Tendon and ligament disease - SA Flashcards
Name 2 types of tendon injury
- traumatic lacerations
- strains (breaking or dehisence of fibres, mechanically induced or result of weakening by degeneration)
Outline mm injury
similar to tendons, less commonly specifically diagnosed
Presentation - tendon/ mm injuries
- lameness (acute/ chronic)
- swelling (diffuse, painful, oedema if acute, organised and established if chronic)
- specific functional disability (e.g. unable to extend stifle)
Diagnosis - tendon/ mm injuries
- CS (dysfunction)
- radiograph (swelling, gap)
- ultrasound (gap, loss of linear orientation of fibres)
Pathophysiology of tendon repair
- fibroblasts and collagen fibres line up along line of action
- sheathed tendons have poorer blood supply and heal slower
- 6 weeks to regain 50% normal strength
- 1 year to regain average 80% normal strength
Tx - tendon injry
- rest
- specific support to protect tendon from loading (dressing, cast, trans-articular fixator)
- primary sx repair for lacerations (tendon sutures to manage load, direct contact of edges, suture of epi-tendon to promote healing)
- ultrasound to monitor
Name 2 suture patterns for tendon repair
- locking loop
- 3 loop pulley (creates loops around collagen fibres)
- appose tendon edges (3mm gap intereferes with tendon healing)
- non-absorbable prolene (takes long time to heal)
Degree of ligament injury/ sprain
- mild/ moderate / severe/ = first/ second/ third degree
- increasing levels of soft tissue damage, swelling, pain, lameness and instability
Ligamentous injury - PE
normal PE but especially ROM
- further tests: (radiography with stressed views, ultrasound, manipulate under anaesthesia)
- always check for ancillary damage
Tx - ligament injury
- rest, reduce swelling (drugs, cooling)
- external coaptation + support
- ligament repair
- internal ligament splintage
- attention to other structures
- arthrodesis
- degree of tx depends on instability, pain and healing potential*
What is arthrodesis?
- a salvage procedure
- joint fusion
- ROM of joint is permanently lost
Tx - long-term tx of ligament injury
- long aftercare periods - slow healing
- not always acceptable function (repair mechanics not perfect, extra-chronic capsular tissue, secondary OA)
- may require arthrodesis at second stage
How common is ligament disease in small animals?
Not very common except canine cranial cruciate ligament
Describe the cranial cruciate
runs from proximal and lateral femur to distal and medial tibia, the caudal cruciate runs in opposite direction.
- cranial cruciate is designed to resist the force that as the dog moves forward and thrust it weight forwards, the reactive force acts caudally and the stifle is vulnerable to this caudal force as the round profile of the femur can slip across the tibial plateau. If the CCL ruptures and the femur can move across the tibia, the menisci can become damaged
What is canine cruciate disease?
- normally related to degeneration
- can be acute (trauma or degenerative ligament giving way)
- associated with MPL (medial patella luxation)
- causes a debilitating cr-cd instability in the stifle
- 60% cases involve medial meniscus
- human CL injuries normally traumatic, canine CL injuries are usually the consequence of gradual degeneration of the ligament
Typical presentation - CCLR
- middle aged dogs (2-10yo)
- overweight, neutered
- medium to large breeds (labrador, rottweiler, spanial, bull breeds, not sighthounds such as greyhounds and lurchers)
- hx: typically insidious onset HL lame, may be bilateral, acute onset lameness can occur
PE - CCLR
- HL lame (ddx hip and LS dz)
- mm atrophy (quadriceps, hamstrings)
- stifle effusion
- medial buttress
- cr-cd stifle instability
- pain on manipulation, sit test
What is a medial buttress?
- sign of CCLR
- soft tissue thickening on medial aspect of joint (stifle)
Which two PE tests are needed for CCLR?
- cranial drawer
- tibial thrust
Describe the tibial thrust test
- test for CCLR (along with cranial drawer)
- push tarsus, puts tension in gastroc, this pushes tibia forwards, to elicit this, you need an almost complete CCLR (partial rupture may not elicit any movement at all)
What is the commonest reason for stifle OA?
CCL dz
What are the broad tx options for CCL dz?
- conservative (non-sx)
- sx tx
Outline conservative (non-surgical) tx of CCL dz
- INDICATIONS: minimal lame, low grade pain, weight
What are the sx options of CCL dz/
- ADVANTAGES: should improve joint stability, should speed up recovery, allows meniscal lesions to be tx
- RECOVERY: joint will never be 100% stable, DJD will always be present thus residual lameness, limb fxn can be very good but not 100%
What are the sx tx options for CCL dz?
- no option for direct repair of cruciate
1. ) use an implant in a position analogous to the CCL. Restore joint stability (temporarily), allows fibrous tissue to stabilise stifle
2. ) change the mechanics of stifle to negate the need for CCL support (e.g. TPLO, TTA, CWTO, TTO) - any sx should involve inspection of meniscus and removal of damaged areas (do before sx, via an arthrotomy)
Define TPLO
- sx correction of CCLR
- Tibial Plateau Levelling Osteotomy = this changes the angle that the tibia meets the femur allowing the articular surfaces to bear more of the caudal shear force from tibial thrust
Define TTA
- sx correction of CCLR
- = Tibial Tuberosity Advancement
- the line of the patella tendon is advanced making it parallel to the line of force transfer across the joint. The tension in the tendon cancels out the compression across the joint negating the caudal movement of the femur
Define CWTO
= Closed Wedge Tibial Osteotomy
- sx correction of CCLR
- similar to TPLO but dorsal displacement of tibial tuberosity
- tendinitis
- cranial wedge
- makes tibial plateau flat
- lowering top of tibia, puts strain on patella tendon thus more prone to tendonitis
Define TTO
= Triple Tibial Osteotomy
- for sx correction of CCLR
What is the best sx procedure for CCLR?
- most of current options based on extracapsular suture or tibial osteotomy have a similar outcome at 12 wks post sx
- that said there are numerous claims for advantages relating to new procedures all the time
Outline post-op management for CCLR
- fast weight bearing
- rest (6-8 wks), lead walks, increase 5 min/ 2wks
- cold packs (48-72h)
- warm packs and PROM 2-3 times/day
- rads 6-8 wks
- no hydrotherapy initially
Outline rehabilitation for tendon//ligament dz
- look for fastest return to reasonable exercise
- depends on condition and tx
- gradual increase in lead exercise
- physio techniques
