Intra-articular sprains Flashcards
1
Q
What is the most common stifle injury/orthopedic problem in the dog?
A
- Cranial cruciate ligament rupture
2
Q
What is the most common type of cranial cruciate tear in the dog?
A
- Partial
3
Q
What comprises the cranial and caudal cruciate ligaments?
A
- Craniomedial and caudolateral bands
- Fascicles - vessels, nerves, mechanoreceptors
4
Q
What is the mechanical function of the cranial cruciate ligament
A
- Prevent cranial displacement of the tibia relative to the femur
- Limit excessive internal rotation of the tibia on the femur
- Prevent hyperextension of the stifle
5
Q
What is a 1° sprain of the cranial cruciate ligament?
A
- Stretched
6
Q
What is a 2° sprain of the cranial cruciate ligament?
A
- Partial tearing or partial rupture
7
Q
What is a 3° sprain of the cranial cruciate ligament?
A
- Complete tearing or complete rupture
8
Q
Underlying pathogenesis of the CCL rupture?
A
- Excessive forces or trauma (rare)
- Progressive, immune-mediated, inflammatory arthropathy (degeneration of the ligament)
9
Q
Trauma causing CCL rupture
A
- Sudden rotation of the flexed stifle (20-30°)
- Hyperextension of the stifle
- Very rarely occurs in dogs
10
Q
Progressive, immune-mediated, inflammatory arthropathy leading to CCL rupture
A
- No traumatic history
- Bilateral disease is common
- Ligaments are extra-synovial and thus self-antigenic
- Anti-collagen antibodies
- Tartrate-resistant Acid phosphatase and Cathepsin K
- Pro-inflammatory cytokines
11
Q
What is the most likely suggested cause of recent increase in CCL rupture?
A
- Early spay and neutering in Labrador retrievers and Golden retrievers
- 5% of gonadally intact males and females had 1 or >1 joint disorders
- Neutering labs at <6 months doubled the incidence of one or more joint disorders in both sexes
- Neutering Goldens at <6 months increased the incidence of a joint disorder to 4-5x that of intact dogs
12
Q
Clinical history of cranial cruciate ruptures
A
- Acute lameness initially, 1-2 weeks later recovered (probably a small sprain)
- Acute lameness with chronic progressive lameness (most common); worse after activity
- May have had previous cruciate rupture/repair on contralateral stifle (40-50% of all unilateral patients)
13
Q
Clinical findings for cranial cruciate ruptures
A
- Mild to moderate weight bearing lameness
- Enlarged stifle joint (effusion, fibrosis, medial buttress)
- Disuse muscle atrophy
- Meniscal “click” or “clunk”
14
Q
Pathognomonic sign for cranial cruciate rupture
A
- Cranial drawer sign
- May not pick it up!
- May be significantly reduced with chronicity (fibrose into cranial drawer)
- May only be slightly present at a point of flexion or extension
15
Q
Other tests for cranial cruciate rupture
A
- +/- Cranial tibial thrust test (tibial compression test) - will usually have if you have a cranial drawer sign, but not the other way around
- Increased internal rotation of the tibia (for partial tears
16
Q
What are the 3 over-represented breeds?
A
- Lab
- Rottweiler
- Newfoundland
17
Q
Genetic component for cranial cruciate rupture
A
- No genetic component except in Newfies
- Commonly come in with a bilateral presentation
- No risk factors to develop a CCL rupture on the contralateral side based on chronicity of a unilateral rupture, weight, etc.
18
Q
What can puppy drawer be mistaken for?
A
- Cranial cruciate ligament rupture
19
Q
Radiographic findings of cranial cruciate ligament
A
- Mild to severe osteoarthritis
- Joint effusion (patellar fat pad, caudal joint capsule)
- Medial buttressing (thickening of the medial aspect of the joint capsule, but not pathognomonic)
20
Q
What are two differentials for medial buttressing?
A
- Cranial cruciate ligament and medial collateral ligament of the medial buttress
21
Q
Diagnosing cranial cruciate rupture injury
A
- Radiographs are probably some of the best
- MRI is not
- Arthroscopic examination is definitive
22
Q
What can you do with arthroscopic examination of the cranial cruciate ligament?
A
- Arthroscopic debridement of the cruciate
- Examination of articular structures including menisci
- Meniscal debridement
23
Q
Conservative treatment statistics by weight for cranial cruciate ligament tears
A
- <15 kg, 86% clinically normal or improved
- > 15 kg, 19.3% clinically normal
- Cats are 100% clinically normal
24
Q
What can determine surgery vs conservative therapy for cranial cruciate ligament tears on dogs less than 15kg?
A
- May require surgical stabilization based on age, physical condition, and expected activity level
- patient lameness and associated discomfort
25
Conservative Treatment Plan
- Restrict to leash walks only for 6 weeks
- NSAIDs for 5-7 days
- Looking for weekly improvement function
- If not improving by 3 weeks recommend surgical intervention
26
Why are animals with CCL tear lame?
- Mechanical instability and not OA
27
Will any single procedure allow an animal to regain perfect normal biomechanical function?
- No
28
What is favorable outcome of most CCL stabilization procedures?
- 85-95%
- OA is progressive with any procedures (including TPLO); animal will have improved function of stifle in face of osteoarthritis due to mechanical stabilization from surgery
29
Surgical treatments for cranial cruciate ligament surgery?
- Extra-articular procedures (e.g. lateral imbrication)
| - Osteotomy stabilizations (TPLO or Tibial Tubercle Transposition)
30
Complications of cranial cruciate ligament surgeries
- Breakdown of stabilization
- Latent or postliminal meniscal tear (10%)
- Infection
31
Cranial cruciate ligament post operative management
- Restricted activity for 8-12 weeks
- Leash walks only
- 8 weeks post-op rads for TPLO and TTA
- Gradual increase in activity for another 4 weeks
- Physical rehabilitation can start 2 weeks after surgery (important!)
32
When can physical rehabilitation start after cranial cruciate ligament surgery?
- 2 weeks after surgery
33
Tibial Plate Leveling Osteotomy vs Tibial Tuberosity Advancement
- At a walk, TTA seems to be okay, but they differ at a trot
- TPLO may allow a quicker return to function and a better function overall
34
How common is a caudal cruciate ligament rupture?
- Very rare as an isolated injury
| - More common as a partial rupture with CCL ruptures
35
Pathogenesis of caudal cruciate ligament rupture
- Traumatic
36
History and physical examination findings of caudal cruciate ligament rupture
- History of lameness
- Lameness more pronounced with activity
- Caudal drawer
- Joint effusion
37
Treatment for caudal cruciate ligament repair
- Conservative (nothing)
| - Surgery
38
TPLO with a caudal cruciate ligament rupture?
- Contraindicated
39
Meniscal anatomy
- Biconcave, C shaped meniscus
40
What are menisci made up of?
- Fibrocartilage
41
Blood supply for menisci
- Vascular: outer 1/3
| - Avascular: inner 2/3
42
What are the primary functions of the menisci?
- Mostly help with hoop stress and to prevent joint instability (like a golf tee)
- Reduced joint friction
- Axial shock absorption (minor function)
- Load transfer
43
Pathogenesis of meniscal injury
- Trauma
- During gait, the meniscus is exposed to constant shearin g
- Caudal pole is pulled back and away
44
Meniscal pathology type
- Bucket handle tears
- Radial tears
- Transverse tears
- Crushing of the caudal pole
- Degenerative
45
Meniscal injury diagnosis
- Physical exam
- Meniscal click or clunk on flexion*** (high likelihood of tear if it's positive)
- Discomfort on medial collateral palpation
- Direct visualization (meniscal click/clunk on physical examination)
46
Diagnosis for meniscal injury
- Usually have to directly visualize with arthroscopy or arthrotomy
- MRI is not beneficial
- Ultrasound is difficult at best
47
Treatment for meniscal tear
- Arthrotomy with partial menisectomy (majority of procedures)
- Arthroscopic assisted partial or complete menisectomy
- People will have a primary repair or meniscal replacement
- Dogs have no apparent morbidity to partial or total menisectomy
48
Prognosis from menisectomy
- Treatment prognosis is good, but may see slower return to function of the stifle
- Menisectomy site following surgery will have regeneration of fibrocartilaginous mass in area of previous meniscus
- Meniscal release does not appear to cause clinical morbidity
