Rupture of a ligament in a dog: symptoms, treatment [veterinarian's recommendations
Rupture of the cranial cruciate ligament is one of the most common orthopedic medical conditions seen in dogs.Cruciate ligament rupture in a dog
The most common symptom noticed by a caregiver is the sudden appearance of lameness in the pelvic limb. In about 30% of cases, there is a partial rupture (tear) of the anterior cruciate ligament, and in the remaining 70% - to its complete rupture.
A torn dog ligament it is unlikely to heal, and the result is constant lameness. Additionally, the condition can develop and lead to complete rupture of a ligament in a dog. When a cruciate ligament is stretched or ruptured, a dog's knee becomes unstable and painful.
The possible causes that could lead to this condition and the options for diagnosis and treatment of the disease are described in this paper. However, to better understand what it is, I will start with a short introduction, in which in a few words I will try to present the most important issues regarding the anatomy of the knee joint and the functions of the anterior cruciate ligament. I invite you to read!
- Construction of the knee joint
- What are they and where are the cruciate ligaments?
- What is a cruciate ligament rupture?
- Sharp (sudden onset)
- Which dogs are at risk of cruciate ligament rupture?
- Risk factors
- Causes and pathogenesis of a ligament rupture in a dog
- Traumatic rupture of the CCL
- CCL degenerative rupture
- A ruptured ligament in a dog, symptoms
- The most common symptoms of a cruciate ligament rupture in a dog
- Diagnosis of a CCL rupture in a dog
- Interview with the pet's guardian
- Subject research
- Physical examination
- Imaging studies
- Laboratory tests
- Differential diagnosis
- Consequences of rupture of the cranial cruciate ligament
- Treatment of a broken ligament in a dog
- Non-surgical treatment
- A broken ligament in a dog is operated on
- Osteostomy techniques
- Post-surgery care for a broken ligament in a dog
- What is normal after surgery for a broken ligament in a dog?
- A broken ligament in a dog, rehabilitation week after week
- First days after the operation (day 2 - 4) - strict rest
- First week (day 4-6) - minimal exercise
- Second week - physiotherapy and hydrotherapy
- Third week
- Fourth week
- Weeks 5-8
- Week eight - x-ray after surgery
- Weeks 8 - 12
- Weeks 12 - 16
- Weeks 16 - 20
- Dog's ligament rupture - prognosis
- Prevention of ligament rupture
Construction of the knee joint
A dog's knee is a joint made of three elements:
- the distal end of the thigh bone (a long bone that extends downward from the hip),
- the proximal end of the tibia (the bone between the knee and foot),
Within the knee there are characteristic "inserts" made of fibrous cartilage - the so-called. meniscus (medial and lateral). There are convex condyles at the end of the femur, which have their counterparts on the tibia.
These bone elements are mismatched to each other, and this inaccuracy is eliminated by the aforementioned meniscuses, which act as knee shock absorbers. The bones within the knee joint are connected to each other by a series of ligaments, which are hard fibrous bands of tissue.
Two ligaments cross in the joint from the femur to the tibia and prevent the bones from slipping during movement. These are the so-called. cruciate ligaments:
Collateral ligaments run on both sides of the joint to prevent the bones from sliding sideways.
What are they and where are the cruciate ligaments?
The cruciate ligaments are strong, fibrous bands that connect the distal femur to the proximal tibia. In the knee joint of dogs (and most other pets) there are two cruciate ligaments: cranial (anterior) and caudal (posterior). These ligaments act as the hinge joint in the knee and are responsible for ensuring the anterior-posterior stability of the knee joint.
They are called cruciate ligaments because they "cross" the knee: the anterior ligament has an oblique course - it starts at the medial surface of the base of the lateral femoral condyle and ends in the intercondylar area of the front end of the tibia.
The posterior cruciate ligament is located posterior and medially to the anterior, crossing it in the shape of the letter X.
The anterior / cranial cruciate ligament (CCL) is divided into two bands: cranio-medial and caudo-lateral; they have separate trailers on the plane of the tibia. The first strand remains taut while both bending and straightening the knee; The tail-lateral band, on the other hand, is taut when straightening, but slack when bent.
This mechanism limits the transverse displacement of the tibia in relation to the femur during movement, i.e. in short: it stabilizes the joint. When the knee is bent, the anterior and posterior cruciate ligaments twist on each other, which limits the degree of rotation of the tibia relative to the femur.
The cranial cruciate ligament is an essential means of stabilizing the knee joint: it prevents the anterior-posterior tibia from shifting and prevents it from excessive internal rotation during load transfer. Thus, it ensures the stability of the joint during loading and twisting movements and prevents knee hyperextension.
Ligaments are very strong tissues, but when damaged they heal slowly and incompletely.
What is a cruciate ligament rupture?
Anterior cruciate ligament rupture is one of the most common orthopedic conditions that affect dogs and can affect one or both knees.
The cranial cruciate ligament tears and then ruptures. This usually happens when this structure degenerates over time (usually between 2 and 18 months), causing the dog to have an intermittent problem - until one day the weakened ligament ruptures completely, perhaps with normal running. This leads to excessive movement of the tibia relative to the femur (sometimes called the cephalic drawer by veterinarians) or to a cephalic push of the tibia.
When the cruciate ligament becomes loose, it is no longer able to provide stable movement or prevent cartilage injuries in the knee joint. As a consequence, the cartilage is damaged and then the development of osteoarthritis. Dogs that break one cruciate ligament have an approximately 50% chance of breaking the other.
This condition may be:
Degenerative, that is, gradually worsening and occurring over a long period of time. In half of the cases, the rupture of the CCL in adult dogs is due to the progressive inflammatory and degenerative processes, often with a completely normal load, but with insufficient cranial cruciate ligament.
In a degenerated ligament, even normal, repetitive activity can cause a progressive tear. As a rule, ligament rupture in dogs occurs gradually, resulting in low-grade lameness that may worsen over time.
Degenerative changes can occur in the cruciate ligaments of both joints, leading to simultaneous or later rupture of the ligament in the other knee. In a significant percentage of dogs with CCL damage in one limb, after 1-2 years, the cruciate or collateral ligament ruptures also in the opposite leg.
Sharp (sudden onset)
The acute condition occurs due to a rotational (rotational) instability over a period of time. A rupture of the cranial cruciate ligament in such a situation occurs suddenly. Acute injury is generally associated with overstretching and internal rotation of the limb, e.g. when it becomes trapped in a hole or well.
Just like a ligament rupture in humans resulting from a sports knee injury, dogs can suffer a ligament injury by jumping up, catching a ball or frisbee, or jumping out of a car. These categories can be related to each other because a ligament that is weakened by a degenerative process is always more susceptible to injury.
Unfortunately, the common opinion is still false beliefs about cruciate ligament rupture:
- "A cruciate ligament rupture is caused by an acute trauma that leads directly to a ligament rupture ". In most cases, this is not true. The exact cause of cruciate ligament disease is unknown, but there are many theories. Only a very small fraction of cases are due to actual acute direct trauma. As a rule, the disease is secondary to ligament degeneration which leads to a rupture when it can no longer support the load (similar to a thick rope that begins to fray before it breaks completely).
- "Injuries of the cruciate ligament occur only in older dogs ". This is often stated but not entirely true. Although older dogs (over eight years of age) are more likely to get the disease than younger dogs, it can also occur in animals less than two years old; the range is six months to 15 years.
The ligament may rupture completely (full tear of the cruciate ligament) or partially (partial cruciate tear). In dogs, the ligament tear is usually partial and occurs gradually, resulting in low-grade lameness that may improve over time. However, progressive injuries can be very damaging; due to a ligament injury, the knee joint becomes inflamed, leading to arthritis, which worsens with further strain. The dog's continued use and weight bearing often causes a complete ligament rupture.
A rupture of the cranial cruciate ligament causes instability of the knee joint and it stops functioning properly.
In more severe chronic cases, the cartilaginous "shock absorbers" of the knees, i.e. the medial and lateral meniscus, tear or crush due to the exposure to abnormal stresses that are present in the "loose" knee. Meniscal damage is common in dogs with a naturally occurring CCL rupture. A trauma to the medial meniscus is a serious problem if not properly diagnosed.
Which dogs are at risk of cruciate ligament rupture?Breeds predisposed to the disease
Anterior cruciate ligament rupture in dogs can occur at any age and breed, but is most common in middle-aged, overweight, middle-aged, overweight, medium to large breed dogs.
There is a strong racial predisposition to rupture CCL in dogs. West Highland White Terriers, Yorkshire Terriers and Rottweilers have a much higher incidence of CCL, and Rottweilers have a five-fold higher incidence compared to other pure breeds, with females being twice as likely to suffer from CCL compared to males. Rottweilers and Cocker Spaniels are the most predisposed to rupture of the anterior cruciate ligament.
The following are also more often affected by this problem:
- labrador retrievers,
- German Shepherds,
- golden retrievers,
- miniature poodles,
- St. Bernardine,
- american staffordshire terriers,
- chesapeake bay retrievery,
- lhasa apso,
- bichon frize,
- akita inu.
An interesting fact is that greyhounds have a significantly reduced incidence of this disorder.
A significant incidence of ligament rupture was found in castrated dogs compared to non-castrated animals. Published studies consistently describe a significant advantage of females over males with CCL rupture; in some cases it is only a slight advantage.
Frequency rupture of CCL in dogs increases with age, with peak incidence occurring in aged dogs from 7 to 10 years. The high incidence of ligament rupture in older dogs is associated with synovial inflammation and degenerative changes in the cells and matrix of the cruciate ligament, in contrast to puppies, where rupture of the CCL is often associated with traumatic injury and detachment of the ligament from its attachment sites.
Dogs 5 years old and older are 2.5 times more likely to experience an anterior cruciate rupture compared to dogs younger than 5 years old.
In a study carried out at the Department of Surgery, Orthopedics and Ophthalmology at the Faculty of Veterinary Medicine in Zagreb, 117 dogs with rupture of the cranial cruciate ligament were examined, which were diagnosed by clinical examination and mini-arthrotomy. It was found that the mean age of small breed dogs with broken CCL was 8.3 years, and that of large breed dogs was 4.2 years.
A common theme in many publications is that cruciate ligament rupture becomes a disease of young large breed dogs. Smaller breed dogs may tear the cranial cruciate ligament later in life than large breed dogs due to slower degeneration of CCL.
Rottweilers are five times more likely to rupture the cruciate ligament than other breeds. Rottweilers have the best chance of bilateral rupture of the cruciate ligament.
If a dog is obese, they are four times more likely to experience cruciate rupture than a normal weight dog, so keeping a lean body is very important.
Females are twice as likely to experience ligament ruptures as males.
Dogs under the age of two are less likely to experience cruciate ligament rupture than dogs over the age of eight.
Causes and pathogenesis of a ligament rupture in a dog
Anterior cruciate ligament rupture may result from acute traumatic rupture secondary to overload or from progressive ligament degeneration of unknown cause.
In the first case, abnormal forces are exerted on the healthy cruciate ligament, while in a degenerative rupture of the CCL, the ligament itself initially degenerates over time, which then breaks up with completely normal physical activity: normal forces act on the ineffective ligament.
Traumatic rupture of the CCL
They perform flexion and extension movements in the knee joint, but also - albeit to a much lesser extent - rotational movements.
Traumatic acute rupture of the cruciate ligament usually results from an overgrowth of the knee and / or excessive internal rotation of the tibia (knee sprain). In both cases, the push of the tibia overloads the CCL, causing it to rupture.
Hyperextension (hyperextension) of the knee joint most often occurs as a result of the foot suddenly getting stuck in some hole or pit while walking or running fast, while excessive rotation of the tibia occurs when the dog turns sharply towards the limb with the foot firmly seated.
From the point of view of biomechanics, a traumatic rupture of the anterior cruciate ligament occurs when the forces involved act too hard in a certain direction.
This is most often seen in dogs and athletes running and making sudden changes of direction so that most of the weight is taken by that single joint. An acute (sudden) cruciate injury occurs when the lower half of the leg remains stationary and the upper half above the knee is forced to rotate.
Such events can occur when an animal jumps up or down and twists during take-off or landing, places its foot in a hole or between stairs and continues forward, or suddenly stops running or changes direction.
In the event of a traumatic rupture of the cranial cruciate ligament, the knee joint is unstable and causes extreme pain, often resulting in lameness. Injury is also common in obese dogs that may simply trip over a pebble while walking.
Traumatic rupture of CCL in dogs, however, represents a small number of cases; Only in 20% of dogs the instability associated with CCL can be attributed to the traumatic event. More often, ligament failure is associated with progressive degeneration of unknown origin.
CCL degenerative rupture
A more chronic form of cross injury can occur due to the weakening of the ligaments as a result of degeneration. Histological examination of ruptured ligaments shows a change in the cell population and the structure of the extracellular matrix of CCL:
- A CCL rupture (degenerative) is associated with a significant loss of fibroblasts - the main tissue element - from the ligament core region.
- The decrease in cell density is further enhanced by the cartilage-like metaplasia of persistent fibroblasts, as a result of which fibroblasts look similar to articular chondrocytes.
- Changes in the extracellular matrix involve a significant disruption of the collagen architecture - the ultra-structure of collagen fibers is lost (most likely as a result of progressive mechanical overload.
Vasseur et al. found that the above-mentioned degenerative changes are more pronounced and occur at an earlier age in dogs weighing more than 15 kg compared to dogs weighing less than 15 kg, confirming the observation that cruciate ligament disease occurs at an earlier age in dogs of large breeds.
Despite extensive research, the exact cause and pathogenesis of ligament instability remains unclear. This is mainly due to the complex and possibly multifactorial origin of the disease process.
Many factors have been proposed that may favor degenerative processes, such as:
- conformation of the knee joint,
- immunological processes,
Genetic factors have been proposed as an important element in the pathogenesis of CCL rupture based on the increased incidence of the disease in Labradors, Rottweilers and many other breeds.
The genetic element could explain the often bilateral nature of a rupture of the cranial cruciate ligament.
Unlike predisposed breeds, CCL rupture in greyhounds is rare, despite their extreme athletic performance.
Authors of one study, focusing on a population of 574 Newfoundlands, proposed a recessive mode of inheritance of cruciate ligament insufficiency.
Another genome-wide study (conducted in Newfoundlands with and without cruciate ligament disease) identified single nucleotide polymorphisms on chromosomes 1, 3, and 33 that could potentially be associated with cruciate ligament failure. Further careful mapping and analysis of these regions could narrow down the list of CCL failure genes.
At this stage, it is unclear whether genetics directly influences the structural properties of CCL or controls conformational factors that predispose to ACL disease.
Conformational factors that affect the cranial cruciate ligament include:
- vertical posture of the pelvic limb,
- deformed knees,
- narrowing of the distal intercondylar field,
- increased plane angle of the tibia,
- tibial tuberosity conformation.
Vertical posture of the pelvic limbs
The role of the cranial cruciate ligament is to prevent cephalic displacement of the tibia in relation to the femur, prevent knee hyperextension and limit internal rotation of the tibia.
Therefore, it is possible that the presence of a "straight" (hyperextended) knee joint exacerbates the degenerative process and predisposes to early CCL rupture.
The condition is associated with varying degrees of varus of the femurs, internal rotation of the tibia, and other conditions such as a medial dislocation of the patella.
It has been suggested that dogs with medial patellar dislocation have an increased risk of developing cruciate ligament disease due to improper alignment of the extensor mechanism and internal rotation of the proximal tibia, which in turn puts continuous stress on the cranial ligament, predisposing it to damage.
Medial dislocation of the patella can also be linked to degenerative joint disease, which produces a specific enzyme environment that can lead to the degradation of CCL.
It has also been speculated that dogs with severe patellar dislocations may have lost the supporting structures of the knee joint as a result of severe lameness (e.g. large lateral muscle or lateral patella), which may contribute to greater instability of the joint and greater tension on the CCL.
Knees with cruciate ligament instability have a much smaller intercondylar fossa compared to normal knees.
Comeford et al. showed that the dimensions of this field are larger in the knees of greyhounds (a breed rarely affected by a CCL rupture) than in Labrador retrievers or golden retrievers (two breeds known to have a predisposition to early CCL degeneration).
They concluded that the impact of the intercondylar fossa on CCL in high-risk breeds could lead to collagen remodeling, and that such degenerative changes ultimately result in a reduction in the structural integrity of the ligament and its rupture.
The plateau angle of the tibia
It has been suggested that excessive pressure on the tibia due to the steep inclination angle of the tibia may contribute to premature CCL failure.
However, there are discrepancies between the various studies, so the actual influence of the tibial plane angle on ligament stress remains unknown.
Also, other factors can influence the amount of stress received by the ligament.
Although this angle has never been clearly identified as a single causative factor in CCL rupture, it may still contribute to early ligament rupture in the presence of other comorbid predisposing factors.
A retrospective study of the knee joints found that the width of the tibial tuberosity is significantly smaller in unstable CCL knees compared to healthy knees. This finding suggests that tibial tuberosity conformation may also be a risk factor for CCL rupture.
The authors of this study hypothesized that the small size of the tibial tuberosity relative to the rest of the structures around the knee joint could theoretically reduce the angle of patellar ligament attachment and lead to increased pressure on the tibia.
This, in turn, may predispose to ligament damage faster, resulting in rupture in younger dogs.
Research has shown that female and castrated dogs are at increased risk of CCL rupture.
In one of them, sterilized females were 2.1 times more likely to be diagnosed with CCL compared to non-sterilized females. This may be due to the higher incidence of obesity in castrated females.
Obese dogs are almost four times more likely to break CCL than dogs of normal weight. Higher BCS may cause abnormal tension in the articular and periarticular structures and tend to tear the ligament.
In addition to mechanical overload of the knee joint, obesity may also contribute to CCL rupture by releasing potentially pro-inflammatory mediators.
Indeed, it is assumed that an excess of white adipose tissue in obese individuals leads to a persistent state of chronic inflammation and thus contributes to connective tissue pathology by releasing key pro-inflammatory adipokines. However, the possible role of systemic fat in the development of CCL rupture has not been investigated and requires further research.
Immunity and inflammation
The cranial cruciate ligament consists mainly of type I collagen.
The demonstration of antibodies to type I and II collagen in the serum and synovial fluid of dogs with CCL disease has led some authors to conclude that immune response may play a role in CCL disease.
In a later study comparing synovial fluid samples from clinically healthy dogs and dogs with knee problems, suffering from cruciate ligament disease or osteoarthritis secondary to other arthropathies, it was found that the increase in anti-collagen autoantibodies in the synovial fluid was not specific to the type of joint disease.
Similarly, more recent studies failed to prove that anti-collagen antibodies initiated CCL damage in dogs. Nevertheless, it is possible that anti-collagen antibodies persist in chronic arthritis in some dogs with an unstable cruciate ligament, even though collagen is not the primary trigger for degenerative changes.
In addition to the immune mechanisms, there has also been considerable interest in the role of arthritis in the pathogenesis of CCL disease.
It is still unknown why osteoarthritis continues to develop despite restoring stability to the knee joint.
It has been suggested that pro-inflammatory cytokines are the factors that can trigger and perpetuate arthritis.
In people with anterior cruciate ligament injury and osteoarthritis, an imbalance between pro-inflammatory and anti-inflammatory cytokines has been demonstrated.
Unfortunately, there is limited information available so far on the role of cytokines and growth factors in osteoarthritis in dogs.
In a study by Muir et al. (2005) found increased expression of matrix degrading enzymes. The release of proteolytic collagenases into the synovial fluid can significantly deteriorate the structural properties of CCL and predispose it to rupture.
A rupture of the cranial cruciate ligament may occur as a result of the following diseases:
- medial dislocation of the patella,
- rheumatoid arthritis,
- immune background polyarthritis,
- septic arthritis,
- joint infection,
- osteochondrosis (a developmental disorder of cartilage).
Some authors (Hayashi et al.) suggest that ligament degeneration may be part of a protective response to hypoxia or oxidative stress.
In more recent studies, Ichinoe et al. propose that cartilage matrix production and fibrocyte metaplasia could be a response to some external forces such as microtrauma.
As you can see, cruciate ligament instability is a complex and multifactorial disease that requires further research to deepen our understanding of this multi-faceted condition and help develop appropriate preventive measures and optimal treatment options for dogs with early symptoms of CCL disease.
A ruptured ligament in a dog, symptomsSymptoms of ligament rupture in a dog
When the cranial cruciate ligament ruptures, the tibia moves freely under the femur and the knee becomes unstable, causing pain and lameness.
A sudden lameness in the hind limb is therefore often the first sign of an injury. Lameness can worsen with activity and improve with rest.
The most common symptoms of a cruciate ligament rupture in a dog
- Lameness of the pelvic limb. The severity of the lameness depends on whether the injury is chronic or acute / traumatic and whether the rupture is partial or complete. The lameness may be mild, wear off and then reappear. As a result, some dogs may only limp slightly, while others are unable to support their weight on an injured limb. With a subtle (partial) rupture, abnormal gait is noticeable, characterized by stiffness when standing up or slight lameness after exercise that appears to improve over days or weeks. Some carers report lameness 12-18 months before the ligament is completely ruptured. This partial tear of the CCL causes inflammation within the knee joint, and the weakened ligament is further damaged with further strain. Ultimately, this leads to a complete break. With severe (complete) rupture of the anterior cruciate ligament, a sudden onset of lameness (usually after a run) appears in the forehead of the symptoms with unburdening the affected limb. Initial lameness after ligament rupture is usually associated with avoiding stress on the knee, but most animals will begin using the limb within 2-3 weeks of the injury, unless surgical repair has been performed before. As periarticular fibrotic tissue forms, the joint becomes progressively more stable and there will be a gradual clinical improvement (though not to normal levels of function) until secondary meniscal damage and / or degenerative changes occur which further deteriorate function.
- Swelling of the knee joint.
- Pain, stiffness, and / or instability in the joint. Knee pain is usually a common symptom of rupture of the cranial cruciate ligament. Pain may not be noticeable until someone accidentally manipulates a dog's leg. A pinch or bite from a normally friendly dog is a common sign that they are in pain.
- Problems getting up. The knee may feel "crunchy" when it is subjected to a series of stretching and flexing treatments.
- Incorrect body position when sitting (the dog cannot or will not bend the knee joint). Owners often find that dogs tend to sit strangely "clumsy" with a diseased leg stretched out to the side.
- Thigh muscle wasting may also occur.
- Dog's level of activity decreased.
- In some cases, especially if the meniscus is damaged, you may hear a clicking noise as you bend and straighten the knee.
If the ligament injury is not removed in time, arthritic changes in the knee joint rapidly develop, leading to chronic lameness and discomfort.
Be aware that other diseases can cause similar symptoms in dogs, so a veterinarian examination is essential. So if your dog suddenly shows signs of pain or is limping, take him to the clinic as soon as possible.
Cruciate ligament rupture is a painful and immobilizing trauma, and although it is not life-threatening, medical intervention is necessary as soon as possible.
Diagnosis of a CCL rupture in a dogDiagnosis of a CCL rupture in a dog
A diagnosis of cruciate ligament disorders can often be made after a veterinarian has completed a thorough interview with the pet owner, observation of the dog while walking and trotting, and performing a complete physical and orthopedic examination.
A key part in the diagnosis is examining the knee for instability; this can be difficult in well-muscled or very tense dogs.
In such situations, it may be necessary to examine the knee under deep sedation or general anesthesia.
X-rays are also considered to rule out other problems in the knee, but they won't show ligament ruptures or cartilage damage.
Often times, a patient may require specialist consultation. Further examination and evaluation by a surgeon can help classify the severity of the problem and then indicate the best option for managing your dog.
Specialists also use advanced imaging and surgical techniques to help diagnose and treat ligament damage.
Interview with the pet's guardian
Already during the interview, the veterinarian obtains very important information from the dog handler. The fact that the patient belongs to races predisposed to injuries of the anterior cruciate ligament, his age, diet, past injuries and noticed symptoms help to establish a list of differential diagnoses at the very beginning.
At home, caregivers may notice that their dog seems to be "stiff " walking or limping when standing up, reluctantly jumps into the car, sits or walks, shows weakness in one or both hind limbs.
It is not uncommon for a dog to sit with the knee turned outwards.
In more severe cases, there is no lameness on the hind limb after running, and some dogs appear to have paralysis of the hind legs when both cruciate ligaments rupture.
In the case of a traumatic cruciate ligament rupture, it is usually the dog that ran and suddenly stopped or squealed, and then was unable to put any weight on the affected leg. However, many animals try to do this by touching the ground with their fingers and putting a little load on the injured limb.
The type and severity of clinical symptoms may vary depending on whether the ligament is completely ruptured, torn or stretched.
Acute tear of the anterior cruciate ligament (up to 14 days after injury)
Patients show either sudden onset of lameness without supporting the limb or severe lameness. It usually decreases without treatment within 3-6 weeks, especially in small breed dogs (weighing less than 10 kg).
In the event of a meniscus injury, diseased dogs provide minimal support to the limb until surgical intervention.
Chronic injury to the anterior cruciate ligament (more than 8 weeks after injury)
Prolonged occurrence of lameness with weight bearing on the leg has been observed in patients.
Previously, there may be a period of acute lameness without support of the limb, after which an improvement in the form of moderate lameness with support was noted.
It is not uncommon to see problems when sitting down and standing up. The dog sits down with the diseased leg stretched to the side. Lameness is clearly worse after exercise or longer rest.
Partial rupture of the anterior cruciate ligament
A ligament tear is difficult to diagnose in the early stages of damage.
The dog shows moderate lameness at first, but this wears off after resting. This stage can last for many months.
As the ligament tears further and the knee instability deepens, the degenerative changes progress - the lameness becomes more pronounced and does not subside after rest.
Bilateral subacute (2-8 weeks after injury) or chronic ligament rupture can occur in dogs of any age.
Animals are unable to use their hind limbs or are reluctant to lean on them, which is often mistakenly perceived as pelvic limb paresis. Guardians also often report that the dog is unable to sit properly, sits on elevated places, e.g. on the steps of the stairs.
Your dog will undergo an orthopedic examination, which usually shows signs of joint exudate (increase in fluid in the knee), joint thickening, and muscle wasting.
Manipulation of the joint also allows the identification of instability.
Following an orthopedic evaluation, sedation or short-term anesthesia is sometimes required to further assess joint instability and take X-rays of the knee joint, which can then be used to plan surgery.
Crank / head drawer test
The "head drawer" is the term doctors use to describe the excessive anterior-posterior movement of the tibia relative to the femur that results from an injury to the cruciate ligament.
There is a symptom specific to the cranial cruciate ligament injury and indicates instability in the knee joint.
Suspicion of a rupture of the cranial cruciate ligament is usually confirmed by the positive sign of a cranial drawer. It is called so because the movement of the femur in relation to the tibia is similar to pulling and pushing a drawer.
- In this test, the dog is lying on its side with the knee slightly bent.
- Pressure is applied to the distal part of the femur and pressure is applied with the other hand to the proximal part of the tibia.
- Displacement of the distal femur over the front of the tibia (positive drawer symptom) indicates a rupture of the cranial cruciate ligament.
In a normal knee joint, there is little or no movement and no pain.
In an animal with a fracture, there is a marked movement or displacement of one bone in front of the other. Movement may be painful.
If the animal is in severe pain or nervousness, the muscles near the knee may become so tense that it is not possible to show this symptom. In a situation where your veterinarian suspects a rupture of the cruciate ligament in your dog but cannot produce a drawer symptom, you may need to pharmacologically calm your dog to let him relax.
Often, in chronic trauma, the drawer symptom is less effective due to some stabilization of the joint resulting from the formation of scarring in the joint capsule.
A ruptured anterior cruciate ligament is not always an obvious condition. To obtain an accurate diagnosis, it is necessary to carefully manipulate and palpate the knee.
Tibia compression test
Cranial Tibia Thrust (CTT) means the movement of the tibial tuberosity forward as the tarsal joint is flexed and the gastrocnemius flexes. This phenomenon is present in the knee joint with damage to the anterior cruciate ligament.
- In the tibia compression test, the knee is held in a slight flexion and the ankle joint is flexed and extended to induce a cephalic tibial ejection.
- With a rupture of the CCL, the tibial tuberosity will move forward when the ankle is flexed.
Sometimes it may be necessary to anesthetize the patient first if the palpation test is too painful for the pet or the dog is not relaxed enough to allow a thorough examination.
The cranial ejection of the tibia responsible for the positive compression test of the tibia at ligament rupture is the force generated in the knee when the joint is loaded.
Under normal conditions, this ejection is passively counteracted by a properly functioning cranial cruciate ligament, and actively - by the biceps muscle of the thigh and the posterior group of muscles of the thigh.
When the ligament fails, the tibial ejection from any strain on the limb causes frictional damage to the cartilage and damage to the medial meniscus; The medial meniscus, strongly associated with the medial collateral ligament, moves cranially with the tibia and is damaged by the femoral condyle by pressing it or running over it.
Patients with an acute, complete rupture of CCL are often fearful during the examination and the muscles are very tense as a result. This makes knee instability difficult to demonstrate in a conscious dog. You may feel a swollen joint near the patellar tendon. A positive result of the tibia compression test in this situation is easier to elicit than with the head drawer test.
Patients with chronic tear CCL sometimes present with atrophy of the femoral muscles and marked crepitus when bending and straightening the knee.
When a ligament injury is accompanied by a tear of the meniscus, when the knee is straightened, a click may be heard or felt.
Often palpable is the so-called. medial abutment, i.e. a macular thickening on the medial side of the knee caused by the formation of osteophytes and fibrous tissue clusters. Antero-posterior lability may be difficult to induce (especially in large or stressed patients) due to fibrous proliferation in the joint capsule.
With incomplete rupture, it is difficult to induce instability as part of the ligament remains intact and restrains anterior-posterior movement of the tibia.
Pain, crackling, and swelling in the joint may be absent at first, and the symptoms of instability and osteoarthritis only become noticeable over time.
Pain is common with an enlarged knee.
At this stage of the examination, the symptoms of a cruciate ligament injury observed by the doctor may be as follows:
- acute lameness with no load on the pelvic limb,
- chronic progressive lameness,
- reluctance to sit with a normally bent knee tucked under the body,
- crepitations (knee "crunches " when performing a range of motion test),
- swelling of the knee,
- reduced range of motion,
- presence of medial patellar support,
- the presence of a meniscal click,
- effusion in the knee,
- thickened joint capsule,
- positive result of the head drawer test (read. next),
- positive compression test of the tibia,
- inability to stand up or walk if the condition is bilateral.
It is often necessary to perform other tests, such as imaging tests or arthroscopy.
Imaging studiesImaging studies
Radiographic changes in patients with ruptured CCL are nonspecific.
In the event of an acute rupture of the cranial cruciate ligament, X-rays can exclude other causes of lameness.
With chronic or partial rupture of CCL, X-rays confirm compression of the fat pad on the anterior side of the joint, expansion of the articular capsule (associated with edema), and the presence of osteophytes (bone growths) along the edge of the block, the caudal plane of the tibia, and the distal pole of the patella.
Avulsion, i.e. detachment of the attachment of a ligament with a piece of bone, is a characteristic symptom if a bone fragment is identified in the photo. These types of ligament ruptures are quite common in young dogs.
Magnetic resonance imaging enables the assessment of CCL and is a more sensitive method (compared to X-ray and computed tomography) in detecting ligament rupture, but the still limited availability of this examination, as well as the cost of its performance, make it relatively rare.
Knee colonoscopy allows for a detailed view of its interior.
It allows you to visualize the site of ligament rupture, determine changes in its color and detect fibrin deposits.
The menisci and cartilage are also assessed.
Thanks to arthroscopy, it is possible to confirm a partial rupture of the cruciate ligament and to assess the advancement of arthritic changes. This test is also used for therapeutic purposes:
- to remove residual CCL,
- ligament reconstruction,
- treatment of meniscal damage,
- in the local therapy of osteoarthritis.
They are recommended especially in doubtful cases, when clinical examination and imaging tests are inconclusive.
In these situations, a knee puncture is performed to test the synovial fluid. The collected material is assessed in terms of physical and chemical properties, and a cytological and bacteriological examination is also carried out.
An increase in fluid volume in the joint and a 2-3-fold increase in the number of cells (6000-9000 WBC / μl with a predominance of mononuclears) is characteristic of osteoarthritis.
The differential diagnosis includes:
- slight joint sprain or muscle strain,
- dislocation of the kneecap,
- rupture of the caudal cruciate ligament,
- primary meniscus rupture,
- Avulsion fracture of the extensor of the long finger,
- primary or secondary arthritis,
- inflammation of the immune background joint.
Consequences of rupture of the cranial cruciate ligament
After cruciate ligament injuries, osteoarthritis is inevitable, and the most effective way to minimize its long-term impact is to maintain lean body mass (diet, diet, and more).
About 40-50% of ruptured cruciate ligaments damage the meniscus.
In a knee with insufficient CCL, the cranial tibial pushing causes crushing of the femoral condyle in the caudal horn of the middle meniscus, strongly connected with the medial collateral ligament and the plane of the tibia. The result is injuries of the meniscus in the form of horizontal splits, crushing of the caudal horn and damage to the meniscus of the "bucket handle".
A tear in the meniscus is often felt as a "click" as the knee is flexed and extended.
A key step during the operation is therefore a thorough examination of the inside of the joint for damage to this structure. During the procedure, the knee joint is opened and examined to confirm the diagnosis of partial or complete rupture of the cruciate ligament.
The remaining ligament strands can be cleaned during this time, the joint is rinsed and the meniscus is checked for tears. If this part of the surgery is missed, dogs may be left with constant pain and lameness. After this stage, the surgeon begins a surgical repair.
Also, since the dog spares the affected leg, it generally places more emphasis on the healthy limb. Therefore, it is not uncommon for an animal to also rupture the cranial cruciate ligament in the other leg due to the increased pressure.
The longer the interval between a knee injury and surgery, the more conservative the prognosis. This is due to scarring and inflammation in the joints.
The torn ends of the cranial cruciate ligament diverge and do not connect with each other. The weakening of the ligament structure remains up to 4 years after the healing process is completed.
Treatment of a broken ligament in a dogTreatment of a cruciate ligament rupture in a dog
In the event of an anterior cruciate ligament rupture, timely diagnosis and treatment are of paramount importance to minimize further cartilage damage in the joint.
The goal of any treatment is to restore the knee joint to normal stability, but unfortunately, the ligament cannot be repaired.
There are many options for dealing with dogs with ruptured cruciate ligaments, each with their own pros and cons. Based on the size of the dog, its temperament, clinical situation, and the carer's financial capabilities, the veterinarian will suggest the most optimal method of treatment.
The management of a ruptured CCL in dogs can be broadly divided into surgical and non-surgical treatment.
Non-surgical management includes:
- effort limitation,
- anti-inflammatory drugs,
- physical therapy,
- weight loss.
These therapies may be effective in dogs with a small body weight, and although these animals will develop arthritis, they may regain nearly normal function.
However, most veterinarians will recommend surgery to treat a ruptured cranial cruciate ligament.
A successful treatment of cruciate ligament rupture should include:
- the dog's ability to sit with full knee flexion,
- return of the thigh muscles,
- cessation of osteoarthritis,
- return of the limbs to their pre-injury function.
A broken ligament in a dog operate or not?
In a small dog (less than 10 kg in weight), a broken ligament can be treated conservatively, keeping close rest and relieving pain until the tissue around the joint thickens enough to stabilize it. In most animals weighing more than 10 kg, conservative treatment of a dog's ruptured ligament is ineffective and should therefore be treated with surgical intervention.
Non-surgical management usually includes:
- Rest. Basically this involves keeping the dog active for 2-6 (sometimes 8) weeks - depending on the clinical condition of the dog. If there is no clinical improvement during this period, surgery is usually recommended. Swimming and light exercise (walking) may be performed in a controlled manner as instructed by your veterinarian to maintain muscle strength.
- Non-steroidal anti-inflammatory drugs such as carprofen, etodolac, meloxicam, deracoxib, or other medications are often used to reduce inflammation in the joint and relieve pain.
- Drugs that support the joints. Dog supplements containing glucosamine, chondroitin, New Zealand mussels, glycosaminoglycans, and other cartilage preservatives are often recommended.
- Change of diet. If you are overweight, your dog should go on a reduced-calorie diet.
- Once your dog goes through the acute phase, it is very important to control your dog's weight and follow an exercise plan approved by your veterinarian.
Such conservative treatment of a broken ligament in a dog may also be recommended when the dog is not a good candidate for surgery.
This happens when the cruciate ligament is only partially torn, the pet is older, has medical conditions that may affect healing, or owners are unable to control the dog for several weeks after surgery.
In many cases, small dogs do well with the medical management. Retrospective studies show that patients weighing less than 10 kg regain good limb function after conservative treatment.
A broken ligament in a dog is operated on
Surgical techniques can be classified into three main classes:
- Intracapsular techniques.
- Extracapsular techniques (depending on the position of the stabilizing material).
- Corrective osteotomies.
Intracapsular techniques provide ligament replacement with:
- synthetic dentures.
This is to stabilize the joint in accordance with the anatomical reconstruction, i.e. to position the replacement ligament in the anatomically correct configuration.
The advantage of intracapsular reconstructions is the ability to most accurately recreate the original position of the original ligament. Disadvantages include the invasiveness and tendency of the graft to stretch.
Parts of the ligament or fascia, and even the skin, are replacements for the cruciate ligament when repairing inside the joint capsule.
The most commonly used material is the autogenous broad fascia. Synthetic material is used less frequently due to stretching and the risk of tearing and contamination.
These materials are passed through the joint itself and fixed in such a place as to approximate the normal location of the ligament.
Unfortunately, no such structure can accurately recreate the cranial ligament - the undamaged ligament has a unique location, surrounded by the synovium, despite its location in the center of the knee joint.
This causes permanent inflammation within the joint following intracapsular repair.
Extracapsular techniques avoid this problem by placing the stabilizing material away from the synovium.
The principle of extracapsular stabilization is based on the passive prevention of cranial tibia, internal torsion and hyperextension of the knee joint.
Extracapsular reconstruction does not involve replacement of a torn ligament. It is performed outside the joint and restores the function of the cruciate ligament rather than physically replacing the damaged ligament.
Over the years, extracapsular fixation has become the preferred method of repairing an anterior cruciate ligament rupture in dogs.
Extracapsular techniques ensure joint stability using various types of biological tissue and synthetic sutures (e.g. fascia, nylon), which replace the limiting function of CCL.
The synthetic or biological material is attached to the femur and tibia, which ensures the stability of the knee until the development of peracapsular fibrosis and consolidation of the biological stabilization of the knee.
Although these methods do not guarantee good long-term results, the development of periarticular fibrosis can ensure long-term proper functioning of the knee joint.
Extracapsular reconstructions have been in use since the 1960s. Of the 1960s, ensuring satisfactory results. Over the years, two categories of extra-articular stabilization have been described:
- techniques using synthetic materials,
- biological techniques using transferred autogenous structures.
They are usually placed on the lateral and / or medial side of the knee joint. Over the years, many different techniques have been proposed:
- Lateral navicular-tibial suture: provides stability to the knee by placing a non-absorbable suture around the lateral sesamoid and securing it to the distal part of the patellar ligament.
- Flo (1975) introduced a new approach using a suture around both the lateral and medial sesamoid which is anchored in a hole drilled in the tibial tuberosity; another suture is placed between the lateral sesamoid and the drawstring to prevent instability of the joint.
- Gambardella et al. (1981) proposed the periorbital technique in combination with two sutures positioned through the lateral collateral ligament, all three sutures anchored to the patellar tendon.
- An improvement in extra-articular stabilization is the introduction of anchors (side-seam anchoring technique or the latest tightrope procedure). Seams are anchored in specific and isometric areas of the knee joint to limit biomechanical changes such as internal rotation and hyperextension. This is to ensure a certain stability of the joint.
Side suture technique (lateral navicular-tibial suture)
The technique involves wrapping the suture around the knee joint in a configuration that returns the tibia to the normal position relative to the femur.
The seam supports the knee joint while the scar grows and the muscles surrounding the knee strengthen. Such an implant essentially replaces the function of a torn cruciate ligament.
The surgery involves placing a nylon implant on the outside of the joint to act as a temporary artificial cruciate ligament. The implant increases the stability of the knee joint during the formation of tissue scarring, which is important for further stabilization of the joint.
It is a traditional treatment, widely used, but recent publications have shown that it does not provide as good results as osteotomy procedures, especially in medium and large breed dogs.
This technique is recommended mainly in the case of small or light breed dogs, dogs suspected of problems with bone fusion after osteotomy (e.g. in geriatric dogs) and in patients with a slight inclination of the tibial plane. This procedure is also recommended in cases of traumatic rupture of the cruciate ligament.
This method is not recommended for patients with a steep tibial angle, for obese patients, and for large and giant breeds.
The downside to this method is that the implant can rupture, which leads to thickening of the tissue around the knee and the development of arthritis. Failure of the implant before sufficient scarring is common and may result in prolonged or poor recovery. It must remain intact for 8-12 weeks for healing to occur.
An animal that weighs more than 20 kg, is overactive or overweight will put significant pressure on the implant, which means there is a greater chance of breaking the suture material.
This technique does not solve the anatomical problem and as such is not the best procedure for animals over 20 kg or those that are hyperactive. However, this is a more economical procedure and still produces a good result up to 85% of the time.
The advantage of this method is that it is a relatively quick and uncomplicated procedure with good results, especially in smaller dogs. Complications are rare, and the procedure itself is not as expensive as other techniques.
Complications can include a reaction to the prosthetic material, infection, and excessive exercise during recovery.
While this technique prevents a cranial drawer (at least initially), other planes of movement (especially normal internal tibia rotation and knee extension) are artificially restricted.
A more recent adaptation of this method is the Tightrope technique.
High tensile material is positioned at isometric points laterally across the knee and secured by bone tunnels drilled into the femur and tibia.
There is no doubt that at least some of these techniques improve the comfort and activity levels of affected dogs, but there are some caveats:
- All operated knees (no matter how stable they seem immediately after surgery) have a cranial drawer back within a few weeks. While this may not bother dogs, such knees are unstable, at least to some extent. The Tightrope technique aims to reduce this phenomenon, although some instability is still apparent in the postoperative time.
- Despite improvements, dogs treated in this way generally do not return to normal sporting activity - especially larger breeds.
- The arthritic changes in the knee continue to worsen over time despite surgical stabilization efforts.
Biological techniques designed to guarantee the stability of the knee joint by altering or displacing the local tissues of the knee (fascia strips from the tailor's muscle, hamstring and biceps tendon) were the first extra-articular techniques described.
The technique of wrinkling the joint capsule
The first technique of wrinkling the articular capsule using Lembert sutures was proposed in the 1960s. In the 1980s, and the modified drawstring technique was described later.
McCurnin proposed a hybrid technique that uses both side mattress seams and Lembert sutures placed laterally and medially on the knee joint.
Fibula head protrusion is an extracapsular repair technique that allows another structure of the knee joint, which is the lateral collateral ligament, to replace the function of the cranial cruciate ligament.
These techniques are not performed inside a joint, rather they function to counteract joint instability, acting in a manner similar to an intact cruciate ligament.
After cranial transposition of the fibula head, the orientation of the collateral lateral ligament is redirected to resemble the cranial cruciate ligament. The surgical procedure is to cut the fixations (attachments) of the fibula head from the tibia and move it forward - to the point where the drawer symptom is eliminated.
This procedure can be used alone or in combination with other stabilization methods.
Possible complications after extracapsular fixation:
- No satisfactory end result (no or insufficient joint stability, no recovery from lameness). This is mainly due to the limited strength of the materials used, which leads to stretching or breaking stabilization and recurrence of lameness.
- Rare infections.
Advantages of extracapsular techniques:
- Low invasiveness of the procedure, and thus less probability of serious complications.
- Can be used in patients at risk (i.e. those who may have problems with healing after osteotomy - the elderly, suffering from chronic metabolic diseases).
- The procedure is technically relatively simple.
- Low cost.
- Availability - no need for specialized equipment (as in the case of more advanced techniques).
Disadvantages of extracapsular techniques:
- Implant wear over time.
- Since this method does not change the tibial angle, it is associated with chronic cranial subluxation of the tibia.
- Proceedings of the inflammatory-degenerative process.
- The possibility of damage or tearing of the menisci (the articular surfaces of the bones are non-physiologically arranged in relation to each other).
Intracapsular and extracapsular methods are techniques that provide the so-called. static repair.
These traditional techniques rely on attempts to prevent the cephalic drawer - an instability that is present and detectable when most dogs are examined with an anterior cruciate ligament rupture.
However, since the condition is almost always degenerative, repairing a ruptured ligament alone is not possible.
Many static repair methods have been tried using the aforementioned natural and synthetic materials, all positioned to counter the drawer head.
Traditional ligament repair techniques performed well in some cases, but in many dogs, especially large and giant dogs, they were poor and often resulted in:
- failure of the procedure,
- recurrence of instability,
- periarticular fibrosis,
- the progression of osteoarthritis,
- incomplete recovery of functions and musculature of the limbs.
The perceived shortcomings of cruciate ligament repair attempts led to some considerations and prompted a San Francisco-based orthopedist named Barclay Slocum to develop a technique of compensatory tibial plate osteotomy (TPLO).
Instead of static repair, a dynamic approach is now used.
The priority in treating an unstable ligament in a dog's knee is considered to be a priority in controlling the cranial tibial ejection, rather than reconstructing the ligament itself.
When the pelvic limb is loaded, the quadriceps and Achilles tendon keep the knee joint in extension, and the loading forces are transmitted through the cartilage surface of the femoral condyle and the inclination of the tibia.
In the dog, the inclination of the tibia is not perpendicular to the long axis of the tibia, but occurs at different angles in different breeds of dogs (18-60 °).
Since the tibial plane is tilted, the load between the femoral condyle and the tibial slope during the transfer of weight produces a force that breaks down into two perpendicular components, one distal towards the tibial axis and one cranial as a cranial tibial push.
The tibial ejection (present at an anterior cruciate ligament rupture) is thus exacerbated by the amount of tibia slope, the dog's weight, and the degree of knee extension (since straightening the knee while carrying a load produces a less favorable lever arm for the appendicular muscles of the thigh).
In a perfectly balanced knee joint, the cranial bulge of the tibia is neutralized by active muscular forces, and the anterior ligament is not subjected to much stress.
Since this balance is frequently altered in the dog, the CCL is subject to periodic or continuous stress caused by the thrust force of the tibia; its rupture occurs when this force exceeds the strength of the ligament.
Without neutralizing this push, any CCL reconstruction could fail because sooner or later it will recreate the same configuration that was at the root of the ligament injury.
An innovative solution proposed by Slocum was the modification of the anatomy of the joint without the help of a ligament or its substitutes.
To neutralize the cranial expulsion of the tibia, it is necessary to eliminate the slope of the tibia, changing it so that all loading forces are transmitted perpendicularly from the femoral condyle to the plane of the tibia.
To illustrate the above assumption, let's compare the cranial cruciate ligament to the car handbrake, which is needed to park the car on a hill.
If the handbrake fails (cruciate ligament rupture), the car will roll down (this is a cranial drawer / tibial push that the doctor senses during the examination).
To solve the problem, park the vehicle on a flat surface, then the handbrake will not be needed. Therefore, the dog's tibia is incised and moved so that there is no longer a slope in the joint.
Osteotomy procedures typically involve cutting the tibia to flatten the slope of the tibia, thereby eliminating the need for a cruciate ligament and preventing movement of the femur relative to the tibia.
The incised bone is then stabilized with metal implants that hold the bone in its new position while it heals. The implants remain in place after healing, unless there is a problem (e.g. infection requiring removal).
TPLO - tibial leveling osteotomy
TPLO is a technique that uses a different approach to treating a cruciate ligament rupture. It is based on the premise that any cruciate ligament replacement will never be as good as the original.
Rather than trying to counter the forces acting on the cruciate ligament in the normal knee joint, TPLO eliminates these forces - that is, the need for a cruciate ligament - by changing the anatomy of the knee joint.
Anterior cruciate ligament reconstruction is not necessary after TPLO as the knee stabilizes when loading the limb if cranial tibial ejection is eliminated. This makes the forces on the femoral condyle perpendicular to the articular surface of the tibia.
During the TPLO procedure, a curved incision is made in the tibia, which allows rotation and smoothing of its inclination. This is then secured in a new position with the bone plate and screws.
TPLO reshapes the joint in such a way that the femur is less prone to slipping (sliding) over the tibia plateau when loading forces are applied, thereby improving the stability of the knee joint.
This is a more complex procedure than the extracapsular method and requires special surgical equipment and training. TPLO is a patented technique, and to perform it, it is necessary to participate in a specific course and purchase special instruments and implants.
TPLO is indicated especially in dogs of large and giant breeds, breeds predisposed to pathology of the CCL ligament and in patients with a steep inclination angle of the tibia.
TPLO is contraindicated in patients with damaged or torn cruciate ligament (this ligament becomes tense after surgery).
Caution should also be exercised in patients with poor healing and a weakened immune system (chronic metabolic and endocrine diseases, immunosuppressive therapy) due to an increased risk of osteitis.
It takes about 2 months for the bones to heal. Partial improvement can be seen within a few days, but a full recovery will take several months, so strict restriction of exercise is essential.
Complications of TPLO
The complication rate ranges from 14% to 28%, and is higher in patients who have had both knees treated simultaneously. The most common complications:
- problems with postoperative wound healing,
- enlargement of the kneecap simple ligament,
- damage to the meniscus,
- fracture of the tibia and / or fibula,
- implant damage / incorrect implant placement,
- intraarticular insertion of screws or bone nail,
- problem with bone fusion.
Disadvantages of the TPLO
- This technique is much more expensive than traditional surgery. The procedure must be performed by a specialized surgeon with specialized equipment and implants, which increases the cost of the procedure performed.
- Possibility of quite serious complications that may - in extreme cases - lead to significant impairment of the operated limb.
Advantages of TPLO
- It is possible to perform the procedure on an animal of any size, even in giant breeds.
- Eliminating the unfavorable inclination of the tibia plane and abolishing the cranial tibial ejection.
- Slower progression of degenerative changes in the joint.
- Rapid healing and fast consolidation of the therapeutic effect.
- Possibility to correct some posture defects and a slight degree of dislocation of the patella
Overall, the long-term prognosis is good and re-injuries are rare.
The plate does not need to be removed unless there are problems afterwards.
The prognosis is good to excellent in most dogs following cruciate rupture surgery, and most small animal surgeons quickly adopted this technique as the method of choice for treating an anterior cruciate rupture.
In recent studies, the function of the operated leg in dogs undergoing TPLO surgery was comparable (both in walking and trotting) to that in healthy dogs 6-12 months after surgery. The results were better than the other techniques studied.
Although rarely clinically relevant, osteoarthritis develops after surgery.
Therefore, the treatment of osteoarthritis is recommended in parallel.
This also includes dietary restrictions, as obesity increases the risk of developing disease in the other knee joint, the progression of osteoarthritis, and surgical complications.
Back to exercise
At the follow-up visit after 6 weeks and assuming that the animal is making satisfactory progress, it is possible to gradually return to training.
It is important to remember that the operated leg will still have to strengthen, so not getting back to exercise can cause complications.
Hydrotherapy and / or physical therapy may also be considered at this point, if not already started.
TTA (Tibial Tuberosity Advancement) - tibial tuberosity advancement technique
Developed by a group of Zurich orthopedic orthopedic engineers, this technique is based on Slocum's original idea, except that instead of looking only at the knee bones, it also takes into account the effects of muscle strength.
In the loaded leg, the quadriceps mechanism represents the strongest force on the knee.
Due to the direction of the patellar ligament (cranio-distal to caudo-distal orientation), during contraction, the quadriceps provide not only a proximal tibial pull, but also a cranially directed force, and this causes a craniocranial pull of the tibia.
By slightly shifting the tibial tuberosity (usually between 6 and 12 mm - depending on the size of the patient), the patellar ligament moves to a position at an angle of 90 degrees to the inclination of the tibia.
When loading the leg, the muscles around the knee contract, and when the quadriceps are pulled perpendicular to the plateau, there is no more pressure on the tibia.
The details of this method are slightly different from the TPLO, but the TTA still involves cutting the tibia and placing metal implants.
This technique changes the biomechanics of the knee joint through the cranial protrusion of the tibial tuberosity.
Appropriate displacement and fixation of the tibial tuberosity sets the inclination of the tibia at right angles to the patellar rectus ligament. This largely eliminates the cranial tibial ejection present in the knee with an unstable cruciate ligament.
Some surgeons describe TTA as a less invasive procedure than TPLO and with faster recovery, while others see only a minor difference.
Both of these procedures, however, quickly became the two most important treatments for canine cruciate ligament rupture among veterinary orthopedic specialists worldwide.
As with TPLO, patients usually put stress on their operated leg within 48 hours after TTA surgery and generally show a quick recovery to normal sporting activity.
One unpublished study by Virginia TEch surgeons comparing the clinical efficacy of TTA and TPLO found that there was no difference in outcomes over the 6-month study period between dogs that received TPLO and those who underwent TTA.
Given a similar end result, the choice between TTA and TPLO in a particular patient depends on factors such as conformation and any other orthopedic abnormalities that may be present.
Operation time, post-operative care, and even the cost of the procedure are very similar for both techniques.
The treatment is indicated in dogs with narrow tuberosity of the tibia, e.g.:
Contraindications to the procedure
- In dogs weighing 10 kg or less, the treatment is very difficult or impossible to perform. The limitations result from technical difficulties - the inability to properly fix the plate and the cage on the cut tibial tuberosity.
- In giant breeds, this procedure is not recommended due to the significant load on the implant and the risk of loosening, tearing or breaking the plate.
- In patients whose tibia angle is very high.
- In dogs with broad tibial tuberosity (difficulty or inability to properly place the TTA).
- In patients with certain posture defects.
Postoperative complications are less frequent than with TPLO.
They can be:
- subcutaneous haemorrhages,
- local swelling
- improper placement of the spacer cage or fixing screws,
- incorrect fit and fastening of the TTA plate, resulting in e.g. fracture of the tibial tuberosity,
- implant instability,
- fracture of the shaft of the tibia,
- fracture of the TTA fluids,
- bone infection - a very undesirable complication that requires removal of the implant from the infected bone.
Advantages of TTA
- Simpler technical execution of the procedure than in the case of TPLO.
- Compared to the extracapsular method, TTA eliminates the excessive inclination of the tibial plane, thus preventing the tibia from tibial thrust (and this reduces the development of degenerative changes).
Disadvantages of TTA
- longer healing time than with TPLO,
- this method is not applicable to all animals,
- compared to the extracapsular technique, the method is more technically difficult, more expensive (higher cost of the implant, the need to have appropriate tools),
- additionally, the possibility of severe complications.
Rapid TTA - is a relatively young modification of the above method.
The whole technique is simplified and the number of implants is reduced to the distance cage itself, which also differs from the original shape.
In contrast to TTA, the tibial tuberosity is not completely severed and remains in contact with the tibial shaft further downstream.
Advantages of Rapid TTA
- simplification of the procedure in relation to the classic TTA,
- wider applicability of this technique also in individuals with broad or distal tibial tuberosity.
Disadvantages of Rapid TTA
It is potentially risky to use this method on giant breeds and breeds with a steep tibia angle.
TWO (Tibial Wedge Osteotomy) - sphenoid osteotomy of the tibia
This technique is the predecessor of TPLO, which has been reported to treat a significant tibial plane angle.
It is based on similar principles as TPLO, except that the osteotomy is performed lower, which changes the position of the tibia crest.
This may interfere with the straightening of the knee.
Nevertheless, it is a valuable technique for treating an anterior cruciate rupture and an increase in the tibial plane angle in young dogs.
They still have an open proximal base, and this technique - unlike TPLO - does not affect this structure.
PTE (Proximal Tibial Epiphysiodesis) - closer tibial epiphysiodesis / TPLP (Dynamic Tibial Plateau Leveling Procedure) - dynamic tibial plane leveling procedure
Certain surgical techniques (e.g. TTA or TPLO) may not be suitable for use in young, growing dogs due to open cartilage of proximal tibial growth.
The above-mentioned angular osteotomy can be performed in such young animals, but it is a more invasive technique than PTE.
During the procedure, the orthopedic screw is placed in the appropriate place in the part closer to the tibia plane.
The goal is to reduce the plane of the tibia as the dog continues to grow.
The screw blocks the growth of one of the two centers of ossification in the growth cartilage of the proximal tibia.
The other ossification center is intact and the tibial plane angle is reduced as the dog grows.
The connection of the two growth centers (depending on the breed) takes place between the age of 6. a 11. month of life and results in the closure of the growth cartilage.
It is important that the procedure is performed before the closure of the growth cartilage.
TTO (Triple Tibial Tuberosity) - triple tibial osteotomy
This technique uses the features of tibial protrusion (TTA) and tibial sphenoid osteotomy (TWO).
It is the younger sister of corrective osteotomies (TPLO, TTA, TWO) and consists in reducing the tilt angle of the tibia.
During the procedure, three osteotomies of the proximal part of the tibia are performed, and then a titanium blocking plate, type TPLO, is attached to the tibia.
The procedure is minimal in most cases and the clinical results are good.
Each of these techniques has advantages and disadvantages, and it is difficult to pinpoint a universal method. The results of these procedures are generally very good; however, some operations are more promising than others for a full recovery.
There can also be significant differences in costs and recovery time. Your veterinarian will detail these surgical options and explain the different procedures.
Although cruciate ligament surgery can be very demanding, professionals who carry out cruciate ligament surgery have vast experience.
Rehabilitation regimens vary, but most vets recommend exercise for movement, staging recovery, swimming, weight loss, and pain medications.
Post-surgery care for a broken ligament in a dog
Post-surgery care is almost as important as the surgery itself. The short-term priority is to ensure that the animal is comfortable and the surgical wound heals without complications.
Initially, the knee may be more painful after surgery. The dog will be given painkillers to keep him comfortable.
It should start putting stress on your leg within a few days and your comfort level should gradually increase.
Licking or biting a wound can result in infection and prevents the wound from healing normally. This is strictly prohibited and may require an Elizabethan collar.
The wound should be monitored for discharge, bleeding, or swelling. Some bruises and haemorrhages are normal after surgery and should go away in the next week.
Soft, fluid swelling of the lower limb is common and usually resolves within a week.
If you have any concerns about your pet's wound appearance or comfort, contact your veterinarian for advice. Usually, follow-up visits are scheduled 3 and 10 days after the surgery.
- Closed area. It is necessary to strictly limit the patient's movement in the postoperative period. You can set up a fenced area, use a kennel or a dog cage, or use a small room in the house.
- No jumping. It is very important not to let the dog jump. Excessive extension of the knee can ruin the effect of the surgery and slow healing.
- It is absolutely forbidden to climb stairs. Like jumping, climbing stairs puts strain on the knee joint and inhibits repair. It is therefore important in the initial stages immediately after surgery to prevent your pet from climbing or climbing stairs.
- No slipping. If possible, use non-slip surface coatings.
After the surgery, the dog must be restricted in movement for 2 weeks.
By day 10 after surgery, most dogs will touch the ground with the fingers of the operated limb and begin to put some weight on it.
Once a dog has reached this point, it is often very difficult to keep it "still" until completely healed.
In general, the dog must be kept on a leash for approximately 4-6 weeks - the exact timing will depend on the extent of the injury and the corrective procedure performed.
This is extremely important to prevent surgical correction from breaking. Your vet's instructions regarding exercise during recovery should be followed very carefully.
What is normal after surgery for a broken ligament in a dog?
Normally you can see:
- presence of swelling around the surgical incision (this should only last for the first 3-4 days after surgery),
- the presence of hematomas,
- a small amount of discharge from the surgical wound (it may be clean or slightly discolored with blood),
- discomfort around the incision and possible pain in the leg.
Irregularities to be reported to the veterinarian:
- swelling that lasts more than 3-4 days,
- presence of hematomas in areas other than around the incision,
- discharge of a different color than normal (e.g. yellowish),
- a significant amount of discharge,
- constant bleeding,
- constant discomfort that does not disappear after applying ice and administering painkillers,
pain that makes an animal groan, feel uncomfortable, or bite.
Regardless of the type of surgery, strict rest and restriction of movement for at least 6-8 weeks after the procedure are of key importance for proper recovery.
Good limb function should recover within three months, as long as the dog is properly cared for and all veterinary guidelines are followed. Following any surgical procedure, close monitoring is necessary to minimize complications and ensure the success of the procedure.
Unfortunately, regardless of the technique used to stabilize the joint, arthritic changes in the dog's knee joint can develop with age.
Weight control and nutritional supplements such as glucosamine / chondroitin can help delay the onset of arthritis in your pet. Physiotherapy is recommended in long-term recovery.
A broken ligament in a dog, rehabilitation week after week
Attention! The information provided is for reference only. The physiotherapy regimen is determined individually for each patient after the procedure by a veterinarian and / or physiotherapist.
Below is information on what you should do at home to help your pet recover as quickly as possible.
These instructions are intended to provide you with guidance on the correct amount of exercise you can allow your dog to do. Remember that these guidelines should be tailored individually for each dog.
As time goes on, you should see a gradual improvement in the use of your leg. Any sudden increase in lameness that persists for more than 24 hours requires rest and a quick re-examination.
Rehabilitation differs depending on the surgical technique used:
- Extracapsular reconstructions ensure quick stabilization of the operated limb, therefore physiotherapy may be introduced early.
- With intracapsular methods using autogenous transplantation of the broad fascia, the prosthesis takes several weeks to achieve relative stability. Initially, you should act very gently, and starting more advanced exercises is possible after stabilizing the implant.
- In the case of osteotomies that align the tibia plane, rehabilitation after surgery depends on the healing time of the osteotomy, usually 4-8 weeks. Too aggressive rehabilitation can cause very serious complications.
- In any case, therapy should begin immediately after the procedure with the use of cryotherapy and NSAIDs and gentle exercises with a passive range of motion.
- Hydrotherapy can be introduced immediately after the sutures are removed (in the case of the external - or intracapsular method). In this case, pain management and reduction of inflammation are important. Walking on a leash extends to a few weeks after the procedure, and hydrotherapy and active exercises should start 5 weeks after the procedure.
- Changes in muscle mass are common in dogs with a ruptured cranial cruciate ligament. The quadriceps and biceps muscles of the thigh are important in lifting body weight while standing, and their rehabilitation should restore their strength and volume. In very severe muscular atrophy, it is important to maintain a minimum of muscle strength and endurance, so it is best to start physiotherapy before the procedure is performed. Thanks to this, it is possible to keep the patient in the best possible condition. Neuromuscular electrostimulation is recommended, as well as exercises in water.
- Postoperative physical therapy should last at least 5 weeks. If you have any concerns about your pet's recovery, see your veterinarian.
First days after the operation (day 2 - 4) - strict rest
In the initial postoperative period, cryotherapy, non-steroidal anti-inflammatory drugs and passive exercise therapy are used along with limited activity in the form of gradually extended walks. As the healing process progresses, it is recommended that you run the limb gradually.
- Continuous rest with short walks (on a leash) only for hygiene purposes (twice a day for a maximum of 5 minutes).
- It is extremely important to prevent overactivity after cruciate ligament surgery. Allowing your pet to be too active too soon can increase the risk of serious complications that may require further surgery and even alter the long-term success of surgery.
- Health check up three days after surgery.
- Physiotherapy should begin within the first 48 hours after the surgery (preferably under the supervision of a qualified therapist who will present activities that can be performed at home):
- Cryotherapy applied to the operated limb as a supplement to the action of painkillers and to combat edema.
- Cold / hotpack used as cold compresses for 10-20 minutes. always applied with a towel.
- Thanks to the use of cryotherapy (with an analgesic effect), it is possible to gently carry out passive mobilization of the range of motion (bending / straightening).
- Massage covering the lumbar region, hips and thighs.
- Short sessions of physiotherapy are repeated 2-4 times a day for 2-4 days after surgery.
First week (day 4-6) - minimal exercise
During the first weeks after the procedure, rehabilitation helps to reduce pain and swelling, allows you to achieve a good range of flexion and extension, and also stimulates and increases the tone of the thigh muscles.
- Rest at home with short, several-minute walks on flat ground.
- Short and slow, controlled walks on a leash for up to 5 minutes, 3-4 times a day.
- A towel or a special harness can be used to support the torso and relieve the limbs. Slow walks make the dog gently load the operated leg, thus accelerating recovery.
- In preparation for passive exercises and massage, heat therapy is used. After 4-6 days, the acute phase of inflammation is over, tissue warming is gone and the swelling is gone. Relaxing warm compresses on the operated limb can be used with hotpacks or bottles filled with warm water (10-15 minutes).
- Passive range of motion: The dog is lying on its side. Bend and straighten (within a controlled range) all joints of the operated limb, starting from its distal end (foot), then moving towards the body, up to the hip joint. Do 10 repetitions 3-4 times a day 10 minutes before exercising.
- Massage. Massage for 5-10 minutes, 3-4 times a day. You can massage a dog's limb, while lying on its side, starting at the end (foot) and working your way towards the body. Gentle pressure will help with circulation.
- The use of TENS and / or EMS electrostimulation (if the dog tolerates electric current) allows for an analgesic effect, and also increases muscle tone and resistance to fatigue.
- Cold therapy:
- carried out for 10-15 minutes after exercise,
- use a cold coldpack on the knee - maximum 10-15 minutes - after this time there will be no effect.
Second week - physiotherapy and hydrotherapy
- Short and slow, controlled walks on a leash. Walk your dog for 5-10 minutes 3-4 times a day.
- Massage for 10 minutes, 3-4 times a day.
- Warm compresses - applied 10 minutes before exercise.
- Passive range of motion: 15 repetitions 3-4 times a day.
- If the recovery is smooth, consider walking on a treadmill to encourage the dog to burden the limb. Such training is especially recommended in restless dogs, because it forces walking "step by step ". This eliminates the risk of sudden movements, and thus - complications and relapses.
- The first sessions are short and last 5-10 minutes, and should be stopped if fatigue is noticed.
- Hydrotherapy in the form of passive exercises in water and marching on an underwater treadmill are started when the postoperative wound is completely healed. Post-operative check-up after 10-14 days.
- Short and slow, controlled walks on a leash. Walk your dog for 15-20 minutes, 3-4 times a day.
- Massage for 10 minutes 2-3 times a day.
- Warm compresses performed 10 minutes before exercise.
- Passive range of motion (if necessary). If the walking is correct, these exercises can be dispensed with.
- Exercises: sit down - stand up:
- simply provoke the animal to sit down and then immediately stand up,
- perform 5-7 repetitions, 3-4 times a day.
- From 2. one week after the surgery, it is recommended to undergo 2-3 physiotherapeutic treatments per week for 4-6 weeks.
- Controlled walks on a leash of up to 20 minutes, 3-4 times a day; may be on a longer leash.
- Massage - as needed.
- Warm compresses 1-2 times a day.
- Passive range of motion as needed (if walking is okay, can be dispensed with).
- Exercise "sit-up " - increase to 10 repetitions, 3-4 times a day.
- Exercise "eights ":
- walking on eight figures to enable a turn,
- do 10 repetitions, 3-4 times a day.
- Controlled walks on a leash combined with training on the hill:
- walk your dog on a leash for 20-30 minutes, 3-4 times a day,
- work on the hill for 5-10 minutes, 1-2 times a day. Start slowly and increase the distance every day.
- Give up warm compresses, passive range of motion and massages. These treatments may be waived if the dog uses the limb consistently
- Exercises: "sit-stand " do 10-15 repetitions, 3-4 times a day.
- Walking in eighths - do 10-20 repetitions, 3-4 times a day.
- Going up a step. Allow your pet to climb a small step or curb, 3-4 times a day while walking. Walk slowly to keep your dog comfortable. If the dog still has difficulty doing this exercise, don't do it yet.
Week eight - x-ray after surgery
X-rays may be required to confirm bone healing.
It is important to realize that until the bone is fully healed, the repair will be susceptible to injury if it is subjected to excessive strain.
Therefore, activity levels must be carefully controlled.
A checkup x-ray may be done approximately 8 weeks after surgery to assess bone healing. Once confirmed, you can begin increasing your exercise regimen.
Weeks 8 - 12
- Increasing controlled exercise.
- Controlled walk several times a day, increasing by five minutes per week.
As the length of walks increases, their frequency decreases.
Weeks 12 - 16
- Controlled exercise with increasing activity without a leash.
- Long walks on a leash followed by allowing 5 minutes of unleashed activity to complete the walk.
- Increase free movement by 5 minutes a week.
- No play with other dogs, no chasing or catching the ball.
Weeks 16 - 20
Controlled, free activity without a leash. Unlimited duration of off-leash walks and activities, but further avoiding strenuous activities / jumping / playing with other dogs.
Dog's ligament rupture - prognosis
The prognosis depends on many factors.
- The longer the trauma occurs, the more arthritic the joint and the more conservative the prognosis.
- If the meniscal cartilage is torn, the prognosis is also more careful.
- Obese animals usually recover more slowly than healthy animals.
- Animals with bilateral ligament rupture take longer to recover than animals with injuries on one side only.
- Dogs with underlying conditions such as rheumatoid arthritis, lupus, or immune-background polyarthritis have a reduced chance of being fully healed.
- Knee joint tissue inflammation is unfortunately unavoidable after injury, even after surgery and may require long-term treatment in some patients. Preventing weight gain during the rehabilitation phase and maintaining lean body condition over the long term is a key factor in minimizing the effects of arthritis.
- The period and method of carrying out rehabilitation, which:
- accelerates convalescence,
- reduces pain,
- supports the healing of postoperative wounds,
- prevents further loss of muscle mass,
- restores normal range of motion in the knee joint,
- enables early limb loading.
- Long-term prognosis after cruciate ligament surgery is usually good, with an 85-90% chance of returning to normal activity levels.
- Patients who:
- They are not overweight. If your pet is overweight, it is recommended that you feed your pet a calorie controlled diet until it reaches its target weight.
- They can be kept in conditions that restrict movement throughout the recovery period.
- They are more calm. Dogs with a very lively temperament, hyperactive dogs are more difficult to control, which often results in complications or even recurrence of the disease.
In general, animals stabilized by any surgical technique will require 3 to 6 months of rehabilitation. After this time, depending on the severity of the arthritis prior to surgery, they should return to a fairly normal level of activity, although the limb is unlikely to regain 100% of its pre-injury function.
These dogs can be sore after strenuous exercise and may sometimes require pain medications.
Working and sporting animals will have a slightly impaired function and it is often the case that they no longer return to work / competition.
Hunting dogs may not be able to hunt as often or for as long as they did before injury.
It is assumed that the TPLO operation allows the animals to be returned to pre-injury performance levels.
Prevention of ligament rupture
Although preventing injury is difficult, there are certain factors that can reduce the likelihood of a cruciate ligament rupture.
Above all, obesity is avoided.
Obesity is a predisposing factor and overweight dogs are more susceptible than lean and fit dogs.
If your dog is suffering from excess pounds, recovery time may also be much longer.
Obesity also increases the risk of injuring the other knee. Losing weight is as important as surgery in getting you back to functioning quickly.
Your veterinarian can assess your dog's condition and provide guidelines for a healthy diet and optimal body weight.
Exercise is also important for dogs as it is for humans because a daily exercise regimen reduces the likelihood of injury.
Since animals with other orthopedic conditions of the knee, such as patellar dislocation, may be more prone to rupture of the cranial cruciate ligament, early surgical correction of such orthopedic problems is an important preventive measure.
Cruciate ligament disease is the most common cause of lameness in an adult dog and the primary cause of osteoarthritis affecting the knee.
While traumatic cruciate ligament ruptures do occur, the vast majority of CCL instability cases are associated with progressive ligament degeneration of unknown cause.
Surgery is the treatment of choice for a ruptured anterior cruciate ligament.
Provided arthritis has not developed significantly, most dogs have a good chance of regaining normal or near-normal knee function after surgery. Some small dogs, however, show signs of improvement by simply resting and limiting exercise.
The prognosis after surgery depends on several factors. Obese dogs usually recover more slowly than athletes in good condition.
Despite the huge amount of research, we still don't understand what the root cause of cruciate ligament insufficiency in a dog is. Thanks to the many surgical techniques described over the past 50 years, it is also clear that the "perfect" treatment has not yet been established.
If your the dog suffered a cruciate ligament injury talk to your vet about a referral to a specialist for this type of injury.
Which breeds are most at risk of ligament rupture?
There is a strong racial predisposition to rupture CCL in dogs. West Highland White Terriers, Yorkshire Terriers and Rottweilers have a much higher incidence of CCL, and Rottweilers have a five-fold higher incidence compared to other pure breeds, with females being twice as likely to suffer from CCL compared to males. Rottweilers and Cocker Spaniels are the most predisposed to rupture of the anterior cruciate ligament.
Does the disease occur in dogs of any age?
The incidence of CCL rupture in dogs increases with age, with peak cases occurring in dogs between 7 and 10 years of age. The high incidence of ligament rupture in older dogs is associated with synovial inflammation and degenerative changes in the cells and matrix of the cruciate ligament, in contrast to puppies, where rupture of the CCL is often associated with traumatic injury and detachment of the ligament from its attachment sites. Dogs 5 years old and older are 2.5 times more likely to experience an anterior cruciate rupture compared to dogs younger than 5 years old.
What are the most important risk factors?
Rottweilers are five times more likely to rupture the cruciate ligament than other breeds. Rottweilers have the best chance of bilateral rupture of the cruciate ligament. If a dog is obese, they are four times more likely to experience cruciate rupture than a normal weight dog, so keeping a lean body is very important. Females are twice as likely to experience ligament rupture as males. Dogs under the age of two are less likely to experience cruciate ligament rupture than dogs over the age of eight.
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