Cranial Cruciate Ligament Surgery Research Articles

Systematic review of postoperative rehabilitation interventions after cranial cruciate ligament surgery in dogs.

ObjectiveTo critically evaluate the evidence for rehabilitation interventions following surgery for cranial cruciate ligament disease (CCLD) in dogs.Study designSystematic review.MethodsGoogle Scholar and Pubmed databases were searched for studies evaluating postoperative CCLD rehabilitation interventions from 1990 until March 2020 per the international Prospective Register of Systematic Reviews (PROSPERO). Each study was assigned a level of evidence score from I to IV and a risk of bias (RoB) score by 2 reviewers, and by a third reviewer, when consensus was not reached.ResultsNineteen studies met the inclusion criteria. Twelve comprised randomized, controlled trials (Level II), 6 were nonrandomized or nonblinded (Level III), and one was retrospective (Level IV). Nine studies had high RoB scores. Sixteen studies yielded positive results. Therapeutic exercise had the most studies with positive results but all had high RoB. Cold compression therapy had 3 supporting studies (2 Level II, low RoB). Extracorporeal shockwave yielded 2 positive Level II studies (low‐moderate and high‐moderate RoB) and photobiomodulation had 1 positive study (Level II, low RoB) with objective outcomes. A negative outcome was noted in 1 photobiomodulation study. There was 1 supporting study on electrical stimulation and there was none on low‐intensity pulsed ultrasound.ConclusionThis systematic review supports the use of rehabilitation interventions in recovery of postoperative CCLD in dogs; however, many studies had a high risk of bias.Clinical significanceThere is a lack of class I level evidence in veterinary rehabilitation. This study supports therapeutic exercise and cold compression therapy for postoperative CCLD rehabilitation. Existing studies on other modalities are limited and demonstrate conflicting results.

Fundamental principles of rehabilitation and musculoskeletal tissue healing.

ObjectiveTo review fundamental principles of tissue healing and physical rehabilitation as they apply to dogs recovering from cranial cruciate ligament (CCL) surgery.Study designInvited Review.Sample populationNone.MethodsA multidisciplinary group of specialists in small animal surgery, rehabilitation/sports medicine, and human physical and occupational therapy reviewed the currently available evidence for rehabilitation post‐CCL surgery. Because current evidence is limited, this group proposes guidelines for rehabilitation after CCL surgery based on the fundamental principles of tissue healing and physical therapy.ResultsThis Review proposes four fundamental principles of small animal physical rehabilitation based on the foundations of tissue healing and patient‐centric and goal‐oriented therapy. Postoperative rehabilitation programs should be designed such that patient progress is based on individual assessment according to the degree of tissue healing, strength, and achievement of functional goals. Therapists must fully understand phases of tissue healing, reassess the patient frequently, and use clinical reasoning skills to progress treatment appropriately for the individual patient.ConclusionUntil more robust evidence is available to guide treatment protocols, fundamental principles of rehabilitation should ideally be adhered to when providing rehabilitation, including after CCL surgery.Clinical significanceWhile this Review specifically addresses post‐CCL surgery rehabilitation, these fundamental principles should be applied broadly to animals enrolled in rehabilitation programs.

Physical rehabilitation for canine patients post cranial cruciate ligament surgery

Surgical treatment of cranial cruciate ligament (CCL) disease is commonly performed in veterinary practice. Perioperative rehabilitation is standard of care in human patients with anterior cruciate ligament injury. Evidence is slowly mounting showing benefits of post-operative rehabilitation in canine patients following CCL surgery. A rehabilitation programme should be developed and guided by a professional trained and certified in canine rehabilitation, and progress through the programme should be based on individual patient assessment and functional goals rather than time elapsed since surgery. This article presents an example of progression through a post CCL surgery rehabilitation programme utilising clinic-based therapies and a home exercise plan. The purpose of this article is to educate primary care veterinary surgeons on what a trained and certified veterinary physiotherapist/rehabilitation therapist may recommend during the rehabilitation period. This manuscript is NOT intended to be used as a formula for all patients following CCL surgery, and examples are NOT intended to be provided to pet owners without individual patient assessment and guidance of a veterinary physiotherapist/rehabilitation therapist.

Surgical Technique and Initial Clinical Experience with a Novel Extracapsular Articulating Implant for Treatment of the Canine Cruciate Ligament Deficient Stifle Joint.

To describe the surgical technique, clinical efficacy, and complications using the Simitri Stable in Stride(®) extracapsular articulating implant (EAI) to treat naturally occurring stifle instability due to cranial cruciate ligament (CrCL) insufficiency. Prospective case series. Client-owned dogs with CrCL-deficient stifles (n=60 dogs; 66 stifles). An EAI was applied to the medial aspect of the distal femur and proximal tibia after stifle exploration and treatment of joint pathology. Outcome measures included lameness score, time to weight bearing, and bilateral assessment of stifle stability, stifle range of motion (ROM), and thigh circumference (TC). Outcome measures were determined preoperatively and at intervals from 4.5 to 16.0 months (median 8.9 months) postoperatively. Data were excluded from bilaterally affected dogs <6 months after CrCL surgery on the contralateral limb, and from dogs with contralateral limb lameness. Within 24 hours of EAI surgery, dogs were weight bearing on 64 of 66 limbs at the walk. Incidence of major complications requiring surgical revision was 15.3% and minor complications was 10.2%. Postoperatively, there were significant improvements in lameness scores and ROM in 34 EAI-treated limbs meeting inclusion criteria, and the mean ROM returned to within normal limits. TC did not change in the operated limb, but decreased significantly in the control limb. The EAI effectively stabilized the CrCL-deficient stifle, and significantly improved lameness scores and stifle ROM. Decreased TC in control limbs may have been due to early return to mobility and weight bearing on the EAI-treated limb.

Retrospective analysis of complications and outcomes inBoxers andStaffordshireBullTerriers undergoing cranial cruciate ligament surgery

The aim of this study was to determine whether Boxers and Staffordshire Bull Terriers (SBT) have a higher incidence of complications or a worse outcome after cranial cruciate ligament (CCL) surgery compared with control breeds. The design was a retrospective cohort study with data reviewed from medical records and outcome assessed by owner questionnaire. The cohort included 210 canine stifles comprising 33 Boxers, 47 SBTs and 130 controls. For Boxers, the overall complication rate (39.4%), major complication rate (30.3%) and revision surgery rates (18.2%) were significantly higher than those of the control groups (14.6%, 10.8% and 4.6%, respectively). Overall, SBTs were no more likely to suffer complications or repeat surgery than the control group. Considering only lateral fabello-tibial suture (LFS) stabilisation, both Boxers (32.0%) and SBTs (23.3%) had higher complication rates than the control group (6.3%). There were no significant differences in outcome among the Boxer, SBT and control groups; median follow-up time was 2 years (range 0.5-7 years). The overall complication rate for Boxers undergoing CCL surgery was higher compared with other breeds of dog. When surgical techniques were analysed separately, the LFS was associated with a higher complication rate in Boxers and SBTs. Further investigation into breed-specific surgical techniques is indicated.

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.

Cranial cruciate ligament injury in the dog: pathophysiology, diagnosis and treatment

Cranial cruciate ligament (CCL) disease in the dog is a multifactorial complex problem that requires a thorough understanding of the biomechanics of the stifle joint to be understood. Successful treatment of rupture of the CCL should be based on managing underlying anatomical and conformational abnormalities rather than attempting to eliminate the tibial cranial drawer sign. The cranial and caudal cruciate ligaments, the patella ligament and quadriceps mechanism, the medial and lateral collateral ligaments, the medial and lateral menisci and the joint capsule provide stability of the joint and load-sharing. The function of the stifle is also significantly influenced by the musculature of the pelvic limb. An active model of biomechanics of the stifle has been described that incorporates not only the ligamentous structures of the stifle but also the forces created by weight-bearing and the musculature of the pelvic limb. This model recognises a force called “cranial tibial thrust”, which occurs during weight-bearing, and causes compression of the femoral condyles against the tibial plateau. In middle-aged, large-breed dogs, forces acting on the CCL together with conformation-related mild hyperextension of the stifle and slightly increased tibial plateau slopes are suspected to cause progressive degeneration of the ligament. Palpation of craniolateral stifle laxity has become pathognomonic for CCL rupture; however, chronic periarticular fibrosis, a partial CCL rupture, and a tense patient, may make evaluation of instability of the stifle difficult. Surgical treatment is broadly separated into three groups: intracapsular, extracapsular, and tibial osteotomy techniques. Tibial osteotomy techniques do not serve to provide stability of the stifle but rather alter the geometry of the joint to eliminate cranial tibial thrust such that functional joint stability is achieved during weight-bearing. Visualisation of both menisci is a critical aspect of CCL surgery, irrespective of the technique being performed. Regardless of the surgical technique employed, approximately 85% of dogs show clinical improvement. However, many of these dogs will demonstrate intermittent pain or lameness. Post-operative management is an integral part of the treatment of CCL rupture, and significant benefits in limb function occur when formalised post-operative physiotherapy is performed.