Cranial Cruciate Ligament Injury Research Articles

Do cats with a cranial cruciate ligament injury and osteoarthritis demonstrate a different gait pattern and behaviour compared to sound cats?

BackgroundOsteoarthritis (OA) is a common cause of chronic pain and dysfunction in older cats. The majority of cats with OA do not show signs of overt lameness, yet cats with orthopaedic disease are known to redistribute their body weight from the affected limb. OA can cause changes in the cat’s behaviour, which is often misinterpreted as signs of aging. The aim of the present study was to investigate if cats with a previous cranial cruciate ligament (CCL) injury perform differently on the pressure mat and exhibit different behaviour compared to sound cats according to the owner´s subjective assessment. Ten cats with a previous CCL injury were assessed with a pressure mat system and their owners were asked to complete an assessment questionnaire. The results were compared to those of 15 sound cats, matched to have the same weight and body condition score.ResultsThe front/hind limb index for peak vertical force (PVF) was significantly higher for CCL cats, and there was a decreased PVF and vertical impulse (VI) on the affected hindlimb compared to the unaffected one. The results indicate that cats with a previous CCL injury put less weight, on the affected hindlimb but for a longer time. There was a significantly higher owner assessment questionnaire score for the group of cats with CCL injury compared to sound cats.ConclusionsCats with a previous CCL injury have a different gait pattern compared to sound cats and a different behaviour according to owner subjective assessment. It is of great importance that further studies are performed to investigate the long term effects of CCL injury as a cause of pain and physical dysfunction, and its role in the development of OA in cats. Improved assessment tools for chronic pain caused by OA in cats are needed, both to facilitate diagnosis and to evaluate pain-relieving treatment.

Do cats with a cranial cruciate ligament injury and osteoarthritis demonstrate a different gait pattern and behaviour compared to sound cats?

Do cats with a cranial cruciate ligament injury and osteoarthritis demonstrate a different gait pattern and behaviour compared to sound cats?

Histological and immunohistological analysis of degenerative changes in the cranial cruciate ligament in a canine model of excessive tibial plateau angle.

To create a canine model of excessive tibial plateau angle (eTPA) and assess the chondroid metaplasia and extracellular matrix alteration in the cranial cruciate ligament. Seven mature female Beagles were included. Cylindrical osteotomy was performed bilaterally in the proximal tibia. The TPA was increased to approximately 40° in the left tibia (eTPA stifle) and left unchanged in the right tibia (control stifle). Exercise stress was started at three months postoperatively, and at 12 months postoperatively the dogs were euthanatized and the cranial cruciate ligaments were collected. The specimens were subjected to haematoxylin and eosin staining to assess the ligamentocyte morphology and immunostaining to assess the type I (COLI), type II (COLII), and type III (COLIII) collagen, and the sry-type HMG box 9 (SOX9) staining. Macroscopic cranial cruciate ligament injury was absent in six dogs but present in the eTPA stifle of one dog, which was excluded from the analysis. The ligamentocyte density decreased and the percentage of round ligamentocytes increased in the eTPA stifles. The COLII, COLIII, and SOX9 staining increased significantly and COLI deposition decreased in the eTPA stifles compared to the control stifle. The extracellular matrix changed, COLI deposition decreased, and COLIII and SOX9 staining increased in the cranial cruciate ligament of the eTPA stifles. SOX9 may contribute to COLII synthesis in the extracellular matrix of the cranial cruciate ligament in eTPA stifles, and eTPA may promote chondroid metaplasia and extracellular matrix alteration.

Engraftment of autologous bone marrow cells into the injured cranial cruciate ligament in dogs

Current research indicates that exogenous stem cells may accelerate reparative processes in joint disease but, no previous studies have evaluated whether bone marrow cells (BMCs) target the injured cranial cruciate ligament (CCL) in dogs. The objective of this study was to investigate engraftment of BMCs following intra-articular injection in dogs with spontaneous CCL injury. Autologous PKH26-labelled BMCs were injected into the stifle joint of eight client-owned dogs with CCL rupture. The effects of PKH26 staining on cell viability and PKH26 fluorescence intensity were analysed in vitro using a MTT assay and flow cytometry. Labelled BMCs in injured CCL tissue were identified using fluorescence microscopy of biopsies harvested 3 and 13 days after intra-articular BMC injection.The intensity of PKH26 fluorescence declines with cell division but was still detectable after 16 days. Labelling with PKH26 had no detectable effect on cell viability or proliferation. Only rare PKH26-positive cells were present in biopsies of the injured CCL in 3/7 dogs and in synovial fluid in 1/7 dogs. No differences in transforming growth factor-β1, and interleukin-6 before and after BMC treatment were found and no clinical complications were noted during a 1 year follow-up period. In conclusion, BMCs were shown to engraft to the injured CCL in dogs when injected into the articular cavity. Intra-articular application of PKH26-labelled cultured mesenchymal stem cells is likely to result in higher numbers of engrafted cells that can be tracked using this method in a clinical setting.

EFFECTS OF STIFLE FLEXION ANGLE AND SCAN PLANE ON VISIBILITY OF THE NORMAL CANINE CRANIAL CRUCIATE LIGAMENT USING LOW‐FIELD MAGNETIC RESONANCE IMAGING

Low-field magnetic resonance imaging (MRI) is commonly used to evaluate dogs with suspected cranial cruciate ligament injury; however, effects of stifle positioning and scan plane on visualization of the ligament are incompletely understood. Six stifle joints (one pilot, five test) were collected from dogs that were scheduled for euthanasia due to reasons unrelated to the stifle joint. Each stifle joint was scanned in three angles of flexion (90°, 135°, 145°) and eight scan planes (three dorsal, three axial, two sagittal), using the same low-field MRI scanner and T2-weighted fast spin echo scan protocol. Two experienced observers who were unaware of scan technique independently scored visualization of the cranial cruciate ligament in each scan using a scale of 0-3. Visualization score rank sums were higher when the stifle was flexed at 90° compared to 145°, regardless of the scan plane. Visualization scores for the cranial cruciate ligament in the dorsal (H (2) = 19.620, P = 0.000), axial (H (2) = 14.633, P = 0.001), and sagittal (H (2) = 8.143, P = 0.017) planes were significantly affected by the angle of stifle flexion. Post hoc analysis showed that the ligament was best visualized at 90° compared to 145° in the dorsal (Z = -3.906, P = 0.000), axial (Z = -3.398, P = 0.001), and sagittal (Z = -2.530, P = 0.011) planes. Findings supported the use of a 90° flexed stifle position for maximizing visualization of the cranial cruciate ligament using low-field MRI in dogs.

Magnetic resonance imaging for detection of late meniscal tears in dogs following tibial tuberosity advancement for treatment of cranial cruciate ligament injury

To document the use of and to estimate the accuracy of magnetic resonance (MR) imaging for detection of late meniscal tears in dogs with cranial cruciate ligament injury treated with tibial tuberosity advancement (TTA). Medical records of dogs that had TTA followed by stifle MR imaging for suspected meniscal tear and subsequent arthrotomy were reviewed retrospectively. Magnetic resonance images were reviewed independently by an observer blinded to clinical information who classified menisci as torn, abnormal but intact, or normal. Magnetic resonance and surgical findings were compared. Eight stifles from large breed dogs were included. Six stifles had a medial meniscal tear identified in MR images and later confirmed surgically. In the remaining two stifles, the menisci appeared intact in MR images and no tear was identified at subsequent arthrotomy. Lateral menisci in all stifles appeared intact in MR images and were considered normal at surgery. Susceptibility artefacts associated with TTA implants were present in all images but did not adversely affect interpretation of intra-articular structures. Magnetic resonance imaging appears to be accurate for diagnosis of late meniscal tears. Artefacts associated with TTA implants did not prevent evaluation of critical intra-articular structures. Further investigation with MR imaging should be considered when late meniscal tear is suspected following TTA.

Stabilization of the CORA Based Leveling Osteotomy for Treatment of Cranial Cruciate Ligament Injury Using a Bone Plate Augmented With a Headless Compression Screw

To report the effectiveness of a bone plate/headless compression screw (HCS) construct in preventing tibial plateau angle (TPA) shift postoperatively and to describe radiographic healing of the osteotomy. Case series. Dogs (n = 31). Records of dogs diagnosed with cranial cruciate ligament (CCL) injury treated with the center of rotation of angulation (CORA) based leveling osteotomy (CBLO) stabilized with a bone plate augmented with a HCS were reviewed. Breed, age, weight, and gender were recorded. Radiographs were reviewed for determination of preoperative tibial plateau angle (PreTPA), postoperative TPA (PostTPA), patellar tendon angle (PTA) postoperatively, and TPA at final evaluation (FinalTPA). Difference between PostTPA and FinalTPA was used to define any TPA shift. Radiographic healing at final evaluation was graded based on a 5-point scale. Mean time to final recheck was 88 days (range 49-237 days) with mean ± SD PreTPA = 28.6 ± 4.8°; PostTPA = 9.2 ± 2.2°; FinalTPA = 9.7 ± 2.6°; and TPA Shift = 0.52 ± 1.61°. There was no significant difference between PostTPA and FinalTPA (P = .084, power > 0.80). Mean postoperative PTA was 89.9 ± 1.7°. There were 2 implant related complications; 1 HCS migration and 1 HCS failure. Stabilization of the CBLO using a bone plate augmented with a HCS was effective in maintaining PostTPA and achieving satisfactory radiographic healing.

Extra-Articular Stabilization of the Canine Cranial Cruciate Ligament Injury Using Arthrex Corkscrew and FASTak Anchors

The objective of this study was to evaluate the long-term outcome in dogs with cranial cruciate ligament injury that were repaired with an Arthrex Corkscrew or FASTak bone anchor and Fiberwire placed at near isometric points of the stifle. A retrospective study (2006-2010) was conducted by reviewing clinical records of dogs treated for cranial cruciate ligament injury with an extra-articular repair method using anchors preloaded with Fiberwire. A questionnaire was given to owners for evaluation of their dog’s performance prior to surgery and at time of follow-up with a minimum of 12 months post-operative. Owner assessment was rated using a visual analogue scale. Completed questionnaires from 34 owners were received. The mean time to follow up was 27.5 months. Owner assessment of their dog prior to surgery versus at the time of follow up were considered significant (P

The intercondylar fossa indices of male and female dog femora

The intercondylar fossa (ICF) indices can be used to evaluate fossa geometry, which may in turn affect the function, pathology and intracapsular surgical repair of the cranial cruciate ligament. The measurements of digital images of the distal femur of 44 dogs were used to calculate the fossa width, shape, height and area indices. The mean values of fossa width index were found to be 0.19, 0.28 and 0.37 at the cranial, central, and caudal levels of the fossa, respectively. The mean values for fossa shape, height and area indices were found to be 0.71, 0.33, and 0.16, respectively. The differences in ICF indices between male and female dog were not significant. Therefore, it is suggested that gender differences related to ICF geometry may not have any effect on incidence of cranial cruciate ligament injury in dogs.

Treatment of Bilateral Medial Femoral Condyle Articular Cartilage Fissures in a Horse Using Bone Marrow-Derived Multipotent Mesenchymal Stromal Cells

The objective of this study was to describe the use, and outcome, of multipotent mesenchymal stromal cells (MSCs) in the treatment of equine articular cartilage defects of the medial femoral condyle. A 4-year-old Thoroughbred gelding (n = 1) with bilateral stifle athroscopy was found to have bilateral articular cartilage fissure defects of the medial femoral condyles with concurrent cranial cruciate ligament injury. Bone marrow derived MSCs were isolated, expanded, and suspended in a partially autologous fibrin glue. The initial cell/fibrin glue mixture was delivered arthroscopically into the articular cartilage defects 90 days after the initial arthroscopic examination. Follow-up treatments included two additional injections of MSCs suspended in lactated Ringers solution, 5 and 13 months after the initial examination, directly into the joint. Post-treatment outcome was assessed by arthroscopic examination and by comparison of preinjury and post-treatment performance records. Arthroscopic evaluation 4 months after the initial MSC treatment revealed marked smoothing, reduction in the depth of cartilage defects and observation of moderate improvement in the cranial cruciate ligament. Approximately 15 months after the initial MSC treatment the horse returned to racing. Analysis of race records demonstrated that the post-treatment (including all three MSC treatments) average race earnings (earnings per start) were comparable with those predating the initial injury. The favorable clinical response in the face of an unknown, but likely, guarded prognosis suggest that MSC therapy is not deleterious and may augment healing of articular cartilage fissures of the medial femoral condyle. MSCs represent a viable and promising alternative therapy in the treatment of articular cartilage injuries in performance horses.

Second Look Arthroscopic Findings after Tibial Plateau Leveling Osteotomy

To describe the long-term (range, 2-69 months) arthroscopic appearance of intraarticular structures of the stifle after tibial plateau leveling osteotomy (TPLO). Case series. Dogs (n=63) that had repeat arthroscopic examination of the stifle after TPLO for treatment of a cranial cruciate ligament (CCL) deficient stifle. Medical records (2002-2008) of dogs that had repeat arthroscopic examination to evaluate intraarticular structures after previous TPLO for treatment of CCL injury. Regions of interest were the CCL, caudal cruciate ligament, articular cartilage, and menisci. Signalment, weight, and time to 2nd look arthroscopy were recorded. Radiographs were reviewed to measure pre- and postoperative tibial plateau angle, and craniocaudal limb alignment. There were 17 partial CCL tears with early fiber tearing and 46 stifles with a complete CCL tear or incompetent partial CCL tear. Stifles with an early partial tear had normal to near normal appearance of intraarticular structures. Most dogs with a complete or incompetent partial CCL tear had axial or abaxial grades 3 or 4 articular cartilage abrasion of the medial or lateral femoral condyle. Intraarticular structures appeared normal or near normal in dogs with early fiber tearing (caudolateral or craniomedial fibers). Most dogs that had a partial tear with an incompetent remaining CCL or a completely ruptured CCL had grades 3 or 4 articular cartilage abrasion. Early diagnosis of a CCL injury and treatment by TPLO may be protective against further CCL disruption lending stability to the joint and decreasing the incidence of meniscal injury and articular cartilage damage.

Comparison of Short- and Long-term Function and Radiographic Osteoarthrosis in Dogs After Postoperative Physical Rehabilitation and Tibial Plateau Leveling Osteotomy or Lateral Fabellar Suture Stabilization

To compare short- and long-term functional and radiographic outcome of cranial cruciate ligament (CrCL) injury in dogs treated with postoperative physical rehabilitation and either tibial plateau leveling osteotomy (TPLO) or lateral fabellar suture stabilization (LFS). Prospective observational clinical study. Medium to large breed dogs with naturally occurring CrCL injury (n=65). Dogs with CrCL injury were treated with either TPLO or LFS and with identical physical rehabilitation regimes postoperatively. Limb peak vertical force (PVF) was measured preoperatively and at 3, 5, and 7 weeks, and 6 months and 24 months postoperatively. Stifles were radiographically assessed for osteoarthrosis (OA) preoperatively and 24 months postoperatively. Thirty-five dogs had LFS and 30 dogs had TPLO. Radiographic OA scores were significantly increased at 24 months compared with preoperative scores in all dogs. Radiographic OA scores preoperatively and at 24 months were not significantly different between treatment groups. PVF was significantly increased from preoperative to 24 months among both treatment groups but not significantly different between treatment groups preoperatively or at 3, 5, 7 weeks, 6, or 24 months. No significant difference in outcome as determined by ground reaction forces or radiographic OA scores were found between dogs with CrCL injury treated with LFS or TPLO. LFS and TPLO remain good options for stabilizing stifles with CrCL injury with all dogs showing significant functional improvement. This study does not support the superiority of either surgical technique.

Ultrasonography of the Canine and Equine Stifle Joint - Correlation with Humans

The gross anatomy and physiology of the knee are similar in people, dogs and horses. However, evolution, way of life and the use of horses and dogs means that the detailed anatomy, physiology and disease processes have altered with time. In dogs, cranial cruciate ligament injury (30%), degenerative joint disease (17%) and patellar ligament injury (17%) are the most frequently encountered disease processes, while in horses, osteochondrosis and subchondral cysts (52%), medial collateral ligament injury (28%), patellar ligament injury (23%), degenerative joint disease (23%) and medial meniscus lesions (19%) are more frequently reported. In addition the technological possibilities and the cooperation of the patient are different between human and veterinary medicine. In people, ultrasonography of the knee is easy to perform and gives lots of information, but it has inferior diagnostic capabilities compared to MRI. In dogs, the small size of the joint and large variation between breeds are responsible for the limited use of knee ultrasonography. In horses, ultrasonography of the knee is risky and time-consuming but is currently the only practical alternative to radiography. There is a lack of ultrasonographic reference values in the dog and horse compared to people. Veterinary radiologists have to define normal variants and reference values in young and adult animals to improve the objectivity, and thus the quality, of knee ultrasonography.

Cranial cruciate ligament injury in dogs ‐ are we really making any progress?

Cranial cruciate ligament injury in dogs ‐ are we really making any progress?

Preliminary study evaluating tests used to diagnose canine cranial cruciate ligament failure

To estimate specificity, sensitivity, positive predictive value and negative predictive value of tests and signs used for the diagnosis of cranial cruciate ligament failure in dogs. One stifle in each of 42 dogs was examined: 25 "affected" and 17 "control" dogs. All dogs were subjected to the following tests when conscious: cranial drawer, tibial compression, patellar tendon palpation and palpation of the medial aspect of the joint. Under general anaesthesia, cranial drawer and tibial compression tests were repeated and a lateral stifle radiograph was taken to evaluate changes of the infrapatellar fat pad. The results were analysed using a 2 x 2 table method. Sensitivity, specificity, positive predictive value and negative predictive value were estimated. The sensitivity of the cranial drawer and tibial compression tests was surprisingly low when performed on conscious patients but significantly better when performed under anaesthesia. Similarly, palpation of the medial aspect of the stifle joint cannot be considered a reliable indicator of cranial cruciate ligament injury. Patellar palpation and radiographic assessment showed excellent sensitivity, specificity, positive predictive value and negative predictive value. In the diagnosis of cranial cruciate ligament, it is essential that the clinician is aware of each test's features and limitations to reduce the risk of misdiagnosis.

Complications associated with lateral fabellotibial suture surgery for cranial cruciate ligament injury in dogs: 363 cases (1997–2005)

To report the complication rate for a commonly performed procedure (lateral fabellotibial suture [LFS]) used in the treatment of dogs with cranial cruciate ligament (CCL) injury. Retrospective case series. 305 dogs evaluated for 363 incidents of CCL injury from January 1997 through December 2005 and treated with LFS. Medical records were reviewed for information on breed, sex, age, body weight, clinical history, duration of surgery and anesthesia, primary surgeon, percentage of ligament tear, condition of medial meniscus, unilateral versus bilateral disease, implant material, duration of follow-up, and perioperative and postoperative complications. 363 LFS procedures met the criteria for inclusion in the study. Complications (n=65) were recorded for 63 of the 363 (17.4%) surgical procedures. Multiple complications developed in 2 dogs. In 26 (7.2%) dogs, a second surgery was required to manage the complications. Breed, side on which surgery was performed, implant material, percentage ligament tear, meniscal condition and treatment, bandage use, perioperative antimicrobial use, and experience of surgeon did not influence the complication rate. Factors significantly associated with a higher rate of complications were high body weight and young age of dog at the time of surgery. LFS is associated with a lower perioperative and postoperative complication rate than has been reported for other surgical procedures to repair CCL injury. Heavier and younger dogs had more complications. Complication rate must be considered when choosing a surgical treatment for dogs with CCL injury.

The Canine Stifle

Cranial cruciate ligament (CCL) injury is a leading cause of lameness in dogs. Recent advances in diagnostic visualization and surgical treatments for CCL injury have stimulated an increased emphasis on early clinical recognition and an early return to function. Many surgical treatments have been described that aim to restore stifle joint stability and minimize the progression of osteoarthritis. Major advances have occurred not only in the treatment of CCL injury, but also in postoperative recovery, specifically, rehabilitation therapy. The benefits of rehabilitation therapy following CCL surgery are multifaceted including pain relief, decreased inflammation and swelling, increased tissue flexibility, strengthening, improved proprioception, improved limb and joint biomechanics, and improved weight-bearing. In this article, we introduce a variety of rehabilitation therapy options for postoperative CCL patients including modalities, manual therapy, therapeutic exercise, and the benchmarks for a full return to function.

Fish oil decreases matrix metalloproteinases in knee synovia of dogs with inflammatory joint disease

This study was designed to determine whether dietary fish oil affects the expression and activity of matrix metalloproteinases (MMP), tissue inhibitors of MMP-2 (TIMP-2) and urokinase plasminogen activator (uPA) in synovial fluid from dogs with spontaneously occurring stifle (knee) instability in a single hind limb resulting from acute cranial cruciate ligament (CCL) injury. Two groups of 12 dogs were fed diets from 1 week prior to surgery on the affected knee to 56 days post-surgery. The fish oil and control diets provided 90 and 4.5 mg, respectively, of combined eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)/kg body weight per day. Plasma and synovial fluid, from both surgical and nonsurgical knee joints, were obtained at start of the diet (−7), surgery day (0) and 7, 14, 28 and 56 days post-surgery. Plasma total EPA and DHA were significantly increased, and plasma total arachidonic acid (AA) was significantly decreased by the fish oil diet. In synovial fluid from the nonsurgical knee, fish oil treatment significantly decreased proMMP-2 expression at Days 7 and 14, and proMMP-9 expression at Day 56, and uPA activity at 28 days and significantly increased TIMP-2 expression at Days 7 and 28. There were no differences in MMP expression or activity, TIMP-2 expression and uPA activity in the surgical joint synovial fluid at any time throughout the study . These results suggest that dietary fish oil may exert beneficial effects on synovial fluid MMP and TIMP-2 equilibrium in the uninjured stifle of dogs with unilateral CCL injury.

Evaluation of Pentosan Polysulfate Sodium in the Postoperative Recovery from Cranial Cruciate Injury in Dogs: A Randomized, Placebo‐Controlled Clinical Trial

To evaluate the efficacy of pentosan polysulfate (PPS) for improving the recovery period and mitigate the progression of osteoarthritis (OA) of the canine stifle after extracapsular stabilization of cranial cruciate ligament (CCL) injuries. Randomized, blinded, placebo-controlled clinical trial. Dogs (n=40) with unilateral CCL instability. Each dog had an extracapsular stabilization of the stifle with or without partial meniscectomy. Dogs were divided into 4 groups based on preoperative radiographic assessment and whether a partial meniscectomy was performed. Dogs were randomly assigned to either (3 mg/kg) PPS or placebo treatment in each group, and then injected subcutaneously weekly for 4 weeks. Lameness, radiographic changes, biological marker concentration in blood and urine, and ground reaction forces (GRFs) were collected preoperatively, and at 6, 12, 24, and 48 weeks. Data were analyzed within and between groups using repeated measures ANOVA; P<.05 was considered significant. No adverse reactions to PPS were reported. Thirty-nine dogs completed a minimum of 24-weeks follow-up and 33 dogs completed 48 weeks. All dogs clinically improved after surgery without differences in lameness score, vertical GRFs, or radiographic progression. Grouped and evaluated only by initial radiographic score, PPS-treated dogs improved significantly faster in braking GRFs than placebo-treated dogs. In dogs with partial meniscectomies, urine deoxypyridinoline, and serum carboxy-propeptide of type II collagen were significantly increased at 6 weeks in placebo-treated dogs compared with PPS-treated dogs. PPS administered after stabilization of the cruciate deficient stifle may prove to be a useful adjunctive treatment option, although further studies are necessary to substantiate this claim.

Geometric implications of the tibial wedge osteotomy for the treatment of cranial cruciate ligament disease in dogs

The tibial wedge osteotomy (TWO), a procedure that reduces the tibial plateau slope, has become an established surgical technique for the treatment of cranial cruciate ligament injuries in dogs, yet variation from the desired postoperative tibial plateau slope of 6 degrees has been noted. The objectives of this study were to investigate the geometric implications of this procedure and to identify factors that affect the postoperative angles. The records of 35 consecutive cases that had a TWO performed were reviewed and comparisons were made between the alignment of the cortices and level of the osteotomy using duplicated tracings of a preoperative radiograph. The existing method for calculating the size of wedge to be removed was found to result in a postoperative slope greater than the expected 6 degrees. Our results indicate that the desired postoperative angle is more likely to be achieved if the cranial cortices are aligned and the osteotomy is performed proximally.