loss of the sub-patella fat pad (red circle).

  
• What are the treatment options for cruciate disease?

  No action - conservative management.

  Surgical management - two categories.

  • Alter the joint mechanics
  • Place an artificial ligament.
• What is the conservative management for cruciate disease?

  About 6 weeks restricted exercise.

  If the lameness is improving then continue conservative management, if not then consider surgery.

  Surgery is not cheap and the owner may not be able to afford it.

  Can use braces to support the unstable stifle.
• What are the candidates for surgical management of cruciate disease?

  Large and arthritic dogs

  Small dogs with steep tibial plateau angles e.g. >30 degrees.

  Those with a strong index of suspicion of meniscal injury
• Treating cruciate disease - the artificial ligament


  This is always a poor second. The natural ligament is highly vascular with neuron's that are important for proprioception.

  It prevents internal rotation as well as well as cranial translation of the tibia/caudal movement of the femur.

  It is adapted to cyclic loading and has precise points of origin and insertions. It is not possible to accurately reflect these points of the femur and tibia.
• The tibial plateau angle levelling and tibial tuberosity advancement

  The techniques attempt to recreate the stability of the joint by altering the dynamics such that the cruciate ligament is no longer required. They include the tibial tuberosity advancement, tibial plateau levelling osteotomy and triple tibial osteotomy.
• What is the post-operative management for cruciate surgery?

  After TPLO surgery three weeks confinement to the garden and house. A lead. should be used in the garden.

  Physiotherapy can start 7-10 days.

  NSAIDs and paracetamol are used immediately post-op with ice-packs and massage.

  Full exercise should not be resumed until 3 to 4 months after the surgery, but this is variable depending in the patients progress.
• What is the prognosis for cranial cruciate injuries?

  The prognosis is generally good to excellent but osteoarthritis is an inevitable consequence of the condition and the owner should be warned. The menisci can also tear after the surgery.