The diagnosis is partial tear or complete rupture of your dog’s anterior cruciate ligament in the knee. Nobody likes to hear this because it can entail a long recovery period and worst of all surgery. All breeds are susceptible to this injury and it is becoming very commonplace. Many of us are questioning why this is occurring? What is the reason that dogs of all breeds are rupturing their cruciate ligaments more often? Questions abound and we search for answers. We need to prod deeper into this injury and have some insight.
There are cases where a dog has a sudden acute rupture from trauma, but most cases are from a slow degenerative process of the fibers within the ligament. Larger breed dogs have a tendency to damage them more frequently than smaller dogs, due to the force that is placed on the knee. Another incidence that has been reported is for spayed females between the ages of 4 to 8 years getting CCL (cranial cruciate ligament) changes.
ACL (term synonymous with CCL) injuries cause a loss of support within the structure of the knee. This loss of support invariably leads to OA (osteoarthritis) degenerative changes. Smaller breed dogs can potentially side step surgery through conservative management, however, the atrophic and degenerative changes will occur.
There has been up to 50 different techniques designed to treat ACL injuries. The most frequently performed procedures are the extra capsular stabilization, intra capsular stabilization method, and TPLO (tibial plateau leveling osteotomy). Further to these stabilization procedures, loose or torn ligament remnants and damaged portions of the menisci have to be debrided, especially the caudal horn of the medial meniscus.
The extra capsular stabilization method uses nylon or stainless steel suture material to mimic the support of the intact CCL. This is passed around the lateral fabella and into a tunnel drilled into the proximal tibial crest. This allows early rehabilitation, minimal cranial drawer and immediate stabilization of the stifle.
During some point of the healing process, the prosthetic material used will fatigue and break, but the fibrosis that develops over 8 to 10 weeks is what will stabilize the knee for their life. A more stable joint will result after surgery if a rehabilitation regime is employed and adhered to.
Another version of the extra capsular technique is by fibular head transposition. In this method it is taken into account that the lateral collateral ligament inserts on the fibular head. This procedure is done by placing the fibular head cranially from its normal position and securing it with a pin and tension band. Limiting internal rotation of the limb, this new position presents the same function as the CCL.
Physical rehabilitation after surgery should follow a protocol of cryotherapy, PROM (passive range of motion) exercises and NSAIDs (non-steroidal anti-inflammatory drugs). Very gentle stretching along with slow and purposeful 10 minute leash walks, are highly recommended for functional use of the limb. Hydrotherapy is strongly recommended as early as one week post surgery if there are no open wounds and the incision has healed. At approximately 10 days post surgery, passive range of motion exercises should have the stifle motion where it was prior to surgery.
The method known as the intra capsular stabilization technique, uses either a prosthetic material or fascial strips and part of the patellar ligament. To imitate the path of the original CCL, this is placed in an intra articular fashion. This is done by way of an arthroscope or arthrotomy and allows for more normal joint movements. A physical rehabilitation regime is applied postoperatively. This protocol is the same as what is done for the extra capsular procedure.
A technique which provides stability to the joint and is fairly new, is the TPLO (tibial plateau leveling osteotomy). This is a method which is preferred for larger, heavier dogs. The foundation that this is built upon is that altered bio mechanical forces and active muscle contraction needs to be done. This will prevent the cranial motion drawer movement during weight bearing. Working on the stifle, this firms the joint while weight bearing.
In the TPLO, an osteotomy of the proximal tibia is performed, which permits the tibial plateau to be rotated to nearly a level position. To secure this in place, a specially designed bone plate and screws are used.
Postoperative difficulties can arise out of any surgery. The modified bio mechanics of the stifle is what usually will cause some difficulty. The patellar ligament may develop inflammation during the first month from this operation. A higher amount of weakness is expected initially with this surgery. Pain will be noticed at the insertion point of the ligament upon examination. This is due to the patellar ligament being wider.
The program for pain management after a TPLO operation is basically imposed rest, non-steroidal anti-inflammatory drugs and cold therapy. Any challenges will be short lived as the joint heals from the tissue alterations. The cartilage and bone of the joint have been altered, and the joint capsule needs time to heal. If there is not proper healing time allowed for the entire joint, bone implant failure is a possibility. Canine hydrotherapy holds impressive results for this kind of surgery due to the ability to greatly reduce weight-bearing stress on the structures.
Additional stress is placed on the CdCL (caudal cruciate ligament) from the TPLO surgery, and this is from over rotation of the tibial plateau. As a result there can be a CdCL injury from this additional pressure. Within 24 hours the physical rehabilitation needs to begin and active use of the limb is encouraged. Aqua therapy can be done one week after surgery as long as the incision has healed.
Partial or complete ruptures of the cranial cruciate ligament almost inevitably involve a meniscal injury. Simultaneously to an CCL injury, 50% of dogs have menisci damage. The medial meniscus can be normal at the time of a CCL surgery, however, it is almost guaranteed that at some time in the future it will be injured. The same protocol is followed for rehabilitation and physiotherapy as is for ACL injuries.
With ACL injuries, each dog needs to be assessed and a specific program developed for their situation. The post surgery regime is individualized as to each dog’s specific circumstances. The rehabilitation and physiotherapy program is tailored to their needs and situation on an individual basis. The dog needs to experience the least amount of pain as is possible for them to succeed. This is of critical importance.
