Canis ISSN: 2398-2942

Stifle: intra-articular stabilization

Synonym(s): Intra-capsular stabilization

Contributor(s): Joseph Harari, Melvyn Pond, Toby J Gemmill

Introduction

  • Aim: to replace the damaged cruciate with a graft, placed to mimic the course and function of the normal cranial cruciate ligament.
  • Normal dogs bear weight on the tibial plateau; the cranial cruciate ligament prevents cranial movement of the tibia (and injury to the caudal medial meniscus) during weight-bearing.
  • 'Over-the-top' technique places a graft of the patellar tendon and fascia lata through the joint and over the proximal and caudal aspect of the femoral condyle.
  • 'Under-and-over' technique puts the autogenous graft under the inter-meniscal ligament before passing through the stifle joint - to provide an anchoring effect at the cranial cruciate ligament insertion site.
  • The two attachment points of the graft should maintain the same relative distance as the joint moves so that there is no lengthening or shortening during joint movement and resulting graft failure; this is known as isometric placement of the graft.
  • Several materials have been used for implants. Autogenous tissues include fascia lata and patellar tendon; exogenous materials have included suture materials (eg polydioxonone) and ligament replacement materials (eg multi-filament polyester, dacron, carbon fiber and 'gortex'). They are either intended to support the joint permanently or to act as temporary support and encourage the development of a new ligament. Exogenous materials are generally less successful and their use has been largely abandoned.
  • Several techniques are practiced. The most common is a simple 'over-the-top' where a graft of fascia lata and a portion of the patellar tendon is passed through the joint and sutured to the lateral femoral condyle. Variations on this technique using tibial or femoral tunnels, or placement of the graft under the cranial intermeniscal ligament (the 'under-and-over' technique) have little clinical advantage and are used less commonly.

Uses

Advantages

  • Relatively straightforward surgical technique.
  • More isometric placement of the graft compared to extra-articular techniques.

Disadvantages

  • Relatively invasive technique as graft passer must be placed through the caudal aspect of the joint.
  • The graft is weaker then the native cranial cruciate ligament and weakens further with time.
  • Instability returns in almost all cases as the graft lengthens, and the graft at best is acting as a temporary internal 'splint' for the joint.
  • Clinically, outcomes have been shown to be less favorable than extra-articular techniques.

Requirements

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Preparation

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Procedure

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Aftercare

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Outcomes

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Prognosis

  • 80-90% success rate based on observation of improved function following surgery.
  • Return to reasonable clinical function is expected within 12-16 weeks.
  • Prognosis must be made with reference to the patient's lifestyle. The likelihood of having an acceptable existence as a pet is far greater than returning to work.
  • No technique prevents radiographic progression of joint changes.
  • Animals with unattended meniscal lesions may remain lame and, thus, require re-exploration of joint Stifle: meniscus lesions.

Further Reading

Publications

Refereed papers

  • Recent references from PubMed and VetMedResource.
  • Bennett D, May C (1991) An 'over the top with tibial tunnel' technique for repair of cranial cruciate ligament rupture in the dog. JSAP 32 (3), 103-110 VetMedResource.

Other sources of information

  • Brinker W, Piermattei D & Flo G (2006) Handbook of Small Animal Orthopaedics and Fracture Repair. 4th edn. Saunders.
  • Piermattei D & Johnson K (2004) Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat. 4th edn. Saunders.


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