Exam 2: Lecture 9: Cranial Cruciate Ligament Injury Disease III Flashcards
Where are extracapsular reconstruction placement of sutures related to the joint or redirection of lateral collateral ligament
outside of the joint
Extracapsular reconstruciton is incorrectly referred to as?
imbrication sutures
Location of origin + insertion of extracapsular suture has significant effects on isometry of the joint. What effect / motion does it effect?
affects amount of drawer motion throughout normal range of motion in the stifle joint
Do you flex or extend the stifle to tighten with extracapsular reconstruction?
flex
Do you flex or extend the stifle to loosen with extracapsular reconstruction
extend
Extracapsular sutures are secured from which two places?
- Bone anchors
- Bone tunnels
What materials are used in extracapsular sutures?
- monofilament nylon or fishing or leader line
- manufactured orthopedic wire
- braided orthopedic suture
Sutures used in extracapsular reconstruction can be connected with which technique and why?
Crimp the suture ends
- alters biochemical properties of loop
What does this image show?
Extracapsular reonstruction using heavy, nonabsorbable suture and suture anchors
In the images, one end is connected to the bone anchor and the other end is connected to?
Tibial tuberosity
Where are the two areas this extracapsular reconstruction is anchored to?
Suturs pass through the deep fascia surrounding the Lateral flabella (top) and predrilled hole in the Tibial tuberosity (bottom)
Tying the suture in the image eliminates?
cranial drawer
What is this instrument used for?
suture crimping
What does A show?
drill guide wire in femur around 2mm distal to lateral fabella - femoral condyle junction in caudal most portion of lateral femoral condyle
What does B show?
overdrill wire
What does C show?
retract LDE cranially and drill 2nd guidewire within groove and exit proximal tibia on media side
What is this technique in the image called?
tightrope stabilization
What is the technique in this image called?
tightrope stabilization
What does D show?
Overdrill wire
What does E show?
place tighrope at medial aspect of tibia hole and ending at medial aspect of femoral hole
What does F show?
Tighten tightrope and secure it with multiple throws
True Imbrication technique is performed by tighting which muscle / structure?
fascia lata
- advancment technique using vest-over-pants suture pattern
- partial excision and closure
The true Imbrication technique is usually in alone or in addition to another techqniue
in addaition to another technqiue
The stifle joint is normally stabilized by which passive contraints
- ligaments
- menisci
- joint capsule
The stifle joint is normally stabilized by which active constraints
- muscles
- tendons
Does the CCL function as an active or passive constraint to cranial tibial translation and internal rotation of the tibia
passive constraint
Which ligaments acts as a passive contraint to the cranial tibial translation and internal rotation of tibia
CCl
Thinking of Stifle biomechanics, ground reaction forces and muscle forces generate compression loads on which surface of the tibia during weight bearing
articular surface of the tibia
describe the tibial plateau on the left
flat
describe the tibial plateau on the right
sloped
_____ tibial plateau angle = greater cranial dorce on tibia during weight bearing
larger tibial plateau angle
When the paw is loaded during weight bearing, the force is created through which areas?
foot to metatarsus / tarsus
When the paw is loading during weight bearing, which tendon react with second force to maitain stability of tarsus during weight bearing angle
Calcanean (Achilles) tendon
A vector force occurs in the _____ = sum of resulting forces of weight bearing
tarsus
A vector force of the tibia creates a simultaneous force through the ______ ligament
patellar ligament
A vector force occurs in the tarsus and creates a simulatenous force through the patellar ligament. What joint does this stabilize
Stifle joint
A combination of forces in the stifle results in a vector force in plant ______ to the patellar ligament at standing weight bearing angle to the stifle (135 degrees)
- this is total joint force across stifle joint at normal weight bearing
parallel
If the slope of tibial plateau is NOT anatomically oriented perpendicular to patellar ligament on weight bearing what is the result
tibiofemoral shear force
What is a tibiofemoral shear force known as?
cranial tibial thrust force
- in direction of cranial drawer or tibial translation
Cranial tibia thrust forces accommodated for in normal animal by which ligament
CCL
When the tibia is loaded caudally the slope of the tibial plateau result in ?
shear force
When the tibia is loaded caudually directed slope of tibia plateau results in a shear force. This creates abnormal tibial translation in which ligament resulting in a deficient stifle joint
CCL
Shear component of compressive force is referred to as?
cranial tibial thrust (CTT)
- normally passively constrained by the CCL
______ is proportional to the slope of the tibial plateau
CTT
If the slope of the tibial plateau decreases so does the?
CTT
The tibial plateau can be reduced. Once this happens what changes?
tibial thrust changes
Tibial plateau slope can be reduced so tibial thrust changes. In what position / direction does this change occur?
from a cranioproximal direction to a neutral or caudal direction
The point where tibial thrust changes direction to a caudal thrust can increase the reliance on which ligament
caudal cruciate ligament
The point where tibial thrust changes direction to a cauda thrust increases reliance on the cadual cruciate ligament. Does this act as a active or passive contratins to abnormal caudal translation of the tibia?
passive constraint
What is the intent of TPLO surgery
- attain a tibial plateau slope of approximately 5 to 7 degrees
- where tibial thrust can be controlled by caudal cruciate ligament and active constraints of the stifle
What muscle group is targeted with a TPLO where the tibial thrust can be controlled by caudal cruciate ligament and active contraints of the stifle?
Quadriceps muscle group
Which ligament is a passive constraint of internal rotation forces of the tibia
CCL
Failure to control internal rotation resulting in drawer with internal rotation is referred to as?
pivot shift
- significance of this motion to function outcome following TPLO surgery is uncertain
What surgery is effective for dogs with a complete or partial tear of the CCL
TPLO
Many surgeons prefer this surgery for treating larger, active dogs
- long term rehabiliation and postoperative control is difficult
TPLO
In the image what does A and B show?
Position jig perpendicular to long axis of the tibia
In the image what does C show?
Perform osteotomy to depth of 1/3 of bone with saw parallel to jog pins
This is part of what surgery
TPLO
This is part of what surgery
TPLO
What does D show?
mark bone for rotation (complete cut)
What does E show?
Rotate proximal segment to align marks
What does F show
Secure osteotomy with appropriate sized bone plate
What does A show?
preop lat radiograph of a dog showing measurement of tibial slope for TPLO
- around 30 degrees
What does B show?
Postop lat radiograph showing leveling of tibial slope (5 degrees) for stabilization of CCL - deficient stifle joint
What is the forerunner of TPLO
tibial wedge osteotomy (TWO)
What was orginally described for treatment of severely increased TPAs in dogs
- same principles at TPLO
Tibial wedge osteotomy
- TWO
TWO lower osteotomy results in change of relative position of tibial crest. This may be associated with?
complication of stifle extensor mechanism
Which technique is for management of CCLR & increased TPA in young dogs with open proximal tibial physis
TWO - tibial wedge osteotomy
Will tibial wedge osteotomy (TWO) affect physes as the TPLO
will not affect physes
What technique is shown in the image?
tibial wedge osteotomy (TWO)
Which technique does the following describe?
- With straight saw mark both lines of osteotomy
- complete osteotomy + remove wedge of bone
- Reduce bone segment and apply bone plate
tibial wedge osteotomy (TWO)
What technique does the image show?
tibial wedge osteotomy (TWO)
What technique is descibed as
- ostetomy of NWB portion of tibia
- patellar ligament aligned 90 degress to common tangent of femorotibial joint (eliminating cranial tibial thrust)
Tibial tuberosity advancement (TTA)
Tibial tuberosity advancement (TTA) positions the patellar ligament at what degree to slope of tibial plateau by advancing insertion in cranial direction
- eliminates tibiofemoral shear force with weight bearing
- relieves function of the CCL
Tibial tuberosity advancement (TTA)
- similar to TPLO
TPLO procedure does the same redirection of vector force as TTA. By rotating the tibial plateau to neutralize _________ shear force
tibiofemoral
TPLO procedure does the same redirection of vector foce at TTA, but the TPLO increases tension on which ligament
patellar ligament
Does the TTA or TPLO theoretically reduce patellar ligament tension?
reduce
- at a 90 degree = able to reduce fice
Does a TTA or TPLO have less postoperatively patellar ligament inflammation
TTA
Does the TTA affect joint congruency?
no
the Tibial tuberosity advancement (TTA) increases load of which ligament
cadual cruciate
- partially offset by reduction of internal joint reactions from longer patellar ligament lever arm
Tibial tuberosity advancement (TTA) places the patellar ligament in what degree slope to tibial plateau
90 degree
- IMPORTANT TO KNOW
How does the TTA place the patellar ligament in a 90 degree slope to the tibial plateau?
by advancing insertion in cranial direction
TTA place the patellar ligament in a 90 degree slope to the tibial plateau by advancing insertion in cranial direction. This eliminates tibiofemoral shear force with weight bearing to help relieve function of which ligament?
CCL
What procedure does this image show?
Tibial tuberosity advancement (TTA)
What procedure does the image show?
Tibial tuberosity advancement (TTA)
What does A describe
position plate on tibial crest to assess size
What does B describe
Place fork template over crest and drill holes
What does C describe
Perform transverse partial crest osteotomy leaving lateral cortex intact
What procedure is shown in this image?
Tibial tuberosity advancement (TTA)
What does D describe
seat plate into tibial crest and complete osteotomy
What does E describe?
open osteotomy gap + insert cage at level of proximal osteotomy + secure with screw
What does F describe
insert screws in plate
What does G describe?
Insert 2nd cage ear screw
fill in gap with bone graft
close surgcial site
What procedure does the image show?
Tibial tuberosity advancement (TTA)
postop radiograph
- in the image you can see the forks that hold everything into place
What does CBLO stand for?
CORA based leveling osteotomy (CBLO)
What is CORA
center of rotation and angulation
CBLO was orginally used for?
angular limb deformity correction in children
- then applied for angular limb deformity correction in veterinary orthopedics
Is circular osteotomy the same or opposite direction of the TPLO?
opposite direction
What type of procedure does this image show?
CBLO
Physcial rehabiliation protocal following TPLO, TTA, TWO, MPL, and Lateral patellar luxation (LPL)
- just the image
Physical rehabilitation protocol following extracapsular cruciate repair
- just the image
Regardless of the technique used, how should the meniscus me inspected
arthrotomy
arthroscopy
Why should the meniscus be inspected by arthrotomy or arthroscopy?
identify tears or other evidence of trauma
Damage to the cadual body of the medial meniscus seen in 50% to 75% of patients with what other issue?
torn CCL
Most patient have a bucket handle tear in the meniscus. What should be done during surgical treatment of ruptures CCL?
the meniscus must be EXCISED!!!!
What are some common complication of CCL surgery
- infection
- lack of stabilization
- meniscale injury (even post-op)
- implant complications
- Progressive osteoarthritis
Additional complications of TPLO surgery include?
- patellar tendon desmitis
- tibial crest fracture
Additional complication of TTA surgery include?
- tibial crest fractures
- patellar luxation
What needs to be done in patients with poor outcome following CCL repair
need thorough evaulation for these potential outcomes
What is the prognois of animals with CCL surgery
long term function for patients that have CCL surgery is GOOD
- results conflicting regarding influence of method of reconstruction
Most published assessments of outcome state of animals with CCL surgery is _______%?
85% to 90% of dogs improve after surgery
What disease progressess regardless of treatment in animals with CCL surgery
DJD
What are 4 common long term outcomes in animals with CCL surgery
- decline in activity over time
- increasing level of disability
- Adverse response to cold weather
- Stiffness after inactivity due to progress of DJD
